National Brazilian survey on the outcomes of hepatitis c retreatment in patients non-responders to direct antiviral agents.

BACKGROUND AND AIMS: Treatment of hepatitis C with direct antiviral agents (DAA) is associated with almost 95% of sustained virological response. However, some patients need retreatment. In Brazil, it should be done according to the Ministry of Health guidelines, frequently updated to include newly available drugs. This study aimed to conduct a national survey about the characteristics and outcomes of retreatment of hepatitis C in previously non-responders to DAAs. PATIENTS AND METHODS: Institutions from all over the country were invited to participate in a national registry for retreatment, including information about clinical and epidemiological characteristics of the patients, type and outcomes of retreatment regimens. Only patients previously treated with interferon-free regimens were included. RESULTS: As previous treatments the distribution was: SOF/DCV (56%), SOF/SIM (22%), 3D (11%), SOF/LED (6%) and SOF/RBV (5%). For retreatment the most frequently used drugs were SOF/GP (46%), SOF/DCV (23%) and SOF/VEL (11%). From 159 patients retreated, 132/159 (83%) had complete information in the registry and among them only seven patients were non-responders (SVR of 94.6%). All retreatments were well tolerated, without any serious adverse events or interruptions. CONCLUSION: The retreatment of patients previously non-responders to DAAs was associated with high rate of SVR in this sample of Brazilian patients. This finding allows us to conclude that the retreatment options available in the public health system in Brazil are effective and safe and are an important component of the strategy of elimination of hepatitis C in our country.

National Brazilian survey on the outcomes of hepatitis c retreatment in patients non-responders to direct antiviral agents

ABSTRACT Background and aims: Treatment of hepatitis C with direct antiviral agents (DAA) is associated with almost 95% of sustained virological response. However, some patients need retreatment. In Brazil, it should be done according to the Ministry of Health guidelines, frequently updated to include newly available drugs. This study aimed to conduct a national survey about the characteristics and outcomes of retreatment of hepatitis C in previously non-responders to DAAs. Patients and methods: Institutions from all over the country were invited to participate in a national registry for retreatment, including information about clinical and epidemiological characteristics of the patients, type and outcomes of retreatment regimens. Only patients previously treated with interferon-free regimens were included. Results: As previous treatments the distribution was: SOF/DCV (56%), SOF/SIM (22%), 3D (11%), SOF/LED (6%) and SOF/RBV (5%). For retreatment the most frequently used drugs were SOF/GP (46%), SOF/DCV (23%) and SOF/VEL (11%). From 159 patients retreated, 132/159 (83%) had complete information in the registry and among them only seven patients were non-responders (SVR of 94.6%). All retreatments were well tolerated, without any serious adverse events or interruptions. Conclusion: The retreatment of patients previously non-responders to DAAs was associated with high rate of SVR in this sample of Brazilian patients. This finding allows us to conclude that the retreatment options available in the public health system in Brazil are effective and safe and are an important component of the strategy of elimination of hepatitis C in our country.

Association of IL-9, IL-10, and IL-17 Cytokines With Hepatic Fibrosis in Human Schistosoma mansoni Infection.

This is a case series study to evaluate immunological markers associated with schistosomiasis advanced fibrosis, including 69 patients from an endemic area from the State of Sergipe and from the Hepatology Service of the University Hospital in Sergipe, Brazil. Hepatic fibrosis was classified based on Niamey protocol for ultrasonography (US). Immune response to Schistosoma mansoni antigens was evaluated by stimulating peripheral blood mononuclear cells (PBMCs) from these patients with either adult worm (SWAP-10 µg/ml) or egg (SEA-10 µg/ml) antigens or purified protein derivative of turberculin (PPD-10 µg/ml) or phytohemagglutinin (PHA-1 µg/ml) for 72 h. The levels of IFN-γ, TNF-α, IL-5, IL-10, and IL-17 were measured in these supernatants by ELISA and IL-9 by Luminex. Single nucleotide polymorphisms in IL-17, IL10, and CD209 genes were genotyped using TaqMan probe by qPCR. Higher levels of IL-9, IL-10, and IL-17 were found in PBMC supernatants of patients with advanced hepatic fibrosis. Direct correlations were detected between IL-9 and IL-17 levels with US spleen sizes, portal vein diameters, and periportal thickening. The CD209 rs2287886 AG polymorphism patients produce higher IL-17 levels. Together, these data suggest a role of these cytokines in the immunopathogenesis of advanced fibrosis in human schistosomiasis.

