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Results of transarterial chemoembolization of hepatocellular carcinoma as a bridging therapy to liver transplantation
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Jotz, Raquel de Freitas

; Horbe, Alex Finger

; Coral, Gabriela Perdomo

; Fontana, Priscila Cavedon

; Morais, Beatriz Garcia de

; Mattos, Angelo Alves de

Radiologia Brasileira

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sep 2023, Volume 56 N. 5 Pages 235 - 241

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

Abstract Objective: To evaluate the degree of tumor necrosis after transarterial chemoembolization (TACE), used as a bridging therapy in patients awaiting liver transplantation, and its effect on survival. Materials and Methods: This was a retrospective cohort study involving 118 patients submitted to TACE prior to liver transplantation, after which the degree of tumor necrosis in the explant and post-transplant survival were evaluated. Results: Total necrosis of the neoplastic nodule in the explant was observed in 76 patients (64.4%). Of the patients with total necrosis in the explanted liver, 77.8% had presented a complete response on imaging examinations. Drug-eluting bead TACE (DEB-TACE), despite showing a lower rate of complications than conventional TACE, provided a lower degree of total necrosis, although there was no statistical difference between the two. By the end of the study period, 26 of the patients had died. Survival was longer among the patients with total necrosis than among those with partial or no necrosis (HR = 2.24 [95% CI: 0.91-5.53]; p = 0.078). Conclusion: In patients undergoing TACE as a bridging therapy, total tumor necrosis appears to be associated with improved patient survival.

Resumo Objetivo: Avaliar os resultados da necrose tumoral após quimioembolização transarterial (TACE) como terapia ponte e seu reflexo na sobrevida dos pacientes. Materiais e Métodos: Estudo de coorte retrospectivo, com 118 pacientes que realizaram TACE, em que foram avaliados o grau de necrose tumoral no explante e a sobrevida pós-transplante. Resultados: Necrose total do nódulo neoplásico no explante foi observada em 76 pacientes (64,4%). Observou-se que 77,8% dos pacientes com necrose total no explante hepático tinham apresentado resposta completa nos exames de imagem. A DEB-TACE, apesar de ter demonstrado menor taxa de intercorrências, proporcionou menor grau de necrose total em relação à TACE convencional, a despeito de não haver diferença estatística. Ao final do seguimento do estudo, o número de óbitos foi de 26. A sobrevida foi maior nos pacientes que tiveram necrose total quando comparada com grau de necrose parcial ou ausência de necrose [HR = 2,24 (IC 95%: 0,91-5,53); p = 0,078]. Conclusão: Necrose completa do tumor nos pacientes submetidos a TACE como terapia ponte parece estar associada com melhora da sobrevida.

https://doi.org/10.1590/0100-3984.2023.0040

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR SYSTEMIC TREATMENT OF HEPATOCELLULAR CARCINOMA
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CHAGAS, Aline Lopes

; LEAL, Cassia Regina Guedes

; MELLO, Vivianne Barreto de

; BARROS, Fábio Marinho Do Rego

; BITTENCOURT, Paulo Lisboa

; MATTOS, Angelo A

; AROUCHA, Dayse

; FONSECA, Leonardo G da

; SILVA, Joyce Roma Lucas de

; DOTTORI, Mariana Fonseca

; TEIXEIRA, Rosangela

; MENDES, Liliana Sampaio Costa

; REZENDE, Rosamar Eulira Fontes

; FILGUEIRA, Norma Arteiro

; COUTINHO, Anelisa K

; ARAÚJO NETO, João Marcello de

; COELHO, Henrique Sergio Moraes

; PESSOA, Mario Guimarães

; CHEINQUER, Hugo

; PARISE, Edison Roberto

; FRANÇA, Alex

; ÁLVARES-DA-SILVA, Mário Reis

; CARRILHO, Flair José

; CORAL, Gabriela P

; PINTO, Paulo de Tarso Aparecida

; PEREIRA, Leila M M Beltrão

; PARANÁ, Raymundo

; ALVES, Rogério Camargo Pinheiro

; BRANDÃO-MELLO, Carlos Eduardo

Arquivos de Gastroenterologia

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jan 2023, Volume 60 N. 1 Pages 106 - 131

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

ABSTRACT Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2020 the updated recommendations for the diagnosis and treatment of HCC. Since then, new data have emerged in the literature, including new drugs approved for the systemic treatment of HCC that were not available at the time. The SBH board conducted an online single-topic meeting to discuss and review the recommendations on the systemic treatment of HCC. The invited experts were asked to conduct a systematic review of the literature on each topic related to systemic treatment and to present the summary data and recommendations during the meeting. All panelists gathered together for discussion of the topics and elaboration of the updated recommendations. The present document is the final version of the reviewed manuscript containing the recommendations of SBH and its aim is to assist healthcare professionals, policy-makers, and planners in Brazil and Latin America with systemic treatment decision-making of patients with HCC.

RESUMO O carcinoma hepatocelular (CHC) é uma das principais causas de mortalidade relacionada a câncer no Brasil e no mundo. A Sociedade Brasileira de Hepatologia (SBH) publicou em 2020 a atualização das recomendações da SBH para o diagnóstico e tratamento do CHC. Desde então, novas evidências científicas sobre o tratamento sistêmico do CHC foram relatadas na literatura médica, incluindo novos medicamentos aprovados que não estavam disponíveis na época do último consenso, levando a diretoria da SBH a promover uma reunião monotemática on-line para discutir e rever as recomendações sobre o tratamento sistêmico do CHC. Um grupo de experts foi convidado para realizar uma revisão sistemática da literatura e apresentar uma atualização, baseada em evidências científicas, sobre cada tópico relacionado ao tratamento sistêmico e a apresentar os dados e recomendações resumidas durante a reunião. Todos os painelistas se reuniram para discutir os tópicos e elaborar as recomendações atualizadas. O presente documento é a versão final do manuscrito revisado, contendo as recomendações da SBH, e seu objetivo é auxiliar os profissionais de saúde, formuladores de políticas e planejadores no Brasil e na América Latina na tomada de decisões sobre o tratamento sistêmico de pacientes com CHC.

