Pesquisa | SciELO

ABSTRACT BACKGROUND: Brazil is facing increasing cycles of numbers of infected people and deaths resulting from coronavirus disease 2019 (COVID-19). This situation involves a series of factors, including the behavior of the population, that can be decisive for controlling the disease. OBJECTIVE: To determine the knowledge, attitudes and practices of the Brazilian population regarding COVID-19. DESIGN AND SETTING: Cross-sectional survey-type study, conducted using a population sample from different Brazilian states. METHODS: A quantitative, descriptive and analytical approach was used. Sampling was done according to convenience and via snowballing. The data collection instrument was a knowledge, attitudes and practices system. RESULTS: 1,655 people from all over Brazil participated in the survey; 80% were living in the southern region and 70.15% were female. More than 90% had knowledge and good attitudes relating to the means of transmission, preventive care and symptoms associated with COVID-19, although their knowledge and attitudes were not fully reflected in daily practices, for which there was lower adherence (80%). Greater knowledge was correlated with older participants, larger number of children, female sex and marital status; better attitude, with female sex and complete higher education; and better practices, with greater age, larger number of children and female sex. CONCLUSION: A large part of the population has general knowledge about COVID-19, but not all knowledge was applied in practice. Older people, females and university graduates stood out as the best informed and most committed to controlling the disease.

https://doi.org/10.1590/1516-3180.2021.0541.23072021

RESULTS OF SURGICAL TREATMENT OF COLORECTAL CANCER, ELECTIVE AND EMERGENCY, IN PATIENTS WITH COVID-19
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NAHAS, Sergio Carlos

; MEIRA JÚNIOR, José Donizeti de

; NAHAS, Caio Sergio Rizkallah

; SOBRADO, Lucas Faraco

; PINTO, Rodrigo Ambar

; ABDALA, Edson

; RIBEIRO JUNIOR, Ulysses

; CECCONELLO, Ivan

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2022, Volume 35 elocation e1644

Resumo: En | Texto: En | PDF: En

https://doi.org/10.1590/0102-672020210002e1644

Diretrizes brasileiras para o manejo de potenciais doadores de órgãos em morte encefálica. Uma força-tarefa composta por Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network e Coordenação Geral do Sistema Nacional de Transplantes
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Westphal, Glauco Adrieno

; Robinson, Caroline Cabral

; Cavalcanti, Alexandre Biasi

; Gonçalves, Anderson Ricardo Roman

; Guterres, Cátia Moreira

; Teixeira, Cassiano

; Stein, Cinara

; Franke, Cristiano Augusto

; Silva, Daiana Barbosa da

; Pontes, Daniela Ferreira Salomão

; Nunes, Diego Silva Leite

; Abdala, Edson

; Dal-Pizzol, Felipe

; Bozza, Fernando Augusto

; Machado, Flávia Ribeiro

; Andrade, Joel de

; Cruz, Luciane Nascimento

; Azevedo, Luciano César Pontes

; Machado, Miriam Cristine Vahl

; Rosa, Regis Goulart

; Manfro, Roberto Ceratti

; Nothen, Rosana Reis

; Lobo, Suzana Margareth

; Rech, Tatiana Helena

; Lisboa, Thiago Costa

; Colpani, Verônica

; Falavigna, Maicon

Revista Brasileira de Terapia Intensiva

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Jan 2021, Volume 33 Nº 1 Páginas 1 - 11

Resumo: Pt En | Texto: Pt En | PDF: Pt | PDF: En

RESUMO Objetivo: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. Métodos: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. Resultados: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. Conclusão: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Abstract Objective: To contribute to updating the recommendations for brain-dead potential organ donor management. Methods: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. Results: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak and 1 was considered a good clinical practice. Conclusion: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

https://doi.org/10.5935/0103-507x.20210001 742 downloads

The impact of hepatitis E infection on hepatic fibrosis in liver transplanted patients for hepatitis C infection
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de Moraes, Adriano Claudio Pereira

