ABSTRACT Purpose: Gene expressions of vascular Endothelial Growth Factor Alpha (VEGFa), Nuclear Factor Kappa-Light-Chain-Enhancer of Activated B cells (NFkB) and cytokines could be useful for identifying potential therapeutic targets to alleviate ischemia-reperfusion injury after liver transplantation. Cytokine gene expressions, VEGFa and NFkB were investigated in a preclinical swine model of liver transplantation. Methods: A total of 12 pigs were used as donors and recipients in liver transplantation without venovenous bypass or aortic clamping. NFkB, IL-6, IL-10, VEGFa and Notch1 gene expression were assessed. These samples were collected in two specific times: group 1 (n= 6) - control, samples were collected before recipient’s total hepatectomy and group 2 - liver transplantation group (n=6), where the samples were collected one hour after graft reperfusion. Results: Liver transplantation was successfully performed in all recipients. Liver enzymes were elevated in the transplantation group. NFkB gene expression was significantly decreased in the transplantation group in comparison with the control group (0.62±0.19 versus 0.39±0.08; p= 0.016). No difference was observed between groups Interleucine 6 (IL-6), interleucine 10 (IL-10), VEGFa and Notch homolog 1 (Notch1). Conclusions: In this survey a decreased NFkB gene expression in a porcine model of liver transplantation was observed. Purpose VEGFa, , (VEGFa) KappaLightChainEnhancer Kappa Light Chain Enhancer (NFkB ischemiareperfusion ischemia reperfusion Methods clamping IL6, IL6 IL 6, IL-6 IL10, IL10 10, IL-10 assessed times n= n (n recipient s n=6, n6 n=6 (n=6) Results 0.62±0.19 062019 0 62 19 (0.62±0.1 0.39±0.08 039008 39 08 p 0.016. 0016 0.016 . 016 0.016) (IL-6) (IL-10) Notch1. (Notch1) Conclusions (VEGFa IL- IL1 IL-1 (n=6 0.62±0.1 06201 (0.62±0. 0.39±0.0 03900 3 001 0.01 01 (IL-6 (IL-10 (Notch1 0.62±0. 0620 (0.62±0 0.39±0. 0390 00 0.0 (IL- (IL-1 (Notch 0.62±0 062 (0.62± 0.39±0 039 0. (IL 0.62± 06 (0.62 0.39± 03 0.62 (0.6 0.39 0.6 (0. 0.3 (0 (

ABSTRACT Intrahepatic biliary proliferations represent a spectrum from reactive (ductular reaction, some with atypical architecture), hamartomatous (von Meyenburg complex), benign (bile duct adenoma) and precursor/borderline entities (biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct) to fully malignant (cholangiocarcinoma) neoplasms. Clinical pictures and even imaging patterns may be similar, requiring refined studies aiming at histopathological and immunohistochemistry for more precise diagnosis, essential for correct patient management. This article discusses updated concepts and definitions of most relevant entities aiming more specifically at the differential diagnosis in practice, focusing on morphology and immunohistochemistry, with a discussion of potential markers to help distinguishing between benign and malignant lesions. ductular reaction architecture, architecture , architecture) von complex, complex complex) adenoma precursorborderline precursor borderline neoplasia cholangiocarcinoma (cholangiocarcinoma neoplasms similar management practice lesions

RESUMO As proliferações biliares intra-hepáticas representam um espectro que abrange desde entidades reativas (reação ductular, algumas com arquitetura atípica), hamartomatosas (complexo de von Meyenburg), benignas (adenoma de ductos biliares) e precursoras/limítrofes (neoplasia intraepitelial biliar, neoplasia papilar intraductal de ducto biliar) até neoplasias totalmente malignas (colangiocarcinoma). Os quadros clínicos e até mesmo os padrões de imagem podem ser semelhantes, exigindo estudos refinados visando critério histológicos e imuno-histoquímicos para diagnósticos mais precisos, essenciais para o correto manejo do paciente. Este artigo discute conceitos atualizados e definições das entidades mais relevantes visando mais especificamente ao diagnóstico diferencial na prática, com foco na morfologia e imuno-histoquímica, com discussão de potenciais marcadores para ajudar na distinção entre lesões benignas e malignas. intrahepáticas intra hepáticas reação ductular atípica, atípica , atípica) complexo Meyenburg, Meyenburg Meyenburg) adenoma precursoraslimítrofes precursoras limítrofes biliar colangiocarcinoma. colangiocarcinoma . (colangiocarcinoma) semelhantes imunohistoquímicos imuno histoquímicos precisos paciente prática imunohistoquímica, imunohistoquímica histoquímica, histoquímica imuno-histoquímica (colangiocarcinoma

