Refractory secondary hyperparathyroidism in waiting list for parathyroidectomy: who we should operate first in a quaternary hospital in Brazil regarding survival.

BACKGROUND: Few centers in Brazil perform parathyroidectomy (PTX) for recalcitrant secondary hyperparathyroidism (SHPT) generating a long queue. There is little data regarding prioritize criteria besides chronological order and survival. OBJECTIVES: To determine the difference of clinical and laboratory factors between PTX patients and those who remained in the line despite the need for surgery and their survival. METHODS: A retrospective cohort study was conducted in a quaternary hospital in Brazil, where 43 patients with PTX indication due to severe SHPT were followed from 2009 to 2016. While 31 patients underwent PTX, 12 remained in the queue. Data on clinical and laboratory factors were collected for comparison and Kaplan-Meier and Cox regression survival analysis were used. RESULTS: PTX group was younger (40.9 vs. 49.3 years, p = .03), had higher PTH levels (2578 vs. 1937 pg/ml, p = .01) and higher CaxP product (62 vs. 47.5, p = .02). There were no percentage differences between groups of fractures, calciphylaxis and other complications due to SHPT. Patients who were not operated had a worst overall survival (5 y 62.2% vs. 96.7%, p = .04) with a HR for death of 8.08 (p = .07, PTX as a TVC). Other variables associated with decreased survival included a history of previous myocardial infarction (HR: 10.4, p = .01) and age per additional year (HR: 1.09, p = .02). CONCLUSIONS: Patients with severe SHPT are at increased risk of death while waiting for PTX. Clinical events like fracture were not used to prioritize patients beyond consecutive order. Therefore, optimizing priority criteria for PTX may result in improved survival in this population.

Comparison between Glasgow prognostic criteria and O-POSSUM/ P-POSSUM physiological indices in patients undergoing gastrectomy for gastric adenocarcinoma and the occurrency of early postoperative complications.

INTRODUCTION: Gastric cancer is still the third cause of death worldwide due to malignant neoplasms. Its prognostic indices have not yet been well defined for surgical intervention in terms of stratifying the intensity of chronic inflammation. The Glasgow Prognostic Score (GPS) and O-POSSUM and P-POSSUM Indices may constitute these standardizations and were tested to assess the association between them and the prognosis after curative gastrectomy. METHOD: Retrospective observational study, analysing medical records of patients with gastric adenocarcinoma who underwent gastrectomy, from 2015 to 2021, in two hospitals in Rio de Janeiro. Surgical extension, pre, peri and postoperative clinical and laboratory data were observed, up to 30 days after surgery. Patients were layered by GPS and compared according to the Clavien-Dindo (CD) classification. Logistic regression was performed to test the association between the outcome and independent variables. RESULTS: Of the 48 patients, 56.25% were female. There was difference between the groups regarding surgical extension and GPS (both with p<0.001), while O-POSSUM, P-POSSUM and age showed no difference. Factors associated with CD ≥ III-a complication in the univariate analysis were GPS (OR: 85,261; CI: 24,909- 291,831) and P-POSSUM (OR: 1,211; CI:1,044-1,404). In the multivariate analysis, the independent factors associated with CD ≥ III-a were GPS (OR:114,865; CI: 15,430-855,086), P-POSSUM (OR: 1,133; CI: 1,086-1,181) and O-POSSUM (OR: 2,238; CI: 1,790-2,797). CONCLUSION: In this model, GPS, P-POSSUM and O-POSSUM predicted serious surgical complications. There is a need for further studies to establish strategies to minimize the inflammatory response in the preoperative period.

Characteristics of the learning curve in robotic thoracic surgery in an emerging country.

It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.

Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study.

Objective: The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS). Materials and methods: In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules. Results: Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer. Conclusion: Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Early Abortions and Congenital Malformations: A Comparison Between Agricultural and Nonagricultural Areas in the State of São Paulo/Brazil.

INTRODUCTION: Areas with higher agricultural production have higher rates of abortion and malformation, probable related to pesticides. OBJECTIVE: To compare the rates of early abortion and fetal malformation in agricultural and nonagricultural areas. METHOD: A survey was carried out on fetal deaths in children weighing less than 500 g or gestational age less than 22 weeks and fetal malformations in live births. RESULTS: From 1996 to 2018, there was an increase in the rates of abortion and, albeit to a lesser extent, malformation. The areas of greater agricultural production have higher rates of fetal mortality and malformation than the others. CONCLUSIONS: The study suggests that areas with higher use of pesticides have higher rates of abortion and fetal malformations than the others, requiring further observational studies, reducing confounders inherent to the ecological study.

