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    Tumor miofibroblástico meníngeo, um desafio diagnóstico
    (Universidade Federal de São Paulo (UNIFESP), 2019-12-18) Peruzzo, Barbara Giovanna [UNIFESP]; Vilanova, Luiz Celso Pereira [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    A 19 years old male patient, with onset of progressive headache 7 years ago, as well as visual and hearing loss, and epilepsy. Physical examination showed proptosis and optic atrophy. Brain magnetic resonance imaging (MRI) revealed diffuse meningeal thickening and enhancement with some nodular areas, edema of the parenchyma and occlusion of the right transverse and sigmoid sinuses. Cerebrospinal fluid (CSF) identified lympho-mononuclear pleocytosis and hyperproteinorrachia. Collagenosis and vasculitis laboratory tests were normal. Cerebral and meningeal biopsy revealed myofibroblast proliferation and lymphoplasmacytic infiltration, without immunohistochemical expression for IgG4 (positivity less than 5%), which suggest the diagnosis of inflammatory myofibroblastic meningeal tumor. The objective of this study is to describe a clinical case that is hard to diagnose, with a long time from onset of symptoms to a diagnostic definition, where definitive diagnosis was possible only after the third meningeal biopsy.
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    Risco de fibrilação atrial em longevos
    (Universidade Federal de São Paulo (UNIFESP), 2019-06-27) Sepulvida, Mariana Bellaguarda De Castro [UNIFESP]; Miranda, Roberto Dischinger [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Background: Ageing is an important risk factor for Atrial Fibrillation (AF) and Cardioembolic Stroke. Objectives: To access, in the very elderly, the AF prevalence and risk using a new method and to estimate the embolic risk by a clinical score. Methods: Elderly aged 80 and over were included from a geriatric outpatient assistance. AF risk was estimated using an automated analysis system from a 60- minute electrocardiogram (Stroke Risk Analysis - SRAÒ). The patients were classified according to the exam as low risk (LR), elevated risk (ER) or manifested AF (mAF). We calculated the presumed cardioembolic stroke risk using CHADS2 and CHA2DS2- VASc scores. Results: Data from 307 patients were analyzed, being 237 of them female (77,2%). The mean age was 86,8 years old. mAF was detected in 16 patients (5,2%), ER in 131 (42,7%) and LR in 160 of them (52,1%). For each year old, they were 9% more likely to present ER (p=0,002) and increased 18% the risk of mAF (p=0,017). A high-risk score, whereas CHADS2 ≥ 2 and CHA2DS2-VASc ≥ 4, was identified in 254 (82,7%) and in 247 (80,5%) participants, respectively. Conclusion: In this very elderly population, the AF risk was elevated, as well as the presumed stroke risk. Our results corroborate the importance of the active AF screening and the SRA might be a promising method for this aim.
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    Achalasia treatment in patients over 80 years of age. A multicenter survey.
    (Universidade Federal de São Paulo (UNIFESP), 2019-10-31) Zotti, Orlando Rondan [UNIFESP]; Fernandes, Fernando Augusto Mardiros Herbella [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Achalasia has a bimodal distribution of incidence according to age with peaks at around 30 and 60 years [1]. Laparoscopic Heller´s myotomy (LHM), per oral endoscopic myotomy (POEM) and pneumatic dilatation (PD) are well-established methods to treat achalasia [2]. It is known that PD has low success rates in young patients [3] but the ideal treatment algorithmin the older patients is, however, still elusive. Age and co-morbities may influence clinical decision towards less invasive procedures. This multicenter study aims to review outcomes and changes in routine clinical therapeutic options in achalasia patients over 80 years of age. Background and aims: laparoscopic heller's myotomy (lhm), per oral endoscopic myotomy (poem) and pneumatic dilatation (pd) are well-established methods to treat achalasia. The ideal treatment algorithm in elderly patients is, however, still elusive. This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in patients over 80 years of age. Methods: worldwide high volume centers for the treatment of achalasia were surveyed. Therapeutic options and outcomes in patients over 80 years of age were reviewed. Results: 85 (54% males, mean age 84±4 years) patients were studied. Primary treatment was endoscopic in 43 (51%) patients; surgical in 39 (46%) patients (30 lhm, 9 cardioplasty + gastrectomy); and medical in 3 (4%) patients. Four centers tailored treatment based on age (14% of the patients). Secondary treatment was necessary in 34 (40%) patients; 30 of them with endoscopic treatment as primary treatment. Lhm performed in 20 patients and endoscopic treatment in 14. A total of 11 (13%) patients had complications after lhm. Seven had lhm or cardioplasty + gastrectomy as primary treatment. Four had lhm as secondary treatment. The mean time of hospitalization was 4±2 days for those who did not had complications, and 7±6 days for those who had complications. Conclusion: most specialized centers do not tailor treatment based on advanced age. Treatment of the oldest-old patients should be based solely on their physiologic and mental health not their age. Endoscopic treatment has a high rate of recurrence and gastrectomy a high rate of complications in his population. Lhm seems to be a safe option with good outcomes in this population.