https://doi.org/10.1590/s0004-2803.202301000-14

Results of transarterial chemoembolization of hepatocellular carcinoma as a bridging therapy to liver transplantation
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Jotz, Raquel de Freitas

; Horbe, Alex Finger

; Coral, Gabriela Perdomo

; Fontana, Priscila Cavedon

; Morais, Beatriz Garcia de

; Mattos, Angelo Alves de

Radiologia Brasileira

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2023, N. ahead

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

https://doi.org/10.1590/0100-3984.2023.0040

Estimación Temporal y Espacial de las Sequías e Inundaciones Meteorológicas con índice China-Z en la Intercuenca Alto Apurímac, Perú
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Cuba, Odilon Correa

; Surco, Rosa Gabriela Coral

Revista Brasileira de Meteorologia

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mar 2022, Volume 37 N. 1 Pages 57 - 67

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

Abstract The Alto Apurimac Interbasin (IAA) is located in southern highlands at the headwaters of the Amazon basin of the Peruvian Andes. This study focused on evaluating the spatial and temporal distribution of meteorological droughts and floods through the China-Z Index (CZI) method for the period 1986-2015, using observed precipitation and Tropical Rainfall Measuring Missions (TRMM) satellite data. The results revealed that the observed data and data obtained from the TRMM satellite present similar statistical characteristics, which represent pluviometric robust information. Thus, through CZI it was possible to identify and classify the types of droughts and floods at a temporal and spatial level. Concluding that the most droughts occurred in december towards the western area on IAA with critical years between 1988-1992 while floods occurred more frequently in february towards the eastern fringe on IAA with 2011 and 2012 were exceptional years. Thus, the research showed that the application of CZI is effective in order to detect and classify droughts and floods for the South American Andes.

Resumen La Intercuenca Alto Apurímac (IAA) está ubicada en la sierra sur de los Andes peruanos, en la cabecera de la cuenca amazónica. Este estudio se enfocó en evaluar la distribución espacial y temporal de las sequías e inundaciones meteorológicas a través de la aplicación del método del índice China-Z (CZI) para el periodo 1986-2015, utilizando datos de precipitación observada y del satélite Tropical Rainfall Measuring Missions (TRMM). Los resultados revelaron que la serie de datos observados y de los datos obtenidos del satélite TRMM presentan características estadísticas similares, suficientemente robustas como para representar información pluviométrica. Así, a través de CZI se logró identificar y clasificar las clases de sequías e inundaciones a nivel temporal y espacial, concluyendo que en su mayoría las sequías se presentaron en el mes de diciembre, hacia la zona del oeste de la IAA, siendo los años críticos entre 1988-1992; mientras que las inundaciones ocurrieron con mayor frecuencia en el mes de febrero, hacia la franja este de la IAA, siendo 2011 y 2012 años excepcionales. Así, la investigación mostró que la aplicación de CZI es eficaz para detectar y clasificar sequías e inundaciones para los Andes sudamericanos.

https://doi.org/10.1590/0102-7786370013

Nonalcoholic fatty liver disease: scintigraphy in the diagnosis of steatohepatitis
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Silva, Alessandro D'Avila da

; Mattos, Ângelo Zambam de

; Tovo, Cristiane Valle

; Daros, Larissa Faraco

; Anselmi, Osvaldo Estrela

; Coral, Gabriela Perdomo

; Mattos, Angelo Alves de

Revista da Associação Médica Brasileira

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nov 2021, Volume 67 N. 11 Pages 1665 - 1669

Abstract: En | Text: En | PDF: En

SUMMARY OBJECTIVE: Nonalcoholic fatty liver disease is the most prevalent cause of chronic liver disease worldwide. Nonalcoholic steatohepatitis is associated with increased mortality rates due to the liver and cardiovascular diseases. The gold standard for discriminating nonalcoholic fatty liver disease activity and staging is the anatomopathological examination, which is an invasive method. In this regard, noninvasive methods, such as scintigraphy, have been under investigation. This study investigated the role of scintigraphy in the diagnosis of nonalcoholic steatohepatitis in obese patients with nonalcoholic fatty liver disease undergoing bariatric surgery. METHODS: Patients undergoing bariatric surgery and liver biopsy were prospectively included. 99mTc-phytate scintigraphy was performed to assess liver/spleen, spleen/heart, and liver/heart uptake ratios, while 99mTc-isonitrile scintigraphy assessed liver/heart ratio. To evaluate the presence of nonalcoholic steatohepatitis, the results of 99mTc-phytate scintigraphy and 99mTc-isonitrile scintigraphy were compared with the anatomopathological examination. RESULTS: Sixty-one patients with nonalcoholic fatty liver disease were allocated into two groups, namely, nonalcoholic steatohepatitis (n=49) and non-nonalcoholic steatohepatitis (n=12). The results of scintigraphic images obtained after the infusion of radiopharmaceutical 99mTc-phytate in liver/spleen, spleen/heart, liver/heart ratios and 99mTc-isonitrile liver/heart ratio presented no difference between groups with and without nonalcoholic steatohepatitis with an accuracy of 47.5, 37.7, 50.8, and 52.5%, respectively. CONCLUSION: Scintigraphy was not proven to be a useful method to differentiate patients with and without nonalcoholic steatohepatitis.

https://doi.org/10.1590/1806-9282.20210718

PERFORMACE OF TRIGLYCERIDE-GLUCOSE INDEX ON DIAGNOSIS AND STAGING OF NAFLD IN OBESE PATIENTS
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SMIDERLE, Carla Alessandra

; CORAL, Gabriela Perdomo

; DE CARLI, Luiz Alberto

; MATTOS, Angelo Alves de

; MATTOS, Angelo Zambam de

; TOVO, Cristiane Valle

Arquivos de Gastroenterologia

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jun 2021, Volume 58 N. 2 Pages 139 - 144

