1
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Malheiro DT, Bernardez-Pereira S, Parreira KCJ, Pagliuso JGD, de Paula Gomes E, de Mesquita Escobosa D, de Araújo CI, Pimenta BS, Lin V, de Almeida SM, Tuma P, Laselva CR, Neto MC, Klajner S, Teich VD, Kobayashi T, Edmond MB, Marra AR. Prevalence, predictors, and patient-reported outcomes of long COVID in hospitalized and non-hospitalized patients from the city of São Paulo, Brazil. Front Public Health 2024; 11:1302669. [PMID: 38317683 PMCID: PMC10839020 DOI: 10.3389/fpubh.2023.1302669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 02/07/2024] Open
Abstract
Background Robust data comparing long COVID in hospitalized and non-hospitalized patients in middle-income countries are limited. Methods A retrospective cohort study was conducted in Brazil, including hospitalized and non-hospitalized patients. Long COVID was diagnosed at 90-day follow-up using WHO criteria. Demographic and clinical information, including the depression screening scale (PHQ-2) at day 30, was compared between the groups. If the PHQ-2 score is 3 or greater, major depressive disorder is likely. Logistic regression analysis identified predictors and protective factors for long COVID. Results A total of 291 hospitalized and 1,118 non-hospitalized patients with COVID-19 were included. The prevalence of long COVID was 47.1% and 49.5%, respectively. Multivariable logistic regression showed female sex (odds ratio [OR] = 4.50, 95% confidence interval (CI) 2.51-8.37), hypertension (OR = 2.90, 95% CI 1.52-5.69), PHQ-2 > 3 (OR = 6.50, 95% CI 1.68-33.4) and corticosteroid use during hospital stay (OR = 2.43, 95% CI 1.20-5.04) as predictors of long COVID in hospitalized patients, while female sex (OR = 2.52, 95% CI 1.95-3.27) and PHQ-2 > 3 (OR = 3.88, 95% CI 2.52-6.16) were predictors in non-hospitalized patients. Conclusion Long COVID was prevalent in both groups. Positive depression screening at day 30 post-infection can predict long COVID. Early screening of depression helps health staff to identify patients at a higher risk of long COVID, allowing an early diagnosis of the condition.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vivian Lin
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Paula Tuma
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | - Takaaki Kobayashi
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Michael B. Edmond
- West Virginia University School of Medicine, Morgantown, WV, United States
| | - Alexandre R. Marra
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States
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2
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Rangel ÉB, Silva ALTE, Vidal ÉKDS, Tomaz V, Watanabe CM, Beyerstedt S, de Sales RO, de Santana EF, Leão RG, Cancello P, Aloia TPA, da Silva JC, Almeida L, de Oliveira LB, Cintra L, Hernandes C, Gamarra LF, Leão ER, Klajner S, Rizzo LV. Scientists of Tomorrow/ Cientistas do Amanhã : a project to inspire, stimulate scientific thinking, and introduce scientific methodology for young students. Einstein (Sao Paulo) 2023; 21:eAE0622. [PMID: 38126653 PMCID: PMC10730266 DOI: 10.31744/einstein_journal/2023ae0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/18/2023] [Indexed: 12/23/2023] Open
Abstract
The Scientists of Tomorrow/ Cientistas do Amanhã project is an immersive science training program developed by the Program of Post-Graduation in Health Sciences at Hospital Israelita Albert Einstein. This program was conducted in partnership with Volunteering and Escola Municipal de Ensino Fundamental Professor Paulo Freire in Paraisópolis, São Paulo, Brazil. The Scientists of Tomorrow Program comprised a short training period conducted in May 2022 involving 37 students, and a long training period from August to December 2022, which included 15 students. It aimed to popularize science through practical activities; transfer knowledge to young students; sensitize and guide them to pursue academic-scientific careers; reduce stereotypes about scientific work and scientists; and help students understand the social, political, and ethical roles of science within society. All activities were led by postgraduate students and professors from our postgraduate program, physicians, nurses, physiotherapists, biomedicals, and veterinarians from Hospital Israelita Albert Einstein, as well as medical students from Faculdade Israelita de Ciências da Saúde Albert Einstein . Activities in the short training included lectures on cinema and science, strategies to combat fake news, non-violent communication, innovation, design-thinking framework, and developing a scientific project. During the long training period, discussions were focused on nanotechnology, animal research, big data, bioinformatics, meditation, blood and bone marrow donation, telemedicine, sex and sexually-transmitted infections, rehabilitation, career opportunities, and scientific integrity. In addition, practical activities were further expanded using optical and confocal microscopy, cytometry, and basic concepts regarding the structure and function of living cells. The program also included the launching of the open-air outreach Education E-natureza activity, which turned students into ambassadors of nature. In conclusion, the Scientists of Tomorrow Program was innovative and enabled young students to learn that science is a collective activity that can enhance public health. In Brief Rangel et al. enumerated the Scientists of Tomorrow/Cientistas do Amanhã program, an immersive science initiative conducted in collaboration with a public school. The program, which involved 15 students, aimed to promote science, share knowledge, inspire academic paths, and underscore societal impacts. Led by postgraduates, professors, and healthcare experts, the program included diverse lectures and practical laboratory activities. Highlights Every research endeavor commences with a fundamental question. Sharing of findings by researchers and students contributes toward the expansion of knowledge. Teaching scientific methodology is a pivotal step in nurturing critical thinking skills. Science permeates our daily lives and plays a crucial role in addressing societal issues.
