De Clinicas Research Articles

Results of Bladder TUR Performed by a Second - Year Urology Resident at the Hospital de Clinicas de Montevideo, Uruguay: Detailed Analysis

Results of Bladder TUR Performed by a Second - Year Urology Resident at the Hospital de Clinicas de Montevideo, Uruguay: Detailed Analysis

Breast cancer treatment access disparities: A retrospective cohort study of breast cancer in patients treated at a high-complex cancer center in southern Brazil.

e13689 Background: More than seventy-three thousand new breast cancer cases are expected in Brazil for the year 2023, representing the most common malignancy in this country. Delaying time to treatment initiation has been associated with increased risk of worse outcomes. The Brazilian government developed several initiatives to accelerate the access of cancer patients to treatment in an adequate time-bound. One of these is a federal law defining that oncological treatment should begin within 60 days of pathological diagnosis. Methods: This retrospective study analyzed data of newly diagnosed breast cancer patients in 2022–2023 in Hospital de Clinicas de Porto Alegre (HCPA), a public hospital in Porto Alegre, Brazil. The primary objective was to build a predictive model of risk factors that could delay the time to first treatment beyond 60 days from diagnosis. The present analysis describes the socio-demographic characteristics of these patients and explores their impact on the time to oncologic treatment initiation. This project was approved by the Ethics and Research Committee (registration CAAE 71160423.7.0000.5327). Results: 184 patients who started their oncological treatment between 2022-2023 in HCPA were enrolled; 32 patients (17,3%) had their first treatment after 60 days from the diagnosis while 152 (82,7%) were treated before 60 days; 106 (57,3%) patients had studied up to elementary school and 32 (17,3%) were non-white; 53 patients (23%) had been submitted to biopsy outside HCPA. Patients who started their first treatment before 60 days had a mean of 38 days from diagnosis to first treatment while those treated after 60 days had a mean of 75,6 days. To evaluate how socio-demographic factors impacted the time to treatment initiation, a multivariate Poisson log-linear model adjusted for race, city of residence, stage of the disease, and type of first treatment considered different variables. Higher educational level had a statistically significant effect, with a rate ratio (RR) of 0.32 (95% CI 0.157 - 0.650, p < 0.05). We also found that performing biopsy in our institution instead of doing it elsewhere had a statistically significant impact on the time to first treatment, with an RR of 0.512 (95% CI 0.274 - 0.957, p = 0.036). Ethnicity was not related to delay of treatment (p-value=0.125). Conclusions: This study identified that socio-demographic factors are crucial to guarantee the appropriate time to start treatment for breast cancer patients in a middle-income country. Higher educational level had a positive impact on time-to-treatment initiation, as well as to perform biopsy in the same institution patients were treated. In this first analysis, ethnicity, clinical staging, and type of first treatment did not meet the statistical criteria to be considered relevant and the accrual of more patients is needed for further conclusions.

NYHA classification for decision-making in heart failure: Time to reassess?

European Journal of Heart FailureAccepted Articles Viewpoint NYHA Classification for Decision-Making in Heart Failure: Time to Reassess? André Zimerman MD, ScD, André Zimerman MD, ScD Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USASearch for more papers by this authorAnderson D. da Silveira MD, ScD, Anderson D. da Silveira MD, ScD Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, BrazilSearch for more papers by this authorScott D. Solomon MD, Scott D. Solomon MD Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USASearch for more papers by this authorLuis E. Rohde MD, ScD, Corresponding Author Luis E. Rohde MD, ScD [email protected] orcid.org/0000-0002-6557-393X Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil Corresponding author. Luis E. Rohde, MD ScD, Cardiovascular Division, Hospital de Clinicas de Porto Alegre, Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil, + 55 51 33598342, Email: [email protected]Search for more papers by this author André Zimerman MD, ScD, André Zimerman MD, ScD Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USASearch for more papers by this authorAnderson D. da Silveira MD, ScD, Anderson D. da Silveira MD, ScD Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, BrazilSearch for more papers by this authorScott D. Solomon MD, Scott D. Solomon MD Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USASearch for more papers by this authorLuis E. Rohde MD, ScD, Corresponding Author Luis E. Rohde MD, ScD [email protected] orcid.org/0000-0002-6557-393X Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil Corresponding author. Luis E. Rohde, MD ScD, Cardiovascular Division, Hospital de Clinicas de Porto Alegre, Post-Graduate Program in Cardiology and Cardiovascular Sciences, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil, + 55 51 33598342, Email: [email protected]Search for more papers by this author First published: 01 June 2023 https://doi.org/10.1002/ejhf.2923 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/ejhf.2923. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

COPD, diabetes, lymphopenia, and increased LDH cause higher mortality in hospitalized COVID-19 patients.

