Hospital Das Clinicas Research Articles

#1864 Phosphorilation of SHP-1 switch does not indicate lupus nephritis activity

Abstract Background and Aims Protein tyrosine kinases (PTKs) are enzymes responsible for the phosphorylation of tyrosine residues in lymphocytes. In 2017, Mkaddem et al. suggested that unique PTK signatures in peripheral leukocytes (PBMC) are associated with lupus nephritis (LN) activity [1]. Lymphocytes express two important PTKs, Lyn and Fyn, that modulate inhibitory or activatory signals depending on ligand avidity or phosphorylation status. SHP-1 tyrosine 536 phosphorylation (pSHP1-Y536) by Lyn activates inhibitory signaling and Fyn-dependent phosphorylation of SHP-1 serine 591 (pSHP1-S591) inactivates the phosphatase, enabling activatory immunoreceptor signaling. We hypothesized that active and refractory patients with proliferative LN have a different PTK profile in PBMC, with lower expression of pSHP1-Y536 and greater expression of pSHP1-S591, in comparison with those who have responded to treatment. Method In a cohort from the Royal Free Hospital, UCL (London, UK) we performed western blotting of PBMC lysates for SHP1-phospho-S591 and-Y536 from healthy individuals (HC; n = 19), LN patients in remission (n = 11) and with ongoing disease activity (n = 4). Densitometry of bands was carried out and a ratio of S591:Y536 expression was calculated (both normalized to actin). For the flow cytometry analysis, we followed up a Brazilian cohort of LN (n = 24) from Hospital das Clinicas, UFPE (Recife, Brazil). All patients had ongoing active LN with initial renal biopsy (class III, IV or/and V). PBMC samples were collected at 0, 3, 6, 9, 12, 18, and 24 months after biopsy. Isolated PBMC samples were stored at −80°C. PBMC samples were stained with antibodies against pSHP1 S591 and p-SHP1 Y536 and cell viability was checked using zombie red dye. Samples were acquired on the Accuri C6 cytometer (BD) and analyzed using the FLOJO software (BD). Results The western blotting relative expression of pSHP-1 S591:Y536 in PBMC was not significantly different when we compared HC with active LN (p = 0.098) and active with remission LN (p = 0.10), Fig. 1. The results obtained by flow cytometry expression ratio of pSHP1-S591:Y536 did not show a significant correlation with the median of proteinuria (Fig. 2), C3, C4, or SLEDAI from time of active kidney biopsy during LN flare throughout induction treatment. Conclusion There was no expression pattern of pSHP-1 Y536 and S591 in PBMC of LN patients, regardless of their renal activity or inflammatory status. Therefore, we cannot state those markers as a potential “liquid biopsy” for LN.

Analysis of Notifications Received by Central de Transplantes in the State of Roraima from 2017 to 2021

Objectives: To analyze brain death (BD) notifications received by Central de Transplantes (CET) in the state of Roraima (RR) from 2017 to 2021. Methods: This is a cross-sectional, quantitative, and observational study, where all notifications received by CET from 2017 to 2021 were analyzed, resulting in 120 patients from health the following centers: Hospital Geral de Roraima (HGR), Hospital Confederação Nacional das Cooperativas Médicas (UNIMED), Hospital da Criança Santo Antônio (HCSA), Hospital das Clínicas (HC), and Hospital Lotty Íris (HLI). The data were collected from the center’s data management system and passed on to the collection form developed by the researcher. Results: This study analyzed 119 notifications after excluding one due to conflicting data. There was a predominance of males (58%), with traumatic brain injury being the most frequent cause of BD. Six organ harvestings were carried out, all at the HGR. This study found no significant associations between organ procurement and sex, age, place of hospitalization, and year. Conclusion: There are considerable challenges concerning organ donation in RR, with a low uptake rate over five years. Only the HGR successfully carried out organ harvesting, while other reporting hospitals were unsuccessful. Improvements are needed, highlighting the importance of more studies for a more in-depth data analysis.