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO: A doença hepática gordurosa não-alcoólica (DHGNA) é a doença hepática mais prevalente no mundo. Nos Estados Unidos, a DHGNA já é a segunda causa de transplante hepático. O espectro da doença abrange desde a esteatose simples, que apresenta curso benigno, até esteato-hepatite não-alcoólica (EHNA), que pode progredir para cirrose e suas complicações. O desenvolvimento de métodos não invasivos para o diagnóstico e estadiamento da EHNA e da fibrose hepática visa diminuir a necessidade de biópsia hepática, um procedimento invasivo e não raro associado a complicações. OBJETIVO: Analisar o desempenho do índice triglicerídeo-glicose (TyG Index) para o diagnóstico e estadiamento da DHGNA em pacientes obesos. MÉTODOS: Este é um estudo transversal retrospectivo. Foram analisados todos os prontuários de pacientes candidatos a cirurgia bariátrica em um hospital de referência do Sul do Brasil e calculado o TyG Index, um escore composto por dois exames laboratoriais (triglicerídeos e glicose de jejum), realizados previamente à cirurgia. O desempenho do TyG Index em relação aos achados anatomopatológicos hepáticos foi avaliado, e calculada a curva ROC para avaliação de esteatose simples, EHNA e fibrose hepática. O NAFLD Fibrosis Score (NFS) também foi avaliado. RESULTADOS: Foram avaliados 423 pacientes. O melhor ponto de corte do TyG Index para a exclusão de esteatose simples significativa (grau 2-3) foi de 8,76, com sensibilidade 67,6%, especificidade 65,1%, valor preditivo positivo (VPP) 46,3%, valor preditivo negativo (VPN) 81,8%, acurácia 65,8% e AUROC 0,66 (P=0,005). Na avaliação de EHNA significativa (grau 2-3), o melhor ponto de corte foi de 8,82 com sensibilidade 57,3%, especificidade 58,6%, VPP 33,7%, VPN 78,8%, acurácia 58,8% e AUROC 0,58 (P=0,022). Em relação à fibrose avançada (grau 3-4), o melhor ponto de corte do TyG Index foi de 8,91 com sensibilidade 61,8%, especificidade 62,5%, VPP 13,8%, VPN 94,4%, acurácia 62,4% e AUROC 0,69 (P<0,001). Ao analisarmos o desempenho do NFS no diagnóstico de fibrose avançada, o ponto de corte de <-1,455 excluiu fibrose avançada com sensibilidade 59,4%, especificidade 51%, VPP 11%, VPN 92,4% e acurácia 51,7%. Entretanto, o ponto de corte de 0,676 para fibrose avançada apresentou sensibilidade de 21,9%, especificidade 83%, VPP 11,7%, VPN 91,2% e acurácia 77,3%. A AUROC foi de 0,54 (P=0,480). CONCLUSÃO: O TyG Index não apresentou bom desempenho para o diagnóstico e estadiamento da esteatose simples e da EHNA. Entretanto, foi capaz de excluir fibrose avançada em pacientes obesos candidatos a cirurgia bariátrica.

ABSTRACT BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in the world, and its prevalence is increasing alongside obesity. In United States, NAFLD is already the second leading cause of liver transplantation. The spectrum of the disease ranges from simple steatosis, which has a benign course, to steatohepatitis, which may progress to cirrhosis and its complications. The rising of noninvasive methods for diagnosing and staging non-alcoholic steatohepatitis (NASH) and fibrosis decreases the need of liver biopsy, as well as the costs and the occurrence of complications related to it. OBJECTIVE: To analyze the performance of the triglyceride-glucose index to evaluate steatosis, NASH and liver fibrosis in obese patients with NAFLD. METHODS: This is a retrospective cross-sectional study. Every medical record of patients who were candidates for bariatric surgery at a leading hospital in Southern Brazil were analyzed. The triglyceride-glucose index (TyG Index), a method composed only of two simple laboratory tests (serum triglycerides and fasting glucose levels), was performed prior to surgery. The TyG Index performance regarding the anatomopathological findings was evaluated, and the AUROC curve was calculated to evaluate the best cut-off point for diagnosing steatosis, non-alcoholic steatohepatitis and liver fibrosis grade. Also, the NAFLD fibrosis Score (NFS) was evaluated. RESULTS: A total of 423 patients were evaluated. The TyG Index with a cut-off point of 8.76 excluded significant simple steatosis (grade 2-3) in obese patients, with 67.6% sensitivity, 65.1% specificity, 46.3% positive predictive value (PPV), 81.8% negative predictive value (NPV), 65.8% accuracy and 0.66 AUROC (P=0.005). In the evaluation of NASH, the TyG Index with a cut-off point of 8.82 excluded significant NASH (grade 2-3) with 57.3% sensitivity, 58.6% specificity, 33.7% PPV, 78.8% NPV, 58.2% accuracy and 0.58 AUROC (P=0.022). When evaluating liver fibrosis, the TyG Index with a cut-off point of 8.91 showed a sensitivity of 61.8%, a specificity of 62.5%, a PPV of 13.8 and a NPV of 94.4% for exclusion of advanced fibrosis (F3-4), with a 62.4% accuracy and 0.69 AUROC (P<0.001). When analyzing the performance of NFS in the diagnosis of advanced fibrosis, the cut-off point <-1.455 excluded advanced fibrosis with sensitivity of 59.4%, specificity of 51%, PPV of 11%, NPV of 92.4% and accuracy of 51.7%. However, the cut-off point of 0.676 to diagnose advanced fibrosis presented sensitivity of 21.9%, specificity of 83%, PPV of 11.7%, NPV of 91.2% and 77.3% accuracy. The AUROC was 0.54 (P=0.480). CONCLUSION: TyG Index did not perform well in the diagnosis of significant steatosis and NASH. However, it was able to exclude advanced fibrosis in obese patients who are candidates for bariatric surgery.

https://doi.org/10.1590/s0004-2803.202100000-24 429 downloads

RESULTS OF IMMUNOHISTOCHEMISTRY IN THE DIFFERENTIAL DIAGNOSIS OF EARLY HEPATOCELLULAR CARCINOMA AND NODULES WITH HIGH-GRADE DYSPLASIA IN PATIENTS WITH CIRRHOSIS
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CORAL, Gabriela Perdomo

; BRANCO, Fernanda

; MEURER, Rosalva

; MARCON, Patrícia dos Santos

; FONTES, Paulo Roberto Ott

; MATTOS, Angelo Alves de

Arquivos de Gastroenterologia

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mar 2021, Volume 58 N. 1 Pages 82 - 86