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Affiliation(s)
- Érika Bevilaqua Rangel
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - André Luiz Teles e Silva
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Érica Kássia de Sousa Vidal
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Victória Tomaz
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Caroline Mitiká Watanabe
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Stephany Beyerstedt
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Romário Oliveira de Sales
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Eliezer Francisco de Santana
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Rômulo Gonçalves Leão
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Pedro Cancello
- Escola Municipal de Ensino Fundamental Professor Paulo FreireSão PauloSPBrazil Escola Municipal de Ensino Fundamental Professor Paulo Freire
;
São Paulo
,
SP
,
Brazil
.
| | - Thiago Pinheiro Arrais Aloia
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Jaciele Conceição da Silva
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Laudiceia Almeida
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Letícia Bernardes de Oliveira
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Luciana Cintra
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Camila Hernandes
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Lionel Fernel Gamarra
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Eliseth Ribeiro Leão
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Sidney Klajner
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
| | - Luiz Vicente Rizzo
- Programa de Pós-Graduação Stricto Sensu em Ciências da SaúdeHospital Israelita Albert EinsteinSão PauloSPBrazil Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde
,
Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein
,
São Paulo
,
SP
,
Brazil
.
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3
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Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | |
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4
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Corrêa TD, Midega TD, Cordioli RL, Barbas CSV, Rabello Filho R, Silva BCD, Silva Júnior M, Nawa RK, Carvalho FRTD, Matos GFJD, Lucinio NM, Rodrigues RD, Eid RAC, Bravim BDA, Pereira AJ, Santos BFCD, Pinho JRR, Pardini A, Teich VD, Laselva CR, Cendoroglo Neto M, Klajner S, Ferraz LJR. Clinical characteristics and outcomes of patients with COVID-19 admitted to the intensive care unit during the first and second waves of the pandemic in Brazil: a single-center retrospective cohort study. Einstein (Sao Paulo) 2023; 21:eAO0233. [PMID: 37493832 PMCID: PMC10356126 DOI: 10.31744/einstein_journal/2023ao0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 02/07/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. METHODS In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. RESULTS In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. CONCLUSION In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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5
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Makdisse M, Ramos P, Malheiro D, Katz M, Novoa L, Cendoroglo Neto M, Ferreira JHG, Klajner S. Value-based healthcare in Latin America: a survey of 70 healthcare provider organisations from Argentina, Brazil, Chile, Colombia and Mexico. BMJ Open 2022; 12:e058198. [PMID: 35667729 PMCID: PMC9171220 DOI: 10.1136/bmjopen-2021-058198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Value-based healthcare (VBHC) is a health system reform gradually being implemented in health systems worldwide. A previous national-level survey has shown that Latin American countries were in the early stages of alignment with VBHC. Data at the healthcare provider organisations (HPOs) level are lacking. This study aim was to investigate how HPOs in five Latin American countries are implementing VBHC. DESIGN Mixed-methods research was conducted using online questionnaire, semistructured interviews based on selected elements of the value agenda (from December 2018 to June 2020), analyses of aggregated data and documents. Qualitative analysis was performed using NVivo QSR International, 1.6.1 (4830). Quantitative analysis used Fisher's exact test. Univariate analysis was used to compare organisations in relation to the implementation of VBHC initiatives. A p≤0.05 was considered significant. PARTICIPANTS Top and middle-level executives from 70 HPOs from Argentina, Brazil, Chile, Colombia and Mexico. RESULTS The definition of VBHC varied across participating organisations. Although the value equation had been cited by 24% of participants, its composition differed in most case from the original Equation. Most VBHC initiatives were related to care delivery organisation (56.9%) and outcomes measurement (22.4%) but in most cases, integrated practice unit features had not been fully developed and outcome data was not used to guide improvement. Information, stakeholders buy-in, compensation and fragmented care delivery were the most cited challenges to VBHC implementation. Fee-for-service predominated, although one-third of organisations were experimenting with alternative payment models. CONCLUSIONS A wide variation in the definition and level of VBHC implementation existed across organisations. Our finding suggests investments in information systems and on education of key stakeholders will be key to foster VBHC implementation in the region. Further research is needed to identify successful implementation cases that may serve as regional benchmark for other Latin American organisations advancing with VBHC.