Abstract PO4-26-02: Evaluation of Tumor Infiltrating Lymphocytes as a predictive biomarker of recurrence in patients with Ductal Carcinoma In Situ of the breast

Abstract Introduction: Ductal carcinoma in situ (DCIS) represents around 20% of early breast cancer diagnoses globally. Some studies evaluated risk factors associated with DCIS recurrence. Among these, age, surgical margins, comedonecrosis (CN), high nuclear grade, negative hormone receptors and HER2 expression stand out. Recent approaches have been evaluating the role of the immune microenvironment and its association with recurrence and progression of DCIS. Objective: To evaluate the association between Tumor Infiltrating Lymphocytes (TILs) in DCIS samples and disease recurrence. To characterize the immunological microenvironment of DCIS, analyzing the presence of TILs, “touching TILs” and desmoplastic reaction and their association with recurrence. Epidemiological, clinical, histological and immunohistochemical (IHC) characteristics were also evaluated. Methods: This is a retrospective cohort study with patients diagnosed with DCIS and treated at Sao Paulo State Cancer Institute and Hospital das Clinicas of University of Sao Paulo. We included women over 18 years old with a diagnosis of DCIS who underwent treatment from Jan/2007 to Dec/2020. Male patients, patients with a diagnosis of invasive or microinvasive disease in the anatomopathological examination of the surgical specimen or patients with history of any neoplasm were excluded. The main outcome was survival analysis according to the quantification of TILs, adjusted for potential confounders. For that, we collected data on age, presence of palpable mass, imaging findings, histological and IHC characteristics, such as expression of estrogen receptor (ER), progesterone receptor (PR) and hyperexpression of HER2, type of surgical approach, type of radiation therapy, use of endocrine therapy, length of follow-up, recurrence, and its type. Two pathologists evaluated TILS in the sample with the highest tumor representation and numerically quantified it as percentage. They also evaluated the presence of “touching tils” (lymphocytes in contact with the basement membrane) and desmoplastic reaction in the tumor stroma. Kaplan-Meier curves, log-rank tests and Cox regression models were used to evaluate survival. Chi-square tests were used to evaluate the association between categorical variables. Results: 283 patients met the eligibility criteria. Mean age of patients was 55 years. 15% had a palpable nodule at physical examination. Clustered amorphous microcalcifications were the most prevalent mammographic presentation, found in 41% of the patients. The most frequent histological and IHC features were cribriform presentation (73%) and ER positivity (86%), respectively. Desmoplastic reaction was absent in 10.5%, discreet in 51.9%, moderate in 24% and intense in 13.6% of the patients. Breast conserving surgery was performed in 189 patients, and 100 of them received adjuvant radiation therapy. Mean follow-up was 77.2 months, with a recurrence rate of 9.2%. We observed that tumors with focal necrosis (HR 6.4 [1.39-34.71] p 0.018) or CN (HR 4.53 [1.34 – 15.28] p 0.015) had higher risks of recurrence. Patients with a percentage value of TILs greater than or equal to 17% also had a higher risks of recurrence (HR 2.97 (1.17-7.51) p 0.02). These patients were mostly under 65 years of age (OR 0.45 [0.21 - 0.97] p 0.049). In a multivariate model, CN and TILs>17% remained significantly associated with recurrence (p=0.034 and p=0.035 respectively). There was a trend for invasive recurrence in 76.9% of the patients that relapsed when TILS were greater than or equal to 17% (p 0.062). “Touching TILs” were present in 12.9% of the patients but were not associated with recurrence (p=0.575). Conclusion: In our cohort, high value of TILs (>= 17%) and presence of CN were independently associated with DCIS recurrence. Our findings suggest that TILS are a prognostic immunological biomarker in DCIS and warrant further investigation in prospective trials to determine the most adequate cut-point. Citation Format: Camila Pasetto, Fernando Aguiar, Marcella Peixoto, Maira Doria, Bruna Mota, Jonathan Maesaka, Jose Roberto Filassi, Edmund Baracat, Rodrigo Gonçalves. Evaluation of Tumor Infiltrating Lymphocytes as a predictive biomarker of recurrence in patients with Ductal Carcinoma In Situ of the breast [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-26-02.