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO: O carcinoma hepatocelular (CHC) é o câncer primário do fígado mais frequente e a cirrose é considerada uma doença pré-maligna. Nesse contexto, a sequência evolutiva do nódulo displásico de baixo grau e nódulo displásico de alto grau (NDAG) para CHC precoce e CHC avançado tem sido estudada. O diagnóstico diferencial entre NDAG e CHC precoce ainda é um desafio, principalmente em biópsias por agulha. OBJETIVO: Avaliar um painel de imunohistoquímica para diferenciar nódulos displásicos de CHC. MÉTODOS: Foram incluídos pacientes com cirrose submetidos à ressecção cirúrgica ou transplante de fígado. A sensibilidade, especificidade e acurácia para o diagnóstico da neoplasia foram analisadas avaliando cinco marcadores: proteína de choque térmico 70kDa, glipican 3, glutamina sintetase, clatrina de cadeia pesada e beta-catenina. P≤0,05 foi considerado estatisticamente significativo. RESULTADOS: Cento e cinquenta e seis nódulos foram incluídos; destes, 57 eram CHC, 14 NDAG, 18 nódulos displásicos de baixo grau e 67 macronódulos regenerativos. A sensibilidade do diagnóstico de CHC foi de 64,9% para glipican 3 e 77,2% para glutamina sintetase, enquanto a especificidade foi de 96,0% e 96,0%, respectivamente. Quando o painel de quatro marcadores foi considerado (excluindo beta catenina), a especificidade variou de 87,9% para um marcador positivo a 100% para pelo menos três marcadores. A melhor acurácia para o diagnóstico de CHC foi obtida com pelo menos dois marcadores positivos, o que foi associado a uma sensibilidade de 82,5% e especificidade de 99%. CONCLUSÃO: O diagnóstico diferencial de nódulos displásicos e CHC por critérios morfológicos pode ser desafiador. Imunomarcadores são úteis e devem ser usados para o diagnóstico diferencial entre CHC e NDAG.

ABSTRACT BACKGROUND: Hepatocellular carcinoma (HCC) is the most frequent primary cancer of the liver and cirrhosis is considered a pre-malignant disease. In this context, the evolutionary sequence from low grade dysplastic nodule and high grade dysplastic nodule (HGDN) to early HCC and advanced HCC has been studied. The differential diagnosis between HGDN and early HCC is still a challenge, especially in needle biopsies OBJECTIVE: To evaluate an immunohistochemistry panel to differentiate dysplastic nodules and HCC. METHODS: Patients with cirrhosis who underwent surgical resection or liver transplantation were included. The sensitivity, specificity and accuracy for the diagnosis of neoplasia were analyzed by evaluating five markers: heat shock protein 70, glypican 3, glutamine synthetase, clathrin heavy chain and beta-catenin. P≤0.05 was considered statistically significant. RESULTS: One hundred and fifty-six nodules were included; of these, 57 were HCC, 14 HGDN, 18 low grade dysplastic nodules and 67 regenerative macronodules. Sensitivity of HCC diagnosis was 64.9% for glypican 3 and 77.2% for glutamine syntetase, while specificity was 96.0% and 96.0% respectively. When the panel of four markers was considered (excluding beta catenin), the specificity ranged from 87.9% for one positive marker to 100% for at least three markers. The best accuracy for HCC diagnosis was obtained with at least two positive markers, which was associated with a sensitivity of 82.5% and specificity of 99%. CONCLUSION: Differential diagnosis of dysplastic nodules and HCC by morphological criteria can be challenging. Immunomarkers are useful and should be used for the differential diagnosis between HCC and HGDN.

https://doi.org/10.1590/s0004-2803.202100000-14 484 downloads

Contaminación por metales pesados de la microcuenca agropecuaria del río Huancaray - Perú
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Correa Cuba, Odilon

; Fuentes Bernedo, Frida Esmeralda

; Coral Surco, Rosa Gabriela

Revista de la Sociedad Química del Perú

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jan 2021, Volume 87 N. 1 Pages 26 - 38

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

ABSTRACT Metals are transported, spatially and temporally, through the ground surface and the atmosphere, generating environmental and social problems in populations located in the hydrographic basins. The present study aimed to determine sources and metal levels in water sediments in the micro-basin of the Huancaray river in Apurímac region (Peru), using the X-ray fluorescence analysis technique (XRF) during the dry and rainy season of 2018 and 2019. The elements detected were K, Ca, Ti, V, Cr, Mn, Fe, Co, Ni, Cu, Zn, Ga, As, Br, Rb, Sr, Y, Zr, Nb and Ba. At each point and sampling period, critical elements have been found, as Zn, Cr, Cu, Pb, Ni and As; concentrations are above permissible limits; likewise, in the rainy and dry seasons there are no significant differences, while the main sources of pollution are populated centers; agricultural practices; presence of illegal mining; and source of natural origin.

RESUMEN Los metales se transportan, a nivel espacial y temporal, a través de la superficie del suelo y la atmósfera, convirtiéndose en un peligro para el medio ambiente y poblaciones vulnerables de las cuencas hidrográficas. El presente estudio tuvo como objetivo determinar fuentes y niveles de metales en sedimentos del agua en la microcuenca del río Huancaray en la región Apurímac (Perú), mediante la técnica de análisis por fluorescencia de rayos X (FRX) durante la época de secas y lluvias de los años 2018 y 2019. Los elementos detectados fueron K, Ca, Ti, V, Cr, Mn, Fe, Co, Ni, Cu, Zn, Ga, As, Br, Rb, Sr, Y, Zr, Nb y Ba. Resalta la presencia de Zn, Cr, Cu, Pb, Ni y As como elementos críticos en cada punto de la microcuenca del río Huancaray; las concentraciones son superiores a los límites permisibles; asimismo, los periodos de lluvia y seca no presentan diferencia significativa, mientras que las principales fuentes de contaminación son centros poblados, prácticas de la agricultura, presencia de la minería ilegal y fuente de origen natural.

https://doi.org/10.37761/rsqp.v87i1.320

Prevalence of hepatitis A in the capitals of the States of North, Southeast and South regions of Brazil: decrease in prevalence and some consequences
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Pereira, Leila M. M. B.

; Stein, Airton T.