Abstract Fecal Immunochemical Test (FIT) followed by a colonoscopy is an efficacious strategy to improve the adenoma detection rate and Colorectal Cancer (CRC). There is no organized national screening program for CRC in Brazil. The aim of this research was to describe the implementation of an organized screening program for CRC through FIT followed by colonoscopy, in an urban low-income community of São Paulo city. The endpoints of the study were: FIT participation rate, FIT positivity rate, colonoscopy compliance rate, Positive Predictive Values (PPV) for adenoma and CRC, and the rate of complications. From May 2016 to October 2019, asymptomatic individuals, 50-75 years old, received a free kit to perform the FIT. Positive FIT (≥ 50 ng/mL) individuals were referred to colonoscopy. 10,057 individuals returned the stool sample for analysis, of which (98.2%) 9,881 were valid. Women represented 64.8% of the participants. 55.3% of individuals did not complete elementary school. Positive FIT was 7.8% (776/9881). The colonoscopy compliance rate was 68.9% (535/776). There were no major colonoscopy complications. Adenoma were detected in 63.2% (332/525) of individuals. Advanced adenomatous lesions were found in 31.4% (165/525). CRC was diagnosed in 5.9% (31/525), characterized as adenocarcinoma: in situ in 3.2% (1/31), intramucosal in 29% (9/31), and invasive in 67.7% (21/31). Endoscopic treatment with curative intent for CRC was performed in 45.2% (14/31) of the cases. Therefore, in an urban low-income community, an organized CRC screening using FIT followed by colonoscopy ensued a high participation rate, and high predictive positive value for both, adenoma and CRC. (FIT . (CRC) Brazil lowincome low income city PPV (PPV complications 201 2019 5075 75 50-7 old ≥ ( 5 ng/mL ngmL ng mL 10057 10 057 10,05 analysis 98.2% 982 98 2 (98.2% 9881 9 881 9,88 valid 648 64 8 64.8 participants 553 55 3 55.3 school 78 7 7.8 776/9881. 7769881 776/9881 776 (776/9881) 689 68 68.9 535/776. 535776 535/776 535 (535/776) 632 63 63.2 332/525 332525 332 525 (332/525 314 31 4 31.4 165/525. 165525 165/525 165 (165/525) 59 5.9 31/525, 31525 31/525 , (31/525) adenocarcinoma 32 3.2 1/31, 131 1/31 1 (1/31) 29 9/31, 931 9/31 (9/31) 677 67 67.7 21/31. 2131 21/31 21 (21/31) 452 45 45.2 14/31 1431 14 (14/31 cases Therefore both (CRC 20 507 50- 1005 05 10,0 98.2 (98.2 988 88 9,8 6 64. 55. 7. 776988 776/988 77 (776/9881 68. 53577 535/77 53 (535/776 63. 332/52 33252 33 52 (332/52 31. 16552 165/52 16 (165/525 5. 3152 31/52 (31/525 3. 13 1/3 (1/31 93 9/3 (9/31 67. 213 21/3 (21/31 45. 14/3 143 (14/3 100 0 10, 98. (98. 9, 77698 776/98 (776/988 5357 535/7 (535/77 332/5 3325 (332/5 1655 165/5 (165/52 315 31/5 (31/52 1/ (1/3 9/ (9/3 21/ (21/3 14/ (14/ (98 7769 776/9 (776/98 535/ (535/7 332/ (332/ 165/ (165/5 31/ (31/5 (1/ (9/ (21/ (14 (9 776/ (776/9 (535/ (332 (165/ (31/ (1 (21 (776/ (535 (33 (165 (31 (2 (776 (53 (3 (16 (77 (5 (7

