Irmandade da Santa Casa de Misericórdia de São Paulo

Metabolic and bariatric surgery (MBS) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are both effective strategies for obesity management, but their comparative efficacy remains uncertain. This systematic review and meta-analysis aimed to compare weight loss outcomes between MBS and GLP-1 RA therapy in adults with obesity. A systematic search of PubMed, Scopus, and Cochrane Library was conducted from inception to September 22, 2025. Eligible studies included randomized and observational comparisons between MBS-specifically sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)-and GLP-1 RA therapy in adults with obesity. Pooled mean differences (MDs) for total weight loss (TWL) and body mass index (BMI) change were calculated using a DerSimonian-Laird random-effects model. Risk of bias was assessed using ROBINS-I V2, and certainty of evidence was graded with GRADE. Five retrospective observational studies (n = 5,944; 3,489 MBS, 2,455 GLP-1 RA) met the inclusion criteria. Pooled analysis showed significantly greater TWL in the MBS group (MD - 18.15%; 95% CI 16.41 to 19.90; p < 0.0001; I² = 95%) and larger BMI reduction (MD 8.73kg/m²; 95% CI 5.87 to 11.58; p = 0.0001; I² = 94.6%). Sensitivity analyses confirmed the robustness of these results. Overall risk of bias was moderate, primarily due to non-randomized designs and treatment selection bias. Certainty of evidence was rated as moderate. MBS achieves significantly greater and more durable weight loss compared with GLP-1 RA therapy, reaffirming its role as the most effective intervention for severe obesity. While GLP-1 RAs represent valuable noninvasive or adjunctive options, surgery remains the benchmark for sustained metabolic and weight outcomes.

Uncertainties persist regarding the allocation of apical lymph nodes in colorectal cancer, the approaches to lymph node dissection and mesocolic excision, which may contribute to inconsistent surgical practices. The aim of this study is to assess surgeons' practices in lymph node dissection and mesocolic excision approaches and to identify areas lacking standardization. A multinational pilot survey of 22 colorectal surgeons from 6 countries was conducted during the FICARE colorectal meeting. The survey consisted of 21 Likert-scale questions on surgical practices and lymph node allocation in colorectal cancer surgery. Majority of the respondents (90.9%) recognized conceptual differences in apical lymph node stratification between right- and left-sided colon cancers, whereas D3 LND for left-sided cancer should include mesocolic tissue along the inferior mesenteric artery from its origin to the last sigmoid artery. Complete lymph node dissection requires excision of mesocolic tissue along inferior mesenteric artery for left colon cancer and superior mesenteric artery for right colon cancer according to 81.8% of respondents. At the same time, 95.5% agreed that intermediate and paracolic lymph nodes are located within a 10-cm resection margin proximally and distally from tumor, while 81.9% of respondents supported the concept of tumor-specific mesocolic excision to be sufficient enough for adequate paracolic and intermediate lymph node dissection. A multinational snapshot showed an existing contraindication in surgeons' perception of lymph node stratification and the variability in mesocolic excision and LND. Further Delphi consensus is needed to prove the suggested concepts.