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Affiliation(s)
- Marcia Makdisse
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Academia VBHC Educacao e Consultoria Ltda, Sao Paulo, Brazil
| | - Pedro Ramos
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | | | - Marcelo Katz
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Luisa Novoa
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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6
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Corrêa TD, Midega TD, Timenetsky KT, Cordioli RL, Barbas CSV, Silva Júnior M, Bravim BDA, Silva BC, Matos GFJD, Nawa RK, Carvalho FRTD, Queiroz VNF, Rabello Filho R, Piza FMDT, Pereira AJ, Pesavento ML, Eid RAC, Santos BFCD, Pardini A, Teich VD, Laselva CR, Cendoroglo Neto M, Klajner S, Ferraz LJR. Clinical characteristics and outcomes of COVID-19 patients admitted to the intensive care unit during the first year of the pandemic in Brazil: a single center retrospective cohort study. Einstein (Sao Paulo) 2021; 19:eAO6739. [PMID: 34878071 PMCID: PMC8664289 DOI: 10.31744/einstein_journal/2021ao6739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p<0.001], had a higher Simplified Acute Physiology Score 3 [59 (54-66) versus 47 (42-53) points; p<0.001], and presented comorbidities more frequently. During the intensive care unit stay, 56.6% of patients received noninvasive ventilation, 32.9% received mechanical ventilation, 31.3% used high flow nasal cannula, 11.7% received renal replacement therapy, and 1.5% used extracorporeal membrane oxygenation. Independent predictors of in-hospital mortality included age, Sequential Organ Failure Assessment score, Charlson Comorbidity Index, need for mechanical ventilation, high flow nasal cannula, renal replacement therapy, and extracorporeal membrane oxygenation support. Conclusion: Patients with severe COVID-19 admitted to the intensive care unit exhibited a considerable morbidity and mortality, demanding substantial organ support, and prolonged intensive care unit and hospital stay.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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7
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Barros LL, da Silva JC, Dantas ACB, Martins LAL, Klajner S, Farias AQ. Peritoneal Chlamydia trachomatis Infection as a Cause of Ascites: A Diagnosis Not to Be Missed. Case Rep Gastroenterol 2021; 15:898-903. [PMID: 34720841 PMCID: PMC8543310 DOI: 10.1159/000519706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Ascites is a common complication of several conditions, but it is rare in cases of Chlamydia trachomatis infection. We report a 36-year-old patient presenting with abdominal swelling for a week prior to hospitalization. An extensive workup excluded liver or heart disease and malignancy. A computed tomography scan demonstrated massive ascites and severe thickening of peritoneal reflections. Laboratory tests showed low serum-ascites albumin gradient, high total protein, and low adenosine. Diagnostic laparoscopy revealed inflammatory signs of both fallopian tubes. The histopathological results from peritoneal biopsy were consistent with lymphoid proliferation with reactive lymphoplasmacytic infiltrate. A gynecological investigation showed a positive DNA for C. trachomatis in the cervical swab. After treatment with doxycycline, there was a complete resolution of ascites.
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Affiliation(s)
- Luísa Leite Barros
- Departamento de Gastroenterologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jessica Calheiros da Silva
- Departamento de Gastroenterologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Alberto Queiroz Farias
- Departamento de Gastroenterologia, Hospital Das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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8
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Ramos P, Savage C, Thor J, Atun R, Carlsson KS, Makdisse M, Neto MC, Klajner S, Parini P, Mazzocato P. It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil. Soc Sci Med 2021; 282:114145. [PMID: 34192620 DOI: 10.1016/j.socscimed.2021.114145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 04/23/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Abstract
Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs - not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.
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Affiliation(s)
- Pedro Ramos
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden; Hospital Israelita Albert Einstein, Brazil.
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | - Johan Thor
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, USA
| | - Karin Solberg Carlsson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | | | | | | | - Paolo Parini
- Theme Inflammation and Infection, Karolinska University Hospital, Sweden; H7 Medicin, Huddinge, Endokrinologi och diabetes, Karolinska Institutet, Sweden
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
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9
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Araujo SEA, Kim NJ, Cendoroglo NM, Klajner S. Value of Nontechnical Skills in Minimally Invasive Surgery. Clin Colon Rectal Surg 2021; 34:131-135. [PMID: 33814993 DOI: 10.1055/s-0040-1718688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Nontechnical skills are of increasing importance in surgery and surgical training. The main studies on its impact on the safety and effectiveness of surgical interventions were mainly published in the first decade of the 2000s. Due to the significant technical complexity and great diversity of instruments for nontechnical skills evaluation, the interest in training and in measuring the impact on surgical safety has relatively decreased. However, the advent of minimally invasive surgery and its peculiar technical characteristics of sophisticated technique and constant innovation through the adoption of new materials and drugs has rekindled interest in this expertise area. In the present review, we have revisited the main instruments available to measure nontechnical skill of surgical teams and analyzed the role of the main competencies on which they are based, such as situational awareness, leadership and communication skills, and the consistency of the intraoperative decision-making process. We conclude that despite the great consensus that exists among all members of the health team on the importance of nontechnical skills for the surgical team in minimally invasive surgery, the reproducible evidence on the subject is scarce and laborious to obtain. To the extent that protecting and expanding nontechnical skills is fundamental to the path toward the high reliability of health institutions, it is possible to anticipate here the role of these institutions as promoters of continuity and new research models in this area of knowledge, especially in minimally invasive surgery, an access route to which more and more patients undergoing surgical treatment in these same institutions are submitted.
