■ RESUMO Introdução: Análise histológica é a principal ferramenta de avaliação de biopróteses acelulares, em sua maioria em caráter experimental. O objetivo é analisar histologicamente a matriz acelular de pericárdio bovino em reparações de parede abdominal implantada em humanos. Método: De uma série de 30 reparações com a membrana, 3 pacientes foram submetidas a revisão cirúrgica não relacionada aos implantes, aos 13, 22 e 23 meses de pós-operatório, obtendo-se biópsias das áreas previamente implantadas. Além da avaliação dos aspectos básicos de biocompatibilidade e neoformação tecidual, as lâminas foram digitalizadas e submetidas a análise computadorizada com o software ImageJ para quantificação da cinética de degradação das membranas, associada à análise da dimensão fractal das amostras. Os valores obtidos para porcentagens de membrana residual tiveram suas médias comparadas por análise de variância (ANOVA) e pelo teste T de Student não pareado, também utilizado para os valores da quantificação da dimensão fractal. Resultados: Foi demonstrada a biocompatibilidade do material, com neoformação tecidual, deposição de colágeno e tecido celularizado de aspecto normal, sem reações locais importantes. Fragmentos residuais da membrana foram quantificados em 40%±7% aos 13 meses, em 20%±6% aos 22 meses e em 17%±6% aos 23 meses de pós-operatório, com a análise da dimensão fractal indicando uma progressiva degradação dos implantes, com significância estatística entre 13 meses e as amostras tardias. Conclusão: Os resultados atestaram a funcionalidade do pericárdio bovino acelular sob diferentes níveis de estresse mecânico nas reparações da parede abdominal em humanos. Introdução acelulares experimental humanos Método implantes 2 pósoperatório, pósoperatório pós operatório, operatório pós-operatório obtendose obtendo se implantadas tecidual membranas ANOVA (ANOVA pareado Resultados material normal importantes 407 40 7 40%±7 1 206 20 6 20%±6 176 17 17%±6 tardias Conclusão 4 40%± 20%± 17%± 40% 20% 17%

■ ABSTRACT Introduction: Histological analysis is the main tool for evaluating acellular bioprostheses, mostly on an experimental basis. The objective is to histologically analyze the acellular matrix of bovine pericardium in abdominal wall repairs implanted in humans. Method: From a series of 30 repairs with the membrane, 3 patients underwent surgical revision unrelated to the implants at 13, 22, and 23 months postoperatively, obtaining biopsies of the previously implanted areas. In addition to evaluating the basic aspects of biocompatibility and tissue neoformation, the slides were digitalized and subjected to computerized analysis with the ImageJ software to quantify the kinetics of membrane degradation associated with the analysis of the fractal dimension of the samples. The values obtained for percentages of residual membrane had their means compared by analysis of variance (ANOVA) and the unpaired Student’s T test, also used for the fractal dimension quantification values. Results: The biocompatibility of the material was demonstrated, with tissue neoformation, collagen deposition, and cellularized tissue with a normal appearance without important local reactions. Residual fragments of the membrane were quantified at 40%±7% at 13 months, at 20%±6% at 22 months, and at 17%±6% at 23 months postoperatively, with the analysis of the fractal dimension indicating a progressive degradation of implants, with statistical significance between 13 months and late samples. Conclusion: The results confirmed the functionality of the acellular bovine pericardium under different levels of mechanical stress in abdominal wall repairs in humans. Introduction bioprostheses basis humans Method 2 postoperatively areas neoformation samples ANOVA (ANOVA Students Student s test Results demonstrated deposition reactions 407 40 7 40%±7 1 206 20 6 20%±6 176 17 17%±6 Conclusion 4 40%± 20%± 17%± 40% 20% 17%