Prevalence and clinical consequences of Hepatitis C virus infection in patients undergoing hematopoietic stem cell transplantation.

Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality among hematopoietic stem cell transplant (HCT) recipients. In Brazil, its occurrence in HCT recipients remains undetermined. We now report on HCV prevalence in HCT recipients and its clinical consequences. The medical records of all HCT recipients seen at Hospital das Clinicas, Sao Paulo University Medical School, from January 2010 to January 2020 were reviewed to determine HCV serostatus. A retrospective analysis of medical charts was undertaken on all seropositive cases to determine HCV genotype, presence of liver fibrosis, co-infections with other viruses, previous treatments, and clinical evolution of liver pathology after HCT. Of the 1,293 HCT recipients included in the study, seven (0.54%) were HCV antibody-positive and five (0.39%) were also viremic for HCV-RNA. Four of these individuals had moderate to severe liver fibrosis (METAVIR F2/F3) and one was cirrhotic. Two of the viremic patients developed acute liver dysfunction following transplantation. All patients had their acute episode of liver dysfunction resolved with no further complications. Four of the viremic patients were treated for HCV infection with direct acting agents (DAA). Information regarding HCV treatment was lacking for one of the viremic HCV patients due to loss of follow up. Sustained anti-virologic responses were observed in three cases after the use of DAA. The detection of HCV in hematological adults undergoing HCT and its successful treatment with DAA highlight the necessity of testing for HCV both prior to and following transplantation.

Evaluation of Dengue, Zika virus, and Chikungunya virus transmission by blood components in recipients of haematopoietic stem cell transplantation.

Brazil has a high prevalence of arboviruses, especially Dengue (DENV), Zika (ZKV), and Chikungunya (CHKV). To study the risk of DENV, ZKV, and CHKV transmission by blood components in the haematopoietic stem cell transplantation (HSCT) population. Prospective cohort of HSCT recipients and donors performed at the Hospital das Clinicas da FMUSP, São Paulo-Brazil. Patients were evaluated by serology and RT-PCR for DENV, ZKV, and CHKV pre-transplantation and once a week until neutrophil grafting. In positive cases (positive RT-PCR and/or serology conversion), an investigation was carried out on the blood components that the patient received to evaluate the possibility of it being transfusion transmitted. A total of 93 patients were included during the study period. The mean age was 52 years with a predominance of males (56.9%). We considered five (5.3%) DENV cases positive by seroconversion in our study. One patient had IgM seroconversion and the other four presented IgG seroconversion to DENV. In the investigation of the blood components, 145 individual samples were analysed. None of the investigated blood components showed a positive RT-PCR. We observed a low prevalence of DENV, ZKV, and CHKV in HSCT donors and recipients by serology and RT-PCR, and no case of blood transfusion transmission by RT-PCR.

Efficacy and safety of methylphenidate and behavioural parent training for children aged 3–5 years with attention-deficit hyperactivity disorder: a randomised, double-blind, placebo-controlled, and sham behavioural parent training-controlled trial

