Accuracy of the Verbal Autopsy questionnaire in the diagnosis of COVID-19 deaths in a Brazilian capital

ABSTRACT The Verbal Autopsy (VA) is a questionnaire about the circumstances surrounding a death. It was widely used in Brazil to assist in postmortem diagnoses and investigate excess mortality during the Coronavirus Disease 2019 (COVID-19) pandemic. This study aimed to determine the accuracy of investigating acute respiratory distress syndrome (ARDS) using VA. This is a cross-sectional study with prospective data collected from January 2020 to August 2021 at the Death Verification Service of Sao Luis city, Brazil. VA was performed for suspected COVID-19 deaths, and one day of the week was randomly chosen to collect samples from patients without suspected COVID-19. Two swabs were collected after death and subjected to reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 detection. Of the 250 cases included, the VA questionnaire identified COVID-19-related ARDS in 67.2% (52.98% were positive for COVID-19). The sensitivity of the VA questionnaire was 0.53 (0.45-0.61), the specificity was 0.75 (0.64-0.84), the positive predictive value was 0.81 (0.72-0.88), and the negative predictive value was 0.44 (0.36-0.53). The VA had a lower-than-expected accuracy for detecting COVID-19 deaths; however, because it is an easily accessible and cost-effective tool, it can be combined with more accurate methods to improve its performance.

Ensino híbrido para ensino de patologia renal na residência médica: um relato / Blended Learning for teaching Renal Pathology in Medical Residency - a report

Resumo: Introdução: O ensino híbrido pode ser utilizado como recurso pedagógico às formas tradicionais de ensinar. A ausência de um laboratório de patologia renal pode gerar uma lacuna na formação de médicos residentes em nefrologia. Este estudo descreve como a complementação do conteúdo com o uso de um atlas on-line de patologia renal foi descrita por médicos residentes. Relato de experiência: Um atlas virtual de patologia renal elaborado por preceptores das residências médicas de nefrologia e patologia foi apresentado a oito médicos residentes matriculados no serviço, que, durante 15 dias, incluíram os estudos desse conteúdo em suas atividades. Os residentes avaliaram a experiência de ensino-aprendizagem por meio de um grupo focal. Discussão: Estratégias de ensino on-line podem ser utilizadas para complementar o conhecimento adquirido durante a residência médica. No entanto, é importante que essa etapa da estratégia de ensino híbrido seja motivadora na visão do estudante e se adapte ao momento vivenciado pelos médicos residentes, os quais já possuem carga de trabalho determinada. Esses pontos estiveram entre os temas emergentes na análise temática do conteúdo do grupo focal, que também incluiu sugestões dos alunos em como modificar a apresentação do conteúdo. Conclusão: A inserção de estratégias de ensino híbrido pode auxiliar a formação dos médicos residentes, bem como abrir espaço para a produção discente. Parcerias interinstitucionais devem ser desenvolvidas para suprir barreiras à elaboração de e-learning pelos formadores médicos.

Abstract: Introduction: Blended Learning can be used as a pedagogical resource to the traditional ways of teaching. The lack of a Renal Pathology laboratory can result in a gap in the training of resident physicians in Nephrology. This study describes how complementing the content with the use of an online Renal Pathology atlas was described by resident physicians. Experience report: A virtual atlas of Renal Pathology prepared by preceptors of the Medical Residencies of Nephrology and Pathology was presented to eight resident physicians enrolled in the service, who, for fifteen days, included the studies of this content in their activities. The residents evaluated the teaching-learning experience through a focus group. Discussion: Online teaching strategies can be used to complement the knowledge acquired during Medical Residency. However, it is important that this stage of the blended learning strategy be motivating in the students' view, adapting to the moment experienced by resident physicians, who already have a pre-determined workload. These points were among the emerging topics in the thematic analysis of the content of the focus group, which also included suggestions from the students on how to modify the content presentation. Conclusion: The inclusion of blended learning strategies can help the training of resident physicians, as well as open space for student production. Inter-institutional partnerships should be developed to overcome barriers to e-learning development by medical trainers.