RESUMO Contexto: Doenças hepáticas frequentemente cursam com encefalopatia hepática (EH), cuja fisiopatologia pode envolver aumento da pressão intracraniana (PIC). Ferramentas de monitorização da PIC e da sua morfologia de pulso podem ser úteis para avaliação da EH. A utilização de um procedimento não invasivo e sensível seria extremamente útil na condução desses casos. Objetivo: Avaliar a factibilidade e o desempenho de um método inédito e não invasivo de monitorização da PIC, como alternativa aos métodos invasivos, e correlacionar o diagnóstico clínico de EH aos achados morfológicos da PIC. Métodos: Trata-se de um estudo analítico transversal, conduzido em um hospital terciário e pioneiro na aplicação do equipamento BWS da brain4care®. A morfologia de pulso da PIC é paralela à arterial, onde existem três picos frequentes: pico de percussão (P1), pelo plasma extravasado pelo plexo coroide; onda de maré (P2), pelo grau de complacência intracraniana à reflexão de P1, e incisura dicrótica (P3), pelo fechamento da valva aórtica. A normalidade aponta P1>P2>P3. Esses picos determinam a complacência intracraniana através de sua relação com o volume sanguíneo cerebral, onde a relação de alturas P2/P1 >1 sugere uma morfologia patológica, com aumento sustentado da PIC e diminuição da complacência. Outra forma de avaliar isso seria por uma alteração no tempo até o pico (Time-to-Peak, TTP). Esses dados foram comparados entre pacientes sem e com quadro clínico indicativo de EH. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da Instituição pelo parecer número 5.493.775. Resultados: Foram avaliados 40 hepatopatas, dos quais, no momento da coleta, 20 não apresentavam quadro clínico de EH (59.5±9.3 anos; 70.0% masculinos) e 20 possuíam quadro clínico de EH (59.6±11.9 anos; 65.0% masculinos). Os grupos são demográfica, clínica e laboratorialmente semelhantes; e foram identificadas diferenças estatisticamente significantes nos padrões morfológicos da PIC entre os grupos avaliados, bem como tendências nos parâmetros. A diferença na relação P2/P1 não se mostrou significante (Mann Whitney: P bicaudal = 0.2978); porém TTP mostrou-se como um parâmetro com diferença estatisticamente significante entre os grupos (Mann Whitney: P bicaudal = 0.0282; diferença mediana = 0,04). A análise pela estatística C, por meio da curva ROC sugeriu como pontos de corte ótimos um P2/P1=1.31 (AUROC: 0.5975) e TTP = 0.22 (AUROC: 0.7013), onde a presença de EH em hepatopatas estaria associada à obtenção de parâmetros abaixo desses limiares. Conclusão: A utilização do sistema BWS da brain4care® mostrou-se factível para utilização em pacientes hepatopatas sem ou com quadro clínico de EH e foi capaz de diferenciá-los. As explicações fisiopatológicas, porém, necessitam ainda de maior casuística, face ao baixo poder amostral constatado, melhor entendimento do quadro hidrodinâmico intracerebral na encefalopatia hepática, heterogeneidade clínica e necessidade de seguimento em mais longo prazo, para conclusões definitivas. Contexto EH, , (EH) . (PIC) casos Objetivo invasivos Métodos Tratase Trata transversal brain4care braincare brain care arterial frequentes P1 (P1) coroide P2, P2 (P2) P3, P3 (P3) aórtica P1P2P3 PPP P1>P2>P3 cerebral P2P1 PP P2/P 1 > patológica TimetoPeak, TimetoPeak Time to Peak, Peak (Time-to-Peak TTP. TTP) 5493775 5 493 775 5.493.775 Resultados 4 quais coleta 2 59.5±9.3 59593 59 9 3 (59.5±9. anos 700 70 0 70.0 masculinos 59.6±11.9 596119 6 11 (59.6±11. 650 65 65.0 masculinos. demográfica semelhantes Mann Whitney 0.2978 02978 2978 0.2978) mostrouse 0.0282 00282 0282 0,04. 004 0,04 04 0,04) C P2P1131 31 P2/P1=1.3 AUROC (AUROC 0.5975 05975 5975 022 22 0.2 0.7013, 07013 0.7013 7013 0.7013) limiares Conclusão diferenciálos. diferenciálos diferenciá los. los diferenciá-los fisiopatológicas casuística constatado prazo definitivas (EH (PIC (P1 (P2 (P3 P1P2P P1>P2>P P2P 549377 49 77 5.493.77 59.5±9. 5959 (59.5±9 7 70. 59.6±11. 59611 (59.6±11 65. 0.297 0297 297 0.028 0028 028 00 0,0 P2P113 P2/P1=1. 0.597 0597 597 02 0. 0701 0.701 701 (P 54937 5.493.7 59.5±9 595 (59.5± 59.6±11 5961 (59.6±1 0.29 029 29 0.02 002 0, P2P11 P2/P1=1 0.59 059 070 0.70 5493 5.493. 59.5± (59.5 59.6±1 596 (59.6± 0.0 P2/P1= 0.5 05 07 0.7 549 5.493 59.5 (59. 59.6± (59.6 54 5.49 59. (59 59.6 5.4 (5 5. (