There is insufficient evidence to support treatment recommendations for preschool children aged 3-5 years with attention-deficit hyperactivity disorder (ADHD). We aimed to investigate the efficacy and safety of methylphenidate and behavioural parent training in reducing the frequency and severity of symptoms and improving global functioning in preschool children with ADHD. We did an 8-week, randomised, double-blind, placebo-controlled and sham behavioural parent training-controlled clinical trial (the MAPPA Study) in children aged 3-5 years with moderate-to-severe ADHD. The trial was conducted at the Institute of Psychiatry, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil. Participants were randomly assigned (1:1:1) to receive immediate-release methylphenidate plus educational intervention (sham behavioural parent training), placebo medication plus behavioural parent training, or placebo medication plus educational intervention. Randomisation was done by an independent research manager by use of a permuted block randomisation procedure. Parents, teachers, study staff, and evaluators remained masked to group allocation. Methylphenidate and placebo were titrated to a maximum dose of 1·25 mg/kg per day administered orally twice daily, and behavioural parent training and the educational intervention were delivered weekly through 90 min sessions with both the child and parent, conducted by two psychologists or learning therapists. The primary outcomes were parents' and teachers' composite scores of the Swanson, Nolan, and Pelham-IV scale (SNAP-IV-P/T), the Clinical Global Impressions Severity (CGI-S) scale, and the Children's Global Assessment Scale (CGAS). This trial is registered with ClinicalTrials.gov, NCT02807870, and is now complete. All participants were invited to participate in an open observational follow-up, which is ongoing. Between Aug 21, 2016, and Oct 21, 2019, 153 children were randomly assigned to receive methylphenidate plus the educational intervention (n=51), placebo plus behavioural parent training (n=51), or placebo plus the educational intervention (n=51). Nine (6%) children discontinued treatment. All participants were included in the intention-to-treat analysis. Children in the methylphenidate plus educational intervention group showed greater reductions in the SNAP-IV-P/T (endpoint mean difference -3·93 [95% CI -7·14 to -0·73], p=0·049; effect size -0·55 [95% CI -0·99 to -0·10]) and CGI-S scores (endpoint mean difference -0·49 [-0·82 to -0·17], p=0·0088; effect size -0·70 [-1·16 to -0·24]) and a greater increase in CGAS scores (endpoint mean difference 5·25 [95% CI 2·09 to 8·40], p=0·0036; effect size 0·80 [95% CI 0·32 to 1·28]) than children in the placebo plus educational intervention group. Children in the placebo plus behavioural parent training group did not have significantly different SNAP-IV-P/T scores (endpoint mean difference -3·18 [95% CI -6·38 to 0·02], p=0·077; effect size -0·44 [95% CI -0·89 to 0·003]) or CGI-S scores (endpoint mean difference -0·35 [-0·68 to -0·03], p=0·052; effect size -0·50 [-0·96 to -0·04]) compared to children in the placebo plus educational intervention group, but they had a greater increase in CGAS scores compared to the placebo plus educational intervention group (endpoint mean difference 3·69 [0·53 to 6·85], p=0·033; effect size 0·56 [0·08 to 1·04]). Children in the methylphenidate plus educational intervention versus placebo plus behavioural parent training group did not have statistically or clinically significant differences in primary outcomes. Children in the methylphenidate plus educational intervention group had more mild adverse events than the other two groups, and there were no between-group differences for moderate or severe adverse events. Methylphenidate was effective in reducing ADHD symptoms and improving functionality, and behavioural parent training was effective in improving functionality for preschool children with ADHD after 8 weeks of treatment. São Paulo Research Foundation and Brazilian National Council for Scientific and Technological Development.

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.

Dermatoscopic features of 67 excised melanocytic lesions in patients at high risk of cutaneous malignant melanoma in a Brazilian hospital

Dermatoscopic features of 67 excised melanocytic lesions in patients at high risk of cutaneous malignant melanoma in a Brazilian hospital

