ABSTRACT Backgrounds: COVID-19 pandemic led to a sharp decline in surgical volume worldwide due to the postponement of elective procedures. This study evaluated the impact of COVID-19 pandemic in surgical volumes and outcomes of abdominal surgery in high-risk patients requiring intensive care unit admission. Methods: patients admitted for postoperative care were retrospectively evaluated. Data concerning perioperative variables and outcomes were compared in two different periods: January 2017-December 2019 and January 2020-December 2022, respectively, before (period I) and after (period II) the onset of COVID-19 pandemic. Results: 1.402 patients (897 women, mean age 62+17 years) were investigated. Most of the patients underwent colorectal (n=393) and pancreato-biliary (n=240) surgery, 52% of elective procedures. Surgical volume was significantly lower in period II (n=514) when compared to period I (n= 888). No recovery was observed in the number of surgical procedures in 2022 (n=135) when compared to 2021(n=211) and 2020 (n=168). Subjects who underwent abdominal surgery in period II had higher Charlson comorbidity index (4,85+3,0 vs. 4,35+2,8, p=0,002), more emergent/urgent procedures (51% vs. 45%, p=0,03) and more clean-contaminated wounds (73,5% vs. 66,8%, p=0,02). A significant decrease in the volume of colorectal surgery was also observed (24% vs, 31%, p<0,0001) after the onset of COVID-19 pandemic, 125 (8,9%) died, no deaths due to COVID-19 infection. Mortality was higher in period II when compared to period I (11% vs. 8%, p=0,08). Conclusions: COVID-19 pandemic was associated with a decrease in surgical volume of high-risk patients without apparent recovery in recent years. No influence of COVID-19 was noted in postoperative mortality. Backgrounds COVID19 COVID 19 COVID-1 highrisk high risk admission Methods periods 2017December December 2017 201 2020December respectively Results 1402 1 402 1.40 897 (89 women 6217 62 17 62+1 years investigated n=393 n393 n 393 (n=393 pancreatobiliary pancreato biliary n=240 n240 240 (n=240 52 n=514 n514 514 (n=514 n= (n 888. 888 . 888) 202 n=135 n135 135 (n=135 2021n=211 2021n211 2021 n=211 211 2021(n=211 n=168. n168 n=168 168 (n=168) 4,85+3,0 48530 4 85 3 0 (4,85+3, vs 43528 35 2 8 4,35+2,8 p=0,002, p0002 p p=0,002 , 002 p=0,002) emergenturgent emergent urgent 51% 51 (51 45 45% p=0,03 p003 03 cleancontaminated clean contaminated 73,5% 735 73 5 (73,5 668 66 66,8% p=0,02. p002 p=0,02 02 p=0,02) 24% 24 (24 31 31% p<0,0001 p00001 0001 12 8,9% 89 9 (8,9% died infection 11% 11 (11 8% p=0,08. p008 p=0,08 08 p=0,08) Conclusions mortality COVID1 COVID- 20 140 40 1.4 (8 621 6 62+ n=39 n39 39 (n=39 n=24 n24 (n=24 n=51 n51 (n=51 88 n=13 n13 13 (n=13 2021n 2021n=21 2021n21 n211 n=21 21 2021(n=21 n16 n=16 16 (n=168 4,85+3, 4853 (4,85+3 4352 4,35+2, p000 p=0,00 00 (5 p=0,0 p00 73,5 7 (73, 66,8 (2 p<0,000 p0000 000 8,9 (8,9 (1 14 1. ( n=3 n3 (n=3 n=2 n2 (n=2 n=5 n5 (n=5 n=1 n1 (n=1 2021n=2 2021n2 n21 2021(n=2 (n=16 4,85+3 485 (4,85+ 435 4,35+2 p=0, p0 73, (73 66, p<0,00 8, (8, 2021n= 2021(n= 4,85+ 48 (4,85 43 4,35+ p=0 (7 p<0,0 2021(n 4,85 (4,8 4,35 p= p<0, 4,8 (4, 4,3 p<0 4, (4 p<

