Analysis of survival and neoplasm recurrence in patients undergoing liver transplantation for hepatocellular carcinoma : association with immunohistochemical profile and tumor characteristics

Orientadores: Ilka de Fátima Santna Ferreira Boin, Cecilia Amélia Fazzio EscanhoelaTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: Apesar de sobrevida ao redor de 70% em cinco anos a recidiva do CHC vem suscitando cuidados com índices que variam na literatura entre 6% a 26%. Muitos são os fatores atrelados ao maior risco de recidiva descritos na literatura, sem definição de qual o melhor método que poderia predizer esse evento de alta letalidade. Objetivo: Os objetivos desse estudo foram: avaliar a sobrevida e recidiva tumoral em pacientes submetidos a transplante hepático por CHC e investigar a imunoexpressão dos marcadores imunohistoquimicos: HSP70, Glipican3, Glutamina sintetase, beta-catenina, CK7, Ck19, HepPar1 e PCNA, estudando sua associação com características tumorais e prognóstico de pacientes submetidos a transplante hepático por CHC. Método: Foram estudados 90 pacientes portadores de CHC submetidos a transplante hepático de 1996 a 2010. Foram estudados fatores correlacionados ao aparecimento da recidiva neoplásica como: tamanho da maior lesão, número de lesões, grau histológico, presença de invasão vascular, nível de alfa-feto proteína (AFP) superior a 200 ng/ml e regime de imunossupressão. Foi estudada também a correlação da expressão dos marcadores imunohistoquimicos estudados com cada uma dessas mesmas variáveis. A técnica de estudo imunohistoquimico foi o arranjo em matriz tecidual (TMA). A análise estatística utilizou testes de regressão uni e multivariadas, teste de Cox, teste de Qui-quadrado ou Fisher, teste de Mann-Whitney e para estudo de sobrevida foi utilizado o método de Kaplan Meyer. Resultados: Foi observada recidiva em 7 pacientes (8%).O tempo de cirurgia, quantidade de concentrados de hemácias administrados, valor do MELD calculado no momento da cirurgia e a presença de recidiva foram associados à menor sobrevida. Pacientes com recidiva tumoral apresentaram tendência à presença de invasão vascular, apresentaram maior número de nódulos e maiores nódulos. Em relação aos marcadores imunohistoquimicos pacientes com glutamina sintetase positiva apresentaram tendência à menor sobrevida; e a presença de HepaPar1 negativo apresentou correlação com o aparecimento de recidiva neoplásica. Pacientes com HSP70 positivo apresentaram maior prevalência do grau histológico III. Pacientes com Glipican3 positivo apresentaram nódulos maiores e presença de mais casos com AFP superior a 200 ng/ml. Pacientes com PCNA positivo apresentaram nódulos maiores. Pacientes com HepPar1 negativo apresentaram nódulos maiores e tendência a apresentar mais nódulos. Pacientes com beta-catenina positiva apresentaram maiores nódulos e presença de maior número de pacientes com grau histológico III. Pacientes com CK19 positivo demonstraram tendência a apresentar nódulos maiores (p=0.05). A associação entre beta-catenina e Glipican3 positivos demonstrou correlação com a presença de nódulos maiores com maior evidência estatística do que quando avaliados separadamente (p=0,003). Conclusão: Não foi possível a associação de nenhum desses marcadores com a sobrevida exceto pela presença de glutamina sintetase positiva que apresentou tendência à associação com piora da sobrevida. A imunoexpressão desses marcadores não se correlacionou com o tempo de aparecimento de recorrência tumoral, com exceção da do HepPar1, o qual, quando negativo, correlacionou-se com maior frequência de aparecimento de recidiva. Entretanto, a maioria dos marcadores estudados apresentaram correlação com pelo menos uma das variáveis em estudo, confirmando nossa hipótese de que esses