WHO criteria for diabetes in pregnancy: a retrospective cohort

BackgroundRecognizing that hyperglycemia in pregnancy can impact both individually a patient’s health and collectively the healthcare system and that different levels of hyperglycemia incur different consequences, we aimed to evaluate the differences and similarities between patients who met the diagnostic criteria for gestational diabetes mellitus (GDM) or diabetes in pregnancy (DIP) according to the World Health Organization diagnostic criteria based on the 75 g oral glucose tolerance test (OGTT).MethodsThis retrospective study included a cohort of 1064 women followed-up at the Gestational Diabetes Unit of Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (Sao Paulo, Brazil). Patients were classified into GDM and DIP groups, according to their OGTT results. Their electronic charts were reviewed to obtain clinical and laboratory data for all participants.ResultsWomen in the DIP group had a higher pre-pregnancy body mass index (30.5 vs 28.1 kg/m2, odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02–1.11), more frequently experienced GDM in a previous pregnancy (25% vs. 11%, OR 2.71, 95% CI 1.17–6.27), and were more likely to have chronic hypertension (43.1% vs. 23.5%, OR 2.46, 95% CI 1.47–4.11), a current twin pregnancy (10.8% vs. 2.9%, OR 4.04, 95% CI 1.70–9.61), or require insulin (46.1% vs. 14.3%, OR 5.14, 95% CI 3.06–8.65) than those in the GDM group. Patients in the DIP group also had a higher frequency of large-for-gestational-age infants (12.3% vs. 5.1%, OR 2.78, 95% CI 1.23–6.27) and abnormal postpartum OGTT (45.9% vs. 12.6%, OR 5.91, 95% CI 2.93–11.90) than those in the GDM group. Nevertheless, in more than half of the DIP patients, glucose levels returned to normal after birth.ConclusionsDiabetes in pregnancy is associated with an increased risk of adverse perinatal outcomes but does not equate to a diagnosis of diabetes post-pregnancy. It is necessary to identify and monitor these women more closely during and after pregnancy. Keeping patients with hyperglycemia in pregnancy engaged in healthcare is essential for accurate diagnosis and prevention of complications related to abnormal glucose metabolism.

Biceps tenotomy or tenodesis in association with rotator cuff repair: is there an influence on functional results? A retrospective cohort study.

Instability or tears of the long head of the biceps tendon (LHBT) may be present in more than 35% of rotator cuff repairs (RCR). To compare clinical results from patients undergoing arthroscopic RCR, according to the procedure performed at the LHBT. Retrospective cohort study designed at the shoulder and elbow clinic of Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil. Functional results among patients were compared using the American Shoulder and Elbow Surgeons (ASES) and University of California Los Angeles (UCLA) scales, according to the LHBT approach adopted: no procedure, tenotomy or tenodesis. We evaluated 306 shoulders (289 patients): 133 underwent no procedure at the LHBT, 77 tenotomy and 96 tenodesis. The ASES scale at 24 months showed no difference (P = 0.566) between the groups without LHBT procedure (median 90.0; interquartile range, IQR 29), tenotomy (median 90.0; IQR 32.1) or tenodesis (median 94.4; IQR 22.7); nor did the UCLA scale (median 33; IQR 7 versus median 31; IQR 8 versus median 33; IQR 5, respectively, P = 0.054). The groups differed in the preoperative functional assessment according to the ASES and UCLA scale, such that the tenodesis group started from higher values. However, there was no difference in pre and postoperative scores between the groups. Tenodesis or tenotomy of the LHBT, in the sample analyzed, did not influence the clinical results from RCR, as assessed using the ASES and UCLA scales.

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.

Adverse events following immunization of elderly with COVID-19 inactivated virus vaccine (CoronaVac) in Southeastern Brazil: an active surveillance study.

