Parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement.

Objective: To describe cases of parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement, correlating the clinical and imaging data. Materials and Methods: This was a retrospective descriptive case series of parafoveal chondral lesion of the femoral head in 21 patients who underwent computed tomography and magnetic resonance arthrography scans of the hip, having then received an imaging-based diagnosis of femoroacetabular impingement. Results: Of the 21 patients evaluated, 15 (71%) had cam-type femoroacetabular impingement, whereas five (24%) had mixed-type impingement, and one (5%) had pincer-type impingement. Twelve patients (57%) had a low frequency of physical activity, which was significantly associated with the presence of cam-type impingement (p = 0.015). Although the extent of the lesion correlated significantly with the acetabular coverage angle (p = 0.04), it did not correlate significantly with the alpha angle or femoral head-neck offset value (p = 0.08 and p = 0.06, respectively). We also found no correlation between the extent of the lesion and the other main parameters that define the femoroacetabular impingement types. Conclusion: This was one of the largest case series of parafoveal chondral lesion of the femoral head in patients with imaging findings of femoroacetabular impingement. The extent of such lesions does not appear to correlate with the parameters of femoroacetabular impingement, with the exception of the acetabular coverage angle.

Objetivo: Descrever casos de lesão condral parafoveal da cabeça femoral em pacientes com impacto femoroacetabular, correlacionando dados clínicos e de imagem. Materiais e Métodos: Esta foi uma série de casos descritiva retrospectiva de lesão condral parafoveal da cabeça femoral em 21 pacientes submetidos a tomografia computadorizada e artrorressonância magnética do quadril e que receberam diagnóstico por imagem de impacto femoroacetabular. Resultados: Dos 21 pacientes avaliados, 15 (71%) tiveram impacto femoroacetabular do tipo cam, enquanto cinco (24%) tiveram impacto do tipo misto e um (5%) teve impacto do tipo pincer. Doze pacientes (57%) apresentaram baixa frequência de atividade física, sendo esta significativamente associada a impacto do tipo cam (p = 0,015). Houve correlação significativa entre a extensão da lesão e o ângulo de cobertura acetabular (p = 0,04), porém, não se correlacionou significativamente com o ângulo alfa ou com o valor do deslocamento cabeça-colo femoral (p = 0,08 e p = 0,06, respectivamente). Também não encontramos correlação entre a extensão da lesão e os outros principais parâmetros que definem os tipos de impacto femoroacetabular. Conclusão: Esta foi uma das maiores casuísticas de lesão condral parafoveal da cabeça femoral em pacientes com achados de imagem de impacto femoroacetabular. A extensão dessas lesões não parece se correlacionar com os parâmetros do impacto femoroacetabular, com exceção do ângulo de cobertura acetabular.

Trust and vaccine hesitancy during the COVID-19 pandemic: A cross-national analysis.

Previous studies of vaccine hesitancy in the context of COVID-19 have reported mixed results in terms of the role played by political and institutional trust. This study addresses this ambiguity with a global analysis of the relationship between trust and vaccine hesitancy, disentangling the effects of generalized trust orientations, trust in specific institutions and conspiracy mentality. It first draws upon a cross-national survey of 113 countries to demonstrate that trust in government is a predictor of vaccine hesitancy across global regions. It further draws on original surveys fielded in seven countries (France, Germany, Spain, Argentina, Croatia, Brazil, India), which deploy a diverse range of measures, to disentangle the individual-level predictors of vaccine hesitancy. Our findings confirm the robust effects of trust in government across countries, but when including other trust measures in the same models, the most robust effects are those of trust in health institutions and conspiracy mentality. Weaker associations are observed for right-wing ideology and online political engagement, while the consumption of traditional media tends to predict the willingness of individuals to be vaccinated.

Parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement / Lesão condral parafoveal da cabeça femoral em pacientes com impacto femoroacetabular

Abstract Objective: To describe cases of parafoveal chondral lesion of the femoral head in patients with femoroacetabular impingement, correlating the clinical and imaging data. Materials and Methods: This was a retrospective descriptive case series of parafoveal chondral lesion of the femoral head in 21 patients who underwent computed tomography and magnetic resonance arthrography scans of the hip, having then received an imaging-based diagnosis of femoroacetabular impingement. Results: Of the 21 patients evaluated, 15 (71%) had cam-type femoroacetabular impingement, whereas five (24%) had mixed-type impingement, and one (5%) had pincer-type impingement. Twelve patients (57%) had a low frequency of physical activity, which was significantly associated with the presence of cam-type impingement (p = 0.015). Although the extent of the lesion correlated significantly with the acetabular coverage angle (p = 0.04), it did not correlate significantly with the alpha angle or femoral head-neck offset value (p = 0.08 and p = 0.06, respectively). We also found no correlation between the extent of the lesion and the other main parameters that define the femoroacetabular impingement types. Conclusion: This was one of the largest case series of parafoveal chondral lesion of the femoral head in patients with imaging findings of femoroacetabular impingement. The extent of such lesions does not appear to correlate with the parameters of femoroacetabular impingement, with the exception of the acetabular coverage angle.

