Hospital De Clinicas Research Articles

Febrile Neutropenia Outcome in Hemato-Oncological Patients after the Implementation of an Adapted Therapeutic Protocol at a University Hospital in Uruguay

Background: Febrile neutropenia (FN) is among the leading causes of mortality and morbidity in hemato-oncologic patients undergoing cytotoxic chemotherapy.The management of FN is typically algorithm-driven. The effectiveness in reducing FN related mortality of the antibacterial protocol proposed by the international guidelines is already reported. In this regard, most of the popular guidelines are based on clinical trials conducted in developed countries. Little is known about results in developing countries where patients delay consultation and have socio-cultural vulnerabilities. The aim of our study was to assess the results of the implementation of a local FN protocol in patients undergoing intensive chemotherapy regimens at Hospital de Clinicas in Uruguay.Methods: We assessed a retrospective study with patients that have undergone intensive chemotherapy in our hemato-oncology service between 2011 and 2014. We included 127 neutropenia episodes (37 patients), with a median age of 37 years (18-79 years). Acute myeloid leukemia 26 (24.4%), acute lymphoblastic leukemia 12 (9.4%), non-Hodgkin lymphoma 74 (58.4%) and Hodgkin Lymphoma 15 (11.8%). Low risk patients were excluded. Additionally, episodes linked with high risk regimens as acute myeloid leukemia induction chemotherapy and alemtuzumab therapy were excluded from the analysis.The initial antibiotic protocol consisted in piperacillin-tazobactam (4.5 gr every 6 hours). For patients with warning signs, more than one week of hospital stay, or having received in the last 30 days ciprofloxacin or 3er generation cephalosporin as prophylaxis meropenem (1gr every 8 hours) was indicated. Prophylactic antiviral (acyclovir) and antifungal (fluconazole) were given in every case. Modification of initial empirical treatment with piperacillin-tazobactam, changing to meropenem, was done if there was: a) deterioration in the clinical state, b) warning signs, hemodynamic instability or other organ dysfunction, c) persistent fever after 4 days of treatment, d) culture with antibiotic-resistant. In patients with hemodynamic instability, skin or soft tissue infection, suspected catheter-related infection or methicillin-resistant Staphylococcus aureus culture positive, vancomycin was added. Empirical antifungal coverage was considered in patients who had persistent fever after 6-7 days of antibiotic treatment without identified fever source.Results: FN incidence was 33.1% (42 episodes). The presence of FN was associated with both the duration and severity of neutropenia. Median days of neutropenia (below 500/μL) in patients with FN was 10.0 ± 7.9 (standard deviation) vs 6.0 ± 3.7 (standard deviation) in patients without FN (p=0,001). Microbiological isolation from any source was achieved in 28.6% of the episodes and bacteremia was the most prevalent (77%). Multiple-antibiotic-resistant (MR) Gram-negative bacillus (GNB) were isolated in 58,3% of all microbiological documented infections, followed by GNB 25%. In 25 episodes the initial treatment was piperacilin/tazobactam (59%), while in 17 episodes Meropenem was. 15 episodes (35.7%) required vacomycin treatment. 32% of the episodes in which the initial treatment was piperacilin/tazobactam, needed to escalate to Meropenem. The mortality rate of febrile neutropenia episodes was 3.9% (40% related to sepsis).Conclusions: In this work we observed high rate of microbiological documentation in FN episodes being bacteriemia the most frequent form and there was a predominance of MR-GNB. The high rate of GNB resistant to piperacilin/tazobactam, front line antibiotics in our protocol, and the early need to escalate to carbapenems raises the question whether it is necessary to change our antibiotic treatment protocol. DisclosuresNo relevant conflicts of interest to declare.

USO DA DIÁLISE PROLONGADA DE BAIXA EFICIÊNCIA EM PACIENTES DO HOSPITAL DE CLÍNICAS-UFPR

Introdução: A Diálise Prolongada de Baixa Eficiência (DPBE), terapia híbrida de substituição da função renal, surgiu como alternativa aos métodos intermitentes e contínuos de diálise na insuficiência renal aguda. Objetivo: Demonstrar a experiência com a DPBE no tratamento de pacientes da Unidade de Terapia Intensiva (UTI) e do Centro de Terapia Semi-Intensiva (CTSI) do Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR) entre Abril/2013 e Outubro/2014. Materiais e Métodos: As informações foram coletadas dos prontuários de pacientes da UTI/CTSI, submetidos à DPBE (sistema GENIUS®) com duração de 8 horas. Incluíram-se dados demográficos como: sexo, idade, presença de diabetes mellitus (DM), hipertensão arterial sistêmica (HAS) e doença renal crônica (DRC), uso de drogas vasoativas (DVA) e de ventilação mecânica (VM). Foram obtidas dosagens plasmáticas de ureia, creatinina, sódio, potássio, fósforo, magnésio, bicarbonato, glicose, saturação de O2 e pressão parcial de O2 e de CO2 em três momentos: antes, na 4ª hora e após o procedimento (8ª hora). Resultados: 41 DPBE foram realizadas em 17 pacientes, 8 mulheres. 88% estavam em VM e DVA. A taxa de mortalidade no internamento foi de 76%. 35% apresentavam DM, quase 60%, HAS, e em torno de 17%, DRC. O percentual médio de redução de ureia (%) foi de 62 ± 8,4. O fósforo (mg/dL) reduziu significativamente entre primeira (4,09l ± 2,28) e oitava horas (2,03 ± 1,04), p<0,05. Conclusão: A DPBE demonstrou-se efetiva e segura em relação à diálise convencional, havendo necessidade de reposição de fósforo durante o tratamento devido à hipofosfatemia observada na maioria dos casos.