ABSTRACT Background: Liver diseases often occur with hepatic encephalopathy (HE), whose pathophysiology may involve increased intracranial pressure (ICP). Tools for monitoring ICP and its pulse morphology can be useful for assessing HE. The use of a non-invasive and sensitive procedure would be extremely useful in managing these cases. Objective: To evaluate the feasibility and performance of a new, non-invasive method of monitoring ICP, as an alternative to invasive methods, and to correlate the clinical diagnosis of HE with the morphological findings of ICP. Methods: This is a cross-sectional analytical study, conducted in a tertiary hospital and pioneer in the application of Brain4Care® BWS equipment. The ICP pulse morphology is parallel to the arterial one, where there are three frequent peaks: percussion peak (P1), due to plasma extravasated by the choroid plexus; tidal wave (P2), due to the degree of intracranial compliance to the reflection of P1, and dicrotic notch (P3), due to the closure of the aortic valve. Normality indicates P1>P2>P3. These peaks determine intracranial compliance through their relationship with cerebral blood volume, where P2/P1 ratio >1 suggests a pathological morphology, with a sustained increase in ICP and decreased compliance. Another way to evaluate this would be by a change in the time-to-peak (TTP). These data were compared between patients with and without clinical signs indicative of HE. The study was approved by the Institution’s Research Ethics Committee (number 5.493.775). Results: A total of 40 liver disease patients were evaluated, of which, at the time of collection, 20 did not have a clinical picture of HE (59.5±9.3 years; 70.0% male) and 20 had a clinical picture of HE (59.6±11.9 years; 65.0% male). The groups are demographically, clinically and laboratory similar; and statistically significant differences were identified in the morphological patterns of ICP between the groups evaluated, as well as trends in the parameters. The difference in the P2/P1 ratio was not significant (Mann Whitney: two-tailed P=0.2978); however, TTP proved to be a parameter with a statistically significant difference between the groups (Mann Whitney: two-tailed P=0.0282; median difference = 0.04). Analysis using the C statistic, using the ROC curve, suggested P2/P1=1.31 (AUROC: 0.5975) and TTP=0.22 (AUROC: 0.7013) as optimal cutoff points, where the presence of HE in liver disease patients would be associated with obtaining parameters below these thresholds. Conclusion: The brain4care® BWS system proved to be feasible for use in liver disease patients with or without clinical signs of hepatic encephalopathy and was able to differentiate them. Pathophysiological explanations, however, still require better causality explanation and understanding of the intracerebral hydrodynamic picture in hepatic encephalopathy. Given the low sample power found, new studies need better clinical heterogeneity and longer-term follow-up for definitive conclusions. Background HE, , (HE) . (ICP) noninvasive non cases Objective methods Methods crosssectional cross sectional Brain4Care BrainCare Brain Care equipment one P1 P (P1) plexus P2, P2 (P2) P3, P3 (P3) valve P1P2P3 PPP P1>P2>P3 volume P2P1 PP P2/P 1 > timetopeak TTP. (TTP) Institutions Institution s number 5.493.775. 5493775 5.493.775 5 493 775 5.493.775) Results 4 evaluated which collection 2 59.5±9.3 59593 59 9 3 (59.5±9. years 700 70 0 70.0 male 59.6±11.9 596119 6 11 (59.6±11. 650 65 65.0 male. demographically similar Mann Whitney twotailed two tailed P=0.2978 P02978 2978 P=0.2978) however P=0.0282 P00282 0282 0.04. 004 0.04 04 0.04) statistic curve P2P1131 31 P2/P1=1.3 AUROC (AUROC 0.5975 05975 5975 TTP022 22 TTP=0.2 0.7013 07013 7013 points thresholds Conclusion brain4care braincare brain care them explanations found longerterm longer term followup follow up conclusions (HE (ICP (P1 (P2 (P3 P1P2P P1>P2>P P2P (TTP 549377 5.493.77 49 77 59.5±9. 5959 (59.5±9 7 70. 59.6±11. 59611 (59.6±11 65. P=0.297 P0297 297 P=0.028 P0028 028 00 0.0 P2P113 P2/P1=1. 0.597 0597 597 TTP02 TTP=0. 0.701 0701 701 (P 54937 5.493.7 59.5±9 595 (59.5± 59.6±11 5961 (59.6±1 P=0.29 P029 29 P=0.02 P002 02 0. P2P11 P2/P1=1 0.59 059 TTP0 TTP=0 0.70 070 5493 5.493. 59.5± (59.5 59.6±1 596 (59.6± P=0.2 P02 P=0.0 P00 P2/P1= 0.5 05 TTP= 0.7 07 549 5.493 59.5 (59. 59.6± (59.6 P=0. P0 54 5.49 59. (59 59.6 P=0 5.4 (5 P= 5. (