Resumo Objetivo: Descrever casos de lesão condral parafoveal da cabeça femoral em pacientes com impacto femoroacetabular, correlacionando dados clínicos e de imagem. Materiais e Métodos: Esta foi uma série de casos descritiva retrospectiva de lesão condral parafoveal da cabeça femoral em 21 pacientes submetidos a tomografia computadorizada e artrorressonância magnética do quadril e que receberam diagnóstico por imagem de impacto femoroacetabular. Resultados: Dos 21 pacientes avaliados, 15 (71%) tiveram impacto femoroacetabular do tipo cam, enquanto cinco (24%) tiveram impacto do tipo misto e um (5%) teve impacto do tipo pincer. Doze pacientes (57%) apresentaram baixa frequência de atividade física, sendo esta significativamente associada a impacto do tipo cam (p = 0,015). Houve correlação significativa entre a extensão da lesão e o ângulo de cobertura acetabular (p = 0,04), porém, não se correlacionou significativamente com o ângulo alfa ou com o valor do deslocamento cabeça-colo femoral (p = 0,08 e p = 0,06, respectivamente). Também não encontramos correlação entre a extensão da lesão e os outros principais parâmetros que definem os tipos de impacto femoroacetabular. Conclusão: Esta foi uma das maiores casuísticas de lesão condral parafoveal da cabeça femoral em pacientes com achados de imagem de impacto femoroacetabular. A extensão dessas lesões não parece se correlacionar com os parâmetros do impacto femoroacetabular, com exceção do ângulo de cobertura acetabular.

Impact of the COVID-19 pandemic on emergency department visits: experience of a Brazilian reference center.

OBJECTIVE: To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil. METHODS: A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients' demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19. RESULTS: A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits - a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020. CONCLUSION: The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.

Impact of the COVID-19 pandemic on emergency department visits: experience of a Brazilian reference center / Impacto da pandemia da COVID-19 no volume de atendimentos no pronto atendimento: experiência de um centro de referência no Brasil

ABSTRACT Objective To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil. Methods A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients' demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19. Results A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits - a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020. Conclusion The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.

RESUMO Objetivo Analisar o impacto da pandemia da COVID-19 nas métricas do pronto atendimento de um hospital terciário de referência no Brasil. Métodos Uma análise retrospectiva das visitas consecutivas ao pronto atendimento, de 1o de janeiro de 2020 a 21 de novembro de 2020, foi realizada e comparada ao mesmo intervalo nos anos de 2018 e 2019. O volume de atendimentos e as características clínicas e demográficas dos pacientes foram comparados. Todos os diagnósticos foram incluídos, exceto os casos confirmados de COVID-19. Resultados Um total de 138.138 visitas ao pronto atendimento ocorreu durante o período do estudo, com redução estatisticamente significativa (p<0,01) de 52% do volume comparado tanto a 2018 como a 2019. Essa queda foi mais pronunciada nos atendimentos de pediatria, com redução de 71% se comparada aos números de anos anteriores. Em relação ao quadro clínico, houve redução dos casos graves em 34,7% e 37,6%, enquanto os casos leves caíram 55,2% e 56,2%, quando comparado 2020 a 2018 e a 2019, respectivamente. Uma queda de 30% foi vista no volume de admissões hospitalares originadas dessas visitas, porém houve aumento percentual da taxa de admissão mensal em relação ao volume desde abril de 2020. Conclusão O impacto da pandemia da COVID-19 gerou redução de 52% no volume de atendimento do pronto atendimento por outras condições clínicas, bem como aumento proporcional na taxa de admissão hospitalar de pacientes com COVID-19. Os profissionais de saúde devem orientar seus pacientes a não atrasar a procura por atendimento médico de condições graves que precisem de cuidados no pronto atendimento.

Combined Brain and Peripheral Nerve Stimulation in Chronic Stroke Patients With Moderate to Severe Motor Impairment.

OBJECTIVES: To evaluate effects of somatosensory stimulation in the form of repetitive peripheral nerve sensory stimulation (RPSS) in combination with transcranial direct current stimulation (tDCS), tDCS alone, RPSS alone, or sham RPSS + tDCS as add-on interventions to training of wrist extension with functional electrical stimulation (FES), in chronic stroke patients with moderate to severe upper limb impairments in a crossover design. We hypothesized that the combination of RPSS and tDCS would enhance the effects of FES on active range of movement (ROM) of the paretic wrist to a greater extent than RPSS alone, tDCS alone or sham RPSS + tDCS. MATERIALS AND METHODS: The primary outcome was the active ROM of extension of the paretic wrist. Secondary outcomes were ROM of wrist flexion, grasp, and pinch strength of the paretic and nonparetic upper limbs, and ROM of wrist extension of the nonparetic wrist. Outcomes were blindly evaluated before and after each intervention. Analysis of variance with repeated measures with factors "session" and "time" was performed. RESULTS: After screening 2499 subjects, 22 were included. Data from 20 subjects were analyzed. There were significant effects of "time" for grasp force of the paretic limb and for ROM of wrist extension of the nonparetic limb, but no effects of "session" or interaction "session x time." There were no significant effects of "session," "time," or interaction "session x time" regarding other outcomes. CONCLUSIONS: Single sessions of PSS + tDCS, tDCS alone, or RPSS alone did not improve training effects in chronic stroke patients with moderate to severe impairment.