; Figueiredo, Gerusa Maria

; Coral, Gabriela Perdomo

; Montarroyos, Ulisses R.

; Cardoso, Maria Regina Alves

; Braga, Maria Cynthia

; Moreira, Regina Celia

; Santos, Alex A. dos

; Ximenes, Ricardo Alencar

Revista do Instituto de Medicina Tropical de São Paulo

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2021, Volume 63 elocation e34

Abstract: En | Text: En | PDF: En

ABSTRACT Hepatitis A virus (HAV) infection has been considered one of the leading causes of acute hepatitis. The aim of the present study was to estimate the prevalence of HAV among children and adolescents in a population-based study in the capitals of the States of the North, Southeast and South of Brazil and identify predictive factors for the infection. A multi-stage sampling was used to select subjects aged between 5-9 and 10-19 years. Individual and household levels aside from the level of variables in the areas were collected. The outcome was the total IgG antibodies to HAV levels detected using a commercial Enzyme Immuno Assay (EIA). The associations between HAV and the independent variables were assessed using the odds ratio. A multilevel analysis was performed by GLLAMM using the Stata software. The prevalence of HAV infection in the 5-9 and 10-19 age groups was 28.7% and 67.5%, respectively for the North, 20.6% and 37.7%, for the Southeast and 18.9% and 34.5% for the South Region. The prevalence of HAV increased according to age in all sites. Variables related to education at the individual level (North and South), family and area level (South and Southeast) and family income level (Southeast and South) were independently associated with HAV infection. This emphasizes the need for individualized strategies to prevent the infection.

https://doi.org/10.1590/s1678-9946202163034 358 downloads

10.

MALNUTRITION IN CIRRHOSIS: ASSOCIATION WITH ETIOLOGY AND HEPATOCELLULAR DYSFUNCTION
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OLIVEIRA, Kalinca S

; OLIVEIRA, Luana Reis

; FERNANDES, Sabrina A

; CORAL, Gabriela P

Arquivos de Gastroenterologia

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dec 2020, Volume 57 N. 4 Pages 375 - 380

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO: A desnutrição proteico-calórica altera o prognóstico dos pacientes com cirrose. Sua prevalência pode variar de acordo com a etiologia da hepatopatia, gravidade da doença e o método de avaliação empregado. A infeção pelo vírus da hepatite C (VHC) e o alcoolismo, estão entre as principais etiologias da cirrose e acarretam significativa morbidade e mortalidade. OBJETIVO: Avaliar o estado nutricional do paciente com cirrose de acordo com a etiologia e gravidade da hepatopatia. MÉTODOS: Estudo prospectivo, em que a amostra foi por conveniência constituída de pacientes com cirrose, infectados pelo vírus da hepatite C (VHC) ou etiologia alcoólica. A avaliação do estado nutricional foi realizada através da antropometria, consumo alimentar, bioimpedância elétrica (BIA) e da avaliação subjetiva global (ASG). Os dados antropométricos avaliados foram: peso, altura, índice de massa corporal (IMC), prega cutânea triciptal (PCT), circunferências do braço (CB), força do aperto de mão não dominante (FAM) e a espessura do músculo adutor do polegar (MAP). Os pacientes foram classificados de acordo com a gravidade da hepatopatia, através do escore Child-Pugh e Model for End-stage Liver Diseases (MELD). RESULTADOS: Foram avaliados 90 pacientes com cirrose, 47 com etiologia pelo VHC e 43 com etiologia alcoólica. A prevalência de desnutrição proteico-calórica variou de 10,9% a 54,3% no grupo do VHC e de 4,7% a 20,9% no grupo dos alcoolistas, dependendo do método utilizado para avaliação. O grupo com infecção pelo VHC apresentou maior prevalência de desnutrição em relação ao de etiologia alcoólica nas seguintes avaliações: PCT (P<0,001), ângulo de fase (AF) (P=0,016) e ASG (P=0,010). Os valores do AF foram menores nos pacientes com cirrose viral (5,68±1,05) quando comparados aos com etiologia alcoólica (6,61±2,31) (P=0,016). Quando analisados todos os pacientes, independente da etiologia da hepatopatia, observou-se uma correlação inversamente proporcional entre a classificação de Child-Pugh e os valores de AF (P=0,018). CONCLUSÃO: A cirrose pelo VHC demonstrou piores parâmetros nutricionais em relação à etiologia alcoólica; entretanto, em ambas etiologias o AF foi associado com pior função hepática em ambas etiologias.

ABSTRACT BACKGROUND: The protein-energy malnutrition alters the prognosis of patients with cirrhosis. Its prevalence may vary according to the etiology of liver disease, it´s severity and the evaluation of the method applied. The infection by the hepatitis C virus (HCV) and alcoholism are the main etiologies of cirrhosis and result in a significant morbidity and mortality. OBJECTIVE: To evaluate the nutritional status of patients with cirrhosis according the liver disease etiology and severity. METHODS: It is a prospective study, in which the sample was for convenience and consisted of patients with cirrhosis, infected by HCV or alcoholic etiology. The nutritional status evaluation was carried out through anthropometry, food consumption, bioelectrical impedance (BIA) and subjective global assessment (SGA). The anthropometric data evaluated were weight, height, body mass index (BMI), triceps skinfold (TSF), circumference of the arm (CA), non-dominant handshake strength (FAM) and the adductor pollicis muscle thickness (APM). Patients were classified according to the severity of liver disease, using the Child-Pugh and Model for End-stage Liver Diseases (MELD) scores. RESULTS: Ninety patients with cirrhosis were evaluated, 47 with HCV and 43 with alcoholic etiology. The prevalence of protein-calorie malnutrition ranged from 10.9% to 54.3% in the HCV group and from 4.7% to 20.9% in the alcoholic group, depending on the method used for evaluation. The group with HCV infection presented a higher malnutrition prevalence in comparison to the alcoholic in the following evaluations: TSF (P<0.001), phase angle (PA) (P=0.016) and SGA (P=0.010). PA values were lower in patients with viral cirrhosis (5.68±1.05) when compared to those with alcoholic etiology (6.61±2.31) (P=0.016). When all patients were analyzed, regardless of etiology, an inversely correlation was observed among Child-Pugh score and PA values (P=0.018). CONCLUSION: HCV cirrhosis showed worse nutritional parameters in comparison to alcoholic etiology; however, the PA was associated with worse liver function in both etiologies.

https://doi.org/10.1590/s0004-2803.202000000-71 1172 downloads

11.

