Clinical and economic impact of coronary artery bypass graft and percutaneous coronary intervention in young individuals with acute coronary syndromes and multivessel disease: A real-world comparison in a middle-income country.

Background: In recent decades, the world watched a dramatic increase in the incidence of acute coronary syndromes (ACS) among young individuals (≤55 years-old) and a relative decrease in the elderly. The management of ACS in young patients with multivessel disease still needs to be elucidated, as these individuals maintain a long life expectancy. Research Question: To compare clinical outcomes and care costs in individuals with premature ACS and multivessel disease undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). Methods and Results: Participants included all individuals ≤55 years-old admitted with ACS to public hospitals in Brasília (Brazil) between 2013 and 2015 and who underwent cardiac catheterization with SYNTAX score ≥23 or Duke category 6. Outcomes were adjudicated with death certificates and data from medical records. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as death due to cardiovascular causes, recurrent hospitalizations due to cardiovascular ischemic events, and incident heart failure New York Heart Association III-IV. As secondary outcome we assessed indirect and direct costs by evaluating the cost of lost productivity (in international dollars (Int$) per year) due to illness and death, outpatient costs and costs with new hospitalizations. Multivariate and principal components (PC) adjusted analyzes were performed. Results: Among 1,088 subjects (111 CABG and 977 PCI) followed for 6.2 years (IQR: 1.1), 304 primary events were observed. MACE was observed in 20.7% of the CABG group and 28.8% of the PCI group (p = 0.037). In multivariate analyses, PCI was associated with a hazard ratio (HR) = 1.227 (95% CI: 1.004-1.499; p = 0.0457) for MACE, and in PC-adjusted HR = 1.268 (95% CI: 1.048-1.548; p = 0.0271) compared with CABG. Despite direct costs were equivalent, the cost due to the loss of labor productivity was higher in the PCI group (Int$ 4,511 (IQR: 18,062)/year vs Int$ 3,578 (IQR: 13,198)/year; p = 0.049], compared with CABG. Conclusions: Among young individuals with ACS and multivessel disease, surgical strategy was associated with a lower occurrence of MACE and lower indirect costs in the long-term.

Prevalência de aleitamento materno e fatores associados entre mães adolescentes de Governador Valadares, Minas Gerais / Prevalence of breastfeeding and associated factors among adolescent mothers of Governador Valadares, Minas Gerais

Introdução: O aleitamento materno (AM) é recomendado pela Organização Mundial da Saúde de forma exclusiva até seis meses de vida e complementado até ≥2 anos. Para as nutrizes, a amamentação oferece benefícios como proteção para diabetes tipo II, retorno mais rápido ao peso pré-gestacional e aumento do espaçamento entre gestações. Entretanto, a prevalência da amamentação no Brasil (2013) foi de apenas 56%, sendo a adolescência fator de risco para a não amamentação e o desmame precoce. Objetivo: Analisar a prevalência de AM aos quatro meses após o parto e seus fatores associados entre mães adolescentes do município de Governador Valadares, MG. Material e Métodos: Estudo transversal, parte de pesquisa intitulada "Consumo alimentar de gestantes adolescentes e retenção de peso pós-parto: um estudo de coorte". Realizou-se um censo abrangendo todas as puérperas adolescentes (idade <20 anos) residentes no município que tiveram seu parto nas três maternidades locais entre outubro de 2018 e outubro de 2019. A coleta de dados ocorreu por questionário nas primeiras 48 horas pós-parto e no 4º mês pós-parto. Os dados foram analisados no software Stata®16.1. Resultados: Foram entrevistadas 367 mães (taxa de resposta 98,6%) com idade média de 17,6 anos (±1,57). Quatro meses após o parto realizou-se visita domiciliar, compreendendo 317 mães. Destas, 75,4% mantiveram a amamentação e somente 25,9% ofereciam exclusivamente leite materno. Conclusão: Verifica-se que, apesar da elevada intenção de amamentar, há baixa prevalência de AM exclusivo ao 4º mês pós-parto. Menor escolaridade, tabagismo, menor idade materna e trabalhar fora de casa apresentaram-se como fatores de risco para menor tempo de manutenção do AM. Deve-se considerar que a lactação é envolta por grande carga emocional e, na adolescência, somam-se outros fatores psicológicos, fisiológicos e inexperiência para lidar com a maternidade, sendo necessária uma forte rede de apoio profissional durante os períodos pré-natal, parto e pós-parto

