Referral Center In Brazil Research Articles

Breastfeeding patterns in cohort infants at a high-risk fetal, neonatal and child referral center in Brazil: a correspondence analysis

BackgroundTo investigate the prevalence and patterns of breastfeeding at discharge and in the first six months of life in a high-risk fetal, neonatal and child referral center.MethodsProspective, longitudinal study that included the following three steps: hospital admission, first visit after hospital discharge and monthly telephone interview until the sixth month of life. The total number of losses was 75 mothers (7.5%). Exposure variables were sorted into four groups: factors related to the newborn, the mother, the health service and breastfeeding. The dependent variable is breastfeeding as per categories established by the WHO. All 1200 children born or transferred to the high-risk fetal, neonatal and child referral center, within a seven-day postpartum period, from March 2017 to April 2018, were considered eligible for the study, and only 1003 were included. The follow-up period ended in October 2018. For this paper, we performed an exploratory analysis at hospital discharge in three stages, as follows: (i) frequencies of baseline characteristics, stratified by risk for newborn; (ii) a multiple correspondence analysis (MCA); and (iii) clusters for variables related to hospital practice and exclusive breastfeeding (EBF).ResultsThe prevalence of EBF at hospital discharge was 65.2% (62.1–68.2) and 20.6% (16.5–25.0) in the six months of life. Out of all at-risk newborns, 45.7% were in EBF at discharge. The total inertia corresponding to the two dimensions in the MCA explained for 75.4% of the total data variability, with the identification of four groups, confirmed by the cluster analysis.DiscussionOur results suggest that robust breastfeeding hospital policies and practices influence the establishment and maintenance of breastfeeding in both healthy and at-risk infants. It is advisable to plan and implement additional strategies to ensure that vulnerable and healthy newborns receive optimal feeding. It is necessary to devote extra effort particularly to at-risk infants who are more vulnerable to negative outcomes.ConclusionAt-risk newborns did not exclusively breastfeed to the same extent as healthy newborns at hospital discharge. A different approach is required for at-risk neonates, who are more physically challenged and more vulnerable to problems associated with initiation and maintenance of breastfeeding.

Overall Maternal Morbidity during Pregnancy Identified with the WHO-WOICE Instrument.

Objective To evaluate the prevalence of nonsevere maternal morbidity (including overall health, domestic and sexual violence, functionality, and mental health) in women during antenatal care and further analyze factors associated with compromised mental functioning and clinical health by administration of the WHO's WOICE 2.0 instrument. Method A cross-sectional study was conducted at a referral center in Brazil with an interview and questionnaire administered to pregnant women at 28 weeks of gestation and beyond. Data collection and management were supported by REDCAP software. A descriptive analysis was performed, and a multiple regression analysis also investigated factors associated with impairment in mental conditions, functionality, and clinical health. Results 533 women at a mean age of 28.9 years (±6.7) were included, and the majority had a partner (77.1%) and secondary education (67.7%). Exposure to violence occurred in 6.8%, and 12.7% reported substance use. Sexual satisfaction was reported by the vast majority (91.7%), although almost one-fifth were sexually abstinent. Overall, women reported very good and good health (72%), despite being told that they had a medical condition (66%). There was an overall rate of anxiety in 29.9%, depression in 39.5%, and impaired functioning in 20.4%. The perception of an abnormal clinical condition was the only factor independently associated with impaired functioning and mental health in the multiple regression model. Obesity was independently associated with clinical impairment. Conclusion During antenatal care, pregnant women in the study reported having a high rate of anxiety, depression, impaired functioning, and substance use. These issues can affect a woman's health and should be further addressed for specific interventions and improved quality of care.