RESUMO Contexto A hepatite C é um relevante problema de saúde pública. A doença pode permanecer clinicamente silenciosa tanto na forma aguda como na crônica e as infecções crônicas podem progredir para doenças avançadas, tais como cirrose e carcinoma hepatocelular (CHC), requerendo tratamentos dispendiosos, comprometendo a qualidade de vida do paciente e até mesmo levando à morte. Por esta razão, é uma das indicações mais frequentes para o transplante hepático. Apesar da introdução do tratamento com antivirais de ação directa (AAD) representar um progresso notável, muitos pacientes não receberam o tratamento e continuam infectados, e mesmo aqueles que eliminaram a infecção viral devem ser seguidos devido às lesões hepáticas anteriores, especialmente no que diz respeito às alterações da arquitetura lobular e dos vasos sanguíneos e linfáticos. Objetivo Avaliar os aspectos imuno-histoquímicos dos brotos linfáticos e dos vasos linfáticos “maduros” com variáveis histológicas de lesão hepática atribuíveis ao vírus da hepatite C (VHC) e à doença gordurosa. Métodos O presente estudo incluiu 72 biópsias hepáticas em pacientes com hepatite C crônica. Foram analisadas alterações estruturais relativas a “estadiamento” e “atividade”. Reações imuno-histoquímicas foram realizadas com anticorpo D2-40 anti-podoplanina. As principais variáveis histológicas também foram semiquantificadas, de modo a permitir a procura de possíveis associações entre os critérios histológicos e imunohistoquímicos, bem como com os genótipos 1 e 3 do VHC. Resultados Os achados histológicos mostraram que os diferentes graus de alterações estrutural estavam bem representados nesta casuística. A atividade necro-inflamatória lobular/parenquimatosa foi predominantemente leve à moderada. A maioria dos casos não apresentava grandes evidências de doença gordurosa, que foi encontrada significativamente mais elevada nos casos infectados com o genótipo 3 do VHC. A quantidade de brotos linfáticos portais aumentou com a progressão de alterações estruturais, sendo máxima na cirrose. Os brotos linfáticos portais, bem como os vasos linfáticos “maduros” portais também mostraram um aumento paralelo ao aumento do grau de infiltrado inflamatório portal/septal. No presente estudo, não foi encontrada qualquer associação significativa entre a proporção de brotos linfáticos portais ou vasos linfáticos maduros portais e o grau de atividade periportal/periseptal. Não foram detectadas relações significativas entre os brotos linfáticos/vasos maduros e a atividade inflamatória periportal ou atividade inflamatória parenquimatosa, nem com infecções devido ao genótipo 1 ou 3 do VHC. Conclusão A reação imunohistoquímica com anticorpo monoclonal D2-40 possibilitou a visualização e a semiquantitação de brotos e vasos linfáticos “maduros” nas amostras obtidas por biópsia hepática. A quantidade de linfáticos aumentou ao longo do processo fibrogênico, significativamente relacionada com a progressão da doença hepática e máxima na cirrose. Não foram detectadas relações significativas com a atividade necro-inflamatória periportal ou parenquimatosa.