COPD, diabetes, lymphopenia, and increased LDH cause higher mortality in hospitalized COVID-19 patients.

A controlled open clinical trial of the positive effect of a physical intervention on quality of life in schizophrenia.

Schizophrenia is a severe mental disorder associated with important physical (obesity and low motor functional capacity) and metabolic (diabetes and cardiovascular diseases) changes that contribute to a more sedentary lifestyle and a low quality of life. The study aimed to measure the effect of two different protocols of physical exercise [aerobic intervention (AI) versus functional intervention ([FI)] on lifestyle in schizophrenia compared with healthy sedentary subjects. A controlled clinical trial involving patients diagnosed with schizophrenia from two different locations [Hospital de Clinicas de Porto Alegre (HCPA) and Centro de Atenção Psicosocial (CAPS) in the city of Camaquã] was carried out. The patients undertook two different exercise protocols (IA: 5-min warm-up of comfortable intensity; 45 min of aerobic exercise of increasing intensity using any of the three modalities-a stationary bicycle, a treadmill, or an elliptical trainer; and 10 min of global stretching of large muscle groups; and FI: a 5 min warm-up with a stationary walk; 15 min of muscle and joint mobility exercises; 25 min of global muscle resistance exercises; and 15 min of breathing body awareness work) twice a week for 12 weeks and were compared with physically inactive healthy controls. Clinical symptoms (BPRS), life quality (SF-36), and physical activity levels (SIMPAQ) were evaluated. The significance level was p ≤ 0.05. The trial involved 38 individuals, of which 24 from each group performed the AI, and 14 from each group underwent the FI. This division of interventions was not randomized but was instead decided upon for convenience. The cases showed significant improvements in quality of life and lifestyle, but these differences were greater in the healthy controls. Both interventions were very beneficial, with the functional intervention tending to be more effective in the cases and the aerobic intervention more effective in the controls. Supervised physical activity improved life quality and reduced sedentary lifestyle in adults with schizophrenia.

EPIDEMIOLOGY OF POST-TRAUMATIC SPINAL CORD INJURY IN A TERTIARY HOSPITAL.

to outline the profile of risk groups for spinal cord injury (SCI) at the Hospital de Clinicas de Campinas by an epidemiological survey of 41 patients with SCI. Data from patients with SCI were collected and analyzed: demographic data, level of neurological injury, visual analogue scale (VAS), and the current American Spinal Injury Association (ASIA) impairment scale (AIS), using questionnaires, medical records, and imaging tests. Fisher's exact test was used to assess the relationship between categorical variables, Spearman's correlation coefficient was used for numerical variables, and the Mann-Whitney and Kruskal-Wallis tests were used to analyze the relationship between categorical and numerical variables, with significance level of 5%. There was a prevalence of 82.9% of men, a mean age of 26.5 years, and traffic accidents as the cause of SCI in 56.1% of cases. Results suggest the importance of SCI prevention campaigns directed at this population. Level of Evidence II, Retrospective Study.

