Hospital Santa Luzia

Renal failure is considered a life-limiting CONDITION that often requires Renal Replacement Therapy, such as dialysis or kidney transplantation. Dialysis can effectively relieve symptoms and prolong life, but its withdrawal results in severe complications and death. The decision to discontinue or refuse to dialysis must be made collaboratively by the patient, family, and healthcare team, considering the clinical condition, life expectancy, symptom burden, and individual preferences. This decision, involving clinical, bioethical, and legal aspects, is complex and requires a collective understanding of the process. Withdrawal to dialysis presents a challenge for nephrologists and the healthcare team due to the lack of clear guidelines, which can compromis the safety of the process and the patient's dignity. In this position statement, the Brazilian Society of Nephrology recommends a process for dialysis withdrawal or refusal, including identifying eligible patients, applying prognostic assessment tools, shared decision-making, advance care planning, and offering dialysis alternatives. The decision must be consensual, allowing adequate time for reflection, and healthcare services must provide comprehensive management of physical, psychological, social, and spiritual symptoms, as well as end-of-life care. Proper documentation in medical records is essential to ensure process transparency. Therefore, refusal or withdrawal to dialysis should be an informed decision that respects individual autonomy and balances clinical, bioethical, spiritual, and legal considerations.

BackgroundWhether potent P2Y12 inhibitor monotherapy without aspirin initiated shortly after successful percutaneous coronary intervention (PCI) is effective and safe for patients with acute coronary syndromes is unclear.MethodsWe conducted a multicenter, open-label, randomized trial in Brazil involving patients with acute coronary syndromes who had undergone successful PCI. Patients were assigned in a 1:1 ratio within the first 4 days of hospitalization to stop treatment with aspirin and receive potent P2Y12 inhibitor monotherapy (ticagrelor or prasugrel) or to receive dual antiplatelet therapy (aspirin and a potent P2Y12 inhibitor) for 12 months. The two ranked primary outcomes, assessed through 12 months, were a composite of death from any cause, myocardial infarction, stroke, or urgent target-vessel revascularization (tested for noninferiority, with a noninferiority margin of 2.5 percentage points) and major or clinically relevant nonmajor bleeding (tested for superiority).ResultsA total of 3410 patients were included in the intention-to-treat population (1712 in the monotherapy group and 1698 in the dual antiplatelet therapy group). At 12 months, death from any cause, myocardial infarction, stroke, or urgent revascularization had occurred in 119 patients (Kaplan–Meier estimate, 7.0%) in the monotherapy group and in 93 patients (Kaplan–Meier estimate, 5.5%) in the dual antiplatelet therapy group (absolute risk difference, 1.47 percentage points; 95% confidence interval [CI], −0.16 to 3.10; P=0.11 for noninferiority). Major or clinically relevant nonmajor bleeding had occurred in 33 patients (Kaplan–Meier estimate, 2.0%) in the monotherapy group and in 82 patients (Kaplan–Meier estimate, 4.9%) in the dual antiplatelet therapy group (absolute risk difference, −2.97 percentage points; 95% CI, −4.20 to −1.73). Stent thrombosis occurred in 12 patients in the monotherapy group and in 4 in the dual antiplatelet therapy group.ConclusionsAmong patients who had undergone successful PCI for acute coronary syndromes, potent P2Y12 inhibitor monotherapy was not found to be noninferior to dual antiplatelet therapy with respect to a composite of death or ischemic events at 12 months. (Funded by the Brazilian Ministry of Health; NEO-MINDSET ClinicalTrials.gov number, NCT04360720.)

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR’s LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

Preoperative clinical MRI protocols for gliomas, brain tumors with dismal outcomes due to their infiltrative properties, still rely on conventional structural MRI, which does not deliver information on tumor genotype and is limited in the delineation of diffuse gliomas. The GliMR COST action wants to raise awareness about the state of the art of advanced MRI techniques in gliomas and their possible clinical translation. This review describes current methods, limits, and applications of advanced MRI for the preoperative assessment of glioma, summarizing the level of clinical validation of different techniques. In this second part, we review magnetic resonance spectroscopy (MRS), chemical exchange saturation transfer (CEST), susceptibility-weighted imaging (SWI), MRI-PET, MR elastography (MRE), and MR-based radiomics applications. The first part of this review addresses dynamic susceptibility contrast (DSC) and dynamic contrast-enhanced (DCE) MRI, arterial spin labeling (ASL), diffusion-weighted MRI, vessel imaging, and magnetic resonance fingerprinting (MRF). EVIDENCE LEVEL: 3. TECHNICAL EFFICACY: Stage 2.

Os gliomas compreendem a grande maioria de todos os tumores cerebrais malignos. A identificação do estado de codeleção cromossômica 1p/19q em gliomas de baixo grau (LGG) é de fundamental importância no manejo clínico. Este trabalho propõe uma assinatura de baixa complexidade para avaliação não invasiva do status 1p/19q a partir de imagens de ressonância magnética, usando radiômica e aprendizado de máquina. Os experimentos foram realizados usando imagens ponderadas em T2 de um conjunto de dados público, com 159 pacientes e status 1p/19q comprovado por biópsia. Um conjunto de 68 características quantitativas foi extraído de cada tumor usando a plataforma PyRadiomics. A normalização foi utilizada para que todas as características apresentem uma ordem de grandeza similar. A análise de componentes de vizinhança foi utilizada para redução de dimensionalidade. A previsão do status 1p/19q foi realizada usando um classificador de k-vizinhos mais próximos, com ajuste de hiperparâmetros usando busca em grade com validação cruzada. O desempenho da classificação foi avaliado usando várias métricas. Os resultados mostram que o desempenho da classificação melhora à medida que incorporamos cada etapa adicional a assinatura, e os melhores resultados foram obtidos ao executar a assinatura completa. Quando comparado com vários métodos de ponta da literatura e com resultados obtidos por neurocirurgiões e neurorradiologistas analisando as mesmas imagens, a assinatura proposta apresentou acurácia (81,88%), especificidade (69,25%), precisão (86,04%), área sob a curva (82,70%) e pontuação F1 (86,28%); o método proposto também apresentou alta sensibilidade (88,48%). Este trabalho demonstra técnicas baseadas em radiômica e aprendizado de máquina que fornecem avaliação não invasiva e promissora do status 1p/19q em LGGs. A assinatura proposta pode ser útil para facilitar a tomada de decisões clínicas, cirúrgicas e terapêuticas.

BACKGROUND:Due to “stay at home” restrictions during the coronavirus disease 2019 (COVID-19) pandemic, people spent more time at home leading to an increase in home accidents, including burns.OBJECTIVE:To investigate the epidemiology of burns that occurred within homes during the COVID-19 pandemic in Brazil.DESIGN AND SETTINGS:This was a quantitative, descriptive, and cross-sectional study with a non-probabilistic sample.METHODS:Data were collected through the distribution of survey links on social networking sites and websites, and through email between December 2020 and February 2021. Participants were over 18 years of age, living in Brazil. Data analysis was performed using descriptive and dispersion statistics.RESULTS:A total of 939 adults (aged > 18 years) participated in this study. The mean age was 37.2 years (standard deviation [SD] = 12.5), 75.6% were female, 70.0% self-reported white skin color, 74% had completed higher education, and 28.1% had an income of 3 to 6 times the monthly minimum wage. A total of 21.6% suffered burns during the pandemic, 44.3% from a hot object. Approximately 49.3% never had access to a burn prevention campaign.CONCLUSION:It is necessary to develop burn prevention strategies that reach a wider population and to strengthen public policies to reduce the prevalence of domestic burns, especially during the pandemic.