RESUMO Introdução: a pandemia COVID-19 levou a um importante declínio mundial no volume cirúrgico devido ao adiamento de procedimentos eletivos. Este estudo avaliou o impacto da pandemia COVID-19 nos volumes e nos resultados da cirurgia abdominal em pacientes criticos. Métodos: pacientes internados para cuidados pósoperatórios foram avaliados retrospectivamente. Dados relativos aos desfechos perioperatórios foram comparados em dois períodos: janeiro-2017 a dezembro-2019 e janeiro-2020 a dezembro-2022, respectivamente, antes (período I) e depois (período II) da pandemia COVID-19. Resultados: foram investigados 1.402 pacientes (897 mulheres, idade 62+17 anos). A maioria dos pacientes foi submetida a cirurgia colorretal (n=393) e pancreatobiliar (n=240), sendo 52% dos procedimentos eletivos. O volume cirúrgico foi significativamente menor no período II (n=514) quando comparado ao período I (n=888). Não foi observada recuperação no número de procedimentos cirúrgicos em 2022 (n=135) quando comparado a 2021 (n=211) e 2020 (n=168). Indivíduos submetidos à cirurgia abdominal no período II apresentaram maior índice de comorbidade de Charlson (4,85+3,0 vs. 4,35+2,8, p=0,002), mais procedimentos emergenciais/urgentes (51% vs. 45%, p =0,03) e mais feridas potencialmente contaminadas (73,5% vs. 66,8%, p=0,02). Observou-se diminuição significativa no volume de cirurgia colorretal (24% vs, 31%, p<0,0001) após o início da pandemia de COVID-19, com 125 (8,9%) óbitos, nenhuma morte por COVID-19. A mortalidade foi maior no período II quando comparada ao período I (11% vs. 8%, p=0,08). Conclusões: a pandemia de COVID-19 foi associada à diminuição do volume cirúrgico de pacientes de alto risco sem recuperação aparente nos últimos anos. Nenhuma influência da COVID-19 foi observada na mortalidade pósoperatória. Introdução COVID19 COVID 19 COVID-1 eletivos criticos Métodos retrospectivamente períodos janeiro2017 janeiro 2017 janeiro-201 dezembro2019 dezembro 2019 dezembro-201 janeiro2020 janeiro-202 dezembro2022, dezembro2022 2022, dezembro-2022 respectivamente COVID19. 19. Resultados 1402 1 402 1.40 897 (89 mulheres 6217 62 17 62+1 anos . anos) n=393 n393 n 393 (n=393 n=240, n240 n=240 , 240 (n=240) 52 n=514 n514 514 (n=514 n=888. n888 n=888 888 (n=888) 202 n=135 n135 135 (n=135 n=211 n211 211 (n=211 n=168. n168 n=168 168 (n=168) 4,85+3,0 48530 4 85 3 0 (4,85+3, vs 43528 35 2 8 4,35+2,8 p=0,002, p0002 p=0,002 002 p=0,002) emergenciaisurgentes emergenciais urgentes 51% 51 (51 45 45% =0,03 003 03 73,5% 735 73 5 (73,5 668 66 66,8% p=0,02. p002 p=0,02 02 p=0,02) Observouse Observou se 24% 24 (24 31 31% p<0,0001 p00001 0001 COVID19, 19, 12 8,9% 89 9 (8,9% óbitos 11% 11 (11 8% p=0,08. p008 p=0,08 08 p=0,08) Conclusões pósoperatória COVID1 COVID- janeiro201 201 janeiro-20 dezembro201 dezembro-20 janeiro202 dezembro202 dezembro-202 140 40 1.4 (8 621 6 62+ n=39 n39 39 (n=39 n24 n=24 (n=240 n=51 n51 (n=51 n88 n=88 88 (n=888 20 n=13 n13 13 (n=13 n=21 n21 21 (n=21 n16 n=16 16 (n=168 4,85+3, 4853 (4,85+3 4352 4,35+2, p000 p=0,00 00 (5 =0,0 73,5 7 (73, 66,8 p00 p=0,0 (2 p<0,000 p0000 000 8,9 (8,9 (1 janeiro20 janeiro-2 dezembro20 dezembro-2 14 1. ( n=3 n3 (n=3 n2 n=2 (n=24 n=5 n5 (n=5 n8 n=8 (n=88 n=1 n1 (n=1 (n=2 (n=16 4,85+3 485 (4,85+ 435 4,35+2 =0, 73, (73 66, p0 p=0, p<0,00 8, (8, janeiro2 janeiro- dezembro2 dezembro- n= (n= (n=8 4,85+ 48 (4,85 43 4,35+ =0 (7 p=0 p<0,0 (n 4,85 (4,8 4,35 = p= p<0, 4,8 (4, 4,3 p<0 4, (4 p<

RESUMO Contexto: O uso crônico e excessivo de álcool é um importante fator de risco para diversos problemas sociais e de saúde. Métodos: Foi realizado um estudo transversal, numa amostra representativa da população brasileira, para avaliar a frequência do consumo de bebidas alcoólicas e comportamentos relativos às doenças hepáticas. Participantes foram entrevistados, prospectivamente, com um questionário sobre consumo de álcool e ações voltadas à saúde do fígado. O estudo aceitou erro amostral máximo de ±2 pontos percentuais e considerou intervalo de confiança de 95%. Resultados: Foram entrevistados 1995 indivíduos (1.048 mulheres, média de idade de 44 anos) de todas as regiões brasileiras. A maioria dos brasileiros (63-87%) acredita que o abuso de álcool é a principal causa de cirrose e câncer de fígado, no entanto, a maioria dos participantes (56%) nunca havia sido examinado para avaliar danos hepáticos relacionados ao consumo excessivo de álcool. Um total de 55% dos brasileiros consomem bebidas alcoólicas. Entre os brasileiros que consomem bebidas alcoólicas, 44% consomem três ou mais doses por vez, 11% consomem mais de 10 doses por dia. Entre aqueles que consomem 1 a 2 doses por dia, as mulheres (42%) consomem mais que os homens (32%) e mais que a média nacional (37%). Conclusão: Há elevada frequência de consumo de álcool, principalmente entre jovens e indivíduos de classes sociais mais baixas, com consumo frequente entre mulheres. Apesar do conhecimento sobre o impacto adverso na saúde do fígado, menos da metade dos brasileiros foram avaliados, em pelo menos uma ocasião, para doença hepática. Estratégias de educação e prevenção precisam ser implementadas para reduzir o uso nocivo do álcool. Contexto Métodos transversal brasileira hepáticas prospectivamente fígado ± 95 95% Resultados 199 1.048 1048 048 (1.04 4 anos brasileiras 6387% 6387 63 87% 87 (63-87% entanto 56% 56 (56% 55 vez 11 dia 42% 42 (42% 32% 32 (32% 37%. 37 37% . (37%) Conclusão baixas avaliados ocasião hepática 9 19 1.04 104 04 (1.0 638 6 8 (63-87 5 (56 (42 3 (32 (37% 1.0 0 (1. (63-8 (5 (4 (3 (37 1. (1 (63- ( (63 (6

