Sociodemographic factors associated with COVID-19 in-hospital mortality in Brazil.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has highlighted inequalities in access to healthcare systems, increasing racial disparities and worsening health outcomes in these populations. This study analysed the association between sociodemographic characteristics and COVID-19 in-hospital mortality in Brazil. STUDY DESIGN: A retrospective analysis was conducted on quantitative reverse transcription polymerase chain reaction-confirmed hospitalised adult patients with COVID-19 with a defined outcome (i.e. hospital discharge or death) in Brazil. Data were retrieved from the national surveillance system database (SIVEP-Gripe) between February 16 and August 8, 2020. METHODS: Clinical characteristics, sociodemographic variables, use of hospital resources and outcomes of hospitalised adult patients with COVID-19, stratified by self-reported race, were investigated. The primary outcome was in-hospital mortality. The association between self-reported race and in-hospital mortality, after adjusting for clinical characteristics and comorbidities, was evaluated using a logistic regression model. RESULTS: During the study period, Brazil had 3,018,397 confirmed COVID-19 cases and 100,648 deaths. The study population included 228,196 COVID-19-positive adult in-hospital patients with a defined outcome; the median age was 61 years, 57% were men, 35% (79,914) self-reported as Black/Brown and 35.4% (80,853) self-reported as White. The total in-hospital mortality was 37% (85,171/228,196). Black/Brown patients showed higher in-hospital mortality than White patients (42% vs 37%, respectively), were admitted less frequently to the intensive care unit (ICU) (32% vs 36%, respectively) and used more invasive mechanical ventilation (21% vs 19%, respectively), especially outside the ICU (17% vs 11%, respectively). Black/Brown race was independently associated with high in-hospital mortality after adjusting for sex, age, level of education, region of residence and comorbidities (odds ratio = 1.15; 95% confidence interval = 1.09-1.22). CONCLUSIONS: Among hospitalised Brazilian adults with COVID-19, Black/Brown patients showed higher in-hospital mortality, less frequently used hospital resources and had potentially more severe conditions than White patients. Racial disparities in health outcomes and access to health care highlight the need to actively implement strategies to reduce inequities caused by the wider health determinants, ultimately leading to a sustainable change in the health system.

Short- and medium-term prognosis of HIV-infected patients receiving intensive care: a Brazilian multicentre prospective cohort study.

OBJECTIVES: The characteristics of critically ill HIV-positive patients and the causes of their admission to intensive care units (ICUs) are only known through retrospective and unicentric studies. This study aims to fill this knowledge gap. METHODS: This is a prospective, multicentre cohort study of short- and medium-term prognostic factors. The setting consisted of ICUs of three tertiary referral hospitals from the three largest metropolitan areas in Brazil in the period January 2014 to November 2015. In all, 161 HIV patients over 18 years old were included. RESULTS: The clinical data of the outcomes (ICU mortality, hospital mortality and 90-day survival) were extracted from medical records using the REDCap®ï¸ web-based form and analysed with the MedCalc®ï¸ application. Median age was 41.7 [interquartile range (IQR): 34-50] years, the Simplified Acute Physiologic Score 3 (SAPS 3) was 64 (IQR: 56-74), and the Sequential Organ Failure Assessment Score (SOFA) was 6 (IQR: 4-9) points. The main causes of admission were sepsis (54.5%) and acute respiratory failure (13.7%). ICU and hospital mortality rates were 32.3% and 40.4%, respectively. In a multivariate analysis, time until ICU admission ≥ 3 days (P = 0.0013), performance status (Eastern Cooperative Oncology Group score, P = 0.0344), coma (Glasgow Coma Scale ≤ 8 points, P = 0.0213) and sepsis (P = 0.0003) were associated with increased hospital mortality. Coma (P = 0.0002) and sepsis (P = 0.0008) were independently associated with 90-day survival. CONCLUSIONS: Delayed ICU admission and the severity of critical illness determine the short- and medium-term mortality rates of HIV-infected patients admitted to the ICU, rather than factors associated with HIV infection. These results suggest that prognostic factors of HIV-infected patients in the ICU are similar to those of non-HIV-infected populations.

Comparison of two databases to detect potential drug-drug interactions between prescriptions of HIV/AIDS patients in critical care.