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Affiliation(s)
| | - Nam Jin Kim
- Hospital Israelita Albert Einstein, São Paulo, Brasil
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10
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Abstract
Properly performing minimally invasive colorectal procedures requires specific skills. With a focus on patient safety, the training of surgeons on patients is only accepted under exceptionally controlled, expensive, and challenging conditions. Moreover, many new techniques in colorectal surgery have been developed. Therefore, undertaking minimally invasive colorectal surgery in modern times requires specific psychomotor skills that trainee surgeons must gather in less time. In addition, there are not enough proctors with sufficient expertise for such an expressive number of new different techniques likes transanal and robotic procedures. Studies that have demonstrated an improvement in minimally invasive surgery skills to the actual operating room in general surgery and a stepwise approach to surgical simulation with a combination of various training methods appears to be useful in colorectal surgery training programs. However, the scientific evidence on the transfer of skills specifically for colorectal surgery is extremely scarce and very variable. Thus, the evaluation of the results remains quite difficult. In this review, we present the best available evidence on the types of training based on simulation, their characteristics, advantages and disadvantages, and finally the results available on their adoption. Nevertheless, scientific evidence about the benefit of simulation training in minimally invasive colorectal surgery is limited and there is a need to build more robust evidence.
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Affiliation(s)
| | - Rodrigo Oliva Perez
- Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sidney Klajner
- Colorectal Surgery Division, Hospital Israelita Albert Einstein, São Paulo, Brazil
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11
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Araujo SEA, Leal A, Centrone AFY, Teich VD, Malheiro DT, Cypriano AS, Cendoroglo Neto M, Klajner S. Impact of COVID-19 pandemic on care of oncological patients: experience of a cancer center in a Latin American pandemic epicenter. Einstein (Sao Paulo) 2020; 19:eAO6282. [PMID: 33338192 PMCID: PMC7793126 DOI: 10.31744/einstein_journal/2021ao6282] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/01/2020] [Indexed: 12/23/2022] Open
Abstract
Objective Since the rising of coronavirus disease 2019 (COVID-19) pandemic, there is uncertainty regarding the impact of transmission to cancer patients. Evidence on increased severity for patients undergoing antineoplastic treatment is posed against deferring oncologic treatment. We aimed to evaluate the impact of COVID-19 pandemic on patient volumes in a cancer center in an epicenter of the pandemic. Methods Outpatient and inpatient volumes were extracted from electronic health record database. Two intervals were compared: pre-COVID-19 (March to May 2019) and COVID-19 pandemic (March to May 2020) periods. Results The total number of medical appointments declined by 45% in the COVID-19 period, including a 56.2% decrease in new visits. There was a 27.5% reduction in the number of patients undergoing intravenous systemic treatment and a 57.4% decline in initiation of new treatments. Conversely, there was an increase by 309% in new patients undergoing oral chemotherapy regimens and a 5.9% rise in new patients submitted to radiation therapy in the COVID-19 period. There was a 51.2% decline in length of stay and a 60% reduction in the volume of surgical cases during COVID-19. In the stem cell transplant unit, we observed a reduction by 36.5% in length of stay and a 62.5% drop in stem cell transplants. Conclusion A significant decrease in the number of patients undergoing cancer treatment was observed after COVID-19 pandemic. Although this may be partially overcome by alternative therapeutic options, avoiding timely health care due to fear of getting COVID-19 infection might impact on clinical outcomes. Our findings may help support immediate actions to mitigate this hypothesis.
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Affiliation(s)
| | | | | | | | | | | | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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12
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Makdisse M, Ramos P, Malheiro D, Felix M, Cypriano A, Soares J, Carneiro A, Cendoroglo Neto M, Klajner S. What Do Doctors Think About Value-Based Healthcare? A Survey of Practicing Physicians in a Private Healthcare Provider in Brazil. Value Health Reg Issues 2020; 23:25-29. [DOI: 10.1016/j.vhri.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/04/2019] [Accepted: 10/08/2019] [Indexed: 11/25/2022]
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13
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Sobrado CW, Klajner S, Hora JAB, Mello A, Silva FMLD, Frugis MO, Sobrado LF. TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY. ACTA ACUST UNITED AC 2020; 33:e1504. [PMID: 32844877 PMCID: PMC7448859 DOI: 10.1590/0102-672020190001e1504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
Background:
Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable
option for treating patients with haemorrhoidal disease. However, there is
still controversy with regard to its efficacy for more advanced grades.
Aim:
To evaluate the effectiveness of THD-M technique for treating hemorrhoidal
disease and to compare the immediate and late results in different grades.
Method:
Seven hundred and five consecutive patients with Goligher’s grade II, III or
IV symptomatic haemorrhoids underwent surgical treatment using the THD-M
method in five participating centres. Six well-trained and experienced
surgeons operated on the patients. Average follow-up was 21 months (12-48).
Results:
Intraoperative complications were observed in 1.1% of cases, including four
cases of haematoma, two of laceration of the mucosa, and two of bleeding.
All of these were controlled by means of haemostatic suturing. In relation
to postoperative complications, the most common of these were as follows:
transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse
(6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal
thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess
(0.3%). Most of the complications were treated conservatively, and only 7.5%
(53/705) required some type of surgical approach. There was no mortality or
any severe complications. The recurrence of prolapse and bleeding was
greater in patients with grade IV haemorrhoidal disease than in those with
grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%),
respectively.
