The National Science and Technology Institute in Child and Adolescence Developmental Psychiatry: a new paradigm for Brazilian Psychiatry focused on our children and their future

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Universidade de São Paulo Faculdade de Medicina Departamento de PsiquiatriaUniversidade Federal de São Paulo (UNIFESP) Departamento de PsiquiatriaUniversidade Federal do Rio Grande do Sul Departamento de PsiquiatriaUNIFESP, Depto. de PsiquiatriaSciEL

Iatrogenic Biliary Strictures: Surgical Experience with 39 Patients

The authors report their experience with surgical treatment of 39 patients with biliary strictures of iatrogenic origin. Patients were grouped according to the level of obstruction as described by Bismuth, and the type of repair was based on this classification. A total of 45 operations were performed, including those for recurrent strictures: 22 hepaticojejunostomies, 10 Hepp and Couinad's operations, 6 choledochojejunostomies, 3 separate right and left hepaticojejunostomies, 1 hepaticojejunostomy with mucosal graft (Smith's technique), 1 intrahepatic cholangiojejunostomy (Longmire's technique), 1 choledochoduodenostomy and 1 choledochoplasty. Results were considered good if the patient was free of symptoms, jaundice or episodes of cholangitis, with serum alkaline phosphatase less than two-times the normal value. Minimum follow-up period of two years (obtained in 35 patients) was required to evaluate the results. Good results were obtained in 26 of those 30 patients (87%) who underwent only one biliary reconstruction, and in 3 of those 5 (60%) with more than one repair. Overall, 29 patients (83% of those 35) presented good results. The complexity of the surgical treatment of biliary strictures imposes the adoption of measures to prevent lesions to the bile duct. Factors related to the prognosis that must be emphasized are surgeonsa' individual experience and skills, location of the stricture and diameter of the anastomosis

Cost-Effectiveness of Routine Screening for Cardiac Toxicity in Patients Treated with Imatinib in Brazil

AbstractWe performed a cost-effectiveness study of different strategies of screening for cardiotoxicity in patients receiving imatinib, the first strategy based on yearly echocardiograms in all patients and the second strategy based on yearly B-type natriuretic peptide level measurement, reserving echocardiograms for patients with an abnormal test result. Results are presented in terms of additional cost per diagnosis as compared with not performing any screening. From the Brazilian private sector’s perspective, strategies 1 and 2 resulted in additional costs of US $30,951.53 and US$19,925.64 per diagnosis of cardiotoxicity, respectively. From the perspective of the Brazilian public health system, the same strategies generated additional costs of US $7,668.00 and US$20,232.87 per diagnosis, respectively. In our study, systematic screening for cardiotoxicity in patients using imatinib has a high cost per diagnosis. If screening is to be adopted, a strategy based on B-type natriuretic peptide level measurement, reserving echocardiography for patients with abnormal results, results in lower costs per diagnosis in the private sector. From the public health system’s perspective, costs per diagnosis will greatly depend on the reimbursement values adopted for B-type natriuretic peptide level measurement

Paliação cirúrgica no câncer de cabeça pancreática : experiência com 53 pacientes

Para o câncer de cabeça pancreática, a ressecção do tumor é o único tratamento curativo existente. No entanto, a cirurgia paliativa é a mais realizada porque a grande maioria dos pacientes no momento do diagnóstico apresenta tumor incurável. Os autores apresentam sua experiência com 53 pacientes portadores de adenocarcinoma de cabeça pancreática submetidos à cirurgia paliativa, focalizando o alívio da obstrução biliar, da obstrução duodenal e da dor, e discutem as alternativas da paliação à luz de uma revisão atualizada da literatura.Tumor ressection is the only curative treatment for carcinoma of the head of the pancreas. However, most patients have incurable disease at diagnosis, making palliative surgery the most commonly used approach. The authors present their experience with 53 patients with adenocarcinoma of the head ofthe pancreas that underwent palliative surgery, emphasizing the bypass of biliary and duodenal obstructions and chronic pain relief. Alternatives of palliation are discussed based on an updated literature review