; Gouvea, Michele Gomes

; Ferreira, Ariana Carolina

; Pinho, João Renato Rebello

; de Mello, Evandro Sobroza

; D'Albuquerque, Luiz Augusto Carneiro

; Terrabuio, Debora

; Abdala, Edson

; Carrilho, Flair José

; Pessoa, Mário Guimarães

Brazilian Journal of Infectious Diseases

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2021, Volume 25 Nº 3 elocation 101587

Resumo: En | Texto: En | PDF: En

ABSTRACT Hepatitis E Virus (HEV) is an infection known worldwide for its asymptomatic and self-limited course in most cases. Some cases progressing to chronicity have been described in immunosuppressed patients, especially in recipients of solid organ transplants. We evaluated laboratory parameters of HEV infection (HEV RNA, anti-HEV IgM and anti-HEV IgG) through enzyme-linked immunosorbent assay (Elisa), confirmed by immunoblotting, in a cohort of 294 patients who received liver transplants at the HCFMUSP (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo). Laboratory and demographic data were collected from the entirety of the transplanted population. Hepatic biopsies of 122 patients transplanted due liver failure secondary to hepatitis C (HCV), with or without serological or molecular markers of HEV, were analyzed according to METAVIR score. Out of 24 (8.2%) patients tested positive for anti-HEV IgG, six (2%) were positive for anti-HEV IgM and 17 (5.8%) for HEV RNA. Of the patients transplanted because of HCV infection, 95 (77.8%) had received treatment including ribavirin for at least six months before blood sample collection. Among patients transplanted due to HCV cirrhosis who tested positive for anti-HEV IgG, only three (37.5%) showed fibrosis beyond stage 2, while five (41.7%) of the HEV RNA-positive patients had liver fibrosis beyond stage 2. Overall, the prevalence of HEV in the post-hepatic transplant scenario appears to be low, and, at least histologically, seemingly not harmful. We conclude that, although some studies reported a risk of HEV chronification, patients who had their livers transplanted due to HCV and showed serological or molecular markers of HEV did not have higher levels of fibrosis compared to patients who showed no indications of HEV infection at the time of the analysis.

https://doi.org/10.1016/j.bjid.2021.101587 35 downloads

Enabling liver transplantation during the COVID-19 era: More than screening donors and recipients for SARS-CoV-2
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Abdala, Edson

; Waisberg, Daniel Reis

; Haddad, Luciana Bertocco

; Ducatti, Liliana

; Rocha-Santos, Vinicius

; de Martino, Rodrigo Bronze

; Andraus, Wellington

; Carneiro-D’Albuquerque, Luiz Augusto

Clinics

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2020, Volume 75 elocation e2377

Resumo: En | Texto: En | PDF: En

https://doi.org/10.6061/clinics/2020/e2377 278 downloads

INTESTINAL PERFORATION CAUSED BY COVID-19
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NAHAS, Sergio Carlos

; MEIRA-JÚNIOR, José Donizeti de

; SOBRADO, Lucas Faraco

; SORBELLO, Maurício

; SEGATELLI, Vanderlei

; ABDALA, Edson

; RIBEIRO-JÚNIOR, Ulysses

; CECCONELLO, Ivan

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2020, Volume 33 Nº 2 elocation e1515

Resumo: Pt En | Texto: Pt En | PDF: Pt | PDF: En

https://doi.org/10.1590/0102-672020190001e1515 3078 downloads

Management of Hepatocellular Carcinoma during the COVID-19 Pandemic - São Paulo Clínicas Liver Cancer Group Multidisciplinary Consensus Statement
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Chagas, Aline Lopes