Non-lupus full-house nephropathy: a case series / Nefropatia "full-house" não relacionada ao lúpus: uma série de casos

Abstract Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune inflammatory disease. However, some patients may exhibit a histological pattern of kidney injury, with characteristics indistinguishable from lupus nephritis, but without presenting any extrarenal symptoms or serologies suggestive of SLE. Such involvement has recently been called non-lupus full-house nephropathy. The objective is to report a series of clinical cases referred to the Laboratory of the Federal University of Maranhão that received the diagnosis of "full-house" nephropathy unrelated to lupus, upon immunofluorescence and to discuss its evolution and outcomes. Non-lupus full-house nephropathy represents a diagnostic and therapeutic challenge, because it is a new entity, which still needs further studies and may be the initial manifestation of SLE, isolated manifestation of SLE or a new pathology unrelated to SLE.

Resumo O lúpus eritematoso sistêmico (LES) é uma doença inflamatória crônica autoimune multissistêmica. Alguns pacientes, contudo, podem exibir um padrão histológico de lesão renal, com características indistinguíveis da nefrite lúpica, porém sem apresentar quaisquer sintomas extrarrenais ou sorologias sugestivas de LES. Tal acometimento tem sido recentemente denominado nefropatia "full-house" não relacionada ao lúpus. O objetivo é relatar uma série de casos clínicos encaminhados ao Laboratório da Universidade Federal do Maranhão que receberam o diagnóstico de nefropatia "full-house" não relacionada ao lúpus à imunofluorescência e discutir sua evolução e desfechos. A nefropatia "full-house" não relacionada ao lúpus representa um desafio diagnóstico e terapêutico por ser uma entidade nova, que ainda necessita de maiores estudos e pode ser a manifestação inicial do LES, manifestação isolada do LES ou uma patologia nova não relacionada ao LES.

Analysis of tissue inflammatory response, fibroplasia, and foreign body reaction between the polyglactin suture of abdominal aponeurosis in rats and the intraperitoneal implant of polypropylene, polypropylene/polyglecaprone and polyester/porcine collagen meshes

ABSTRACT Purpose To compare tissue inflammatory response, foreign body reaction, fibroplasia, and proportion of type I/III collagen between closure of abdominal wall aponeurosis using polyglactin suture and intraperitoneal implant of polypropylene, polypropylene/polyglecaprone, and polyester/porcine collagen meshes to repair defects in the abdominal wall of rats. Methods Forty Wistar rats were placed in four groups, ten animals each, for the intraperitoneal implant of polypropylene, polypropylene/polyglecaprone, and polyester/porcine collagen meshes or suture with polyglactin (sham) after creation of defect in the abdominal wall. Twenty-one days later, histological analysis was performed after staining with hematoxylin-eosin and picrosirius red. Results The groups with meshes had a higher inflammation score (p < 0.05) and higher number of gigantocytes (p < 0.05) than the sham group, which had a better fibroplasia with a higher proportion of type I/III collagen than the tissue separating meshes (p < 0.05). There were no statistically significant differences between the three groups with meshes. Conclusions The intraperitoneal implant of polypropylene/polyglecaprone and polyester/porcine collagen meshes determined a more intense tissue inflammatory response with exuberant foreign body reaction, immature fibroplasia and low tissue proportion of type I/III collagen compared to suture with polyglactin of abdominal aponeurosis. However, there were no significant differences in relation to the polypropylene mesh group.

Is splenectomy an option for multiple relapses in a child with visceral leishmaniasis? A case report

Abstract Visceral leishmaniasis (VL) is an infectious disease caused by Leishmania spp. The recurrence of the disease occurs, in general, in patients with decreased or loss of T-cell function, whether due to the use of corticosteroids, immunosuppressive disease, or another cause. In some cases, splenectomy may be a therapeutic option. However, the effectiveness of splenectomy is not well defined. This report describes the evolution of a pediatric patient with seven recurrences of VL, who relapsed post-surgery after drug therapy and splenectomy.