Conclusion:
The THD-M method is safe and effective for haemorrhoidal disease grades II
and III with low rates of surgical complications. However, for grade IV
hemorrhoids, it is associated with higher recurrence of prolapse and
bleeding. So, THD-M method should not be considered as an effective option
for the treatment of grade IV hemorrhoids.
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Affiliation(s)
- Carlos Walter Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
| | | | | | | | | | | | - Lucas Faraco Sobrado
- Department of Gastroenterology, Faculty of Medicine, University of São Paulo, SP, Brazil
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14
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Teich VD, Klajner S, Almeida FASD, Dantas ACB, Laselva CR, Torritesi MG, Canero TR, Berwanger O, Rizzo LV, Reis EP, Cendoroglo Neto M. Epidemiologic and clinical features of patients with COVID-19 in Brazil. Einstein (Sao Paulo) 2020; 18:eAO6022. [PMID: 32813760 PMCID: PMC7422909 DOI: 10.31744/einstein_journal/2020ao6022] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/31/2020] [Indexed: 01/08/2023] Open
Abstract
Objective This study describes epidemiological and clinical features of patients with confirmed infection by SARS-CoV-2 diagnosed and treated at
Hospital Israelita Albert Einstein
, which admitted the first patients with this condition in Brazil. Methods In this retrospective, single-center study, we included all laboratory confirmed COVID-19 cases at
Hospital Israelita Albert Einstein
, São Paulo, Brazil, from February until March 2020. Demographic, clinical, laboratory and radiological data were analyzed. Results A total of 510 patients with a confirmed diagnosis of COVID-19 were included in this study. Most patients were male (56.9%) with a mean age of 40 years. A history of a close contact with a positive/suspected case was reported by 61.1% of patients and 34.4% had a history of recent international travel. The most common symptoms upon presentation were fever (67.5%), nasal congestion (42.4%), cough (41.6%) and myalgia/arthralgia (36.3%). Chest computed tomography was performed in 78 (15.3%) patients, and 93.6% of those showed abnormal results. Hospitalization was required for 72 (14%) patients and 20 (27.8%) were admitted to the Intensive Care Unit. Regarding clinical treatment, the most often used medicines were intravenous antibiotics (84.7%), chloroquine (45.8%) and oseltamivir (31.9%). Invasive mechanical ventilation was required by 65% of Intensive Care Unit patients. The mean length of stay was 9 days for all patients (22 and 7 days for patients requiring or not intensive care, respectively). Only one patient (1.38%) died during follow-up. Conclusion These results may be relevant for Brazil and other countries with similar characteristics, which are starting to deal with this pandemic.
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Affiliation(s)
| | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Makdisse M, Ramos P, Malheiro D, Cypriano A, Soares J, Carneiro A, Felix M, Neto M, Klajner S. PNS42 A SURVEY OF PRACTICING PHYSICIANS ON VALUE-BASED HEALTH CARE IN A PRIVATE HEALTH SYSTEM IN BRAZIL. Value Health Reg Issues 2019. [DOI: 10.1016/j.vhri.2019.08.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Makdisse M, Ramos P, Katz M, Malheiro D, Ferreira J, Neto M, Klajner S. PNS41 VALUE BASED HEALTH CARE (CUIDADO BASADO EM VALOR) EN AMERICA LATINA: RESULTADOS PRELIMINARES DE UNA INVESTIGACION CON 40 HOSPITALES DE CINCO PAISES LATINOAMERICANOS. Value Health Reg Issues 2019. [DOI: 10.1016/j.vhri.2019.08.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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17
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Araújo SEA, Marcante MT, Mendes CRS, Bertoncini AB, Seid VE, Horcel LA, Perez RO, Klajner S. INTERESFINCTERIAL LIGATION OF FISTULA TRACT (LIFT) FOR PATIENTS WITH ANAL FISTULAS: A BRAZILIAN BI-INSTITUTIONAL EXPERIENCE. ACTA ACUST UNITED AC 2018; 30:235-238. [PMID: 29340544 PMCID: PMC5793138 DOI: 10.1590/0102-6720201700040002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/21/2017] [Indexed: 02/06/2023]
Abstract
Background: The best treatment for anal fistula should extirpate infection and promote healing of the tract, whilst preserving the anal sphincter complex and full continence. Aim: To analyze the success rate after a modified technique for ligation of the intersphincteric fistula tract (LIFT) for patients with anal fistulas. Methods: A prospective (observational cohort study) Brazilian bi-institutional experience with a modified (ligation of the intersphincteric fistula tract without excision) LIFT technique was undertaken. A clinical database was settled for the following variables: age, gender, BMI, comorbidities, distance between external orifice and the anus, previous fistula surgery, type of fistula, operative time, intra- and postoperative complications, duration of follow-up, and success rate. Results: Between November 2015 and January 2017, 38 patients with transsphincteric fistulas were operated on using the modified LIFT procedure. Seventeen (44.7%) were men. Median age was 41 (18-67) years. Median BMI was 26.4 (22-38) kg/m2. Five (13.2%) had undergone previous surgery. The fistula was transsphincteric in all cases. Median follow-up was 32 (range, 14-56) weeks. Success was observed in 30 (79%) patients. Conclusions: The LIFT technique without excision of the fistula tract proved to be safe and effective for transsphincteric anal fistulas.