; da Fonseca, Leonardo Gomes

; Coelho, Fabricio Ferreira

; da Cunha Saud, Lisa Rodrigues

; Abdala, Edson

; Andraus, Wellington

; Fiore, Lucas

; Moreira, Airton Mota

; Menezes, Marcos Roberto

; Carnevale, Francisco César

; Tani, Claudia Megumi

; Alencar, Regiane S.S.M

; D'Albuquerque, Luiz Augusto Carneiro

; Herman, Paulo

; Carrilho, Flair José

Clinics

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2020, Volume 75 elocation e2192

Resumo: En | Texto: En | PDF: En

More than 18 million people in 188 countries have been diagnosed as having coronavirus disease (COVID-19), and COVID-19 has been responsible for more than 600,000 deaths worldwide. Brazil is now the second most affected country globally. Faced with this scenario, various public health measures and changes in the daily routines of hospitals were implemented to stop the pandemic. Patients with hepatocellular carcinoma (HCC) are at an increased risk for severe COVID-19 as they present with two major diseases: cancer and concomitant chronic liver disease. The COVID-19 pandemic can significantly impact the management of HCC patients from diagnosis to treatment strategies. These patients need special attention and assistance at this time, especially since treatment for tumors cannot be delayed in most cases. The aim of this guideline was to standardize the management of HCC patients during the COVID-19 pandemic. This document was developed, on the basis of the best evidence available, by a multidisciplinary team from Instituto do Câncer do Estado de São Paulo (ICESP), and Instituto Central of the Hospital das Clínicas da Universidade de São Paulo (HC-FMUSP), which are members of the São Paulo Clínicas Liver Cancer Group.

https://doi.org/10.6061/clinics/2020/e2192 361 downloads

How should health systems prepare for the evolving COVID-19 pandemic? Reflections from the perspective of a Tertiary Cancer Center
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Chen, Andre Tsin Chih

; Moniz, Camila Motta Venchiarutti

; Ribeiro-Júnior, Ulysses

; Diz, Maria Del Pilar Estevez

; Salvajoli, João Victor

; Da Conceição Vasconcelos, Karina Gondim Moutinho

; Auler-Júnior, José Otávio Costa

; Cecconello, Ivan

; Abdala, Edson

; Hoff, Paulo Marcelo Gehm

Clinics

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2020, Volume 75 elocation e1864

Resumo: En | Texto: En | PDF: En

https://doi.org/10.6061/clinics/2020/e1864 2142 downloads

Top 10 evidence-based recommendations from the Brazilian Society of Infectious Diseases for the Choosing Wisely Project
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Pasqualotto, Alessandro C.

; Almeida, Camila S.

; Kliemann, Dimas A.

; Barcellos, Guilherme B.

; Queiroz-Telles, Flávio

; Abdala, Edson

; Resende, Mariangela

; Batista, Filipe P.

; Vidal, José E.

; Rocha, Jaime

; Raboni, Sonia M.

; Cimerman, Sergio

; Gales, Ana C.

Brazilian Journal of Infectious Diseases

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Out 2019, Volume 23 Nº 5 Páginas 331 - 335

Resumo: En | Texto: En | PDF: En

ABSTRACT The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

https://doi.org/10.1016/j.bjid.2019.08.004 372 downloads

10.

Urinary infection or radiation cystitis? A prospective evaluation of urinary symptoms in patients submitted to pelvic radiotherapy
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Xavier, Vítor Fonseca

; Gabrielli, Flávia Carolina Grosso

; Ibrahim, Karim Yaqub

; Gomes, Mariana Vilela Soares

; Guimarães, Roger Guilherme Rodrigues

; Abdala, Edson

; Carvalho, Heloisa de Andrade

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2019, Volume 74 elocation e1388