ABSTRACT Background Viral hepatitis C is a significant public health challenge. The disease may remain clinically silent in both acute and chronic forms, and chronic infections may progress to advanced disease such as cirrhosis and hepatocellular carcinoma, requiring costly treatment, compromising the patient’s quality of life and even leading to death. For this reason, it is one of the most frequent indications for liver transplantation. Although treatment with direct-acting antivirals represents remarkable progress, many patients are still infected and even those who cleared the viral infection must be followed due to their previous hepatic lesions, especially regarding the disturbances of lobular architecture and the sanguineal and lymphatic vessels. Objective To assess immunohistochemical aspects of lymphatic sprouts and mature lymphatic vascularity with histological variables of liver injury attributable to hepatitis C virus (HCV) and fatty disease. Methods The present study included 72 liver biopsies of cases with chronic hepatitis C. Morphologic changes reflecting “staging” and “activity” were analyzed. Immunohistochemical reactions were performed with monoclonal antibody D2-40 anti-podoplanin. Major histological variables were also semiquantified so as to enable the search for possible associations among histological and Immunohistochemical criteria, as well as with genotypes 1 and 3 of HCV. Results Histological findings showed that the different degrees of strutural changes were well represented in this casuistic. Intralobular/parenchymal necro-inflammatory activity was predominantly mild to moderate. Most cases did not show major evidences of fatty disease, which was found significantly higher in cases infected with HCV genotype 3. The amount of portal lymphatic sprouts increased along with the progression of structural changes, maximal at cirrhosis. Portal lymphatic sprouts as well as portal mature lymphatic vessels also showed an increase parallel to the increase in the degree of portal/septal inflammatory infiltrate. In the present study, no significant association was found between the proportion of portal lymphatic sprouts or portal mature lymphatic vessels and the degree of periportal/periseptal activity. No significant relations were detected between lymphatic sprouts/mature vessels and periportal or parenchymal inflammatory activity, nor with infections due to HCV genotype 1 or 3. Conclusion Visualization and semiquantitation of sprouts and mature lymphatic vessels were clearly yielded by Immunohistochemical staining with monoclonal antibody D2-40. The amount of lymphatics was increased along fibrogenic process, significantly related to progression of liver disease and maximal at cirrhosis. No significant relations were detected with necro-inflammatory activity at interface or in the parenchyma.

Abstract Objective: The aim of the present study was to evaluate the clinical features, Hepatocellular Carcinoma (HCC) screening, treatment modalities, and Overall Survival (OS) in a series of Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma (NAFLD-HCC) Brazilian patients. Methods: This was a cross-sectional study at the Instituto do Cancer do Estado de São Paulo, at the Faculdade de Medicina da Universidade de São Paulo with the approval of the local research ethics committee. NAFLD patients with HCC diagnosed, from May 2010 to May 2019, were included. Results: A total of 131 patients were included. Risk factors for NAFLD were present in 94.7% of the patients. Only 29% of patients were in the HCC screening program before diagnosis. HCC treatment was performed in 84.7% of patients. Cumulative survival at the end of the first year was 72%, second-year 52%, and fifth-year 32%. HCC screening before diagnosis was not significantly associated with higher cumulative survival. The independent factors associated with shorter general survival were BCLC C-D, p < 0.001, and the size of the largest nodule > 42 mm, p = 0.039. Conclusions: Although the efficacy of screening in our population regarding overall survival was hampered due to the sample size (29% had screening), BCLC stages C‒D and the size of the largest nodule larger than 42 mm were identified as independent factors of worse prognosis.

OBJECTIVES: Whole genome expression profiles allow the stratification of bladder urothelial carcinoma into basal and luminal subtypes which differ in histological patterns and clinical behavior. Morpho-molecular studies have resulted in the discovery of immunohistochemical markers that might enable discrimination between these two major phenotypes of urothelial carcinoma. METHODS: We used two combinations of immunohistochemical markers, i.e., cytokeratin (CK) 5 with CK20 and CK5 with GATA3, to distinguish subtypes, and investigated their association with clinicopathological features, presence of histological variants, and outcomes. Upon searching for tumor heterogeneity, we compared the findings of primary tumors with their matched lymph node metastases. We collected data from 183 patients who underwent cystectomy for high-grade muscle-invasive urothelial carcinoma, and representative areas from the tumors and from 76 lymph node metastasis were organized in tissue microarrays. RESULTS: Basal immunohistochemical subtype (CK5 positive and CK20 negative, or CK5 positive and GATA3 negative) was associated with the squamous variant. The luminal immunohistochemical subtype (CK5 negative and CK20 positive, or CK5 negative and GATA3 positive) was associated with micropapillary and plasmacytoid variants. Remarkably, only moderate agreement was found between the immunohistochemical subtypes identified in bladder tumors and their lymph node metastasis. No significant difference in survival was observed when using either combination of the markers. CONCLUSION: This study demonstrates that these three routinely used immunohistochemical markers could be used to stratify urothelial carcinomas of the bladder into basal and luminal subtypes, which are associated with several differences in clinicopathological features.