TREATING MULTIPLE MYELOMA IN A RESOURCE-LIMITED SETTING: REAL-WORLD OUTCOMES

Over 70% of the Brazilian population (> 150 million people) do not have access to private health care. Alkylating agents, thalidomide, and autologous stem cell transplantation (ASCT) are the mainstay of newly diagnosed multiple myeloma (NDMM) treatment in the public health care system. Therefore, real-life data from resource-limited countries are scarce and essential to optimize the incorporation of new technologies into this scenario. Describe characteristics of patients with NDMM, access to therapy, and outcomes, including overall survival (OS) and progression-free survival (PFS). Retrospective chart study including all patients with NDMM treated at Hospital das Clinicas de São Paulo Complex between 2009 and 2019. A total of 816 patients with NDMM were included. Mean age was 63 years and 55% were male. At the diagnosis, 91% of patients had bone lesions, 56% anemia, 41% hypercalcemia, and 26% presented with impaired renal function. Regarding the clinical stage, 88% were Durie Salmon III clinical stage, and 46% were ISS III stage. Median follow-up time was 5 years. A triplet regimen (cyclophosphamide, dexamethasone, and thalidomide) was the most prescribed in the frontline (446/792, 56%), followed by alkylating agent + dexamethasone regimens (281/792, 27%). Only three patients (0.4%) in this cohort received bortezomib upfront. 379 (46%) were referred to ASCT for consolidation, and 257 (25%) proceeded with it in the first-line treatment. 36% of the patients received three or more lines of therapy. Patients who underwent ASCT had fewer comorbidities by Charlson's index, lower ECOG at diagnosis, and fewer ISS stage III patients (31%) (p < 0.001 for all). Only 16% of the patients over 60 years underwent ASCT. Median time from diagnosis to transplant was ten months. Early mortality (≤ 120 days after diagnosis) was 9.7%, mainly due to infection. For the whole cohort, the overall response rate (ORR) after the first induction was 408/647 (63%), and 144 (22%) had disease progression. PFS and OS were 1.7 years (95% CI 1.6-1.9) and 3.7 years (95% CI 3.4-4.2), respectively. Median OS for patients that received ASCT was 5.9 (95%CI 5.1-7.8) years. This real-world cohort demonstrated that the available therapy in a resource-limited setting is far from the current gold standard for NDMM. Alkylating-based therapy results in suboptimal response rates, while the ASCT procedure is not timely available for all patients. In addition, poor clinical status and advanced disease may impact the choice of not using triplet regimens upfront. Early diagnosis, incorporating proteasome inhibitors and newer agents into the frontline, and ASCT availability are the major initiatives to decrease the disparity between rich and developing countries.

The millionaire friend-to-friend fundraising

The case portrays a real dilemma experienced by Alexandre, founder of the fourth largest Brazilian social mobilisation movement for health called VemPraGuerra He joined efforts with his brother and a friend (both resident doctors) to structure a project during the first half of 2020. Amid the COVID-19 medical supplies shortage, they were able to gather R$6 million (about US$1.2 million at that time). This funding was summoned to assist Hospital das Clinicas de Sao Paulo, the largest Brazilian health complex. The case study contributes to the currently scarce body of knowledge devoted to teaching stakeholder theory. It is an applied example of social entrepreneurship, the promotion of social change, and the contemporaneity of the COVID-19 pandemic.

O-3 TRENDS IN DECEASED DONOR AND LIVING DONOR LIVER TRANSPLANTATION IN LATIN AMERICAN COUNTRIES DURING A DECADE (2010-2019) . THE ALEH SPECIAL INTEREST GROUP, INTERNATIONAL SURVEY 2020

Brazilian public health system currently provides universal free all oral direct-acting antiviral (DAA) therapy for patients with hepatitis C virus (HCV) infection. Despite high rates of sustained virological response (SVR), patients with cirrhosis remain at risk for hepatocellular carcinoma (HCC). The aim of this study was to investigate incidence, risk factors and tumor pattern at presentation in a cohort of Brazilian HCV-related cirrhotic patients treated with DAAs. This prospective cohort study included patients with HCV-related cirrhosis treated with DAAs and followed for at least 24 weeks after therapy at the Viral Hepatitis Outpatient Clinic of Hospital de Clinicas de Porto Alegre, Brazil, between August 2016 and November 2017. Ultrasound screening was performed within 24 weeks before DAA therapy and patients with presumed past or current HCC were excluded. Primary outcome was HCC incidence. Secondary outcomes were risk factors for HCC ocurrence and tumor pattern at presentation. Multivariate analysis was used to identify independent variables associated with HCC development. A total of 234 patients with HCV cirrhosis were included. Fifty-six percent were males with a mean age of 61.2±10.9 years. Overall SVR was 97.4%. Child-Turcotte-Pugh (CTP) A, B and C at baseline was found, respectively, in 89.3%, 9.4% and 1,3%. Mean Model for End Stage Liver Disease (MELD) score was 9.17 ± 2.82. Esophageal varices were found in 43.6% of the patients. Type 2 diabetes was present in 18.8%. De novo HCC was diagnosed in 9% (21/234) of the patients during follow-up. Tumor pattern at presentation according to BCLC staging was 0, A, B, C and D in 19,1%, 47.6%, 4.8%, 28.6% and 0%, respectively. Multivariate analysis showed significant relative risk (RR) for HCC occurrence associated with the following variables: baseline MELD score ≥10 (RR: 1.8; p =0.05); absence of SVR (RR: 6.9; p =0.04); baseline platelet count <120 × 10 9 /L (RR: 5.0; p =0.04) and baseline albumin level <3.5 mg/dL (RR: 4.6. A high incidence of HCC was found after DAA therapy compared to the literature, particularly among patients with more advanced cirrhosis, particularly those with baseline albumin levels < 3.5 g/dL plus platelets < 120 × 10 9 /L. Absence of SVR was also significantly associated with HCC development. The majority of patients presented with very early (BCLC 0) or early (BCLC A) HCC, although a significant proportion showed advanced stage (BCLC C) at presentation.

