Sixteen Years of Heart Transplant in an Open Cohort in Brazil: Analysis of Graft Survival of Patients using Immunosuppressants. / Dezesseis Anos de Transplante Cardíaco em Coorte Aberta no Brasil: Análise de Sobrevivência de Pacientes em Uso de Imunossupressores.

BACKGROUND: Heart transplant is the main therapeutic alternative for advanced heart failure patients. Several risk factors affect these patients' survival; however, few studies about the topic are available in Brazil. OBJECTIVES: To review the survival rates of heart transplant patients in the Brazilian Public Health System (Sistema Único de Saúde - SUS) between 2000 and 2015. METHODS: This is a non-concurrent, open cohort study, involving cardiac transplant patients in Brazil. The cumulative survival probability was estimated by the Kaplan-Meier curve, and the curve comparison was done using the Log-Rank test. The Cox model was used to calculate the Hazard-Ratio (HR). Analyses were conducted at the 95% confidence level. RESULTS: The heart transplant survival rate median in Brazil, during the period, was 8.3 years. Each additional year in the recipient's age, the occurrence of infections, and the performance of the surgical procedure in the South Region were associated with a higher risk of graft loss. A higher use ratio of immunosuppressants mycophenolate and azathioprine acted as a protection factor. CONCLUSIONS: The analyses conducted provide the first information about the median survival time in heart transplant patients in Brazil. The difference noticed among the geographical regions may be related to the different treatment protocols adopted in the country, especially in the early 2000s. The rate of mycophenolate and azathioprine use as a protection factor suggests that, despite the absence of differences among therapeutic strategies, use of these drugs may favor survival of certain patients. The study provides robust epidemiological data, which are relevant for public health.

FUNDAMENTO: O transplante cardíaco é a principal alternativa terapêutica para pacientes com insuficiência cardíaca avançada. Diversos fatores de risco influenciam a sobrevivência desses pacientes, entretanto, poucos estudos acerca do tema estão disponíveis no Brasil. OBJETIVOS: Analisar a sobrevivência de pacientes transplantados cardíacos pelo Sistema Único de Saúde no Brasil entre 2000-2015. MÉTODOS: Trata-se de uma coorte não concorrente, aberta, de pacientes transplantados cardíacos no Brasil. A probabilidade acumulada de sobrevivência foi estimada por Kaplan-Meier e a comparação entre as curvas realizada pelo Teste de Log-Rank. O modelo de Cox foi utilizado para calcular o Hazard-Ratio (HR). As análises foram realizadas ao nível de 95% de confiança. RESULTADOS: A mediana de sobrevivência do transplante cardíaco no Brasil no período foi 8,3 anos. Cada ano adicional na idade do receptor, a ocorrência de infecções e a realização do procedimento cirúrgico na região Sul relacionaram-se ao maior risco de perda do enxerto. Maior proporção de uso dos imunossupressores micofenolato e azatioprina atuou como fator protetor. CONCLUSÕES: As análises realizadas fornecem a primeira informação quanto ao tempo de sobrevivência mediana do transplante cardíaco no Brasil. A diferença observada entre as regiões pode estar relacionada aos diferentes protocolos de tratamento adotados no país, principalmente no início dos anos 2000. A proporção de uso de micofenolato e azatioprina como fator protetor sugere que, apesar de não haver diferença entre as estratégias terapêuticas, o uso desses medicamentos pode favorecer a sobrevida de determinados pacientes. O estudo apresenta dados epidemiológicos robustos e importantes para a saúde pública.

Sixteen-Year Cohort of Liver Transplantation in the National Health System in Brazil: Analysis of Immunosuppression Maintenance Therapies.

OBJECTIVE: To evaluate factors related to liver graft survival with a focus on immunosuppressive schemes based on calcineurin inhibitors (tacrolimus or cyclosporine). METHODOLOGY: This study was carried out through an open cohort constructed by deterministic and probabilistic matching through three databases of the SUS with assessment of liver graft survival from 2000 to 2015 in Brazil. From this first cohort, a second cohort was constructed by pairing 1: 1 to more precisely assess the effect of the immunosuppressive scheme on graft survival. The Kaplan-Meier method and was used to estimate the probability of survival. Cox's model of proportional risks was used to assess factors related to graft loss. RESULT: We found 12,687 patients in the Full cohort and 470 patients in the Matched cohort. The overall graft survival rates at 1, 5, 10, and 16 years were 72.6, 63.3, 52.8, and 45.3%, respectively. Patients younger had a longer graft survival than older ones. In the Full cohort, male patients had a higher survival rate than female ones. Therapeutic schemes based on tacrolimus were more prevalent and had a better survival rate when compared to schemes that used cyclosporine. Tacrolimus without association with antiproliferative agents or rapamycin inhibitors was the therapeutic scheme associated with greater survival rate in both cohorts (HR = 0.81, 95% CI = 0.72-0.91), (HR = 0.50, 95% CI = 0.30-0.85). In addition, white-skinned patients had longer survival rate in both cohorts (HR = 0.55, 95% CI = 0.50-0.61 and HR = 0.50, 95% CI = 0.34-0.75). On the other hand, patients who a greater time ratio without using an immunosuppressant had lower graft survival rate (HR = 6.46, 95% CI = 5.05-8.27 and HR = 6.57, 95% CI = 2.66-16.22). CONCLUSION: This 16-year cohort showed that the older age and the greater time ratio without using an immunosuppressant are risk factors for liver graft loss. White-skinned patients and tacrolimus-based regimens, especially tacrolimus without other immunosuppressants, are factors of better prognosis to the graft.