OBJECTIVES: Co-infection with hepatitis A or B viruses may aggravate liver injury in patients infected with hepatitis C virus (HCV). However, few studies have assessed co-infection with hepatitis E virus (HEV) and HCV. Therefore, this study aimed to assess the prevalence and impact of HEV infection among Brazilian patients with chronic HCV infection. METHODS: This observational study included adult patients with chronic HCV infection who were naive to antiviral therapy from January 2013 to March 2016. A total of 181 patients were enrolled, and HEV serology and PCR were performed for all patients. RESULTS: Seropositivity for anti-HEV IgG was detected in 22 (12.0%) patients and anti-HEV immunoglobulin M in 3 (1.6%). HEV RNA showed inconclusive results in nine (4.9%) patients and was undetectable in the remaining patients. HEV serology positive patients had more severe liver disease, characterized by liver fibrosis ≥3 versus ≤2 (p<0.001), Aspartate Aminotransferase-to-Platelet Ratio Index of ≥1.45 (p=0.003), and Fibrosis-4 score of ≥3.25 (p=0.001). Additionally, the odds of HEV-positive patients developing diabetes mellitus were 3.65 (95% CI 1.40-9.52) times the corresponding odds of HEV-negative patients. A case-control-based histological analysis (n=11 HEV-HCV-positive patients and n=22 HCV-positive patients) showed no significant differences between the groups. CONCLUSIONS: This prevalence is higher than that reported in previous studies of the general population in Brazil. Thus, HEV infection may influence the severity of liver disease and may represent an additional risk of developing diabetes mellitus in patients with HCV infection.

RESUMO O carcinoma hepatocelular (CHC) é uma das principais causas de mortalidade relacionada a câncer no Brasil e no mundo. A Sociedade Brasileira de Hepatologia (SBH) publicou em 2015 suas primeiras recomendações sobre a abordagem do CHC. Desde então, novas evidências sobre o diagnóstico e tratamento do CHC foram relatadas na literatura médica, levando a diretoria da SBH a promover uma reunião monotemática sobre câncer primário de fígado em agosto de 2018 com o intuito de atualizar as recomendações sobre o manejo da neoplasia. Um grupo de experts foi convidado para realizar uma revisão sistemática da literatura e apresentar uma atualização baseada em evidências científicas visando que pudesse nortear a prática clínica multidisciplinar do CHC. O texto resultante foi submetido a avaliação e aprovação de todos membros da SBH através de sua homepage. O documento atual é a versão final que contêm as recomendações atualizadas e revisadas da SBH.

ABSTRACT Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.

RESUMO Racional: A elastografia hepática tem sido relatada nos carcinomas hepatocelulares (CHC); porém, não é claro identificar o risco de morbimortalidade na lista de transplante hepático. Objetivo: Avaliar a morbimortalidade com elastografia transitória e escore MELD. Método: Pacientes adultos com cirrose na triagem para transplante de fígado foram incluídos no estudo. Resultados: Foram incluídos 103 pacientes (sem CHC n=58 (66%), CHC n=45 (44%). O escore MELD médio foi de 14,7±6,4, a hipertensão portal foi de 83,9% e o valor médio de elastografia transitória foi de 32,73±22,5 kPa. O valor médio de ARFI (Impulsão de Força de Radiação Acústica) do parênquima hepático foi de 1,98 (0,65-3,2) m/s e 2,16 (0,59-2,8) m/s no grupo CHC. O grupo CHC foi significativamente associado à infecção por vírus da hepatite C (OR 26,84, p<0,0001), níveis mais altos de alfa-feto proteína sérica (OR 5,51; p=0,015), hipertensão portal clínica (OR 0,25; p=0,032) e pontuação MELD semelhante (p=0,693). Os valores de AUROCs (Area Under the Receiver Operating Characteristics) mostraram sensibilidade e especificidade para a alfa-feto proteína sérica (limite de 9,1 ng/ml), valor elastografia transitória (valor de corte 9 kPa) e valor ARFI (valor de corte 2,56 m/s) de 50% e 86%, 92% e 17% e 21% e 92%, respectivamente. O grupo de sobrevivência apresentou valor elastografia transitória médio de 31,65±22,2 kPa vs. 50,87±20,9 kPa (p=0,098) e valores mais elevados de MELD (p=0,035). Conclusão: Valores mais elevados na elastografia do fígado e nos escores MELD predizem a mortalidade.

