Understanding the Elevated Lethality of COVID-19 in Liver Transplant Recipients: Does Immunosuppression Management Matter? Results from a Brazilian Multicentric Historical Cohort.

BACKGROUND: Infections by SARS-CoV-2 in liver transplant recipients (LT) patients are of particular concern, notably due to perceived added risks related to immunosuppression and comorbidity burden. Current literature on this topic often relies on small, non-standardized, and geographically limited studies. This manuscript describes COVID-19 presentations and causes for elevated mortality in a large cohort of LT recipients. METHODS: This study was designed as a multicentric historical cohort, including LT recipient patients with COVID-19 in 25 study centers, with the primary endpoint being COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. RESULTS: Two hundred and thirty-four cases were included. The study population was predominantly male and White and had a median age of 60 years. The median time from transplantation was 2.6 years (IQR 1-6). Most patients had at least one comorbidity (189, 80.8%). Patient age (P = .04), dyspnea (P < .001), intensive care unit admission (P < .001), and mechanical ventilation (P < .001) were associated with increased mortality. Modifications of immunosuppressive therapy (P < .001), specifically the suspension of tacrolimus, maintained significance in multivariable analysis. CONCLUSIONS: Attention to risk factors and the individualization of patient care, especially regarding immunosuppression management, is crucial for delivering more precise interventions to these individuals.

BAR, SOFT AND DRI POST-HEPATIC TRANSPLANTATION: WHAT IS THE BEST FOR SURVIVAL ANALYSIS?

BACKGROUND: Liver transplantation is the treatment of choice for patients with terminal liver disease. The Balance of Risk Score (BAR), Survival Outcomes Following Liver Transplantation (SOFT) and Donor Risk Index (DRI) scores are predictive systems for post-transplant survival. AIM: To evaluate the most accurate score and the best cutoff point for each predictor in the brazilian population. METHOD: Retrospective cross-sectional study of 177 patients. Data on the recipient, donor and transplant were analyzed and the prognostic scores BAR, SOFT and DRI were calculated for each transplant. To determine the BAR and SOFT cutoff points associated with death in three months, ROC curves were adjusted. Results : The best cutoff point for BAR was 9 points with an area under the ROC curve=0.69 and for SOFT it was 12 points with an area under the ROC curve=0.73. The DRI score did not discriminate survival (p = 0.139). CONCLUSION: The SOFT score proved to be better than BAR for survival analysis post-hepatic transplantation and the DRI was not effective.

Fatores de risco para prever a necessidade de uso de propofol nas endoscopias digestivas / Risk factors to prevent the need to propofol use in digestive endoscopies

O uso de midazolam e fentanil é para realização de sedação consciente em endoscopia digestiva é opção; porém, o propofol vem sendo cada vez mais utilizado. O objetivo deste estudo foi identificar dos fatores de risco para prever a necessidade de uso de propofol em pacientes submetidos à endoscopia digestiva. È estudo retrospectivo em que foram avaliados 620 pacientes submetidos à endoscopia digestiva alta e colonoscopia ou ambos os procedimentos. Foram analisados variáveis epidemiológicas e doenças associadas. Em conclusão, epidemiológicas não se apresentaram como fatores de risco relacionados ao aumento da dose e uso do propofol, mas houve necessidade de aumento naqueles com doença psiquiátrica, quando não receberam sedação com midazolam, fentanil, e quando foram submetidos a procedimento combinado.

The use of midazolam and fentanyl for conscious sedation in digestive endoscopy is an option; however, propofol has been increasingly used. The aim of this study was to identify risk factors to predict the need for propofol use in patients undergoing digestive endoscopy. It is a retrospective study in which 620 patients undergoing upper digestive endoscopy and colonoscopy or both procedures were evaluated. Epidemiological variables and associated diseases were analyzed. In conclusion, epidemiological factors did not present themselves as risk factors related to the increase in the dose and use of propofol, but there was a need for those with psychiatric disease, when they did not receive sedation with midazolam, fentanyl, and when they underwent a combined procedure.

D-Meld como preditor de sobrevida após transplante hepático é alternativa superior? / D-Meld as a predictor of survival after hepatic transplantation is a superior alternative?