Resumo: En | Texto: En | PDF: En

OBJECTIVES: The purpose of this study was to evaluate the incidence of urinary tract infection (UTI) in patients with cystitis symptoms who underwent pelvic radiation therapy and identify correlated predictive factors. METHODS: A prospective cohort study was conducted of patients who met the following: primary pelvic cancer treated with curative intent, older than 18 years old, and good performance status. The exclusion criteria were patients being treated for a UTI, using a urinary catheter, in dialysis or with cystostomy or nephrostomy, and using antibiotics during treatment. Urinalysis and urine culture were collected before the beginning of radiation therapy. Weekly evaluations of urinary symptoms were subsequently performed. In cases of new or worsening symptoms, a questionnaire was applied, and new urine exams were collected. The UTI diagnosis was defined by uroculture as bacterial growth greater than 104 CFU/mL. RESULTS: From September 2014 to November 2015, 112 patients were sequentially recruited, and 72 (64%) fulfilled the inclusion criteria. During follow-up, 24 (33%) patients had new urinary symptoms or worse preexisting symptoms. A UTI was confirmed in the second urinary culture in only one (1.4%) patient. CONCLUSIONS: The incidence of UTI was much lower than expected, suggesting that asymptomatic bacteriuria develops symptoms due to radiotherapy. Due to the low rate of UTI, no predictive factor was identified.

https://doi.org/10.6061/clinics/2019/1388 1240 downloads

11.

A Brazilian university hospital position regarding transplantation criteria for HIV-positive patients according to the current literature
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Pierrotti, Lígia Camera

; Litvinov, Nadia

; Costa, Silvia Figueiredo

; Azevedo, Luiz Sérgio Fonseca de

; Strabelli, Tânia Mara Varejão

; Campos, Silvia Vidal

; Odongo, Fatuma Catherine Atieno

; Reusing-Junior, Jose Otto

; Song, Alice Tung Wan

; Lopes, Max Igor Banks Ferreira

; Batista, Marjorie Vieira

; Lopes, Marta Heloisa

; Maluf, Natalya Zaidan

; Caiaffa-Filho, Hélio Helh

; de Oliveira, Maura Salarolli

; Sousa Marques, Heloisa Helena de

; Abdala, Edson

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2019, Volume 74 elocation e941

Resumo: En | Texto: En | PDF: En

Human immunodeficiency virus (HIV) infection was considered a contraindication for solid organ transplantation (SOT) in the past. However, HIV management has improved since highly active antiretroviral therapy (HAART) became available in 1996, and the long-term survival of patients living with HIV has led many transplant programs to reevaluate their policies regarding the exclusion of patients with HIV infection. Based on the available data in the medical literature and the cumulative experience of transplantation in HIV-positive patients at our hospital, the aim of the present article is to outline the criteria for transplantation in HIV-positive patients as recommended by the Immunocompromised Host Committee of the Hospital das Clínicas of the University of São Paulo.

https://doi.org/10.6061/clinics/2019/e941 688 downloads

12.

Screening of Strongyloides infection using an ELISA test in transplant candidates
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Toledo, Beatriz

; Corral, Marcelo A.

; Meisel, Dirce Mary C.L.

; Gottardi, Maiara

; Abdala, Edson

; Costa, Silvia F.

; Pierrotti, Lígia Camera

; Lescano, Susana A.Z.

; Gonçalves, Elenice M.N.

; Castilho, Vera L.P.

; Chieffi, Pedro P.

; Gryschek, Ronaldo C.B.

; Paula, Fabiana M.

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2019, Volume 74 elocation e698

Resumo: En | Texto: En | PDF: En

OBJECTIVES: Hyperinfection or disseminated strongyloidiasis has been frequently reported after transplants and is related to high mortality. This study aimed to screen for strongyloidiasis using serological diagnoses in transplant candidates. METHODS: An ELISA test was performed with filariform larvae of Strongyloides venezuelensis as a source of antigen. RESULTS: In the serum from transplant candidates, anti-Strongyloides IgG antibodies were detected in 35/150 (23.3%) samples by soluble fractions in phosphate buffered saline (PBS), 31/150 (20.7%) samples by soluble fractions in Tris-HCl, 27/150 (18.0%) samples by membrane fractions in PBS and 22/150 (14.7%) samples by membrane fractions in Tris-HCl. CONCLUSIONS: The present results suggest the ELISA test, ideally using soluble fractions of filariform larvae S. venezuelensis in PBS, as an additional strategy for the diagnosis of strongyloidiasis in transplant candidates.

https://doi.org/10.6061/clinics/2019/e698 1065 downloads

13.