ABSTRACT Background: Liver elastography have been reported in hepatocellular carcinoma (HCC) with higher values; however, it is unclear to identify morbimortality risk on liver transplantation waiting list. Aim: To assess liver stiffness, ultrasound and clinical findings in cirrhotic patients with and without HCC on screening for liver transplant and compare the morbimortality risk with elastography and MELD score. Method: Patients with cirrhosis and HCC on screening for liver transplant were enrolled with clinical, radiological and laboratory assessments, and transient elastography. Results: 103 patients were included (without HCC n=58 (66%); HCC n=45 (44%). The mean MELD score was 14.7±6.4, the portal hypertension present on 83.9% and the mean transient elastography value was 32.73±22.5 kPa. The median acoustic radiation force impulse value of liver parenchyma was 1.98 (0.65-3.2) m/s and 2.16 (0.59-2.8) m/s in HCC group. The HCC group was significantly associated with HCV infection (OR 26.84; p<0.0001), higher levels of serum alpha-fetoprotein (OR 5.51; p=0.015), clinical portal hypertension (OR 0.25; p=0.032) and similar MELD score (p=0.693). The area under the receiver operating characteristics (AUROC) showed sensitivity and specificity for serum alpha-fetoprotein (cutoff 9.1 ng/ml), transient elastography value (cutoff value 9 kPa), and acoustic radiation force impulse value (cutoff value 2.56 m/s) of 50% and 86%, 92% and 17% and 21% and 92%, respectively. The survival group had a mean transient elastography value of 31.65±22.2 kPa vs. 50.87±20.9 kPa (p=0.098) and higher MELD scores (p=0.035). Conclusion: Elastography, ultrasound and clinical findings are important non-invasive tools for cirrhosis and HCC on screening for liver transplant. Higher values in liver elastography and MELD scores predict mortality.

OBJECTIVES: Although liver biopsy is the gold standard for determining the degree of liver fibrosis, issues regarding its invasiveness and the small amount of liver tissue evaluated can limit its applicability and interpretation in clinical practice. Non-invasive evaluation methods for liver fibrosis can address some of these limitations. The aim of this study was to evaluate the accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI), enhanced liver fibrosis (ELF), the aspartate aminotransferase-to-platelet ratio index (APRI), and the FIB-4 index compared with liver biopsy in hepatitis C. METHODS: We evaluated chronic hepatitis C patients who were followed at the Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, São Paulo, Brazil, and who underwent liver biopsy. The accuracy of each method was determined by a receiver operating characteristic (ROC) curve analysis, and fibrosis was classified as significant fibrosis (≥F2), advanced fibrosis (≥F3), or cirrhosis (F4). The Obuchowski method was also used to determine the diagnostic accuracy of each method at the various stages of fibrosis. In total, 107 FibroScan®, 51 ARFI, 68 ELF, 106 APRI, and 106 FIB-4 analyses were performed. RESULTS: A total of 107 patients were included in the study. The areas under the ROC curve (AUROCs) according to fibrosis degree were as follows: significant fibrosis (≥F2): FibroScan®: 0.83, FIB-4: 0.76, ELF: 0.70, APRI: 0.69, and ARFI: 0.67; advanced fibrosis (≥F3): FibroScan®: 0.85, ELF: 0.82, FIB-4: 0.77, ARFI: 0.74, and APRI: 0.71; and cirrhosis (F4): APRI: 1, FIB-4: 1, FibroScan®: 0.99, ARFI: 0.96, and ELF: 0.94. The accuracies of transient elastography, ARFI, ELF, APRI and FIB-4 determined by the Obuchowski method were F0-F1: 0.81, 0.78, 0.44, 0.72 and 0.67, respectively; F1-F2: 0.73, 0.53, 0.62, 0.60, and 0.68, respectively; F2-F3: 0.70, 0.64, 0.77, 0.60, and 0.67, respectively; and F3-F4: 0.98, 0.96, 0.82, 1, and 1, respectively. CONCLUSION: Transient elastography remained the most effective method for evaluating all degrees of fibrosis. The accuracy of all methodologies was best at F4.