Cannabis users show increased susceptibility to false memories

Drug and Alcohol Dependence 156 (2015) e183–e245 e189 areas of sexual risk reduction, prevention and treatment for substanceabuseandmental health. Publichealthprogramsprioritizing the different populations are necessary. Financial support: Fogarty International Center; Grant 1R03TW007612; Fundo de Incentivo e Auxilio a Pesquisa (FIPE) from Hospital de Clinicas de Porto Alegre, Brazil (GPPGHCPA – No. 07-391). http://dx.doi.org/10.1016/j.drugalcdep.2015.07.507 Crack, powdered cocaine, both or neither: A generalized logit analysis of a community-based sample Grace L. Reynolds1,2,∗, Dennis G. Fisher1, Erlyana Erlyana2 1 Center for Behavioral Research and Services, California State University, Long Beach, Long Beach, CA, United States 2 Health Care Administration, California State University, Long Beach, Long Beach, CA, United States Aims: To understand factors associated with use of both crack cocaine and non-injected powered cocaine. Methods: The Risk Behavior Assessment (RBA; 1993) was used to elicit information on past month, past 48-hours and drugs used before/during sex drug use in a sample of out-of-treatment drug users (N=8538). Past 30 day, past 48h, and before/during sex drug use were coded into (1) use of crack (smokable cocaine) only, (2) powdered cocaine use only, (3) both drugs used during the timeframe and (4) neither drug used. Generalized logit analysis was used to develop models for each timeframe (48-hour and 30-day). For all models the reference group was using neither drug. Results: Respondents who reported use of both crack and powdered cocaine (N=306) included both men (n=207) and women (n=99). The 48-hour, 30-day, and before/during sex models were almost identical. Those who reported using both crack and cocaine were more likely to: be Black (OR=1.65, CI 1.27, 2.14); bisexual (OR=1.85, CI 1.39, 2.47); trade sex fordrugs (OR=4.88CI 3.73, 6.39); tobehomeless (OR=3.50, CI 2.66, 4.62), havehighernumberof days used alcohol in the pastmonth (OR=1.09, CI 1.08, 1.10); and to have had gonorrhea (OR=1.42, CI 1.07, 1.88). Conclusions: The general logit model highlights factors associated with use of both crack and powdered cocaine within the same timeframe, includinghomelessness, andbeingamemberof anethic or sexual minority, and sex trading. Financial support: Funding was provided in part by grant R01 DA030234 from the National Institute on Drug Abuse, P20MD003942 from the National Institute of Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Institute ofMinority Health and Health Disparities or the National Institutes of Health. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.508 Cannabis users show increased susceptibility to false memories Jordi Riba1,∗, Frederic Sampedro2, Aina Rodriguez-Pujadas2, Saul Martinez-Horta1, Jaime Kulisevsky1, Jose-Carlos Perez-de-los-Cobos1, Antoni Rodriguez-Fornells1, Marta Valle1 1 Hospital Sant Pau, Barcelona, Spain 2 University of Barcelona, Barcelona, Spain Aims: Previous studies on the neurocognitive impact of cannabis use have found working and declarative memory deficits that tend to normalize with abstinence. An unexplored aspect of cognitive function in chronic cannabis users is the ability to distinguish between veridical and illusory events; a crucial aspect of reality monitoring that relies on adequate memory function and cognitive control. Methods: Sixteen heavy cannabis users not seeking treatment for their cannabis consumptionwerematched to a group of healthy controls taking into account sex, age, years of education, verbal intelligence and fluid intelligence. All participants performed a modified version of the Deese–Roediger–McDermott paradigm in an MRI scanner. Following a study phase, subjects were presented with 75 old words, 40 semantically unrelated new words and 40 semantically related new words or lures. They were required to judge whether a word had been presented in the study phase and make an old vs. new decision by button press. Results: Cannabis users showed an increased susceptibility to false memories, failing to identify lure stimuli as events that never occurred. In addition to impaired performance, they displayed reduced activation in areas associated with memory processing within the medial temporal lobe (MTL), and in parietal and frontal brain regions involved in attention and performance monitoring. Reduced activity in the MTL was associated with greater cannabis consumption. Conclusions: These findings indicate that cannabis users have an increased susceptibility to memory distortions even when abstinent and drug-free, suggesting a long-lasting compromise of memory and cognitive control mechanisms involved in reality monitoring. Financial support: This research was supported by the “Plan Nacional Sobre Drogas” of the Spanish Government. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.509 CaMKII inhibition affects cocaine-cue memory processes to attenuate reinstatement Matthew T. Rich1,∗, Mary M. Torregrossa2 1 University of Pittsburgh, Pittsburgh, PA, United States 2 Psychiatry, University of Pittsburgh, Pittsburgh, PA,

Correlates between Brazilian club drug users men who have sex with men, psychiatric vulnerabilities and multiple sexual partners