Fast Tracks: Estratégia de enfrentamento da pandemia de COVID-19 em um hospital privado / Fast tracks: facing strategy for covid-19 pandemic in a private hospital

Objetivo: Descrever as etapas de elaboração e execução de um plano de contingência para a pandemia de coronavírus em um hospital privado com uso de sistema Fast Tracks. Metodologia: Trata-se de um estudo descritivo com objetivo de elaboração de plano e organização de Fast Track para pacientes com sintomas respiratórios que busquem o setor de urgência do hospital. Resultados: A proposta deste sistema consiste no atendimento de pacientes com Síndrome Gripal de forma isolada ao da Unidade de Urgência, sendo atendidos em ambiente sem contato direto com o setor da urgência. Conclusão: Os Fast Tracks visam otimizar os serviços prestados, e principalmente, a diminuição cruzada do vírus, tão preconizada pelos órgãos mundiais em combate a pandemia, além de evitar a superlotação da unidade de emergência. (AU)

Objective: To describe the steps for preparing and executing a contingency plan for the coronavirus pandemic in a private hospital using the Fast Tracks system. Methodology: This is a descriptive study with the objective of developing a plan and organization of Fast Track for patients with respiratory symptoms who seek the emergency department of the hospital. Results: The purpose of this system is to assist patients with Flu Syndrome in isolation from the Emergency Unit, being treated in an environment without direct contact with the emergency department. Conclusion: Fast Tracks aim to optimize the services provided, and mainly, the cross-reduction of the virus, so advocated by world agencies in fighting the pandemic, in addition to avoiding overcrowding of the emergency unit. (AU)

Objetivo: Describir los pasos para preparar y ejecutar un plan de contingencia para la pandemia de coronavirus en un hospital privado utilizando el sistema Fast Tracks. Metodología: Este es un estudio descriptivo con el objetivo de desarrollar un plan y organización de Fast Track para pacientes con síntomas respiratorios que buscan el servicio de urgencias del hospital. Resultados: El objetivo de este sistema es ayudar a los pacientes con síndrome de gripe aislados de la unidad de emergencia, que reciben tratamiento en un entorno sin contacto directo con el departamento de emergencias. Conclusión: Fast Tracks tiene como objetivo optimizar los servicios prestados, y especialmente, la reducción cruzada del virus, tan defendido por las agencias mundiales en la lucha contra la pandemia, además de evitar el hacinamiento de la unidad de emergencia. (AU)

Spatial analysis of viral hepatitis and schistosomiasis coinfection in an endemic area in Northeastern Brazil.

INTRODUCTION:: This cross-sectional study analyzed the spatial distribution of hepatitis B or C virus (HBV/HBC) and schistosomiasis coinfection. METHODS:: Serum samples were collected from patients with Schistosoma mansoni infection. These were tested for serological markers of HBV/HCV infection. The spatial distribution of coinfection was analyzed using intensity kernel estimation. RESULTS:: Overall, 9.4% of individuals had contact with HBV and 1.7% of samples tested positive for anti-HCV antibodies. We identified clusters of risk located in the central region. CONCLUSIONS:: Spatial analysis allowed visualization of high-risk areas, leading to a definition of priority areas to be targeted for intensification of control interventions.

Spatial analysis of viral hepatitis and schistosomiasis coinfection in an endemic area in Northeastern Brazil

Abstract INTRODUCTION: This cross-sectional study analyzed the spatial distribution of hepatitis B or C virus (HBV/HBC) and schistosomiasis coinfection. METHODS: Serum samples were collected from patients with Schistosoma mansoni infection. These were tested for serological markers of HBV/HCV infection. The spatial distribution of coinfection was analyzed using intensity kernel estimation. RESULTS: Overall, 9.4% of individuals had contact with HBV and 1.7% of samples tested positive for anti-HCV antibodies. We identified clusters of risk located in the central region. CONCLUSIONS: Spatial analysis allowed visualization of high-risk areas, leading to a definition of priority areas to be targeted for intensification of control interventions.

