Clinics Hospital of Ribeirão Preto

Introdução: O carcinoma hepatocelular (CHC) é o câncer hepático primário mais prevalente, fortemente associado à cirrose, hepatite crônica e hemocromatose. Sua alta incidência e mortalidade exigem métodos diagnósticos sensíveis e específicos para identificação precoce e planejamento terapêutico adequado. A tomografia computadorizada (TC) trifásica, realizada com contraste iodado, destaca-se como ferramenta essencial, pois permite caracterizar o comportamento vascular das lesões hepáticas e, assim, diferenciar nódulos benignos, pré-malignos e malignos. A padronização dos achados pelo Liver Imaging Reporting and Data System (LI-RADS) reduziu a variabilidade interobservador e aumentou a precisão diagnóstica, favorecendo o estadiamento e a seleção terapêutica. Objetivo: Analisar o papel da TC trifásica associada ao LI-RADS no diagnóstico e estadiamento do CHC, destacando seu diferencial frente a outros métodos de imagem e suas perspectivas inovadoras, incluindo inteligência artificial e aplicabilidade em fígados não cirróticos. Material e Métodos: Foi conduzida uma revisão narrativa baseada em 31 artigos científicos selecionados entre 2015 e 2025 nas bases PubMed, Scielo e Google Scholar, incluindo revisões sistemáticas, metanálises e protocolos institucionais. Os dados extraídos foram sintetizados segundo relevância, qualidade metodológica e aplicabilidade clínica. Resultados: A TC trifásica demonstrou alta especificidade para CHC quando associados os critérios clássicos: hiper-realce arterial, washout portal e pseudocápsula. A categoria LR-5 do LI-RADS apresentou especificidade próxima a 100% para CHC em múltiplos estudos, enquanto categorias intermediárias (LR-3 e LR-4) requerem acompanhamento ou métodos adicionais. O uso do critério “threshold growth” aumentou a sensibilidade para lesões ≤3 cm sem reduzir a especificidade. Em fígados não cirróticos com esteatose, o LI-RADS manteve desempenho elevado, sugerindo aplicabilidade ampliada. Protocolos brasileiros exemplificam a integração entre ultrassonografia inicial e TC trifásica para caracterização de lesões. Evidências emergentes apontam que algoritmos de inteligência artificial e análise radiômica aplicados à TC podem aprimorar a estratificação de risco e previsão de resposta terapêutica, configurando um novo paradigma na avaliação do CHC. Conclusão: A TC trifásica, aliada ao LI-RADS, consolida-se como pilar no diagnóstico e estadiamento do carcinoma hepatocelular, oferecendo acurácia comparável à ressonância magnética em muitos cenários. Seu uso sistemático favorece diagnóstico precoce, seleção de candidatos ao transplante e planejamento de terapias loco-regionais. A incorporação de inteligência artificial e radiômica projeta um futuro em que a TC ultrapassa a detecção de lesões, tornando-se instrumento estratégico de medicina personalizada. Essa combinação de padronização, disponibilidade e inovação tecnológica representa um diferencial essencial para o manejo do CHC no contexto brasileiro e internacional.

To investigate the effects of dietary NO3- on cardiovascular, autonomic, and strength performance in men with AAS abuse. In this double-blind, randomised, placebo-controlled crossover trial, participants consumed beetroot juice (12.8 mmol [800 mg] NO3-) or a placebo (0.3 mmol NO3-). After two hours, assessments included saliva collection, endothelial function, heart rate, and systolic (SBP) and diastolic (DBP) blood pressure at rest, during, and after an isometric handgrip test. Thirteen resistance-trained males [mean (standard deviation) age: 31 (9) y; body mass index (BMI): 30 (4) kg/m2; SBP: 132 (3) mmHg; DBP: 70 (2) mmHg] completed the protocol. NO3--rich juice significantly increased salivary NO3- (40.6 μM, p < 0.001) and nitrite (NO2-) (3.1 μM, p = 0.002) versus placebo. Flow-mediated dilation was greater with NO3- both at pre-exercise (2.37%, p = 0.02) and post-exercise (2.57%, p = 0.01). No between-group differences were observed in isometric strength (0.02 kgf, p = 0.99) or systolic/diastolic blood pressure across conditions. Dietary NO3- enhanced salivary NO2- and NO3- concentrations and modestly improved endothelial function but did not reduce the elevated blood pressure or alter cardiac autonomic responses associated with AAS abuse.

