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ABSTRACT Objective To calculate the positive likelihood ratio to determine whether telemedicine is able to optimize referral to the emergency department. Methods Unicenter study with 182 consecutive patients admitted to Hospital Israelita Albert Einstein due to respiratory symptoms. All patients were submitted to oxygen saturation measurement using the standard method Welch Allyn finger device vital sign monitor and a 2-minute evaluation (Binah.ai mobile application). The reproducibility of oxygen saturation measurements made with both methods was investigated using interclass correlation coefficients and analysis of dispersion. Bland-Altman plots were constructed and kappa concordance coefficients used to examine data normality. Accuracy was also estimated. Results Oxygen saturation measurement differences between methods were ≤2% in more than 85% of cases. The mean difference (bias) between methods was near zero (0.835; Bland-Altman analysis). Oxygen saturation measurements made using the Binah.ai mobile application had an average ability to detect patients with altered oxygen saturation levels compared to the conventional method (ROC analysis). The positive likelihood ratio of the mobile application was 6.23. Conclusion Mobile applications for oxygen saturation measurement are accessible user-friendly tools with moderate impact on clinical telemedicine evaluation of patients with respiratory symptoms, and may optimize referral to the emergency department.

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ABSTRACT Objective To analyze the karyotype test and myeloid panel with next-generation sequencing findings in patients with myelofibrosis, and to compare transplant characteristics in patients referred for bone marrow transplantation. Methods Retrospective, single-center study with patients diagnosed with myelofibrosis treated at Hospital Israelita Albert Einstein between 2010 and 2020. Results A total of 104 patients with myelofibrosis were examined. Patients who had not been submitted to tests in our service were excluded. The final sample comprised 69 patients. Of these 69, 56 were submitted to karyotyping and 22 to myeloid panel with next-generation sequencing. Karyotype was normal in 60% of the patients and altered in 40%. The prevalence of high-risk molecular mutations was higher in patients referred for bone marrow transplantation (100% versus 50%). The median follow-up of transplant patients was 2.4 years and the overall survival at 2 years was 80% (95%CI: 62-100%). Conclusion The molecular analysis enables estimating the patient’s risk and thus instituting more aggressive treatment such as bone marrow transplant for patients at higher risk, being a relevant tool to guide therapy. Given the significance of molecular analysis for therapeutic decision-making in myelofibrosis, collection and disclosure of data on the prevalence of cytogenetic changes and findings of next-generation sequencing in affected patients is important.

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ABSTRACT Objective To characterize the immunophenotypic profile of acute leukemias in the population of the state of Bahia, Brazil. Methods This is a descriptive, retrospective study. From 2014 to 2018, 796 new cases of acute leukemia were evaluated. The data were obtained from analysis of reports and records of tests performed by flow cytometry immunophenotyping. All individuals of all age groups diagnosed as acute lymphoblastic leukemia or acute myeloid leukemia were included in the study. Demographic variables and expression of leukemia antigens were evaluated. Results Most cases were diagnosed as acute myeloid leukemia and 42.7% as acute lymphoblastic leukemia. Significant differences were found in expression of markers in acute leukemias when age groups were compared, as well as in demographic characteristics. B-cell acute lymphoblastic leukemia was more prevalent than cases of T-cell origin. Assessing the aberrant markers in acute myeloid leukemias, the non-acute promyelocytic leukemia group presented expression of CD7 and CD56 as the most frequent ones. In B-cell acute lymphoblastic leukemia, the most frequent aberrant markers were CD66c, CD13 and CD33. Conclusion Significant differences were found as to several antigens when comparing adults and children, and these findings may contribute to future studies correlating the phenotypic profile to genetic characteristics and therapeutic response, including specific antigen therapies, which may be better targeted.

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ABSTRACT Objective To estimate the prevalence of syphilis and its associated factors in women who were treated at public maternity hospitals and received prenatal care in a primary healthcare unit. Methods This cross-sectional study included 399 postpartum women. Interviews were conducted, and additional data were extracted from the pregnant woman’s booklet, medical records, and printed tests. The dependent variable was a gestational syphilis diagnosis. The independent variables were grouped into socioeconomic and demographic, behavioral, reproductive, and prenatal blocks. The prevalence, prevalence ratios, and 95% confidence intervals (95%CI) were calculated. The χ 2 test was also performed (p≤0.05). Multivariate analysis was performed using Poisson regression models. Results The prevalence of gestational syphilis was 9.61% (95%CI: 7.14-12.83). We identified the following determining factors (adjusted prevalence ratios): history of sexually transmitted infections (2.3), first sexual intercourse by the age of 15 (2.42), partner having a history of syphilis (5.98), partner using crack/cocaine (6.42) and marijuana and others (3.02), not having a partner (3.07), low income (2.85), history of stillbirth (5.21), beginning prenatal care in the third trimester (3.15), and prenatal care received in a primary healthcare unit (without a Family Health Strategy team) (0.35). Conclusion Individual and prenatal factors were associated with gestational syphilis. To control congenital syphilis, targeted interventions are needed to control syphilis in the adult population including expansion of access to quality prenatal care with identification of risks for syphilis and connection between prevention and treatment actions, implementation of strategies focused on early sexual education, effective establish prenatal care involving both partners, and effective implementation of the National Men’s Health Policy (PNAISH - Política Nacional de Atenção Integral à Saúde dos Homens ).

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ABSTRACT Objective To evaluate the influence of onco-hematological pathologies on seroconversion to COVID-19 vaccines, in addition to the effects of chemotherapy treatment on this response. Methods The present study evaluated the immunogenic response of 76 patients with onco-hematological diseases to multiple vaccine platforms compared to 25 control individuals. Results Our results showed positive response rates of 74.02% in patients with onco-hematological diseases and 100% in controls. When analyzed according to etiological group, patients with lymphoproliferative disorders achieved a positive vaccine response rate of 58.7%, whereas those with myeloproliferative diseases achieved a 100% response rate. We also observed that patients previously exposed to COVID-19 presented a 75% increase in their antibody values after vaccination, and these values were 37% higher than those of patients who did not have such exposure. We found that patients who underwent B-lymphocyte-depleting therapy in the last 2 years before vaccination had a worse response rate of 18.75%. Conclusion Despite the immunosuppression of patients with onco-hematological diseases, caused by the biology of their diseases and treatment, benefit and safety in vaccinating these patients are observed, in view of the important recall immune response and incidence of adverse effects similar to those of the healthy population.