ABSTRACT Introduction: Since the reduction of healthcare-associated infections has been a focus for quality patient care, this study aimed to evaluate the surgical site infection rate of children who underwent cardiovascular surgery after implementation of ozonized water system for hand and body hygiene allied to previously implemented preventive measures. Methods: Two uniformly comparable groups of pediatric patients underwent cardiovascular surgery. Group A (187) patients were operated prior to installation of ozonized water system (March 1 to August 31, 2019), and group B (214) patients were operated after installation of ozonized water system (October 1, 2019, to March 31, 2020). Ozonized water was used for professional hand hygiene and patient body hygiene. Results: There was statistical significance for surgical site infection reduction in group B (P=0.0289), with a relative risk of 0.560 (95% confidence interval = 0.298 to 0.920), inferring the risk of being diagnosed with surgical site infections in group B was 44% less than in group A. There was no statistical significance regarding mechanical ventilation time (P=0.1998) or mortality (P=0.4457). Conclusion: Ozonized water for professional hand hygiene and patient body hygiene was an adjuvant combined with traditional preventive methods to reduce the risk of surgical site infection, although no impact on hospital stay or mortality was observed. Introduction healthcareassociated healthcare associated care measures Methods 187 (187 31 2019 , 2019) 214 (214 October 2020. 2020 . 2020) Results P=0.0289, P00289 P P=0.0289 0 0289 (P=0.0289) 0560 560 0.56 95% 95 (95 0298 298 0.29 0.920, 0920 0.920 920 0.920) 44 P=0.1998 P01998 1998 (P=0.1998 P=0.4457. P04457 P=0.4457 4457 (P=0.4457) Conclusion observed 18 (18 3 201 21 (21 202 P0028 P=0.028 028 (P=0.0289 056 56 0.5 9 (9 029 29 0.2 092 0.92 92 4 P=0.199 P0199 199 (P=0.199 P0445 P=0.445 445 (P=0.4457 (1 20 2 (2 P002 P=0.02 02 (P=0.028 05 5 0. ( 09 0.9 P=0.19 P019 19 (P=0.19 P044 P=0.44 (P=0.445 P00 P=0.0 (P=0.02 P=0.1 P01 (P=0.1 P04 P=0.4 (P=0.44 P0 P=0. (P=0.0 (P=0. (P=0.4 P=0 (P=0 P= (P= (P

ABSTRACT Introduction: Pediatric heart transplantation is the definitive therapy for children with end-stage heart failure. This paper describes our initial experience in pediatric heart transplantation in a tertiary center in Brazil Methods: This is a historical prospective descriptive cohort study based on a review of the medical records of children undergoing heart transplantation at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto. Variables were displayed as frequency, mean, or median. Statistical analysis and Kaplan-Meier actuarial curve were obtained with the aid of Microsoft® Excel® 2019 and STATSDirect version 3.3.5. Results: Between January 2010 and December 2020, ten children underwent bicaval orthotopic heart transplantation, 30% of which were under one year of age. Nine patients had end-stage heart failure (International Society for Heart and Lung Transplantation-Heart Failure D) and 50% of the recipients were transplanted under conditions of progressive clinical deterioration (Interagency Registry for Mechanically Assisted Circulatory Support ≤ 2). Forty percent of the recipients had a panel-reactive antibody > 20% on virtual crossmatch. In the postoperative period, 80% of patients required high dose of inotropic support (vasoactive-inotropic score > 10) for > 48 hours. The death-free survival rate at 131 months was 77.1±14.4%. Most patients (88.9%) in late follow-up had an episode of active cytomegalovirus infection. Cellular rejection, with or without clinical repercussion, was present in 44.4% of the patients. Conclusion: Pediatric heart transplantation produces acceptable and feasible outcomes as definitive therapy for children with end-stage heart failure.

RESUMO Objetivo: verificar associação do ângulo de fase com estado nutricional, tempo de internação e óbito de pacientes críticos. Métodos: estudo longitudinal com 57 pacientes críticos avaliados na admissão em unidade de terapia intensiva durante o ano de 2019, no interior de São Paulo - BR. O ângulo de fase foi obtido por bioimpedância elétrica, e a avaliação nutricional, pelo instrumento de avaliação subjetiva global e antropometria. Os dados foram associados ao tempo de internação e óbito. Para a análise, utilizaram-se testes de Mann-Whitney e Qui-quadrado de Pearson. Resultados: na avaliação subjetiva global, 59,6% dos pacientes apresentavam risco nutricional, e em 91,2% o ângulo de fase estava baixo. A desnutrição foi associada ao maior tempo de internação hospitalar (p=0,001) em unidade de terapia intensiva (p =0,023). Verificou-se tendência ao óbito no grupo com risco nutricional (p=0,054). Conclusão: o ângulo de fase pode contribuir para melhor acurácia da avaliação nutricional, principalmente, quando combinado com outros métodos de avaliação.

ABSTRACT Objective: to verify the association of phase angle with nutritional status, length of hospitalization and death in critically ill patients. Methods: longitudinal study with 57 critically ill patients evaluated upon admission to an intensive care unit during the year 2019, in the countryside of São Paulo - BR. The phase angle was obtained by electrical bioimpedance, and nutritional assessment, by the global subjective assessment instrument and anthropometry. The data were associated with the time of hospitalization and death. For the analysis, Mann-Whitney and Pearson’s chi-square tests were used. Results: in the global subjective evaluation, 59.6% of the patients presented nutritional risk, and in 91.2% the phase angle was low. Malnutrition was associated with longer hospital stay (p=0.001) in intensive care unit (p=0.023). There was a tendency to death in the group with nutritional risk (p=0.054). Conclusion: The phase angle can contribute to a better accuracy in nutritional assessment, especially when combined with other assessment methods.