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Affiliation(s)
| | | | | | | | | | | | | | - Sidney Klajner
- Coloproctology, Hospital Israelita Albert Einstein, São Paulo, SP
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18
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Klajner S. Accelerating patient experience performance: Collaboration and engagement as drivers for success. Patient Experience Journal 2017. [DOI: 10.35680/2372-0247.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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19
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Araujo SEA, Horcel LDA, Seid VE, Bertoncini AB, Klajner S. LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY. Arq Bras Cir Dig 2017; 29:159-163. [PMID: 27759778 PMCID: PMC5074666 DOI: 10.1590/0102-6720201600030008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/24/2016] [Indexed: 12/29/2022]
Abstract
Background: Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients. Aim: To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique. Method: In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up. Results: The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97). Conclusion: Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.
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Affiliation(s)
| | | | | | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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20
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Araujo SEA, Seid VE, de Araujo Horcel L, Klajner S. WITHDRAWN: Long term results after stapled hemorrhoidopexy alone and supplemented by excisional hemorrhoidectomy: A retrospective cohort study. International Journal of Surgery Open 2017. [DOI: 10.1016/j.ijso.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Affiliation(s)
- Sidney Klajner
- Sociedade Beneficente Israelita Brasileira Albert Einstein, São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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22
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Araujo SEA, Perez RO, Seid VE, Bertoncini AB, Klajner S. Laparo-endoscopic Transanal Total Mesorectal Excision (TATME): evidence of a novel technique. MINIM INVASIV THER 2016; 25:278-87. [DOI: 10.1080/13645706.2016.1199435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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Padovesi Mota IL, Klajner S, da Costa Gonçalves MO, Passman LJ, Podgaec S. Appendiceal Nodules in the Setting of Endometriosis Can Be Carcinoid Tumors. JSLS 2016; 19:JSLS.2015.00028. [PMID: 26175555 PMCID: PMC4489857 DOI: 10.4293/jsls.2015.00028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction: Endometriosis is occasionally found in the appendix, particularly in severe forms of deep infiltrating disease. Carcinoid tumor is the most common neoplasm of the appendix and may be overlooked or misdiagnosed when there are multiple endometriosis lesions in the pelvis. Case Description: We describe two cases of carcinoid tumor diagnosed in patients who underwent surgery to treat endometriosis, in whom the diagnosis of appendiceal endometriosis was presumed. Discussion: In the context of endometriosis, surgery is indicated when the appendix is affected. Despite the more likely diagnosis of appendiceal endometriosis, carcinoid tumors cannot be ruled out by imaging examinations.
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Affiliation(s)
| | | | | | - Leigh J Passman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Sergio Podgaec
- Department of Obstetrics and Gynecology, University of São Paulo School of Medicine, São Paulo, Brazil
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Araujo SEA, Seid VE, Klajner S. Robotic surgery for rectal cancer: Current immediate clinical and oncological outcomes. World J Gastroenterol 2014; 20:14359-14370. [PMID: 25339823 PMCID: PMC4202365 DOI: 10.3748/wjg.v20.i39.14359] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 05/21/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic rectal surgery continues to be a challenging operation associated to a steep learning curve. Robotic surgical systems have dramatically changed minimally invasive surgery. Three-dimensional, magnified and stable view, articulated instruments, and reduction of physiologic tremors leading to superior dexterity and ergonomics. Therefore, robotic platforms could potentially address limitations of laparoscopic rectal surgery. It was aimed at reviewing current literature on short-term clinical and oncological (pathological) outcomes after robotic rectal cancer surgery in comparison with laparoscopic surgery. A systematic review was performed for the period 2002 to 2014. A total of 1776 patients with rectal cancer underwent minimally invasive robotic treatment in 32 studies. After robotic and laparoscopic approach to oncologic rectal surgery, respectively, mean operating time varied from 192-385 min, and from 158-297 min; mean estimated blood loss was between 33 and 283 mL, and between 127 and 300 mL; mean length of stay varied from 4-10 d; and from 6-15 d. Conversion after robotic rectal surgery varied from 0% to 9.4%, and from 0 to 22% after laparoscopy. There was no difference between robotic (0%-41.3%) and laparoscopic (5.5%-29.3%) surgery regarding morbidity and anastomotic complications (respectively, 0%-13.5%, and 0%-11.1%). Regarding immediate oncologic outcomes, respectively among robotic and laparoscopic cases, positive circumferential margins varied from 0% to 7.5%, and from 0% to 8.8%; the mean number of retrieved lymph nodes was between 10 and 20, and between 11 and 21; and the mean distal resection margin was from 0.8 to 4.7 cm, and from 1.9 to 4.5 cm. Robotic rectal cancer surgery is being undertaken by experienced surgeons. However, the quality of the assembled evidence does not support definite conclusions about most studies variables. Robotic rectal cancer surgery is associated to increased costs and operating time. It also seems to be associated to reduced conversion rates. Other short-term outcomes are comparable to conventional laparoscopy techniques, if not better. Ultimately, pathological data evaluation suggests that oncologic safety may be preserved after robotic total mesorectal excision. However, further studies are required to evaluate oncologic safety and functional results.
