Transplantation in Hepatocellular Carcinoma: Observational Multivariate Analysis of Survival and Recurrence Factors in 414 Patients.

BACKGROUND: We sought to identify the risk factors involved in survival of and tumor recurrence in patients with hepatocellular carcinoma (HCC) undergoing liver transplant (LTx). METHODS: We conducted a retrospective observational study and analyzed the medical records of 414 patients with HCC undergoing deceased donor LTx in São Paulo between January 2007 and December 2011. Multifactorial analysis of survival and recurrence was performed using clinical, laboratory, and pathology data. RESULTS: The mortality rate was 27.5%; mean survival time was 68.1 months (95% confidence interval, 64.7-71.6); and estimated 1-, 3-, and 5-year survival probabilities were 83.8%, 75.8%, and 71.5%, respectively. Altered donor blood glucose, female sex, vascular invasion, advanced age, high Model for End-Stage Liver Disease, and tumor size were the main risk factors determining survival in LTx recipients. Recurrence was noted in 7.2% of patients during the study period and was more frequent in women (hazard ratio, 2.6). Vascular invasion increased the chance of recurrence by 5.4 times. Each additional 1-year increase in recipient age increased the chance of recurrence by 5.6%, and each 1-mm increase in tumor size increased the chance of recurrence by 3%. CONCLUSIONS: Risk factors for reduced survival are donor blood glucose, female recipient, older age, increased Model for End-Stage Liver Disease score, and nodule size. Tumor recurrence risk factors are vascular invasion, female sex, recipient age, and nodule size.

Analysis of the Functional Aspects of Sperm and Testicular Oxidative Stress in Individuals Undergoing Metabolic Surgery.

PURPOSE: Metabolic surgery is a recommended treatment for obese patients that results in BMI reduction; however, the observed impact of this therapy on male fertility is inconsistent. This research aimed to study the effects of BMI changes after metabolic surgery on seminal analysis, sex hormonal profile, sperm functional integrity, and the seminal plasma lipid peroxidation levels. MATERIALS AND METHODS: A prospective study was performed in 15 patients for whom metabolic surgery was recommended. The patients were evaluated by the techniques proposed in this study before and after the surgical procedure for 12 months. In each analysis, the male sex hormonal profile, semen analysis, sperm functional integrity, and seminal lipid peroxidation levels were assessed. RESULTS: The surgery resulted in BMI reduction and improvement in seminal characteristics and male sex hormone profile. The semen analysis showed increases in volume, sperm progressive motility, and in sperm morphology and a decrease in immotile sperms. Sperm mitochondrial activity and sperm DNA integrity were improved, and the levels of seminal lipid peroxidation were decreased. The hormonal profile showed lower levels of estradiol and highest levels of luteinizing hormone (LH), sex hormone-binding globulin (SHBG), and testosterone. CONCLUSION: BMI changes resulting from this treatment and its metabolic consequences can be associated with changes in the male fertile potential, leading to an improvement in the seminal quality, male sex hormone profile, sperm functional aspects, and levels of seminal lipid peroxidation, thus decreasing the testicular oxidative stress.

MnSOD gene polymorphism association with steroid-dependent cancer.