O-19 INCIDENCE, PATTERN OF PRESENTATION AND RISK FACTORS FOR HEPATOCELLULAR CARCINOMA AFTER DIRECT ACTING ANTIVIRAL TREATMENT IN PATIENTS WITH HEPATITIS C VIRUS CIRRHOSIS

Brazilian public health system currently provides universal free all oral direct-acting antiviral (DAA) therapy for patients with hepatitis C virus (HCV) infection. Despite high rates of sustained virological response (SVR), patients with cirrhosis remain at risk for hepatocellular carcinoma (HCC). The aim of this study was to investigate incidence, risk factors and tumor pattern at presentation in a cohort of Brazilian HCV-related cirrhotic patients treated with DAAs. This prospective cohort study included patients with HCV-related cirrhosis treated with DAAs and followed for at least 24 weeks after therapy at the Viral Hepatitis Outpatient Clinic of Hospital de Clinicas de Porto Alegre, Brazil, between August 2016 and November 2017. Ultrasound screening was performed within 24 weeks before DAA therapy and patients with presumed past or current HCC were excluded. Primary outcome was HCC incidence. Secondary outcomes were risk factors for HCC ocurrence and tumor pattern at presentation. Multivariate analysis was used to identify independent variables associated with HCC development. A total of 234 patients with HCV cirrhosis were included. Fifty-six percent were males with a mean age of 61.2±10.9 years. Overall SVR was 97.4%. Child-Turcotte-Pugh (CTP) A, B and C at baseline was found, respectively, in 89.3%, 9.4% and 1,3%. Mean Model for End Stage Liver Disease (MELD) score was 9.17 ± 2.82. Esophageal varices were found in 43.6% of the patients. Type 2 diabetes was present in 18.8%. De novo HCC was diagnosed in 9% (21/234) of the patients during follow-up. Tumor pattern at presentation according to BCLC staging was 0, A, B, C and D in 19,1%, 47.6%, 4.8%, 28.6% and 0%, respectively. Multivariate analysis showed significant relative risk (RR) for HCC occurrence associated with the following variables: baseline MELD score ≥10 (RR: 1.8; p =0.05); absence of SVR (RR: 6.9; p =0.04); baseline platelet count <120 × 10 9 /L (RR: 5.0; p =0.04) and baseline albumin level <3.5 mg/dL (RR: 4.6. A high incidence of HCC was found after DAA therapy compared to the literature, particularly among patients with more advanced cirrhosis, particularly those with baseline albumin levels < 3.5 g/dL plus platelets < 120 × 10 9 /L. Absence of SVR was also significantly associated with HCC development. The majority of patients presented with very early (BCLC 0) or early (BCLC A) HCC, although a significant proportion showed advanced stage (BCLC C) at presentation.

Accuracy of a Simple Screening Tool (PALI-SP) to Predict Palliative Care Needing of In-Hospital Adult Patients in Five Tertiary Brazilian Hospitals