Conducting multicenter, longitudinal epidemiological studies on emerging pathogens in real time during health emergencies presents significant challenges, especially in low- and middle-income countries, where substantial logistical and resource constraints hinder the rapid design and implementation of research protocols. This is particularly difficult when the disease spreads rapidly and its nature changes due to the onset of vaccination. During the COVID-19 pandemic, a cohort study (AVISA) was conducted in eleven research sites to assess seroprevalence. The objective of this study is to identify the challenges to the successful execution of the AVISA study through a retrospective analysis of quantitative and qualitative indicators. The rapid spread of SARS-CoV-2 infections, particularly in large urban areas in Brazil, and the initiation of COVID-19 vaccination in January 2021 posed significant challenges for recruiting individuals who met the eligibility criteria. Participant enrollment was slower than initially planned, and fewer participants from the youngest and oldest cohorts were recruited. The implementation of the study protocol encountered significant logistical and operational challenges due to the evolving COVID-19 context, including the effects of vaccination, the loosening of social distancing measures, and difficulties conducting household visits and collecting samples in high-risk areas. To ensure participant retention and protocol adherence, the study employed flexible strategies, including rescheduling visits, enhancing communication, and mobilizing experienced staff, which were crucial for maintaining data collection and study continuity over time. Despite concurrent demands of the COVID-19 response, Instituto Butantan and its partners successfully mobilized resources, staff, and infrastructure to conduct the AVISA study across 11 sites, leveraging existing collaborations from prior clinical trials. The study conducted over 16,000 household visits, collected nearly 7,000 blood samples, and gathered detailed clinical and sociodemographic data from participants. Despite the complexities of conducting real-time research during a public health emergency, the AVISA study demonstrated that large-scale, multi-site longitudinal studies can be implemented in resource-constrained settings through adaptive strategies, institutional partnerships, and flexible field operations. The lessons learned offer essential insights for strengthening the design and execution of epidemiological studies in future health emergencies, particularly in low- and middle-income contexts.

Biallelic pathogenic variants in MCM3AP, encoding the germinal center-associated nuclear protein (GANP), have been linked to autosomal recessive peripheral neuropathies variably accompanied by cognitive impairment and multisystem involvement. To date, anterior horn cell involvement has not been documented in association with MCM3AP-related disorders. To describe a patient with biallelic MCM3AP variants presenting with a motor neuronopathy phenotype and to provide the first whole-body muscle MRI characterization associated with this gene. A 53-year-old woman born to non-consanguineous parents presented with early-onset motor neuronopathy and lifelong learning difficulties. Neurological examination revealed generalized areflexia and widespread fasciculations without sensory abnormalities. Electroneuromyography demonstrated diffuse mixed acute-on-chronic denervation process. Whole-body muscle MRI showed a selective non-length-dependent pattern of fatty infiltration. Whole-exome sequencing identified two likely pathogenic heterozygous variants in the MCM3AP gene. According to the policies of our institution, single-patient case reports do not require review or approval by the institutional ethics committee. Written informed consent for participation and for publication of clinical information, photographs, electrophysiological data, and muscle MRI images was obtained from the patient. No clinical trial registration was applicable. This case extends the phenotypic spectrum of MCM3AP-related disorders to include a slowly progressive, non-syndromic motor neuronopathy with electrophysiological evidence of active denervation and distinctive MRI findings. These observations highlight the hidden boundaries between hereditary motor neuropathies and anterior horn cell diseases, emphasizing the need for integrated clinical, neurophysiological, and genetic evaluation.