Hospital Leforte

Abstract Chronic pain incurs substantial global healthcare costs, requiring long-term specialized care. However, the variability in treatment approaches hampers the feasibility of value-based healthcare. To advance management and prevention efforts, data science tools like supervised and unsupervised machine learning algorithms offer promising solutions. This study employed data from six questionnaires to evaluate pain conditions in patients. Correlation techniques were applied to determine the questions most strongly correlated with low back pain, back pain, and leg pain. Five machine learning algorithms predicted the presence or absence of pain in the low back region. Seven variables were identified as input for the prediction models, with the XBoost Classifier demonstrating the highest accuracy, precision, recall, and F1-Score (0.8 accuracy, precision, recall; 0.78 F1-Score). By incorporating the machine learning model, it predicts the allocation of chronic back pain patients to integrated practice in a value-based healthcare system. Finally, our findings show that data science methods, such as machine learning, improve chronic pain management, expedite surveys, and improve value-based healthcare through efficient allocation.Graphical abstractHighlightsCorrelation analysis identified pain-related questions (back, leg, chronic low back).7 characteristics used by ML algorithms to forecast chronic low back pain occurrence.XBoost algorithm and neural network achieved best performance (Precision, Recall ∼0.8).Outcomes aid patient allocation, screening, and reducing costs in value-based healthcare.Streamlining surveys boosts response rates and enables larger datasets for improved modeling.

Introduction: Donor-specific antibodies (DSA) against human leukocyte antigen (HLA) are key factors in the diagnosis of antibody-mediated rejection (ABMR) and related to allograft dysfunction, which negatively impacts the allograft survival rate after pancreas transplant (PT). However, no study has compared the simple positivity of posttransplant DSA and MFI evolution over time after pancreas transplantation. Methods: From March/2018 until July/2022 we evaluated the sera of 270 PT recipients (164 SPK and 106 solitary[S]-PT: 90 PAK and 16 PTA). All PT recipients with de novo DSA were included. Posttransplant anti-HLA antibodies were screened by Luminex as follows: 3, 6, and 12 months or when a rejection episode occurred and twice a year thereafter for all S-PT recipients; for SPK recipients with a PRA>0 or when a rejection episode occurred at the same frequency. Patients were considered positive for these antibodies with an MFI >500. De novo DSAs were categorized in two groups, according to MFI evolution: MFI increase ≥ 50% or stable MFI (increasing or decreasing ≤ 50%) versus MFI decrease ≥ 50% or dnDSA disappearance. We evaluate the course of MFI evolution in acute rejection, pancreas immunological graft loss and long-term pancreas survival. Results: During 4.4 years of follow-up, we identified 38 patients with dnDSA, which accounts for 14% of the total population of 270 PT recipients. Among the 38 patients with dnDSA, 19/38 (50%) had increased or stable MFI over time and the other 50% showed decreased MFI or disappeared dnDSA. The median number of DSA collections per patient was 2.4, but 36.6% of patients had ≥4 tests performed. The average time from transplantation to the first occurrence of each dnDSA was 5.5 months (1-28), mainly in the first year (84.61% SPK and 84% S-PT). More rejection episodes were observed in patients with increased or stable MFI (19[100%] vs 12[63.2%], p=0.008), and the rate of pancreas immunological graft loss was higher (p<0.0001) in this group. ABMR occurred in 11/38(21%) and graft loss in 5/11(62.5%) of recipients with ABMR, especially in patients with both class I and II dnDSA, and those with multiple dnDSA. Comparing both groups, more ABMR episodes occurred in patients with increased or stable MFI (9[81.8%] vs 2[18.2%], p=0.029). In the group with dnDSA disappearance or MFI decrease ≥ 50% at some point during follow-up, there was better long-term pancreas survival (p<0.0001). Conclusion: Our study suggests that the persistence or increase of MFI dnDSA posttransplant has a negative impact on allograft survival and describes a relevant number of patients with a stable disappearance or decrease of dnDSA, which is related to better allograft survival.