Diagnosis and treatment of benign liver nodules: Brazilian Society of Hepatology (SBH) recommendations

ABSTRACT Space-occupying lessions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenoms and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenoms are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenoms may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenoms growth, particularly of the hepatocyte nuclear factor-1 alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of hte liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the adsence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agentes are indicated.

RESUMO As lesões que ocupam espaço no fígado podem ser císticas ou sólidas. A ultrassonografia é extremamente útil como rastreamento inicial, bastando como método diagnósticos em casos de cistos simples. Em cistos complexos e em nódulos sólidos é necessária a complementação diagnóstica com tomografia computadorizada ou ressonância magnética. Em casos de cistadenoma ou cistadenocarcinoma, a ampla retirada cirúrgica está indicada. Dados clínico-epidemiológicos são importantes, já que nódulos em fígados não-cirróticos têm maiores probabilidades de serem benignos. Para os hemangiomas, tumores benignos mais frequentes, após a confirmação diagnóstica não existe necessidade de acompanhamento sistemático quando os nódulos são pequenos e assintomáticos. Hemangiomas gigantes sintomáticos ou comprimindo órgãos vizinhos devem ser encaminhados a centros de referência para avaliação de intervenção cirúrgica. A heterogeneidade genética nos adenomas hepatocelulares bem como características epidemiológicas e prognósticas motivou sua classificação em quatro subtipos, com base em achados histológicos e de imunohistoquímica. As principais complicações que ocorrem com o adenomas hepatocelulares são ruptura com hemorragia e transformação carcinomatosa. A primeira ocorre em cerca de 30% dos casos e o principal fator de risco para esta complicação são tumores maiores do que 5 cm, do subtipo hiperplasia nodular focal 1A, esses medicamentos devem ser suspensos. A hiperplasia nodular focal é o segundo tumor benigno mais frequente, mais comum nas mulheres entre 20 e 60 anos, sendo assintomáticos em 70% a 90% dos casos. Na ausência de lesão cicatricial central e/ou outros sinais sugestivos de hiperplasi nodular focal, havendo dúvida diagnóstica com adenoma hepatocelular, o uso de contraste hepatespecíficos está indicado.

Diagnosis and treatment of benign liver nodules: Brazilian Society of Hepatology (SBH) recommendations.

Space-occupying lesions of the liver may be cystic or solid. Ultrasonography is an extremely useful method for initial screening, and suffices for diagnosis of simple hepatic cysts. Complex cysts and solid masses require computed tomography or magnetic resonance imaging for confirmation. Wide surgical excision is indicated in cystadenoma or cystadenocarcinoma. Clinical and epidemiological data are important, as nodules in noncirrhotic livers are more likely to be benign. Hemangiomas, the most common benign tumors, require no follow-up after diagnostic confirmation if they are small and asymptomatic. Patients with giant, symptomatic hemangiomas or compression of adjacent structures should be referred to hepatobiliary centers for potential surgery. The genetic heterogeneity of hepatocellular adenomas and their epidemiology and prognosis prompted classification of these tumors into four subtypes based on histology and immunohistochemistry. The major complications of hepatocellular adenomas are rupture with bleeding and malignant transformation. Rupture occurs in approximately 30% of cases. The main risk factors are tumors size >5 cm and inflammatory subtype. Hepatocellular adenomas may enlarge during pregnancy due to marked hormonal stimulation. As oral contraceptive pills and anabolic steroids have associated with hepatocellular adenomas growth, particularly of the hepatocyte nuclear factor-1alfa subtype, these drugs should be discontinued. Focal nodular hyperplasia is the second most common benign tumor of the liver. It is most frequent in women aged 20 to 60, and 70% to 90% of cases are asymptomatic. In the absence of a central scar and/or other hallmarks of Focal nodular hyperplasia, with uncertainty between this diagnosis and hepatocellular adenoma, liver-specific contrast agents are indicated.