ABSTRACT PURPOSE: To quantify the amount of lymph nodes harvested in modified radical neck dissection. METHODS: Cross-sectional anatomical study conducted in 28 non-preserved cadavers. RESULTS: The mean number of lymph nodes found in each nodal level of the 56 modified radical neck dissections performed were: level IA - 1.5 (95% CI: 1.1 - 1.8), level IB - 2.5 (95% CI: 2.1 - 2.9), level IIA - 7.2 (95% CI: 6.0 - 8.5), IIB level - 6.5 (95% CI: 5.5 - 7.4), level III - 6.6 (95% CI: 5.7 - 7.4), level IV - 8.6 (95% CI: 7.1 - 10.1), level V - 11 (95% CI: 9.2 - 12.7), totalizing 43.8 lymph nodes (95% CI: 40.3 - 47.4). CONCLUSION: The results defined a parameter in relation to the minimum recommended nodal yield in a modified radical neck dissection, as well as the number of lymph nodes in each level of this dissection, performed in clinical practice.

Histology is the gold standard for diagnosing acute rejection and hepatitis C recurrence after liver transplantation. However, differential diagnosis between the two can be difficult. We evaluated the role of C4d staining and quantification of hepatitis C virus (HCV) RNA levels in liver tissue. This was a retrospective study of 98 liver biopsy samples divided into four groups by histological diagnosis: acute rejection in patients undergoing liver transplant for hepatitis C (RejHCV+), HCV recurrence in patients undergoing liver transplant for hepatitis C (HCVTx+), acute rejection in patients undergoing liver transplant for reasons other than hepatitis C and chronic hepatitis C not transplanted (HCVTx-). All samples were submitted for immunohistochemical staining for C4d and HCV RNA quantification. Immunoexpression of C4d was observed in the portal vessels and was highest in the HCVTx- group. There was no difference in C4d expression between the RejHCV+ and HCVTx+ groups. However, tissue HCV RNA levels were higher in the HCVTx+ group samples than in the RejHCV+ group samples. Additionally, there was a significant correlation between tissue and serum levels of HCV RNA. The quantification of HCV RNA in liver tissue might prove to be an efficient diagnostic test for the recurrence of HCV infection.

OBJETIVO: avaliar a dispensação dos medicamentos para o tratamento da hepatite viral C crônica verificando sua adequação às recomendações do Ministério da Saúde e estimar gastos com a dispensação inadequada dos medicamentos. MÉTODOS: estudo transversal descritivo sobre 643 prontuários de pacientes portadores de hepatite viral C crônica cadastrados em 2010, em quatro farmácias do Sistema de Dispensação de Medicamentos Excepcionais da Secretaria de Estado da Saúde de São Paulo (SES/SP). RESULTADOS: foram identificadas diferenças expressivas entre as farmácias, em relação ao processo de dispensação dos medicamentos; com base nos laudos das biópsias, estimou-se que 64,5% dos pacientes teriam indicação de tratamento e que R$1.096.132,32 foram despendidos com o tratamento de pacientes em não conformidade com as diretrizes terapêuticas. CONCLUSÃO: faz-se necessária uma padronização mais rigorosa nos procedimentos de dispensação de medicamentos para o tratamento da hepatite C crônica na rede pública da SES/SP.

OBJECTIVE: to assess whether the medication dispensing procedures for chronic viral hepatitis C treatment follow Ministry of Health guidelines and to estimate possible costs of inadequate procedures. METHODS: this was a descriptive cross-sectional study of 643 medical records of patients with chronic viral hepatitis C registered in 2010 with four São Paulo State Health Department (SES/SP) Exceptional Drug Dispensing System pharmacies. RESULTS: relevant discrepancies regarding medication dispensing procedures were detected. Based on the histopathology reports it was estimated that only 64.5% of assessed patients actually met the guideline criteria for treatment and therefore R$ 1,096,132.32 was spent in nonconformity with the guidelines. CONCLUSION: a more rigorous standardization of procedures for dispensing medication for the treatment of chronic hepatitis C in SES/SP Public Health Services must be implemented.