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ABSTRACT Objective To verify whether the presence of related nutritional risk indicators prior to COVID-19 diagnosis is associated with poor survival in patients with cancer. Methods We retrospectively analyzed the data of hospitalized cancer patients who tested positive for COVID-19 between March 2020 and February 2021. Nutritional risk was defined as the presence of one of the following characteristics: body mass index <20kg/m 2 , scored Patient-generated Subjective Global Assessment ≥9 points or classification B, albumin level <3.5g/dL, and C-reactive protein level ≥10mg/L, evaluated between 7 and 60 days prior to the date of patient inclusion. The endpoint measure was all-cause mortality within 30 days of COVID-19 diagnosis. Results A total of 253 patients were included, most of whom were elderly (62.4%) and female (63.6%). Overall, 45.4% of the patients were at nutritional risk. Survival was significantly lower in patients at nutritional risk (8 days; interquartile range [IQR]: 3-29) than in patients not at nutritional risk (16 days; IQR: 6-30) (p<0.001). The presence of prior nutritional risk was associated with increased 30-day mortality (HR: 1.42; 95%CI: 1.03-1.94), regardless of age, gender, tumor site or stage, and other risk factors, and the model had good discrimination accuracy (concordance statistic: 0.744). Conclusion The presence of prior nutritional risk indicators is related to poor prognosis in patients with cancer and COVID-19, emphasizing the importance of nutritional care, notably during this pandemic.

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ABSTRACT Objective This study aimed to assess diagnostic radiology training and exposure during medical school, from the perspective of medical students in Brazil. Methods In this multicenter study approved by the Institutional Review Board, medical students from multiple universities in Brazil filled out an online questionnaire regarding their perception about diagnostic radiology training during medical school, including knowledge and use of the American College of Radiology Appropriateness Criteria and their confidence level in interpreting common radiological findings. Medical students from different regions of Brazil were sent invitations to participate in the anonymous survey through radiology group emails initiated by radiology professors and a group of ambassadors representing different institutions. Informed consent was obtained electronically at the beginning of the survey. Results The survey demonstrated diagnostic radiology is frequently included in preclinical exams; however, radiology training during medical school was considered inadequate from the medical students´ perspective. Overall, radiological imaging teaching was provided by radiologists for more than half of the survey respondents; however, radiological imaging is frequently shown to students by non-radiologist physicians during case discussion rounds. Moreover, few respondents had a mandatory radiology training rotation during medical school. Conclusion This Brazilian medical student survey demonstrated that from the medical students’ perspective, diagnostic radiology is an important subject in clinical practice; however, their radiology training and exposure are overall heterogeneous.

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ABSTRACT Objective To evaluate the effectiveness of the levonorgestrel intrauterine system in the treatment of patients with heavy menstrual bleeding and an enlarged uterus and to compare satisfaction and its complications with hysterectomy. Methods This was a comparative cross-sectional observational study of women with heavy menstrual bleeding and an enlarged uterus. Sixty-two women were treated and followed up for four years. Insertion of the levonorgestrel intrauterine system was performed in Group 1, and laparoscopic hysterectomy was performed in Group 2. Results In Group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern, and 11 patients (35.5%) had amenorrhea. Five patients (16.1%) remained with heavy bleeding and were considered to have experienced treatment failure. There were seven expulsions (22.6%); in five patients, bleeding remained heavy, but in two patients the bleeding returned to that of normal menstruation. No relationship was found between treatment failure and greater hysterometries (p=0.40) or greater uterine volumes (p=0.50), whereas expulsion was greater in uteri with smaller hysterometries (p=0.04). There were 13 (21%) complications, seven (53.8%) in the group that underwent insertion of the levonorgestrel intrauterine system (all were device expulsions), and six (46.2%) in the surgical group, which were the most severe ones (p=0.76). Regarding satisfaction, 12 patients (38.7%) were dissatisfied with the levonorgestrel intrauterine system and one (3.23%) was dissatisfied with the surgical treatment (p=0.00). Conclusion Treatment with the levonorgestrel intrauterine system in patients with heavy menstrual bleeding and an enlarged uterus was effective, and when compared with laparoscopic hysterectomy, it had a lower rate of satisfaction and the same rate of complications, although less severe.

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ABSTRACT Objective We aimed to evaluate how breaking bad news training was implemented in neurology residency programs in Brazil and to assess the perception and preparedness of trainees and program directors. Methods We performed a cross-sectional descriptive study. Neurology trainees and program directors were recruited from the Brazilian Academy of Neurology registry through convenience sampling. Participants answered a survey evaluating the breaking bad news training at their institution and their preparedness and perception towards the topic. Results We collected 172 responses from 47 neurology institutions from all five socio-demographic regions of Brazil. More than 77% of trainees were dissatisfied with their breaking bad news training, and around 92% of program directors believed their programs required substantial improvement. Approximately 31% of neurology trainees reported never having a lecture about communicating bad news, 66% reported never having a simulated training, and nearly 61% never received feedback regarding their communication abilities. Moreover, 59% of program directors acknowledged that feedback was not a standard practice and nearly 32% reported the absence of any specific training. Conclusion This study suggested that the breaking bad news training in neurology residencies across Brazil is deficient and highlighted challenges to achieve this core competency. Program directors and trainees recognized the importance of the topic, and program directors acknowledged that many factors hinder the ability to implement formal training. Given the relevance of such a skill to patient care, every effort should be made to provide structured training opportunities during residency.

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ABSTRACT Objective To analyze the relationship between microcephaly and social inequality indicators in the state of Paraíba during the biennium January 2015 and December 2016. Methods Ecological study with data from newborn microcephaly records and municipal socioeconomic, environmental, and demographic indicators was conducted using two health information systems from the Brazilian Ministry of Health (SINASC and SINAN) and the Brazilian Institute of Geography and Statistics. A Poisson multiple regression model was applied with a significance level of 5%. Results Among 223 municipalities in Paraíba, 74 registered new cases of microcephaly. The number of Zika virus cases, number of inhabitants, number of households without adequate water supply, and household income were predictor variables of the number of new cases of microcephaly in Paraíba. Conclusion Microcephaly is associated with indicators of social inequality in Paraíba. Zika virus cases, water supply, and family income are the indicators that best explain the increase in microcephaly cases. Therefore, these variables must be monitored by health professionals and authorities.

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ABSTRACT Objective To assess the effects of enfuvirtide on pregnancy in albino rats and their fetuses. Methods Forty pregnant EPM 1 Wistar rats were randomly allocated into four groups: control (E) (distilled water twice/day), G1 (4mg/kg/day enfuvirtide), G2 (12mg/kg/day enfuvirtide), and G3 (36mg/kg/day enfuvirtide) groups. On the 20th day of gestation, the rats were anesthetized and subjected to cesarean section. Their blood was collected for laboratory analysis, and they were sacrificed. The offspring’s fragments of their kidneys, liver, and placentas and the maternal rats’ fragments of their lungs, kidneys, and liver were separated in the immediate postpartum period for light microscopy analysis. Results No maternal deaths occurred. In the second week at the end of pregnancy, the mean weight of the G3 Group was significantly lower than that of the G2 Group (p=0.029 and p=0.028, respectively). Analyzing blood laboratory parameters, the G1 Group had the lowest mean amylase level, and the G2 Group had the lowest mean hemoglobin level and the highest mean platelet count. In the morphological analysis, there were no changes in organs, such as the kidneys and liver, in both the maternal rats and offspring. Three maternal rats in the G3 Group had pulmonary inflammation in the lungs. Conclusion Enfuvirtide has no significant adverse effects on pregnancy, conceptual products, or functional alterations in maternal rats.