RESUMEN Objetivo: Verificar la asociación del ángulo de fase con el estado nutricional, la duración de la estancia hospitalaria y la muerte en pacientes críticos. Métodos: estudio longitudinal con 57 pacientes críticos evaluados al ingreso en la unidad de cuidados intensivos durante el año 2019, en el interior de São Paulo - BR. El ángulo de fase se obtuvo mediante bioimpedancia eléctrica, y la valoración nutricional, mediante el instrumento de valoración subjetiva global y la antropometría. Los datos se asociaron al momento de la hospitalización y a la muerte. Para el análisis se utilizaron las pruebas de Mann-Whitney y Chi-cuadrado de Pearson. Resultados: en la evaluación subjetiva global, el 59,6% de los pacientes presentó riesgo nutricional, y en el 91,2% el ángulo de fase fue bajo. La desnutrición se asoció a una mayor estancia hospitalaria (p=0,001) en la unidad de cuidados intensivos (p=0,023). Hubo una tendencia a la muerte en el grupo con riesgo nutricional (p=0,054). Conclusión: el ángulo de fase puede contribuir a una mayor precisión en la evaluación nutricional, especialmente cuando se combina con otros métodos de evaluación.

Resumo Fundamento: Gráficos de recorrência (GR) permitem uma análise não linear da variabilidade de frequência cardíaca (VFC) e fornecem informações sobre o sistema nervoso autônomo (SNA). Objetivos: Avaliar se a mobilização precoce em pacientes submetidos a angioplastia coronária transluminal percutânea (ACTP) influencia os componentes quantitativos e qualitativos dos GR. Métodos: Um total de 32 participantes que foram submetidos a ACTP foram divididos entre um grupo de controle (GC - sem exercícios físicos) e grupo de mobilização precoce (GMP - com exercícios físicos) A frequência cardíaca batimento a batimento foi registrada utilizando um cardiofrequencímetro em ambos os grupos na admissão e na alta. Os índices lineares nos domínios de tempo e frequência foram analisados, bem como os índices não lineares obtidos pelos GR. O protocolo fisioterapêutico de mobilização precoce começou 12-18 horas após a ACTP. Um teste T não pareado bicaudal foi utilizado para as comparações, e p-valores <0,05 foram aceitos como significativos. Resultados: Ao comparar os dois grupos, na alta, o GMP apresentou um aumento no SDNN (23,55 ± 12,05 a 37,29 ± 16,25; p=0,042), índice triangular (8,99 ± 3,03 a 9,66 ± 3,07; p=0,014) e VLF (694,20 ± 468,20 a 848,37 ± 526,51; p=0,004), mas não apresentou alterações significativas na avaliação não linear. Além disso, na análise qualitativa dos GR, observou-se um padrão mais difuso e menos geométrico no GMP, indicando maior variabilidade, enquanto no GC, notou-se um padrão geométrico mais alterado. Conclusão: O protocolo de mobilização precoce promove uma melhoria no comportamento autonômico, conforme avaliado por VFC e GR, e pode ser considerado um procedimento útil para a melhor recuperação de pacientes submetidos a ACTP.

Abstract Background: Recurrence Plots (RP) enable a nonlinear analysis of Heart Rate Variability (HRV) and provide information on the Autonomic Nervous System (ANS). Objectives: To evaluate whether early ambulation in patients undergoing Percutaneous Transluminal Coronary Angioplasty (PTCA) influences the quantitative and qualitative components of RP. Methods: A total of 32 participants who underwent PTCA were divided into a Control Group (CG - no physical exercises) and an Early Ambulation Group (EAG – with physical exercises). Beat-to-beat heart rate was recorded using a heart rate monitor in both groups upon admission and discharge. The linear indices in the time and frequency domains were analyzed, and nonlinear indices were obtained through RP. The Early Ambulation Physical Therapy Protocol began 12-18 hours after PTCA. A two-tailed unpaired t-test was used for comparisons, and p-values < 0.05 were accepted as significant. Results: When comparing both groups, upon discharge, EAG showed an increase in SDNN (23.55 ± 12.05 to 37.29 ± 16.25; p=0.042), Triangular Index (8.99 ± 3.03 to 9.66 ± 3.07; p=0.014), and VLF (694.20 ± 468.20 to 848.37 ± 526.51; p=0.004), but without significant changes in the nonlinear evaluation. In addition, in the qualitative analysis of RP, a more diffuse and less geometric pattern was observed in EAG, indicating greater variability, while in CG, an altered and more geometric pattern was noted. Conclusion: The Early Ambulation Protocol promotes an improvement in autonomic behavior as evaluated by HRV and by RP, which can thus be considered a useful procedure for better recovery of patients undergoing PTCA.