Methods for glomerular quantification in dogs: a comparative study / Metodologias para quantificação glomerular em cães: um estudo comparativo

ABSTRACT: It was evaluated the different methodologies for glomerular enumeration described in the literature in a quantitative, double-blind study on the number of glomeruli present in kidney biopsy specimens obtained using a Tru-cut-type biopsy needle. Eighteen samples were taken (n=18) from various regions of canine kidneys harvested immediately after euthanasia. Sample collection was carried out using Tru-cut-type, semi-automated, 16 gauge needles. Reading and evaluation of the specimens were performed independently by four researchers by means of eye loupe inspection, light microscopy, light microscopy with a reduced condenser aperture, and dissection microscopy. Samples were also subjected to histopathological evaluation for comparison purposes. There was no inter-researcher variation for any of the tested methods. The glomerular counts obtained using light microscopy with reduced condenser aperture were similar to those reported in the histopathological evaluation (P=0.44);whereas, the other glomerular enumeration methods yielded significantly lower counts when compared to the histopathological analysis (eye loupe inspection: P<0.01; conventional light microscopy: P=0.02; dissection microscopy: P<0.01).Light microscope with lowering of the condenser lens delivers better results than conventional light microscopy and eye loupe inspection. Results obtained using dissection microscopy and eye loupe inspection did not correlate well with those provided by histopathological evaluation; consequently, these two methods should be avoided.

RESUMO: Avaliou-se as diferentes metodologias de quantificação glomerular descritas na literatura em um estudo quantitativo, duplo-cego, sobre o número de glomérulos presentes em amostras de biópsias renais obtidas com agulha de biópsia tipo Tru-cut. Dezoito amostras foram coletadas (n=18) de várias regiões de rins caninos colhidos imediatamente após a eutanásia. A coleta das amostras foi realizada com agulhas semi-automáticas de calibre 16, tipo Tru-cut. A leitura e avaliação das amostras foram realizadas de forma independente por quatro pesquisadores por meio de inspeção visual, microscopia de luz, microscopia de luz com redução da lente condensadora e microscopia de dissecção. As amostras também foram submetidas à avaliação histopatológica para fins de comparação e variação do pesquisador para qualquer um dos métodos testados. As contagens glomerulares obtidas por microscopia de luz com redução da lente condensadora foram semelhantes àquelas encontradas na avaliação histopatológica (P=0.44), enquanto que os outros métodos de quantificação glomerular produziram contagens significativamente mais baixas a análise histopatológica (inspeção da lupa dos olhos: P<0.01; microscopia de luz convencional: P=0.02; microscopia dissecação: P<0.01). Microscópio de luz com abaixamento da lente condensadora fornece melhores resultados do que microscopia de luz convencional e inspeção da lupa. As contagens obtidas usando microscopia de dissecção e inspeção de lupa de olho não se correlacionaram bem com aqueles fornecidos pela avaliação histopatológica; consequentemente, estes dois métodos devem ser evitados.

Rhinosporidiosis: the largest case series in Brazil

Abstract: INTRODUCTION: Rhinosporidiosis is a chronic infection of the mucous membrane and is caused by Rhinosporidium seeberi, an aquatic mesomycetozoan. The mode of infection is probably transepithelial penetration. The large number of rivers and lakes and the strong presence of riparian populations in the State of Maranhão are strong predisposing factors for rhinosporidiosis. METHODS: A 5-year retrospective study was conducted in a tertiary medical center situated in Maranhão, Northeast Brazil. Twenty-five Maranhense patients diagnosed with rhinosporidiosis were analyzed. RESULTS: Most of the patients were children, adolescents and young adults (age range: 7-24 years, mean age: 14 years). The majority of the participants were male (84%), brown (76%), and students (92%). All lesions involved the entire nasal cavity and presented with a vascular polypoid mass. All patients were treated by surgical excision of the lesions. CONCLUSIONS: Rhinosporidiosis affects younger age groups, especially students from the countryside and the outskirts of urban areas. This study will aid and guide physicians in diagnosing and treating this infection in endemic areas.

The effects of aqueous extract of babassu (Orbignya phalerata) on the pleura and lung parenchyma in rats

PURPOSE: To evaluate macro and microscopically, changes following the use of the aqueous extract of babassu (Orbignya phalerata) in the lung parenchyma and pleura of rats. METHODS: Sixty adult male rats with average weight of 350 g, were randomized into two groups of 30 animals (experimental and control) further divided into sub-groups of 10 to be sacrificed at 48 h, 72 h and 21 days. The substance was injected into the right pleura of the animals. RESULTS: There was intense pleuropulmonary macroscopic reaction with statistically significant differences between groups respectively (p<0.05, p<0.02, p<0.03). Microscopically, no statistically significant difference was evident (p>0.05). CONCLUSION: The aqueous extract of babassu (Orbignya phalerata) was found to be highly irritating to the pleura and lung of rats, evidenced macroscopically by numerous adhesions and inflammation while no major changes were evident microscopically.