Novos preditores de sobrevida são desenvolvidos com a finalidade de auxiliar o processo de decisão do transplante hepático. Apesar disso, até o momento utilizam-se apenas o Model for End-Stage Liver Disease (MELD) como clinicamente útil. O objetivo deste estudo foi verificar a epidemiologia dos pacientes submetidos ao transplante hepático, verificar o melhor ponto de corte dos escores prognósticos BAR, SOFT, e D-MELD e avaliar se o escore D-MELD é melhor preditor de mortalidade em 1 ano comparativamente com os escores BAR e SOFT. É estudo retrospectivo transversal com base na análise dos prontuários médicos. Como conclusão, todos os escores avaliados apresentaram capacidade abaixo do ideal em predizer mortalidade em 1 ano após transplante hepático.

New survival predictors are developed in order to help the liver transplant decision process. Despite this, to date, only the Model for End-Stage Liver Disease (MELD) has been used as clinically useful. The aim of this study was to verify the epidemiology of patients undergoing liver transplantation, verify the best cutoff point for BAR, SOFT, and D-MELD prognostic scores, and assess whether the D-MELD score is a better predictor of 1-year mortality compared with the BAR and SOFT scores. It is a cross-sectional retrospective study based on the analysis of medical records. In conclusion, all scores evaluated had a suboptimal ability to predict 1-year mortality after liver transplantation.

Bar, soft and dri post-hepatic transplantation: what is the best for survival analysis? / Bar, soft e dri pós-transplante hepático: qual é o melhor para análise da sobrevida?

ABSTRACT Background: Liver transplantation is the treatment of choice for patients with terminal liver disease. The Balance of Risk Score (BAR), Survival Outcomes Following Liver Transplantation (SOFT) and Donor Risk Index (DRI) scores are predictive systems for post-transplant survival. Aim: To evaluate the most accurate score and the best cutoff point for each predictor in the brazilian population. Method: Retrospective cross-sectional study of 177 patients. Data on the recipient, donor and transplant were analyzed and the prognostic scores BAR, SOFT and DRI were calculated for each transplant. To determine the BAR and SOFT cutoff points associated with death in three months, ROC curves were adjusted. Results: The best cutoff point for BAR was 9 points with an area under the ROC curve=0.69 and for SOFT it was 12 points with an area under the ROC curve=0.73. The DRI score did not discriminate survival (p = 0.139). Conclusion: The SOFT score proved to be better than BAR for survival analysis post-hepatic transplantation and the DRI was not effective.

RESUMO Racional: Transplante hepático é tratamento de escolha para pacientes com doença hepática terminal. Os escores Balance of Risk Score (BAR), Survival Outcomes Following Liver Transplantation (SOFT) e o Donor Risk Index (DRI) são sistemas preditores de sobrevida após o transplante. Objetivo : Avaliar o escore de maior acurácia e o melhor ponto de corte de cada preditor na população brasileira. Método : Estudo retrospectivo transversal de 177 pacientes. Foram analisados dados sobre o receptor, doador e o transplante e calculados os escores prognósticos BAR, SOFT e DRI para cada transplante. Para a determinar os pontos de corte de BAR e SOFT, associados a óbito em três meses, foram ajustadas curvas ROC. Resultados : O melhor ponto corte para BAR foi 9 pontos com área sob a curva ROC=0,69 e para SOFT foi 12 pontos com área sob a curva ROC=0,73. O escore DRI não discriminou a sobrevida (p=0,139). Conclusão: O escore SOFT mostrou-se melhor do que o BAR para análise de sobrevida pós-transplante hepático, e o DRI não foi efetivo.

Tumor carcinóide de estômago tipo 1 / Gastric carcinoid tumor type 1

Gastric carcinoid occurs in less than 1 percent of gastric neoplasias and around 2 percent of carcinoids tumors. They are classified into three forms: type 1, associated with atrophic gastritis, type 2, associated with multiple endocrine neoplasia 1 and Zollinger Ellison syndrome, and type 3, a sporadic tumor. This study report a case of gastric carcinoid type 1, which manifested with chronic anemia, dyspeptic symptoms and hypergastrinemia. A 44 years old female patient, presented multiple lesions with diameter between 3 and 20 mm, with lynphonodal metastases. A total gastrectomy was performed associated with lymphnodes ressection and Y Roux reconstruction.