Drug and Alcohol Dependence 156 (2015) e183–e245 e189 areas of sexual risk reduction, prevention and treatment for substanceabuseandmental health. Publichealthprogramsprioritizing the different populations are necessary. Financial support: Fogarty International Center; Grant 1R03TW007612; Fundo de Incentivo e Auxilio a Pesquisa (FIPE) from Hospital de Clinicas de Porto Alegre, Brazil (GPPGHCPA – No. 07-391). http://dx.doi.org/10.1016/j.drugalcdep.2015.07.507 Crack, powdered cocaine, both or neither: A generalized logit analysis of a community-based sample Grace L. Reynolds1,2,∗, Dennis G. Fisher1, Erlyana Erlyana2 1 Center for Behavioral Research and Services, California State University, Long Beach, Long Beach, CA, United States 2 Health Care Administration, California State University, Long Beach, Long Beach, CA, United States Aims: To understand factors associated with use of both crack cocaine and non-injected powered cocaine. Methods: The Risk Behavior Assessment (RBA; 1993) was used to elicit information on past month, past 48-hours and drugs used before/during sex drug use in a sample of out-of-treatment drug users (N=8538). Past 30 day, past 48h, and before/during sex drug use were coded into (1) use of crack (smokable cocaine) only, (2) powdered cocaine use only, (3) both drugs used during the timeframe and (4) neither drug used. Generalized logit analysis was used to develop models for each timeframe (48-hour and 30-day). For all models the reference group was using neither drug. Results: Respondents who reported use of both crack and powdered cocaine (N=306) included both men (n=207) and women (n=99). The 48-hour, 30-day, and before/during sex models were almost identical. Those who reported using both crack and cocaine were more likely to: be Black (OR=1.65, CI 1.27, 2.14); bisexual (OR=1.85, CI 1.39, 2.47); trade sex fordrugs (OR=4.88CI 3.73, 6.39); tobehomeless (OR=3.50, CI 2.66, 4.62), havehighernumberof days used alcohol in the pastmonth (OR=1.09, CI 1.08, 1.10); and to have had gonorrhea (OR=1.42, CI 1.07, 1.88). Conclusions: The general logit model highlights factors associated with use of both crack and powdered cocaine within the same timeframe, includinghomelessness, andbeingamemberof anethic or sexual minority, and sex trading. Financial support: Funding was provided in part by grant R01 DA030234 from the National Institute on Drug Abuse, P20MD003942 from the National Institute of Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Institute ofMinority Health and Health Disparities or the National Institutes of Health. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.508 Cannabis users show increased susceptibility to false memories Jordi Riba1,∗, Frederic Sampedro2, Aina Rodriguez-Pujadas2, Saul Martinez-Horta1, Jaime Kulisevsky1, Jose-Carlos Perez-de-los-Cobos1, Antoni Rodriguez-Fornells1, Marta Valle1 1 Hospital Sant Pau, Barcelona, Spain 2 University of Barcelona, Barcelona, Spain Aims: Previous studies on the neurocognitive impact of cannabis use have found working and declarative memory deficits that tend to normalize with abstinence. An unexplored aspect of cognitive function in chronic cannabis users is the ability to distinguish between veridical and illusory events; a crucial aspect of reality monitoring that relies on adequate memory function and cognitive control. Methods: Sixteen heavy cannabis users not seeking treatment for their cannabis consumptionwerematched to a group of healthy controls taking into account sex, age, years of education, verbal intelligence and fluid intelligence. All participants performed a modified version of the Deese–Roediger–McDermott paradigm in an MRI scanner. Following a study phase, subjects were presented with 75 old words, 40 semantically unrelated new words and 40 semantically related new words or lures. They were required to judge whether a word had been presented in the study phase and make an old vs. new decision by button press. Results: Cannabis users showed an increased susceptibility to false memories, failing to identify lure stimuli as events that never occurred. In addition to impaired performance, they displayed reduced activation in areas associated with memory processing within the medial temporal lobe (MTL), and in parietal and frontal brain regions involved in attention and performance monitoring. Reduced activity in the MTL was associated with greater cannabis consumption. Conclusions: These findings indicate that cannabis users have an increased susceptibility to memory distortions even when abstinent and drug-free, suggesting a long-lasting compromise of memory and cognitive control mechanisms involved in reality monitoring. Financial support: This research was supported by the “Plan Nacional Sobre Drogas” of the Spanish Government. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.509 CaMKII inhibition affects cocaine-cue memory processes to attenuate reinstatement Matthew T. Rich1,∗, Mary M. Torregrossa2 1 University of Pittsburgh, Pittsburgh, PA, United States 2 Psychiatry, University of Pittsburgh, Pittsburgh, PA,

Prevalence of dermatoses in dermatologic evaluation requests from patients admitted to a tertiary hospital for 10 years.

Skin diseases are common in hospitalized patients. However, there is a lack of data concerning their frequency. The objective of this study is to evaluate the prevalence of dermatological diagnoses in hospitalized patients after consultation requested by nondermatologist physicians to the Department of Dermatology, Hospital de Clinicas de Porto Alegre period of 10 years. A total of 5685 patients were evaluated, representing an average of 48.2 patients per month. The five most frequent groups were infectious dermatoses(33.25%), eczematous dermatoses (11.49%), drug reactions (11.43%), vascular dermatoses (6.81%) and group of pruritus, prurigo nodularis and urticaria (hives) (4.71%).

