Clinico-Pathological Discrepancies in a General University Hospital in São Paulo, Brazil

INTRODUCTION: The autopsy rate has continuously diminished over the past few decades, reducing the quality of medical care and the accuracy of statistical health data. OBJECTIVE: To assess the accuracy of clinical diagnoses by comparing pre- and postmortem findings, and to identify potential risk factors for misdiagnoses. METHODS: Retrospective evaluations performed between June 2001 and June 2003 in a 2500-bed tertiary university hospital in São Paulo, Brazil, including 288 patients who died at that institution and had a postmortem examination. RESULTS: Clinical and autopsy records were reviewed and compared for categorization using the adapted Goldman criteria. The overall major and minor discrepancy rates were 16.3% and 28.1%, respectively. The most common missed diagnoses were pulmonary embolism, pneumonia, and myocardial infarction, and the most prevalent underlying diseases were infectious diseases, cerebro-cardiovascular conditions, and malignancies. Patients age 60 or older had an increased risk of diagnostic disagreement, as did female patients. The period of hospitalization, last admission unit at the hospital and underlying disease were not significantly related to the pre-mortem diagnostic accuracy. DISCUSSION: The discrepancy rate found in this study is similar to those reported globally. The factors influencing diagnostic accuracy as well as the most commonly missed diagnoses are also consistent with the literature. CONCLUSION: Autopsy remains a crucial tool for improving medical care, and effort must be focused on increasing its practice worldwide

Bronchial remodeling in asthma

The relationship between structure and function in asthma has been extensively studied. All the compartments of the airway have been shown to have some structural alterations contributing to functional defects. The structural alterations are thought to be a consequence of the chronic inflammation present in asthmatic airways, leading ultimately to remodeling. The decline of the ventilatory function over time in some asthmatic patients may be a consequence of airway remodeling. In this review, the authors describe the phenomena leading to airway remodeling and discuss the role of inflammatory mediators involved in this process. The structural alterations of the asthmatic airways are presented and the possible correlated functional defects are discussed.É sabido que certos pacientes asmáticos apresentam perda parcial e irreversível da função respiratória ao longo do tempo. Postula-se que o processo inflamatório crônico em vias aéreas, característico da doença, poderia, através da liberação de diversos mediadores inflamatórios, ocasionar alterações estruturais irreversíveis nas vias aéreas e conseqüente piora da broncoconstrição, contribuindo assim para o fenômeno de perda de função pulmonar. A este processo creditou-se o nome de remodelamento brônquico. Nesta revisão descrevem-se os mecanismos propostos para o remodelamento brônquico, o papel dos diversos mediadores inflamatórios envolvidos e as diversas alterações patológicas observadas em vias aéreas asmáticas. Para cada alteração estrutural descrita, discute-se a possível conseqüência funcional. O entendimento do remodelamento brônquico é importante para o melhor manejo dos pacientes com asma e para a prevenção da deterioração funcional definitiva.Universidade de São Paulo Faculdade de Medicina Departamento de PatologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Carcinoma de próstata com diferenciação neuroendócrina: relato de caso

Neuroendocrine differentiation in prostatic carcinomas generally confers a more aggressive clinical behavior and less favorable prognosis than usual prostatic carcinomas. In this manuscript, we report a case of a 58-year-old man with prostatic carcinoma who died 1 year after initial diagnosis. Autopsy showed a disseminated prostatic carcinoma with neuroendocrine differentiation. There were metastasis to the spleen, an organ infrequently involved by disseminated epithelial neoplasms. Neuroendocrine differentiation was demonstrated by immunohistochemical studies in the biopsy and autopsy material.Os carcinomas da próstata com diferenciação neuroendócrina apresentam comportamento mais agressivo e prognóstico menos favorável que as neoplasias prostáticas usuais. No presente relato de caso é reportada a rápida evolução para o óbito de um paciente de 58 anos portador de adenocarcinoma de próstata com diferenciação neuroendócrina. A autópsia mostrou neoplasia disseminada, acometendo inclusive o baço, sítio incomum de envolvimento metastático de neoplasias de origem epitelial. A diferenciação neuroendócrina foi demonstrada por estudo imunohistoquímico em material de biópsia e autópsia

Utilization of the Lower Inflection Point of the Pressure-Volume Curve Results In Protective Conventional Ventilation Comparable to High Frequency Oscillatory Ventilation in an Animal Model of Acute Respiratory Distress Syndrome