Movement disorders in children with congenital Zika virus syndrome

BackgroundCongenital Zika Virus Syndrome (CZVS) denotes the neurologic and developmental sequelae of congenital infection of the Zika virus. While prior studies have detailed the associated clinical phenotypes, new findings continue to be identified. Abnormal postures and movements have been previously described in children with CZVS, but not in detail. ObjectiveTo examine a cohort of infants with CZVS and characterize the spectrum of motor abnormalities, especially movement disorders. DesignCross-sectional prospective study of 21 infants with confirmed CZVS. SettingSingle-center cohort of 32 patients with serologically confirmed CZVS cared for in a referral center in Brazil. Participants21 children (67% female), evaluated by two child neurologists and one movement disorders specialist, with clinical and laboratory diagnosis of CZVS aged between 16 and 30 months, with a mean age of 16 months at the time of the last examination. Main outcome(s) and measure(s)Prospective neurologic examination by a team of three neurologists, including one movement disorders specialist. Sixteen (76.2%) children had a longitudinal evaluation with a six-month interval. The same team of experts analyzed recorded videos of all patients to characterize motor abnormalities and movement disorders. Neuroimaging findings were also analyzed to correlate with clinical findings. ResultsTwenty (95.2%) patients presented with dystonic postures, including “125” posture of the fingers in 17 (80.1%), “swan neck” posture of the fingers in three (18.8%), oromandibular dystonia in nine (42.9%), extensor axial hypertonia in eight (38.1%) and internal rotation of the shoulder posture in two (9.5%). Four (19%) patients had tremor. All children had malformations of cortical development, and in 13 (61.9%), the pattern was consistent with a severe and diffuse gyral simplification. Seventeen children (81%) had calcification in the transition of grey and white matter, whereas 11 (52.4%) patients had basal ganglia calcifications. Conclusion and relevanceIn our series, dystonic postures and other extrapyramidal signs were frequent and potentially disabling. Although children with CZVS are assessed and treated for spasticity, dystonia and other movement disorders remain neglected. This study emphasizes that extrapyramidal findings may potentially influence optimal strategies for rehabilitation and management.

Expression of the type 3 inositol 1, 4, 5-trisphosphate receptor according to the chronic liver disease etiology in hepatocellular carcinoma.

e16604 Background: The expression of type 3 isoform of the inositol 1, 4, 5-trisphosphate receptor (ITPR-3), an intracellular calcium (Ca2+) channel reported in liver cancer cells, is important in the Ca2+ signalling. Thus, it may be involved in the many events of hepatocarcinogenesis. Here, we investigated the ITPR-3 expression in hepatocellular carcinoma (HCC) and its association with clinicopathological parameters and long-term outcomes, according to the etiology of underlying chronic liver disease (CLD). Methods: Clinical and laboratory data from patients (n = 53) who underwent orthotopic liver transplantation for HCC treatment in a Brazilian referral center were retrospectively collected. After pathological reviewing of their explanted liver samples, ITPR-3 expression in both tumor and underlying cirrhosis were assessed by immunohistochemistry, and quantified using density histograms in the ImageJ software. Event (tumor recurrence or death from any cause) occurrence and event-free survival (EFS) were analysed. Results: Hepatitis C virus (HCV) (n = 31), alcohol abuse (n = 16) and cryptogenic cirrhosis (n = 6) were the underlying CLD etiology, and the groups were, in general, well balanced regarding clinicopathological indices. Median EFS was 78.9 months (range, 63.6-94.1). The ITPR-3 expression profile was cytoplasmatic, predominantly perinuclear, and was stronger in tumor than in adjacent cirrhosis, considering all etiologies together (intensity 9.1% higher in tumors, p < 0.001) However, analyzing each etiologic group, the cryptogenic was the only one in which there was no difference between tumor and underlying CLD. Comparing the ITPR-3 expression only in tumors, there was no difference regarding the etiology of CLD. The tumor ITPR-3 higher intensity was correlated with higher serum aspartate alanine-transferases (ALT) levels (p = 0.018) and lower mitotic index ( < 5 per 10 high power fields) (p = 0.009). There was no association between receptor expression and event occurrence or EFS. Conclusions: The ITPR-3 was expressed in HCC, regardless of the underlying CLD etiology. Its correlation with mitotic index, a cell proliferation marker, was demonstrated, but there were no associations with clinical outcomes. Apart from cryptogenic cirrhosis, ITPR-3 expression was more intense in tumors than in underlying cirrhosis. These findings suggest that ITPR-3 could have a role in carcinogenesis. However, the prognostic and therapeutic implications need to be investigated.

Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center

Background/PurposeGastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center. MethodsSingle-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients. ResultsIn total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients. ConclusionsThis study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect. Type of studyPrognostic. Level of evidenceIV

HEPATITIS C TREATMENT OF RENAL TRANSPLANT AND CHRONIC KIDNEY DISEASE PATIENTS: EFFICACY AND SAFETY OF DIRECT-ACTING ANTIVIRAL REGIMENS CONTAINING SOFOSBUVIR.

Direct-acting antivirals have revolutionized hepatitis C treatment, also for patients with chronic kidney disease (CKD), but some controversy exists regarding the use of sofosbuvir (SOF) in patients with glomerular filtration rate (GFR) <30 mL/min. To evaluate the efficacy and safety of these regimens for hepatitis C treatment of patients with CKD and after renal transplantation, as well as the impact of SOF on renal function in non-dialysis patients. All patients with hepatitis C and CKD or renal transplant treated with direct-acting antivirals at a referral center in Brazil between January 2016 and August 2017 were included. Efficacy was evaluated based on viral load (HCV RNA) and a sustained virological response (SVR) consisting of undetectable RNA 12 and/or 24 weeks after the end of treatment (SVR12 and SVR24) was defined as cure. Safety was determined by adverse events and ribavirin, when combined, was administered in escalating doses to all patients with GFR <60 mL/min. The impact of SOF on renal function was determined by the measurement of baseline creatinine during and after the end of treatment and its increase was evaluated using the Acute Kidney Injury Network (AKIN) classification. A total of 241 patients (52.7% females) with a mean age of 60.72±10.47 years were included. The combination of SOF+daclatasvir was the predominant regimen in 75.6% of cases and anemia was present in 28% of patients who used ribavirin (P=0.04). The SVR12 and SVR24 rates were 99.3% and 97.1%, respectively. The treatment was well tolerated and there were no major clinically relevant adverse events, with the most prevalent being asthenia (57.7%), itching (41.1%), headache (40.7%), and irritability (40.2%). Among conservatively treated and renal transplant patients, oscillations of creatinine levels (AKIN I) were observed in 12.5% of cases during treatment and persisted in only 8.5% after the end of treatment. Of these, 2.0% had an initial GFR <30 mL/min and this percentage decreased to 1.1% after SOF use. Only 0.5% and 1.6% of the patients progressed to AKIN II and AKIN III elevation, respectively. The direct-acting antivirals were safe and efficacious in CKD patients treated with SOF-containing regimens, with the observation of high SVR rates, good tolerability and few severe adverse events. The combination with ribavirin increased the risk of anemia and the administration of escalating doses seems to be useful in patients with GFR <60 mL/min. In patients with GFR <30 mL/min, SOF had no significant renal impact, with serum creatinine returning to levels close to baseline after treatment.

Clinical and laboratory parameters as predictors of long-term outcome according to the etiology of underlying chronic liver disease in patients who underwent liver transplantation for hepatocellular carcinoma treatment

OBJECTIVES:This study aimed to analyze clinical and laboratory parameters and their association with long-term outcomes in patients who underwent liver transplantation for hepatocellular carcinoma treatment, according to the etiology of the underlying chronic liver disease, in order to identify predictors of response to this therapeutic modality.METHODS:Demographic, clinical, and laboratory data from a cohort of 134 patients who underwent orthotopic liver transplantation for hepatocellular carcinoma treatment at a referral center in Brazil were retrospectively selected and compared according to the etiologic group of the underlying chronic liver disease. Events, defined as tumor recurrence or death from any cause, and event-free survival were also analyzed, and multivariate analysis was performed.RESULTS:The etiologies comprised hepatitis C and B virus infection, alcohol abuse, and cryptogenic disorder. Although liver transplantation was performed outside the Milan criteria in 33.3% of the subjects, according to pathologic examination of the explanted liver, the Model for End-Stage Liver Disease score was low (<22) in most patients (70.6%) and recurrence was identified in only 10 (7.9%) patients. Events occurred in 37 patients (28.5%), and the median event-free survival was 75 months (range, 24-116 months). No difference among etiologic groups was found in the parameters analyzed, which were not independently associated with outcome.CONCLUSION:Clinical and laboratory characteristics according to etiologic groups were not different, which might have led to comparable long-term outcomes among these patient groups and failure to identify predictors that could aid in better selection of subjects for liver transplantation in the management of this cancer.