Association of the Nonalcoholic Hepatic Steatosis and Its Degrees With the Values of Liver Enzymes and Homeostasis Model Assessment-Insulin Resistance Index.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is among the most common chronic diseases of the modern world with a wide variety of factors including genetic, environmental and metabolic. The aim of this study was to verify the association between the degrees of hepatic steatosis at the abdominal ultrasound and the values of aminotransferases (aspartate aminotransferase (AST) and alanine transferase (ALT)), gamma glutamyl transpeptidase (GGT) and homeostasis model assessment-insulin resistance (HOMA-IR) index. METHODS: A prospective, descriptive survey study, using a quantitative analytical examination, was conducted from July 2013 to July 2014. In the statistical analysis, values were expressed as median, first and third quartiles. We used the nonparametric Kruskal-Wallis test to compare the medians between the degrees of steatosis, adopted a statistical significance of 5% (P ≤ 0.05) and used the statistical program SPSS 22.0. RESULTS: We diagnosed 233/800 (29.1%) patients with hepatic steatosis on routine ultrasound, and 65.7% were female. Regarding degrees, 119 had grade 1 (51.0%), 94 grade 2 (40.4%) and 20 grade 3 (8.6%). The median age of the patients with grade 1, 2 or 3 did not vary significantly (P > 0.05). The median body mass index (BMI), although clinically important because of its elevation, did not differ significantly (P > 0.05). ALT levels increased as the degree of hepatic steatosis has advanced as well as the levels of AST, GGT and HOMA-IR. AST values showed a greater association with the severity of fatty liver (P = 0.0001) than the ALT (P = 0.001). CONCLUSIONS: ALT, AST, GGT and HOMA-IR are associated to the degrees of hepatic steatosis on ultrasound and can help in the selection of patients for the liver histological evaluation.

Aspectos ultrassonográficos associados à morbidade de formas clínicas crônicas de esquistossomose mansônica, utilizando-se protocolo proposto pela Organização Mundial da Saúde / Sonographic features associated with morbidity of chronic clinical presentations of schistosomiasis mansoni using the protocol proposed by the World Health Organization

OBJECTIVE: To evaluate sonographic features associated with morbidity in patients with chronic clinical presentations of schistosomiasis mansoni, according to the protocol proposed by the World Health Organization (WHO). MATERIALS AND METHODS: Two distinctive populations were evaluated: a) patients from an endemic area, and b) patients from a tertiary institution, with histopathologically confirmed periportal fibrosis. Inclusion criteria: diagnosis confirmed by parasitological stool examination for Schistosoma mansoni (Kato-Katz method). Exclusion criteria: positive serology for HIV, HTLV-1, HBV or HCV. The Niamey protocol on ultrasonography proposed by the WHO was utilized. RESULTS: As the measures of periportal spaces were isolatedly evaluated, no alteration was observed in 21% of the tertiary institution patients with advanced disease. As all parameters of the Niamey protocol were considered, 100% of patients from the tertiary institution, with severe disease, presented advanced periportal fibrosis. In hepatosplenic patients from endemic areas, fibrosis was not identified at ultrasonography. CONCLUSION: The sonographic protocol proposed by the WHO can detect advanced periportal fibrosis in patients with severe form of disease with higher sensitivity than the isolated measurement of periportal space. The complexity involved in the sonographic identification of early stages of periportal fibrosis in endemic areas may give rise to the field of diagnostic supplementation and to a continued improvement of sonographic protocols in these areas.

OBJETIVO: Avaliar aspectos ultrassonográficos associados à morbidade em pacientes com formas clínicas crônicas de esquistossomose mansônica, utilizando-se protocolo proposto pela Organização Mundial da Saúde (OMS). MATERIAIS E MÉTODOS: Foram avaliadas duas populações distintas: a) área endêmica e b) institucional terciária, com histopatológico confirmando fibrose. Critérios de inclusão: diagnóstico confirmado por parasitológico de fezes para Schistosoma mansoni (método Kato-Katz). Critérios de exclusão: sorologia positiva para HIV, HTLV-1, VHB ou VHC. Foi utilizado protocolo ultrassonográfico de Niamey, proposto pela OMS. RESULTADOS: Avaliando-se isoladamente as medidas dos espaços periportais, estas se mostraram sem alterações em 21% dos indivíduos com doença avançada da instituição terciária. Utilizando-se todos os parâmetros do protocolo, 100% dos indivíduos da instituição terciária, com forma grave da doença, apresentaram fibrose periportal avançada. Em pacientes hepatoesplênicos da área endêmica não se identificou fibrose à ultrassonografia. CONCLUSÃO: O protocolo ultrassonográfico proposto pela OMS detecta fibrose periportal avançada nos pacientes com forma grave da doença, com maior sensibilidade do que a medida do espaço periportal isoladamente. A complexidade de identificação das fases iniciais da fibrose periportal, em áreas endêmicas, pela ultrassonografia, pode suscitar o campo da complementação diagnóstica e a continuidade do aprimoramento dos protocolos ultrassonográficos nestas áreas.