Oxidative stress enhances carcinogenesis due to DNA damage. Manganese superoxide dismutase (MnSOD) Val16Ala polymorphism has been recently associated with breast and prostate cancer. The role of oxidative stress in male breast cancer is poorly investigated due to the low prevalence of this neoplasia. We studied the relationship between prostate cancer (PC), male (MBC) and female breast cancer (FBC) and this polymorphism in a case-control study. Human genetic polymorphism Val16Ala of MnSOD was obtained from blood and paraffin-embedded tumor samples. The polymorphism was determined in 11 cases of MBC, 51 cases of PC, 89 cases of FBC and 372 age-adjusted healthy controls by polymerase chain reaction-restriction fragment length polymorphism techniques using restriction enzyme Hae III. Chi-square or Fisher test were used to compare the MnSOD frequency distribution. The observed genotypic frequencies of all samples were AA = 9.6% (n = 50), VV = 25.4% (n = 133) and AV = 64% (n = 340), all at Hardy-Weinberg equilibrium. Breast and prostate cancer risk was elevated in male and female patients with the Ala/Ala genotype compared to controls (p = 0.006, odds ratio = 2.5, 95% confidence interval 1.393-4.541). Even though the frequency of the Ala allele was low (9.6%) in the studied population, these data support the hypothesis that MnSOD and oxidative stress play a significant role in breast cancer risk both in males and females and also brings new information on the role of this polymorphism in prostate cancer. This is the first study which provides some evidence that genetic polymorphism in the MnSOD gene may be associated with an increased risk of male breast cancer. Studies with a larger sample size are needed to confirm the findings.

Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant. / Avaliação do tratamento dos nódulos do hepatocarcinoma nos pacientes em lista de espera para transplante hepático.

OBJECTIVE: to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients. METHODS: retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment. RESULTS: the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494). CONCLUSION: there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

OBJETIVO: comparar o resultado do transplante de fígado por hepatocarcinoma em pacientes submetidos ou não ao tratamento loco-regional e downstaging, em relação à sobrevida e risco de recidiva na fila de transplante. MÉTODOS: estudo retrospectivo dos pacientes portadores de hepatocarcinoma submetidos a transplante hepático na região metropolitana de São Paulo, entre janeiro de 2007 e dezembro de 2011, a partir de doador falecido. A amostra foi constituída de 414 pacientes. Destes, 29 foram incluídos na lista por downstaging. Os demais 385 foram submetidos ou não ao tratamento loco-regional. RESULTADOS: as análises dos 414 prontuários demonstraram um predomínio de pacientes do sexo masculino (79,5%) e com média de idade de 56 anos. O tratamento dos nódulos foi realizado em 56,4% dos pacientes em fila de espera para o transplante. O método mais utilizado foi a quimio-embolização (79%). Os pacientes submetidos ao tratamento loco-regional tiveram redução significativa no tamanho do maior nódulo (p<0,001). Não houve diferença estatística entre grupos com e sem tratamento loco-regional (p=0,744) e em relação à mortalidade entre pacientes incluídos no Critério de Milão ou ao downstaging (p=0,494). CONCLUSÕES: não houve diferença na sobrevida e ocorrência de recidiva associadas ao tratamento loco-regional. Os pacientes incluídos através do processo de downstaging apresentaram resultados de sobrevida comparáveis àqueles previamente classificados como Critério de Milão/Brasil.

LIVER TRANSPLANTATION FOR CARCINOMA HEPATOCELLULAR IN SÃO PAULO: 414 CASES BY THE MILAN/BRAZIL CRITERIA.

Background: The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules. Aim: To evaluate the outcome of liver transplantation within the CMB. Methods: The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed. Results: 414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival. Conclusions: CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.

Racional: O critério de Milão (CM) vem sendo utilizado como padrão para indicação do transplante hepático (TxH) por hepatocarcinoma (HCC) em todo mundo há quase 20 anos. Diversos centros têm adotado critérios expandidos com intuito de aumentar o número de pacientes candidatos ao transplante, mantendo bons índices de sobrevida. No Brasil, desde 2006, o critério de Milão/Brasil (CMB), que desconsidera nódulos <2 cm, é adotado, incluindo pacientes com maior número de nódulos pequenos. Objetivo: Avaliar o resultado do transplante hepático dentro do CMB. Métodos: Foram analisados os prontuários dos pacientes com HCC submetidos ao TxH em relação à recidiva e sobrevida através da comparação entre CM e CMB. Resultados: Em 414 TxH por HCC, a sobrevida em 1 e 5 anos foi de 84,1 e 72,7%. Destes, 7% atingiram o CMB através de downstaging, com sobrevida em 1 e 5 anos de 93,1 e 71,9%. O grupo de pacientes do CMB que excederam o CM (8,6%) teve sobrevida de 58,1% em cinco anos. Não houve diferença estatística na sobrevida entre os grupos CM, CMB e downstaging. A invasão vascular (p<0,001), tamanho do maior nódulo (p=0,001) e número de nódulos >2 cm (p=0,028) associaram-se com recidiva. A idade (p=0,001), sexo feminino (p<0,001), MELD real (p<0,001), invasão vascular (p=0,045) e o número de nódulos >2 cm (p<0,014) estiveram associados com a piora na sobrevida. Conclusões: O CMB aumentou em 8,6% as indicações de TxH e apresentou índices de sobrevida semelhantes ao CM.