Computed tomography imaging study of the superior attachment of the uncinate process.

The superior attachment of the uncinate process (SAUP) is an important landmark in the nasofrontal recess, but its anatomical distribution is still unclear. The objective of this study was to assess the location and number of superior attachments of the uncinate process on computed tomography (CT) images. A cross-sectional, retrospective study conducted at the Department of Radiology, Hospital de Clinicas de Porto Alegre, Brazil. Sinus CT scans of adult patients with no history of sinonasal surgery, craniofacial fractures, malignant neoplasms, or malformations were examined for identification of the site of SAUP. 152 CT scans (304 sides) were assessed. The SAUP was appropriately identified in 292 sides (96%). Six distinct SAUP patterns were identified: to the lamina papyracea or anterior ethmoidal cells (193, 63.48%); to the middle turbinate (19, 6.25%); to the skull base (19, 6.25%); to the lamina papyracea and middle turbinate (29, 9.53%); to the lamina papyracea and skull base (29, 9.53%); and to the skull base and middle turbinate (3, 0.98%). The site of superior attachment of the uncinate process is highly variable, but is in contact with the lateral nasal wall in 82.5% of the cases.

Variables Associated With the Risk of Early Death After Liver Transplantation at a Liver Transplant Unit in a University Hospital

BackgroundGraft dysfunction after liver transplantation is a serious complication that can lead to graft loss and patient death. This was a study to identify risk factors for early death (up to 30 days after transplantation). MethodsIt was an observational and retrospective analysis at the Liver Transplantation Unit, Hospital de Clinicas, State University of Campinas, Brazil. From July 1994 to December 2012, 302 patients were included (>18 years old, piggyback technique). Of these cases, 26% died within 30 days. For analysis, Student t tests and chi-square were used to analyze receptor-related (age, body mass index, serum sodium, graft dysfunction, Model for End-Stage Liver Disease score, renal function, and early graft dysfunction [EGD type 1, 2, or 3]), surgery (hot and cold ischemia, surgical time, and units of packed erythrocytes [pRBC]), and donor (age, hypotension, and brain death cause) factors. Risk factors were identified by means of logistic regression model adjusted by the Hosmer-Lemeshow test with significance set at P < .05. ResultsWe found that hyponatremic recipients had a 6.26-fold higher risk for early death. There was a 9% reduced chance of death when the recipient serum sodium increased 1 unit. The chance of EGD3 to have early death was 18-fold higher than for EGD1 and there was a 13% increased risk for death for each unit of pRBC transfused. ConclusionsDonor total bilirubin, hyponatremia, massive transfusion, and EGD3 in the allocation graft should be observed for better results in the postoperative period.

ALTA DENSIDADE MINERAL ÓSSEA: DENTRO DA NORMALIDADE OU MASCARANDO A FRAGILIDADE ÓSSEA?

Objetivo: O objetivo deste estudo foi avaliar indivíduos com alta DMO e correlacionar com parâmetros clínicos e laboratoriais. Métodos: Foi realizada uma pesquisa ao longo dos últimos 4 anos, nos arquivos da densitometria óssea do Departamento de Endocrinologia (Hospital de Clínicas da Universidade Federal do Paraná), em pacientes com Z-score ≥ 2,0 DP na coluna ou fêmur. Após a seleção, foram revisados os prontuários de cada paciente, avaliando sua história médica e comorbidades. Resultados: Foram selecionados 104 pacientes com idade média de 62 anos, sendo 96% da amostra do sexo feminino. O peso médio encontrado foi 70 kg e o índice de massa corporal foi 29 kg/m². Observou-se uma correlação estatisticamente significativa entre presença de artefatos e diagnóstico densitométrico anormal (p &lt;0,001). Em pacientes com aumento da densidade óssea da coluna, aproximadamente 60% apresentavam osteopenia ou osteoporose em um ou mais locais, enquanto que em pacientes com artrose, 68% tiveram o diagnóstico de osteoporose ou osteopenia. Além disso, uma correlação significativa entre artefatos e Z-score ≥ 2,0 DP no colo do fêmur foi encontrada (p = 0,008). De todas as comorbidades analisadas, houve correlação entre hipertensão e presença de artefatos (p &lt;0,001), como artrose e escoliose. Observou-se ainda que 72% dos pacientes com hipotireoidismo apresentaram artefatos (p = 0,014). Conclusão: Encontramos elevada prevalência de pacientes com alta massa óssea e diagnóstico final anormal na densitometria. Estes resultados mostram que a análise de um único sítio de densitometria pode conduzir ao diagnóstico incorreto, especialmente em pacientes com doença degenerativa.