Guidelines for the management of neuroendocrine tumours by the Brazilian gastrointestinal tumour group.

Neuroendocrine tumours are a heterogeneous group of diseases with a significant variety of diagnostic tests and treatment modalities. Guidelines were developed by North American and European groups to recommend their best management. However, local particularities and relativisms found worldwide led us to create Brazilian guidelines. Our consensus considered the best feasible strategies in an environment involving more limited resources. We believe that our recommendations may be extended to other countries with similar economic standards.

Effectiveness and safety of monoclonal antibodies for metastatic colorectal cancer treatment: systematic review and meta-analysis.

BACKGROUND: The effectiveness of chemotherapy (CT) for select cases of metastatic colorectal cancer (MCRC) has been well established in the literature, however, it provides limited benefits and in many cases constitutes a treatment with high toxicity. The use of specific molecular biological treatments with monoclonal antibodies (MA) has been shown to be relevant, particularly for its potential for increasing the response rate of the host to the tumour, as these have molecular targets present in the cancerous cells and their microenvironment thereby blocking their development. The combination of MA and CT can bring a significant increase in the rate of resectability of metastases, the progression-free survival (PFS), and the global survival (GS) in MCRC patients. OBJECTIVE: To assess the effectiveness and safety of MA in the treatment of MCRC. METHODS: A systematic review was carried out with a meta-analysis of randomised clinical trials comparing the use of cetuximab, bevacizumab, and panitumumab in the treatment of MCRC. RESULTS: Sixteen randomised clinical trials were selected. The quality of the evidence on the question was considered moderate and data from eight randomised clinical trials were included in this meta-analysis. The GS and PFS were greater in the groups which received the MA associated with CT, however, the differences were not statistically significant between the groups (mean of 17.7 months versus 17.1 months; mean difference of 1.09 (CI: 0.10-2.07); p = 0.84; and 7.4 versus 6.9 months. mean difference of 0.76 (CI: 0.08-1.44); p = 0.14 respectively). The meta-analysis was not done for any of the secondary outcomes. CONCLUSION: The addition of MA to CT for patients with metastatic colorectal cancer does not prolong GS and PFS.

Increase in Short-Interval Intracortical Facilitation of the Motor Cortex after Low-Frequency Repetitive Magnetic Stimulation of the Unaffected Hemisphere in the Subacute Phase after Stroke.

Low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere (UH-LF-rTMS) in patients with stroke can decrease interhemispheric inhibition from the unaffected to the affected hemisphere and improve hand dexterity and strength of the paretic hand. The objective of this proof-of-principle study was to explore, for the first time, effects of UH-LF-rTMS as add-on therapy to motor rehabilitation on short-term intracortical inhibition (SICI) and intracortical facilitation (ICF) of the motor cortex of the unaffected hemisphere (M1UH) in patients with ischemic stroke. Eighteen patients were randomized to receive, immediately before rehabilitation treatment, either active or sham UH-LF-rTMS, during two weeks. Resting motor threshold (rMT), SICI, and ICF were measured in M1UH before the first session and after the last session of treatment. There was a significant increase in ICF in the active group compared to the sham group after treatment, and there was no significant differences in changes in rMT or SICI. ICF is a measure of intracortical synaptic excitability, with a relative contribution of spinal mechanisms. ICF is typically upregulated by glutamatergic agonists and downregulated by gabaergic antagonists. The observed increase in ICF in the active group, in this hypothesis-generating study, may be related to M1UH reorganization induced by UH-LF-rTMS.

Motor development of Brazilian breastfeeding infants in socially unfavorable condition of life

The early years of life are of essential importance for child development and growth. The child's development in a social vulnerability and unfavorable life condition can be injured, and that early detection of disorders is fundamental for healthy development. PURPOSE: To assessment the Alberta Infant Motor Scale as an assessment tool to identify early of disorders in infants until 18 months. METHODS: This is an observational, cross-sectional study undertaken in "educational program for the growth and development promotion" at the health unit administered by reference hospital of Health Public System, in Paraisópolis community, São Paulo. The sample (n=71) was composed for infants less than 18 months of age, eutrophic, low biological risk at birth; singleton, full-term births, weight at birth between 2,000g e" and d" 4,500g and no associated congenital neurological, cardiac or orthopedic pathologies at the clinical exam. RESULTS: This study presented the greatest prevalence of delay motor neuromotor when compared with the AIMS reference population. First, 8.5% of the breastfeeding infants are classified as being mdA and 7.0% are classified as dmS and secondly that, although the category mdT contains 84.5% of the children, the median of the z-score has shifted from the central point of the normal standardized distribution, only 33.7% of the children, i.e., 24 in 71, being equal to or above Z=0 (p<0.05). CONCLUSION: The use of AIMS was efficient, practice, low cost and quick applies. Plus a quick view of motor milestone presents by infant. Features that became possible take decision by health team...(AU)