ABSTRACTHealthcare workers, the elderly and other vulnerable populations were the first to receive COVID-19 vaccines in public health programs. There were few vaccine safety data available on the elderly. This observational study aimed to evaluate the inactivated vaccine (CoronaVac) safety in the elderly, at the beginning of the vaccination program, in Sao Paulo city, Brazil. The elderly people that received CoronaVac at the Reference Center for Special Immunobiologicals (CRIE) or at home, administered by the Interdisciplinary Home Care Team (NADI) of the Hospital das Clinicas were invited to participate in this phase 4 observational study. The vaccination schedule included two CoronaVac doses 28 days apart. The information on solicited and unsolicited adverse events following immunization were collected by phone calls on days 4 and 8 after each vaccine dose. We enrolled 158 adults aged 65 to 101 years (mean of 84.1 years); 63.9% were females and 95.6% had chronic conditions, 21.5% had moderate or severe impairment in daily living activities; 34.2% were pre-frail and 19.6% were frail. We were able to contact 95.6% and 91.6% of the vaccinated people, after the first and second doses, respectively; 31.8% and 23.4% of the contacted participants reported some adverse events (AE) following the first and second doses, respectively. Pain at the injection site, fatigue, myalgia and headaches were the most frequent solicited AE. Most AE were mild to moderate. There were eight severe adverse events, but none of them were considered related to the vaccine. The CoronaVac was safe and well tolerated by these adults of advanced age with frailty and comorbidities.

Hereditary demyelinating neuropathies in the developing world

HEREDITARY DEMYELINATING NEUROPATHIES IN THE DEVELOPING WORLD At the Hospital das Clinicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo we have categorized so far 1319 CMT1/CMT4 patients. At the beginning of our activities (1997), those patients suspected of having CMT were submitted to nerve conductions studies and those with upper limbs CV < 38 m/s or having intermediate values were initially submitted to the PMP22 duplication/deletion test. Gradually, we introduced PMP22, MPZ and GJB1 Sanger sequencing.

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.

The Quality and Inflammatory Index of Diet in Patients With Migraine

ObjectivesThis study aims to verify if the quality of diet and the Dietary Inflammatory Index (DII) of migraine patients differ from that consumed by healthy individuals, and whether the severity of migraine is associated with these parameters. MethodsThis cross-sectional study was conducted at the Neurology Outpatient Clinic, Hospital das Clinicas, Universidade Federal de Minas Gerais – UFMG (Belo Horizonte, MG, Brazil). Patients with episodic migraine of both sexes, aged between 18–65 years were enrolled. Healthy volunteers without a history of primary headaches were recruited through advertisements and invitation to participate. Disability and impact caused by migraine were evaluated, respectively, by the Migraine Disability Test (MIDAS) and the Headache Impact Test, version 6 (HIT-6) questionnaires. Dietary intake was assessed using a 24-hour dietary recall and/or a three-day non-consecutive dietary record. The quality of diet was calculated using the Healthy Eating Index (HEI)-2015, adapted to the Brazilian population and DII was calculated based on the method developed by Shivappa et al. (2014). ResultsNinety patients with migraine and 62 individuals without migraine were included in the study. The groups did not differ regarding age, sex, marital status, years of schooling and anthropometric characteristics. Patients with migraine had lower HEI total score than controls [50.9 (23.9 – 83.2) vs. 44.6 (27.1 – 67.7); P < 0.01], indicating that these patients have poorer quality of diet. The scores of total fruits, whole fruits, total vegetables, added sugars, refined grains, and seafood and plant proteins were lower in the migraine group (P < 0.05). In agreement with that, patients with migraine had higher DII than controls [1.0 (–1.80 – 3.17) vs. 1.7 (–1.52 – 3.67); P = 0.02] indicating that the intake of pro-inflammatory type foods and nutrients was higher in the migraine group. The HEI and DII scores did not correlate with migraine impact or severity (P > 0.05). ConclusionsThe quality and the inflammatory index of the diet may contribute to the physiopathology of migraine, but not necessarily to its severity. Funding SourcesBrazilian government funding agencies (CNPq and CAPES) and UTHealth Houston Department of Psychiatry and Behavioral Sciences.

The Cost-Effectiveness of Congenital Adrenal Hyperplasia Newborn Screening in Brazil: A Comparison Between Screened and Unscreened Cohorts.