WHAT IS KNOWN AND OBJECTIVE: Adverse drug events (ADE), common and underestimated in ICU patients, have direct consequences on length of stay, mortality and hospital costs. Critically ill patients with HIV/AIDS are at a high risk of ADE because of their need for multiple drug therapies. ADE can be prevented, especially by the identification of potentially harmful drug-drug interactions (DDIs). Electronic databases are useful tools for the investigation of DDIs to avoid potential ADEs, thereby increasing patient safety. The purpose of this study was to compare the classification and severity rating of potential adverse drug interactions seen in the prescriptions for patients with HIV/AIDS in two databases, one with free access (Drugs.com(™)) and another requiring payment for access (Micromedex(®)). METHODS: A cross-sectional retrospective study of the prescriptions issued for 40 ICU HIV/AIDS patients on mechanical ventilation, admitted for more than 48 h, in a referral hospital for infectious diseases in Rio de Janeiro, Brazil, was undertaken. One prescription was reviewed each week for each patient from the second day after admission. A list of all drug-drug interactions was generated for each patient using the two drug-drug interactions databases. The weighted kappa index was estimated to assess the agreement between the classifications of DDIs identified by both databases and qualitative assessment made of any discordant classification of recorded drug-drug interactions. RESULTS AND DISCUSSION: Of the 106 prescriptions analysed, Micromedex(®) and Drugs.com identified 347 and 615 potential DDIs, respectively. A predominance of moderate interactions and pharmacokinetic interactions was observed. The agreement between the databases regarding the severity rating was only 68.3%. The weighted kappa of 0.44 is considered moderate. Better agreement (82.4%) was observed in the classification of mechanism of interaction, with a weighted kappa of 0.61. WHAT IS NEW AND CONCLUSION: DDIs are common between the prescriptions of patients with HIV/AIDS admitted to the ICU. Although both databases were able to identify the clinically relevant DDIs, we observed a significant discrepancy in the classification of the severity of DDIs in the two bases. The free access database could serve as an alternative to the identification of DDIs in resource-limited settings; however, there is a need for better evidence-based assessments for your use on clinical management of more serious DDIs.

A rare histopathological spiradenocylindroma: a case report.

Background: Spiradenocylindroma is an extremely rare entity composed by two distinct neoplasms in one lesion: spiradenoma and cylindroma. It may arose solitary or multiple, sporadic or familial and often affect the scalp. Surgical removal is curative and histopathological examination is mandatory for diagnosis. Aim: The aim of this article is to define the clinical features of spiradenocylindroma and its importance in the differential diagnoses of head and neck tumors. Case presentation: A 58 years-old female with a preauricolar painless, tender nodule presented to our attention. The patient under-went ultrasonography and MRI, which showed a non-specific cystic lesion. Surgery was performed and histopathological examination revealed a spiradenocylindroma. A 3-years disease-free follow-up was achieved. Conclusion: Spiradenocylindroma is often misdiagnosed and, in our study, we highlight its role in the differential diagnoses of head and neck masses.

Advantages of temporal muscle flap with no fascia in oral reconstruction after tumor removal.

ABSTRACT: Temporalis Muscle Flap is known to be a first choice rotational flap for oral reconstruction even though a few postoperative complications were reported in Literature. Among these, fascia necrosis may prolong recovery, increase discomfort and elevate sanitary cost. The aim of the study is to report the advantages of temporalis muscle flap without deep fascia in the reconstruction of the maxilla. The study group comprised seven patients aged between 43 and 64 years who underwent oral surgical reconstruction with TMF with no fascia. Reconstruction with the temporalis muscle flap was done in the same time of demolitive surgery and the same surgeon performed all the surgeries. In no case, TMF was covered with slough and this permitted to all our patients to undergo an easier rehabilitation with a low number of medications. Our experience showed that removing the fascia from TMF is a safe procedure that strongly decreased time of oral healing and improves patient comforts.

Branchiogenic carcinoma with rapid growth and skin involvement: a case report.

ABSTRACT: Branchiogenic carcinoma (BC) is an extremely rare and still controversial clinic entity with few cases reported in literature. This malignant squamous epithelial wall degeneration of a pre-existing second branchial cleft cyst (SBCC) was first described by Von Volk-mann in 1882. Here we present a case of cervical cystic mass that was histologically diagnosed as a primary branchial cleft cyst carcinoma. This is the first documented cases of primary BC presenting with skin involvement on initial examination.

Transnasal endoscopic management of frontal sinus mucopyocele with orbital and frontal lobe displacement as minimally invasive surgery.

