TRANSPLANTE RENAL EM DADOR VIVO — UM CASO VASCULAR COMPLEXO

Introdução: A presença de múltiplos vasos renais é frequente na população geral e, quando presente num dador, aumenta a complexidade da cirurgia de transplantação renal, aumentando o risco de complicações. Embora a transplantação de enxertos de dador cadáver com estas características seja aceite, o mesmo procedimento em dador vivo permanece controverso. O objetivo deste trabalho é apresentar o caso de uma cirurgia de transplantação de dador vivo com anatomia vascular complexa – duas artérias e duas veias renais.  Caso Clínico: Mulher de 42 anos, com doença renal crónica terminal (DRCT) por nefropatia IgA, em programa regular de hemodiálise há 9 meses, avaliada em mais de um centro para transplantação renal de dador vivo e recusada pela complexidade da anatomia vascular do par dador - rim direito com duas artérias e duas veias renais curtas.  No nosso centro, onde a cirurgia vascular integra a equipa multidisciplinar de transplantação renal, foi aceite o transplante considerando-se tecnicamente exequível a reconstrução vascular ex-vivo do enxerto (back table).  Na reconstrução arterial foi realizada anastomose látero-lateral das duas artérias renais. A reconstrução venosa incluiu o alongamento das veias renais com veia safena interna (VSI) da recetora e a sua posterior anastomose em “cano de espingarda”. O rim foi implantado na fossa ilíaca direita da recetora.  Verificou-se diurese imediata após desclampagem, com descida rápida dos valores de creatinina para o normal e com alta ao 16.º dia de pós-operatório.  Conclusão: A escassez de órgãos é um importante fator limitante à transplantação renal. A inclusão de dadores com múltiplos vasos renais tem demonstrado bons resultados e pode aumentar a disponibilidade de órgãos. A integração de um cirurgião vascular experiente na equipa multidisciplinar de transplantação renal permite a realização de reconstruções arteriais e venosas complexas em enxertos com anatomia vascular menos favorável.

ENDOVASCULAR MANAGEMENT OF TRANSPLANT RENAL ARTERY STENOSIS: EARLY AND MID-TERM RESULTS

OBJECTIVE: Renal graft dysfunction or worsened hypertension in renal transplanted patients may be a manifestation of graft hypoperfusion due to transplant renal artery stenosis (TRAS) or stenosis of iliac arteries proximal to renal transplant (pseudo-TRAS). Endovascular management of TRAS has been increasingly used to preserve renal graft function. With this study, we aim to evaluate the impact of endovascular treatment of TRAS on renal function in the short to medium term. MATERIAL AND METHODS: This is an observational, retrospective, single-center study that included all adult renal transplant patients who underwent endovascular intervention on TRAS between September 2017 and June 2020. Renal graft function was monitored by serum Creatinine (sCr) levels. RESULTS: Thirteen patients were included (53.8% female), with a median age of 57 (21-70) years. Eleven patients (84.6%) presented with graft dysfunction. Ten subjects (76.9%) underwent transluminal angioplasty and stenting of renal artery and three (23,1%) of donor iliac arteries. Most cases (69.2%) were interventioned in the first-year post-transplant. Overall technical success was 100%, with no periprocedural deaths. Overall 30-day morbidity was 15.4%. Median follow-up time was 20.2 (1,3 – 36,3) months. One patient died during follow up and other worsened graft dysfunction, requiring hemodi- alysis and nephrectomy. Reduction in sCr levels was statistically significant in the first postoperative month, compared to preoperative values, but sCR levels were still increased when compared to baseline levels (pre-TRAS diagnosis). CONCLUSIONS: The majority (12/13) of patients showed improvement or stabilization of renal graft function compared to the preoperative period, during the follow-up period, supporting the procedure’s safety. Despite this, most patients did not recover baseline sCr levels, reinforcing the importance of prompt graft revascularization. Delayed diagnosis of TRAS may compromise the benefit of revascularization and prevent full recovery of renal function

Clinical Features and Inflammatory Markers in Autoimmune Encephalitis Associated With Antibodies Against Neuronal Surface in Brazilian Patients

Acute encephalitis is a debilitating neurological disorder associated with brain inflammation and rapidly progressive encephalopathy. Autoimmune encephalitis (AE) is increasingly recognized as one of the most frequent causes of encephalitis, however signs of inflammation are not always present at the onset which may delay the diagnosis. We retrospectively assessed patients with AE associated with antibodies against neuronal surface diagnosed in reference centers in Northeast of Brazil between 2014 to 2017. CNS inflammatory markers were defined as altered CSF (pleocytosis >5 cells/mm3) and/or any brain parenchymal MRI signal abnormality. Thirteen patients were evaluated, anti-NMDAR was the most common antibody found (10/13, 77%), followed by anti-LGI1 (2/13, 15%), and anti-AMPAR (1/13, 7%). Median time to diagnosis was 4 months (range 2–9 months). Among these 13 patients, 6 (46.1%) had inflammatory markers and when compared to those who did not present signs of inflammation, there were no significant differences regarding the age of onset, time to diagnosis and modified Rankin scale score at the last visit. Most of the patients presented partial or complete response to immunotherapy during follow-up. Our findings suggest that the presence of inflammatory markers may not correlate with clinical presentation or prognosis in patients with AE associated with antibodies against neuronal surface. Neurologists should be aware to recognize clinical features of AE and promptly request antibody testing even without evidence of inflammation in CSF or MRI studies