Cytomegalovirus (CMV) prevention can be achieved by prophylaxis or preemptive therapy. As no pharmacological CMV prophylaxis is offered by public health system in Brazil we have developed a preemptive CMV monitoring protocol in pancreas transplant (PT) recipients. The aim of this study is to report the outcomes with this preemptive protocol among PT patients. We analyzed 240 technically successful PT recipients from 2018 to 2022 enrolled in this CMV protocol, being 151 SPK, 74 PAK and 15 PTA. Rabbit thymoglobulin was given at 1-1.5mg/kg/dosage with a cumulative total dose of 5mg/kg for SPK and 7mg/kg for S-PT+SPLK according to total lymphocyte count. Immunosuppresive maintenance included tacrolimus, mycophenolate/sirolimus and steroids for all patients. Our CMV monitoring protocol included weekly CMV PCR testing from third to 12th week post-transplant. For asymptomatic and pre-transplant IgG+ patients, preemptive therapy with valganciclovir (from 900mg-1800mg/day) was initiated either for a CMV-PCR rise over 20.000IU/ml or a log increase more than 0.5 compared to the last test. For pre-transplant CMV negative or symptomatic patients a PCR threshold of 2500IU/ml triggered CMV treatment. Pretransplant CMV was positive in 89% of recipients and 87% of pancreas donors. Post-transplant CMV infection or disease occurred in 148(61%) patients, being 129(87%) infections and 21(14.1%) diseases. Readmissions were necessary in 16(6.7%) patients. Infections occurred in average of 44.3 days while CMV disease in average of 39.5 days post-transplant. Patient death was observed in 16(6.7%) patients and only one case due to pulmonar and suspicious of CMV pneumonitis. Preemptive CMV monitoring and treatment protocol after PT has shown favorable outcomes, preventing use of prophylaxis in 39% of our patients, with a low rate of CMV disease and need of readmission.

The use of older donor(OD) remains controversial among pancreas transplant(PT) programs. We reviewed our experience with the use of older pancreas donors in our 27-year program of PT. We analyzed 1,065 PT from 1996 to 2021, being 514 SPK, 74 simultaneous pancreas and living-donor kidney (SPLK), 326 PAK and 151 PTA. A separate analysis was conducted for the 514 SPK and 551 solitary PT(S-PT) +SPLK. The primary end-points were1-year patient and graft survivals and technical graft failure. Secondary end-points were kidney delayed graft function (KDGF) and rate of reoperations. Older donors were defined as those aged > 40 years. Overall, there were 89(8.3%) older donors, 64(11%) in the SPK group and 25(5.2%) among S-PT+SPLK group. As expected, donor age (43.2 x 26.2), KDPI (50.2 x 21.4) and cerebro-vascular accident (CVA) as cause of donor death (72% x 26.7%) were significantly higher in SPK/OD group(p<0.001). Donor hospital stay (6.5 x 5.5 days), donor acute kidney injury (53% x 41%), pancreas (11.8 x 11.1 hours) and kidney (10.1 x 10.5 h) cold ischemia time were similar between SPK/OD and SPK/Younger donors (YD) groups, respectively. Recipient age (36.5 x 36.2), time on dialysis (24.6 x 42.5 months) and preemptive transplants (23.4% x 18%) were also similar between SPK/OD and YD groups. 1-year death-censored (DC) kidney (92% x 94%) and pancreas (83% in both) survival, rate of kidney (1.6% x 2.1%) and pancreas (11% in both) technical failures, 1-year patient survival (83% in both) and KDGF (32% x 30%) were similar between SPK/OD and YD groups. Reoperation rate (54% x 31%) was higher in SPK/OD group(p=0.016). Among S-PT+SPLK recipients, donor age (43.7 x 22.3) and the rate of CVA (61% x 18.4%) were significantly higher in OD group(p<0.001). Recipient age (37.2 x 36 y) and rate of retransplants (8% x 21.9%) were similar between OD and YD groups. 1-year patient (84% x 92%), DC-pancreas (71.4% x 72.4%) survival, technical failure (16% x 15.5%) and reoperations (24% x 22%) were similar between OD and YD groups, respectively. Bladder drainage technique was significantly more used in OD compared to YD transplants both for SPK (32.8% x 21.4%, p=0.039) as S-PT+SPLK (72% x 35.7%,p<0.001). Use of OD was significantly more concentrated in the first 15 years than in the last decade of our program(p<0.001) both among SPK (75% x 25%) as in S-PT+SPLK (84% x 16%) groups. Our results showed that the use of pancreas donor > 40 years, even having predominantly CVA as cause of death, did not impact patient and graft outcomes, but showed higher rate of reoperations in SPK patients. Our use of OD has significantly reduced over time and should be reconsidered given the current results.