ABSTRACT Background: Chronic excessive use of alcohol is an important risk factor for several health and social conditions. Methods: A cross-sectional survey, in a sample representative of the Brazilian population,was conducted to evaluate the frequency of consumption of alcoholic beverages and behaviors concerning liver diseases. Participants were prospectively interviewed using a questionnaire regarding alcohol consumption and actions toward liver health. The study accepted at most one sampling error of ±2 percentage points and considered a 95% confidence interval. Results: One thousand nine hundred ninety-five subjects (1.048 women, mean age 44 years) from all Brazilian regions were interviewed. Most of the Brazilian subjects believe that alcohol abuse (63-87%) is the leading cause of cirrhosis and liver cancer, however, most responders (56%) had never been screened to assess liver damage related to alcohol consumption. A total of 55% of Brazilians drink alcoholic beverages. Among Brazilians who drink alcoholic beverages, 44% consume three or more drinks at a time, 11% consume more than 10 doses a day. Among those who consume 1 to 2 drinks a day, women (42%) consume more than men (32%) and more than the national average (37%). Conclusion: There is a high frequency of alcohol consumption, especially among young people, and individuals from lower social classes, with frequent consumption among women. Despite the knowledge of its adverse impact on liver health, less than half of the Brazilians have been evaluated at least once for liver disease. Education and prevention strategies need to be implemented to reduce theharmful use of alcohol. Background conditions Methods crosssectional cross sectional survey populationwas population was diseases ± 95 interval Results ninetyfive ninety five 1.048 1048 048 (1.04 4 years 6387% 6387 63 87% 87 (63-87% cancer however 56% 56 (56% 55 time 11 day 42% 42 (42% 32% 32 (32% 37%. 37 37% . (37%) Conclusion people classes disease 9 1.04 104 04 (1.0 638 6 8 (63-87 5 (56 (42 3 (32 (37% 1.0 0 (1. (63-8 (5 (4 (3 (37 1. (1 (63- ( (63 (6

Abstract Introduction Depression in aging may lead to loss of autonomy and worsening of comorbidities. Understanding how positive attributes contribute to healthier and happier aging has been one ofthe purposes of Positive Psychology. However, the literature still lacks studies that evaluate how depression in the elderly is related to constructs considered positive. Objective The present study aimed comparing scores of constructs of spiritual well-being, social support, selfesteem, life satisfaction, affection, optimism, and hope in the elderly with minimal, mild, moderate, and severe depression and healthy controls in order to investigate possible indirect and mediated relationships between positive constructs and depression. Methods A cross-sectional study was conducted with elderly, 62 of whom were diagnosed with different severity of Major Depression (DSM-V) (minimum, mild, moderate, and severe according to the Beck Depression Inventory — BDI) and 66 healthy controls matched by age, sex and schooling. The instruments used were adapted and validated versions of the Spirituality Self-Rating Scale, the Rosenberg Self-Esteem Scale, the Medical Outcomes Social Scale of Support, the Life Satisfaction Scale, the Positive and Negative Affect Schedule, the Revised Life Orientation Test, and the Adult Dispositional Hope Scale. After comparing the means of scores between groups, an analysis of normalized partial association networks was performed to investigate the direct and mediated relationships between depression and other evaluated constructs. Results Scores of spiritual well-being, social support, self-esteem, life satisfaction, positive affect, optimism, negative affects, and hope differed significantly between the control group and the degrees of depression (p < 0.001). The analysis of normalized partial association networks has shown that the relations of depression with the constructs of life satisfaction, self-esteem, and social support are mediated, while the constructs of dispositional hope, positive affect, spiritual well-being, and optimism are indirectly related to depression. The social class was also positively related to depression. Conclusion Depression in different degrees is associated with a reduction in the scores of instruments that evaluate positive attributes. The constructs directly associated with depression are spiritual well-being, optimism, positive affect, and dispositional hope. The others had mediated relationship. These results may contribute to the planning of future interventions for the prevention of depression among the elderly. comorbidities Psychology However wellbeing, wellbeing well being, being well-being selfesteem satisfaction affection minimal mild moderate crosssectional cross sectional 6 DSMV DSM V (DSM-V minimum, minimum (minimum BDI age schooling SelfRating Self Rating SelfEsteem Esteem Support Schedule Test groups self esteem, esteem self-esteem affect affects p 0.001. 0001 0.001 . 0 001 0.001) relationship 000 0.00 00 0.0 0.