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Araujo SEA, Seid VE, Klajner S, Bertoncini AB. Left colectomy with intracorporeal anastomosis: technical aspects. Einstein (Sao Paulo) 2014; 12:386-8. [PMID: 25295460 PMCID: PMC4872958 DOI: 10.1590/s1679-45082014md3030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 04/22/2014] [Indexed: 12/19/2022] Open
Abstract
Oncologic laparoscopic colectomy represents a fully validated surgical approach to the management of colorectal cancer. However, laparoscopic surgery for distal transverse and descending colon lesions remains a challenging procedure. A total laparoscopic approach to the left colectomy is an interesting option for critically ill patients although reports in the literature on this subject are scarce and its approach still not standardized because of its selective nature for indication. There are several advantages associated with conduction of totally laparoscopic approach to the left colon. Intracorporeal vessel sealing ensures an adequate lymph node dissection. Moreover, it enables the construction of a well-vascularized anastomosis. Ultimately, the occurrence of late wound complications are possibly reduced for the placement of a low abdominal incision exclusively used for specimen extraction. This paper aimed at describing our technique for a totally laparoscopic left colectomy for distal transverse and descending colon lesions.
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Affiliation(s)
| | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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26
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Podgaec S, Gonçalves MO, Klajner S, Abrão MS. Epigastric pain relating to menses can be a symptom of bowel endometriosis. SAO PAULO MED J 2008; 126:242-4. [PMID: 18853038 DOI: 10.1590/s1516-31802008000400012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Accepted: 06/18/2008] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Endometriosis is a common affliction that may affect the intestinal tract. The objective of this case report was to describe an unusual clinical presentation of this form of the disease. CASE REPORT The patient was a 35-year-old woman with epigastric pain that only occurred during menstruation, who had a history of bladder endometriosis. Endoscopy of the upper digestive tract showed normal results. Transvaginal ultrasound and nuclear magnetic resonance of the pelvis showed a lesion involving the ileocecal junction and appendix, measuring 30 x 22/x/13/mm, that was suggestive of endometriosis. The patient underwent laparoscopic resection of the bowel segment affected by the disease, followed by anastomosis of the ileum and ascending colon for immediate restoration of intestinal transit. Histological analysis confirmed the diagnosis of endometriosis. CONCLUSIONS In young women, recurrent epigastric pain should be evaluated with regard to its relationship to menstruation, particularly if there is a history of endometriosis, since this may be a clinical sign that the disease is affecting the intestinal transit.
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Santoro S, Malzoni CE, Velhote MCP, Milleo FQ, Santo MA, Klajner S, Damiani D, Maksoud JG. Digestive Adaptation with Intestinal Reserve: a neuroendocrine-based operation for morbid obesity. Obes Surg 2007; 16:1371-9. [PMID: 17059749 DOI: 10.1381/096089206778663841] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mechanical obstacles to food ingestion, nutrient-excluded segments and malabsorption are common strategies of bariatric surgery which are a potential cause of symptoms or complications. We describe an operation "Digestive Adaptation with Intestinal Reserve" (DAIR) that does not utilize these tools, aiming fundamentally at neuroendocrine changes. METHODS The operation includes sleeve gastrectomy, omentectomy and enterectomy, maintaining the initial 40 cm of jejunum and final 260 cm of ileum (keeping the bowel length at the lower limit for adaptation to normal). Jejunum is laterally anastomosed to ileum 80 cm proximal to the cecum. A gastroileostomy creates a transit bipartition (ileum and proximal bowel in transit). 55 patients are presented whose follow-up is >12 months (12-34 months). Fasting ghrelin and resistin, and postprandial GLP-1 and PYY were measured. RESULTS Mean BMI reduction was 4.8, 9.5, 15.4 and 20.1 kg/m(2) respectively at 1, 3, 6 and 12 months. Patients have early satiety and major improvement in pre-surgical co-morbidities, especially diabetes and hypertension. GLP-1 and PYY response to food ingestion were enhanced; fasting ghrelin and resistin were significantly reduced (P<0.05). Radiographic studies show nutrient transit through the pylorus and through the gastroileostomy. Early surgical complications (2 in 55 patients) resolved without sequelae. There were no signals of malabsorption, no deaths, and most patients present no symptoms at all. CONCLUSIONS DAIR amplifies postprandial neuroendocrine response and provokes intense weight loss. DAIR reduces production of ghrelin and resistin and enables more nutrients to be absorbed distally enhancing GLP-1 and PYY secretion. Diabetes improved significantly without duodenal exclusion.
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Affiliation(s)
- Sérgio Santoro
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil.