Background: Newborn screening for congenital adrenal hyperplasia (CAH-NBS) is not yet a worldwide consensus, in part due to inconclusive evidence regarding cost-effectiveness because the analysis requires an understanding of the short- and long-term costs of care associated with delayed diagnosis.Objective: The present study aimed to conduct a cost-effectiveness analysis (CEA) to compare the costs associated with CAH-NBS and clinical diagnosis.Methods: A decision model comparing the two strategies was tested by sensitivity analysis. The cost analysis perspective was the public health system. Unscreened patients' data were extracted from medical records of Hospital das Clinicas, Saõ Paulo, and screened data were extracted from the NBS Referral Center of São Paulo. The population comprised 195 classical patients with CAH, clinically diagnosed and confirmed by hormonal/CYP21A2 analysis, and 378,790 newborns screened during 2017. Adverse outcomes related to late diagnosis were measured in both cohorts, and the incremental cost-effectiveness ratio (ICER) was calculated. We hypothesized that CAH-NBS would be cost-effective.Results: Twenty-five screened infants were confirmed with CAH (incidence: 1:15,135). The mortality rate was estimated to be 11% in unscreened infants, and no deaths were reported in the screened cohort. Comparing the unscreened and screened cohorts, mean serum sodium levels were 121.2 mEq/L (118.3–124.1) and 131.8 mEq/L (129.3–134.5), mean ages at diagnosis were 38.8 and 17 days, and hospitalization occurred in 76% and 58% of the salt-wasting patients with the in the two cohorts, respectively. The NBS incremental cost was US$ 771,185.82 per death averted, which yielded an ICER of US$ 25,535.95 per discounted life-year saved.Conclusions: CAH-NBS is important in preventing CAH mortality/morbidity, can reduce costs associated with adverse outcomes, and appears cost-effective.

AIRA, an Artificial Intelligence Realistic Assistant that Will Save Your Time: Proof of Concepts

Background: AIRA is an AI designed to reduce the time that doctors dedicate filling out EHR, winner of the first edition of MIT Hacking Medicine held in Brazil in 2020.As a proof of concept, AIRA was implemented in administrative process before its application in a medical process. Aim: The aim of the study is to determinate the impact of AIRA by eliminating the Medical Care Registration (MCR) on Electronic Health Record (EHR) by Administrative Officer. Setting: The study was conducted at Hospital das Clinicas of the Faculty of Medicine of the University of Sao Paulo (HCFMUSP)´s employee´s care center. Methods: This is a comparative before-and-after study following the guidance “Evaluating digital health products” from Public Health England. An Artificial Intelligence named AIRA was created and implemented at CEAC (Employee Attention Center) from HCFMUSP. A total of 25,507 attendances were evaluated along 2020 for determinate AIRA´s impact. Total of MCR, time of health screening and time between the end of the screening and the beginning of medical care, were compared in the pre and post AIRA periods. Results: AIRA eliminated the need for Medical Care Registration by Administrative Officer in 92% (p<0.0001). The nurse´s time of health screening increased 16% (p<0.0001) during the implementation, and 13% (p<0.0001) until three months after the implementation, but reduced in 4% three months after implementation (p<0.0001). The mean and median total time to Medical Care after the nurse’ Screening was decreased in 30% (p<0.0001) and 41% (p<0.0001) respectively. Conclusion: The implementation of AIRA reduced the time to medical care in an urgent care after the nurse´ screening, by eliminating non-value-added activity the Medical Care Registration on Electronic Health Record (EHR) by Administrative Officer. Funding Statement: Fundacao Faculdade de Medicina (FFM) for the costs of equipment, S.K.O. would like to thank Brazilian Council for Development of Science and Technology (CNPq) for grant PQ 308609/2018-2. Declaration of Interests: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no financial support for this work that could have influenced its outcome.