ABSTRACT BACKGROUND: Clinical features and outcomes of patients admitted to the intensive care unit due to acute abdomen are important to be investigated. AIMS: To evaluate the outcomes of critically ill subjects with acute abdomen according to etiology, comorbidity and severity. METHODS: Outcomes of 1,523 patients (878 women, mean age 66±18 years) consecutively admitted to a specialized gastrointestinal intensive care unit with different causes of acute abdomen from January 2012 to December 2019, were retrospectively evaluated according to etiology, comorbidity and severity. RESULTS: The most common causes of acute abdomen were obstructive and inflammatory, particularly large bowel obstruction (27%), small bowel obstruction (18%) and acute pancreatitis (17%). Overall mortality was 13%. Surgery was required in 34% of patients. Median length of stay in the hospital was 9 [1-101] days. On univariate analysis mortality was significantly associated with age, APACHE II, Charlson comorbidity index, requirement for surgery and malignancy (p<0.0001), but only APACHE II, Charlson comorbidity index and surgical interventional remained significant on multivariate analysis. CONCLUSIONS: Critically ill patients admitted to the intensive care unit with acute abdomen constitute a heterogeneous group of subjects with different prognosis. Mortality is more related to the severity of the disease, comorbidity and need for surgery than to the etiology of the acute abdomen. BACKGROUND investigated AIMS METHODS 1523 1 523 1,52 878 (87 women 6618 66 18 66±1 years 201 2019 RESULTS inflammatory 27%, 27 27% , (27%) 18% (18% 17%. 17 17% . (17%) 13 13% 34 1101 101 [1-101 days II p<0.0001, p00001 p p<0.0001 0 0001 (p<0.0001) CONCLUSIONS prognosis disease 152 52 1,5 87 (8 661 6 66± 20 2 (27% (18 (17% 3 110 10 [1-10 p0000 p<0.000 000 (p<0.0001 15 5 1, 8 ( (27 (1 (17 11 [1-1 p000 p<0.00 00 (p<0.000 (2 [1- p00 p<0.0 (p<0.00 [1 p0 p<0. (p<0.0 [ p<0 (p<0. p< (p<0 (p< (p

RESUMO RACIONAL: As características clínicas e os desfechos dos pacientes internados na unidade de terapia intensiva devido ao abdômen agudo são importantes serem investigados. OBJETIVOS: Avaliar os desfechos de indivíduos gravemente doentes com abdômen agudo de acordo com etiologia, gravidade e comorbidade. MÉTODOS: Os desfechos de 1.523 pacientes (878 mulheres, média de idade 66±18 anos) que foram previamente admitidos em uma unidade de terapia intensiva especializada em doenças gastrointestinais, com diferentes causas de abdômen agudo entre janeiro de 2012 e dezembro de 2019, foram avaliados retrospectivamente segundo etiologia, comorbidade e gravidade. RESULTADOS: As causas mais comuns de abdômen agudo foram obstrutivas e inflamatórias, com destaque para obstrução em colon (27%), em intestino delgado (18%) e pancreatite aguda (17%). A mortalidade geral foi de 13%. A cirurgia foi necessária em 34%. A média de permanência no hospital foi de 9 [1-101] dias. Na análise univariada a mortalidade foi significativamente associada à idade, APACHE II, índice de comorbidade de Charlson, necessidade de abordagem cirúrgica e presença de malignidade (p<0,0001), mas apenas APACHE II, índice de comorbidade de Charlson e intervenção cirúrgica permaneceram significativos na análise multivariada. CONCLUSÕES: Pacientes internados na unidade de terapia intensiva com abdômen agudo constituem um grupo heterogêneo de indivíduos com prognóstico diferente. A mortalidade está mais relacionada com a gravidade da doença, comorbidade e necessidade de cirurgia do que com a etiologia do abdome agudo. RACIONAL investigados OBJETIVOS MÉTODOS 1523 1 523 1.52 878 (87 mulheres 6618 66 18 66±1 anos gastrointestinais 201 2019 RESULTADOS inflamatórias 27%, 27 27% , (27%) 18% (18% 17%. 17 17% . (17%) 13 13% 34 34% 1101 101 [1-101 dias II p<0,0001, p00001 p p<0,0001 0 0001 (p<0,0001) multivariada CONCLUSÕES diferente doença 152 52 1.5 87 (8 661 6 66± 20 2 (27% (18 (17% 3 110 10 [1-10 p0000 p<0,000 000 (p<0,0001 15 5 1. 8 ( (27 (1 (17 11 [1-1 p000 p<0,00 00 (p<0,000 (2 [1- p00 p<0,0 (p<0,00 [1 p0 p<0, (p<0,0 [ p<0 (p<0, p< (p<0 (p< (p

RESUMO Contexto Pré-eclâmpsia (PE) e eclâmpsia (E) estão entre as principais causas de morbimortalidade materna e fetal. Ambas estão associadas a comprometimento hepático com diferentes formas de evolução. Objetivo O objetivo deste estudo foi avaliar a frequência e a gravidade do envolvimento hepático em gestantes internadas em uma unidade de terapia intensiva (UTI) com PE/E e avaliar sua influência em desfechos maternos e fetais adversos. Métodos: Pacientes hospitalizados entre janeiro 2012 e março 2019 com PE/E foram avaliados retrospectivamente quanto às anormalidades clínicas e bioquímicas relacionadas ao fígado e suas frequências foram posteriormente correlacionadas com os resultados materno-fetais. Resultados: Um total de 210 mulheres (idade média 31±6,4 anos, idade gestacional média 33,8±4,1 semanas) com PE/E foram incluídas no estudo. A maioria delas apresentava hipertensão grave (n=184), sintomas de dor abdominal (48%) e cefaleia (40%). Anormalidades das enzimas hepáticas foram observadas em 49% dos indivíduos, geralmente menos de cinco vezes o limite superior do normal. Hemorragia subcapsular e ruptura hepática espontânea foram identificadas em uma mulher que faleceu. Nenhuma paciente teve diagnóstico definitivo de esteatose hepática aguda da gravidez, nem insuficiência hepática aguda grave. Um total de 62% dos partos ocorreu antes de 37 semanas. A mortalidade fetal foi observada em 6 (3%) casos. Não houve correlação entre os níveis médios de enzimas hepáticas e os resultados maternos e fetais. Conclusão Anormalidades bioquímicas hepáticas são frequentemente vistas em mulheres com PE/E, mas fora do contexto da síndrome HELLP, não estão associadas a resultados maternos e fetais adversos. As complicações relacionadas ao fígado são raras, mas podem ser fatais.