Os primeiros anos de vida são de importância essencial para o desenvolvimento infantil. O desenvolvimento neurosensoriomotor de crianças, vivendo em condição de pobreza, pode ser prejudicado, sendo a detecção precoce de anormalidades essencial para um desenvolvimento saudável. OBJETIVO: Avaliar o uso da AIMS como instrumento de avaliação para detecção precoce de anormalidades. MÉTODO: Trata-se de um estudo descritivo, do tipo transversal, realizado com lactentes brasileiros matriculados no "Programa educativo de promoção do crescimento e desenvolvimento", do ambulatório de uma unidade de saúde gerenciada por um Hospital de referência do Sistema Público de Saúde, na Comunidade de Paraisópolis, São Paulo. A amostra (n = 71) foi composta por lactentes menores de 18 meses, eutróficos, de baixo risco biológico ao nascimento, nascidos de parto único, termo, peso ao nascer entre 2.000g e 4.500g, sem associação com patologias congênitas neurológicas, cardíacas ou ortopédicas no exame clinico. RESULTADOS: Este estudo apresenta prevalência de atraso motor quando comparado com a população de referencia da AIMS. Primeiro, 8,5% dos lactentes foram classificados como mdA e 7% como dmS, além da categoria mdT conter 84,5% dos lactentes, a media do escore Z tem modificado o ponto central da distribuição padronizada, apenas 33,7% do grupo, isto e, 24 em 71, estão igual ou acima do Z = 0 (p < 0.05). CONCLUSÃO: A utilização da AIMS neste estudo foi eficiente na avaliação do desenvolvimento motor, prática, de baixo custo e rápida aplicação. Forneceu rápida visualização da posição do lactente. Característica que permite tomada de decisões oportunas pelos profissionais que integram as equipes de saúde...(AU)

Motor development of Brazilian breastfeeding infants in socially unfavorable condition of life

The early years of life are of essential importance for child development and growth. The child's development in a social vulnerability and unfavorable life condition can be injured, and that early detection of disorders is fundamental for healthy development. PURPOSE: To assessment the Alberta Infant Motor Scale as an assessment tool to identify early of disorders in infants until 18 months. METHODS: This is an observational, cross-sectional study undertaken in "educational program for the growth and development promotion" at the health unit administered by reference hospital of Health Public System, in Paraisópolis community, São Paulo. The sample (n=71) was composed for infants less than 18 months of age, eutrophic, low biological risk at birth; singleton, full-term births, weight at birth between 2,000g e" and d" 4,500g and no associated congenital neurological, cardiac or orthopedic pathologies at the clinical exam. RESULTS: This study presented the greatest prevalence of delay motor neuromotor when compared with the AIMS reference population. First, 8.5% of the breastfeeding infants are classified as being mdA and 7.0% are classified as dmS and secondly that, although the category mdT contains 84.5% of the children, the median of the z-score has shifted from the central point of the normal standardized distribution, only 33.7% of the children, i.e., 24 in 71, being equal to or above Z=0 (p<0.05). CONCLUSION: The use of AIMS was efficient, practice, low cost and quick applies. Plus a quick view of motor milestone presents by infant. Features that became possible take decision by health team...

Os primeiros anos de vida são de importância essencial para o desenvolvimento infantil. O desenvolvimento neurosensoriomotor de crianças, vivendo em condição de pobreza, pode ser prejudicado, sendo a detecção precoce de anormalidades essencial para um desenvolvimento saudável. OBJETIVO: Avaliar o uso da AIMS como instrumento de avaliação para detecção precoce de anormalidades. MÉTODO: Trata-se de um estudo descritivo, do tipo transversal, realizado com lactentes brasileiros matriculados no "Programa educativo de promoção do crescimento e desenvolvimento", do ambulatório de uma unidade de saúde gerenciada por um Hospital de referência do Sistema Público de Saúde, na Comunidade de Paraisópolis, São Paulo. A amostra (n = 71) foi composta por lactentes menores de 18 meses, eutróficos, de baixo risco biológico ao nascimento, nascidos de parto único, termo, peso ao nascer entre 2.000g e 4.500g, sem associação com patologias congênitas neurológicas, cardíacas ou ortopédicas no exame clinico. RESULTADOS: Este estudo apresenta prevalência de atraso motor quando comparado com a população de referencia da AIMS. Primeiro, 8,5% dos lactentes foram classificados como mdA e 7% como dmS, além da categoria mdT conter 84,5% dos lactentes, a media do escore Z tem modificado o ponto central da distribuição padronizada, apenas 33,7% do grupo, isto e, 24 em 71, estão igual ou acima do Z = 0 (p < 0.05). CONCLUSÃO: A utilização da AIMS neste estudo foi eficiente na avaliação do desenvolvimento motor, prática, de baixo custo e rápida aplicação. Forneceu rápida visualização da posição do lactente. Característica que permite tomada de decisões oportunas pelos profissionais que integram as equipes de saúde...