Effectiveness of Maintenance Immunosuppression Therapies in a Matched-Pair Analysis Cohort of 16 Years of Renal Transplant in the Brazilian National Health System.

The maintenance of patients with renal transplant typically involves two or more drugs to prevent rejection and prolong graft survival. The calcineurin inhibitors (CNI) are the most commonly recommended medicines in combinations with others. While immunosuppressive treatment regimens are well established, there is insufficient long-term effectiveness data to help guide future management decisions. The study analyzes the effectiveness of treatment regimens containing CNI after renal transplantation during 16 years of follow-up with real-world data from the Brazilian National Health System (SUS). This was a retrospective study of 2318 SUS patients after renal transplantion. Patients were propensity score-matched (1:1) by sex, age, type and year of transplantation. Kaplan-Meier analysis was used to estimate the cumulative probabilities of survival. A Cox proportional hazard model was used to evaluate factors associated with progression to graft loss. Multivariable analysis, adjusted for diabetes mellitus and race/color, showed a greater risk of graft loss for patients using tacrolimus plus mycophenolate compared to patients treated with cyclosporine plus azathioprine. In conclusion, this Brazilian real-world study, with a long follow-up period using matched analysis for relevant clinical features and the representativeness of the sample, demonstrated improved long-term effectiveness for therapeutic regimens containing cyclosporine plus azathioprine. Consequently, we recommend that protocols and clinical guidelines for renal transplantation should consider the cyclosporine plus azathioprine regimen as a potential first line option, along with others.

Mitral valve aneurysms: Clinical characteristics, echocardiographic abnormalities, and possible mechanisms of formation.

AIMS: Mitral valve aneurysms (MVA) are most frequently associated with endocarditis. Echocardiography is the method of choice for diagnosis, and color flow imaging is an important, easy method to detect MVA ruptures. We aimed to study the clinical and echocardiographic findings and their relation to the mechanism of aneurysm formation. METHODS AND RESULTS: We reviewed clinical and echocardiographic records of 18 patients during a 17-year period, corresponding to 0.02% of the total studies performed at our institution. All patients underwent transthoracic echocardiogram (TTE), and all except two underwent transesophageal echocardiogram (TEE). The aneurysm was located either on the anterior leaflet (16 cases) or on the posterior leaflet (two cases). In seven cases, the probable aneurysm formation mechanism was an aortic regurgitant jet striking the anterior mitral leaflet. Perforation was present in 17 (94.4%) patients, and 10 (55.5%) cases presented more than one aneurysm. No patients underwent surgery exclusively because of the echocardiography finding. CONCLUSION: Different etiologies and formation mechanisms can occur in MVA. Echocardiography plays a fundamental role, providing meticulous examination of the mitral valve anatomy and flow. Unlike standard recommendations, clinical management is possible, and diagnosis does not imply immediate surgical correction.

Óbitos hospitalares no estado de Minas Gerais de 2007 a 2009: perspectivas para o MG Transplantes / Hospital deaths in the state of Minas Gerais from 2007 to 2009: prospects for the MG Transplants

Os transplantes estão entre os procedimentos mais complexos da medicina moderna e representam a terapêutica mais eficaz em algumas situações críticas de insuficiência de órgãos. O Brasil tem o maior programa público do gênero no mundo regulamentado pelo Sistema Nacional de Transplantes de outubro de 2009. A notificação de potenciais doadores é uma etapa essencial do processo e necessita de otimização através da implementação efetiva do sistema de busca ativa de potenciais doadores e identificação dos estabelecimentos com maior sub-notificação, para implementação de ações corretivas, buscando o aumento do número de doadores de órgãos e tecidos em Minas Gerais. Identificaram-se através da análise de óbitos por doenças cérebro-vasculares e causas externas os hospitais com potencial de aumento de captação de órgãos e tecidos e classificou-se o nível de complexidade das comissões intra-hospitalares necessárias nos hospitais de Minas Gerais, conforme critérios da nova regulamentação.(AU)