Abstract Aim: To analyze whether the proposed physiotherapy protocol during hemodialysis (HD) increases knee extensor muscle strength, palmar grip strength, respiratory muscle strength, lung function, and functional capacity of individuals with Chronic Renal Insufficiency (CRI) on HD. Methods: A preliminary results study, in which physical therapy intervention was performed in 11 subjects (49.2 ± 8.6 years) with CRI on HD treatment. Initially, Heart Rate Variability (HRV) was collected, with the individual at rest, for 15 minutes, and later, HRV linear and non-linear analyses were performed using HRV Kubios Premium Software. The protocol was performed in the first two hours of the HD session, three times a week for eight weeks, consisting of respiratory exercises, aerobic exercises, and electrical stimulation associated with progressive resistive exercises. The variables evaluated were respiratory muscle strength, knee extensor muscle strength, palmar grip strength, lung function, and functional capacity. Student's t-tests for paired samples and Wilcoxon's tests for non-parametric samples were used considering a significance level of 5%. Results: There was a significant increase in expiratory muscle strength (p = 0,012; Cohen’s d = 0,59), knee extensor muscle strength (p = 0,025; Cohen’s d = 0,77), palmar grip strength (P = 0,001; Cohen’s d = 0,52) and functional capacity (P = 0,009; Cohen’s d = 0,83). Conclusion: The proposed protocol is effective in increasing knee extensor muscle strength, palmar grip strength, expiratory muscle strength, and functional capacity of individuals with CRI on HD.

Abstract Objective: To characterize the behavior of cardiac autonomic modulation in individuals with different times after orthotopic heart transplantation (HTx) using symbolic dynamics analysis. Methods: Sixty patients were evaluated after HTx. We recorded their instantaneous R-R intervals (RRi) by cardiac monitor Polar® RS800CX™ (Polar Electro Oy, Kempele, Finland) for 10 minutes. The same sequence of RRi with 256 consecutive beats was used to perform spectral analysis and symbolic dynamics analysis. We used hierarchical clustering to form groups. One-way analysis of variance (ANOVA) (with Holm-Sidak method) or one-way Kruskal-Wallis test (with Dunn´s post-hoc test) was used to analyze the difference between groups. Linear correlation analysis between variables was performed using Pearson’s or Spearman’s tests. P-value < 0.05 was considered statistically significant. Results: The 0V% index increased, the 2UV% index and the normalized complexity index decreased with an increase of HTx postoperative time. There were a negative correlation between complexity indexes and 0V% and a positive correlation between complexity indexes and 2UV%. Conclusion: Symbolic dynamics indexes were able to show a specific cardiac autonomic modulation pattern for HTx recipients with different postoperative times.

Abstract Introduction: Renal function is an independent risk factor for mortality among on-pump coronary bypass grafting (ONCABG) patients. This association is well known in the international literature, but there is a lack of knowledge of how admission creatinine (AC) levels modulate each cardiovascular risk factor. Objective: The aim of this paper was to assess the effect of different AC levels on mortality among ONCABG patients. Methods: 1,599 patients who underwent ONCABG between December 1999 and February 2006 at Hospital de Base in São José do Rio Preto/SP-Brazil were included. They were divided into quartiles according to their AC levels (QI: 0.2 ≤AC < 1.0 mg/dL; QII: 1.0 ≤ AC < 1.2 mg/dL; QIII: 1.2 ≤ AC < 1.4 mg/dL; and QIV: 1.4 ≤ AC ≤ 2.6 mg/dL). Seven risk factors were then evaluated in each stratum. Results: Mortality was higher in the QIV group than QI or QII groups. Factors such as age (≥ 65 years) and cardiopulmonary bypass (CPB) time (≥ 115 minutes) in QIV, as well preoperative hospital stay (≥ 5 days) in QIII, were associated with higher mortality rates. Creatinine variation greater than or equal to 0.4 mg/dL increased mortality rates in all groups. The use of intra-aortic balloon pump and dialysis increased mortality rates in all groups except for QII. Type I neurological dysfunction increased the mortality rate in the QII and III groups. Conclusion: Creatinine levels play an important role in ONCABG mortality. The combination of selected risk factors and higher AC values leads to a worse prognosis. On the other hand, lower AC values were associated with a protective effect, even among elderly patients and those with a high CPB time.

Abstract Background: It is known that predisposing factors for periodontal disease (PD) and cardiovascular diseases are similar, just as dissemination of oral flora pathogens can induce the development of cardiovascular diseases, which play a direct role on the morbimortality of patients. Objective: To assess the impact of periodontal disease in the presence of acute coronary syndrome on late morbimortality after long-term follow-up of patients (10 years). Methods: The historical prospective study of continuous assessment was based on the evaluation of 345 medical records of patients hospitalized for acute coronary syndrome, divided into 3 groups: edentulous, with periodontal disease and without periodontal disease. The patients studied were in the ICU, in 2006, with a clinical picture of acute coronary syndrome submitted to invasive stratification with coronary angiography on the basis of clinical indication and were reassessed over the next 10 years. The qualitative variables were compared using the Chi-square test. Long-term mortality was assessed using the Kaplan-Meier curves, quantified with the hazard ratio (HR) and a confidence interval of 95% and compared through Cox regression. P values of less than or equal to 0.05 were regarded as statistically significant. Results: Of the 345 patients, 233 had at least one coronary obstruction greater than or equal to 50%, being the main group for comparison according to the different status of periodontal disease (without periodontal disease, with periodontal disease and edentulous). In this cardiovascular condition, we found a difference in mortality among edentulous patients compared to those free of periodontal disease, with a p = 0.004 and a hazard ratio of 10.496 (95% CI: 4.988-22.089). A significant difference was also noted between edentulous patients and patients with periodontal disease, with a p = 0.0017 and a hazard ratio of 2.512 (95% CI: 1.491-4.234). Conclusion: A significant increase in mortality was found according with the progression of periodontal disease, which justifies its classification as an important risk factor for the development of cardiovascular diseases, as well as the need for prevention and treatment of oral diseases.