marcadores podem, sim, auxiliar na avaliação do prognóstico de pacientes submetidos a transplante hepático por CHCAbstract: Introduction: Although overall survival rates have been around 70% after five years, recurrence of HCC has indices in literature ranging from 6 to 26%. There is no consensus therapy for treatment of HCC recurrence after liver transplantation that could lead to a significant increase in survival. Many factors are linked to higher risk of recurrence in the literature, without defining the best method that could predict this highly lethal event. Objective: The aim of this study was first to evaluate the survival and tumor recurrence in patients undergoing liver transplantation for HCC and second to evaluate immunoexpression of immunohistochemical markers: HSP70, Glipican3, Glutamin synthetase, Beta-Catenin, CK7, Ck19, HepPar1 and PCNA, which are capable of assessing the malignant cellular potential, studying its association with tumor characteristics and prognosis of patients undergoing liver transplantation for HCC. Methods: We studied 90 patients who underwent liver transplantation from 1996 to 2010. We evaluated factors related to survival and tumor recurrence. Factors were also studied related to the onset of neoplastic recurrence as size of the largest lesion, number of lesions, histological grade, presence of vascular invasion, AFP level greater than 200 ng / ml and the immunosuppressive regimen. The correlation of expression of immunohistochemical markers studied was correlated with each of these variables. The immunohistochemistry technique was the tissue matrix arrangement (TMA) and the statistical analysis used was regression testing univariate and multivariate, Cox test, chi-square or Fisher test and Mann-Whitney test, while for study of survival the Kaplan Meyer curve was used. Results: The duration of surgery and recurrence was associated with shorter survival. Patients with tumor recurrence tended to have the presence of vascular invasion, showing a higher number of nodules and larger nodules. Regarding the presence of immunohistochemical markers glutamin synthetase showed a positive trend toward lower survival, and presence of HepPar1 negative correlated with the appearance of neoplastic recurrence. HSP70 positive patients had higher prevalence of histologic grade III. Patients with positive Glipican3 showed larger lesions and more patients had AFP greater than 200 ng / ml. PCNA positive patients had bigger lesions. HepPar1 negative patients had larger lesions and tended to have more nodules. Patients with positive Beta-Catenin showed larger nodules and more histologic grade III. Patients with positive CK19 showed a tendency to have larger nodules. The association between Beta-catenin and Glipican3 showed positive association with larger nodules. Conclusion: There was no statistical correlation of these markers and the specific disease survival except for the presence of glutamine synthetase which showed only a positive trend of association with survival. The immunoreactivity of these markers did not correlate with the time of appearance of a recurrent tumor, with the exception of the Hep-Par1, which, if negative, was correlated with higher frequency of occurrence of relapse. However, most of the markers studied showed correlation with at least one of the variables studied, whether of characteristics of the population (AFP level, the presence of recurrence and survival time) or characteristics of the lesion (tumor number, the greater lesion size, presence of vascular invasion and degree of differentiation) confirming our hypothesis that these markers can indeed assist in assessing the prognosis of patients undergoing liver transplantation for HCCDoutoradoFisiopatologia CirúrgicaDoutor em Ciências da Cirurgi