ABSTRACT Background: Pre-eclampsia (PE) and eclampsia (E) are among the leading causes of maternal and fetal morbidity and mortality. Both are associated with an evolving spectrum of liver disorders. Objective: The aim of this study was to evaluate the frequency and severity of liver involvement in pregnant women admitted to an intensive care unit with PE/E and to assess its influence on adverse maternal and fetal outcomes. Methods: All subjects, hospitalized between January 2012 and March 2019, were retrospectively evaluated for clinical and biochemical liver-related abnormalities and their frequencies were subsequently correlated with maternal-fetal outcomes. Results: A total of 210 women (mean age 31±6.4 years, mean gestational age 33.8±4.1 weeks) with PE/E were included in the study. Most of them had severe hypertension (n=184) and symptoms of abdominal pain (48%) and headache (40%). Liver enzymes abnormalities were seen in 49% of the subjects, usually less than five times the upper limit of normal. Subcapsular hemorrhage and spontaneous hepatic rupture were identified in one woman who died. No patient had definitive diagnosis for acute fatty liver of pregnancy, neither acute liver failure. A total of 62% of deliveries occurred before 37 weeks. Fetal mortality was observed in 6 (3%) cases. There was no correlation between mean levels of liver enzymes and maternal and fetal outcomes. Conclusion: Biochemical abnormalities of liver enzymes are frequently seen in women with PE/E, but outside the spectrum of HELLP syndrome, they are not associated with adverse maternal and fetal outcomes. Liver-related complications are rare but can be life-threatening.

RESUMO Contexto As infecções bacterianas ocorrem em 43—59% dos pacientes cirróticos internados em unidade de terapia intensiva com impacto na morbimortalidade. Um aumento na frequência de bactérias multirresistentes e com resistência estendida foi descrito em infecções bacterianas em pacientes cirróticos, com um impacto adverso na sobrevida. Objetivo Caracterizar as infecções adquiridas na comunidade, relacionadas aos cuidados de saúde (RCS) e hospitalares em pacientes cirróticos e seu impacto na ocorrência de desfechos adversos. Métodos Este estudo incluiu todos os pacientes cirróticos internados em uma unidade de terapia intensiva especializada em doenças hepáticas e gastrointestinais no Brasil entre janeiro de 2012 e junho de 2018. A frequência e topografia das infecções foram avaliadas retrospectivamente, bem como a frequência de bactérias multirresistentes e resistência estendida, e seu impacto na ocorrência de lesão renal aguda, síndrome hepatorrenal, insuficiência hepática crônica agudizada, sepse e mortalidade. Resultados Um total de 374 infecções foram observadas e classificadas como infecções adquiridas na comunidade (22%), RCS (34%) e infecções hospitalares (44%). Oitenta e nove (54%) episódios de infecções hospitalares foram identificadas como segunda infecção. Peritonite bacteriana espontânea (32%) e infecção do trato urinário (23%) foram as infecções mais comuns. As infecções comprovadas por cultura foram positivas em 61% dos casos, principalmente ocasionadas por bactérias gram-negativas (73%). Lesão renal aguda, síndrome hepatorrenal e sepse foram observados respectivamente, em 48%, 15% e 53% dos casos. Bactérias multirresistentes e resistência estendida foram observadas respectivamente, em 35% e 16%, principalmente nos RCS (48% vs 26% em infecções adquiridas na comunidade, P=0,02) e infecções hospitalares (58% vs 26% em infecções adquiridas na comunidade, P=0,0009). Os resultados adversos foram observados com mais frequência em indivíduos com infecções nosocomiais em comparação com infecções relacionadas aos cuidados de saúde e comunitárias. Infecções hospitalares, RCS e ocorrência de uma segunda infecção foram independentemente associadas à mortalidade intra-hospitalar. Conclusão Infecções hospitalares, relacionadas aos cuidados de saúde e reinfecções estão cada vez mais associadas a bactérias multirresistentes e/ou resistência estendida e são preditores independentes de mortalidade intra-hospitalar. Seu reconhecimento e seleção adequada de regimes antibióticos empíricos apropriados são medidas importantes para reduzir a mortalidade intra-hospitalar.

ABSTRACT Background Bacterial infections occur in 43—59% of cirrhotic patients admitted to the intensive care unit with impact in morbidity and mortality. An increase in the frequency of multidrug-resistant (MDRO) and extensively drug-resistant (XDRO) organisms has been described in bacterial infections in cirrhotic patients with an adverse impact on survival. Objective To characterize community-acquired (CA), healthcare-associated (HCA), and hospital-acquired (HA) infections in cirrhotic patients and their impact in the occurrence of adverse outcomes. Methods This study included all cirrhotic patients admitted in an intensive care unit specialized in liver and gastrointestinal diseases in Brazil between January 2012 and June 2018. Frequency and topography of infections were retrospectively evaluated, as well as the frequency of MDRO and XDRO organisms, and their impact in occurrence of acute kidney injury, hepatorenal syndrome, acute-on-chronic liver failure, sepsis and mortality. Results A total of 374 infections were observed and classified as CA (22%), HCA (34%) and hospital-acquired (44%). Eighty-nine (54%) episodes of hospital-acquired infections were second infections. Spontaneous bacterial peritonitis (32%) and urinary tract infection (23%) were the most common infections. Culture-proven infections were positive in 61% of the cases, mainly gram-negative bacteria (73%). Acute kidney injury, hepatorenal syndrome and sepsis were observed, respectively, in 48%, 15% and 53% of the cases. MDRO and XDRO were seen, respectively, in 35% and 16%, mainly in HCA (48% vs 26% in CA infections, P=0.02) and hospital-acquired (58% vs 26% in CA infections, P=0.0009). Adverse outcomes were more frequently observed in subjects with hospital-acquired infections when compared to HCA and CA infections. Hospital-acquired, HCA and second infections were independently associated with in-hospital mortality. Conclusion Hospital-acquired, HCA and second infections are increasingly associated with either MDRO and/or XDRO and are independent predictors of in-hospital mortality. Their recognition and proper selection of appropriate empiric antibiotic regimens are important measures to reduce in-hospital mortality.