Discutindo a educação ambiental no cotidiano escolar: desenvolvimento de projetos na escola formação inicial e continuada de professores

A presente pesquisa buscou discutir como a Educação Ambiental (EA) vem sendo trabalhada, no Ensino Fundamental e como os docentes desta escola compreendem e vem inserindo a EA no cotidiano escolar., em uma escola estadual do município de Tangará da Serra/MT, Brasil. Para tanto, realizou-se entrevistas com os professores que fazem parte de um projeto interdisciplinar de EA na escola pesquisada. Verificou-se que o projeto da escola não vem conseguindo alcançar os objetivos propostos por: desconhecimento do mesmo, pelos professores; formação deficiente dos professores, não entendimento da EA como processo de ensino-aprendizagem, falta de recursos didáticos, planejamento inadequado das atividades. A partir dessa constatação, procurou-se debater a impossibilidade de tratar do tema fora do trabalho interdisciplinar, bem como, e principalmente, a importância de um estudo mais aprofundado de EA, vinculando teoria e prática, tanto na formação docente, como em projetos escolares, a fim de fugir do tradicional vínculo “EA e ecologia, lixo e horta”.Facultad de Humanidades y Ciencias de la Educació

A comunicação do diagnóstico "sombrio" na relação médico-paciente entre estudantes de Medicina: uma experiência de dramatização na educação médica

O objetivo do trabalho foi apresentar a dramatização como prática para a humanização da relação médico- paciente entre estudantes do terceiro semestre do curso de Medicina da Universidade Estadual do Ceará (Uece). Por meio de metodologia qualitativa, aplicaram-se perguntas referentes aos sentimentos vivenciados enquanto na posição de médicos e de pacientes, e à vivência com a técnica, após a mesma ser apresentada em sala de aula (n=24).Os dados permitiram identificar que os temas abordados se referiam a doenças graves e perdas. Em relação aos sentimentos, no papel tanto de paciente quanto de médico, demonstraram angústia, impotência, apreensão,medo e ansiedade. Expressaram dificuldades frente ao diagnóstico e à transmissão de má notícia, ao mesmo tempo em que valorizaram a construção do vínculo médico-paciente. Frente à experiência, destacaram a técnica como geradora de auto conhecimento e vivência da futura profissão. Estudos prospectivos devem ser realizados para avaliar o impacto dessa estratégia na humanização da relação médico- paciente e educação médica, explorando o máximo de potencialidade frente às suas limitações

NEOTROPICAL CARNIVORES: a data set on carnivore distribution in the Neotropics

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data

NEOTROPICAL ALIEN MAMMALS: a data set of occurrence and abundance of alien mammals in the Neotropics

Biological invasion is one of the main threats to native biodiversity. For a species to become invasive, it must be voluntarily or involuntarily introduced by humans into a nonnative habitat. Mammals were among first taxa to be introduced worldwide for game, meat, and labor, yet the number of species introduced in the Neotropics remains unknown. In this data set, we make available occurrence and abundance data on mammal species that (1) transposed a geographical barrier and (2) were voluntarily or involuntarily introduced by humans into the Neotropics. Our data set is composed of 73,738 historical and current georeferenced records on alien mammal species of which around 96% correspond to occurrence data on 77 species belonging to eight orders and 26 families. Data cover 26 continental countries in the Neotropics, ranging from Mexico and its frontier regions (southern Florida and coastal-central Florida in the southeast United States) to Argentina, Paraguay, Chile, and Uruguay, and the 13 countries of Caribbean islands. Our data set also includes neotropical species (e.g., Callithrix sp., Myocastor coypus, Nasua nasua) considered alien in particular areas of Neotropics. The most numerous species in terms of records are from Bos sp. (n = 37,782), Sus scrofa (n = 6,730), and Canis familiaris (n = 10,084); 17 species were represented by only one record (e.g., Syncerus caffer, Cervus timorensis, Cervus unicolor, Canis latrans). Primates have the highest number of species in the data set (n = 20 species), partly because of uncertainties regarding taxonomic identification of the genera Callithrix, which includes the species Callithrix aurita, Callithrix flaviceps, Callithrix geoffroyi, Callithrix jacchus, Callithrix kuhlii, Callithrix penicillata, and their hybrids. This unique data set will be a valuable source of information on invasion risk assessments, biodiversity redistribution and conservation-related research. There are no copyright restrictions. Please cite this data paper when using the data in publications. We also request that researchers and teachers inform us on how they are using the data

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)