EVALUATION OF PATIENTS WITH AUTOIMMUNE HEPATITIS IN A SPECIALIZED OUTPATIENT CLINIC IN SOUTHERN BRAZIL
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FEDRIZZI, Renata S

; CORAL, Gabriela P

; MATTOS, Angelo A de

; MATTOS, Ângelo Z de

; TOVO, Cristiane V

Arquivos de Gastroenterologia

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dec 2020, Volume 57 N. 4 Pages 361 - 365

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO: A hepatite autoimune (HAI) é uma doença hepática crônica, de caráter necroinflamatório e etiologia autoimune. Os estudos que avaliam as características de pacientes com HAI são escassos no Brasil. OBJETIVO: Nosso objetivo foi avaliar o perfil dos pacientes com HAI atendidos em um centro de referência do sul do Brasil e verificar fatores relacionados à resposta ao tratamento. MÉTODOS: Este foi um estudo de coorte retrospectivo, que analisou dados demográficos, epidemiológicos e clínicos. Nas biópsias hepáticas, foram avaliados o grau de fibrose, a atividade histológica, a presença de rosetas, de infiltrado plasmocitário e de necrose confluente. Na análise estatística, o nível de significância foi de 5%. RESULTADOS: Foram incluídos 40 pacientes adultos com diagnóstico de HAI. Houve predomínio do sexo feminino (75,0%), e a média de idade no diagnóstico foi de 44,2 anos. A associação com doenças autoimunes extra-hepáticas ocorreu em 20,0% dos casos. Clinicamente, 35,0% dos pacientes se apresentaram sob forma de hepatite aguda, 37,5% com cirrose e 27,5% com outras formas de apresentação. A manifestação clínica mais comum na apresentação foi a icterícia (47,5%). Trinta e cinco pacientes foram tratados, sendo que destes, 97,1% utilizaram prednisona associada com azatioprina. A média do tempo de tratamento foi 2,7 anos. A resposta ao tratamento foi completa ou parcial em 30 (85,7%) e ausente em 5 (14,3%) pacientes. Não houve diferença estatisticamente significativa quando avaliada a resposta ao tratamento em relação à forma de apresentação, aos achados histológicos e à presença de autoanticorpos. Em relação à fibrose, foi observada regressão em 18,75% dos casos. CONCLUSÃO: A maioria dos pacientes era jovem no momento do diagnóstico e do sexo feminino. A associação com doenças autoimunes extra-hepáticas e com cirrose na apresentação foi vista em uma parcela considerável dos casos. O tratamento foi eficaz, mas não houve parâmetros clínicos, histológicos ou sorológicos capazes de prever a resposta ao tratamento.

ABSTRACT BACKGROUND: Autoimmune hepatitis (AIH) is a chronic liver disease, characterized by necroinflammation and autoimmune etiology. Studies evaluating the characteristics of patients with AIH are scarce in Brazil. OBJECTIVE: Our objective was to evaluate the profile of patients with AIH in a specialized center in Southern Brazil and to verify factors related to treatment response. METHODS: this was a retrospective cohort study, which analyzed demographic, epidemiological, clinical, laboratory, and histologic data. Patients with AIH diagnosed according to the criteria of the International Autoimmune Hepatitis Group (IAIHG) were included. In liver biopsies, the degree of fibrosis, histological activity, presence of hepatocyte rosettes, plasma cell infiltrates, and confluent necrosis were evaluated. In the statistical analysis, the significance level was 5%. RESULTS: Forty adults patients diagnosed with AIH were included. The evaluated population predominantly consisted of women (75.0%) and the average age at diagnosis was 44.2 years. The association with extrahepatic autoimmune diseases occurred in 20.0% of cases. Clinically, 35.0% of patients presented with acute onset hepatitis, 37.5% with cirrhosis, and 27.5% with other forms of presentation. The most common clinical manifestation was jaundice (47.5%). Thirty-five patients were treated, and of these, 97.1% used prednisone combined with azathioprine. The average treatment time was 2.7 years. Response to treatment was complete or partial in 30 (85.7%) and absent in 5 (14.3%) patients. There was no statistically significant difference when evaluating response to treatment in relation to forms of presentation, histological findings, and the presence of autoantibodies. Regarding fibrosis, regression was observed in 18.75% of the cases. CONCLUSION: Most patients with AIH were young at presentation and of female sex. The association with extrahepatic autoimmune diseases and cirrhosis at presentation was seen in a considerable proportion of patients. Treatment was effective, but there were no clinical, histological or serological parameters capable of predicting treatment response.

https://doi.org/10.1590/s0004-2803.202000000-69 739 downloads

12.

IMPACT OF ACUTE KIDNEY INJURY STAGING ON PROGNOSIS OF PATIENTS WITH CIRRHOSIS
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SCHACHER, Fernando C

; MATTOS, Angelo A

; MULAZZANI, Carolina M

; DETANICO, Rafaela B

; FAVERO, Bruna

; FONSECA, Bárbara B

; FELIX, Patricia H

; PASE, Tales Henrique S

; KUPSKI, Carlos

; MACHADO, Marta B

; CORAL, Gabriela P

; WILTGEN, Denusa

; MATTOS, Angelo Z

Arquivos de Gastroenterologia

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sep 2020, Volume 57 N. 3 Pages 244 - 248