Background: To identify near of end-of-life in-hospital patients to provide them adequate support is a complex task. A simple and easily applicable tool is still needed. The aim of this study was to measure the accuracy of a simple tool with four questions, including two surprise questions, to predict one-year mortality of adult patients. Methods: This was a multicenter prospective observational cohort accomplishing five Brazilian public tertiary hospitals. A four questions tool (PALI-SP), able to classify patients in five categories was previously developed to help the coordination of care based on disease progression. This questionnaire was applied to the caring physician of each consecutively hospital admitted patient, during seven consecutive days. Data were collected between 2014 and 2015. A proportional hazard Cox model was used to the analysis. Results: A total of 1810 patients were studied. Patients’ age was 55±19 years-old, 833(46%) were females, 798(44%) were in a medical ward, and 1231(68%) have no advanced diseases. 975(54%) of analyses were done for physicians who had ≤ 3 years since graduation. The one-year mortality was 439(24%), death occurred within 27[9,111] days after the initial evaluation, non-survivors were younger, and have no-advanced diseases in 40% (174/439), followed by metastatic cancer [91/439(21%)]. The tool had the unadjusted and adjusted accuracies of 0.716(CI-95%=0.687-0.746) and 0.769(CI-95%=0.742-0.795) respectively. The five prognostic classification groups had incremental risk-ratios of one-year mortality: Group I = reference, Group II =1.484(0.885-2.487), Group IIIA=3.114(1.634–5.936), Group IIIB = 3.728(2.962–4.692), and Group IV = 6.339(4.618–8.702). Interpretation: This simple screening tool (PALI-SP) has a good overall accuracy to predict one-year mortality of in-hospital patients. Funding Statement: Study funded by the governmental agency Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP). Declaration of Interests: The authors have no conflict of interests to declare. Ethics Approval Statement: The study was approved by the local ethics committee of the Hospital das Clinicas de Sao Paulo under the process number 507007/07/2014. Informed consent was obtained from all patients and physicians prior to data collection. Trial Registration: The authors state that there is no Brazilian or US national clinical trials registration.

Real World Data: Delay on Symptoms and Diagnosis Recognition Associated with Relapse and Death in Thrombocytopenic Thrombotic Purpura (PTT)

Introduction: PTT is a rare disease and plasmapheresis have change the dismal and the fatal disease prognosis, increasing the survival rate to 80 -85%. Relapses can occur in 40% and are associated with a worse prognosis. Rituximab is an option for the refractory patients.Objectives: Analyze clinical and laboratory parameters, timelines to diagnosis and plasmapheresis of PTT patients at Hospital de Clinicas de Porto Alegre and correlate these data to survival and relapse rates.Material and Methods: Retrospective data obtained from medical records from 2007 to 2016. Were analyzed data from the first disease symptoms, diagnosis, patient admission and of the first plasmapheresis. Were collected clinical-laboratory data from the admission date and after the first week of plasmapheresis treatment to define initial response or not to treatment. The definition of initial response to treatment was as a progressive and maintain the increase in platelet counts simultaneous with a decrease in DHL blood level. Were included only patients treated with plasmapheresis and/or corticosteroids in the first week of treatment.Results: A total of 29 patients were included in the final analyses. Median age was 37 years (21-88), and 17 (58%) responded to plasmapheresis in the first week of treatment. The laboratory exams of this group of patients (Hb, DHL, creatinine) was not different from the nonresponders ones. A median number of plasmapheresis was 12. Deaths related to PTT and relapses were significantly higher in the patients with a delay from the beginning of the symptoms and the time from diagnosis to the first plasmapheresis was significantly higher in the patients (p=0,000, p=0,001, respectively). The time from the pt admission to the beginning of treatment had no impact on survival (p=0,750). Median survival rate was 279 days (75-1210) and was different between pts groups. Death related to TTP occurred in 9 pts (31%). Initial responders to therapy presented a median survival of 1450 days (21-2880) and the non-responders 285 days (21-2880), with p=0.05. Just 5 pts were treated with rituximab, and no impact on survival was observed (p=0.390)Conclusions: PTT is a fatal disease if not early recognized and treated. This study was done in a university hospital, a regional reference center and in 31% of patients death was the evolution. The factors associated with fatal event and relapse were the delay in recognizing the disease and late plasmapheresis treatment. With this result, we propose to increase medical awareness of PTT for emergency care team and to create a preference admission in reference hospitals with apheresis capacity installed. DisclosuresFogliatto:Roche: Honoraria, Other: Travel Support; accomodations; Novartis: Honoraria, Other: Travel support; AbbVie: Other: Travel Support.