Epidemiological analysis of serological markers of hepatitis B in HIV+ patients from Curitiba and metropolitan region

Introduction: The presence of hepatitis B virus (HBV) in patients infected by the human immunodeficiency virus (HIV) leads to a higher incidence of liver disorders due to persistence and recurrence of HBV infection in addition to increased morbidity and mortality. Objective: To determine the prevalence of serological markers for hepatitis B in patients infected by HIV followed at Hospital de Clinicas da Universidade Federal do Parana (HC-UFPR). Methods: The clinical and epidemiological data were collected through a questionnaire applied to the patients, as well as a retrospective analysis of medical records. Serum levels of total hepatitis B core antibody (anti-HBc) and surface antigen of the hepatitis B virus (HBsAg) were evaluated through chemiluminescent microparticle immunoassay. Among the 297 HIV+ patients, 49.8% were seropositive only for anti-HBc, and 2.6 % were positive for both markers. Results and discussion: The prevalence of hepatitis B markers was significantly associated with HIV infection when compared with the prevalence observed in the general population from the same geographical area (anti-HBc+ HBsAg+: 0.14% vs. 2.6%, OR: 18.82, 95% CI 2.34-151.19, p = 0.00052). Concerning the associated risks to acquire HIV/HBV infection, 44.87% of the patients reported having been infected through sexual contact. A total of 16.66% HIV/HBV positive patients were in the age group 18-30 years, 62.82% were between 31-50 years and 16.66% were over 60 years old. Conclusion: The findings of the present study corroborate the need to investigate systematically the presence of markers for HBV in HIV+ patients from different regions of the country.

The concentration of il-1β in saliva of children with oral lesions associated to histiocytosis.

Langerhans Cell Histiocytosis (LCH) is a disease whose etiology and pathogenesis are still unknown. It affects several organs and tissues, producing lesions of different severity. Its histopathology and clinical picture suggest the participation of cytokines in its pathogenesis. IL-1β might have an important role in its development. The purpose of this study was to determine the concentrations of IL-1β in saliva of pediatric patients diagnosed with LCH, with and without oral manifestations (Groups 1 and 2 respectively) compared to a Control Group (Group 3) of pediatric patients without medical antecedents or oral lesions. The saliva of twenty patients with LCH was studied and compared to a Control Group consisting of eleven pediatric patients without medical antecedents. The children with histiocytosis, aged four months to sixteen years, were referred by the Oncohaematology Service at Garrahan Hospital and Hospital de Clinicas, to the Department of Comprehensive Children's Dentistry, School of Dentistry, University of Buenos Aires (UBA). The concentrations of IL-1β in the different groups were determined using the Enzyme Immune Assay Kit (Cayman MI, USA) and expressed in pg/ml. Results were analyzed by the Kruskall Wallis test. Significant differences between the three cohorts were found, (H = 20.36, P < 0.001). Dunn´s multiple comparison analysis was performed, which showed significant differences between Groups 1 and 2, and between Groups 1 and 3 (P < 0.05). Higher values of IL-1β were found in the patients with histiocytosis with oral manifestations (Group 1) than in patients without manifestations (Group 2) and patients in the Control Group (Group 3).

The role of MRI in Clinically Suspected Appendicitis During Pregnancy

A 31 years female with approximately 20 weeks of gestation attends the emergency department of the Hospital de Clinicas de Porto Alegre (HCPA) reporting pain in the lower abdomen radiating to the right iliac fossa. After clinical and laboratory examination, the clinical diagnosis of appendicitis was suspected, and then performed magnetic resonance imaging (MRI) of the abdomen for diagnostic reasons. The MRI of the abdomen was performed and revealed signs of appendicitis. The intraoperative findings were purulent fluid in the right iliac fossa and appendix with necrotic appearance without signs of perforation. The pathological diagnosis was acute suppurative appendicitis, with periviscerite signals. In pregnant women the enlarged uterus can alter the position of the abdominal contentes and thus make sonography and clinical diagnosis more difficult. CT can be performed in such cases, but it involves a considerable amount of radiation. A typical dose for an abdominal CT examination is on the order of 10 mSv. The routine use of diagnostic CT for benign diseases, as in appendicitis, raises the question whether the diagnosis can be obtained by other radiologic means, especially in pregnant women and even more when the fetus is in the direct beam. The International Commission on Radiological Protection recently published a report on radiation and pregnancy. They recommended that if the expected dose for the fetus is high, one should question whether the diagnosis could be obtained without using ionizing radiation. MRI has been described as a valuable technique for the evaluation of patients with suspected acute appendicitis.

Major bleeding risk assessment in atrial fibrillation patients taking vitamin K antagonists

Background. The use of risk scores for the assessment of major bleeding and stroke in patients with atrial fibrillation (AF) helps evaluate the risks and benefits of oral anticoagulation therapy. The aim of this study was to describe the percentage of patients receiving anticoagulants for non-valvular AF with a high risk of major bleeding based on the HAS-BLED score, as well as identify potential modifiable risk factors of bleeding and compare the risk of major bleeding with the risk of stroke. Methods. Retrospective cohort study involving patients of the anticoagulation outpatient clinic of the Division of Internal Medicine at Hospital de Clinicas de Porto Alegre. Major bleeding risk was estimated based on the HAS-BLED score and stroke risk was determined using the CHADS 2 and CHA 2 DS 2 -VASc scores. Results. Sixty-three patients were investigated (mean age 74.3±10.9 years). The median HAS-BLED score was 2 points, 19 (30.2%) patients had a score ≥ 3 (high risk). The most prevalent modifiable risk factors were labile TP/INR (36.5%) and concomitant use of drugs (30.2%). The absolute risk of major bleeding based on the HAS-BLED score was higher than the risk of stroke in three (4.8%) and four (6.3%) patients in comparison with the CHADS 2 and CHA 2 DS 2 -VASc score, respectively. Conclusions. We concluded that the percentage of patients with high risk of major bleeding is similar to the rate found in the national literature (30.2%). In addition, the most prevalent modifiable risk factors in our cohort were labile TP/INR and concomitant drug use.