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO: A lesão renal aguda (LRA) é uma complicação comum e grave na cirrose. OBJETIVO: Avaliar o impacto dos estágios da LRA na mortalidade em 30 dias de pacientes com cirrose. MÉTODOS: Realizou-se um estudo de coorte retrospectivo com pacientes com cirrose hospitalizados. LRA foi diagnosticada de acordo com as recomendações do International Club of Ascites e o estadiamento foi feito de acordo com as recomendações da European Association for the Study of the Liver. Comparações entre os grupos foram feitas por análise de variância unidirecional e teste de Tukey. O teste do qui-quadrado foi calculado para variáveis categóricas. Comparações quanto à lesão renal entre os pacientes foram realizadas com estatísticas de Kaplan-Meier, e diferenças entre os grupos foram analisadas pelo teste de log-rank. Um P-valor <0,05 foi considerado estatisticamente significativo. RESULTADOS: Duzentos e trinta e dois pacientes foram incluídos no estudo. O diagnóstico de LRA foi realizado em 98 (42,2%) deles. A mortalidade geral em 30 dias foi de 19,8% (46/232). A mortalidade aumentou de acordo com a progressão dos estágios de LRA. Entre pacientes sem LRA, a mortalidade foi de 5,2% (7/134). Quando comparados aos pacientes sem LRA, pacientes diagnosticados com LRA estágio 1a tiveram mortalidade de 12,1% (4/33, P=0,152); pacientes com LRA estágio 1b tiveram mortalidade de 45% (18/40, P<0,001); e pacientes com LRA estágios 2 ou 3 tiveram mortalidade de 68% (17/25, P<0,001). Além disso, é importante ressaltar que a resposta completa ao tratamento associou-se à menor mortalidade quando comparada à ausência de recuperação completa da função renal (14,3% vs 57,9%, P<0,001). CONCLUSÃO: LRA estágios 1b ou superior, mas não estágio 1a, estão associadas à maior mortalidade em 30 dias de pacientes com cirrose.

ABSTRACT BACKGROUND: Acute kidney injury (AKI) is a common and severe complication of cirrhosis. OBJECTIVE: To evaluate the impact of AKI staging on 30-day mortality of patients with cirrhosis. METHODS: We performed a retrospective cohort study of hospitalized patients with cirrhosis. Acute kidney injury (AKI) was diagnosed according to the International Club of Ascites recommendations and staged according to the European Association for the Study of the Liver guidelines. Comparisons between groups were made by one-way analysis of variance and Tukey test. Chi-square was calculated for dichotomous variables. Comparisons of renal impairment status among patients were performed using Kaplan-Meier statistics and differences between groups were analyzed using the log-rank test. A P-value <0.05 was considered to be statistically significant. RESULTS: Two hundred and thirty-two patients were included in the study. The diagnosis of AKI was performed in 98 (42.2%) of them. The overall 30-day mortality was 19.8% (46/232). Mortality increased as the degree of AKI progressed. Among patients who did not have AKI, mortality was 5.2% (7/134). When compared to patients without AKI, patients diagnosed with AKI stage 1a had mortality of 12.1% (4/33, P=0.152); patients with AKI stage 1b had mortality of 45% (18/40, P<0.001); and patients with AKI stages 2 or 3 had mortality of 68% (17/25, P<0.001). Moreover, it is noteworthy that full response to treatment was associated to a decreased mortality when compared to patients who did not show complete recovery of renal function (14.3% vs 57.9%, P<0.001). CONCLUSION: AKI stages 1b or greater, but not AKI stage 1a, are associated to higher 30-day mortality of patients with cirrhosis.

https://doi.org/10.1590/s0004-2803.202000000-46 409 downloads

13.

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA
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CHAGAS, Aline Lopes

; MATTOS, Angelo Alves de

; CARRILHO, Flair José

; BITTENCOURT, Paulo Lisboa

; VEZOZZO, Denise Cerqueira Paranaguá

; HORVAT, Natally

; ROCHA, Manoel de Souza

; ALVES, Venâncio Avancini Ferreira

; CORAL, Gabriela Perdomo

; ALVARES-DA-SILVA, Mario Reis

; BARROS, Fabio Marinho do Rego

; MENEZES, Marcos Roberto

; MONSIGNORE, Lucas Moretti

; COELHO, Fabricio Ferreira

; SILVA, Renato Ferreira da

; SILVA, Rita de Cássia Martins Alves

; BOIN, Ilka de Fatima Santana Ferreira

; D`ALBUQUERQUE, Luiz Augusto Carneiro

; GARCIA, José Huygens Parente

; FELGA, Guilherme Eduardo Gonçalves

; MOREIRA, Airton Mota

; BRAGHIROLI, Maria Ignez Freitas Melro

; HOFF, Paulo Marcelo Gehm

; MELLO, Vivianne Barretto de

; DOTTORI, Mariana Fonseca

; BRANCO, Tiago Pugliese

; SCHIAVON, Leonardo de Lucca

; COSTA, Thaisa de Fátima Almeida

Arquivos de Gastroenterologia

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2020, Volume 57 Suppl. 1 Pages 1 - 20

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO O carcinoma hepatocelular (CHC) é uma das principais causas de mortalidade relacionada a câncer no Brasil e no mundo. A Sociedade Brasileira de Hepatologia (SBH) publicou em 2015 suas primeiras recomendações sobre a abordagem do CHC. Desde então, novas evidências sobre o diagnóstico e tratamento do CHC foram relatadas na literatura médica, levando a diretoria da SBH a promover uma reunião monotemática sobre câncer primário de fígado em agosto de 2018 com o intuito de atualizar as recomendações sobre o manejo da neoplasia. Um grupo de experts foi convidado para realizar uma revisão sistemática da literatura e apresentar uma atualização baseada em evidências científicas visando que pudesse nortear a prática clínica multidisciplinar do CHC. O texto resultante foi submetido a avaliação e aprovação de todos membros da SBH através de sua homepage. O documento atual é a versão final que contêm as recomendações atualizadas e revisadas da SBH.

ABSTRACT Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.

https://doi.org/10.1590/s0004-2803.202000000-20 4088 downloads

14.

Los paradigmas femeninos plasmados en el arte y la percepción de la mujer de principios del siglo XXI en México y Latinoamérica
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García-Guerra, Gabriela Arhelí

; Revueltas-Valle, Coral

Índex, revista de arte contemporáneo

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jun 2019, N. 7 Pages 26 - 31

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

ABSTRACT Women image represented in art has been transformed according to their time context, which in turn was subject to beliefs and purposes. Two decades ahead 21st century it is possible to identify paradigms origins in the feminine image, as well as to make a criticism towards these obsolete thoughts nowadays. In this way, the present work has as purpose to indicate some of the feminine conceptions mainly in Mexico and Latin America. First, it is pointed out by different authors and artistic works contain dormant elements of domination over woman's body, but also about other vulnerable groups. Finally, by way of conclusion different reflections on the meaning of art and the power it has on viewers.