Spirometry results after treatment for pulmonary tuberculosis: comparison between patients with and without previous lung disease: a multicenter study.

ABSTRACTObjective:To compare patients with and without previous lung disease, in terms of the spirometry results after they had been treated for pulmonary tuberculosis (PTB) and cured, as well as to analyze risk factors related to functional severity. Methods:This was a cross-sectional, multicenter study conducted at four referral centers in Brazil. Patients were divided into two groups: those with a history of lung disease or smoking (LDS+ group); and those with no such history (LDS− group). Patients underwent spirometry (at least six months after being cured). Sociodemographic and clinical data were collected. Results:A total of 378 patients were included: 174 (46.1%) in the LDS+ group and 204 (53.9%) in the LDS− group. In the sample as a whole, 238 patients (62.7%) had spirometric changes. In the LDS+ group, there was a predominance of obstructive lung disease (in 33.3%), whereas restrictive lung disease predominated in the LDS− group (in 24.7%). Radiological changes were less common in the LDS− group than in the LDS+ group (p < 0.01), as were functional changes (p < 0.05). However, of the 140 (79.1%) LDS− group patients with a normal or minimally altered chest X-ray, 76 (54%) had functional changes (p < 0.01). The risk factors associated with functional severity in the LDS− group were degree of dyspnea (p = 0.03) and moderate or severe radiological changes (p = 0.01). Conclusions:Impaired pulmonary function is common after treatment for PTB, regardless of the history of lung disease or smoking. Spirometry should be suggested for patients who develop moderate/severe dyspnea or relevant radiological changes after treatment for PTB.