Is the Val16Ala manganese superoxide dismutase polymorphism associated with the aging process?

Oxidative stress has been related to aging. Recent evidences suggest that a genetic dimorphism that encodes for either alanine or valine in superoxide dismutase (SOD2) is involved with oxidative stress. However, the current literature is still controversial, and the potential role of the Ala16Val polymorphism in human aging needs to be established. Here we investigated the role of the SOD2 polymorphism in: a) age-related mortality, b) morbidity (breast and prostate cancer), c) immunological markers, and d) DNA damage in peripheral blood cells. We did not find an association between SOD2 polymorphisms and mortality. However, the AA genotype was associated with increased risk for prostate and breast cancer, immunosenescence profile, as well as DNA damage. These data suggest that SOD2 presents characteristics that support the free radical theory of aging.

The effect of superoxide anion and hydrogen peroxide imbalance on prostate cancer: an integrative in vivo and in vitro analysis.

The epidemiological impact of SOD2 imbalance on prostate cancer (PC) risk associated with genetic variations has previously been studied. However, we found no previous studies clarifying the nature of SOD2 effects on prostate cancer. Here, we performed integrated in vivo and in vitro protocols that analyzed the association between Ala16Val-SOD2 polymorphism and prostate cancer aggressiveness at the time of diagnosis and evaluated the effect of the imbalance on PC proliferation using the DU-145 PC cell line treated with paraquat and porphyrin. In the pharmacological model, paraquat was used to increase superoxide anion levels and porphyrin was the SOD2 analog. The results confirmed the impact of superoxide-hydrogen peroxide imbalance on PC cell biology since porphyrin decreased cell proliferation and both treatments modulated antioxidant genes. Therefore, our results corroborate previous suggestions that alteration of redox status could be exploited therapeutically in the treatment of PC.

Video game addiction in gambling disorder: clinical, psychopathological, and personality correlates.

OBJECTIVE: We studied the prevalences of video game use (VGU) and addiction (VGA) in gambling disorder (GD) patients and compared them with subjects with non-video game use (non-VGU) in relation to their gambling behavior, psychopathology, and personality characteristics. METHOD: A sample of 193 GD patients (121 non-VGU, 43 VGU, and 29 VGA) consecutively admitted to our pathological gambling unit participated in the study. Assessment. Measures included the video game dependency test (VDT), symptom checklist-90-revised, and the temperament and character inventory-revised, as well as a number of other GD indices. RESULTS: In GD, the observed prevalence of VG (use or addiction) was 37.3% (95% CI :30.7% ÷ 44.3),VGU 22.3% (95% CI :17.0% ÷ 28.7), and VGA 15% (95% CI :10.7% ÷ 20.7). Orthogonal polynomial contrast into logistic regression showed positive linear trends for VG level and GD severity and other measures of general psychopathology. After structural equation modeling, higher VG total scores were associated with younger age, general psychopathology, and specific personality traits, but not with GD severity. Patients' sex and age were involved in the mediational pathways between personality traits and VG impairment. CONCLUSIONS: GD patients with VG are younger and present more dysfunctional personality traits, and more general psychopathology. The presence of VG did not affect the severity of GD.