Clinical findings of speech therapy swallowing assessments in patients with oropharyngeal dysphagia following orotracheal intubation

Purpose: Endotracheal intubation has been associated with oropharyngeal dysphagia. The aim of this study was to identify the prevalence of oropharyngeal dysphagia among patients in an intensive care unit (ICU) by comparing patients requiring orotracheal intubation with those who did not undergo this procedure. Method: This is a cross-sectional study that analyzed the medical records of 681 patients admitted to the ICU of Hospital de Clinicas de Porto Alegre between 2014 and 2017; inclusion criteria were patients aged 18 years and older who had been assessed by the hospital’s Speech Therapy Service. Patients who had undergone tracheostomy, who had incomplete medical records or multiple speech-language assessments were excluded. Results: A total of 380 patients were included in the statistical analysis: 97 (25.5%) had not undergone orotracheal intubation (Group 1), 229 (60.3%) had undergone orotracheal intubation once (Group 2), and 54 (14.2%) had undergone orotracheal intubation on 2 or more occasions (Group 3). Regarding the Functional Oral Intake Scale (FOIS), 61.1% of patients in Group 3 received a FOIS I classification (p = 0.020), whereas 16.5% of patients from Group 1 received a FOIS V. Concerning their outcomes, 40.7% of patients in Group 3 died (p = 0.006), and 82.5% of patients in Group 1 were discharged from the ICU. Considering the severity of oropharyngeal dysphagia according to the Dysphagia Risk Evaluation Protocol (PARD), no statistically significant association was observed between groups (p = 0.261). Conclusion: In this study, the prevalence of oropharyngeal dysphagia was higher in patients who had undergone orotracheal intubation in the ICU.

Influence of Different Asparaginase Formulations in the Prognosis of Children With Acute Lymphocytic Leukemia in Brazil: A Multicenter, Retrospective Controlled Study

Background: Our research group recently showed that the only ASNase formulation available in Brazil from 2017 to 2018 when used at the same dose and frequency as the formulation provided previously did not reach, in most cases, the serum activity considered therapeutic. Based on these data, our goal was to assess the impact of these facts on the prognosis of children with ALL at 10 different pediatric oncology centers in our country. Methods: a multicenter retrospective observational study followed by prospective follow-up. Patients aged >1 and <18 years in first-line treatment followed up at 10 referral centers of Brazil, between 2014 and 2018 who received the formulation Leuginase® were identified (Group B). For each patient, the center registered 2 patients who received ASNase in the presentation of Aginasa® exclusively (Group A). Data collection was performed by searching for medical records and registered using Redcap® software. Findings: A total of 419 patients were included; 282 in Group A and 137 in Group B. Clinical features at diagnosis were similar in both groups. Group A had a 3-year OS and EFS of 91·8% and 84·8% respectively, while Group B had a 3-year OS of 83·8% (p= 0·003) and EFS of 76·1% (p = 0·008). Interpretation: There was an impact on 3-year OS and EFS of children who received an asparaginase formulation that previously showed inferior activity in laboratory analysis. This result highlights the importance of evaluating asparaginase formulations and monitoring their activity during treatment. Funding Statement: The research was supported by FIPE/HCPA (Fundo de Incentivo a Pesquisa e Eventos do Hospital de Clinicas de Porto Alegre). Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: Ethical approval to conduct this study has been granted by the Ethics Committee of Hospital de Clinicas de Porto Alegre (HCPA). Participating adults as well as those responsible for minors signed informed consents in duplicate, keeping a copy for themselves.

Efficacy and Tolerability of Thermocoagulation Treatment of High-Grade Cervical Intraepithelial Neoplasia

Purpose: Cervical cancer is still one of the main causes of cancer and mortality in women, especially in low- and middle-income countries, although it is a completely preventable disease through the detection and treatment of pre-cancer lesions. We evaluated the efficacy and tolerability of thermocoagulation treatment of high-grade cervical intraepithelial neoplasia (CIN 2 and 3). Methods: We evaluated 115 women with high-grade cervical intraepithelial neoplasia, 54 with CIN 2 and 61 with CIN 3, confirmed by biopsy and without previous treatment, from January 2016 to December 2018, undergoing thermocoagulation treatment at the Lower Genital Tract Pathology and Colposcopy Service of the Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil. Results: The mean age was 33.11 years (SD = 9.83) for CIN 2 and 35.28 years (SD = 7.97) for CIN 3 patients. Treatment efficacy was 90.8% in CIN 2 and 94.9% in CIN 3 cases. Pain was the main symptom reported at the time of treatment, occurring more frequently in the CIN 3 group (49.1% versus 27.8% in the CIN 2 group). As the more important long-term complication, there were 3 cases of pelvic inflammatory disease in CIN 2 (5.6%) and 3 in CIN 3 group (5.0%). The percentage of residual lesion was very low in both groups, 5 in CIN 2 group (9.2%) and 2 in CIN 3 group (3.4%). Conclusion: Thermocoagulation is an effective method for the treatment of cervical pre-cancer lesions (CIN 2 and CIN 3), with a low risk of adverse events and complications.