Extranodal NK/T Cell Lymphoma Nasal Type: A Cohort Study from Latin America

Introduction: Extranodal natural killer/T cell lymphoma (ENKTL) nasal type is a rare and highly aggressive subtype of lymphoid neoplasia, with a characteristic epidemiology, predominating in the Asian population and some sites in Latin and Central America. Diagnostic pitfalls and the lack of large randomized trials partly explain the unsatisfactory outcomes reported, even with the recent advances such as the incorporation of asparaginase in the frontline regimens and the description of new prognostic factors. Since few reports from Latin America and non-Asian population are available, we conducted this retrospective study to evaluate clinical characteristics and outcomes in a Brazilian referral center. Methods: This is a retrospective single-center study, conducted in an academic center in Brazil. All patients diagnosed with ENKTL from May 1993 to March 2019 were included. Staging was performed according to Ann-Arbor classification. Patients were treated based at discretion of the physician. Survival analysis was performed using the Kaplan-Meier method and log-rank test for comparison. Cumulative incidence of relapse (CIR) was calculated using death as a competitor. Results: A total of 37 patients with ENKTL was included. Median age was 46 years (range, 18 - 84), with male predominance (54%) and Caucasian ethnic majority (87%). Localized disease (Stages I and II) was predominant (81%) and five cases of primary extranasal disease were found. Skin was the most frequent extranasal site affected (60%). Five patients had central nervous system (CNS) disease (3 at diagnosis and 2 during progression/relapse). Tumor site infection at diagnosis was documented in 74%. Only six patients had EBV viral load available at diagnosis, with an median of 650 copies/ml (range, 482 - 997). Other features are summarized in Table 1. Five patients did not receive any regimen (3 subjects died from sepsis before treatment and 2 received only supportive care). Among the treated patients, anthracycline-based regimens (CHOP-like including or not methotrexate) were the most common regimen (16/32, 50%), followed by concomitant chemotherapy/radiotherapy (CCRT) strategy (8/32, 25%). Asparaginase was included in the treatment in 16% of cases (5/32) and 9% received isolated radiotherapy (RT) (3/32). RT was performed in 81%, mostly using sequential strategies (61%). Incidence of febrile neutropenia and grade 3/4 mucositis during treatment was 88% and 65%, respectively. Complete response (CR) rate after the first-line regimen was 62.5% (95% confidence interval [CI]: 43.7 - 78.3) and primary refractory disease was found in 18.7%. Regarding the patients who achieved CR, 5-year CIR was 19.1% (95% CI 6.6 - 36.4). Autologous stem cell transplantation (ASCT) was performed in two cases after achieving a second CR. Median follow-up was 8.7 years, with 5-year OS of 45.9% (95% CI: 31.4 - 67.1) for all patients and 53.9% (95% CI: 38 - 76.5) among the treated group (Figure 1). Albumin level (&lt;3.5 g/dL) at diagnosis was associated with worse PFS (p = 0.011) and OS (p = 0.0057) in the univariate analysis (unadjusted hazard ratio [HR]=5.16 (95% CI 0.06 - 0.60, p = 0.004) (Figure 2 and 3). Sex, staging, age, blood counts, infection at diagnosis, extranasal type, international prognostic index or employed regimen were not associated with outcomes in our cohort. Conclusion: There are few reports of clinical characteristics and outcomes of ENKTL in the Latin American population. Although the current data show an increase in response and survival rates in localized stages, published reports from non-Asian population still display poor outcomes. Hypoalbuminemia, as previously described, was associated with worse outcomes in our cohort and, along with the higher toxicity and infection rates, denote the challenge of adapting regimens in the Brazilian population. Cooperative multicenter initiatives and prospective strategies are essential to improve outcomes of this rare and poorly described disease in the non-Asian population. Disclosures No relevant conflicts of interest to declare.

Short Communication: Getting Older with HIV: Increasing Frequency of Comorbidities and Polypharmacy in Brazilian HIV Patients.

Life expectancy of HIV patients has increased over time. Older HIV patients have a higher frequency of noncommunicable diseases (NCD) than general population, and require multiple treatments. The main objective is to evaluate the changes in frequency of NCD and polypharmacy in HIV patients of three referral centers in Salvador and São Paulo. We compared the frequency of NCD and use of concomitant treatments in HIV patients, >50 years, in three Brazilian referral centers (São Paulo and Salvador). Data on sociodemographic characteristics, HIV therapy, CD4 count and viral load measurements, and frequency of NCD at baseline and last medical visit were recorded. We evaluated 451 patients, 128 in Salvador and 323 in São Paulo. Mean age was 57.9 ± 6.9 years. Mean baseline CD4 count was 199 ± 169. At baseline, dyslipidemia (4.0%) was the most frequent comorbidity, but at last visit we detected a high frequency of diabetes (14.9%), dyslipidemia (26.7%), osteoporosis (6.7%), stroke (4.4%), and malignancies (3.1%). Use of concomitant drugs for treatment of NCD increased significantly between first and last visit, especially antihypertensive, lipids lowering, and diabetes drugs. Aging in HIV patients in Brazil is characterized by an increasing incidence of NCD and polypharmacy.

Epidemiologic Features of Systemic Vasculitides in the Southeast Region of Brazil: Hospital-Based Survey.