Avaliação do tratamento dos nódulos do hepatocarcinoma nos pacientes em lista de espera para transplante hepático / Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant

RESUMO Objetivo: comparar o resultado do transplante de fígado por hepatocarcinoma em pacientes submetidos ou não ao tratamento loco-regional e downstaging, em relação à sobrevida e risco de recidiva na fila de transplante. Métodos: estudo retrospectivo dos pacientes portadores de hepatocarcinoma submetidos a transplante hepático na região metropolitana de São Paulo, entre janeiro de 2007 e dezembro de 2011, a partir de doador falecido. A amostra foi constituída de 414 pacientes. Destes, 29 foram incluídos na lista por downstaging. Os demais 385 foram submetidos ou não ao tratamento loco-regional. Resultados: as análises dos 414 prontuários demonstraram um predomínio de pacientes do sexo masculino (79,5%) e com média de idade de 56 anos. O tratamento dos nódulos foi realizado em 56,4% dos pacientes em fila de espera para o transplante. O método mais utilizado foi a quimio-embolização (79%). Os pacientes submetidos ao tratamento loco-regional tiveram redução significativa no tamanho do maior nódulo (p<0,001). Não houve diferença estatística entre grupos com e sem tratamento loco-regional (p=0,744) e em relação à mortalidade entre pacientes incluídos no Critério de Milão ou ao downstaging (p=0,494). Conclusões: não houve diferença na sobrevida e ocorrência de recidiva associadas ao tratamento loco-regional. Os pacientes incluídos através do processo de downstaging apresentaram resultados de sobrevida comparáveis àqueles previamente classificados como Critério de Milão/Brasil.

ABSTRACT Objective: to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients. Methods: retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment. Results: the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494). Conclusion: there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

Islet versus pancreas transplantation in Brazil: Defining criteria for pancreas allocation decision.

BACKGROUND: Many studies have evaluated whether there are characteristics related to pancreas donors and the islet isolation process that can influence pancreatic islet yield. However, this analysis has not yet been performed in Brazil, one of the world leaders in whole pancreas organ transplantation (WOPT), where pancreas allocation for pancreatic islet transplantation (PIT) has no officially defined criteria. Definition of parameters that would predict the outcome of islet isolation from local pancreas donors would be useful for defining allocation priority in Brazil. OBJECTIVE: To analyze the relationship between multiple donor-related and islet isolation variables with the total number of isolated pancreatic islet equivalents (IEQ) in a brazilian sample of pancreas donors. METHODS: Several variables were analyzed in 74 pancreata relative to the outcome of total IEQs obtained at the end of the process. RESULTS: In univariate analysis, body mass index (BMI) (p = 0.003), the presence of fatty infiltrates in the pancreas as observed during harvesting (p = 0.042) and pancreas digestion time (p = 0.046) were identified as variables related to a greater IEQ yield. In a multivariate analysis a statistically significant contribution to the variability of islet yield was found only for the BMI (p = 0.017). A ROC curve defined a BMI = 30 as a cut-off point, with pancreata from donors with BMI > 30 yielding more islets than donors with BMI < 30 (p< 0.001). CONCLUSION: These data reinforce the importance of the donor BMI as a defining parameter for successful islet isolation and establishes this variable as a potential pancreas allocation criterion in Brazil, where there is unequal competition for good quality organs between WOPT and PIT.

Liver transplantation for carcinoma hepatocellular in Aão Paulo: 414 cases by the Milan/Brazil criteria / O transplante hepático por hepatocarcinoma na era meld em São Paulo: análise de 414 casos transplantados pelo critério de Milão/Brasil

ABSTRACT Background: The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules. Aim: To evaluate the outcome of liver transplantation within the CMB. Methods: The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed. Results: 414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival. Conclusions: CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.