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    Alterações hepáticas em transplantados renais: experiência de um ambulatório especializado
    (Universidade Federal de São Paulo (UNIFESP), 2019-01-31) Vieira, Gustavo De Almeida [UNIFESP]; Ferraz, Maria Lucia Cardoso Gomes [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Introduction: Renal transplantation is considered the treatment of choice for patients with end-stage renal disease (ESRD) and is associated with decreased mortality when compared to dialysis methods. Kidney transplants are one of the most frequent in the world and Brazil is the second country that transplants most kidneys in the world. Liver changes are common complications in renal transplant patients (RTx) and their incidence is about 20-50% post-transplantation, with significant impact on patient’s survival and quality of life. The frequency and characteristics of these abnormalities are poorly described in the literature. Objective: To determine the prevalence of causes of hepatic abnormalities in RTx, to associate the characteristics of liver changes to demographic, epidemiological and clinical variables, to compare the characteristics of liver abnormalities among the different etiologies and to evaluate possible changes in the diagnoses in two different time periods. Methods: A cross-sectional and descriptive epidemiological observational study was carried out at an outpatient clinic of the Hospital São Paulo (EPM / Unifesp) specialized in the care of patients with liver abnormalities and underlying renal diseases. Results: The most prevalent etiologies in this study were: hepatitis C (HCV), hepatitis B (HBV), iron overload, non-alcoholic fatty liver disease (NAFLD) and drug induced hepatic injury (DILI). Comparing to the other etiologies, patients with hepatitis C were older, with the female gender occurring more in HCV compared to the other etiologies and had a longer time of transplantation and hemodialysis; hepatitis B patients has the lowest levels of gamma-glutamyl transferase; in iron overload the patients were younger and remained on hemodialysis for longer period of time; in non-alcoholic fatty liver disease, the patients were older and had association with diabetes mellitus and systemic arterial hypertension; in the drug-induced liver injury patients had higher levels of liver enzymes. In the two evaluation periods it was observed that in P1 (period from 1993 to 2005) the patients were older and were more frequently evaluated due to positive serology for HCV and HBV; in P2 (period from 2006 to 2018) the main reason for evaluation was abnormal levels of amintransferases. The predominant diagnoses in P1 were HCV and HBV; in P2 predominated the DHGNA and DILI. Conclusion: The evaluation of the main hepatic changes in TxR is important because it provides bases for a better management of these patients and also for prevention of these complications in this special group of patients.
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    Comparação qualitativa de dois softwares na geração de tratografia por ressonância magnética em pacientes portadores de tumores do sistema nervoso central
    (Universidade Federal de São Paulo (UNIFESP), 2019-02-28) Salu, Samuel [UNIFESP]; Paiva Neto, Manoel Antonio De [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Introduction: Diffusion Tensor Imaging (DTI) tractography is widely used in neurosurgery for surgical planning and white matter delineation. One of the several factors that influence the generation of DTI tractography is the software. Objective: Since there is still no gold-standard software in the generation of tractography in patients with central nervous system tumors, this study aims to determine if the choice of software would result in a change of position of the white matter tracts in relation to the tumor and if this would alter the surgical planning. Methods: Twenty-one patients with central nervous system tumors had their 273 tracts evaluated by two different software (Philips – Extended MR WorkSpace e Eximius – Version 3.5.7234.r6563c). The tracts evaluated were corpus callosum, corticospinal tract, uncinate fasciculus, inferior fronto-occipital fasciculus, superior longitudinal fasciculus, arcuate fasciculus, and cingulum. Each tract was evaluated for its position relative to the tumor. The results were also separated into two categories: affected and not affected by tumors. Results: There was a perfect agreement (κ = 1.00) for position of the 273 tracts in all patients, despite slightly differences in morphology of fibers generated. Tracts that could not be reconstructed in one software could not be reconstructed in the other. Conclusion: There was no divergence between software in the generation of tracts affected by intracranial neoplasia. There was no divergence between software in the generation of tracts not affected by intracranial neoplasia. The choice of software did not influence the surgical approach to tumors.