Tomographic finiings of gastric gastrointestina stromal tumor and correlation with the mitotic index / Aspectos tomograficos do tumor estromal gastrointestinal de origem gastrica e correlacao com indice mitotico

Context Gastrointestinal stromal tumors are uncommon abdominal neoplasms and can affect any portion of the gastrointestinal tract. Objectives Describe the tomographic findings of the gastrointestinal stromal tumor of gastric origin, correlating it with the mitotic index. Methods Twenty-one patients were selected within the period of January 2000 and 2008, with histopathological and immunohistochemical diagnosis of gastric gastrointestinal stromal tumors, who presented computed tomography done before the treatment. The tomographic variables analyzed were lesion topography, dimensions, contours, morphology, pattern and intensity enhancement through venous contrast, growth pattern, invasion of adjacent organs, presence of ulceration, fistula, calcifications, infiltration of mesenteric fat, lymphadenopathy and metastasis. The mitotic index was determined through optic microscopy, counting the number of mitosis figures in 50 high power fields. Results The tumors were located in the body (66.7%) or gastric fundus (33.3%), with dimensions varying between 4.2 and 21.2 cm (average of 10.5 cm). The growth was predominantly extraluminal (47.6%) or intra/extra luminal (28.6%). The enhancement by venous contrast was heterogeneous in 66.7%. The statistical analysis showed that irregular morphology (P = 0.027) and infiltration of mesenteric fat (P = 0.012) presented correlation with the high mitotic index. Conclusions In the present study, most part of the tumors were located in the gastric body, with average size of 10.5 cm, presenting central hypo dense area, heterogeneous enhancement through contrast and predominantly extra luminal growth. Irregular morphology and infiltration of mesenteric fat present statistical correlation with high mitotic level. .

Contexto Tumores estromais gastrointestinais são neoplasias raras e podem acometer qualquer segmento do trato gastrointestinal. A tomografia computadorizada é o método de imagem mais importante na detecção e caracterização do tumor. Objetivos Descrever os achados tomográficos do tumor estromal gastrointestinal de origem gástrica, correlacionando com o índice mitótico. Métodos No período de janeiro de 2000 a dezembro de 2008, foram selecionados 21 pacientes com diagnóstico histopatológico e imunohistoquímico de tumor estromal gastrointestinal, que apresentavam tomografia computadorizada realizada anteriormente ao tratamento. As variáveis tomográficas analisadas foram topografia da lesão, dimensões, contornos, morfologia, padrão e intensidade do realce pelo meio de contraste venoso, padrão de crescimento, invasão de órgãos adjacentes, presença de ulceração, fístula, calcificações, infiltração da gordura mesentérica, linfonodomegalias e metástases. O índice mitótico foi determinado através de microscopia óptica, com contagem do número de figuras de mitoses em 50 campos de grande aumento. Resultados Os tumores foram localizados no corpo (66,7%) ou fundo gástrico (33,3%), com dimensões variando entre 4,2 e 21,2 cm (média de 10,5 cm). O crescimento foi predominantemente extraluminal (47,6%) ou intra/extraluminal (28,6%). O realce pelo contraste venoso foi heterogêneo em 66.7%. A análise estatística mostrou que morfologia irregular (P = 0.027) e infiltração da gordura mesentérica (P = 0,012) apresentaram correlação com índice mitótico elevado. Conclusões No presente estudo, a maioria dos tumores localizava-se no corpo gástrico, com tamanho médio de 10.5 cm, ...

Colon and rectum neuroendocrine tumors: experience of the National Cancer Institute in Brazil.

BACKGROUND: Neuroendocrine tumors (NETs) are rare, comprising nearly 0.49% of all malignancies. The majority occurs in the gastrointestinal tract. AIM: To analyze the demographic factors, clinicopathologic features, treatment employed, prognostic factors and the oncologic results related to colorectal NETs. METHODS: Between the period from 1996 to 2010 174 patients were treated. From these, 34 were localized in the colon and rectum. Demographic factors, stage, therapeutics and its results were analyzed. All patients were followed for more than three years with image exams, urinary 5-hydroxyindolacetic acid (5-HIIA), serum chromogranin A and prostatic acid phosphatase. RESULTS: The median age was 54,4 years (22-76), the majority was female (64,7%). Out of the 12 patients with colon NETs, one (8.3%) patient was classified as Stage IA; one (8.3%) as Stage IB; three (25%) as Stage IIIB and seven (58.4%) as Stage IV. Out of the 22 patients with rectum NETs, six (27.3%) were classified as Stage IA; four (18.2%) as IB; three (13.6 %) as IIIA; one (4.5%) as IIIB and eight (36.4%) as IV. Of rectal NETs, nine (41%) were treated with endoscopic resection, six (27.2%) underwent conventional surgical treatment and six (27.2%) were treated with chemotherapy. Eleven patients with colon NETs (91.6%) were surgically treated, seven of them with palliative surgery, one (8.4%) was treated with endoscopic resection and no patient was submitted to chemotherapy. After an average follow-up of 55 months, 19 (55%) patients were alive. Analyzing the overall survival was obtained an average overall survival of 29 months in Stage IA, 62 months in IB, 12 months in IIIA, 31 months in IIIB and 39 months in IV. CONCLUSION: The treatment of colon and rectal NETs is complex, because it depends of the individuality of each patient. With adequate management, the prognosis can be favorable with long survival, but it is related to the tumor differentiation degree, efficacy of the chosen treatment and to the patient adhesion to the follow-up after treatment.