Transplants are among the most complex procedures in modern medicine and represent the most effective therapy in some critical situations of organ failure. Brazil has the largest public program of its kind in the world regulated by the National Transplantation October 2009. The notification of potential donors is a key step in the process and requires optimization through the effective implementation of the system of active search for potential donors and identifying the establishments with greater underreporting, for implementation of corrective actions, seeking to increase the number of donors organs and tissues in Minas Gerais. It was identified through analysis of deaths from vascular brain diseases and external causes hospitals with potential for increased uptake in organs and tissues and was ranked the level of complexity of in-hospitals committees required in the hospitals of Minas Gerais, according to the criteria of the new regulations.(AU)

Quality of life and neuropsychological changes in mild head trauma. Late analysis and correlation with S100B protein and cranial CT scan performed at hospital admission.

INTRODUCTION: mild head trauma (MHT) is defined as a transient neurological deficit after trauma with a history of impairment or loss of consciousness lasting less than 15 min and/or posttraumatic amnesia, and a Glasgow Coma Scale between 13 and 15 on hospital admission. We evaluated 50 MHT patients 18 months after the trauma, addressing signs and symptoms of post-concussion syndrome, quality of life and the presence of anxiety and depression. We correlate those findings with the S100B protein levels and cranial CT scan performed at hospital admission after the trauma. METHOD: patients were asked to fill out questionnaires to assess quality of life (SF36), anxiety and depression (HADS), and signs and symptoms of post-concussion syndrome. For the control group, we asked the patient's household members, who had no history of head trauma of any type, to answer the same questionnaires for comparison. RESULTS: total quality of life index for patients with MHT was 58.16 (+/-5), lower than the 73.47 (+/-4) presented by the control group. Twenty patients (55.2%) and four (11.1%) controls were depressed. Seventeen patients (47.2%) presented anxiety, whereas only eight (22.2%) controls were considered anxious. Victims of MHT complained more frequently of loss of balance, dry mouth, pain in the arms, loss of memory and dizziness than their respective controls (p<0.05). We found no correlation between the presence of these signs and symptoms, quality of life, presence of anxiety and depression with S100B protein levels or with presence of injury in the cranial CT performed at hospital admission. CONCLUSION: MHT is associated with a higher incidence of post-concussion syndrome symptoms, lower quality of life and anxiety than their respective controls even 18 months after the trauma.

Measurement of S-100B for risk classification of victims sustaining minor head injury--first pilot study in Brazil.

BACKGROUND: Release of the neuronal protein S-100B into the circulation has been suggested as a specific indication of neuronal damage. The hypothesis that S-100B is a useful and cost-effective screening tool for the management of minor head injuries was tested. METHODS: Fifty consecutive patients sustaining isolated minor head injury were prospectively evaluated in the emergency room of a Brazilian hospital by routine cranial computed tomography scan. Venous blood samples (processed to serum) were assayed for S-100B using a newly developed immunoassay test kit. Twenty-one normal healthy individuals served as negative controls. Data are presented as median and 25 to 75 percentiles. RESULTS: Patients reached the emergency room an average of 45 minutes (range: 30-62 minutes) after minor head injury. Six of 50 patients (12%) showed relevant posttraumatic lesions in the initial cranial computed tomography scan and were counted as positive. The median systemic concentration of S-100B in those patients was 0.75 microg/L (range: 0.66-6.5 microg/L), which was significantly different (U-test, P < .05) from the median concentration of 0.26 microg/L (range: 0.12-0.65 microg/L), of patients without posttraumatic lesions as counted by the cranial computed tomography. A sensitivity of 100%, a specificity of 20%, a positive predictive value of 15%, and a negative predictive value of 100% was calculated for the detection of patients suffering from intracranial lesions. CONCLUSIONS: Protein S-100B had a very high sensitivity and negative predictive value and could have an important role in ruling out the need for cranial computed tomography scan after minor head injury. This appears to be of substantial clinical relevance, particularly in countries where trauma incidence is high and medical resources are limited, such as in Brazil.

Measurement of S-100B for risk classification of victims sustaining minor head injury: first pilot study in Brazil