Pancreatite aguda biliar: um estudo de coorte prospectivo

OBJECTIVE: Acute biliary pancreatitis (ABP) is a disease with high morbidity and mortality rates but poorly studied in Brazil. Our objective was to describe the differential  diagnosis for the etiology of ABP and assess the severity and treatment of the disease at the Hospital de Clínicas de Porto Alegre, in 1999. MATERIALS AND METHODS: We carried out a cohort, prospective study in 65 (78.4%) patients who presented amylase greater than 440 mg/dl and acute biliary pancreatitis (ABP). We assessed biliary Ranson scores, modified Glasgow scores, APACHE-II and APACHE-O of our population in order to determine the severity of the disease. These scores and values were followed-up during the evolution of the disease. RESULTS: Twelve patients presented clinical evolution of the disease. The systemic complications were kidney failure (n=4), respiratory failure (n=3), shock (n=3), and sepsis associated with cholangitis (n=1). The local complications, in turn, were peripancreatic fluid collection (n=3), pancreatic necroses (n=3), pancreatic pseudocyst (n=1), and pancreatic fistula (n=1). There was only one case of death, which occurred due to acute myocardial infarction and refractory hypocalcemia. The prognostic criteria, according to the number of positive parameters, indicated relative risk (RR) from 4.7 to 11.2, sensitivity from 33.3% to 83.3%, specificity from 79.2% to 98.1%, positive predictive value from 45.0% to 83.3%, negative predictive value from 86.4% to 95.5%, and accuracy from 78.5% to 89.6%. The parameters that presented a separate correlation with severity were white blood cell count >18,000/mm3 , LDH >400 UI/l, 10% decrease in hematocrit levels, serum calcium levels <8 mg/dl, increase in urea nitrogen levels >2 mg/dl, AST >200 mg/dl, LDH >600 UI/l, white cell count >15,000/mm3 , urea >45 mg/dl, arterial pH £7.33 or ³7.49, creatinine levels £0.6 or ³1.4, hematocrit levels £30 or ³45,9, white cell count £3,000 or ³14,900. CONCLUSION: biliary Ranson scores, modified Glasgow scores, APACHE-II and APACHE-O presented good sensitivity and specificity. Multidisciplinary protocols should be implemented in order to achieve optimal treatment results. OBJETIVO: A pancreatite aguda biliar (PAB) é uma doença com morbidade e mortalidade elevadas mas pouco estudada no Brasil. O objetivo deste trabalho é detalhar o diagnóstico diferencial etiológico, a gravidade e o tratamento da PAB no Hospital de Clínicas de Porto Alegre em 1999. MATERIAIS E MÉTODOS: Foram avaliados em estudo de coorte, prospectivo, todos os pacientes com amilase superior a 440 mg/dl e incluídos 65 (78,4%) que apresentavam PAB. Esta amostra foi submetida à determinação de gravidade pelos critérios de Ranson biliar, Glasgow modificado, APACHE-II e APACHE-O e acompanhada durante a evolução da doença. RESULTADOS: Doze pacientes (18,5%) apresentaram evolução clínica com 19 complicações. As sistêmicas foram: falência renal (n = 4), insuficiência respiratória (n = 3), choque (n = 3) e sepse por colangite (n = 1). As complicações locais foram: coleções líquidas peripancreáticas (n = 3), necroses pancreáticas (n = 3), pseudocisto pancreático (n = 1), fístula pancreática (n = 1). Houve apenas uma morte relacionada a infarto agudo do miocárdio e hipocalcemia refratária. Os critérios prognósticos, conforme o número de parâmetros positivos, apresentaram um risco relativo que variou de 4,7 a 11,2, sensibilidade de 33,3% a 83,3%, especificidade de 79,2% a 98,1%, valor preditivo positivo de 45,0% a 83,3%, valor preditivo negativo de 86,4% a 95,5% e acurácia de 78,5% a 89,6%. Isoladamente, os parâmetros que apresentaram correlação com a gravidade foram leucograma >18000/mm3 , LDH >400 UI/L, queda ³10% hematócrito, cálcio sérico <8 mg/dL, aumento do nitrogênio uréico >2 mg/dL, AST >200 mg/dL, LDH >600 UI/L, leucograma >15000 mm3 , uréia >45 mg/dL, pH arterial £7,33 ou ³7,49, creatinina £0,6 ou ³1,4, Ht £30 ou ³45,9, leucócitos £ 3 ou ³14,9 (mil). CONCLUSÕES: Os critérios de Ranson, Glasgow, APACHE-II e APACHE-O apresentam boa sensibilidade e especificidade. O manejo da PAB deve ser revisto a partir de protocolos institucionais multidisciplinares

Shared genetic background between children and adults with attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by age-inappropriate symptoms of inattention, impulsivity, and hyperactivity that persist into adulthood in the majority of the diagnosed children. Despite several risk factors during childhood predicting the persistence of ADHD symptoms into adulthood, the genetic architecture underlying the trajectory of ADHD over time is still unclear. We set out to study the contribution of common genetic variants to the risk for ADHD across the lifespan by conducting meta-analyses of genome-wide association studies on persistent ADHD in adults and ADHD in childhood separately and jointly, and by comparing the genetic background between them in a total sample of 17,149 cases and 32,411 controls. Our results show nine new independent loci and support a shared contribution of common genetic variants to ADHD in children and adults. No subgroup heterogeneity was observed among children, while this group consists of future remitting and persistent individuals. We report similar patterns of genetic correlation of ADHD with other ADHD-related datasets and different traits and disorders among adults, children, and when combining both groups. These findings confirm that persistent ADHD in adults is a neurodevelopmental disorder and extend the existing hypothesis of a shared genetic architecture underlying ADHD and different traits to a lifespan perspectiv

Genome-wide analyses of ADHD identify 27 risk loci, refine the genetic architecture and implicate several cognitive domains

Attention-deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder with a major genetic component. Here, we present a genome-wide association study meta-analysis of ADHD comprising 38,691 individuals with ADHD and 186,843 controls. We identified 27 genome-wide significant loci, highlighting 76 potential risk genes enriched among genes expressed particularly in early brain development. Overall, ADHD genetic risk was associated with several brain-specific neuronal subtypes and midbrain dopaminergic neurons. In exome-sequencing data from 17,896 individuals, we identified an increased load of rare protein-truncating variants in ADHD for a set of risk genes enriched with probable causal common variants, potentially implicating SORCS3 in ADHD by both common and rare variants. Bivariate Gaussian mixture modeling estimated that 84–98% of ADHD-influencing variants are shared with other psychiatric disorders. In addition, common-variant ADHD risk was associated with impaired complex cognition such as verbal reasoning and a range of executive functions, including attention