Resgatando o percurso histórico da Enfermagem no Brasil, é possível reconhecer as características desta profissão e a sua importância na atualidade, Dentre as conquistas do enfermeiro, está sua atuação na Medicina Tradicional Chinesa (MTC), e, portanto, na Auriculoterapia, também chamada acupuntura auricular. No exercício profissional, os enfermeiros, estão aptos na prática da Auriculoterapia, contudo, para realizá-la precisam não apenas habilidades técnicas como também de preparo técnico-científico. É necessário, realizá-la, com domínio, segurança, excelência e empatia, ou seja, protagonismo. Assim, esta pesquisa teve como objetivo identificar, por meio da revisão bibliográfica, o protagonismo profissional do enfermeiro na Auriculoterapia. Após a pesquisa online e a utilização dos critérios de inclusão, considerou-se 06 publicações para a estudo. Os resultados mostraram que o enfermeiro está presente nas práticas de Auriculoterapia, seja na sua indicação ou realização, não havendo destaque e nem detalhamento das ações específicas deste profissional que demonstrem a sua liderança, mas há estudos apontando os efeitos e resultados das suas aplicações, assim necessita-se dar voz às atividades do enfermeiro através de pesquisas, divulgação nos serviços de saúde, marketing nas mídias sociais, apresentando-o como profissional que proporciona melhor qualidade de vida ao indivíduo, família e comunidade pela forma como realiza o seu trabalho.

Introduction: Ipsilateral simultaneous pancreas-kidney transplantation(iSPK) is an attractive surgical strategy searching to reduce operative time and preserve the left iliac fossa for an eventual future transplant. Traditionally, pancreas is placed and reperfused first followed by kidney transplant. The aim of the study was to compare a technical variant of iSPK(v-iSPK) with concomitant reperfusion of both pancreas and kidney grafts to the standard contralateral SPK(cSPK). Methods: A retrospective analysis was performed of 42 v-iSPK and 117 cSPK from 2018 to 2022. There was also a small group(n=9) of iSPK without concomitant reperfusion(iSPKw/o) for comparison of some specific variables. The decision for graft placement was made during the procedure and based on physical characteristics both of recipient(dimension of pelvis, quality of vessels) and of donor pancreas and kidney. In v-iSPK pancreas was firstly reperfused and after a few minutes for hemostasis, kidney was soon reperfused. Donor and recipient data, surgical and cold ischemia time(CIT), delta time between kidney and pancreas CIT, surgical complications, reoperations and patient and graft survival were compared between the 2 groups. Results: Donor age(28.5x28.3) and KDPI(26.2x23.8), recipient age(36.5x35.8), race and gender were similar between v-iSPK and cSPK, respectively. Cerebrovascular event as cause of donor death (33.3% x 25.6%, p=0.45) and rate of preemptive SPK(4.8% x 2.6%, p=0.85) were also similar between v-iSPK and cSPK groups. The operative time was shorter(312 x 329min, p= 0.05) while pancreas CIT was higher(8.7 x 7.8 hours,p<0.001) and kidney CIT was lower (8.8 x 9.8 hours,p<0.001) for v-iSPK. Delta time between kidney and pancreas CIT was significantly inferior in v-iSPK compared to iSPKw/o and cSPK(6 x 105.2 x 121.2 min, respectively, p<0.001). Peak amylase(UI/ml) (231x167x263,p=0.33),peak lipase (204x117x196,p=0.25), peak drain amylase(1164x725x1191,p=0.31), 7-day amylase(137x77x117,p=0.20) and 7-day lipase(87x74x81,p=0.44) were similar among v-iSPK, iSPKw/o and SPK,respectively.The rate of kidney DGF (52.4% x 41.9%,p=0.73) and hospital stay(8.5 x 8.2 days, p=0.65) were similar between v-iSPK and cSPK. There was a tendency of higher 1-year patient (90.5% x 79.5%,p=0.17) and 1-year death censored pancreas(88.1% x 73.7%,p=0.08), similar kidney(92.3% x 87.5%,p=0.60) survival between v-iSPK and cSPK. Pancreas technical failure (2.3% x 12.8%, p=0.01) was lower for iSPK and the need of blood transfusion(11.9% x 16.2%, p=0.67) and rate of reoperations(19% x 18.8%, p=1.0) were similar between the groups. Conclusion: v-iSPK is a new variant technique and seems to be as safe as the standard cSPK. The attractive of this new technique is to facilitate the implantation of the ipsilateral kidney graft with a still empty pancreas graft and can shorten surgical time and the time-interval between pancreas and kidney reperfusion in addition to reduce pancreas technical failure.