Dynamic and metabolic quantification of nuclear medicine images in the PET/CT modality

Imaging using nuclear medicine is one of the most common procedures in medical centers. Its great advantage is its capacity to analyze the metabolism of the patient, resulting in early diagnosis. However, quantification in nuclear medicine is complicated by many factors, including degradation due to attenuation, scattering, reconstruction algorithms, and assumed models. This project seeks to improve the accuracy and the precision of quantification in PET/CT images. We developed a framework, comprising consecutively interlinked steps initiated with the simulation of 3D anthropomorphic phantoms. These phantoms were used to generate realistic PET/CT projections by applying the Geant4 Application for Tomography Emission platform using Monte Carlo simulation. Then, a 3D image reconstruction was created, followed by an Anscombe/Wiener filter and a fuzzy connectedness segmentation process. After defining the region of interest, input activity and response activity curves were generated as excitation functions of the compartment model to enable metabolic quantification of the selected organ or structure. Finally, real PET/CT images provided by the Heart Institute of Hospital das Clinicas, School of Medicine of the University of Sao Paulo were analyzed using the method. Metabolic parameters of the three-compartment model based on the MASH anthropomorphic phantom and real PET images were computed for each of the approaches used in this project; the results were similar to the theoretically characteristic values. The three-dimensional filtering step using the Ascombe/Wiener filter was preponderant and had a high impact on the metabolic quantification process and on other important stages of the whole project.

Susceptibility to chlorhexidine and mupirocin among methicillin-resistant Staphylococcus aureus clinical isolates from a teaching hospital.

ABSTRACTDespite the widespread use of chlorhexidine (CHX) to prevent infection, data regarding the in vitro action of CHX against methicillin-resistant Staphylococcus aureus (MRSA) are limited. Clinical isolates from Hospital das Clinicas, Sao Paulo, Brazil, identified during 2002/2003 and 2012/2013 were studied to describe the susceptibility to CHX and mupirocin, molecular characteristics, and virulence profile of MRSA. Susceptibility test to Mupirocin was performed by the disk diffusion method and to CHX by the agar dilution technique. PCR for virulence genes, mecA gene and Staphylococcal Cassette Chromosome mec (SCCmec) types were investigated as well. Mupirocin- and CHX-resistant isolates were sequenced using the IlluminaTM plataform. Two hundred and sixteen MRSA clinical isolates were evaluated: 154 from infected and 62 from colonized patients. Resistance to mupirocin was observed in four isolates assigned as SCCmec type III and STs (ST05; ST239 and ST105) carrying mupA and blaZ, two of them co-harboring the ileS gene. Only one isolate assigned as SCCmec type III was resistant to CHX (MIC of 8.0 μg.mL-1) and harbored the qacA gene. Resistance to chlorhexidine and mupirocin were found in isolates carrying qacA and mupA in our hospital. Since these genes are plasmid-mediated, this finding draws attention to the potential spread of resistance to mupirocin in our hospital.

Evaluation of exposure of a multidisciplinary team to ionizing radiation due to the use of fluoroscopy equipment in a surgical center.

INTRODUCTION:Ionizing radiation-producing equipment is used in surgical centers to guide invasive procedures. Technological advances have enabled improvements in image quality, which may be accompanied by increased radiation doses in the surgical team. Correct use of personal protective equipment and monitoring of radiation levels are required to a safe practice.OBJECTIVES:To evaluate radiation exposure conditions in occupationally exposed persons working at the Surgical Center at Hospital das Clínicas da Faculdade de Medicina de Botucatu for implementation of radiation protection measures.METHODS:Three different types of fluoroscopy equipment were used: C-arms, a dosimetric system with ionization chambers, and optically stimulated dosimeters. A three-stage evaluation was conducted, consisting of a first stage for observation, a second stage for estimation of kerma rate simulating exposure conditions, and a final stage for dosimetry to estimate the effective dose in workers.RESULTS:The most frequent procedures and the disposition for each team member were determined. Kerma values were estimated for both the principal physician and the assistant physician. The maximum number of annual procedures was also estimated so that the dose limits are not exceeded.CONCLUSIONS:Dosimetry for the surgical team is indicated as an approach to monitor occupational dose levels. The dose rates and effective dose found in this study are low but not negligible. Thus, proper use of equipment and periodic training for workers are still the best options for radiation protection.