RESUMEN La imagen de la mujer representada en el arte se ha transformado de acuerdo al contexto de su época, el cual a su vez estuvo sometido a creencias y propósitos. A dos décadas del siglo XXI es posible identificar los orígenes de los paradigmas en la imagen femenina, así como hacer una crítica hacia estos pensamientos, hoy en día obsoletos. De tal manera, el presente texto tiene como propósito señalar algunas de las concepciones femeninas, principalmente en México y Latinoamérica. Primero, se señala, por medio de diferentes autores, cómo las obras artísticas contienen latentemente elementos de dominación sobre el cuerpo de la mujer, pero también sobre otros grupos vulnerables. Por último, se encuentra, a modo de conclusión, distintas reflexiones sobre el sentido del arte y el poder que este tiene sobre los espectadores.

https://doi.org/10.26807/cav.v0i07.210 22 downloads

15.

Recomendaciones latinoamericanas para el manejo de la hipertensión arterial en adultos (RELAHTA 2)
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Sabio, Rodrigo

; Valdez, Pascual

; Abuabara Turbay, Yazmin

; Andrade Belgeri, Rodrigo Eduardo

; Arbo Oze de Morvil, Gustavo Adolfo

; Arias, Claudia

; Cámera, Luis Alberto

; Carballo Zárate, Virgil

; Celauro Falcón, Hugo

; Chahin, Ramez Constantino

; Contreras Monchez, Jorge

; Contreras Zambrano, Miguel Ángel

; Cristaldo Id, Coral

; Dávila, Erik

; De los Santos Godoy, Ernesto

; Díaz, Sergio

; Díaz Salazar, Lorenzo

; Durán Castillo, Maritza

; Echegaray Castro, Katia Ninoska

; Figueroa Guilamo, Fredy Antonio

; Galarza Nuñez, José

; García Méndez, Jorge Óscar

; Hernández Ayazo, Helí

; Hernández Araque, Sara

; López Sánchez, Cristina

; Melgar Cuellar, Felipe

; Montúfar, Rubén

; Ortellado Maidana, José

; Ormaechea, Gabriela

; Patiño Torres, Mario J.

; Penny Montenegro, Eduardo

; Pérez Papadopulos, Verónica

; Puello Galarcio, Homero Luis

; Rojas Cifuentes, Williams

; Romero, Selva

; Salazar Rodríguez, Samuel

; Salazar Matos, Virginia Alejandra

; Vera, Mariflor

; Vergara Hanson, Pablo

; Zelechower, Hugo

Revista Virtual de la Sociedad Paraguaya de Medicina Interna

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mar 2019, Volume 6 N. 1 Pages 86 - 123

Abstract: En Es | Text: En Es | PDF: En | PDF: Es

ABSTRACT The second part of the Latin American recommendations for the management of Arterial Hypertension (HTA) in adults is presented. In a first phase, the most relevant aspects of epidemiology, physiopathological aspects, how to diagnose, therapeutic guidelines, hypertension emergencies, special populations, refractory hypertension and the application of guides in real life have been described. In this second part, recommendations are issued answering specific questions for primary, secondary, tertiary and quaternary prevention. In general, few recommendations regarding the management of arterial hypertension arise from the medical clinic / internal medicine, despite two situations: the majority of patients with hypertension are evaluated and managed by the clinicians, and the medical clinic is the specialty that allows the holistic and integrated look of the health problems in adults, allowing to add the biographical approach to the biological, to understand and interpret not only the health problem but its causes and consequences (which often correspond to different parenchyma, which in the fragmented model would make the patient move through different specialties). The low percentage of controlled hypertensive patients forces all the professionals involved in the management of them to optimize resources and detect problems that are associated with a deficit control such as the under utilization of pharmacological treatment, low rate of patients treated with combined strategy (the most patients currently receive monotherapy), lack of adequate prescription of changes in lifestyle, low therapeutic adherence and clinical inertia. This publication presents recommendations made by specialists in medical clinic/internal medicine for the management of hypertension in adults, answering primary, secondary, tertiary and quaternary prevention questions.

RESUMEN Se presenta la segunda parte de las recomendaciones latinoamericanas para el manejo de la Hipertensión Arterial (HTA) en adultos. En una primera fase se han descripto los aspectos más relevantes de la epidemiología, aspectos fisiopatológicos, cómo hacer diagnóstico, pautas terapéuticas, urgencias y emergencias hipertensivas, poblaciones especiales, hipertensión refractaria y la aplicación de las guías en la vida real. En esta segunda parte, se emiten recomendaciones respondiendo a preguntas específicas para prevención primaria, secundaria, terciaria y cuaternaria. En general pocas recomendaciones al respecto del manejo de la hipertensión arterial surgen desde la clínica médica/ medicina interna, a pesar de dos situaciones: la mayoría de los pacientes con hipertensión arterial son evaluados y manejados por los clínicos, y la clínica médica es la especialidad que permite la mirada holística e integrada de los problemas de salud del adulto, permitiendo agregar el enfoque biográfico al biológico, comprender e interpretar no solo el problema de salud sino sus causas y consecuencias (que muchas veces suelen corresponder a diferentes parénquimas, lo cual en el modelo fragmentado haría transitar al paciente por distintas especialidades). El bajo porcentaje de pacientes hipertensos controlados obliga a todos los profesionales involucrados en el manejo de los mismos a optimizar recursos y detectar problemas que se asocien a un control deficitario como la sub utilización del tratamiento farmacológico, baja tasa de pacientes tratados con estrategia combinada (la mayoría de los pacientes actualmente recibe monoterapia), falta de prescripción adecuada de los cambios en el estilo de vida, baja adherencia terapéutica e inercia clínica. En la presente publicación se presentan recomendaciones efectuadas por especialistas en clínica médica / medicina interna para el manejo de la hipertensión arterial en adultos, respondiendo preguntas de prevención primaria, secundaria, terciaria, y cuaternaria.

https://doi.org/10.18004/rvspmi/2312-3893/2019.06(01)86-123 2038 downloads

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