Liver transplantation for acute liver failure due to antitubercular drugs – a single-center experience
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Martino, Rodrigo Bronze de

; Abdala, Edson

; Villegas, Felipe Castro

; D’Albuquerque, Luiz Augusto Carneiro

; Song, Alice Tung Wan

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2018, Volume 73 elocation e344

Resumo: En | Texto: En | PDF: En

OBJECTIVES: Patients receiving treatment for tuberculosis are at risk of developing acute liver failure due to the hepatotoxicity of antitubercular drugs. We aimed to describe our experience with liver transplantation from deceased donors in this situation. METHODS: We identified patients undergoing transplantation for acute liver failure due to antitubercular drugs in our prospectively maintained database. RESULTS: Of 81 patients undergoing transplantation for acute liver failure, 8 cases were attributed to antitubercular drugs during the period of 2006-2016. Regarding the time of tuberculosis treatment until the onset of jaundice, patients were on antitubercular drugs for a mean of 64.7 days (21-155 days). The model for end-stage liver disease (MELD) score of patients ranged from 32 to 47 (median 38), and seven patients underwent transplantation under vasopressors. The 1-year survival was 50%. Three patients died during the week following transplantation due to septic shock (including a patient with acute liver failure due to hepatic/disseminated tuberculosis), and the remaining patient died 2 months after transplantation due to pulmonary infection. There were 2 cases of mild rejection and 1 case of moderate rejection. Of the surviving patients, all were considered cured of tuberculosis after alternative drugs were given. CONCLUSION: Patients arrived very sick and displayed poor survival after deceased donor transplantation.

https://doi.org/10.6061/clinics/2018/e344 902 downloads

14.

Plasmid-mediated mcr-1 in carbapenem-susceptible Escherichia coli ST156 causing a blood infection: an unnoticeable spread of colistin resistance in Brazil?
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Rossi, Flavia

; Girardello, Raquel

; Morais, Carlos

; Cury, Ana Paula

; Martins, Layla Farage

; da Silva, Aline Maria

; Abdala, Edson

; Setubal, João Carlos

; da Silva Duarte, Alberto José

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Out 2017, Volume 72 Nº 10 Páginas 642 - 644

Resumo: En | Texto: En | PDF: En

OBJECTIVE: We describe an IncX4 pHC891/16mcr plasmid carrying mcr-1 in a colistin-resistant and carbapenem-susceptible E. coli isolate (HC891/16), ST156, which caused a blood infection in a Brazilian patient with gallbladder adenocarcinoma. METHODS: Strain HC891/16 was subjected to whole genome sequencing using the MiSeq Platform (Illumina, Inc., USA). Assembly was performed using Mira and ABACAS. RESULTS: The isolates showed resistance only to ciprofloxacin, ampicillin and cefoxitin, and whole-genome sequencing revealed the presence of aac(6’)Ib-cr and blaTEM1. CONCLUSION: Our findings warn of the possible silent dissemination of colistin resistance by carbapenem-susceptible mcr-1 producers, as colistin susceptibility is commonly tested only among carbapenem-resistant isolates.

https://doi.org/10.6061/clinics/2017(10)09 1031 downloads

15.