Introduction: The World Health Organization recommends exclusive breastfeeding (BF) for the first six months of life and continued breastfeeding with complementary foods for up to ≥2 years. For nursing mothers, breastfeeding offers benefits such as protection against type II diabetes, faster return to pre-pregnancy weight and increased spacing between pregnancies. However, the prevalence of breastfeeding in Brazil (2013) was only 56%, with adolescence being a risk factor for non-breastfeeding and early weaning. Objective: Analyze the prevalence of BF at four months after delivery and its associated factors among adolescent mothers in the city of Governador Valadares, MG. Material and Methods: Cross-sectional study, part of a research entitled "Food consumption of pregnant adolescents and postpartum weight retention: a cohort study". A census was carried out covering all adolescent mothers (age <20 years) residing in the city who gave birth in the three local maternity hospitals between 10/2018 and 10/2019. Data were obtained through a questionnaire in the first 48h postpartum and in the 4th month postpartum. Data were analyzed using Stata®16.1 software. Results: 367 mothers were interviewed (response rate 98.6%) with a mean age of 17.6 years (±1.57). Four months after birth, of 317 interviewed mothers, 75.4% maintained breastfeeding, and only 25.9% offered exclusively breast milk. Conclusion: Despite the high intention to breastfeed, there is a low prevalence of exclusive breastfeeding at the 4th month postpartum. Less education, smoking, young maternal age and working out were risk factors for a shorter duration of BF maintenance. It should be considered that lactation is surrounded by a great emotional charge and, in adolescence, there are other psychological, physiological factors and inexperience to deal with the maternity, requiring a strong professional support network during the prenatal periods, childbirth and postpartum

Acinetobacter baumannii infections in Amazon Region driven by extensively drug resistant international clones, 2016-2018.

BACKGROUND: Acinetobacter baumannii is a leading cause of nosocomial infections. This species is characterised by the presence of pandemic lineages (International Clones) that present a broad antimicrobial resistance profile. OBJECTIVE: To perform the molecular epidemiology of carbapenem-resistant A. baumannii from a clinical setting in the Amazon Basin, and to characterise their antimicrobial resistance determinants. METHODS: The genetic relationship of carbapenem-resistant A. baumannii were assessed by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Class A, B and D ß-lactamase genes were screened by polymerase chain reaction (PCR) and sequencing. The antimicrobial susceptibility profile was obtained by Disc-diffusion method and minimum inhibitory concentration (MIC) determination. FINDINGS: All carbapenem-resistant A. baumannii strains belonged to three international clones, IC-1, IC-5 and IC-6, the latter recently reported by the first time in Brazil. The major determinant of carbapenem resistance in IC-1 and IC-5 strains was bla OXA-23, associated with ISAba1 and ISAba3, respectively, while IC-6 harboured the bla OXA-72. CONCLUSIONS: The A. baumannii epidemiology in Brazilian Amazon Region was unknown. It was demonstrated that A. baumannii XDR international clones were responsible for nosocomial infections in Boa Vista during 2016-2018, revealing that the epidemiological scenario of A. baumannii infections in Amazon Region resembles those from the cosmopolitan regions worldwide.

Correction to: Chronic Granulomatous Disease in a Brazilian Patient Mimetizing Sarcoidosis.

The original version of abstract PO-162 "Chronic Granulomatous Disease in a Brazilian Patient Mimetizing Sarcoidosis" incorrectly listed the name of the second author as Micheli Barsioti. The correct spelling of the author's name is Michele Baziotti Man.

Serum uric acid levels are associated with lupus nephritis in patients with normal renal function.