Comparison between Glasgow prognostic criteria and O-POSSUM/ P-POSSUM physiological indices in patients undergoing gastrectomy for gastric adenocarcinoma and the occurrency of early postoperative complications / Comparação entre os critérios prognósticos de Glasgow e os índices fisiológicos O-POSSUM / P-POSSUM em pacientes com adenocarcinoma gástrico submetidos à gastrectomia e a ocorrência de complicações no pós-operatório precoce

ABSTRACT Introduction: Gastric cancer is still the third cause of death worldwide due to malignant neoplasms. Its prognostic indices have not yet been well defined for surgical intervention in terms of stratifying the intensity of chronic inflammation. The Glasgow Prognostic Score (GPS) and O-POSSUM and P-POSSUM Indices may constitute these standardizations and were tested to assess the association between them and the prognosis after curative gastrectomy. Method: Retrospective observational study, analysing medical records of patients with gastric adenocarcinoma who underwent gastrectomy, from 2015 to 2021, in two hospitals in Rio de Janeiro. Surgical extension, pre, peri and postoperative clinical and laboratory data were observed, up to 30 days after surgery. Patients were layered by GPS and compared according to the Clavien-Dindo (CD) classification. Logistic regression was performed to test the association between the outcome and independent variables. Results: Of the 48 patients, 56.25% were female. There was difference between the groups regarding surgical extension and GPS (both with p<0.001), while O-POSSUM, P-POSSUM and age showed no difference. Factors associated with CD ≥ III-a complication in the univariate analysis were GPS (OR: 85,261; CI: 24,909- 291,831) and P-POSSUM (OR: 1,211; CI:1,044-1,404). In the multivariate analysis, the independent factors associated with CD ≥ III-a were GPS (OR:114,865; CI: 15,430-855,086), P-POSSUM (OR: 1,133; CI: 1,086-1,181) and O-POSSUM (OR: 2,238; CI: 1,790-2,797). Conclusion: In this model, GPS, P-POSSUM and O-POSSUM predicted serious surgical complications. There is a need for further studies to establish strategies to minimize the inflammatory response in the preoperative period.

RESUMO Introdução: O câncer gástrico segue como terceira causa de mortalidade mundial por neoplasias malignas. Seus índices prognósticos ainda não foram bem definidos para intervenção cirúrgica quanto à estratificação da intensidade da inflamação crônica. Os Critérios Prognósticos de Glasgow (CPG) e os índices de O-POSSUM e PPOSSUM podem constituir essas padronizações e foram testados para avaliar a associação entre eles e o prognóstico após gastrectomia curativa. Método: Estudo retrospectivo, analisando prontuários de pacientes com adenocarcinoma gástrico e submetidos à gastrectomia, no período de 2015 até 2021, em dois hospitais no Rio de Janeiro. Foram observados a extensão cirúrgica, os dados clínicos e laboratoriais pré, peri e pós-operatórios, até 30 dias após a cirurgia. Os pacientes foram estratificados pelos CPG e comparados segundo classificação de ClavienDindo (CD). Regressão logística foi realizada para testar associação entre o desfecho e variáveis independentes. Resultados: Dos 48 doentes, 56,25% eram do sexo feminino. Houve diferença entre os grupos quanto à extensão cirúrgica e CPG (ambos com p<0,001), enquanto O-POSSUM, P-POSSUM e idade não apresentaram diferença. Fatores associados com complicação CD ≥ III-a na análise univariada foram CPG (OR: 85,261; IC: 24,909-291,831) e P-POSSUM (OR: 1,211; IC: 1,044-1,404). Na análise multivariada, os fatores independentes associados ao CD ≥ III-a foram CPG (OR: 114,865; IC: 15,430-855,086), P-POSSUM (OR: 1,133; IC: 1,086-1,181) e O-POSSUM (OR: 2,238; IC: 1,790-2,797). Conclusão: Neste modelo, CPG, P-POSSUM e O-POSSUM previram complicações cirúrgicas graves. Há necessidade de estudos mais aprofundados para instituir estratégias de forma a minimizar a resposta inflamatória no período pré-operatório.

Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study

ABSTRACT Objective: The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS). Materials and methods: In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules. Results: Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer. Conclusion: Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Acurácia da tomografia computadorizada de múltiplos detectores no diagnóstico da doença arterial coronariana: revisão sistemática / Accuracy of multi-detector computed tomography for diagnosing coronary artery disease: systematic review

A doença arterial coronariana (DAC) é uma das condições mais prevalentes entre as doenças cardiovasculares. A angiografia coronariana invasiva (ACI) é o padrão de referência para o diagnóstico da DAC, sendo indicada quando há suspeita de estenose coronariana em pacientes com alta probabilidade de DAC. A angiocoronariografia com tomografia computadorizada de múltiplos detectores (TCMD) surgiu como nava técnica de diagnóstico, não invasiva, que permite a visão direta da artéria coronária. Sua indicação no diagnóstico de DAC, em pacientes sintomáticos com probabilidade pré-teste intermediária para essa condição, tem sido reportada. entretanto, os estudos apresentados até 2008 foram pequenos, de um único centro, envolvendo pacientes selecionados e, frequentemente, os segmentos com baixa nitidez de imagem eram excluídos da análise. O objetivo desta revisão sistemática foi avaliar a acurácia da TCMD no diagnóstico da DAC em pacientes que apresentavam probabilidade intermediária para essa condição. Dos 414 artigos encontrados, 13 estudos foram selecionados, os quais incluíam pacientes com probabilidade intermediária par DAC e que foram submetidos à angiocoronariografia invasica (ACI) e angiotomografia coronariana (ATC) de 64 detectores. Foram estudados 1992 pacientes em 12 dos 13 estudos selecionados, e somente oito estudos apresentaram dados disponíveis para a análise de 14725 segmentos coronarianas. Não houve diferença estatisticamente significativa...