ABSTRACT Leukocyte biomarkers, including the neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte-(MLR), platelet-to-lymphocyte (PLR) ratios and systemic immune-inflammation index (SII) have been associated with severity and mortality of patients with COVID-19. The purpose of this study was to evaluate the association of baseline leukocyte biomarkers calculated in the emergency department (ED) with the disease severity and mortality. This was a retrospective cohort study that evaluated 1,535 (mean age 57+18 years) patients with SARS-CoV-2 infection in the ED of a single reference center. Outcomes were severity, defined as intensive care unit (ICU) admission requirement, and in-hospital mortality. All leukocyte biomarkers were calculated in the ED before the hospital admission. Their ability to predict the severity and mortality was measured using receiver operating characteristic (ROC) curves. Severity and mortality were observed in 30.9% and 12.6% of the patients, respectively, and were significantly correlated with NLR, MLR, PLR and SII, but only NLR was independently associated with both outcomes on multivariate analysis. Analysis of ROC curves revealed that NLR (0.78 for severity and 0.80 for mortality) and SII (0.77 for severity and 0.75 for mortality) had the best ability to predict mortality, when compared to other ratios. The highest AUC was observed for NLR, employing cut-off points of 5.4 for severity and 5.5 for mortality. Leukocyte biomarkers, particularly NLR, are capable of predicting the severity and mortality of patients with SARS-CoV-2 infection and could be important adjunct tools to identify patients in the ED that are more prone to develop adverse outcomes.

SUMMARY OBJECTIVE: Brazil ranks second in gross numbers of kidney and liver transplantations, but deceased organ donation is still far below the national demand for organs. Apart from a high family refusal rate, another significant barrier is healthcare workers’ inappropriate knowledge concerning organ donation and transplantation. Since most of them have recently graduated from university, this study aimed to evaluate the awareness and attitudes of medical students concerning organ donation. METHODS: Between August and September 2021, a web-based survey with 10 overlapping questions was sent to medical students from several Brazilian universities after advertisements on social media. RESULTS: A total of 391 (60% female, mean age: 23 [17–41] years) students answered the survey. Most of them (91%) would like to donate organs in case of death, and 75% have already notified their family. The main reasons for not becoming a donor were fear of body manipulation (n=3) or family reaction (n=2) and religious reasons (n=2). When inquired, 54% were unaware of brain death criteria, and half of them claimed to have never discussed the topic in medical classes. Except for Glasgow coma scale (97%), pupillary (72%), and corneal (53%) reflexes, less than 25% knew other reflexes required for brain death diagnosis. CONCLUSION: Most medical students declared themselves as organ donors, and most informed their families. However, many students have never learned about crucial steps toward organ donation, which may impact their adequate recognition of potential organ donors later in life.

ABSTRACT Background and aims: Treatment of hepatitis C with direct antiviral agents (DAA) is associated with almost 95% of sustained virological response. However, some patients need retreatment. In Brazil, it should be done according to the Ministry of Health guidelines, frequently updated to include newly available drugs. This study aimed to conduct a national survey about the characteristics and outcomes of retreatment of hepatitis C in previously non-responders to DAAs. Patients and methods: Institutions from all over the country were invited to participate in a national registry for retreatment, including information about clinical and epidemiological characteristics of the patients, type and outcomes of retreatment regimens. Only patients previously treated with interferon-free regimens were included. Results: As previous treatments the distribution was: SOF/DCV (56%), SOF/SIM (22%), 3D (11%), SOF/LED (6%) and SOF/RBV (5%). For retreatment the most frequently used drugs were SOF/GP (46%), SOF/DCV (23%) and SOF/VEL (11%). From 159 patients retreated, 132/159 (83%) had complete information in the registry and among them only seven patients were non-responders (SVR of 94.6%). All retreatments were well tolerated, without any serious adverse events or interruptions. Conclusion: The retreatment of patients previously non-responders to DAAs was associated with high rate of SVR in this sample of Brazilian patients. This finding allows us to conclude that the retreatment options available in the public health system in Brazil are effective and safe and are an important component of the strategy of elimination of hepatitis C in our country.

RESUMO Desde a publicação em 2015 das recomendações da Sociedade Brasileira de Hepatologia sobre a prevenção e tratamento de doenças hepáticas autoimunes, novos dados baseados em evidências científicas foram publicados na literatura, mudando o diagnóstico e tratamento da hepatite autoimune (HAI), colangite biliar primária (CBP), colangite esclerosante primária (CEP), síndromes de sobreposição de HAI, CBP e CEP e o manejo de complicações específicas além de outros tópicos relativos à HAI e doenças hepáticas colestáticas. Este manuscrito atualiza as recomendações anteriores de acordo com as melhores evidências disponíveis na literatura até o momento. O mesmo painel de experts que participou da primeira diretriz revisou todas as recomendações de acordo com os dados publicados na literatura e elaborou um manuscrito submetido subsequentemente à apreciação e revisão de todos os membros da Sociedade Brasileira de Hepatologia via homepage da sociedade. As recomendações finais atualizadas foram condensadas no presente documento.