Uric acid has been recognised as a potential marker of endothelial dysfunction and kidney disease but there are scarce data about its importance in systemic lupus erythematosus (SLE) nephritis. This study aimed to evaluate serum uric acid (UA) levels in lupus nephritis (LN), by comparing SLE patients with normal renal function, with and without nephritis. Forty-six female SLE patients were consecutively selected and divided in two groups according to renal activity at the evaluation: presence of a recently diagnosed lupus nephritis (LN+, n = 18) and absence of lupus nephritis (LN-, n = 28). Age-matched healthy women were selected (CONTROL, n = 28). Patients with gout, creatinine clearance lower than 80 ml/min and use of drugs that interfere in UA were excluded. Laboratory and clinical data were analysed by appropriate tests. A multivariate analysis was performed, and a receiver operating characteristic (ROC) curve was plotted, and the area under the curve was calculated to assess the diagnostic strength of UA in LN. The mean age was similar among LN+, LN- and CONTROL groups (32.44 ± 6.09 vs. 30.68 ± 5.36 vs. 30.86 ± 5.00 years, p = 0.52). UA was significantly higher in LN+ compared to LN- (5.54 ± 1.67 vs. 3.65 ± 1.090 mg/dL, p < 0.001) and CONTROL (5.54 ± 1.67 vs. 3.92 ± 0.95 mg/dL p < 0.001). Multivariate analysis confirmed that high UA was an independent variable related to LN (p < 0.001). The cut-off value for UA using the ROC curve was 4.47 mg/dL (AUC 0.86, p = 0.00004, CI 95% 0.75-0.96). Lupus nephritis was associated with higher UA. Hyperuricemia as a predictor of renal damage in SLE needs to be evaluated in further studies.

Systemic sclerosis and silica exposure: a rare association in a large Brazilian cohort.

The objective of this study is to describe the characteristics of patients with Erasmus syndrome (ES) in a large SSc Brazilian cohort. Nine hundred and forty-seven SSc patients attended at the Scleroderma Outpatient Clinic at two academic medical centers in Brazil and classified as SSc according to the ACR/EULAR criteria were retrospectively studied. Information on demographics, clinical, and laboratory features was obtained by chart review. ES patients had their HLA class II characterized by PCR-SSO method as available. Among the 947 SSc patients studied, nine (0.9 %) had ES. These ES patients were predominantly male (78 %) and smokers (68 %) and presented diffuse SSc (67 %). Mean time of occupational exposure to silica was 13.7 years, with mean age at onset of 47 years. Previous history of tuberculosis was referred by 33 % of the ES patients. All the ES patients presented Raynaud's phenomenon, esophageal involvement, and interstitial lung disease (ILD). Antinuclear antibodies were present in all the ES patients, while anti-topoisomerase I was positive in 44 % and no patient had anticentromere antibody. Three different HLA-DQB alleles (0506, 0305, and 0303) were observed. Compared to non-ES cases, patients with ES were associated with male gender (p < 0.001), diffuse SSc (p < 0.05), ILD (p < 0.05), positive anti-topoisomerase I antibodies (p < 0.05), and death (p < 0.05). Multivariate analysis did not confirm that silicosis is an independent risk factor for SSc. To conclude, ES was rare in this large SSc cohort, although associated with a bad prognosis.

Cross-cultural adaptation and validation of the Brazilian version of the Scleroderma Health Assessment Questionnaire (SHAQ).

The Scleroderma Health Assessment Questionnaire (SHAQ) is a feasible multisystem specific tool that has been extensively used as an additional assessment for systemic sclerosis (SSc). The aim of this study is to cross-culturally adapt and validate the Brazilian version of the SHAQ. Construct validity was assessed based on the correlations between SHAQ and both the Medical Outcomes Survey Short Form 36 version 2 (SF-36v2™) and the Health Assessment Questionnaire Disability Index (HAQ-DI). The correlation between the SHAQ and disease severity was assessed by Spearman's correlation coefficient. The reproducibility of the SHAQ was evaluated by the intraclass correlation coefficient (ICC). Among the 151 consecutive outpatients evaluated, 59 % had limited SSc subtype. The overall disease severity visual analog scale (VAS) of the SHAQ was statistically significantly correlated to HAQ-DI, pain VAS, and the SF-36v2™ physical component summary score (r = 0.595, r = 0.612, and r = -0.582, respectively; p < 0.001). Further analysis of all SF-36v2™ components revealed statistically significant correlations between overall disease severity VAS and bodily pain (r = -0.621, p < 0.001), vitality (r = -0.544, p < 0.001), physical function (r = -0.510, p < 0.001), and role limitation-physical dimensions (r = -0.505, p < 0.001). Moreover, digestive, pulmonary, and overall disease severity VASs were statistically significantly correlated to the number of organs involved (r = 0.178, p = 0.029; r = 0.214, p = 0.008; r = 0.282, p < 0.001). We also demonstrated high reproducibility for SHAQ (ICC = 0.757, 95 % confidence interval = 0.636-0.842). The Brazilian version of the SHAQ demonstrated both construct and discriminant validities as well as good reproducibility.