Abstract Objective: To analyze data related to surgical treatment in patients with congenital heart defects (CHD) and Down syndrome (DS) based on information from International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). Methods: Between July 1, 2010 and December 31, 2017, 139 patients with CHD and DS underwent surgery at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME)/Faculdade de Medicina de São José do Rio Preto - SP (FAMERP). A quantitative, observational and cross-sectional study was performed in which the pre, intra and postoperative data were analyzed in an IQIC database. The data included gender, age, prematurity, weight, preoperative procedures, diagnosis, associated cardiac and non-cardiac anomalies, Risk Adjustment for Congenital Heart Surgery (RACHS-1), type of surgery, cardiopulmonary bypass (CPB), perfusion time, aortic clamping time and CPB temperature, bacterial sepsis, surgical site infection and other infections, length of stay in intensive care unit (ICU), length of hospital stay and in-hospital mortality. Results: The most prevalent procedures were complete atrioventricular septal defect repair (58 - 39.45%), followed by closure of ventricular septal defect (36 - 24.49%). The RACHS-1 categories 1, 2, 3 and 4 were distributed as 22 (15%); 49 (33.3%); 72 (49%) and 4 (2.7%), respectively. There were no procedures classified as categories 5 or 6. Bacterial sepsis occurred in 10.2% of cases, surgical site infection in 6.1%, other infections in 14.3%. The median length of ICU stay was 5 days and the median length of hospital stay was 11 days. In-hospital mortality was 6.8%. Conclusion: Surgical treatment in patients with CHD and DS usually does not require highly complex surgical procedures, but are affected by infectious complications, resulting in a longer ICU and hospital length of stay with considerable mortality.

RESUMO CONTEXTO: A desnutrição é uma condição frequente entre pacientes hospitalizados e é um fator de risco para complicações pós-operatórias. OBJETIVO: Este estudo tem como objetivo avaliar o impacto da desnutrição sobre o ângulo de fase (AF), a distribuição de água corporal e complicações clínicas em pacientes cirúrgicos com doença colorretal. MÉTODOS: Trata-se de um estudo retrospectivo realizado em um hospital universitário terciário com 40 pacientes admitidos eletivamente. Na avaliação pré-operatória, foram realizadas a avaliação subjetiva global e análise de bioimpedância elétrica com a finalidade de determinarem o estado nutricional, AF, água extracelular (AEC), água intracelular (AIC) e água corporal total (ACT). Na avaliação pós-operatória, o tempo de internação hospitalar e a presença de complicações graves, segundo a classificação de Clavien-Dindo, foram determinados. O melhor ponto de corte do AF para o rastreamento de desnutrição foi obtido a partir da análise da curva ROC. RESULTADOS: Dezessete (42,5%) pacientes foram diagnosticados como desnutridos e 23 (57,5%), como bem nutridos de acordo com a avaliação subjetiva global. Doze (30,0%) pacientes desenvolveram complicações pós-operatórias graves. O grupo desnutrido apresentou menores valores de albumina sérica (P=0,012), hematócrito (P=0,026) e AF (P=0,002); enquanto que as relações de AEC/AIC (P=0,019) e AEC/ACT (P=0,047) estiveram elevadas. Além disso, 58,8% dos pacientes desnutridos desenvolveram complicações pós-operatórias graves em comparação a 8,7% dos pacientes bem nutridos. A desnutrição foi fator preditivo independente para o desenvolvimento de complicações pós-operatórias graves (OR=15,00, IC: 2,63-85,68; P=0,002). O melhor ponto de corte do AF obtido foi 6.0º (AUC=0,82; P=0,001) com sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de 76,5%, 87,0%, 81,3% e 83,4%, respectivamente. CONCLUSÃO: A desnutrição foi fator preditivo para o desenvolvimento de complicações graves em pacientes submetidos à cirurgia eletiva coloproctológica de grande porte. Além disso, a desnutrição foi associada a menores valores de AF e maior proporção de AEC. O AF forneceu boa acurácia no rastreamento da desnutrição, sugerindo seu uso como potencial marcador de desnutrição.

ABSTRACT BACKGROUND: Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication. OBJECTIVE: This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease. METHODS: This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis. RESULTS: Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively. CONCLUSION: Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition.