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ABSTRACT Objective To investigate the expression of human papillomavirus (HPV), p16, p53, and p63 in non-schistosomiasis-related squamous cell carcinoma of the bladder and to develop an accurate and automated tool to predict histological classification based on clinicopathological features. Methods Twenty-eight patients with primary bladder pure squamous cell carcinoma who underwent cystectomy or transurethral resection of bladder tumor (TURBT) for bladder cancer between January 2011 and July 2017 were evaluated. Clinical data and follow-up information were obtained from medical records. Formalin-fixed, paraffin-embedded surgical specimens were used for immunohistochemical staining for p16, p53, and p63. Human papillomavirus detection was evaluated by PCR. Statistical analysis was performed, and statistical significance was set at p<0.05. Finally, decision trees were built to classify patients’ prognostic features. Leave-one-out cross-validation was used to test the generalizability of the model. Results Neither direct HPV detection nor its indirect marker (p16 protein) was identified in most cases. The absence of p16 was correlated with less aggressive histological grading (p=0.040). The positive p16 staining detection found only in pT1 and pT2 cases in our sample suggests a possible role for this tumor suppressor protein in the initial stages of bladder squamous cell carcinoma. The decision trees constructed described the relationship between clinical features, such as hematuria/dysuria, the level of tumor invasion, HPV status, lymphovascular invasion, gender, age, compromised lymph nodes, and tumor degree differentiation, with high classification accuracy. Conclusion The algorithm classifier approach established decision pathways for semi-automatic tumor histological classification, laying the foundation for tailored semi-automated decision support systems for pathologists.

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ABSTRACT Objective To describe the personal protective equipment training strategies during the beginning of the pandemic and to investigate the association between training and COVID-19 infection among healthcare workers. Methods This cross-sectional study conducted between March and May 2020 included 7,142 healthcare professionals who were eligible for both online and face-to-face simulation-based training on personal protective equipment use. Simulation training attendance was assessed by reviewing the attendance list, and the COVID-19 sick leave records recovered from the institutional RT-PCR database used to grant sick leave. The association between personal protective equipment training and COVID-19 was investigated using logistic regression, adjusted for sociodemographic and occupational characteristics. Results The mean age was 36.9 years (± 8.3), and 72.6% of participants were female. A total of 5,502 (77.0%) professionals were trained: 3,012 (54.7%) through online training, 691 (12.6%) through face-to-face training, and 1,799 (32.7%) through both strategies. During the study period, 584 (8.2%) COVID-19 cases were diagnosed among these professionals. The number of positive RT-PCR tests was 180 (11.0%) for untrained professionals, 245 (8.1%) for those trained only online, 35 (5.1%) for those trained face-to-face, and 124 (6.9%) for those trained with both strategies (p<0.001). Participants who received face-to-face training had a 0.43 lower risk of contracting COVID-19. Conclusion Personal protective equipment training decreased the odds of COVID-19 among healthcare professionals, with face-to-face simulation-based training being most effective.

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ABSTRACT Objective To compare viral suppression in treatment-naïve adults starting antiretroviral therapy with dolutegravir (50mg)- and efavirenz (600mg)-based regimens. Methods We analyzed secondary data from Brazilian health information systems of people living with human immunodeficiency virus who started antiretroviral therapy between 2015 and 2017 in Minas Gerais, Brazil. The outcome was viral suppression, defined as the achievement of the first viral load <50 copies/mL within 12 months after initiating antiretroviral therapy. This outcome was also compared with viral load <1,000 copies/mL and analyzed in two scenarios: intention-to-treat versus per-protocol. Time to viral suppression and adjusted odds ratio accompanied by 95% confidence intervals were estimated. Results Of the 2,599 participants enrolled, 77.5% were men, and the median age was 34 years. In the intention-to-treat analysis, viral suppression was 58.1% for efavirenz and 76.7% for dolutegravir. People living with HIV on dolutegravir-based regimen were more likely to achieve viral suppression (aOR: 2.44; 95%CI: 2.01-2.95) and had a shorter median time to viral suppression (p<0.0001). Antiretroviral therapy initiation within <120 days, baseline CD4⁺T-cells ≥200 cells/mm3, and viral load <100,000 copies/mL had higher odds of viral suppression. According to the per-protocol analysis, viral suppression ≥90% was observed by considering viral load <1,000 copies/mL. Conclusion Our study demonstrated that viral suppression improved after introducing dolutegravir, although the proportion of patients with viral load <50 copies/mL was lower than expected. Improved access to routine viral load examinations and continuous surveillance of the effectiveness of antiretroviral therapy should be considered.

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ABSTRACT Objective This study verified the replication efficiency of the Rocio virus in a primary culture of mouse neural cells. Methods Mixed primary cultures (neurons/glia) obtained from the brains of newborn isogenic BALB/c mice were inoculated with Rocio virus on the 7 th day of culture, and the development of cytopathogenic effects was monitored. The infection was confirmed via immunocytochemistry (anti-ROCV), while viral replication was quantified in infected primary cultures. The titration method used depended on the infection period. Results Rocio virus efficiently infected primary cultured neural cells, with the highest viral titer causing cytopathic changes was observed at 2 days post infection. The virus-infected primary culture survived for up to 7 days post infection, and viral load quantitation showed viral replication kinetics compatible with the cell death kinetics of cultures. Conclusion The findings of this study suggest that mouse neural cell primary cultures support Rocio virus replication and could be used as an alternative system for studying Flavivirus infection in the central nervous system.

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ABSTRACT Objective Neck circumference is a simple anthropometric measurement that may be linked to chronic diseases, physical activity, and muscle strength. We sought to verify the association of moderate and vigorous physical activity levels and relative muscle strength with neck circumference in a community in southern Brazil. Methods We cross-sectionally analyzed data from 2,488 participants (51% women), aged 20-79 years old from the Study of Health in Pomerode (SHIP-Brazil) conducted in Pomerode, Santa Catarina, Brazil. Increased neck circumference was defined with cutoff points of >39cm for men and >35cm for women. The independent variables were the level of moderate and vigorous physical activity using the short International Physical Activity Questionnaire, and relative muscle strength using the handgrip test and body mass. Univariate and multiple Poisson regression models were used to determine the association between variables (p≤0.05). Results The prevalence of increased neck circumference was 48.2% (60.4% in men, 39.6% in women) and was associated with low relative muscle strength (PR=1.26, 95%CI: 1.17-1.35) in men, insufficient moderate and vigorous physical activity levels (PR=1.23, 95%CI: 1.14-1.32), and relative muscle strength (PR=1.73, 95%CI: 1.61-1.87) in women. After adjusting for covariates, no significant associations were observed between insufficient moderate and vigorous physical activity levels in men (PR=1.02, 95%CI: 0.95-1.07). Conclusion Increased neck circumference seems to be an important predictor of low moderate and vigorous physical activity and relative strength loss in adults, and more pronounced in women.