Mild Decrease in Renal Function in HIV-Infected Patients on Antiretroviral Therapy: A Neglected Diagnosis

Background: Renal impairment is increasingly reported among HIV-Infected patients and has been associated to an increased chance of cardiovascular disease and death. Therefore, early identification of this problem could help to reduce morbidity and mortality among these individuals. The objective of the study was to determine the prevalence and associated factors with mild decrease in renal function of HIV-infected patients on highly-active antiretroviral therapy (HAART) and undetectable viral load in Brazil. Methods: Individuals between 18-70 years of age with time on HAART ≥ 12 months, viral load < 50 copies/mm3, and CD4 ≥ 200 cells/mm3, were consecutively enrolled at the outpatient clinic of Hospital de Clinicas de Porto Alegre, Brazil. Exclusion criteria were chronic kidney disease, pregnancy and known hepatic disease. Renal function was assessed by the Chronic Kidney Disease Epidemiology Collaboration equation. Mild decrease in renal function was defined as an estimated glomerular filtration rate between 89-60 mL/min/1.73m2, for a period of at least 3 months. Results: From the total of 213 enrolled volunteers, 193 were included in the final analysis. The mean age was 41.5 years, 102 were men (52.6%), and 156 (80.4%) were euro-descendants. Mild renal decline was diagnosed in 33.5% of the patients. Every other year of life (RR=1.05, 95%CI 1.03-1.06, p<0.001) and being euro-descendant (RR=1.94; 95%CI 1.07-3.78; p=0.049) were associated to mild decreases, whereas high body mass index (BMI) (RR=1.04, 95% CI 1.013-1007, p<0,001) was associated to normal function. Conclusions: Mild decrease in renal function was extremely common and more than expected in our cohort (33.5%) which deserves further attention while assisting HIV-positive individuals.

Quality of Life in Patients with Dohlman-Doane Type 1 Keratoprosthesis(Boston Kpro)

Introduction: The aim of this study was to assess quality of life in patients undergoing implantation of a Dohlman keratoprosthesis. Materials and methods: Cross-sectional controlled, with patients undergoing implant Dohlman keratoprosthesis type I at the Hospital de Clinicas de Porto Alegre between September 2005 and May 2013. Two questionnaires of quality of life were administered in these patients SF-36 and VF-14. Furthermore, a retrospective patient charts analysis was performed. Results: Keratoprosthesis implant surgery was performed in 33 eyes of 26 patients. A statistically significant difference was found between groups (separated by visual acuity) for the questionnaire of visual acuity (p=0.01). In SF-36 domains, there were difference in general health (p=0.036), vitality (p=0.028) and mental health (p=0.037). On the Spearman correlation analysis, 5 of the 8 domains of the SF-36, correlated with visual questionnaire (VF-14), when analyzed for the entire sample. When we separated the analysis by subgroups (according to visual acuity), in the group of lowest visual acuity had only one domain correlation (mental health). In the group of best vision, the 5 domains remained with a positive association. Conclusion: Patients with greater visual acuity showed better results in the VF-14 responses, with a statistically significant difference between groups.

209-POS

Objectives To verify the behavior of glycosylated hemoglobin (HbA1c) and homeostasis model assessment (HOMA), which assesses insulin resistance from insulin and fasting glucose levels in pregnant women with GDM after an aerobic training on a cycle ergometer. Methods Randomized clinical trial where mothers with GDM are randomly allocated to the intervention group (IG), which is part of a program of regular aerobic exercise with 50-min sessions, three times a week for 10 weeks, or the control group (CG), which makes stretching and relaxation sessions with 50 min once a week for 10 week. The groups are selected from prenatal clinics in the Hospital de Clinicas de Porto Alegre. Results At this moment, six patients completed the proposed trainings, two in the intervention group and four in the control group. We will only describe the data, since the present study is still in progress, under recruitment of pregnant women. The average age of IG is 30.5 ± 9.2 years and in CG 27.5 ± 8.7 years. Four are primiparous and two are pregnant for the fourth time. At baseline, the overall mean HbA1c is 5.2 ± 0.5 and 6.1 ± 2.0 HOMA. After the intervention of 10 weeks, the overall mean HbA1c is 5.5 ± 0.4 and 6.3 ± 4.0 HOMA. The mean gestational age at IG and CG is the same, 38 weeks and 5 days ± 1 day. Weight and height of the newborn IG was 3620.0 ± 714.2 g and 49.5 ± 2.1 cm, respectively, and in controls was 4037.5 ± 180.5 g and 50.8 ± 2.2 cm, respectively. Conclusions After 10 weeks of training we noticed an increase in mean HbA1c and HOMA, compared to baseline, and that the intervention group delivered lighter and smaller babies. Disclosures J.G. Ramos: None. R. Bgeginski: None. M.L. Opperman: None. S. Martins-Costa: None. R. Delevatti: None. R. Schuch: None. L.F. Kruel: None.