ABSTRACT New data concerning the management of autoimmune liver diseases have emerged since the last single-topic meeting sponsored by the Brazilian Society of Hepatology to draw recommendations about the diagnosis and treatment of autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), overlap syndromes of AIH, PBC and PSC and specific complications and topics concerning AIH and cholestatic liver diseases. This manuscript updates those previous recommendations according to the best evidence available in the literature up to now. The same panel of experts that took part in the first consensus document reviewed all recommendations, which were subsequently scrutinized by all members of the Brazilian Society of Hepatology using a web-based approach. The new recommendations are presented herein.

RESUMO Introdução: Este trabalho visa avaliar alterações neurodegenerativas detectadas por depósitos proteicos anormais em Córtex Entorrinal (CE) de indivíduos acima de 50 anos e correlacionar os achados com suspeição de demência detectada por meio do IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly). Métodos: Catorze encéfalos foram submetidos à técnica imuno-histoquímica para diferentes proteínas (beta-amiloide, tau, alfa-sinucleína e fosfo-TDP-43) e esses dados foram comparados com os valores obtidos pelo IQCODE. Resultados: 57% dos indivíduos mostraram resultados de IQCODE compatíveis com demência, sendo classificados no grupo com demência (GD): 87,5% desses pacientes tinham achados neuropatológicos correspondentes a patologia cerebral Alzheimer-símile (ALBP). Entre os pacientes do grupo sem demência (GSD), 16,7% apresentaram critérios neuropatológicos para ALBP. Todos os indivíduos do GD tinham depósitos de mais de um tipo de proteína no CE. A associação proteica mais comum foi tau hiperfosforilada e proteína beta-amiloide (87,5%). Discussão: A maioria dos indivíduos com demência apresentaram achados neuropatológicos de ALBP e um indivíduo, que não tinha evidências de demência, apresentou achados compatíveis com ALBP, caracterizando um estágio pré-clínico. Este trabalho sugere que depósitos de um único tipo de proteína anômala são achados normais do cérebro em envelhecimento, enquanto mais de um tipo de proteínas ou a presença combinada de depósitos proteicos anômalos indica manifestações de demência.

ABSTRACT Introduction: The aims of this study were to survey neurodegenerative changes detected by abnormal protein deposits in the Entorhinal Cortex (EC) of subjects aged 50 years or older and to correlate these findings with suspected dementia, as detected by the IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) . Methods: Fourteen brains were submitted to the immunohistochemistry technique for different proteins (beta-amyloid, tau, -synuclein and phospho-TDP-43) and data obtained compared with IQCODE scores. Results: Fifty-seven percent of the individuals exhibited IQCODE results compatible with dementia, being classified into the demented group (DG): 87.5% of patients had neuropathological findings corresponding to Alzheimer's-like brain pathology (ALBP). Of the patients in the non-demented group (NDG), 16.7% met neuropathological criteria for ALBP. All individuals in the DG showed deposits of more than one kind of protein in the EC. The most common association was hyperphosphorylated tau and beta-amyloid protein (87.5%). Discussion: Most individuals with dementia had neuropathological findings of ALBP, as did one individual with no signs of dementia, characterizing a preclinical stage. The results of this study suggest that deposits of a single type of anomalous protein are normal findings in an aging brain, while more than one kind of protein or the combined presence of anomalous protein deposits indicate the presence of dementia.

RESUMO Para definir as recomendações baseadas em evidências científicas sobre o diagnóstico e tratamento das doenças autoimnus do fígado, a Sociedade Brasileira de Hepatologia organizou em Outubro de 2014, encontro monotemático em São Paulo. Um Comitê organizador de sete investigadores foi selecionado pela Diretoria da Sociedade para organizar a agenda científica, assim como para selecionar vinte debatedores para fazer uma revisão sistemática e apresentar tópicos relacionados à hepatite autoimune, colangite esclerosante primária, cirrose biliar primária e suas síndromes de superposição (overlap). O texto inicial do submetidoo a apreciação e aprovação da Sociedade Brasileira de Hepatologia através de consulta a todos associados através da home page da Sociedade, O trabalho apresentado representa a versão final do trabalho original, devidamente revisado e organizado em tópicos, segundo as recomendações da Sociedade Brasileira de Hepatologia.

ABSTRACT In order to draw evidence-based recommendations concerning the management of autoimmune diseases of the liver, the Brazilian Society of Hepatology has sponsored a single-topic meeting in October 18th, 2014 at São Paulo. An organizing committee comprised of seven investigators was previously elected by the Governing Board to organize the scientific agenda as well as to select twenty panelists to make a systematic review of the literature and to present topics related to the diagnosis and treatment of autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and their overlap syndromes. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.

RESUMO A sobrevida de pacientes cirróticos críticos aumentou significantemente nos últimos anos devido a inúmeros avanços obtidos no manejo do paciente com cirrose descompensada e com insuficiência hepática aguda grave, particularmente após a incorporação na prática clínica de uma série de estratégias baseadas em evidencias com impacto reconhecido na redução de mortalidade. Com o intuito de discutir as principais evidencias disponíveis na literatura médica sobre o assunto, a Sociedade Brasileira de Hepatologia, em conjunto com a Associação de Medicina Intensiva Brasileira e a Associação Brasileira de Transplantes de Órgãos promoveu uma reunião monotemática sobre o manejo do paciente hepatopata crítico, que ocorreu em 21 de maio de 2014 na cidade do Rio de Janeiro. O relatório da reunião foi resumido no presente manuscrito com o objetivo de nortear a prática clínica de intensivistas, gastroenterologistas e hepatologistas no manejo do paciente hepatopata em ambiente de terapia intensiva.