RESUMO Introdução Glioma, tumor cerebral maligno, é altamente agressivo e associado a mau prognóstico. Os objetivos deste estudo foram avaliar a associação de polimorfismos genéticos relacionados a angiogênese e apoptose em pacientes com glioma, bem como suas comorbidades, hábitos de vida, perfil clínico, sobrevida e resposta ao tratamento (temozolomida [TMZ] e radioterapia [RT]). Métodos 303 indivíduos foram genotipados por PCR em tempo real, e foram coletados dados clínicos, hábitos de vida e comorbidades. Admitiu-se nível de significância para valor p < 0,05. Resultados Tabagismo, elitismo, hipertensão arterial sistêmica, diabetes mellitus e índice de massa corporal prevaleceram entre os pacientes, comprados aos controles (p < 0,05). O genótipo heterozigoto rs1468727 (T/C) e homozigoto rs2010963 (G/G) (p > 0,05) foram observados em ambos os grupos. Tabagismo, elitismo, hipertensão arterial sistêmica, diabetes mellitus e índice de massa corporal apresentaram fatores de risco independentes para a doença (p < 0.0001, p = 0.0069, p = 0.0394, respectivamente). Os pacientes com gliomas de baixo grau apresentaram sobrevida de 80,0 ± 1,7% em três anos. Para a combinação de RT e TMZ, a sobrevida foi de 78,7±7,6% em 20 meses, em comparação com TMZ (21,9 ± 5,1%, p = 0,8711). Conclusões As variantes genéticas não estiveram associadas aos gliomas. Hábitos de vida e comorbidades específicas destacaram-se como fatores de risco independentes para a doença. O tratamento com TMZ + RT mostrou aumento na sobrevida dos pacientes.

ABSTRACT Background Glioma, the most common primary malignant brain tumor in adults, is highly aggressive and associated with a poor prognosis. The objectives of this study were to evaluate the association of genetic polymorphisms related to angiogenesis and apoptosis with gliomas, as well as comorbidities, lifestyle, clinical profile, survival and response to treatment (temozolomide [TMZ] and radiotherapy [RT]) in patients with the disease. Methods In a total of 303 individuals, genotypes were performed by real-time PCR, and clinical data, lifestyle and comorbidities were obtained from medical records and questionnaires. The significance level was set at 5%. Results Smoking, alcohol consumption, systemic arterial hypertension, diabetes mellitus and body mass index prevailed among patients, compared to controls (p < 0.05). The heterozygous genotype rs1468727 (T/C) and the homozygous genotype rs2010963 (G/G) (p > 0.05) were observed in both groups. Lifestyle and comorbidities showed independent risk factors for the disease (p < 0.0001, p = 0.0069, p = 0.0394, respectively). Patients with low-grade gliomas had a survival rate of 80.0 ± 1.7% in three years. For the combination of TMZ+RT, survival was 78.7 ± 7.6% in 20 months, compared to TMZ only (21.9 ± 5.1%, p = 0.8711). Conclusions Genetic variants were not associated with gliomas. Specific lifestyle habits and comorbidities stood out as independent risk factors for the disease. Low-grade gliomas showed an increase in patient survival with TMZ+RT treatment.

A origem anômala da artéria coronária esquerda da artéria pulmonar (síndrome de Bland-White-Garland ou ALCAPA: anomalous left coronary artery from the pulmonary artery) é uma cardiopatia congênita rara. Apresenta predominantemente na infância e suas principais formas de apresentação são como isquemia miocárdica ou insuficiência cardíaca. A sobrevivência à idade adulta é bastante incomum. Se não tratada, a mortalidade por ALCAPA se aproxima ao 90% na infância, portanto o reconhecimento precoce e a correção cirúrgica são essenciais. Apresentamos um caso de uma mulher de 56 anos, que acompanha em nosso ambulatório com o diagnóstico de síndrome de ALCAPA, e com piora recente da classe funcional de dispnéia.

The anomalous origin of the coronary artery from the pulmonary artery (ALCAPA or White-Bland-Garland syndrome) is a rare congenital cardiopathy. It presents predominantly in childhood and its main presentation forms are myocardial ischemia and heart failure. The survival to adulthood is unusual. If not treated, mortality by ALCAPA syndrome is close to 90% in childhood, therefore, the early recognition and surgical repair are essential. We present the case of a 56 years old woman, followed by our ambulatory with the ALCAPA Syndrome diagnosis, and recent functional class and dyspnea worsening

El origen anómalo de la arteria coronaria izquierda de la arteria pulmonar (síndrome de Bland-White-Garland o ALCAPA: anomalous left coronary artery from the pulmonary artery) es una cardiopatía congénita rara. Se presenta predominantemente en la infancia y sus principales formas de presentación son la insuficiencia cardíaca y la isquemia miocárdica. La supervivencia hasta la edad adulta es inusual. Si no se trata, la mortalidad por el síndrome ALCAPA se cerca al 90% en la infancia, por lo que el reconocimiento precoz y el tratamiento quirúrgico son esenciales. Se presenta el caso de una mujer de 56 años, con diagnóstico de síndrome de ALCAPA y empeoramiento de la clase funcional por disnea.