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ABSTRACT Objective To determine the role of the AKT pathway in the regulating of natural Killer-induced apoptosis of acute myeloid leukemia cells and to characterize the associated molecular mechanisms. Methods BALB/c nude mice were injected with HL60 cells to induce a xenogenic model of subcutaneous leukemic tumors. Mice were treated with perifosine, and their spleens were analyzed using biometry, histopathology, and immunohistochemistry. Gene expression analysis in leukemia cells was performed by real-time PCR. Protein analysis of leukemia and natural Killer cells was performed by flow cytometry. AKT inhibition in HL60 cells, followed by co-culture with natural Killer cells was performed to assess cytotoxicity. Apoptosis rate was quantified using flow cytometry. Results Perifosine treatment caused a reduction in leukemic infiltration in the spleens of BALB/c nude mice. In vitro , AKT inhibition reduced HL60 resistance to natural Killer-induced apoptosis. AKT inhibition suppressed the immune checkpoint proteins PD-L1, galectin-9, and CD122 in HL60 cells, but did not change the expression of their co-receptors PD1, Tim3, and CD96 on the natural Killer cell surface. In addition, the death receptors DR4, TNFR1, and FAS were overexpressed by AKT inhibition, thus increasing the susceptibility of HL60 cells to the extrinsic pathway of apoptosis. Conclusion The AKT pathway is involved in resistance to natural Killer-induced apoptosis in HL60 cells by regulating the expression of immune suppressor receptors. These findings highlight the importance of AKT in contributing to immune evasion mechanisms in acute myeloid leukemia and suggests the potential of AKT inhibition as an adjunct to immunotherapy.

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ABSTRACT Objective A comparative analysis of the association between sedentary behavior versus physical activity levels and tumor staging in women with breast cancer. Methods The present research adopted a cross-sectional study design to recruit a total of 55 adult and elderly women newly diagnosed with breast cancer for data collection and analysis. Inclusion criteria involved patients in procession of a formal approval for participation in the study by the treating physician and those not hitherto subjected to the first cycle of chemotherapy. Results Physical activity levels did not influence the pathological stage of breast cancer (p=0.26) or histological tumor grade (p=0.07) in the analyzed subjects. However, there was a significant association between physical activity levels and responsiveness to hormones (epidermal growth factor receptor (HER2), p<0.05) in the analyzed subjects. Significant difference was detected in the histological tumor grade in relation to the mean time spent sitting during the weekend (p<0.05). However, sedentary behavior had no influence on the tumor stage (p>0.05). Conclusion Physical activity levels did not influence the tumor stage and histological tumor grade. Sedentary behavior had a significant influence on the histological tumor grade.

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ABSTRACT Objective To compare the sociodemographic and clinico-functional characteristics of patients admitted to a stroke unit immediately before and during two different COVID-19 pandemic phases. Methods This exploratory study was conducted in the stroke unit of a public hospital in Brazil. Patients consecutively admitted to a stroke unit for 18 months with primary stroke aged ≥20 years were included and divided into three groups: G1: Pre-pandemic; G2: Early pandemic; and G3: Late pandemic. The sociodemographic and clinico-functional characteristics of the groups were compared (α=0.05). Results The study included 383 individuals (G1=124; G2=151; G3=108). The number of risk factors (higher in G2; p≤0.001), smoking (more common in G2; p≤0.01), type of stroke (ischemic more common in G3; p=0.002), stroke severity (more severe in G2; p=0.02), and level of disability (more severe in G2: p≤0.01) were significantly different among the groups. Conclusion A greater number of serious events and risk factors including smoking and higher level of disability was observed in patients in the beginning of the pandemic than in the late phases. Only the occurrence of ischemic stroke increased in the late phase. Therefore, these individuals may have an increased need for rehabilitation services monitoring and care during their lifespan. Additionally, these results indicate that health promotion and prevention services should be strengthened for future health emergencies.

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ABSTRACT Objective To evaluate the time interval and possible delay in transportation to referral units for the treatment of testicular torsion. Methods We retrospectively analyzed all cases of spermatic cord torsion surgically treated at a university hospital between January 2018 to December 2021. We evaluated the time intervals, including pain onset until the first presentation (D1), interhospital transference time (D2), pain onset until urological evaluation in a tertiary service (D3), urological evaluation until surgery (D4), and time from pain onset to surgical treatment (D5). We analyzed demographic and surgical data, orchiectomy rates, and time intervals (D1–D5). Torsions presented to the first medical presentation within 6h were considered early for testicular preservation. Results Of the 116 medical records evaluated, 87 had complete data for the time interval analysis (D1 to D5) and were considered the total sample. Thirty-three had D1 ≤6h, 53 had D1 ≤24h (includes patients in the D1 ≤6h subgroup), and 34 had D1 >24h. The median time intervals of the total samples and subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were D1 = 16h 42min, 2h 43min, 4h 14min and 72h, D2 = 4h 41min, 3h 39min, 3h 44min and 9h 59min; D3 = 24h, 6h 40min, 7h and 96h; D4 = 2h 20min, 1h 43min, 1h 52min and 3h 44min; D5 = 24h 42min, 8h 03min, 9h 26min and 99h 10min, respectively. Orchiectomy rates of the total sample, subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were 56.32%, 24.24% (p<0.01), 32.08% (p<0.01), and 91.18% (p<0.01), respectively. Conclusion Late arrival at the emergency department or a long interhospital transference time determined a large number of patients who underwent orchiectomy. Thus, public health measures and preventive strategies can be developed based on the data from this study aiming to reduce this avoidable outcome.

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ABSTRACT Objective To compare serum amyloid A concentrations between overweight and eutrophic children and adolescents and to relate it to lipid profiles, glucose tolerance, and carotid intima-media thickness. Methods One hundred children and adolescents (mean age: 10.8±3.16 years) were included and divided into two groups: overweight and non-overweight. The following were evaluated: Z-score body mass index, carotid intima-media thickness, lipid metabolism biomarkers (lipid profile and apolipoproteins A1 and B), inflammatory biomarkers (ultra-sensitive C-reactive protein and serum amyloid A), and glucose homeostasis model assessment of insulin resistance. Results The groups were homogeneous in age, sex, and pubertal stage. Higher levels of triglycerides, apolipoprotein B, homeostasis model assessment of insulin resistance, ultrasensitive C-reactive protein, serum amyloid A, and carotid intima-media thickness were observed in the overweight group. In the multivariate analysis, age (OR=1.73; 95%CI: 1.16-2.60, p=0.007), Z-score body mass index (OR=3.76; 95%CI: 1.64-8.59, p=0.002), apolipoprotein-B (OR=1.1; 95%CI: 1.01-1.2, p=0.030), and carotid intima-media thickness (OR=5.00; 95%CI: 1.38-18.04, p=0.014) were independently associated with serum amyloid A levels above the fourth quartile of the studied sample (>9.4mg/dL). Conclusion Overweight children and adolescents had higher serum amyloid A concentrations than eutrophic children. There was an independent association between higher concentrations of serum amyloid A and Z-score, body mass index, apolipoprotein B, and carotid intima-media thickness, indicating the importance of this inflammatory biomarker in identifying the early risk of atherosclerosis.

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ABSTRACT Objective To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. Methods In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. Results In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. Conclusion In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.