AIM: An obstructive condition of paranasal sinus secondary to surgery, trauma, flogosis or neoplasms could become a predisposing state to the occurrence of mucocele. Frontal sinus mucoceles, which can turn into mucopyoceles due to bacterial super-infections, may invade the orbit, erode the skull base and displace respectively the ocular bulb and the frontal lobe. The surgical treatment of this disease ranges from mini-invasive approaches, such as the transnasal endoscopic marsupialization, to a more aggressive surgery such as osteoplasty through coronal flap and frontal sinus exclusion by fat tissue. METHODS: From 2005 to 2007, we treated with transnasal endoscopic surgery 10 patients, affected by frontal sinus mucopyoceles displacing both the ocular bulb and the frontal lobe. RESULTS AND DISCUSSION: In the present study, we report the clinical and diagnostic features of this series, the treatment modalities and the achieved results and confirm the effectiveness of the mini-invasive transnasal endoscopic technique in the treatment of the frontal sinus mucopyocele.

Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery.

BACKGROUND: The effect of neuromuscular blockade (NMB) and positive end-expiratory pressure (PEEP) on the elastic properties of the respiratory system during pneumoperitoneum (PnP) remains a controversial subject. The main objective of the present study was to evaluate the effects of NMB and PEEP on respiratory mechanics. METHODS: We performed a dynamic analysis of respiratory mechanics in patients subjected to PnP. Twenty-one patients underwent cholecystectomy videolaparoscopy and total intravenous anesthesia. The respiratory system resistance (R(RS)), pulmonary elastance (E(P)), chest wall elastance (E(CW)), and respiratory system elastance (E(RS)) were computed via the least squares fit technique using an equation describing the motion of the respiratory system, which uses primary signs such as airway pressure, tidal volume, air flow, and esophageal pressures. Measurements were taken after tracheal intubation, PnP, NMB, establishment of PEEP (10 cmH2O), and PEEP withdrawal [zero end-expiratory pressure (ZEEP)]. RESULTS: PnP significantly increased E(RS) by 27%; both E(P) and E(CW) increased 21.3 and 64.1%, respectively (P < 0.001). NMB did not alter the respiratory mechanic properties. Setting PEEP reduced E(RS) by 8.6% (P < 0.05), with a reduction of 10.9% in E(P) (P < 0.01) and a significant decline of 15.7% in R(RS) (P < 0.05). These transitory changes in elastance disappeared after ZEEP. CONCLUSIONS: We concluded that the 10 cmH2O of PEEP attenuates the effects of PnP in respiratory mechanics, lowering R(RS), E(P), and E(RS). These effects may be useful in the ventilatory approach for patients experiencing a non-physiological increase in IAP owing to PnP in laparoscopic procedures.

Predicting acquisition of carbapenem-resistant Gram-negative pathogens in intensive care units.

BACKGROUND: Infections by multidrug-resistant Gram-negative (MDRGN) bacteria are among the greatest contemporary health concerns, especially in intensive care units (ICUs), and may be associated with increased hospitalization time, morbidity, costs, and mortality. AIM: The study aimed to predict carbapenem-resistant MDRGN acquisition in ICUs, to determine its risk factors, and to assess the impact of this acquisition on mortality rate. METHODS: A matched case-control study was performed in patients admitted to the ICU at a large Brazilian hospital over a five-year period. Cases were defined as patients who acquired carbapenem-resistant MDRGN bacteria during hospitalization. Controls were defined as patients who had no detection of carbapenem-resistant MDRGN bacteria. Cases were matched to controls according to the admission period. Risk factors were identified by multiple logistic regression using a stepwise selection method. FINDINGS: In total, 343 cases and 1029 controls were analysed. The 30-day mortality rate for subjects with ICU-associated carbapenem-resistant MDRGN was 37.6%. Five variables were identified as statistically significant and more relevant for the acquisition of multidrug-resistant strains: increased Simplified Acute Physiology Score 3, patients with severe chronic obstructive pulmonary disease and exposure to haemodialysis catheter, central venous catheter, or mechanical ventilation. Models developed displayed good results with an accuracy of ∼90%. Patients who acquired MDRGN were 2.72 times more likely to die than non-MDRGN acquisition patients. CONCLUSION: Finding risk factors and developing predictive models may benefit patients through early detection and by controlling the spread of MDR. The presence of mechanical ventilation and central venous catheter were the main risk factors demonstrated, and their use requires special attention.

FDG-PET in patients at risk for acute respiratory distress syndrome: a preliminary report.