Diagnosing acute appendicitis during pregnancy is challenging due to physiological changes and concerns regarding fetal radiation exposure from Computed Tomography (CT). This systematic review and meta-analysis evaluates the diagnostic accuracy and safety of Magnetic Resonance Imaging (MRI) for suspected acute appendicitis, providing an updated synthesis based on a large dataset and modern MRI protocols. Following PRISMA guidelines and PROSPERO registration, we performed a systematic review and diagnostic meta-analysis. Studies involving pregnant women with suspected appendicitis, extractable diagnostic accuracy data (true positives, false positives, false negatives, true negatives), and surgical/histopathological confirmation were included. PubMed, EMBASE, and Cochrane Central were systematically searched until September 3, 2025. Risk of bias was assessed using QUADAS-2, and evidence certainty with GRADE. Statistical analysis used R, employing bivariate random-effects models for sensitivity/specificity, sROC curves, meta-regression, and Deeks' test for publication bias. Thirty-four studies were included. Pooled sensitivity was 0.95 (95% CI: 0.91-0.98; I² = 0%) and pooled specificity 0.97 (95% CI: 0.96-0.98; I² = 55.3%), demonstrating strong diagnostic performance (AUC = 0.961; Diagnostic Odds Ratio = 273.1). A positive MRI result increased post-test probability from 30% to 93%, while a negative result reduced it to 2.2%. QUADAS-2 revealed patient selection and index-test interpretation as common bias sources, particularly in older retrospective studies. Moderate heterogeneity in specificity (I² = 55.3%) was observed, but not explained by gestational age. Deeks' test indicated potential publication bias (p = 0.0024), though pooled estimates remained robust in sensitivity analyses. Non-contrast MRI is a highly accurate and safe diagnostic tool for suspected acute appendicitis in pregnancy, demonstrating performance comparable to CT in non-pregnant populations. We recommend MRI as the standard second-line imaging modality following inconclusive ultrasound findings to enhance diagnostic confidence, minimize fetal radiation exposure, and reduce unnecessary surgical interventions.

Abstract Background: Neoadjuvant chemotherapy (NAC) may alter tumor biology, leading to immunohistochemical (IHC) subtype conversions between diagnosis and residual disease. The prognostic impact of such changes remains unclear. This systematic review and meta-analysis evaluated the effect of NAC-induced IHC subtype conversion on overall survival (OS) and disease-free survival (DFS) in patients with residual disease (non-pCR). Methods: This study was registered in PROSPERO (CRD42024558811). PubMed, EMBASE, and Cochrane Library were searched through 2025 for studies reporting IHC subtype conversions after NAC and associated survival outcomes in non-pCR patients. Eligible studies included randomized trials and observational cohorts of adult women with primary breast cancer. Two reviewers independently selected studies and extracted data. Risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane tool. Pooled risk ratios (RRs) were calculated using random-effects models. Heterogeneity was quantified with I2, and publication bias was assessed by Egger’s test. Results: Twenty-five retrospective studies (n=5,263 non-pCR patients) were included. Mean patient age ranged from 46-54 years, and tumors were predominantly T2-T3. IHC subtype conversion occurred in 20% [95% CI: 0.17-0.24], with high heterogeneity (I2=89.8%). Common conversions included luminal-to-TNBC (35%), luminal-to-HER2+ (25%), HER2+-to-luminal (20%), and TNBC-to-luminal (20%).Patients without subtype conversion had significantly better OS (RR=1.13 [95% CI: 1.01-1.26], p=0.03; I2=62%). Luminal tumors showed the greatest OS benefit without conversion (RR=1.19 [1.01-1.41], p=0.04), while HER2+ (RR=1.11 [0.95-1.31], p=0.19) and TNBC (RR=0.98 [0.84-1.16], p=0.85) showed no significant OS impact. DFS was not significantly affected by conversion overall (RR=0.95 [0.80-1.14], p=0.58; I2=79%). Sensitivity analysis confirmed OS findings. Egger’s test revealed no publication bias for OS (p=0.33) but suggested bias for luminal DFS (p=0.044). Conclusion: IHC subtype conversion after NAC occurs in 1 in 5 patients with residual disease and is associated with worse OS—particularly in luminal breast cancer. Routine post-NAC IHC reassessment should be considered to improve prognostication and guide adjuvant treatment. Prospective studies with standardized reporting are needed to validate these findings and refine treatment algorithms. Citation Format: M. Antonini, A. Mattar, F. P. Cavalcante, F. Zerwes, E. C. Millen, F. P. Brenelli, L. A. Frasson, L. X. Félix, J. C. Vieira, R. C. Campos, M. Teixeira, M. Figueiredo, M. Madeira, H. C. Lima, G. Facina, R. Arakelian, A. D. Lima, L. R. Soares, R. J. Freitas, G. N. Garcia, F. Bagnoli, G. T. Tosello, L. H. Gebrim. Immunohistochemical Subtype Conversion After Neoadjuvant Chemotherapy and Its Impact on Breast Cancer Survival: A Systematic Review and Meta-analysis [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PD2-01.