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ABSTRACT Objective To evaluate prenatal and puerperium care levels received and identify their association with sociodemographic and obstetric characteristics. Methods This cross-sectional study was conducted from May to December 2020 and included women who gave birth at the Municipal Hospital of Fazenda Rio Grande, Paraná, Brazil. Data were collected through interviews and review of portfolios and medical records. The variables extracted from the prenatal protocols of Paraná and the Ministry of Health were grouped into five compliance indices: CI1 - clinical examination; CI2 - health education; CI3 - queries; CI4 - examinations and vaccines; and CI5 - postpartum appointments. Prenatal care was considered adequate when 80% or more adequacy was obtained. Results A total of 307 women participated in this study. Prenatal compliance was 16.6% considering the entire set of variables. The best performance was for CI4 (54.7%) and the worst for CI5 (13.3%). The lowest adequacy occurred among single women (10.9%) compared to those who lived with a partner (19.9%) (p=0.043) and among women with black/brown skin color (9.5%) compared to those with white/yellow skin color (20.3%) (p=0.016). Conclusion Most women did not receive adequate care, with those in situations of greater social vulnerability received worse quality care.

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ABSTRACT Objective To evaluate the perceptions of students and teachers regarding remote teaching modality in comparison with the traditional face-to-face method. Methods In this observational, retrospective, comparative, single-center study, questionnaires containing three major assessment domains were sent to two groups: university professors and undergraduate and graduate students. The first domain collected demographic and general data on the platforms used. The second and third domains contained questions that compared the perception of the quality of information offered by the two systems. Results Between May and September 2020, 162 students and 71 teachers participated in the study. A greater proportion of students demonstrated previous contact with the online method, while professors had presented a greater number of courses. Most participants reported that their expectations regarding the remote teaching method were met (students, 80.3%; teachers, 94.4%). A significant number of students (83.3%) and teachers (88.7%) rated the classes as easier to attend and manage. Despite difficulties, such as concentration retention, most of the participants agree (at least partially) that the format should be maintained. Conclusion The remote teaching methodology, although still incipient in Brazil, has become a reality in light of current health restrictions. Our study demonstrated a high level of overall satisfaction and a high sense of learning from both students and faculty. However, new challenges associated with this system have been identified, such as retention of attention and interference from the external environment. Longitudinal comparative studies that incorporate various aspects of medical education in all cycles are necessary to corroborate the findings of this study. Design Retrospective comparative study, level III evidence.

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ABSTRACT Objective This study aimed to correlate oral and general health in frail and non-frail older adults. Methods This observational study included 52 older adults, of whom 35 were frail (Frail Group), and 17 were non-frail (Non-Frail Group), according to Fried’s self-reported test addressing oral health variables, number of systemic diseases, and medications in use. The geriatric oral health assessment index was used to assess the oral hygiene of the groups. Results The number of preserved teeth in dentulous older adults was significantly higher in the Non-Frail Group (p=0.048). No significant differences were observed between the two groups in the use of dental prostheses or in the detection of soft tissue lesions. Overall, 74.3% of the Frail Group had a “bad” geriatric oral health index score, which significantly differed from that of the Non-Frail Group (p=0.045). The numbers of systemic diseases and medicines used were higher in the Frail Group than in the Non-Frail Group (p<0.001), demonstrating the pathophysiological characteristics of multimorbidity and polypharmacy in frailty syndrome. Conclusion The results showed a clear correlation between oral and general health conditions and frailty syndrome.

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ABSTRACT Objective To assess the predictive value of preoperative serum laboratory test results for identifying choledocholithiasis and reduce the use of cholangioresonance and its inherent costs. Methods Patients aged 21-69 years who underwent preoperative cholangioresonance examination at our institute were included. Patients with a history of fluctuating jaundice or biliary pancreatitis, bile duct dilatation on ultrasonography, and elevated levels of canalicular enzymes (alkaline phosphatase >100U/L and gamma-glutamyl transferase >50U/L) underwent cholangioresonance-guided surgery. Cases of choledocholithiasis confirmed by cholangioresonance were compared with those without choledocholithiasis. Serum laboratory data were evaluated and the diagnostic capabilities of these examinations were analyzed. Results A total of 104 patients were included. For detecting choledocholithiasis using alkaline phosphatase, the cut-off point was 78U/L, sensitivity was 97.6% (95%CI: 87.4-99.9), and specificity was 72.6% (95%CI: 59.8-83.1). In the binary logistic regression analysis, age (OR= 0.92; 95%CI: 0.86-0.98) and alkaline phosphatase level (OR= 1.02; 95%CI: 1.01-1.05) were selected for the final model. Conclusion Serum alkaline phosphatase levels may aid preoperative diagnosis of asymptomatic choledocholithiasis. After a global clinical assessment of the patient, serum laboratory findings may contribute to a reduction in cholangioresonance-related heathcare costs.

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ABSTRACT Objective To analyze the refusal rate of elective aortic aneurysm surgery in asymptomatic patients after the presentation of a detailed informed consent form followed by a meeting where patient and their families can analyze each item. Methods We conducted a retrospective analysis of 49 patients who had aneurysms and were offered surgical treatment between June 2017 and February 2019. The patients were divided into two groups: the Rejected Surgery Group, which was composed of patients who refused the proposed surgical treatment, and the Accepted Surgery Group, comprising patients who accepted the proposed surgeries and subsequently underwent them. Results Of the 49 patients, 13 (26.5%) refused surgery after reading the informed consent and attending the comprehensive meeting. We observed that patients who refused surgery had statistically smaller aneurysms than those who accepted surgery (9% versus 26%). These smaller aneurysms were above the indication size, according to the literature. Conclusion One-quarter of patients who were indicated for elective surgical repair of aortic aneurysms rejected surgery after shared decision-making, which involved presenting patients with an informed consent form followed by a clarification meeting for them and their families to analyze each item. The only factor that significantly influenced a rejection of the procedure was the size of the aneurysm; patients who rejected surgery had smaller aneurysms than those who accepted surgery.

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ABSTRACT Objective To report the effects of a tunica vagina flap on testicular compartment syndrome. Methods This single-arm clinical trial was conducted from September 2020 to October 2021. Consecutive patients with suspected testicular torsion within 24 hours of pain onset were included. Patients with past testicular torsion, bilateral torsion, or previous atrophy were excluded. The tunica vaginalis was opened, and the intratesticular pressure was measured before testicular retrieval from the scrotum and detorsion (P1), after detorsion (P2), and after transverse incision (P3). A tunica vaginalis flap was performed and a new intratesticular pressure was recorded (P4). The contralateral testicular pressure was recorded before fixation (Pc). The minimum follow-up period was 6 months. Results Fifteen patients were recruited from September 2020 to October 2021. Nine patients completed the follow-up. The median age (range) was 15 years (9-19). The mean P1, P2, P3, P4, and Pc (range) were 43, 60, 23, 20, and 14mmHg, respectively. The atrophy rate was 66.3% and the viability was 88.9%. No major complications were observed. Conclusion The modified tunica vaginalis flap in acute testicular torsion decreased intratesticular pressure. Furthermore, normal testicular pressure can improve testicular preservation. It can also decrease testicular pressure to normal levels and preserve the testicular parenchyma.