Side effects of the therapy with peginterferon and ribavirin in chronic hepatitis C: a small audit.

This study sought to decribe, quantify, and classify any adverse reactions occurring in patients with chronic hepatitis C treated with peginterferon and ribavirin, as well as verify the occurrence of potential medication interactions. The most prevalent reactions were fatigue (84.8%), fever (83%), weight loss (80%), irritability (74%), and body pain (72%). Most of the reactions were classified as mild (95%), whereas 4.5% were classified as moderate and 0.4% as severe. Adverse reactions led to the rearrangement of therapy for 9 patients (20%), where there was a reduction in dose for 7 (15%), temporary interruption of treatment for 5 (11%), and permanent discontinuation for 3 patients (7%). A total of 11 potential medication interactions were identified in 9 patients (20%), with the most frequent between peginterferon-α2a and captopril (45%). Given the above, it is observed that the treatment of chronic hepatitis C is marked by several adverse reactions of varying severity, which can interfere with the patient's quality of life or in treatment compliance, and that can be aggravated by potential drug-drug interactions.

Prevalence, genotypes and factors associated with HCV infection among prisoners in Northeastern Brazil.

AIM: To determine hepatitis C virus (HCV) seroprevalence and its genotypes, and to identify the factors associated with HCV infection. METHODS: This cross-sectional study, conducted in two prisons (one male and one female) in the State of Sergipe, Brazil, comprised 422 subjects. All of the prisoners underwent a rapid test for the detection of HCV antibodies. Patients with a positive result were tested for anti-HCV by enzyme linked immunosorbent assay and for HCV RNA by qualitative polymerase chain reaction (PCR). The virus genotype was defined in every serum sample that presented positive for PCR-HCV. In order to determine the factors independently associated with positive serology for HCV, multivariate logistic regression was used. RESULTS: HCV seroprevalence was 3.1%. Of the 13 subjects with positive anti-HCV, 11 had viremia confirmed by PCR. Of these, 90.9% had genotype 1. A total of 43 (10.2%) were injecting drug users, and HCV seroprevalence in this subgroup was 20.6%. The variable most strongly associated with positive serology for HCV was use of injecting drugs [odds ratio (OR), 23.3; 95% confidence interval (CI), 6.0-90.8]. Age over 30 years (OR, 5.5; 95%CI, 1.1-29.2), history of syphilis (OR, 9.8; 95%CI, 1.7-55.2) and history of household contact with HCV positive individual (OR, 14.1; 95%CI, 2.3-85.4) were also independently associated with HCV infection. CONCLUSION: Most of the HCV transmissions result from parenteral exposure. However, there is evidence to suggest a role for sex and household contact with an infected subject in virus transmission.

Sobrecarga de ferro transfusional em portadores de anemia falciforme: comparação entre ressonância magnética e ferritina sérica / Transfusional iron overload in patients with sickle cell anemia: comparison between magnetic resonance imaging and serum ferritin

OBJETIVO: Identificar variáveis preditoras de sobrecarga de ferro em portadores de anemia falciforme e correlacionar indicadores bioquímicos e imaginológicos. MATERIAiS E MÉTODOS: Foi realizado estudo transversal envolvendo 32 portadores de anemia falciforme, que foram submetidos a dosagem sérica de ferro, ferritina e a ressonância magnética do fígado. Foram realizadas cinco sequências gradiente-eco e uma spin-eco. A intensidade de sinal foi obtida em cada sequência pelas médias das regiões de interesse no fígado e musculatura paravertebral para obter a razão da intensidade de sinal (RIS) fígado/músculo. A partir da RIS foi obtida a concentração hepática estimada de ferro (CHEF) pela fórmula: e[5,808 - (0,877 × T2*) - (1,518 × PI)], onde T2* é a RIS na sequência com TE de 13 ms e PI é a RIS da sequência com ponderação intermediária. Os pacientes foram agrupados segundo o regime de transfusão de hemácias (regulares mensais versus esporádicas). RESULTADOS: Os grupos transfusionais foram comparados pelas variáveis clínico-laboratoriais, sendo significativas as diferenças entre RIS, CHEF e ferritina sérica: o grupo que recebeu transfusões regulares apresentou sobrecarga de ferro hepático mais intensa. CONCLUSÃO: A ressonância magnética foi ferramenta eficiente para avaliação de sobrecarga hepática de ferro em portadores de anemia falciforme.