OS DESAFIOS DO ENSINO DE LÍNGUA INGLESA EM UMA ESCOLA DE TEMPO INTEGRAL

Este artigo busca refletir sobre o ensino de Língua Inglesa em uma escola de Araguaína (TO). Em como esse desafio se perpetua em sala de aula na relação entre professor-aluno. Após experiências vividas durante o período do Programa de Residência Pedagógica, enquanto cursava o curso de Letras - Língua Inglesa e Literaturas da Universidade Federal do Tocantins, que foi realizado em uma escola de tempo integral de ensino médio. Serão destacados, por meio de relatos reflexivos, quais foram os obstáculos e desafios enfrentados durante essa vivência e quais os pontos positivos e negativos do ensino de Língua Inglesa na escola. Como embasamento teórico serão utilizados documentos que trazem orientações sobre o ensino de Língua Inglesa, como BNCC (Base Nacional Comum Curricular), OCEM (Orientações Curriculares para o Ensino Médio) e PCN (Parâmetros Curriculares Nacionais)

Walking the talk for dementia: a unique immersive, embodied, and multi‐experiential initiative

Coping with dementia requires an integrated approach encompassing personal, health, research, and community domains. Here we describe “Walking the Talk for Dementia,” an immersive initiative aimed at empowering people with dementia, enhancing dementia understanding, and inspiring collaborations. This initiative involved 300 participants from 25 nationalities, including people with dementia, care partners, clinicians, policymakers, researchers, and advocates for a 4-day, 40 km walk through the Camino de Santiago de Compostela, Spain. A 2-day symposium after the journey provided novel transdisciplinary and horizontal structures, deconstructing traditional hierarchies. The innovation of this initiative lies in its ability to merge a physical experience with knowledge exchange for diversifying individuals' understanding of dementia. It showcases the transformative potential of an immersive, embodied, and multi-experiential approach to address the complexities of dementia collaboratively. The initiative offers a scalable model to enhance understanding, decrease stigma, and promote more comprehensive and empathetic dementia care and research

Gender Differences in COVID-19 Among Liver Transplant Recipients: Results from a Multicenter Brazilian Cohort

Introduction: Existing literature presents varying perspectives on the impact of COVID-19 on liver transplant recipients.However, no research has specifically investigated the role of gender differences in the manifestation of COVID-19 among liver transplant recipients. This study aims to examine the effects of COVID-19 on liver transplant recipients, with a focus on gender differences in disease presentation and progression. Methods: Conducted as a multicenter historical cohort study, this research collected patient records through an online questionnaire. Assessing COVID-related mortality was the main objective. Additionally, demographic, clinical, and laboratory data pertaining to disease presentation and progression werecollected. Results: The study included a total of 283 patients, of whom 76 were female and 206 were male. The median follow-up period for males was 99 days (IQR 38-283), while for females, it was 126 days (IQR 44-291). A higher prevalence of cardiovascular disease was observed in males (p=0.002). Females frequently experienced a loss of smell (p=0.021), whereas males commonly exhibited fever (p=0.031). Levels of ALT and gamma-glutamyl transferase were significantly elevated in males (p=0.008 and 0.004, respectively). Although there was a trend towards increased mortality in males, it did not reach statistical significance. Conclusion: This study is the first attempt to investigate gender differences in COVID-19 among liver transplant recipients. Our findings highlight the need for a comprehensive and personalised approach to treating this patient population and underscore the importance of further elucidating the disease presentation in these individuals

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Resíduos Sólidos: Influência das obsolescências discutida nas aulas de Química

The aim of this study was to analyze the learning of students in the second year of high school based on interventions involving the problem of solid waste. Data collection instruments were used: a questionnaire to investigate students’ prior knowledge, open questions, elaboration of argumentative texts and a game involving questions and answers. During the interventions, concepts about programmed and induced obsolescence and the National Solid Waste Policy, as well as their relationship with conceptual chemistry contents were developed. The results highlight the importance of work with subjects involving this problem and point out as potentialities the development of the capacity for discussion in a Science, Technology, Society and Environment (STSE) perspective, due to the proximity of the subject to the daily life of the students, contributing for the formation of citizens more active in society and interested in issues associated with the environment.El objetio de este estudio fue analizar el aprendizaje de los alumnos en el segundo año de la enseñanza media, a partir de una serie de intervenciones sobre residuos sólidos. El estudio tuvo un enfoque cualitativo con una perspectiva de evaluación formativa. Como instrumentos de discusión de recolección de datos, fueron utilizados: cuestionario de conocimiento previo, cuestiones abiertas para discusión, redacción y juego de preguntas y respuestas. Las intervenciones abordaron temas tales los diferentes tipos de obsolescencia y la Política Nacional de Residuos Sólidos, así como su relación con el tema de los residuos, vinculada a los contenidos conceptuales de la química. Los resultados destacan la importancia del desarrollo de actividades sobre estos conceptos y apuntan a la potencial capacidad de discusión, debido a la proximidad del tema con el cotidiano de los alumnos, y a la perspectiva de la Ciencia, Tecnología, Sociedad y Medio Ambiente (CTSA), que permite abordar integralmente el tema, contribuyendo a la formación de ciudadanos activos en la sociedad y preocupados por el medio ambiente.O estudo realizado teve por objetivo analisar a aprendizagem dos alunos do 2º ano do ensino médio a partir de uma série de intervenções realizadas envolvendo a temática dos resíduos sólidos. Como instrumentos de coleta de dados foram utilizados: questionário para investigar o conhecimento prévio dos discentes, questões abertas para discussão, elaboração de textos argumentativos e um jogo envolvendo perguntas e respostas. As intervenções abordaram os conceitos das obsolescências programada e induzida e a Política Nacional dos Resíduos Sólidos, além da relação destes com conteúdos conceituais de química. Os resultados evidenciam a necessidade do desenvolvimento de trabalhos envolvendo a essa problemática e apontam como potencialidades o desenvolvimento da capacidade de discussão em uma perspectiva de Ciência, Tecnologia, Sociedade e Ambiente (CTSA), devido à proximidade da temática com o cotidiano dos alunos, contribuindo para a formação de cidadãos mais atuantes na sociedade e interessados em questões associadas ao meio ambiente