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ABSTRACT Objective To verify the involvement of the endocannabinoid system in the immunomodulatory profile of stem cells from human exfoliated deciduous teeth, in the presence or absence of TNF-α, and agonist and antagonists of CB1 and CB2. Methods Stem cells from human exfoliated deciduous teeth were cultured in the presence or absence of an agonist, anandamide, and two antagonists, AM251 and SR144528, of CB1 and CB2 receptors, with or without TNF-α stimulation. For analysis of immunomodulation, surface molecules linked to immunomodulation, namely human leukocyte antigen-DR isotype (HLA-DR), and programmed death ligands 1 (PD-L1) and 2 (PD-L2) were measured using flow cytometry. Results The inhibition of endocannabinoid receptors together with the proinflammatory effect of TNF-α resulted in increased HLA-DR expression in stem cells from human exfoliated deciduous teeth, as well as, in these cells acquiring an anti-inflammatory profile by enhancing the expression of PD-L1 and PD-L2. Conclusion Stem cells from human exfoliated deciduous teeth respond to the endocannabinoid system and TNF-α by altering key immune response molecules.

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ABSTRACT Objective To reduce surgical center idleness by analyzing the competitive structure of the surgical center in a hospital, and thereby generate value in operations and increase hospital revenue. Methods The study used qualitative and quantitative methods and an action research approach involving the surgical center leadership of a small private specialized hospital in southeastern Brazil. We used the Strengths, Weaknesses, Opportunities, and Threats or SWOT tool to analyze the competitive structure of the surgical center and then implemented interventions as proposed by the science of improvement method proposed by the Institute of Healthcare Improvement. Results By applying the SWOT tool, we identified a concentration of surgeries in the specialty of Otolaryngology and the need to establish a health management system to reduce the idleness of the operating rooms. Based on subsequent intervention, procedures from other specialties were inserted that increased surgical production by 2.62X, reduced idleness by 67.84%, and increased revenue by over US$ 276,609.87 in 2018 compared to the previous year 2017. Conclusion Investing in quality, surgical schedule management, and inducting new surgeons to the clinical staff resulted in decreased surgical idleness, increased production, better uniformity in scheduling, and increased revenue, while costs remained below the linear trend, allowing for increased profits.

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ABSTRACT Introduction The human immunodeficiency virus (HIV) pandemic remains an important issue. In 2020, approximately 37.7 million people were living with the disease and there were more than 680 thousand deaths due to complications linked to the disease. Despite these exorbitant numbers, the introduction of highly active antiretroviral therapy has marked a new era, changing the epidemiological profile of the infection and related pathologies, including neoplasms. Objective We performed a literature review to assess the role of neoplasms in patients with HIV after the introduction of antiretroviral therapy. Methods A literature review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, searching the MEDLINE, LILACS, and COCHRANE databases for articles published from 2010 onwards. Results Using specific key terms, 1,341 articles were identified; two were duplicates, 107 were selected for full-text evaluation, and 20 were included in the meta-analysis. The selected studies included 2,605,869 patients. Fifteen of the 20 articles indicated a reduction in the global incidence of AIDS-defining neoplasms and 12 indicated an overall increase in non-AIDS-defining cancers after the introduction of antiretrovirals. This growth trend could be explained by a range of factors including the aging population with HIV, risky behaviors, and coinfection with oncogenic viruses. Conclusions There was a decreasing trend in the incidence of AIDS-defining neoplasms and increasing trend in non-AIDS-defining neoplasms. However, the carcinogenic effect of antiretrovirals could not be confirmed. In addition, studies focusing on the oncogenic role of HIV and screening for neoplasms in individuals with HIV are required.

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ABSTRACT Introduction COVID-19 is associated with endothelial activation and systemic inflammation; consequently, statins can be used in its treatment as they have anti-inflammatory, antithrombotic, and profibrinolytic properties and may interfere with COVID-19 viral entry into cells through disruption of cell membrane lipid rafts. Objective We performed a meta-analysis of randomized clinical trials that compared statin therapy to placebo or to standard care in adult patients hospitalized for COVID-19. Methods We searched the MEDLINE, EMBASE, and Cochrane Library databases for all-cause mortality, hospitalization duration, and admission to the intensive care unit. Results Of the 228 studies reviewed, four studies were included, with a total of 1,231 patients, of whom 610 (49.5%) were treated with statins. There was no significant difference in all-cause mortality (odds ratio [OR] 0.96; 95% confidence interval [95%CI]: 0.61-1.51; p=0.86; I2=13%), duration of hospitalization (mean difference [MD] 0.21; 95%CI: -1.74-2.16; p=0.83; I2=92%), intensive care unit admission (OR= 3.31; 95%CI: 0.13-87.1; p=0.47; I2=84%), need for mechanical ventilation (OR= 1.03; 95%CI: 0.36-2.94; p=0.95; I2=0%), or increase in liver enzyme levels (OR= 0.58; 95%CI: 0.27-1.25; p=0.16; I2=0%) between patients treated with or without statin therapy. Conclusion Our findings suggest that in adult patients hospitalized with COVID-19, statin therapy results in no difference in clinical outcomes when compared to outcomes by placebo or standard of care. Prospero database registration: (www.crd.york.ac.uk/prospero) under the number CRD42022338283.

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ABSTRACT Background Major depressive disorder is a difficult-to-treat psychological disorder. Approximately 30% of patients with major depressive disorder do not respond to conventional therapies; thus, the efficacy of alternative therapies for treating major depressive disorder, such as neurofeedback, a non-invasive neuromodulation method used in the treatment of psychiatric diseases, must be investigated. Objective We aimed to evaluate the efficacy of neurofeedback in minimizing and treating major depressive disorder and its application as a substitute to or an adjuvant with conventional therapies. Methods We searched for experimental studies published between 1962–2021 in Scopus, PubMed, Web of Science, and Embase databases and identified 1,487 studies, among which 13 met the inclusion exclusion criteria. Results We noted that not all patients responded to neurofeedback. Based on depression scales, major depressive disorder significantly improved in response to neurofeedback only in a few individuals. Additionally, the number of training sessions did not influence the results. Conclusion Neurofeedback can reduce depression symptoms in patients; however, not all patients respond to the treatment. Therefore, further studies must be conducted to validate the effectiveness of neurofeedback in treating major depressive disorder.