The epidemiology of vasculitis is variable in different geographic areas, and this issue has not been approached in Brazil yet. The objective of this study was to assess the frequency of vasculitis in specialized centers in Brazil. This cross-sectional study was performed in 9 vasculitis outpatient clinics from 6 different states mainly from the Southeast and the Northeast regions of Brazil between 2015 and 2017. Diagnosis and/or classification criteria for Behçet disease (BD), Takayasu arteritis (TA), giant cell arteritis (GCA), polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and cryoglobulinemic vasculitis (CryoVas) were used to include patients with at least 6 months of follow-up in this hospital-based survey. A total of 1233 patients with systemic vasculitis were included from the Southeast region. Behçet disease was the most frequent vasculitis (35.0%) followed by TA (26.4%), GPA (16.2%), PAN (5.8%), GCA (5.8%), EGPA (4.3%), MPA (3.4%), and CryoVas (3.0%). Up to 7.8% of vasculitis patients had a juvenile onset, and the frequency of vasculitides found in children and adolescents was as follows: TA (52.6%), BD (24.7%), GPA (12.4%), and PAN (10.3%). No cases of EGPA, MPA, and CryoVas were diagnosed before the age of 18 years. As a comparator, 103 vasculitis patients were included in the Northeast of Brazil where TA was found in 36.9% and BD in 31.1% of vasculitis cases. No GCA cases were found in the Northeast part of Brazil. Similar to the epidemiology of vasculitis in Asia, BD and TA are the most frequent vasculitis in Southeastern Brazilian referral centers.

Specific characteristics of urethral strictures in a developing country (Brazil).

Evaluate the main etiologies and clinical characteristics of male urethral stricture disease (USD) in Brazil. This multicentric study was performed using retrospective data collected from six Brazilian referral centers of urethral reconstruction. The database comprised data from 899 patients with USD who had undergone surgical treatment from 2008 to 2018. Age, stricture site and primary stricture etiology were identified for each patient. The mean age was 52.13 ± 16.9years. The most common etiology was iatrogenic (43.4%), followed by idiopathic (21.7%), trauma (21.5%) and inflammatory (13.7%). Of the iatrogenic causes, 59% were secondary to urethral instrumentation (60% by urethral catheterization and 40% by transurethral procedures), 24.8% by other procedures (prostatectomy, radiotherapy, postectomy) and 16.2% by failed hypospadia repairs. Pelvic fracture urethral distraction injuries were responsible for most of the trauma-related strictures (62.7%). When stratified by age, the most common stricture etiology was trauma in the 0-39years old group (42.8%), idiopathic in the 40-59years old group (32.4%) and iatrogenic in patients over 60years old (68%). In regard to the stricture site, 80% presented with an anterior urethral stricture and 20% with a posterior stenosis. In the anterior stenosis group, the most common stricture site was bulbar (39.5%). In Brazil, as in many developed countries, the most common cause of urethral stricture diseases is iatrogenic, especially urethral catheterization. These findings emphasize the need of a careful urethral manipulation and a better training of healthcare professionals. Trauma is still responsible for a great proportion of strictures and inflammatory etiologies are now less frequently observed.

MAPK pathway proteins expression and correlation with clinicopathological indices and long-term outcome according to the etiology of underlying chronic liver disease in hepatocellular carcinoma.

286 Background: Different etiologies of chronic liver disease (CLD) potentially lead to hepatocellular carcinoma (HCC) by multiple mechanisms that can be translated into clinicopathological and prognostic differences. We evaluated the expression of some proteins of MAPK pathway, an important signalling cascade in HCC, and correlated them to clinical and histopathological parameters, and long-term outcome, according to the etiology of the CLD. Methods: 80 patients (pts) who underwent orthotoptic liver transplantation (OLT) for HCC at Universidade Federal de Minas Gerais, a referral center in Brazil, were randomly selected: 41 viral (V) (HBV or HCV infection), 39 nonviral (NV) (alcohol abuse and cryptogenic) etiology. Clinical pre-OLT and histological data were retrospectively collected. Event (E) was defined as death and/or HCC-recurrence since OLT. In explanted liver, tumor and adjacent cirrhosis were subjected to immunohistochemistry, using antibodies against K-RAS, B-RAF and MEK, analysed by two pathologists. Results: V and NV groups were well balanced regarding clinicopathologic indices, but alcohol was the main etiology in men (95%) and HCV in women (38.7%). Median E-free survival (EFS) was 74.5 months (range, 8.5-105), without difference between groups. Microvascular invasion (MIV) (p &lt; 0.01) and age (p = 0.04) were independently associated with E. 11 pts (26.8%) of the V group had strong expression (SE) of K-RAS in tumor comparing to 0 (0%) in cirrhosis (p = 0.008) and to three (7.7%) in NV group HCC (p = 0.024). SE of B-RAF was seen in seven pts (17.0%) in V versus 11 (28.2%) in NV (p = 0.257), without difference from cirrhosis (p = 0.755). SE of MEK was not seen. Weak KRAS expression was more common in older pts (p = 0.04). The proteins expression was not related to E or EFS. Conclusions: SE of K-RAS, but not of BRAF and MEK, were more frequent in V group HCC than in cirrhosis and NV group tumors. It suggests that HBV and HCV can lead to HCC by different mechanisms comparing to NV etiology and KRAS could have a role on carcinogenesis. As there were no differences in clinical outcomes, prognostic, and therapeutic implications need to be stablished.