OBJECTIVE: To compare the pattern of lung uptake of 18F-fluorodeoxyglucose (FDG) by positron emission tomography (PET) imaging in patients with lung contusion that developed or did not progress to acute respiratory distress syndrome (ARDS). DESIGN: Prospective, observational study. SETTING: Trauma Center (academic urban hospital). PATIENTS AND INTERVENTIONS: Eight patients with blunt thoracic trauma and pulmonary contusion, confirmed by computed tomography (CT) on admission, underwent repeat CT and FDG-PET (on the same day) 24-72 h after admission. RESULTS: No subjects met the criteria for ARDS at the time of the PET and second CT. Four subjects subsequently developed ARDS 1-3 days after the PET scan; the other four did not develop the syndrome. Three of the four subjects who subsequently developed ARDS showed diffuse FDG uptake throughout the entire lungs, while those who did not develop ARDS showed significant FDG uptake only in areas of focal lung opacity (non or poorly aerated lung units) on CT. FDG uptake in normally aerated lung regions was higher for those who subsequently developed ARDS than those who did not, approaching statistical significance. The normally aerated tissue:liver ratio was significantly higher in subjects who developed ARDS than in those who did not (P = 0.029). CONCLUSION: In this small series of patients with thoracic trauma, diffuse lung uptake of FDG was detected by PET imaging 1-3 days prior to clinically determined ARDS.

Endoscopic sinus surgery for a tension pneumocephalus after severe cranio-facial trauma.

Tension pneumocephalus is a rare form of pneumocephalus in which the air is under pressure; it is generally due to communication between the atmosphere and the intracranial cavity, and is an infrequent (0.88%) complication of cranial trauma. Tension pneumocephalus causes an increase in intracranial pressure with deterioration of the neurological situation and requires emergency treatment. Endoscopic surgery of the paranasal sinuses, which is generally applied in the diagnosis and treatment of fistulas with cerebrospinal fluid leakage, was here used to treat a case of pneumocephalus due to cranio-ethmoidal communication, in a patient we had treated previously for severe cranio-facial trauma.

Adverse birth outcomes associated with Zika virus exposure during pregnancy in São José do Rio Preto, Brazil.

OBJECTIVES: We aimed to report the first 54 cases of pregnant women infected by Zika virus (ZIKV) and their virologic and clinical outcomes, as well as their newborns' outcomes, in 2016, after the emergence of ZIKV in dengue-endemic areas of São Paulo, Brazil. METHODS: This descriptive study was performed from February to October 2016 on 54 quantitative real-time PCR ZIKV-positive pregnant women identified by the public health authority of São José do Rio Preto, São Paulo, Brazil. The women were followed and had clinical and epidemiologic data collected before and after birth. Adverse outcomes in newborns were analysed and reported. Urine or blood samples from newborns were collected to identify ZIKV infection by reverse transcription PCR (RT-PCR). RESULTS: A total of 216 acute Zika-suspected pregnant women were identified, and 54 had the diagnosis confirmed by RT-PCR. None of the 54 women miscarried. Among the 54 newborns, 15 exhibited adverse outcomes at birth. The highest number of ZIKV infections occurred during the second and third trimesters. No cases of microcephaly were reported, though a broad clinical spectrum of outcomes, including lenticulostriate vasculopathy, subependymal cysts, and auditory and ophthalmologic disorders, were identified. ZIKV RNA was detected in 18 of 51 newborns tested and in eight of 15 newborns with adverse outcomes. CONCLUSIONS: Although other studies have associated many newborn outcomes to ZIKV infection during pregnancy, these same adverse outcomes were rare or nonexistent in this study. The clinical presentation the newborns we studied was mild compared to other reports, suggesting that there is significant heterogeneity in congenital Zika infection.

Maxillary ameloblastoma.

Maxillary ameloblastoma is a rare odontogenic neoplasm that is histologically benign and originates from epithelial cells present in bone tissue. If excised through conservative surgery, this tumour has a high relapse rate and is locally aggressive. The risk, in particularly extensive forms, that the ameloblastoma will invade extra-maxillary structures such as the orbit, the pterygomaxillary fossa, the infratemporal fossa and the base of the skull, means that surgical treatment is difficult if it is to be oncologically radical while respecting function and aesthetics. Thus, in these cases a complete and in-depth diagnostic work-up and careful planning of surgical treatment are needed: surgery entails an ablative phase with en-bloc resection of the neoformation to margins free of neoplastic infiltration, and a reconstruction phase that, within a short time-frame, will re-establish functionality and provide a good aesthetic result. Our experience in treating 2 cases of maxillary ameloblastoma is reported.

Macrophage-colony stimulating factor (M-CSF) in the cerebrospinal fluid.

In a series of 145 cases with neurological diseases, macrophage-colony stimulating factor (M-CSF) was detected in cerebrospinal fluid of patients with brain tumors, bacterial meningitis, and less frequently, AIDS-dementia complex. Granulocyte-colony stimulating factor (G-CSF) was found only in patients with bacterial meningitis; granulocyte-macrophage (GM)-CSF was never detected. These findings suggest that M-CSF may play an important intrathecal immunoregulatory role in neoplastic and infectious diseases of the central nervous system.