Tumores neuroendócrinos do cólon e reto: experiência do Instituto Nacional do Câncer no Brasil / Colon and rectum neuroendocrine tumors: experience of the National Cancer Institute in Brazil

RACIONAL: Os tumores neuroendócrinos (TNEs) são raros e compreendem apenas 0,49% de todas as neoplasias malignas. A maioria acomete o trato gastrointestinal. OBJETIVO: Analisar os fatores demográficos, características clinicopatológicas, tratamento empregado, fatores prognósticos e resultados oncológicos relacionados aos TNEs colorretais. MÉTODOS: No período compreendido entre 1996 e 2010 foram tratados 174 pacientes. Destes, 34 localizavam-se no cólon e reto. Foram analisados fatores demográficos, estadiamento, os procedimentos terapêuticos aplicados e seus resultados. No seguimento todos os pacientes foram acompanhados acima de três anos com exames de imagem, dosagem de 5-HIIA urinário, cromogranina-A sérica e fosfatase ácida prostática. RESULTADOS: A média de idade no diagnóstico foi de 54,5 anos (22-76), com predominância do sexo feminino (64,7%). Dos 12 com TNEs de cólon, um (8,3%) foi classificado como estádio IA; um (8,3%) em IB; três (25%) em IIIB e sete (58,4%) em IV. Dos 22 pacientes com TNEs de reto, seis (27,3%) foram classificados como estádio IA; quatro (18,2%) em IB; três (13,6%) em IIIA; um (4,5%) em IIIB e oito (36,4%) em IV. Dos TNEs de reto, nove (41%) foram tratados com ressecção endoscópica, seis (27,2%) com procedimento cirúrgico e seis (27,2%) somente com quimioterapia. Onze pacientes com TNEs de cólon (91,6%), foram tratados cirurgicamente, sendo sete paliativamente, um (8,4%) com ressecção endoscópica e nenhum foi submetido à quimioterapia no primeiro momento. Após seguimento médio de 55 meses, 19 (55%) pacientes estavam vivos. Analisando a sobrevida global obteve-se média de 29 meses no estádio IA, 62 meses no IB, 12 meses no IIIA, 31 meses no IIIB e 39 meses no IV. CONCLUSÃO: O tratamento dos TNEs de cólon e reto é complexo, pois depende de variáveis que são individuais a cada paciente. Com adequado manuseio, o prognóstico pode ser favorável e a sobrevida longa, mas ela está relacionada ao grau de diferenciação tumoral, tamanho, localização do tumor, estadiamento no momento do diagnóstico, eficácia da terapêutica adotada e à aderência do paciente ao seguimento após o tratamento.

BACKGROUND: Neuroendocrine tumors (NETs) are rare, comprising nearly 0.49% of all malignancies. The majority occurs in the gastrointestinal tract. AIM: To analyze the demographic factors, clinicopathologic features, treatment employed, prognostic factors and the oncologic results related to colorectal NETs. METHODS: Between the period from 1996 to 2010 174 patients were treated. From these, 34 were localized in the colon and rectum. Demographic factors, stage, therapeutics and its results were analyzed. All patients were followed for more than three years with image exams, urinary 5-hydroxyindolacetic acid (5-HIIA), serum chromogranin A and prostatic acid phosphatase. RESULTS: The median age was 54,4 years (22-76), the majority was female (64,7%). Out of the 12 patients with colon NETs, one (8.3%) patient was classified as Stage IA; one (8.3%) as Stage IB; three (25%) as Stage IIIB and seven (58.4%) as Stage IV. Out of the 22 patients with rectum NETs, six (27.3%) were classified as Stage IA; four (18.2%) as IB; three (13.6 %) as IIIA; one (4.5%) as IIIB and eight (36.4%) as IV. Of rectal NETs, nine (41%) were treated with endoscopic resection, six (27.2%) underwent conventional surgical treatment and six (27.2%) were treated with chemotherapy. Eleven patients with colon NETs (91.6%) were surgically treated, seven of them with palliative surgery, one (8.4%) was treated with endoscopic resection and no patient was submitted to chemotherapy. After an average follow-up of 55 months, 19 (55%) patients were alive. Analyzing the overall survival was obtained an average overall survival of 29 months in Stage IA, 62 months in IB, 12 months in IIIA, 31 months in IIIB and 39 months in IV. CONCLUSION: The treatment of colon and rectal NETs is complex, because it depends of the individuality of each patient. With adequate management, the prognosis can be favorable with long survival, but it is related to the tumor differentiation degree, efficacy of the chosen treatment and to the patient adhesion to the follow-up after treatment.

Tomographic findings of gastric gastrointestinal stromal tumor and correlation with the mitotic index.