Corneal Transplantation Outcomes at a Teaching Hospital: Residents vs Experts

Abstract Background: Corneal transplantation is the most successful procedure among human tissue transplants and is the most widely practiced and taught form of allograft in the world. Although it is generally successful, some cases may progress to graft failure, and even in transplants with corneal transparency, refractive outcomes are not always satisfactory, which is often related to the surgical technique. Methods: The medical records of all patients undergoing corneal transplantation from 2011 to 2013 at Hospital de Clinicas de Porto Alegre were reviewed, and clinical data were collected from the preoperative period up to 36 months after transplantation. For visual acuity, groups were created according to the best corrected visual acuity (BCVA): group 1 (worse than 20/200), group 2 (between 20/200 and 20/60) and group 3 (20/40 or better). Results: A total of 567 transplants were included, 315 (55.5%) performed by training surgeons and 252 (44.4%) by experts; 140 (24.6%) were classified as high-risk transplants. A significant difference was observed in the subgroups with low and high risk: 88.9% and 68.8% for residents (p<0.001) and 91.4% and 78.4% for experienced surgeons, respectively (p=0.005). Rejection within 36 months was greater among residents (p=0.001), especially in low-risk transplants. There was a significant improvement in visual acuity both in the training group (Kappa=0.935) and experienced group (Kappa=0.112). Conclusion: The corneal transplantation learning curve in a teaching hospital is quite safe, with visual outcomes and graft survival results for residents comparable to those for experienced surgeons. Rejection episodes were significantly higher among residents. Keywords Corneal transplantation; Graft survival; Training surgeons; Visual outcomes Abbreviations BCVA: Best Corrected Visual Acuity; DALK: Deep Anterior Lamellar Keratoplasty; HCPA, Hospital de Clinicas de Porto Alegre; PK: Penetrating Keratoplasty

Definition of Reference Range for the Immature Granulocytes Parameter Provided by a Hematology Analyzer.

Some pathologies or physiological changes may show forms of granulocytes in peripheral blood. Hematology analyzers have brought new parameters such as the detection of immature granulocytes (IG), which may be useful biomarkers. The objective of this study was determined the IG count in a control group to establish the reference range. A group of healthy donors was used to obtain the reference value of IG in the laboratory of the Hospital de Clínicas de Porto Alegre. The reference range of IG (n = 115) was 0 - 0.06 x 109/L and 0 - 0.63%. This reference interval was similar to that of previous studies. The determination of the specific reference interval for each region is an important tool in the direct application of biomarkers in clinical laboratory routines. The use of reference values is essential so that the true positive cases for microscopic review are detected without a large number of false positives, which would impair laboratory efficiency.

Gene Expression of Inhibitory Receptors and Immune Regulatory Molecules in Polarized Macrophages Derived from Early- and Late-Stage BD Patients

Background: Bipolar disorder (BD) has been associated with increased levels of peripheral inflammatory mediators and neuroinflammation. Previously, we observed different immune responses in macrophages of BD patients at different stages of the disorder. Thus, we aimed to further evaluate the regulation of immune response in BD by quantifying the expression of immune checkpoint receptors and respective ligands, as well as molecules involved in regulation and transcription of inflammatory mediators in polarized macrophages of early and late stages individuals with BD. Methods: qRT-PCR was performed to analyze the expression of TLR1, TLR6, PD-1, NFKB1, PD-L1, PD-L2 and TIM-3 in samples of proinflammatory M1 or M(IFNγ+LPS) and anti-inflammatory M2 or M(IL-4) macrophages derived from peripheral blood mononuclear cells (PBMCs) of euthymic BD patients (n=16), classified as early-stage BD (BD-E, n=9) and late-stage BD (BD-L, n=7) - according to Functional Assessment Short Test (FAST) - and healthy controls (HC, n=10). Results: M(IL-4) from BD-E showed higher expression levels of NFKB1 and PD-L1 in comparison to HC (p<0.05), while BD-L only had higher expression levels of PD-L1 compared to HC (p<0.05). No statistical differences were found between groups for the expression levels of TLR1, PD-L2 and TIM-3 in M(IL-4) phenotype, while expression levels remained unchanged in M(IFNγ+LPS) for all markers. TLR6 and PD-1 did not show PCR amplification in both macrophage phenotypes. Conclusion: Our findings suggest an immunological regulation acting as a compensatory mechanism by M2 anti-inflammatory macrophages at an early stage of BD, although decreased regulation in these cells seems to be observed at late stages of the disorder. We hypothesize that such alterations are possibly due to chronic low-grade inflammation during the course of BD, resulting in the ‘exhaustion’ of macrophage response. However, further investigation is required to comprehend better the role of immune regulatory mechanisms in the disorder. Funding Information: This work was supported by the FIPE-HCPA (Project Number 150396) and National Council for Scientific and Technological Development (CNPq, Brazil; Project Number PQ 302382/2019-4); and BA is a scholarship recipient from CNPq, Brazil. Declaration of Interests: None to declare. Ethics Approval Statement: All participants provided written informed consent before their inclusion, and this study was approved by the Institutional Review Board of Hospital de Clinicas de Porto Alegre (HCPA, Project Number 150396).