INTRODUCTION: Studies comparing high frequency oscillatory and conventional ventilation in acute respiratory distress syndrome have used low values of positive end-expiratory pressure and identified a need for better recruitment and pulmonary stability with high frequency. OBJECTIVE: To compare conventional and high frequency ventilation using the lower inflection point of the pressure-volume curve as the determinant of positive end-expiratory pressure to obtain similar levels of recruitment and alveolar stability. METHODS: After lung lavage of adult rabbits and lower inflection point determination, two groups were randomized: conventional (positive end-expiratory pressure = lower inflection point; tidal volume=6 ml/kg) and high frequency ventilation (mean airway pressures= lower inflection point +4 cmH2O). Blood gas and hemodynamic data were recorded over 4 h. After sacrifice, protein analysis from lung lavage and histologic evaluation were performed. RESULTS: The oxygenation parameters, protein and histological data were similar, except for the fact that significantly more normal alveoli were observed upon protective ventilation. High frequency ventilation led to lower PaCO2 levels. DISCUSSION: Determination of the lower inflection point of the pressure-volume curve is important for setting the minimum end expiratory pressure needed to keep the airways opened. This is useful when comparing different strategies to treat severe respiratory insufficiency, optimizing conventional ventilation, improving oxygenation and reducing lung injury. CONCLUSIONS: Utilization of the lower inflection point of the pressure-volume curve in the ventilation strategies considered in this study resulted in comparable efficacy with regards to oxygenation and hemodynamics, a high PaCO2 level and a lower pH. In addition, a greater number of normal alveoli were found after protective conventional ventilation in an animal model of acute respiratory distress syndrome

Agricultura urbana no município de São Paulo: considerações sobre produção e comercialização

A Agricultura Urbana (AU) tem sido apontada, mais recentemente, como elemento importante nos discursos e nas práticas que visam à segurança alimentar urbana. O presente artigo procurou discutir a produção agrícola do Município de São Paulo (MSP) e seu escoamento, considerando a diversidade de perfis que a AU pode assumir. Para tal, foi avaliada a produção agrícola em bases de dados oficiais. No que se refere à comercialização, foram coletadas informações em sete entrevistas semiestruturadas com agricultores do MSP entre 2018 e 2020. Os principais resultados encontrados indicam que houve um crescimento das práticas agropecuárias no município, acessando uma ampla variedade de canais de comercialização. A abertura de novos mercados, o desenvolvimento de políticas públicas e o reconhecimento público foram essenciais para o crescimento da agricultura no MSP.Urban agriculture (UA) has recently been pointed out as an important element in the discussion and practices of urban food security. This article seeks to discuss agricultural production and distribution in the city of São Paulo , considering the diversity of profiles that UA can assume. To this end, official databases were used to compute agricultural production. With regard to commercialization, information was collected from seven semi-structured interviews with farmers of the city of São Paulo between 2018 and 2020. The main findings indicate that there was an increase in agricultural practices in the city, encompassing a wide variety of commercialization channels. The opening of new markets, the development of public policies and public recognition were essential for the growth of agriculture in the city of São Paulo

Extended minimally invasive autopsy: Technical improvements for the investigation of cardiopulmonary events in COVID-19

OBJECTIVES: Ultrasound-guided minimally invasive autopsies (MIA-US) are an alternative to conventional autopsies and have been used in our institution to investigate the pathophysiology of COVID-19 since the beginning of the pandemic. Owing to the limitations of post-mortem biopsies for evaluating cardiopulmonary events involving large vessels, we continuously improved the technique during this period. Objectives: To demonstrate the usefulness of an extended MIA-US technique (EMIA-US) for the study of thoracic involvement in COVID-19. METHOD: US-guided percutaneous tissue sampling was combined with a small thoracic incision (≤5 cm), allowing for the sampling of larger tissue samples or even the entire organ (lungs and heart). RESULTS: EMIA-US was performed for eight patients who died of COVID-19 in 2021. We demonstrate cardiopulmonary events, mainly thromboembolism and myocardial infarction, that could be evaluated using EMIA-US. CONCLUSIONS: Minimally invasive image-guided post-mortem tissue sampling is a flexible and practical method to conduct post-mortem studies of human diseases, mainly in areas that do not have autopsy facilities or, alternatively, when autopsy is not possible owing to financial constraints, cultural and religious values, or for safety reasons, such as in the case of highly contagious infectious diseases. We present evidence that EMIA-US is feasible and can be used as an alternative to increase the accuracy of MIA-US in detecting cardiopulmonary events involving large vessels, which may not be assessed through post-mortem biopsies