RESUMO Racional: O critério de Milão (CM) vem sendo utilizado como padrão para indicação do transplante hepático (TxH) por hepatocarcinoma (HCC) em todo mundo há quase 20 anos. Diversos centros têm adotado critérios expandidos com intuito de aumentar o número de pacientes candidatos ao transplante, mantendo bons índices de sobrevida. No Brasil, desde 2006, o critério de Milão/Brasil (CMB), que desconsidera nódulos <2 cm, é adotado, incluindo pacientes com maior número de nódulos pequenos. Objetivo: Avaliar o resultado do transplante hepático dentro do CMB. Métodos: Foram analisados os prontuários dos pacientes com HCC submetidos ao TxH em relação à recidiva e sobrevida através da comparação entre CM e CMB. Resultados: Em 414 TxH por HCC, a sobrevida em 1 e 5 anos foi de 84,1 e 72,7%. Destes, 7% atingiram o CMB através de downstaging, com sobrevida em 1 e 5 anos de 93,1 e 71,9%. O grupo de pacientes do CMB que excederam o CM (8,6%) teve sobrevida de 58,1% em cinco anos. Não houve diferença estatística na sobrevida entre os grupos CM, CMB e downstaging. A invasão vascular (p<0,001), tamanho do maior nódulo (p=0,001) e número de nódulos >2 cm (p=0,028) associaram-se com recidiva. A idade (p=0,001), sexo feminino (p<0,001), MELD real (p<0,001), invasão vascular (p=0,045) e o número de nódulos >2 cm (p<0,014) estiveram associados com a piora na sobrevida. Conclusões: O CMB aumentou em 8,6% as indicações de TxH e apresentou índices de sobrevida semelhantes ao CM.

Slow breathing test increases the suspicion of white-coat hypertension in the office.

BACKGROUND: It would be useful to have a clinical test that increases the suspicion of white coat hypertension (WCH) during the medical consultation. OBJECTIVE: To evaluate the Slow Breathing Test (SBT) when differentiating hypertension from WCH. METHODS: 101 hypertensive patients selected at triage had their medication withdrawn for 2-3 weeks. The blood pressure (BP) was measured before and after the SBT at two consultations at the office. The test consisted in breathing for 1 minute at the frequency of one respiratory cycle every 10 seconds. Two diagnostic criteria were compared: 1--decrease in diastolic BP > or = 10% in at least one visit or 2--decrease in BP to normal levels (<140/90 mm Hg) in at least one visit. The ambulatory blood pressure monitoring (ABPM) was performed while blinded to the clinical measurements. RESULTS: 71 women and 30 men, with a mean age of 51+/-10 years, with mean pre and post-test BP of 152+/-17/ 99+/-11 and 140+/-18/ 91+/-11 mm Hg were assessed. Nine patients had normal clinical and ambulatory measurements. Of the 92 patients, 28 (30%) were classified as having WCH; 15 had a positive test for Criterion 1 and 21 for the Criterion 2. Among 64 (70%) hypertensive individuals, 14 tested positive for Criterion 1 and 12 for Criterion 2. Sensitivity and specificity (95% CI): 0.54 (0.36-0.71) and 0.78 (0.67-0.87) for Criterion 1; 0.75 (0.57-0.87) and 0.81 (0.70-0.89) for Criterion 2. CONCLUSION: The SBT showed an increase in the clinical suspicion of WCH in two visits when using the BP normalization criterion. This finding suggests that the test can help in the optimization of ABPM requests for suspected cases.