CONTEXT: Gastrointestinal stromal tumors are uncommon abdominal neoplasms and can affect any portion of the gastrointestinal tract. OBJECTIVES: Describe the tomographic findings of the gastrointestinal stromal tumor of gastric origin, correlating it with the mitotic index. METHODS: Twenty-one patients were selected within the period of January 2000 and 2008, with histopathological and immunohistochemical diagnosis of gastric gastrointestinal stromal tumors, who presented computed tomography done before the treatment. The tomographic variables analyzed were lesion topography, dimensions, contours, morphology, pattern and intensity enhancement through venous contrast, growth pattern, invasion of adjacent organs, presence of ulceration, fistula, calcifications, infiltration of mesenteric fat, lymphadenopathy and metastasis. The mitotic index was determined through optic microscopy, counting the number of mitosis figures in 50 high power fields. RESULTS: The tumors were located in the body (66.7%) or gastric fundus (33.3%), with dimensions varying between 4.2 and 21.2 cm (average of 10.5 cm). The growth was predominantly extraluminal (47.6%) or intra/extra luminal (28.6%). The enhancement by venous contrast was heterogeneous in 66.7%. The statistical analysis showed that irregular morphology (P = 0.027) and infiltration of mesenteric fat (P = 0.012) presented correlation with the high mitotic index. CONCLUSIONS: In the present study, most part of the tumors were located in the gastric body, with average size of 10.5 cm, presenting central hypo dense area, heterogeneous enhancement through contrast and predominantly extra luminal growth. Irregular morphology and infiltration of mesenteric fat present statistical correlation with high mitotic level.

Limitações da terapêutica da insuficiência cardíaca com fração de ejeção preservada / Limitations of therapy heart failure with preserved ejection fraction

Insuficiência cardíaca com função sistólica preservada (ICFEP) apresenta elevada incidência, prevalência, morbidade e mortalidade. Diferentemente, a insuficiência cardíaca com disfunção sistólica, na qual o bloqueio farmacológico neurohormonal reduziu significativamente mortalidade e morbidade, na ICFEP, até o presente momento, não há tratamento específico suportado por evidências. Entretanto, ensaios clínicos com desfechos clinicamente significativos que testam medicamentos especificamente para ICFEP estão em andamento. O tratamento da ICFEP, portanto, deve ser norteado pelo alívio da hipervolemia preferencialmente por diuréticos de alça, controle da frequência cardíaca e anticoagulação, principalmente nos portadores de fibrilação atrial, rigorosos controle da hipertensão com vasodilatadores e alívios da isquemia com revascularização miocárdica nos coronariopatas.

Heart failure with preserved ejection fraction (HFPEF) presents high incidence, prevalence, morbidity e mortality. Unlike the heart failure with systolic dysfunction, where the neurohormonal and autonomic pharmacologic block significantly reduced mortality and morbidity, in the HFPEF, up to this point, there is no specific treatment supported by evidence. However, clinical trials with clinically significant outcomes that test drugs specifically for HFPEF are in progress. The treatment of HFPEF, therefore, must be guided by hypervolemia relief preferably by diuretics, heart rate control and anticoagulation in atrial fibrillation carriers, rigorous control of hypertension with vasoldilators and ischemia relief in the people with coronary ischemic disease.

Comparison of survival and prognostic factors in patients with gastric adenocarcinoma in T2 and T3.

OBJECTIVE: To compare the survival and prognosis after surgical treatment of patients with gastric adenocarcinoma which extends to the muscular layer (T2), and patients whose tumor invades the subserosa (T3). METHODS: This was a retrospective study of 122 patients with gastric cancer invading the muscularis propria and subserosa, undergoing surgical treatment from January 1997 to December 2008 and followed-up until December 2010. We analyzed demographic, surgical and pathological variables. RESULTS: Of the 122 patients, 22 (18%) were excluded from the final analysis because they showed: positive margin or less than 15 lymph nodes in the surgical specimen, early postoperative mortality and second primary tumors. Among the 100 patients included, 75 had tumors inveding the muscularis propria (T2) and 25 with extension to the subserosa (T3). Overall survival was 83.8%, and 90.6% for T2 and 52.1% or T3. Univariate analysis showed statistical significance in: lymph node metastasis (p = 0.02), tumor size (p = 0.000), tumor pathological stage (p = 0.000), lymph node pathologic stage (p = 0.000) and staging by classification of groups TNM-UICC/AJCC, 2010 (p = 0.000). In multivariate analysis, independent prognostic factors were tumor size and lymph node pathological staging (pN). CONCLUSION: The lymph node status and tumor size are independent prognostic factors in tumors with invasion of the muscularis propria and in tumors with invasion of subserosa. T2 lesions have smaller size, lower rate of lymph node metastasis and therefore better prognosis than T3.

Comparação da sobrevivência e dos fatores prognósticos em pacientes com adenocarcinoma gástrico T2 e T3 / Comparison of survival and prognostic factors in patients with gastric adenocarcinoma in T2 and T3