Social Distancing, Mask Use and the Transmission of SARS-CoV-2: A Population-Based Case-Control Study

Background: Ecologic studies support non-pharmacologic measures to protect against SARS-CoV-2, but few studies have evaluated their effects at the individual level in the community. We aimed to assess the magnitude of the associations of social distancing and mask use with laboratory-confirmed infection by SARS-CoV-2 in adults living in Porto Alegre, Brazil, a city with 1,483,771 inhabitants.Methods: We conducted a population-based case-control study from late April to June 2020. Cases came from a list of all cases mandatorily notified to municipal authorities; controls were antibody-negative participants of three representative household surveys conducted at the same time-period.Findings: In logistic regression analyses of 271 cases and 1396 controls adjusted for age, sex, race, educational attainment, income, household size and pandemic moment, those reporting moderate to greatest adherence to social distancing had between 59% (OR=0·41; 95%CI 0·24-0·70) and 75% (OR=0·25; 0·15-0·42) lower odds of becoming infected, compared to those reporting very little adherence. Lesser out-of-household exposure reduced odds between 52% (OR=0·48; 0·29-0·77) and 75% (OR=0·25; 0·18-0·36), compared to going out every day all day. In a subsample of controls with data on mask use and cases of equivalent pandemic moment (198 cases and 420 controls), mask use reduced odds of infection by 87% (OR=0·13; 0·04-0·36).Interpretation: Greater social distancing and always using masks while away from home provided major protection against SARS-CoV-2. These simple measures can be of great benefit during the upcoming phases of the pandemic.Funding: IATS/FAPERGS, UNIMED Porto Alegre, Instituto Cultural Floresta, Instituto Serrapilheira, Ministry of Health.Declaration of Interests: The authors have no conflicts of interest to declare.Ethics Approval Statement: The ethics committee of the Hospital de Clínicas de Porto Alegre approved our study (No. 31499420·5·0000·5327) and the Brazilian National Ethics Committee (No. 30415520·2·0000·5313) approved the accompanying seroprevalence surveys. All participants gave prior informed consent, in written form by the controls and verbally for cases.

Cavernous carotid aneurysms do not influence the occurrence of upstream ipsilateral aneurysm

Objective Cavernous carotid aneurysms (CCA) comprehend around 5% of all intracranial aneurysms. The main risk factors for an intracranial aneurysm seem not to influence the incidence of CCAs. The aim of this study was to investigate the association of CCAs and the presence of upstream aneurysms. Methods 1403 patients, admitted in Hospital das Clinicas de São Paulo, Brazil, from September 2009 to August 2018, enrolled this study. Diagnosis was performed with Digital Subtraction Angiography (DSA). Upstream aneurysm was defined as an intracranial aneurysm on anterior cerebral circulation, ipsilateral to the CCA (if present) or crossing the midline (e.g. anterior communicating artery). Results 177 individuals were diagnosed with CCA (12.6% of the population), totalizing 225 aneurysms (10% of the total number of aneurysms, 2253). No association was found between CCA and UA (p= .090, OR: 1.323, 95% CI: 0.957–1.828). Studying only patients with CCA, multivariable analysis showed smoking as the only factor associated with UA (p= .010, OR: 0.436, 95% CI: 0.232–0.821). Conclusions Cavernous carotid aneurysms were present in 12% of our population, mostly in female. They seem to be independent of the modifiable risk factors already associated with intracranial aneurysms. A higher frequency of mirror aneurysms was seen in this location. CCA did not influence the presence of ipsilateral and anterior circulation aneurysms.