Systemic sclerosis sine scleroderma: distinct features in a large Brazilian cohort.

OBJECTIVE: Systemic sclerosis sine scleroderma (ssSSc) is an infrequent SSc variant characterized by visceral and immunological manifestations of SSc in the absence of clinically detectable skin involvement. We sought to delineate the characteristics of ssSSc in a cohort of Brazilian patients and contrast them with those in the literature. METHODS: SSc patients seen at two academic medical centres in Brazil were retrospectively analysed. Patients were classified as ssSSc if they presented with RP, positive ANAs and at least one visceral involvement typical of SSc in the absence of skin thickening. Demographics, clinical and laboratory data were obtained by chart review. Literature review was performed by searching available original studies up until June 2012. RESULTS: Among the 947 consecutive patients with SSc, 79 (8.3%) were classified as ssSSc. Oesophagus was the most frequently affected organ (83.1%), followed by pulmonary involvement (63.2%). Compared with the limited cutaneous form of SSc, telangiectasia was the only variable significantly different after multivariate logistic regression analyses (odds ratio 0.46; 95% CI 0.27, 0.81). Compared with the diffuse cutaneous form of SSc, multivariate analyses revealed that ssSSc patients were less likely to be male (odds ratio 0.15; 95% CI 0.04, 0.57), have digital ulcers (odds ratio 0.26; 95% CI 0.13, 0.51) or anti-Scl70 antibodies (odds ratio 0.19; 95% CI 0.07, 0.55) and less frequently treated with CYC (odds ratio 0.23; 95% CI 0.12, 0.43). These features were comparable to those in the published literature. CONCLUSION: In this series, patients with ssSSc had a relatively mild disease with good prognosis.

Survival, causes of death, and prognostic factors in systemic sclerosis: analysis of 947 Brazilian patients.

OBJECTIVE: To analyze survival, prognostic factors, and causes of death in a large cohort of patients with systemic sclerosis (SSc). METHODS: From 1991 to 2010, 947 patients with SSc were treated at 2 referral university centers in Brazil. Causes of death were considered SSc-related and non-SSc-related. Multiple logistic regression analysis was used to identify prognostic factors. Survival at 5 and 10 years was estimated using the Kaplan-Meier method. RESULTS: One hundred sixty-eight patients died during the followup. Among the 110 deaths considered related to SSc, there was predominance of lung (48.1%) and heart (24.5%) involvement. Most of the 58 deaths not related to SSc were caused by infection, cardiovascular or cerebrovascular disease, and cancer. Male sex, modified Rodnan skin score (mRSS) > 20, osteoarticular involvement, lung involvement, and renal crisis were the main prognostic factors associated to death. Overall survival rate was 90% for 5 years and 84% for 10 years. Patients presented worse prognosis if they had diffuse SSc (85% vs 92% at 5 yrs, respectively, and 77% vs 87% at 10 yrs, compared to limited SSc), male sex (77% vs 90% at 5 yrs and 64% vs 86% at 10 yrs, compared to female sex), and mRSS > 20 (83% vs 90% at 5 yrs and 66% vs 86% at 10 yrs, compared to mRSS < 20). CONCLUSION: Survival was worse in male patients with diffuse SSc, and lung and heart involvement represented the main causes of death in this South American series of patients with SSc.