Acoustic radiation force impulse (ARFI) elastography compared with biopsy for evaluating hepatic fibrosis after liver transplantation: a cross-sectional diagnostic study
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Schmillevitch, Joel

; Chammas, Maria Cristina

; Pugliese, Vincenzo

; Abdala, Edson

; Rizzon, Adriana Cortez

; Alves, Venâncio

; Carneiro, Luiz Augusto

; Cerri, Giovanni

Sao Paulo Medical Journal

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Dez 2016, Volume 134 Nº 6 Páginas 513 - 518

Resumo: Pt En | Texto: Pt En | PDF: Pt | PDF: En

RESUMO CONTEXTO E OBJETIVO: Biópsias são utilizadas para avaliar fibrose após transplante de fígado. O estudo objetivou avaliar a elasticidade hepática após transplante por meio de um exame não invasivo, a elastografia ARFI (acoustic radiation force imaging ), correlacionando-a com a análise histológica. TIPO DE ESTUDO E LOCAL: Estudo transversal em hospital público universitário. MÉTODOS: Todos os pacientes consecutivamente operados entre 2002 e 2010, com indicação para biópsia, foram avaliados por elastografia. O radiologista avaliando ARFI e o patologista fazendo exames anatomopatológicos estavam cegos para as avaliações um do outro. RESULTADOS: No período do estudo, 33 pacientes foram incluídos. A indicação para o transplante foi cirrose por hepatite C em 21 (63%). As biópsias mostraram ausência de fibrose (F0) em 10 pacientes, F1 em 11, F2 em 8, F3 em 4 e nenhum caso de F4 (cirrose). A diferença nos valores de ARFI (grau de fibrose) foi de 0,26 (intervalo de confiança, IC, de 95%: 0,07-0,52) entre os grupos F0-F1 e F2-F4 (P = 0,04). A área sob a curva de 0,74 (IC: 0,55-0,94) e o valor de corte de 1,29 m/s entre os grupos resultaram na melhor relação entre sensibilidade e especificidade, de 0,57. A sensibilidade (0,66; IC: 0,50-0,83) foi menor que a especificidade (0,85; IC: 0,72-0,97). Não houve diferença significativa em ARFI entre pacientes com hepatite C e aqueles com outras doenças. CONCLUSÕES: Os valores obtidos com a elastografia não foram afetados por reação inflamatória ou alterações anatômicas. Foi identificado ponto de corte de 1,29 m/s que separa pacientes com ou sem fibrose significativa.

ABSTRACT CONTEXT AND OBJECTIVE: Biopsies are used after liver transplantation to evaluate fibrosis. This study aimed to evaluate the elasticity of transplanted livers by means of a non-invasive examination, acoustic radiation force imaging (ARFI) elastography, correlating the results with the histological analysis. DESIGN AND SETTING: Cross-sectional study in a public university hospital. METHODS: All patients consecutively operated between 2002 and 2010 with an indication for biopsy were evaluated by means of elastography. The radiologist evaluating ARFI and the pathologist doing anatomopathological examinations were blinded to each other's evaluations. RESULTS: During the study period, 33 patients were included. The indication for transplantation was cirrhosis due to hepatitis C in 21 cases (63%). Liver biopsies showed absence of fibrosis (F0) in 10 patients, F1 in 11, F2 in 8 and F3 in 4. There were no cases of F4 (cirrhosis). The difference in ARFI values (degree of fibrosis) was 0.26 (95% confidence interval, CI: 0.07-0.52) between the groups F0-F1 and F2-F4 (P = 0.04). An area under the curve of 0.74 (CI: 0.55-0.94) and a cutoff of 1.29 m/s between the groups resulted in the best relationship between sensitivity and specificity. Sensitivity (0.66; CI: 0.50-0.83) was lower than specificity (0.85; CI: 0.72-0.97). There was no significant difference in ARFI between patients with hepatitis C and those with other diseases. CONCLUSIONS: The values obtained from elastography were not affected by inflammatory reaction or anatomical alterations. A cutoff point of 1.29 m/s separating patients with or without significant fibrosis was identified.

https://doi.org/10.1590/1516-3180.2016.0158170816 3187 downloads

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