Computed tomography imaging study of the superior attachment of the uncinate process

The superior attachment of the uncinate process (SAUP) is an important landmark in the nasofrontal recess, but its anatomical distribution is still unclear. The objective of this study was to assess the location and number of superior attachments of the uncinate process on computed tomography (CT) images. A cross-sectional, retrospective study conducted at the Department of Radiology, Hospital de Clinicas de Porto Alegre, Brazil. Sinus CT scans of adult patients with no history of sinonasal surgery, craniofacial fractures, malignant neoplasms, or malformations were examined for identification of the site of SAUP. 152 CT scans (304 sides) were assessed. The SAUP was appropriately identified in 292 sides (96%). Six distinct SAUP patterns were identified: to the lamina papyracea or anterior ethmoidal cells (193, 63.48%); to the middle turbinate (19, 6.25%); to the skull base (19, 6.25%); to the lamina papyracea and middle turbinate (29, 9.53%); to the lamina papyracea and skull base (29, 9.53%); and to the skull base and middle turbinate (3, 0.98%). The site of superior attachment of the uncinate process is highly variable, but is in contact with the lateral nasal wall in 82.5% of the cases.

Outcomes and Prognostic Factors in Critically Ill Patients with Hematologic Malignancies Admitted in an Intensive Care Unit: A Single Center Experience. Hospital De Clínicas, Montevideo, Uruguay

Introduction: patients with hematologic malignancies (HM) admitted in intensive care units (ICU) have been traditionally seen as patients with very poor prognostic. Recently reports have informed that mortality has dropped and nowadays is in the order of 40-60 %, this is still high but closer to mortality in non-malignant patients admitted in an ICU. In an attempt to change this view we perform a study in order to evaluate the results and prognostic factors that contribute to mortality in HM patients who need critical care assistance.Methods: a retrospective study in 62 patients with HM who were admitted in ICU in the University Hospital, Hospital de Clinicas from Uruguay from 2003 to 2012. These 62 patients had 82 admissions, which are the population of our trial. Statistical analysis: Values are expressed as mean +/- standard deviation (SD), median and percentages. Comparison variable most used: discharge of ICU: dead or alive. Both groups were compared using Student’s t test and Chi square. Multivariate logistic regression analysis was performed. Overall survival with Kaplan Meier. Significance p<0.05.Results: 50% of the episodes were in men. The median age was 56 years old (17-80). The distribution according to HM was: Non-Hodgkin Lymphoma 40.2%, Acute Myeloid Leukemia 23.2%, Multiple Myeloma 13.4%, Chronic Lymphocytic Leukemia 7.3%, Acute Lymphoblastic Leukemia 4.9%, Hodgkin Lymphoma 3.7%, other 3.7%, Myeloproliferative Neoplasm 2.4% and aplasia 1.2%. The mortality during ICU’s treatment was 47.6%. The causes of death in ICU were: septic shock: 74.4%; disease progression: 10.3%; Other: 7.7%; refractory respiratory failure: 5,1%; severe hemorrhage: 2.6%. Median days of overall survival in ICU were 11 days (CI 1.9 to 20.06). In table 1 we show the univariate analysis of prognostic factors. The parameters that showed a significant difference were; underlying diagnosis of ALL, presence of central catheter line prior to entering ICU; need for mechanical ventilation, diagnosis of septic shock, use and hours of vasopressors and the value of APACHE II. Of the 47 patients who required mechanical ventilation 33 died (70.2%), this is a risk factor for death, with an OR of 1.83 (CI: 1.1 to 3.02). The diagnosis on admission to ICU septic shock is a significant risk factor for death with an OR of 0.449 (CI: 0.351 to 0.574). In the multivariable analysis, admission to ICU for mechanical ventilation, use of mechanical ventilation at some point and use of vasopressors were statistically significant.TABLE 1Univariate analysis of prognostic factors:AliveDeathP valueDiagnostic ALLYes: 0 No: 43Yes: 4 No: 350,03Type of ChemotherapyStandard: 19High dose: 11Allogeneic SCT: 1Purine analogs: 1No Chemotherapy: 11Standard: 19High dose: 11Allogeneic SCT: 0Purine analogs: 1No Chemotherapy: 80,920,430,340,940,58NeutropenicNo data: 8Yes: 14 No: 29Yes: 17 No: 140,304CatheterNo data: 2Yes: 16 No: 26Yes: 24 No: 140,025Cretinine, mean (SD)1,53 ±(1,55)1,75 ±(1,17)0,66Urea, mean (SD)68,2 ±(53,41)89,27 ±(61,24)0,09Prothrombin time, mean (SD)68,36 ±(21,37)59,65 ±(20,67)0,87PAFI, mean (SD)301,63 ±(110,41)290,24 ±(123,25)0,22Bilirubin, mean (SD)1,2 ±(1,78)1,5 ±(2,49)0,701Use of mechanical VentilatoryYes: 14 No: 29Yes: 33 No: 6<0,001Septic Shock at admissionYes: 0 No: 43Yes: 4 No: 350,032Use of vasopressorYes: 7 No: 36Yes: 31 No: 8< 0,001Hours of vasopressors46,2986,630,023Renal replacement TherapyYes: 3 No: 40Yes: 8 No: 310,074APACHE II17,05 ± (8,24)20,66 ± (6,00)0,042SOFA at admission4,99 ± (3,84)7,32 ± (3,24)0,35SOFA at 48 hours3,89 ± (3,83)9,20 ± (4,43)0,13Conclusions: this is the first report on the impact of prognostic factors in the outcome of HM patients admitted to ICU in Hospital de Clinicas. HM patient’s acute complications are strong factors that contribute to prognostic in critically ill patients and not only the hematologic disease per se or presence of neutropenia or type of chemotherapy. The mortality rate in this series is similar to international reports and also in patients without HM admitted in ICU. Therefore, we support the idea that survival in critically ill HM patient is related with the intercurrent complication in a significant part, and we have to make more efforts to improve results in this area by working together with intensive care medicine physicians. DisclosuresNo relevant conflicts of interest to declare.