Corticotherapy response in primary IgA nephropathy / Resposta à corticoterapia na nefropatia da IgA primária

INTRODUCTION: Some beneficial effects from long-term use of corticosteroids have been reported in patients with IgA nephropathy. OBJECTIVE: This retrospective study aimed to evaluate the outcome of proteinuria and renal function according to a protocol based on a 6-month course of steroid treatment. METHOD: Twelve patients were treated with 1 g/day intravenous methylprednisolone for 3 consecutive days at the beginning of months 1, 3, and 5 plus 0.5 mg/kg oral prednisone on alternate days for 6 months (treated group). The control group included 9 untreated patients. RESULTS: Proteinuria (median and 25th and 75th percentiles) at baseline in the treated group was 1861 mg/24h (1518; 2417 mg/24h) and was 703 mg/24h (245; 983) and 684 mg/24h (266; 1023) at the 6th (p < 0.05 vs. baseline) and 12th months (p < 0.05 vs. baseline), respectively. In the control group the proteinuria was 1900 mg/24h (1620; 3197) at baseline and was 2290 mg/24h (1500; 2975) and 1600 mg/24h (1180; 2395) at the 6th and 12th months, respectively (not significant vs. baseline). When compared with the control group, the treated group showed lower proteinuria (p < 0.05) during the follow-up and a higher number of patients in remission (p < 0.05) at the 6th and 12th months. Renal function did not change during the follow-up and the adverse effects were mild in most of the patients. CONCLUSION: The 6-month course of steroid treatment was effective in reducing proteinuria during the 12 months of the follow-up, and was well-tolerated by most of the patients.

INTRODUÇÃO: Tem sido sugerido que tratamento mais prolongado com corticosteroides pode ser benéfico em pacientes com nefropatia da IgA primária. OBJETIVO: Neste estudo retrospectivo avaliamos os efeitos na proteinúria e na função renal após 12 meses do protocolo baseado no uso por 6 meses de corticosteroides. MÉTODO: Doze pacientes receberam pulsos de 1 g/dia de metilprednisolona intravenosa por 3 dias consecutivos no início dos meses 1, 3 e 5, seguidos por prednisona (0,5 mg/kg) por via oral em dias alternados após cada pulso durante 6 meses (grupo tratado). O grupo controle foi composto por nove pacientes não tratados. RESULTADOS: A proteinúria (mg/24h; mediana; 25º; 75º percentis) no período basal no grupo tratado foi de 1861 (1518; 2417) e de 703 (245; 983) e de 684 (266; 1023) nos 6º (p < 0,05 vs. basal) e 12º (p < 0,05 vs. basal) meses, respectivamente. No grupo controle, a proteinúria foi de 1900 (1620; 3197) no período basal e de 2290 (1500; 2975) e de 1600 (1180; 2395) nos 6º e 12º meses, respectivamente (não significantes vs. basal). Comparado com o grupo controle, o grupo tratado teve menor proteinúria (p < 0,05) e número maior de pacientes em remissão (p < 0,05) nos 6º e 12º meses. A função renal não teve alteração significante e eventos adversos foram de pequena intensidade na maioria dos pacientes. CONCLUSÃO: O protocolo terapêutico base-ado no uso por 6 meses de corticosteroides foi efetivo em reduzir a proteinúria durante os 12 meses de seguimento e foi bem tolerado pela maioria dos pacientes.