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ABSTRACT Introduction Gratitude has several implications. Over time, a logical relationship has been established between gratitude and well-being. In addition, researchers aimed to establish associations between gratitude and other factors of positive feelings using scientific methods. We conducted a systematic review and meta-analysis of interventions to develop gratitude and its benefits to human beings. Objective This study aimed to evaluate and quantify the available scientific evidence on interventions to acquire knowledge on gratitude as a quantifiable causal factor of benefit to human beings. Methods A systematic literature search was conducted to identify studies that investigated the effects of gratitude interventions. MEDLINE, Embase, and Central Cochrane databases were searched in addition to gray (Google Scholar) and manual search. Two authors independently evaluated the titles and abstracts, and selected the studies that met the inclusion criteria. The searches were conducted between January and July 2022. Results Sixty-four randomized clinical trials were included. The meta-analysis demonstrated that patients who underwent gratitude interventions experienced greater feelings of gratitude, better mental health, and fewer symptoms of anxiety and depression. Moreover, they experienced other benefits such as a more positive mood and emotions. Conclusion The results demonstrate that acts of gratitude can be used as a therapeutic complement for treating anxiety and depression and can increase positive feelings and emotions in the general population. Prospero database registration: (www.crd.york.ac.uk/prospero) under the number CRD42021250799.

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ABSTRACT Introduction The increasing popularity of cannabinoids for treating numerous neurological disorders has been reported in various countries. Although it reduces tetrahydrocannabinol psychoactivity, it helps patients tolerate higher doses and complements the anti-spasmodic effects of tetrahydrocannabinol. One of the most important potential of cannabinoids are related to its potential to help children with cerebral palsy, a contributor of lifelong disability. Therefore, this systematic review aimed to assess the efficacy and safety of medical cannabinoids in children with cerebral palsy. Methods This review adhered to The Preferred Reporting Items for Systematic Reviews and Meta-analysis 2020 guidelines. Seven databases, namely, Scopus, PubMed, EBSCO Host, ProQuest, Google Scholar, Semantic Scholar, and JSTOR, were used to identify relevant studies. Studies examining pediatric patients with cerebral palsy and reporting the efficacy and safety of medical cannabinoids through clinical trials, observational cross-sectional studies, or cohort designs were included. The outcomes of the studies included the efficacy of medical cannabinoids administered for spasticity, motor components, pain control, sleep difficulties, adverse effects, and seizure control. Results Of 803 identified articles, only three met the inclusion criteria for data synthesis. One study exhibited a moderate risk-of-bias. A total of 133 respondents, mainly from Europe, were investigated. Overall effectiveness and safety were considered good. However, the results are inconsistent, especially regarding spasticity treatment variables. Conclusion The anti-spasticity, anti-inflammatory, and anti-seizure properties of cannabinoids might be beneficial for patients with cerebral palsy, although their effectiveness has not been widely studied. Further studies with larger sample sizes and various ethnicities are warranted. Prospero database registration: (www.crd.york.ac.uk/prospero) under ID CRD42022358383.

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ABSTRACT Diabetes insipidus is a rare disorder characterized by the inability to concentrate urine, which results in hypotonic urine and increased urinary volume. It may occur because of antidiuretic hormone deficiency or resistance to its action in the renal tubules. When there is a deficiency in the synthesis of antidiuretic hormones, diabetes insipidus is called central; when there is resistance to its action in the renal tubules, it is said to be nephrogenic. We report a case of idiopathic partial central diabetes insipidus and highlight the management and treatment of the disease.

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ABSTRACT Meckel’s diverticulum is the most common gastrointestinal tract anomaly. It arises from the incomplete closure of the omphalomesenteric conduit, which is a true diverticulum at the antimesenteric border of the ileum. Although the majority of patients are asymptomatic, they can present with inflammation, hemorrhage, intussusception, intestinal obstruction, and perforation, among others; this constitutes an important differential diagnosis for acute abdomen. A 19-year-old female sought medical attention because of intermittent diffuse abdominal pain for two months, nausea, and diarrhea. In the requested imaging tests, tomography, and enterotomography, a diagnosis of Meckel’s diverticulum with some degree of intussusception was suggested. The patient underwent elective surgical treatment without complications and was discharged on the second postoperative day with clinical improvement. In this section, we review publications on similar cases published in the last five years.

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ABSTRACT Chest pain is a frequent, potentially life-threatening condition in the emergency department and requires immediate investigation and treatment. This case report highlights a rare differential diagnosis of pleuritic chest pain: epipericardial fat necrosis. A 29-year-old man presented with normal clinical evaluation, electrocardiography, point-of-care ultrasound, and unremarkable laboratory tests. The initial hypothesis was acute pleuritis. Chest radiography revealed peri-cardiac nonspecific findings, and computed tomography revealed epicardial fat necrosis. Despite the rarity of this condition, accurate diagnosis allows for better practices. An algorithm for a diagnostic approach is proposed.

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ABSTRACT A male infant presented with progressive jaundice immediately after birth. Fecal acholia and choluria associated with extensive bullous skin lesions in his trunk, abdomen, and upper and lower limbs developed during phototherapy. Several diagnostic hypotheses were presented, including neonatal porphyria, hemochromatosis, Alagille syndrome, and neonatal lupus. A 24-hour urine sample for the dosage of urinary porphyrins was collected, showing high results (1823.6µg in 100mL). At 50 days of life, fluorescence spectroscopy using a Wood’s lamp revealed simultaneous bright red fluorescence of urine-stained diapers and sample blood. A definitive diagnosis of congenital erythropoietic porphyria was made following identification of a mutation of the uroporphyrinogen synthetases III gene on genetic testing. The patient was subsequently maintained in a low light environment since then, resulting in improvement of the lesions. Congenital erythropoietic porphyria is a disease of the group of porphyrias that presents shortly after birth with blistering occurring in regions exposed to the sun or other ultraviolet light. Atrophic scars, mutilated fingers, and bright red fluorescence of the urine and teeth may also be observed. There is no specific treatment, and prophylaxis comprising a total avoidance of sunlight is generally recommended. A high degree of suspicion is required for diagnosis. An early diagnosis can lead to less damage. Here, we present the case of a newborn with congenital erythropoietic porphyria diagnosed after presenting with bullous lesions secondary to phototherapy.

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ABSTRACT Polycystic liver disease, a hereditary pathology, usually manifests as autosomal dominant polycystic kidney disease. The many cysts in the liver cause massive hepatomegaly, majorly affecting the patient’s quality of life. In cases of refractory symptoms, liver transplantation is the only treatment choice. A 43-year-old woman was followed up as a hepatology outpatient in August 2020, with a progressive increase in abdominal volume, lower limb edema, and cachexia. The patient was diagnosed with polycystic renal and liver disease with massive hepatomegaly in March 2021, a combined kidney-liver transplant. Liver size represented 13% of the patient’s corporal composition, weighing 8.6kg. The patient was discharged on the 7th postoperative day with no complications. Only 10-20% of patients with polycystic liver disease have clinical manifestations, most of which result from hepatomegaly. An increase in liver volume deteriorates liver function until the condition becomes end-stage liver disease, as kidney function is already compromised; liver-kidney transplantation remains the only treatment choice. The case described drew significant attention to the massive hepatomegaly presented in the patient, with the liver representing over 10% of the patient’s body weight, approximately five to six times larger than a normal-sized liver.

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ABSTRACT We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.

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ABSTRACT Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel®). Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.