OBJECTIVE: To identify predictive variables of iron overload in patients with sickle cell anemia, correlating biochemical and imaging markers. MATERIALS AND METHODS: The authors developed a cross-sectional study involving 32 patients with sickle cell anemia who were evaluated for ferritin and iron serum levels and submitted to liver magnetic resonance imaging with one spin-echo and five gradient-echo sequences. The signal intensity was obtained at each sequence, corresponding to the arithmetical mean of the measurements on regions of interest in the liver and paraspinal muscles to obtain the liver/muscle signal intensity ratio (SIR). Based on such SIR, the liver iron concentration (LIC) was estimated by means of the following formula: e[5.808 - (0.877 × T2*) - (1.518 × IW)], where T2* is the SIR on the sequence with echo time = 13 ms and IW is the SIR on the intermediate-weighted sequence. Patients were grouped according to their blood transfusion regimen (regular monthly versus sporadic transfusions). RESULTS: The comparison between the transfusion groups was based on clinical-laboratory variables, with significant differences in SIR, LIC and serum ferritin levels: the group with regular transfusions demonstrated greater hepatic iron overload. CONCLUSION: Magnetic resonance imaging is an efficient tool for evaluating liver iron overload in patients with sickle cell anemia.

Metástase cardíaca de carcinoma hepatocelular / Cardiac metastasis in hepatocellular carcinoma

As metástases cardíacas são cerca de 40 vezes mais comuns do que os tumores primários. Metástases de carcinoma hepatocelular ocorrem em estágios avançados da neoplasia, para ossos, pulmões e suprarrenais, sendo raras para o coração. O presente relato apresenta paciente portador de carcinoma hepatocelular, associado à metástase cardíaca, confirmada ao ecocardiograma transesofágico. Ausência de trombo no sistema porta, neste relato de caso, é um achado incomum.

[Liver transplantation: teaching strategies used with patients waiting for surgery]. / Transplante de fígado: resultados de aprendizagem de pacientes que aguardam a cirurgia.

This study aims to describe the learning results of the implementation of teaching strategies involving patients who will be submitted to liver transplantation. One of these strategies is to give the patients a manual with orientations and the subsequent application of a questionnaire related to the content of the manual. Authors analyzed 13 patients who were waiting for liver transplantation. With respect to the answers regarding the questionnaire, an average of 83.8% of correct responses was given and only one patient got all the questions right. During the correction and the time to clarify their doubts, authors concluded that the opportunity of reading the manual and applying the questionnaire allowed patients and families to get a better understanding about the surgery's most important aspects.

Transplante de fígado: resultados de aprendizagem de pacientes que aguardam a cirurgia / Liver transplantation: teaching strategies used with patients waiting for surgery

O objetivo deste estudo é descrever os resultados de aprendizagem da experiência de implementação de estratégias de ensino com os pacientes que serão submetidos a transplante de fígado. Uma delas é a entrega de um manual de orientação aos pacientes que entram no programa, com posterior aplicação de questionário relacionado ao conteúdo do manual. Analisou-se 13 pacientes em lista de espera para transplante de fígado, todos ocupando as primeiras posições no cadastro técnico. Em relação às respostas obtidas dos questionários aplicados, a média de acertos foi de 80,6 por cento, sendo que apenas um paciente acertou todas as questões. Durante a correção e esclarecimento das dúvidas, concluiu-se que a leitura do manual de orientação e a aplicação do questionário proporcionam esclarecimento melhor dos pacientes e de seus familiares em relação aos aspectos mais importantes da cirurgia

Cryptococcosis in cirrhotic patients.

The objective of the present study was to report on three distinct forms of presentation of Cryptococcus neoformans infection in three cirrhotic patients. One patient had disseminated cryptococcosis with detection of the fungus in ascitic fluid, cerebrospinal fluid and blood; the second patient had pleural involvement and the third had cutaneous infection caused by C. neoformans.