Renal macrophage infiltration is associated with a poor outcome in IgA nephropathy

OBJECTIVES: The objectives of our study were as follows: 1) to analyze the prognostic value of macrophage infiltration in primary IgA nephropathy (IgAN) and 2) to study the relationship between macrophages and other factors associated with the development of renal fibrosis, including mast cells, TGF-β1, α-SMA and NF-kB. METHODS: We analyzed 62 patients who had been diagnosed with IgAN between 1987 and 2003. Immunohistochemical staining was performed with monoclonal antibodies against CD68 and mast cell tryptase and polyclonal antibodies against TGF-β1, α-SMA and NF-kB p65. We also used Southwestern histochemistry for the in situ detection of activated NF-kB. RESULTS: The infiltration of macrophages into the tubulointerstitial compartment correlated with unfavorable clinical and histological parameters, and a worse clinical course of IgAN was significantly associated with the number of tubulointerstitial macrophages. Kaplan-Meier curves demonstrated that increased macrophage infiltration was associated with decreased renal survival. Moreover, the presence of macrophages was associated with mast cells, tubulointerstitial α-SMA expression and NF-kB activation (IH and Southwestern histochemistry). In the multivariate analysis, the two parameters that correlated with macrophage infiltration, proteinuria and tubulointerstitial injury, were independently associated with an unfavorable clinical course. CONCLUSION: An increased number of macrophages in the tubulointerstitial area may serve as a predictive factor for poor prognosis in patients with IgAN, and these cells were also associated with the expression of pro-fibrotic factors.

Minimal change disease associated with type 1 and type 2 diabetes mellitus / Glomerulopatia de lesões mínimas associada ao diabetes melito do tipo 1 e do tipo 2

A 19-year-old female with type 1 diabetes for four years, and a 73-year-old female with type 2 diabetes for twenty years developed sudden-onset nephrotic syndrome. Examination by light microscopy, immunofluorescence, and electron microscopy (in one case) identified minimal change disease (MCD) in both cases. There was a potential causative drug (meloxicam) for the 73-year-old patient. Both patients were treated with prednisone and responded with complete remission. The patient with type 1 diabetes showed complete remission without relapse, and the patient with type 2 diabetes had two relapses; complete remission was sustained after associated treatment with cyclophosphamide and prednisone. Both patients had two years of follow-up evaluation after remission. We discuss the outcomes of both patients and emphasize the role of kidney biopsy in diabetic patients with an atypical proteinuric clinical course, because patients with MCD clearly respond to corticotherapy alone or in conjunction with other immunosuppressive agents.

Uma paciente de 19 anos de idade com diabetes tipo 1 durante quatro anos e uma paciente de 73 anos de idade com diabetes tipo 2 durante vinte anos desenvolveram quadro súbito de síndrome nefrótica. O exame histológico à microscopia de luz, imunofluorescência e microscopia eletrônica (em um caso) diagnosticou glomerulopatia de lesões mínimas (GLM) em ambos os casos. Na paciente de 73 anos de idade, houve uma associação com o uso de meloxicam. As duas pacientes foram tratadas com corticosteroides e responderam com remissão completa do quadro. A paciente de 19 anos com diabetes tipo 1 apresentou remissão completa sem recidivas, e a paciente de 73 anos com diabetes tipo 2 apresentou dois episódios de recidiva; a remissão completa foi conseguida após associação ao tratamento com ciclofosfamida. As duas pacientes foram seguidas dois anos após a remissão completa. Os casos descritos enfatizam o papel da biópsia renal em pacientes diabéticos com evolução atípica do aparecimento de proteinúria, pois pacientes com GLM respondem bem à corticoterapia como único tratamento ou associado a outro agente imunossupressor.

Acidente botrópico fatal / Death caused by bothrops poisoning

Os acidentes ofídicos causados pelo gênero Bothrops ocasionam manifestações locais secundárias à ação inflamatória aguda do veneno. A ocorrência de óbito (em torno de 0,6% do total de casos atendidos anualmente no Brasil) é rara, mas certamente, traumática. O relato deste caso visa chamar a atenção para possíveis complicações locais e sistêmicas (insuficiência renal e sepsis) neste tipo de envenenamento e enfatizar as medidas terapêuticas e de suporte que devem ser realizadas em tempo hábil.

The Snakebite caused by Bothrops gender cause local events secondary to acute inflammatory action of the poison. The occurrence of death (about 0.6% of all cases occurred each year in Brazil) is rare, but certainly traumatic. The report of this case aims to draw attention to possible local and systemic complications (sepsis and renal failure) in this type of poisoning and emphasize the therapeutic and supportive measures that should be carried out in a timely fashion.