Immune activation in multiple sclerosis: study of IL-2, sIL-2R, and gamma-IFN levels in serum and cerebrospinal fluid.

Serum and cerebrospinal fluid (CSF) levels of interleukin-2 (IL-2), soluble IL-2 receptor (sIL-2R), and gamma-interferon (gamma-IFN) were measured in multiple sclerosis (MS) patients, human immunodeficiency virus type 1 (HIV-1)-infected patients and normal controls (NC). Increased levels of both IL-2 and sIL-2R were found in MS serum. Moreover, 11 of 50 MS patients showed detectable levels of IL-2 in the CSF. HIV-1-infected patients had increased levels of sIL-2R in serum and, less frequently, in the CSF. gamma-IFN was never detected in serum and CSF of all the patients studied. These findings confirm preliminary reports, further stress a systemic T-cell activation in MS, and support the hypothesis that an immunologic disorder exists in such patients.

Transferrin receptors in rat central nervous system. An immunocytochemical study.

Using an immunocytochemical method we demonstrated the presence of TfR on adult rat neurons, particularly in the cerebral cortex and brain stem. The monoclonal antibody (mab) against rat TfR (clone OX 26) stained neurons of all cortical layers and in the brain stem where the reaction was most evident. Purkinje cells in the cerebellum and scattered neurons in the gray matter of the cervical spinal cord were weakly stained. Choroid plexus cells also reacted with the mab against TfR whereas oligodendrocytes in the cerebral white matter were faintly outlined by the mab. The presence of TfR on endothelial cells of brain capillaries was here confirmed.

Sentinel node biopsy in breast cancer.

Axillary lymph node dissection (ALND) is an important tool in staging patients with breast cancer. However, this procedure has several sequelae and complications and improvement in early diagnosis has led to an increasing number of cases of ALND in which axillary nodes are found to be negative. Sentinel node (SN) biopsy appears to be a less invasive alternative to ALND. The aim of the present study was to assess whether SN is a reliable indicator for axillary staging. We studied 126 consecutive patients with T1-T2 breast cancer and clinically negative axilla. In each case, 30-70 MBq of 99mTC-labelled colloidal albumin was injected subdermally close to the tumour and SN was visualised by lymphoscintigraphy. Surgery was performed 24 h after injection and the SN was removed under the guidance of a gamma ray-detecting probe. ALND was then undertaken in all cases. A histopathologic examination of the SNs was then made and the findings compared with the status of the other axillary nodes. SNs were identified and biopsied in 115/126 patients (91.3%) and correctly predicted the axillary status in 110/115 cases (95.6%). In five cases (4.4%), SNs were found to be negative, but other axillary nodes were positive. Our data confirm that SN biopsy is a good method for staging the axilla in patients with breast cancer. However, before SN biopsy can replace ALND in daily clinical practice, some technical aspects must be standardized, and clinical trials are required in order to clarify the prognostic impact of false-negative cases.

Influence of age and menopausal status on pathologic and biologic features of breast cancer.

The distribution of the main prognostic factors in different age groups was evaluated in 1226 patients operated on for primary breast cancer, in order to identify those influenced by age and/or menopausal status. Patients were divided into the following groups: 1) 40 years of age and under; 2) premenopausal over 40 years of age; 3) postmenopausal under 75 years of age and 4) 75 years of age and over. Our findings showed that the youngest patients had the worst prognostic pattern, which improves as age increases and is the best in patients over 75 years of age. Some of the parameters investigated (tumour size, histologic and nuclear grade, tumour infiltrating lymphocytes, p53 and Ki 67) were found to be influenced by age, some (necrosis and oestrogen receptors) were influenced by menopausal status and/or age, some (vascular invasion, ploidy, S-phase and progesterone receptors) showed significant differences in different age groups but there was no consistent relation with patient age or menopausal status, and others (node status, ErbB2/Neu and Cathepsin D) were not influenced by age or menopause.

The osteo-chondro-mucous flap of the nasal septum in orbital reconstruction.

This paper describes a technique for orbital infero-medial wall reconstruction after "en bloc" resection of squamous cell carcinomas involving ethmoidal and maxillary sinuses utilizing an osteo-chondro-mucous flap of the nasal septum. This technique seems to be superior for many reasons: rapidity in flap preparation, direct access to the donor area in the resection surgical field, reliabilty due to good vascular supply, major functional and aesthetic results (low risk of diplopia and eyeball displacement). In our opinion, among the orbital reconstruction techniques, the osteo-chondro-mucous flap of the nasal septum can be the preferred reconstructive choice in ethmoid-orbital-maxillectomy with excision of the whole medial and two thirds of the lower orbital walls.