Impacto do DSM-5 no diagnóstico de transtornos de aprendizagem em crianças e adolescentes com TDAH: um estudo de prevalência

Estudos de prevalencia de Transtornos de Aprendizagem (TA) em criancas e adolescentes com TDAH apresentam resultados nao conclusivos, apesar da frequente comorbidade entre as sindromes. Esse artigo descreve e analisa a prevalencia de TA em uma amostra referida de 270 criancas e adolescentes com TDAH atendidas no Programa de Transtornos de Deficit de Atencao/Hiperatividade/Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do Sul (ProDAH/HCPA-UFRGS), de acordo com os criterios diagnosticos do Manual Diagnostico e Estatistico de Transtornos Mentais IV - versao revisada (DSM-IV-TR). Verificou-se que 46,7% dos estudantes apresentam, pelo menos, um TA, sendo o Transtorno da Expressao Escrita o mais frequente (32,6%). Discutiu-se o potencial impacto das mudancas nos criterios diagnosticos para os TA, propostas pelo DSM-5 na prevalencia desses transtornos. Embora seja possivel afirmar que ocorrerao alteracoes nas taxas de prevalencia de TA, o impacto do DSM-5 sobre a prevalencia, especificidade e comorbidade do TA permanece incerto, ja que ha mudancas que ampliarao a abrangencia dos criterios de inclusao e outras que a reduzirao.

INJÚRIA RENAL AGUDA: ESTUDO DE 179 CASOS INTERNADOS NO HOSPITAL DE CLÍNICAS DA UNIVERSIDADE FEDERAL DO PARANÁ (UFPR)

Introdução: a injúria renal aguda (IRA) é caracterizada por um declínio súbito da filtração glomerular e é uma complicação frequente em pacientes internados em hospitais terciários. Objetivo: este estudo teve como objetivo avaliar a epidemiologia, as principais etiologias e a evolução dos pacientes com IRA atendidos no Hospital de Clínicas da UFPR (HC/UFPR). Métodos: Realizou-se um estudo retrospectivo por meio de análise de prontuários dos casos de IRA definidos conforme a classificação AKIN, atendidos no HC/UFPR entre janeiro e dezembro de 2010. Resultados: foram avaliados 179 pacientes com média de idade de 57.3 anos. Entre estes, 98 (55%) tiveram diagnóstico presumido de IRA intrínseca, 72 (40%) lesão pré-renal e 9 (5%) causa pós-renal. De acordo com a classificação AKIN, 36 doentes atingiram o estágio 1 (20.1%), 38 o estágio 2 (21.3%) e 105 o estágio 3 (58.6%) no momento do diagnóstico sendo que 45% dos pacientes foram submetidos à terapia de substituição renal (TSR). A duração média da TSR foi de 10,9 dias e mortalidade atingiu 38,5% e cerca de 15 % deles permaneceram em TSR após a alta. A mortalidade foi significativamente maior entre os pacientes dialíticos comparada aos não dialíticos (26% vs 12%, p&lt;0.0001). Conclusões: a IRA intrínseca foi a principal causa de IRA entre esses pacientes. Observou-se uma maior mortalidade em indivíduos que necessitaram de TSR, principalmente os classificados como AKIN 2 e 3. Dessa forma, o diagnóstico e o tratamento precoce, da IRA, parece ser uma estratégia importante no manejo de pacientes com IRA em um hospital terciário.

Efeitos da estimulação da sucção não nutritiva com dedo enluvado na transição alimentar em recém-nascido prematuro de muito baixo peso

Objetivos analisar os efeitos da estimulação da sucção não nutritiva com a técnica do dedo enluvado, sobre o início e a transição alimentar da via gástrica para a via oral em prematuros de muito baixo peso. Métodos estudo aleatório, prospectivo, longitudinal, experimental e controlado, que incluiu 40 prematuros internados na UTI Neonatal do Hospital de Clínicas, com idade gestacional £ 32 semanas e peso de nascimento £ 1500g, clinicamente estáveis. Os prematuros foram distribuídos aleatoriamente, por meio de sorteio, em 2 grupos: grupo controle, sem SNN e grupo experimental, com SNN com dedo enluvado, 3 vezes ao dia, 3 dias na semana. Foram avaliados critérios quanto ao escore da avaliação da prontidão para início da alimentação oral, intercorrências durante a sucção nutritiva (SN) e o tempo de transição alimentar. Resultados quando comparado o grupo experimental em relação ao grupo controle observou-se um escore significantemente maior na avaliação da prontidão para início da alimentação via oral, uma menor frequência de sinais de estresse durante a sucção nutritiva e um menor tempo de transição alimentar da via gástrica para via oral. Conclusão a estimulação da sucção não nutritiva com a técnica do dedo enluvado melhorou a prontidão do prematuro para início da alimentação via oral, diminuiu a frequência dos sinais de estresse durante a alimentação via oral e reduziu o tempo de transição alimentar no grupo experimental quando comparado ao grupo controle.