INTRODUÇÃO: A liberação da proteína neuronal S-100B na circulação tem sido sugerida como indicadora de dano neuronal. Foi testada a hipótese de que a S-100B é um marcador útil e custo efetivo para a triagem de pacientes com trauma craniano leve. MÉTODO: Cinqüenta pacientes consecutivos com trauma craniano isolado foram prospectivamente avaliados na sala de emergência de um Centro de Trauma brasileiro pela tomografia computadorizada de crânio e por amostras de sangue venoso, para a medida no soro da proteína S-100B utilizando um teste recentemente desenvolvido; 21 pessoas normais foram utilizadas como controles negativos. Os resultados são apresentados como mediana e percentis 25-75. RESULTADOS: Os pacientes chegaram ao Centro de Trauma em média 45 min (30-62) após o trauma craniano leve. Seis dos 50 pacientes tiveram lesões pós-traumáticas relevantes segundo a tomografia computadorizada de crânio inicial (12%) e foram considerados como positivos. A concentração mediana de S-100B nestes pacientes foi de 0,75µg/L (0,66-6,5), significativamente maior (U-teste, p<0,05) do que a concentração mediana de 0,26µg/L (0.12-0.65) dos pacientes sem lesões pós-traumáticas, segundo a tomografia computadorizada de crânioCCT-. O cálculo para a detecção dos pacientes com lesões intra-cranianas revelou sensibilidade de 100%, especificidade de 20%, valor preditivo positivo de 15% and valor preditivo negativo de 100%. CONCLUSÃO: A proteína S-100B tem altas taxas de sensibilidade e valor preditivo negativo, podendo ter um importante papel para descartar a necessidade de tomografia de crânio após trauma craniano leve. Acreditamos que este achado é de relevância clínica, principalmente em países onde o trauma é muito frequente e os recursos médicos limitados.

Traumatismo vascular no membro supeior tratado por ponte extra-anatômica: relato de caso / Vascular trauma in the upper limb treated with extra-anatomic bypass: a case report

Os autores relatam o caso de um paciente com traumatismo grave no membro superior, após acidente automobilístico, com lesão de artéria braquial e grande laceração de partes moles. O paciente foi submetido a reparo primário, com interposição de enxerto venoso anatômico,evoluíndo para infecção e ruptura do mesmo no terceiro dia de pós-operatório. Foi re-operado com reconstrução extra-anatômica,apresentando boa evolução. Neste trabalho, dicutimos o uso da via extra-anatômica como alternativa para revascularização e salvamento de membros nos traumatismos complexos...

Lesões traumáticas do coração. Análise comparativa de dois períodos de tratamento / Traumatic injuries of the heart - a compative analysis between two periods of management

O trauma é a principal causa de morte, na população abaixo de 40 anos, no mundo ocidental. O trauma cardíaco é um dos maiores desafios à Medicina de Emergência. Apresentamos a evolução dos resultados, das características, da mortalidade e da abordagem cirúrgica das lesões traumáticas do coração, ocorridos em pacientes pertencentes a uma metrópole composta de uma grande população civil, subdivididos em grupo A - período entre 1933 a 1961 e grupo B - período entre 1975 a 1996, que foram atendidos no maior e mais especializado hospital do trauma do Estado de Minas Gerais. Foram admitidos 189 casos, com predomínio absoluto de homens jovens, vítimas de agressões cardíacas devida à arma branca. Houve uma homogeneidade das localizações anatômicas, sendo mais acometido o ventrículo direito, seguido pelo esquerdo e posteriormente as câmaras atriais. A abordagem cirúrgica se deu prevalentemente através de toracotomias, apesar de seu decréscimo no 2§ grupo. Observa-se que geralmente ocorre uma seleção natural para que se possa sobreviver ao trauma cardíaco. O desafio permanece: tentar diminuir a mortalidade das vítimas com lesões cardíacas de perfil desfavorável

Remodelamento do coracao pos-IAM / Heart remodeling following acute myocardial infarction

O remodelamento do coracao e o conjunto de alteracoes observadas no musculo cardiaco durante determinadas situacoes, podendo ocorrer em patologias que envolvam um aumento constante do trabalho cardiaco. O remodelamento pode ser de quatro tipos, hipertrofico concentrico, hipertrofico excentrico, remodelamento concentrico e de geometria normal. No Infarto Agudo do Miocardio, a dilatacao ventricular ocorre como resposta a agressao ao colageno cardiaco. Ha evidencias que hormonios difusiveis sao fundamentais neste processo, especialmente a Angiotensina II e a Prostaglandina E. Estes hormonios agem diretamente sobre o fibroblasto cardiaco, sendo que esta interacao parece ser de grande importancia para a regulacao da fibrose do miocardio. Considerando-se estes efeitos do sistema renina-angiotensina-aldosterona e o acumulo de colageno pos-infarto, o tratamento por inibidores da enzima conversora de angiotensina e bloqueadores do receptor cardiaco para angiotensina parece promissor na regressao da fibrose do miocardio...

Pseudo-aneurisma de artéria subclávia pós-fratura de clavícula: relato de caso / Subclavian artery pseudoaneurysm after clavicle fracture: case report

Os autores descrevem a formaçäo de um pseudo-aneurisma de artéria subclávia esquerda após trauma contuso seguido de fratura de clávicula esquerda. Comentários e uma breve revisäo da literatura säo mencionados.