Clinical and Epidemiological Features Of Children With Egg Allergy (EA) Followed In A Brazilian Referral Center Of Allergy

Clinical and Epidemiological Features Of Children With Egg Allergy (EA) Followed In A Brazilian Referral Center Of Allergy

How cutaneous leishmaniasis and treatment impacts in the patients' lives: A cross-sectional study.

BackgroundUntil now, few studies have evaluated the effect of cutaneous leishmaniasis (CL) on patients' quality of life, and none have used a specific instrument to measure this effect. The objective of this study was to identify factors that may be associated with the high impact of CL and to assess patients’ satisfaction with treatment and health services by utilizing a disease-specific questionnaire.MethodologyBetween December 2015 and May 2017, 100 patients with localized cutaneous leishmaniasis were interviewed at a leishmaniasis referral center in Brazil. Data were collected by two questionnaires. One questionnaire compiled the sociodemographic, economic, and clinical information related to the disease. The second questionnaire was the Cutaneous Leishmaniasis Impact Questionnaire (CLIQ), which consisted of two subscales that measured 1) the general impact of CL and 2) patients’ perceptions of treatment and health services. The median scores from each of these two subscales were used to dichotomize the dependent variables. Risk factors for the high impact of CL and for low patient satisfaction with treatment and health services were analyzed with a logistic regression analysis.ResultsThe chance of higher impact of CL was increased in patients with the presence of comorbidities (OR: 3.9; CI 1.25–12.36), in those with absences from work (OR: 12.0; CI 3.78–42.55), in those who relied on public transportation by a municipal bus (OR: 5.8; CI 1.27–26.77), and in those who had illness-related expenses greater than U$137 (OR: 3.5; CI 1.17–10.24). The chance of patient dissatisfaction with treatment and health services increased with higher education (OR: 5.0; CI 1.19–21.03) and with illness-related expenses exceeding U$137 (OR: 4.64; CI 1.49–14.48). Once the sample was non-probabilistic, findings are not representative of CL patients in general.ConclusionsCL and its treatment have a negative impact on patients’ quality of life. Considering these effects during public health planning may help patients to confront the disease.

The ghost of the great imitator: prognostic factors for poor outcome in syphilitic uveitis

BackgroundSyphilitic uveitis is reemerging globally, may lead to any type of intraocular inflammation, and is potentially sight-threatening. We aim to characterize clinical features and prognostic factors in patients with syphilitic posterior uveitis.MethodsRetrospective chart review at two tertiary university-based referral centers in Brazil. Clinical data, laboratory results, and treatment outcomes were analyzed. Statistical analysis was performed using Fisher’s exact test for categorical variables and Mann-Whitney U test for continuous variables.ResultsForty-four patients (81 eyes) were consecutively diagnosed with syphilitic posterior uveitis between March 2011 and April 2013.Thirty-one were male (70.5%) and the mean age was 43.8 years (range 15–81). HIV confection was disclosed in 12 patients (29.3%). The most prevalent finding was vitritis (85.2%), followed by retinal involvement (76.4%) and optic disc abnormalities (63.5%). After treatment, mean visual acuity improved from 1.2 (20/320) to 0.6 (20/80; median 20/30), but 19 eyes (23.5%) persisted with ≤ 1.0 (20/200). Factors associated with final visual acuity ≤ 1.0 despite therapy were prior use of systemic corticosteroids (p = 0.001), higher Venereal Disease Research Laboratory titers (p = 0.004), longer duration of symptoms (p = 0.024), and worse initial VA (p < 0.001).ConclusionsSyphilitic uveitis is reemerging. Delayed diagnosis and inadvertent use of systemic corticosteroids are potentially modifiable prognostic factors to be considered for possibly improving outcomes.