Artificial intelligence (AI) is a promising tool in the modernization of ophthalmic practice, particularly in ocular biometrics for cataract surgery. This review explores how AI can optimize the accuracy and personalization of human eye biometrics, which are crucial for diagnosis, surgical planning success, and the reduction of intra- and postoperative complications. The research was conducted through a systematic review using the PRISMA methodology across databases such as PubMed, Scopus, and Web of Science. Eight studies were included that met eligibility criteria, focusing on machine learning tools and other AI approaches. The results show that AI improves the prediction of biometric parameters, such as the power and position of intraocular lenses, in addition to identifying risk factors and optimizing resources, especially in contexts with limited infrastructure. AI-based models outperformed traditional methods, from advanced calculations to accessibility in remote regions. The review concludes that AI has transformative potential in ophthalmology, although challenges such as methodological validation, generalization, and ethical regulation remain. The study's implications include advancements in clinical practice and the need for public policies that promote the ethical and effective use of these technologies.

Evidence on antibiotic therapy for diabetic foot infections can help clinical management. The objective of this study was to identify the evidence on systemic antibiotics for treatment of diabetes mellitus-related foot infections. An integrative literature review was conducted of randomized clinical trials, systematic reviews, and meta-analyses. The keywords “Diabetic foot” AND “Antibiotics” were used to search PubMed and 15 articles were selected (nine randomized clinical trials, four systematic reviews, and two meta-analyses). Seven randomized clinical trials revealed clinical results that were comparable for beta lactam antibiotics with beta-lactamase inhibitors, carbapenems, and fluoroquinolones. Two randomized clinical trials found significant differences comparing ertapenem and tigecycline and in analyses of subsets with severe infections between piperacillin-tazobactam and ertapenem. The literature revealed comparable clinical results for different systemic antibiotics used to treat foot infections related to diabetes, except for the difference between ertapenem and tigecycline, which did not meet the parameters for non-inferiority, highlighting the need for higher-quality evidence.

Introdução: O envelhecimento populacional tem ampliado a prevalência de doenças crônicas e multimorbidades, incluindo a dor crônica, que acomete mais da metade dos idosos e impacta funcionalidade, autonomia e qualidade de vida. Alterações fisiológicas, maior sensibilização central e presença de comorbidades agravam esse quadro, exigindo abordagens de cuidado integradas e seguras. Nesse contexto, terapias não farmacológicas surgem como alternativas promissoras para manejo da dor em idosos, reduzindo riscos associados ao uso prolongado de analgésicos. Objetivo: Realizar uma revisão da literatura sobre terapias alternativas utilizadas no tratamento da dor crônica em idosos. Método: Revisão integrativa realizada na base PUBMED, utilizando a estratégia: (geriatr*[title] OR elderly[title]) AND chronic[title] AND pain[title], considerando artigos publicados nos últimos 10 anos. Foram incluídos estudos que abordavam exclusivamente intervenções não farmacológicas. Resultados: A busca inicial identificou 18 artigos. Após exclusão de estudos focados em terapias farmacológicas, 11 compuseram a amostra final. As intervenções avaliadas incluíram exercícios físicos, educação em saúde, ioga adaptada, estabilização muscular, realidade virtual, acupuntura, hipnose, ablação por radiofrequência e terapias complementares. A maioria dos estudos relatou redução da intensidade da dor, melhora funcional e impacto positivo na qualidade de vida. Técnicas como ablação por radiofrequência e acupuntura yin-yang apresentaram efeitos particularmente robustos, enquanto intervenções como estimulação vagal por vibrações abdominais mostraram eficácia limitada, embora seguras e bem toleradas. Conclusão: As terapias alternativas constituem estratégias eficazes e seguras para o manejo da dor crônica em idosos, oferecendo benefícios multidimensionais. A literatura reforça a necessidade de abordagens multimodais, individualizadas e integradas, além de pesquisas adicionais que aprimorem protocolos, identifiquem perfis de resposta e ampliem a aplicabilidade clínica dessas intervenções.