Yellow fever disease in a renal transplant recipient: case report and literature review

Yellow fever (YF) is a viral disease, with clinical presentation among immunosuppressed patients not fully understood. YF vaccination (YFV), a live vaccine, is contraindicated in patients receiving immunosuppressive treatment due to the risk of developing the disease after vaccination. We report a case of a 50-year-old male recipient who presented wild-type YF five years after a deceased donor kidney transplant. He lived in a YF endemic area and inadvertently received YFV. One day after YFV, the patient presented nausea, vomiting, fever, diarrhea, polyarthralgia, thrombocytopenia, and increased levels of liver function enzymes. The serological test was compatible with YF disease, and quantitative viral load confirmed the diagnosis of wild-type YF. The patient received supportive care for twelve days, with hospital discharge in good clinical condition and stable renal function. One month after discharge, the patient developed de novo donor-specific anti-HLA antibodies (DSA) and histological evidence of endothelial lesion, with a diagnosis of acute antibody-mediated rejection (AMR), treated with plasmapheresis and human IVIg therapy. Six months after therapy, he presented normal renal function with a reduction of DSA MFI. In the reported case, we observed a clinical wild-type YF diagnosed even after YF vaccine administration, with good clinical outcome. De novo DSA and AMR occurred after the recovering of disease, with an adequate response to therapy and preserved allograft function. We reviewed the published literature on YF and YFV in solid organ transplantation21

Bloodstream infections in early postsurgery liver transplant: an analysis of 401 patients over 10 years

Bloodstream infections are a major factor contributing to morbidity and mortality following liver transplantation. The increasing occurrence of multidrug-resistant bloodstream infections represents a challenge for the prevention and treatment of those infections. The aim of this study was to evaluate the occurrence and microbiological profile of bloodstream infections during the early postoperative period (from day 0 to day 60) in patients undergoing liver transplantation from January 2005 to June 2016 at the State University of Campinas General Hospital. A total of 401 patients who underwent liver transplantation during this period were included in the study. The most common cause of liver disease was hepatitis C virus cirrhosis (34.01%), followed by alcoholic disease (16.24%). A total of 103 patients had 139 microbiologically proven bloodstream infections. Gram-negative bacteria were isolated in 63.31% of the cases, gram-positive bacteria in 28.78%, and fungi in 7.91%. Fifty-six infections (43.75%) were multidrug-resistant bacteria, and 72 (56.25%) were not. There was no linear trend concerning the occurrence of multidrug-resistant organisms throughout the study period. Patients with multidrug-resistant bloodstream infections had a significantly lower survival rate than those with no bloodstream infections and those with non multidrug-resistant bloodstream infections. In conclusion, the occurrence of bloodstream infections during the early postoperative period was still high compared with other profile patients, as well as the rates of multidrug-resistant organisms. Even though the occurrence of multidrug resistance has been stable for the past decade, the lower survival rates associated with that condition and the challenge related to its treatment are of major concern.5161972197