Síndrome hepatopulmonar: patogenia, diagnóstico e tratamento / Hepatopulmonary syndrome: pathogenesis, diagnosis and treatment

RACIONAL: A síndrome hepatopulmonar é caracterizada por tríade clínica que consiste em: 1) doença hepática e/ou hipertensão portal, 2) dilatações vasculares intra-pulmonares, e 3) anormalidades da oxigenação arterial (pressão parcial de oxigênio <70 mm Hg ou gradiente alvéolo-arterial de oxigênio >20 mm Hg). Sua freqüência varia de acordo com os métodos diagnósticos utilizados. OBJETIVOS: Fazer revisão da literatura sobre patogenia, diagnóstico e tratamento da síndrome hepatopulmonar. MÉTODOS: Levantamento no MEDLINE das publicações nacionais e internacionais mais relevantes sobre a síndrome hepatopulmonar. RESULTADOS: A prevalência da síndrome hepatopulmonar varia de 4 por cento a 17,5 por cento, a depender dos critérios diagnósticos utilizados. A doença hepática associada mais comum é a cirrose. O gradiente alvéolo-arterial de oxigênio parece ser o melhor parâmetro para avaliação das anormalidades da oxigenação arterial. Em relação à detecção das dilatações vasculares intra-pulmonares, a ecocardiografia com contraste é o método de escolha, pois é de fácil realização e pode diferenciar as comunicações intra-pulmonares das intra-cardíacas. No tratamento da síndrome hepatopulmonar, poucos relatos bem sucedidos puderam ser reproduzidos e confirmados utilizando terapia farmacológica e/ou radiologia intervencionista. Atualmente, o transplante de fígado é considerado a principal opção terapêutica desses pacientes, com resultados animadores. CONCLUSÕES: A síndrome hepatopulmonar é uma enfermidade freqüente. Exames gasométricos são necessários para o seu diagnóstico. O transplante de fígado é o tratamento de escolha para os portadores da síndrome.

Brain metastasis of hepatocellular carcinoma detected after liver transplantation

OBJETIVO: Relatar o caso de paciente com carcinoma hepatocelular submetido a transplante de fígado, que subseqüentemente manifestou recurrência tumoral em cérebro após o transplante. DESCRIÇÃO DO CASO: Homem de 48 anos de idade, com cirrose hepática secundária à infecção pelo vírus da hepatite C, com duas lesões focais hepáticas diagnosticadas como carcinoma hepatocelular pela citologia e histologia. Antes do transplante, foi submetido a tratamento coadjuvante com embolização da artéria hepática e injeção intra-tumoral de etanol. No terceiro mês pós-transplante, o paciente apresentou cefaléia, náuseas e vômitos, sem déficit neurológico focal. Tomografia computadorizada e ressonância magnética de crânio identificaram lesão expansiva hipervascular com sangramento interno. Avaliação da peça cirúrgica do transplante de fígado evidenciou invasão tumoral macroscópica da veia porta. CONCLUSÃO: A metástase cerebral de carcinoma hepatocelular após transplante de fígado pode ocorrer antes ou logo após a cirurgia. Pacientes, em lista para transplante de fígado, devem ser investigados para presença de metástase cerebral. Invasão vascular pode indicar disseminação tumoral hematogênica.

Brain metastasis of hepatocellular carcinoma detected after liver transplantation.

AIM: We report the case of a patient with hepatocellular carcinoma submitted to liver transplantation, who subsequently manifested tumor recurrence initially as brain metastasis. CASE DESCRIPTION: A 48-year-old male cirrhotic patient with hepatitis C infection, and two focal hepatic lesions, had a cytologic and histologic diagnosis of hepatocellular carcinoma. Before transplant, he was submitted to adjuvant treatment with a combination of arterial embolization and intratumoral ethanol injection. In the 3rd month post-liver transplantation, the patient developed headache, nausea and vomiting, without any neurological impairment. Brain computed tomography and magnetic resonance imaging identified an expansive hypervascular lesion with internal bleeding. Evaluation of the surgical explant revealed macroscopic invasion of portal vessels. CONCLUSION: Brain metastasis of a hepatocellular carcinoma after liver transplantation may occur. This metastasis may have occurred before or soon after the transplant. Patients with hepatocellular carcinoma, awaiting liver transplant, should be screened for cerebral metastasis. Vascular invasion may indicate hematogenic dissemination of the tumor.