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Santoro S, Velhote MCP, Malzoni CE, Milleo FQ, Klajner S, Campos FG. Preliminary results from digestive adaptation: a new surgical proposal for treating obesity, based on physiology and evolution. SAO PAULO MED J 2006; 124:192-7. [PMID: 17086299 DOI: 10.1590/s1516-31802006000400004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Accepted: 07/10/2006] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Most bariatric surgical techniques include essentially non-physiological features like narrowing anastomoses or bands, or digestive segment exclusion, especially the duodenum. This potentially causes symptoms or complications. The aim here was to report on the preliminary results from a new surgical technique for treating morbid obesity that takes a physiological and evolutionary approach. DESIGN AND SETTING Case series description, in Hospital Israelita Albert Einstein and Hospital da Polícia Militar, São Paulo, and Hospital Vicentino, Ponta Grossa, Paraná. METHODS The technique included vertical (sleeve) gastrectomy, omentectomy and enterectomy that retained three meters of small bowel (initial jejunum and most of the ileum), i.e. the lower limit for normal adults. The operations on 100 patients are described. RESULTS The mean follow-up was nine months (range: one to 29 months). The mean reductions in body mass index were 4.3, 6.1, 8.1, 10.1 and 10.7 kg/m2, respectively at 1, 2, 4, 6 and 12 months. All patients reported early satiety. There was major improvement in comorbidities, especially diabetes. Operative complications occurred in 7% of patients, all of them resolved without sequelae. There was no mortality. CONCLUSIONS This procedure creates a proportionally reduced gastrointestinal tract, leaving its basic functions unharmed and producing adaptation of the gastric chamber size to hypercaloric diet. It removes the sources of ghrelin, plasminogen activator inhibitor-1 (PAI-1) and resistin production and leads more nutrients to the distal bowel, with desirable metabolic consequences. Patients do not need nutritional support or drug medication. The procedure is straightforward and safe.
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Strassmann V, Velhote MC, Santoro S, Malzoni CE, Klajner S, Borges PC. [Videolaparoscopic appendectomy with linear stapler]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:230-3. [PMID: 10436631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
It is presented the experience of 126 cases of acute appendicitis treated by a videolaparoscopic appendectomy using a 12 mm endostapler with 4 lines of staples and a linear cutting device in the middle. It has been used two trocars (5 mm) at the left side and one other (12 mm) trocar at the umbilicus. In the first cases other dispositions were used but this one seemed to be better. Through the left trocars, a dissection is promoted, isolating the appendix, its base and its mesentery, in which a small hole is made, close to the base. Through this hole, it is passed one of the sides of the 12 mm stapler. The device promotes the bilateral stapling and cuts the appendix at its base. The stapler is reloaded with vascular staples and then the mesentery is stapled and cut by the same way. It is a very fast method. Besides, the laparoscopic option gives the opportunity to equally treat appendicitis at unusual positions, to examine other pelvic organs (eventually treating diseases) and to aspirate secretions under direct view, anywhere in the cavity. The specimen is taken out of the cavity inside a plastic bag and we had no case of infection at the trocar sites. Only in 3 cases there were conversion to open surgery, due to difficult dissection and identification of structures, in all of them with very advanced disease and necrosis. It is concluded that this method is fast, safe, easy (although more expensive) and can be utilized routinely, at least in the first approach of the treatment of acute appendicitis.
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Affiliation(s)
- V Strassmann
- Disciplina de Cirurgia do Aparelho Digestivo, Faculdade de Medicina, Universidade de São Paulo
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Domene CE, Amico EC, Klajner S, Ribeiro LA, Santo MA, Pinotti HW. [Acute appendicitis following laparoscopic inguinal hernioplasty. Coincidence or complication?]. Rev Hosp Clin Fac Med Sao Paulo 1998; 53:199-201. [PMID: 9922501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Intraperitoneal complications related to laparoscopic inguinal hernia repair by transabdominal approach had been described. The authors report the first case of postoperative acute appendicitis in a patient submitted to a transuretral prostate resection and bilateral inguinal hernioplasty by the TAPP technique, resulting in a second laparoscopic intervention.
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Affiliation(s)
- C E Domene
- Unidade de Cirurgia Laparoscópica da Disciplina de Cirurgia do Aparelho Digestivo, Faculdade de Medicina da Universidade de São Paulo
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Herman P, Klajner S, Borges PC, Pugliese V, Miranda MP, Genzini T, D'Albuquerque LA, Chaib E, Cunha JE, Machado MC, Saad WA, Pinotti HW. [Surgical treatment of solitary liver cysts]. Arq Gastroenterol 1996; 33:6-9. [PMID: 8762680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Solitary hepatic cysts an uncommon disease in the past, which incidental diagnosis is increasing with the advent of ultrasound and computed tomography, are nowadays very frequent. Cysts that reach massive proportions often become symptomatic and necessitate surgical intervention. Surgical wide unroofing technique is a simple procedure advocated for the treatment of symptomatic patients. Ten patients with solitary liver cysts were submitted to wide unroofing with good immediate and late results.
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Affiliation(s)
- P Herman
- Faculdade de Medicina da Universidade de São Paulo
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Herman P, Pugliese V, Chaib E, D'Albuquerque LA, Klajner S, Shu FB, Machado MC, Saad WA, Pinotti HW. [Splenic artery aneurysm in patients with hepato-splenic schistosomiasis mansoni and portal hypertension. Report of 3 cases]. Arq Gastroenterol 1994; 31:149-53. [PMID: 7575175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The authors present three cases of splenic artery aneurysm in a group of 96 patients with portal hypertension due to Schistosomiasis mansoni. Etiology, diagnosis and treatment are discussed.
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Affiliation(s)
- P Herman
- Serviço de Cirurgia do Fígado e Hipertensão Portal do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, HCFMUSP
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