OBJETIVO: evaluar la dispensación de los medicamentos para el tratamiento de la hepatitis viral C crónica, verificando su adecuación a las recomendaciones del Ministerio de Salud y estimar gastos con la dispensación inadecuada de los medicamentos. MÉTODOS: estudio transversal descriptivo sobre 643 prontuarios de pacientes portadores de hepatitis viral C crónica registrados en 2010, en cuatro farmacias del Sistema de Dispensación de Medicamentos Excepcionales de la Secretaría de Estado de la Salud de São Paulo (SES/SP). RESULTADOS: se identificaron diferencias expresivas entre las farmacias, en relación al proceso de dispensación de los medicamentos; con base en los laudos de las biopsias, se estimó que 64,5% de los pacientes tendría indicación de tratamiento y que se gastaron R$ 1.096.132,32 con el tratamiento de pacientes en no-conformidad con las directrices terapéuticas. CONCLUSIÓN: es necesaria una estandarización más rigurosa en los procedimientos de dispensación de medicamentos para el tratamiento de la hepatitis C crónica en la red pública de la SES/SP.

OBJETIVO:avaliar a dispensação dos medicamentos para o tratamento da hepatite viral C crônica verificando sua adequação às recomendações do Ministério da Saúde e estimar gastos com a dispensação inadequada dos medicamentos.MÉTODOS:estudo transversal descritivo sobre 643 prontuários de pacientes portadores de hepatite viral C crônica cadastrados em 2010, em quatro farmácias do Sistema de Dispensação de Medicamentos Excepcionais da Secretaria de Estado da Saúde de São Paulo (SES/SP).RESULTADOS:foram identificadas diferenças expressivas entre as farmácias, em relação ao processo de dispensação dos medicamentos; com base nos laudos das biópsias, estimou-se que 64,5% dos pacientes teriam indicação de tratamento e que R$1.096.132,32 foram despendidos com o tratamento de pacientes em não conformidade com as diretrizes terapêuticas.CONCLUSÃO:faz-se necessária uma padronização mais rigorosa nos procedimentos de dispensação de medicamentos para o tratamento da hepatite C crônica na rede pública da SES/SP.

OBJECTIVE:to assess whether the medication dispensing procedures for chronic viral hepatitis C treatment follow Ministry of Health guidelines and to estimate possible costs of inadequate procedures.METHODS:this was a descriptive cross-sectional study of 643 medical records of patients with chronic viral hepatitis C registered in 2010 with four São Paulo State Health Department (SES/SP) Exceptional Drug Dispensing System pharmacies.RESULTS:relevant discrepancies regarding medication dispensing procedures were detected. Based on the histopathology reports it was estimated that only 64.5% of assessed patients actually met the guideline criteria for treatment and therefore R$ 1,096,132.32 was spent in nonconformity with the guidelines.CONCLUSION:a more rigorous standardization of procedures for dispensing medication for the treatment of chronic hepatitis C in SES/SP Public Health Services must be implemented.

OBJETIVO:evaluar la dispensación de los medicamentos para el tratamiento de la hepatitis viral C crónica, verificando su adecuación a las recomendaciones del Ministerio de Salud y estimar gastos con la dispensación inadecuada de los medicamentos.MÉTODOS:estudio transversal descriptivo sobre 643 prontuarios de pacientes portadores de hepatitis viral C crónica registrados en 2010, en cuatro farmacias del Sistema de Dispensación de Medicamentos Excepcionales de la Secretaría de Estado de la Salud de São Paulo (SES/SP).RESULTADOS:se identificaron diferencias expresivas entre las farmacias, en relación al proceso de dispensación de los medicamentos; con base en los laudos de las biopsias, se estimó que 64,5% de los pacientes tendría indicación de tratamiento y que se gastaron R$ 1.096.132,32 con el tratamiento de pacientes en no-conformidad con las directrices terapéuticas.CONCLUSIÓN:es necesaria una estandarización más rigurosa en los procedimientos de dispensación de medicamentos para el tratamiento de la hepatitis C crónica en la red pública de la SES/SP.