OBJETIVO: Comparar a sobrevivência e os fatores prognósticos, após o tratamento cirúrgico de pacientes com adenocarcinoma gástrico que compromete a camada muscular própria (T2), e de pacientes cujo tumor invade a subserosa (T3). MÉTODOS: Estudo retrospectivo de 122 pacientes com câncer gástrico invadindo a muscular própria e subserosa, submetidos ao tratamento cirúrgico no período de janeiro de 1997 a dezembro de 2008 e acompanhados até dezembro de 2010. Foram analisadas variáveis demográficas, cirúrgicas e anatomopatológicas. RESULTADOS: Dos 122 pacientes, 22 (18%) foram excluídos da análise final porque apresentaram: margem positiva, mortalidade pós-operatória, segundo tumor primário e menos de 15 linfonodos na peça cirúrgica. Entre os 100 pacientes incluídos, 75 apresentavam tumores com invasão da muscular própria (T2) e 25 com invasão da subserosa (T3). A sobrevivência global foi 83,8%, sendo 90,6% no T2 e 52,1% no T3. Na análise univariada apresentaram significância: metástase linfonodal (p=0,02), tamanho do tumor (p=0,000), estadiamento patológico do tumor (p=0,000), estadiamento patológico linfonodal (p=0,000) e estadiamento por grupos da classificação TNM-UICC/AJCC, 2010 (p=0,000) Na análise multivariada, os fatores prognósticos independentes foram o tamanho do tumor e o estadiamento patológico linfonodal (pN). CONCLUSÃO: O comprometimento linfonodal e o tamanho do tumor são fatores prognósticos independentes nos tumores com invasão da muscular própria e nos tumores com invasão da subserosa. O T2 apresenta menor tamanho, menor taxa de linfonodos metastáticos e consequentemente, melhor prognóstico que o T3.

OBJECTIVE: To compare the survival and prognosis after surgical treatment of patients with gastric adenocarcinoma which extends to the muscular layer (T2), and patients whose tumor invades the subserosa (T3). METHODS: This was a retrospective study of 122 patients with gastric cancer invading the muscularis propria and subserosa, undergoing surgical treatment from January 1997 to December 2008 and followed-up until December 2010. We analyzed demographic, surgical and pathological variables. RESULTS: Of the 122 patients, 22 (18%) were excluded from the final analysis because they showed: positive margin or less than 15 lymph nodes in the surgical specimen, early postoperative mortality and second primary tumors. Among the 100 patients included, 75 had tumors inveding the muscularis propria (T2) and 25 with extension to the subserosa (T3). Overall survival was 83.8%, and 90.6% for T2 and 52.1% or T3. Univariate analysis showed statistical significance in: lymph node metastasis (p = 0.02), tumor size (p = 0.000), tumor pathological stage (p = 0.000), lymph node pathologic stage (p = 0.000) and staging by classification of groups TNM-UICC/AJCC, 2010 (p = 0.000). In multivariate analysis, independent prognostic factors were tumor size and lymph node pathological staging (pN). CONCLUSION: The lymph node status and tumor size are independent prognostic factors in tumors with invasion of the muscularis propria and in tumors with invasion of subserosa. T2 lesions have smaller size, lower rate of lymph node metastasis and therefore better prognosis than T3.

Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function.

Low-frequency repetitive transcranial magnetic stimulation (rTMS) of the unaffected hemisphere can enhance function of the paretic hand in patients with mild motor impairment. Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown. In this pilot, randomized, double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation, in 30 patients within 5-45 days after ischemic stroke, and mild to severe hand paresis. The primary feasibility outcome was compliance with the interventions. The primary safety outcome was the proportion of intervention-related adverse events. Performance of the paretic hand in the Jebsen-Taylor test and pinch strength were secondary outcomes. Outcomes were assessed at baseline, after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment. Baseline clinical features were comparable across groups. For the primary feasibility outcome, compliance with treatment was 100% in the active group and 94% in the sham group. There were no serious intervention-related adverse events. There were significant improvements in performance in the Jebsen-Taylor test (mean, 12.3% 1 month after treatment) and pinch force (mean, 0.5 Newtons) in the active group, but not in the sham group. Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible, safe and potentially effective to improve function of the paretic hand, in patients with mild to severe hemiparesis. These promising results will be valuable to design larger randomized clinical trials.

Type IV Borrmann gastric adenocarcinoma: analysis of curative resection results.

OBJECTIVE: To evaluate the results obtained with curative resection of Borrmann IV gastric adenocarcinoma (B IV) through the analysis of clinical, surgical and pathological data, identifying which of these prognostic factors were associated with survival. METHODS: We retrospectively analyzed 123 patients with B IV gastric adenocarcinoma undergoing surgical treatment at the Department of the pelvic-abdominal surgeries of the National Cancer Institute (INCA) from January 1997 to December 2005. The group undergoing curative resection was examined for various prognostic factors regarding overall survival. RESULTS: Of the 123 patients studied, 68 underwent gastrectomy, 52 (42.3%) with curative intent and 16 (13%) palliative resection, while 55 (44.7%) had disease not subject to resection. Three postoperative deaths followed the curative resection, constituting a mortality rate of 5.76%. In nine (17.3%) patients there were technical complications, and esophagojejunal fistula seven cases, the most frequent. All technical complications and deaths occurred after total gastrectomy, which was the most commonly performed curative resection type in this series. The most common pattern of recurrence was peritoneal carcinomatosis. The location of the tumor, lymph node metastasis, lymphatic invasion and pathological staging were considered significant prognostic factors. The median survival time was 29 months, with a rate of five-year survival of 33% in patients undergoing curative resection. CONCLUSION: The curative resection of B IV gastric adenocarcinoma had a positive impact on survival of patients with the disease in stages IB, II and III, with up to 15 lymph nodes (pN2) and localized type.