Teste de respiração lenta aumenta a suspeita da hipertensão do avental branco no consultório / Slow breathing test increases the suspicion of white-coat hypertension in the office

FUNDAMENTO: Seria útil dispor de um teste clínico que aumentasse a suspeita da hipertensão do avental branco (HAB) durante a consulta. OBJETIVO: Avaliar o teste de respiração lenta (TRL) na diferenciação entre hipertensão e HAB. MÉTODOS: Cento e um pacientes hipertensos selecionados em triagem tiveram a medicação suspensa por duas a três semanas. A pressão arterial (PA) foi medida antes e depois do TRL em duas visitas. O teste consistiu em respirar por 1 minuto na freqüência de um ciclo respiratório a cada 10 segundos. Dois critérios diagnósticos foram comparados: 1- queda da PA diastólica >10 por cento em pelo menos uma consulta, ou 2- queda da PA para níveis normais (<140/90 mmHg) em pelo menos uma consulta. A MAPA foi realizada de forma cega às medidas clínicas. RESULTADOS: Setenta e uma mulheres e 30 homens, idade média 51+10 anos, média pré e pós-teste de 152+17/ 99+11 e 140+18/ 91+11 mmHg. Nove pacientes tiveram medidas clínicas e ambulatoriais normais. De 92 pacientes, 28 (30 por cento) foram classificados como HAB; 15 tiveram teste positivo para o critério 1, e 21 para o critério 2. Entre 64 (70 por cento) hipertensos, 14 testaram positivo para o critério 1, e 12 para o critério 2. Sensibilidade e especificidade (95 por cento IC): 0,54 (0,36-0,71) e 0,78 (0,67-0,87) critério 1; 0,75 (0,57-0,87) e 0,81 (0,70-0,89) critério 2. CONCLUSÃO: O TRL mostrou aumento da suspeita clínica de HAB em duas consultas ao utilizar o critério de normalização da PA. Isso sugere que esse teste pode auxiliar na otimização dos pedidos de MAPA para casos suspeitos.

BACKGROUND: It would be useful to have a clinical test that increases the suspicion of white coat hypertension (WCH) during the medical consultation. OBJECTIVE: To evaluate the Slow Breathing Test (SBT) when differentiating hypertension from WCH. METHODS: 101 hypertensive patients selected at triage had their medication withdrawn for 2-3 weeks. The blood pressure (BP) was measured before and after the SBT at two consultations at the office. The test consisted in breathing for 1 minute at the frequency of one respiratory cycle every 10 seconds. Two diagnostic criteria were compared: 1 - decrease in diastolic BP >10 percent in at least one visit or 2- decrease in BP to normal levels (<140/90 mm Hg) in at least one visit. The ambulatory blood pressure monitoring (ABPM) was performed while blinded to the clinical measurements. RESULTS: 71 women and 30 men, with a mean age of 51+10 years, with mean pre and post-test BP of 152+17/ 99+11 and 140+18/ 91+11 mm Hg were assessed. Nine patients had normal clinical and ambulatory measurements. Of the 92 patients, 28 (30 percent) were classified as having WCH; 15 had a positive test for Criterion 1 and 21 for the Criterion 2. Among 64 (70 percent) hypertensive individuals, 14 tested positive for Criterion 1 and 12 for Criterion 2. Sensitivity and specificity (95 percent CI): 0.54 (0.36-0.71) and 0.78 (0.67-0.87) for Criterion 1; 0.75 (0.57-0.87) and 0.81 (0.70-0.89) for Criterion 2. CONCLUSION: The SBT showed an increase in the clinical suspicion of WCH in two visits when using the BP normalization criterion. This finding suggests that the test can help in the optimization of ABPM requests for suspected cases.

Carcinoma inaparente de vesícula biliar / Early carcinoma of the gallbladder

Defini-se como carcinoma inaparente de vesícula biliar aquela neoplasia que näo havia sido suspeitada no pré-operatório ou durante a colecistectomia, todavia diagnosticada pelo estudo anatomopatológico da peça operatória. De 3.389 colecistectomias realizadas em um período de oito anos, na ISCMPA, 27 (0,8 por cento) pacientes apresentavam carcinoma inaparente. Devido à baixa mortalidade da colecistectomia, cotejada com a alta mortalidade do carcinoma de vesícula, a colecistectomia em portadores de litíase assintomática deve ser considerada quando näo há contra-indicaçäo clínica