Patient: Female, 69-year-oldFinal Diagnosis: Lichen planusSymptoms: Dysphagia • ocular irritation • oral cavity erosive lesions • visual acuity loss • weight lossClinical Procedure: —Specialty: Dermatology • OphthalmologyObjective: Unusual clinical courseBackgroundLichen planus, a chronic autoimmune inflammatory disorder, primarily affects the skin and mucous membranes but may occasionally involve the ocular surface. Ocular manifestations are rare, often underrecognized, and potentially similar to other cicatrizing conjunctivitides. If left untreated, ocular lichen planus may lead to substantial morbidity and permanent visual impairment. Early identification and interdisciplinary management are essential to prevent irreversible damage and systemic complications. Awareness of this entity among ophthalmologists and dermatologists is crucial for timely diagnosis.Case ReportA 69-year-old woman developed chronic conjunctivitis and visual decline 3 months after bilateral uncomplicated cataract surgery. Ocular findings included conjunctival hyperemia, punctate keratitis, and meibomian gland dysfunction. Systemic evaluation revealed oral ulcers, violaceous skin plaques, onychodystrophy, and dysphagia. Oral biopsy confirmed lichenoid mucositis, and nail biopsy supported a diagnosis of systemic erosive lichen planus (ELP). Both direct and indirect immunofluorescence findings were negative; hepatitis C and autoimmune serologies were unremarkable. A multidisciplinary team established the diagnosis of ELP with ocular involvement. The patient received azathioprine (100 mg/day) and a short course of oral corticosteroids, which resulted in substantial improvement of ocular inflammation, mucocutaneous lesions, and visual acuity within 4 months. Sustained remission was evident after 1 year of follow-up.ConclusionsThis case underscores the importance of considering ELP in patients who present with chronic ocular surface inflammation and concomitant mucocutaneous lesions. Ophthalmologists play a key role in recognizing systemic inflammatory disorders and coordinating interdisciplinary care. Prompt diagnosis, long-term follow-up, and systemic immunosuppressive therapy are vital to prevent scarring and permanent sequelae.

BackgroundAnti‐amyloid therapy has emerged as a promising approach for Alzheimer’s disease (AD), aiming to reduce beta‐amyloid plaques, a hallmark of the disease. However, global access to these therapies remains uneven, raising concerns about equity and representation in real‐world clinical use.MethodWe analyzed real‐world data from the TriNetX platform, which included patient data globally. Patients receiving anti‐amyloid therapy (lecanemab, donanemab, or aducanumab) were retrieved from the dataset from March to April/2025. Demographic and geographic characteristics were evaluated by age, sex, race, ethnicity, and region. We also examined the clinical stage at treatment initiation to assess early versus late intervention. Descriptive analyses are shown in mean ± SD.ResultA total of 900 patients ranged from 39 to 90 years (73±8 years). Women comprised 55.11% of the cohort. The racial distribution showed 90.66% were White, while Black or African American (1.55%), Asian (2.00%), and other races (5.55%) were markedly underrepresented. Regarding ethnicity, 84.11% were non‐Hispanic, 3.56% Hispanic or Latino, and 12.33% unknown. Geographically, 885 patients (98.3%) were from the United States. Notably, 86.3% (777 patients) had a diagnosis of dementia syndrome at therapy initiation.ConclusionPatients receiving anti‐amyloid therapy are largely biased towards White race and non‐hispanic individuals. Individuals with dementia comprised the majority of individuals receiving anti‐amyloid therapy. These data reveal significant disparities in access to anti‐amyloid therapy. The low inclusion of Black and Hispanic populations compromises the generalizability of clinical outcomes and reflects broader systemic inequities. Initiating therapy predominantly at the dementia stage suggests missed opportunities for early diagnosis and may attenuate treatment benefits. Addressing these disparities through inclusive trial design, public health policy, and cost reduction is essential to ensure equitable access and maximize the impact of disease‐modifying therapies in AD.