ABSTRACT Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.

Com o aumento da expectativa de vida no Brasil e no mundo, crescem as preocupações com as doenças mais prevalentes entre os idosos, dentre elas as doenças neurodegenerativas (DN) como a doença de Alzheimer (DA) e a doença de Parkinson (DP). Sabe-se que os depósitos proteicos relacionados com o desenvolvimento destas doenças podem preceder a fase sintomática em anos. A proteína tau é de particular interesse, uma vez que parece ser encontrada no tronco encefálico e bulbo olfatório muito antes de atingir o córtex límbico, quando ocorrem os primeiros sintomas. Dos 14 encéfalos coletados neste estudo, a proteína tau foi encontrada, no tronco encefálico, em 10 (71,42%) e no bulbo olfatório em 3 de 11. Dos 7 indivíduos que tiveram diagnóstico final de DA, todos apresentavam depósitos de tau em alguma região do tronco encefálico. Nossos dados estão de acordo com a literatura mais recente, que tem confirmado a presença de proteína tau no tronco encefálico e bulbo olfatório nos estágios mais precoces da DA.

With the increase in life expectancy in Brazil, concerns have grown about the most prevalent diseases in elderly people. Among these diseases are neurodegenerative diseases, such as Alzheimer’s and Parkinson’s diseases. Protein deposits related to the development of these diseases can pre-date the symptomatic phases by years. The tau protein is particularly interesting: it might be found in the brainstem and olfactory bulb long before it reaches the limbic cortex, at which point symptoms occur. Of the 14 brains collected in this study, the tau protein was found in the brainstems of 10 (71.42%) and in olfactory bulbs of 3 out 11. Of the 7 individuals who had a final diagnosis of Alzheimer’s disease (AD), 6 presented tau deposits in some region of the brainstem. Our data support the idea of the presence of tau protein in the brainstem and olfactory bulb in the earliest stages of AD.

Resumo Este artigo apresenta revisão das recomendações sobre os exames complementares empregados para o diagnóstico clínico de doença de Alzheimer (DA) no Brasil, publicadas em 2005. Foram avaliados de modo sistemático consensos elaborados em outros países e artigos sobre o diagnóstico de DA no Brasil disponíveis no PUBMED ou LILACS. Os exames laboratoriais recomendados são hemograma completo, creatinina sérica, hormônio tíreo-estimulante, albumina, enzimas hepáticas, vitamina B12, ácido fólico, cálcio, reações sorológicas para sífilis e, em pacientes com idade inferior a 60 anos, com apresentações clínicas atípicas ou com sintomas sugestivos, sorologia para HIV. Exame de neuroimagem estrutural, tomografia computadorizada ou - preferencialmente - ressonância magnética, é indicado na investigação diagnóstica de síndrome demencial, para exclusão de causas secundárias. Exames de neuroimagem funcional (SPECT e PET), quando disponíveis, aumentam a confiabilidade diagnóstica e auxiliam no diagnóstico diferencial de outras formas de demência. O exame do líquido cefalorraquidiano é preconizado em casos de demência de início pré-senil, com apresentação ou curso clínico atípicos, hidrocefalia comunicante e quando há suspeita de doença inflamatória, infecciosa ou priônica do sistema nervoso central. O eletroencefalograma de rotina auxilia no diagnóstico diferencial de síndrome demencial com outras condições que interferem no funcionamento cognitivo. A genotipagem da apolipoproteína E ou de outros polimorfismos de susceptibilidade não é recomendada com finalidade diagnóstica ou para avaliação de risco de desenvolvimento da doença. Os biomarcadores relacionados às alterações moleculares da DA ainda são de uso quase exclusivo em protocolos de pesquisa, mas quando disponíveis podem contribuir para maior precisão diagnóstica da doença.

Abstract This article presents a review of the recommendations on supplementary exams employed for the clinical diagnosis of Alzheimer's disease (AD) in Brazil published in 2005. A systematic assessment of the consensus reached in other countries, and of articles on AD diagnosis in Brazil available on the PUBMED and LILACS medical databases, was carried out. Recommended laboratory exams included complete blood count, serum creatinine, thyroid stimulating hormone (TSH), albumin, hepatic enzymes, Vitamin B12, folic acid, calcium, serological reactions for syphilis and serology for HIV in patients aged younger than 60 years with atypical clinical signs or suggestive symptoms. Structural neuroimaging, computed tomography or - preferably - magnetic resonance exams, are indicated for diagnostic investigation of dementia syndrome to rule out secondary etiologies. Functional neuroimaging exams (SPECT and PET), when available, increase diagnostic reliability and assist in the differential diagnosis of other types of dementia. The cerebrospinal fluid exam is indicated in cases of pre-senile onset dementia with atypical clinical presentation or course, for communicant hydrocephaly, and suspected inflammatory, infectious or prion disease of the central nervous system. Routine electroencephalograms aid the differential diagnosis of dementia syndrome with other conditions which impair cognitive functioning. Genotyping of apolipoprotein E or other susceptibility polymorphisms is not recommended for diagnostic purposes or for assessing the risk of developing the disease. Biomarkers related to the molecular alterations in AD are largely limited to use exclusively in research protocols, but when available can contribute to improving the accuracy of diagnosis of the disease.