Risk factors for physical disability upon release from multidrug therapy in new cases of leprosy at a referral center in Brazil.

ABSTRACTThe present study sought to investigate the risk factors for physical disability upon release from multidrug therapy (MDT) in new cases of leprosy, registered at a referral center in Brazil. This is a longitudinal and retrospective study that evaluated 260 patients. Multivariate analyses, using both the ordinal logistic regression, as well as the classification and regression tree (CART) algorithm were performed to determine the factors associated with physical disability upon release from treatment. The prevalence of disability did not differ significantly between diagnosis and release from treatment. Number of affected nerves and sensory impairment upon diagnosis were risk factors for disability at the end of MDT. The analysis using the CART algorithm resulted in the development of a clinical score to predict the risk of disability upon release from MDT. The decision tree may have a direct applicability in clinical practice for professionals dealing with leprosy, as it allows them to identify patients with a higher risk of physical disability through the use of simple and widely available clinical tests. This study also shows that the disability grade upon admission is the main risk factor for disability upon release from MDT. This result draws attention to the importance of early diagnosis in disability prevention.

How are HCV-infected patients being identified in Brazil: a multicenter study

BackgroundHepatitis C is an important health problem. In Brazil, 1–2 million people are infected. Despite this expressive number, and the availability of very successful treatment, many patients remained undiagnosed mainly because of the asymptomatic nature of the infection. ObjectivesTo describe epidemiological characteristics of HCV-infected patients seen at referral centers in Brazil, the source of referral, and the time spanned to reach a reference center, in order to improve the identification of undiagnosed patients. MethodsMulticenter observational, cross-sectional study carried out in 15 centers of Brazil, between January/2016 and June/2017. Data of patients with a confirmed diagnosis (anti-HCV and HCV-RNA) were collected by interview using standard questionnaires and by review of charts. ResultsTwo thousand patients were included; 55.1% were male, mean age 58±11 years. Only 14.9% had higher education and 84.2% received up to five monthly minimum Brazilian wages (approximately US$260.00/month). The time between diagnosis and beginning of follow-up was 22.9 months. The most common reasons for testing were check-up (33.2%) and blood donation (19%). General practitioners diagnosed most of the patients (30.1%). Fibrosis stage was mainly evaluated by liver biopsy (61.5%) and 31.3% of the patients were cirrhotic at diagnosis. ConclusionsThis multicenter Brazilian study showed that the mean time to reach a referral center for treatment was almost two years. Primary care physicians diagnoses most hepatitis C cases in the country. Population campaigns and medical education should be encouraged to intensify screening of asymptomatic individuals, considering the efficiency of check-ups in identifying new patients.

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study.

To assess the association between maternal potentially life-threatening conditions(PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes. Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval). Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68-3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81-4.66) and anyadverseperinatal outcome (2.16; 1.59-2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08-2.25). We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

Impact of Omalizumab in Children From a Middle-Income Country With Severe Therapy-Resistant Asthma: A Real Life Study

PM Pitrez, RG de Souza, C Roncada. Pediatr Pulmonol. 2017;52(11):1408–1413 In this study, the authors examined the health care effects associated with the use of omalizumab for severe childhood asthma in low- and middle-income countries (LMICs). This retrospective chart review included 6- through 12-year-olds who were managed at a tertiary referral center in Brazil with a confirmed diagnosis of severe therapy-resistant asthma (STRA) on the basis of European Respiratory Society/American Thoracic Society criteria, including requiring treatment with inhaled corticosteroids (ICSs) with long-acting β2 agonists and leukotriene modifier …