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ABSTRACT In equatorial Brazil, the association of Burkitt lymphoma and Epstein–Barr virus manifests at high rates. Here, we report, for the first time, amplifications of aurora kinase genes (AURKA/B) in a patient with a history of periodontal abscess and the presence of a remaining nodule, diagnosed with Burkitt lymphoma and Epstein–Barr virus, and /HIV positive. The patient was a 38-year-old man who presented with a 2-week-old severe jaw pain and a 3-day-old severe bilateral headache. He had a history of human papilloma virus. Interphase FISH analysis showed AURKA and AURKB amplification. The patient’s condition worsened, progressing to death a month after the initial care. Changes in the MYCC and AURKA pathways are directly associated with genomic instability. Thus, MYCC rearrangements and higher expression of AURKA/B may be associated with therapy resistance, highlighting the importance of AURKA/B evaluation in Burkitt lymphoma.

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ABSTRACT In this article, we present a case of diffuse follicular variant papillary thyroid carcinoma with pituitary metastasis, which is a rare cause of pituitary metastasis. The follicular variant of papillary thyroid carcinoma is an uncommon variant of papillary carcinoma. A 74-year-old male was presented with weakness, fatigue, and a decreased appetite. The patient was diagnosed with secondary adrenal and thyroid insufficiencies. Imaging revealed a pituitary mass with suprasellar extension, right cavernous sinus invasion, and optic chiasm compression. Thyroid ultrasonography revealed a nodule with a maximum size of 7.2cm in the right lobe. Cytological examination via fine-needle aspiration suggested papillary thyroid cancer. Total thyroidectomy with central and right lateral neck dissection confirmed the diagnosis of diffuse follicular variant of papillary thyroid carcinoma. Owing to visual field defects, the patient underwent transsphenoidal surgery. Histological and immunohistochemical evaluations confirmed pituitary metastasis from the papillary thyroid cancer. Radioactive iodine treatment and gamma knife radiotherapy of the pituitary gland were performed. The initiation of sorafenib treatment was deemed appropriate during the follow-up. A significant decrease in the thyroglobulin levels was observed after sorafenib treatment. Pituitary metastasis should be considered in patients diagnosed with hypopituitarism and pituitary lesions at initial evaluation. The presence of visual field defects may be an indication for neurosurgical intervention and guide both diagnosis and treatment. The management of papillary thyroid cancer and the role of treatment modalities in prognosis depend on the biological behavior of the tumor. Early diagnosis and multidisciplinary management are crucial for the treatment of these patients.

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ABSTRACT Despite its rarity, symptomatic micronutrient deficiency remains a public health problem. Scurvy is the differential diagnosis for bleeding disorders and hematological and rheumatological diseases, especially in patients with eating disorders. However, it is unrelated to autism spectrum disorders or other neurodevelopmental disorders. A previously healthy 10-year-old boy living in São Paulo, Brazil, had a history of significant food selectivity unrelated to autism spectrum disorder, resulting in symptomatic ascorbic acid deficiency (scurvy). This resulted in pain and purpuric lesions on the lower limbs, gingival edema, bleeding during tooth brushing, asthenia, weakness, malaise, and sadness. Therefore, dietary anamnesis is important for routine monitoring of child growth and development. This process helps prevent nutritional deficiencies, facilitates early diagnosis of eating disorders, and enables multidisciplinary follow-up for these patients.

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ABSTRACT Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient.

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ABSTRACT Nicolaides-Baraitser Syndrome is a rare genetic condition that clinically presents with intellectual disabilities, facial and bone changes, and sparse hair. In Brazil, only one case has been previously reported without genetic confirmation. We present the case of an 8-year-old boy, clinically and genetically diagnosed with Nicolaides-Baraitser Syndrome, who developed autism spectrum disorder characteristics with a formal diagnosis at the age of eight. Diagnosing autism spectrum disorder in patients with intellectual disabilities is a clinical challenge requiring careful evaluation.

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ABSTRACT Tailgut cysts are rare congenital lesions that are remnants of the embryonic hindgut. This abnormality presents with non-specific symptoms or no symptoms; therefore, misdiagnosis is common. Here, we present four cases of tailgut cysts that were successfully removed using a robotic surgical approach. A 42-year-old woman with tenesmus, pain in the right gluteal region, and discomfort in the rectal region during evacuation was referred to our medical center. Another patient was a 28-year-old woman who presented with the same symptoms to our general practitioner. Both patients underwent upper abdominal and pelvic magnetic resonance imaging that revealed a tailgut cyst. Further, a 36-year-old woman was referred with coccyx and hypogastric pain. Magnetic resonance imaging revealed two pararectal cystic formations. She underwent robot-assisted surgery, and after analysis by a pathologist, the conclusion was that the tailgut cyst was associated with scarring fibrosis. A 55-year-old woman with posterior epigastric pelvic pain associated with heartburn underwent robot-assisted surgery to resect a retroperitoneal tumor. These cases highlighted the importance of tailgut cysts in the differential diagnosis of rectal lesions. Surgical treatment is preferred because malignant transformations can occur. The difference between laparoscopic and robotic approaches is the better visualization and stability of the latter, inducing less tissue damage. Robotic resection is a safe procedure, especially in patients with a narrow pelvis, because it reduces tissue damage.

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ABSTRACT A total of 1.67 million breast cancer cases per year are reported worldwide. Of these, 5%–10% are caused by inherited mutations. Phenocopy is a rare phenomenon, with only a few cases reported in the literature. In phenocopies, phenotypes identical to those with genetic origin occur because of environmental factors rather than familial mutations. We describe a case of phenocopy in a 44-year-old female patient with triple-negative breast cancer. The mother and sister wee heterozygous for c.1813delA, p.Ile605TyrfsTer9 in BRCA2 . The patient underwent genetic testing for BRCA1 and BRCA2 and exome sequencing. Familial or other cancer variants were not detected. The most accepted phenocopy theory is that patients without genetic variants but who are carriers of these mutations undergo cellular changes due to environmental factors, increasing the risk of breast cancer. Therefore, the detection of phenocopy in patients with breast cancer is important in clinical practice.

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ABSTRACT A 49-year-old patient with changes in the nails of the hallux for 10 years was diagnosed with onychomycosis. The identity of the causative agent was confirmed as Cladosporium halotolerans from the Cladosporium sphaerospermum species complex using molecular techniques. MALDI-TOF identified the agent as C. sphaerospermum complex species. Overall, species such as onychomycosis agents should attract special attention to avoid mistakes in the identification process while considering a probable contaminant as responsible for the disease. These species deserve attention since there are rare descriptions of them as causes of onychomycosis. It is important to recognize them as causes of disease and not just as a probable contaminant.

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ABSTRACT This study proposes a strategy for large-scale testing among a large number of people for the early diagnosis of COVID-19 to elucidate the epidemiological situation. Pool testing involves the analysis of pooled samples. This study aimed to discuss a reverse transcription technique followed by quantitative real-time polymerase chain reaction using pool testing to detect SARS-CoV-2 in nasopharyngeal swab samples. The study proposes an innovative diagnostic strategy that contributes to resource optimization, cost reduction, and improved agility of feedback from results.

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ABSTRACT Objective To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. Methods This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. Results There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. Conclusion After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery.