Large-scale provider-to-provider teleconsultation models remain underreported in low- and middle-income countries. Optimal strategies for scaling outpatient telemedicine and evaluating its impact on quality, efficiency, and patient experience are still being investigated. We conducted a retrospective descriptive implementation study of synchronous, video-based, provider-to-provider teleconsultations coordinated by the Telemedicine Department of Hospital Israelita Albert Einstein, São Paulo, Brazil. We summarized program reach, site implementation, consultation volume, specialty distribution, consultation disposition, no-show rate, schedule utilization, and post-consultation experience indicators. A total of 365 service points were established, offering 12 specialties and performing 201,012 teleconsultations. Schedule occupancy remained at 99.8%. Among consultations, 79% resulted in follow-up within the same specialty, 16% were discharged from specialty care, and 5% were referred elsewhere. Common diagnoses included hypertension (3.9%), autism spectrum disorder (3.7%), joint pain (3.7%), ADHD (3.6%), and generalized anxiety disorder (3.3%). Net Promoter Scores were 91 for physicians and 85 for patients. A centralized, structured, multi-specialty telehealth strategy was feasible across remote locations, sustained high appointment occupancy, and effectively resolved or redirected 95% of cases. Both clinician and patient satisfaction were notably high, supporting the scalability of this model in underserved regions.
This article analyzed the impact of Law No. 12,732/2012 on breast cancer care in São Paulo State (Brazil) between 2013 and 2024, as well as the role of external oversight. This qualitative-quantitative study used 58,892 records from the São Paulo Oncocenter Foundation database and cases judged by the São Paulo State Court of Accounts. The analysis revealed significant and persistent delays in diagnosis (31.3-66.8%) and treatment initiation (38-72%) across all Regional Health Directorates, although delays fluctuated over time, no consistent trend toward reduced delays was observed between the 2013-2024 period. The São Paulo State Court of Accounts, as an external oversight mechanism, focused on formal analyses rather than results-oriented evaluations, particularly regarding the identified delays. Our findings led us to conclude that the 60-day Law has had a limited impact in ensuring timely access to breast cancer diagnosis and treatment in the state, as delays have remained high and have not consistently improved over time. It is recommended that external control strategically strengthen this public policy by inducing managerial accountability and ensuring the right to access and comprehensive care.
Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory in-hospital cardiac arrest (IHCA), but Brazilian data are scarce. We compared ECPR with conventional CPR (cCPR) at the first Brazilian center with a protocolized ECPR program. Retrospective single-center cohort at Einstein Hospital Israelita, São Paulo. Adults (18-75 years) with witnessed and refractory IHCA fulfilling institutional ECPR eligibility were included. The cCPR cohort (2017-2025) comprised eligible patients who did not receive ECPR due to absence of 24/7 ECMO coverage; the ECPR cohort (2020-2025) included all protocolized cases. The primary outcome was hospital survival with favorable neurological outcome (Cerebral Performance Category, CPC, of 2 or less). Groups were compared descriptively; survival was estimated by the Kaplan-Meier method with the log-rank test, and the absolute risk reduction and number needed to treat were calculated. Thirty-eight patients were analyzed (16 ECPR, 22 cCPR). Hospital survival was higher in the ECPR group (43.7% vs 13.6%, p = 0.04), corresponding to an absolute risk reduction of 30.1% (95% CI 1.9-58.3) and a number needed to treat of 4. Estimated 30-day survival was 50.0% versus 12.1% (log-rank p = 0.02). All survivors achieved CPC of 2 or less. The groups differed substantially at baseline, including in age and sex. In this first Brazilian single-center cohort, hospital survival was higher and neurological recovery uniformly favorable among patients treated with ECPR for refractory IHCA. These descriptive findings are hypothesis-generating and support the feasibility of a structured in-hospital ECPR program in the Brazilian setting.
The aim of this study was to evaluate the epidemiological profile of first-trimester pregnant women attending a tertiary reference center in São Paulo, Brazil, and to assess its association with the development of preeclampsia. This study involved retrospective and prospective cohorts of pregnant women undergoing first-trimester ultrasound for aneuploidy screening between 11 and 13+6 weeks' gestation from 2020 to 2023. Maternal, obstetric, and clinical characteristics, including mean arterial pressure, were collected via questionnaire and clinical measurements. Statistical analyses included descriptive statistics and stepwise forward logistic regression to identify factors associated with preeclampsia development. A total of 104 pregnant women were included, with a mean age of 30.9 years. Most were White (48.3%), non-smokers (86.5%), overweight (mean body mass index: 28.5 kg/m2), and had spontaneous pregnancies (100%). Nulliparous and primiparous women accounted for 71.9% of the sample. Low risk for preeclampsia was observed in 84.3% and high risk in 15.7%. History of previous preeclampsia (OR 46.0, 95%CI 3.2-654.2), chronic arterial hypertension (OR 11.2, 95%CI 1.9-64.6), and increased first-trimester mean arterial pressure (OR 1.2, 95%CI 1.1-1.4) were independently associated with higher preeclampsia risk. Other variables, including race, parity, body mass index, and uterine artery Doppler indices, were not significant predictors. Prior history of preeclampsia, chronic hypertension, and elevated first-trimester mean arterial pressure were key predictors of preeclampsia development. These findings support the importance of first-trimester risk stratification using maternal history and mean arterial pressure measurement to guide early preventive interventions, particularly in settings where biochemical markers are not routinely available.
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The treatment landscape of hepatocellular carcinoma (HCC) has evolved substantially; however, limited access to novel therapies and regional epidemiologic differences lead to heterogeneous real-world treatment patterns worldwide. The purpose of this study was to describe the epidemiology, treatment patterns, and outcomes of patients diagnosed with HCC in Brazil between 2017 and 2022. This was a national, multicenter, retrospective, real-world observational study including patients with confirmed HCC and first diagnosis between 2017 and 2022. Data were collected from 10 centers across four geographic regions in Brazil. Of 318 patients screened, 303 were included: 107 with early-stage disease Barcelona Clinic Liver Cancer (BCLC 0-B) and 196 with advanced-stage disease (BCLC C-D). The median age was 71 years (64-77); 77.6% were men, 48.5% self-identified as Black or mixed race, and 62% were treated in public institutions. Main etiologies were hepatitis C virus (35%), alcohol-related liver disease (27.4%), hepatitis B virus (7.6%), and metabolic dysfunction-associated steatotic liver disease (MASLD; 10.9%). Among early-stage patients, 57% was classified as Child-Pugh A and 85% received local therapy (26.7% surgery or ablation; 58.8% transarterial chemoembolization [TACE]/Drug-Eluting Bead-TACE). The median progression-free survival was 10.4 months (95% CI, 8.7 to 15.7), and the median overall survival (OS) was 19.6 months (95% CI, 15.9 to 29.0). In advanced disease, 41% was classified as Child-Pugh A, portal vein thrombosis was present in 39.8%, and extrahepatic disease was present in 42.9%. Systemic therapy was administered to 48.5% of patients. The median OS was 8 months with systemic therapy versus 3 months without treatment. In this Brazilian real-world cohort, hepatitis C and alcohol were the predominant etiologies, whereas MASLD accounted for 10% of cases. Although most localized cases received locoregional therapy with outcomes consistent with the literature, access to modern systemic treatments for advanced disease remained limited.
Stroke remains a leading cause of death and disability across the Americas, disproportionately affecting low- and middle-income countries. According to the 2023 Global Burden of Disease (GBD) Study, the Americas recorded approximately 1.2 million incident strokes and 15.7 million prevalent cases. This narrative review synthesizes epidemiological evidence on stroke trends in the Americas, with emphasis on disparities in healthcare access. We integrated estimates from the GBD, peer-reviewed studies and national surveillance systems. Although age-standardized stroke rates declined after 1990, recent analyses demonstrate a concerning resurgence, particularly among younger adults. Stroke incidence, prevalence, and disability burden vary widely across countries. Latin America and the Caribbean show higher incidence but lower prevalence than high-income settings, reflecting limited access to acute care and higher case fatality. Socioeconomic and racial inequities drive delayed treatment and poorer functional outcomes. Over 75% of stroke burden is attributable to modifiable risk factors. Urgent system-level action is needed. O acidente vascular cerebral (AVC) permanece como uma das principais causas de morte e incapacidade nas Américas, afetando de forma desproporcional os países de baixa e média renda. De acordo com o estudo Global Burden of Disease (GBD) 2023, as Américas registraram aproximadamente 1.2 milhão de casos incidentes de AVC e 15.7 milhões de casos prevalentes. Esta revisão narrativa sintetiza evidências epidemiológicas sobre as tendências do AVC nas Américas, com ênfase nas desigualdades no acesso à assistência em saúde. Foram integradas estimativas do GBD, estudos revisados por pares e sistemas nacionais de vigilância. Embora as taxas de AVC padronizadas por idade tenham diminuído após 1990, análises recentes demonstram uma preocupante retomada do aumento, particularmente entre adultos mais jovens. A incidência, prevalência e carga de incapacidade por AVC variam amplamente entre os países. A América Latina e o Caribe apresentam maior incidência, porém menor prevalência em comparação com países de alta renda, refletindo acesso limitado ao cuidado agudo e maior letalidade. Desigualdades socioeconômicas e raciais contribuem para atrasos no tratamento e piores desfechos funcionais. Mais de 75% da carga de AVC é atribuível a fatores de risco modificáveis, ressaltando a necessidade urgente de ações em nível de sistema de saúde. El accidente cerebrovascular (ictus) sigue siendo una de las principales causas de mortalidad y discapacidad en las Américas, afectando de manera desproporcionada a los países de ingresos bajos y medianos. Según el estudio Global Burden of Disease (GBD) 2023, las Américas registraron aproximadamente 1.2 millones de casos incidentes de ictus y 15.7 millones de casos prevalentes. Esta revisión narrativa sintetiza la evidencia epidemiológica sobre las tendencias del ictus en las Américas, con énfasis en las desigualdades en el acceso a la atención sanitaria. Se integraron estimaciones del GBD, estudios revisados por pares y sistemas nacionales de vigilancia. Aunque las tasas de ictus ajustadas por edad disminuyeron después de 1990, análisis recientes muestran una preocupante reaparición del aumento, particularmente entre adultos más jóvenes. La incidencia, la prevalencia y la carga de discapacidad por ictus varían ampliamente entre los países. América Latina y el Caribe presentan una mayor incidencia, pero una menor prevalencia en comparación con los países de altos ingresos, lo que refleja un acceso limitado a la atención aguda y una mayor letalidad. Las desigualdades socioeconómicas y raciales contribuyen a retrasos en el tratamiento y a peores resultados funcionales. Más del 75% de la carga del ictus es atribuible a factores de riesgo modificables, lo que subraya la necesidad urgente de acciones a nivel de los sistemas de salud.
Stroke remains a leading cause of death and disability throughout the Americas, disproportionately impacting low-and middle-income countries and underserved populations. In this review, we examine the status of stroke prevention in the Americas. Prevention is essential, yet unequal access to healthcare has led to major disparities - especially among rural populations, ethnic minorities, and lower socioeconomic status. Models like the WHO HEARTS Program demonstrate that evidence-based programs can be tailored to local contexts. Telehealth and digital tools play a critical role in empowering patients, educating communities, and supporting healthcare workers. Despite growing efforts, challenges persist due to health inequities, gaps between policy and implementation, and underinvestment. Strengthening prevention will support countries in achieving the United Nations Sustainable Development Goals, targeting a one-third reduction in premature deaths from non-communicable diseases by 2030. This paper outlines effective strategies for implementing stroke prevention, emphasizing healthy lifestyles, early detection of risk factors, and system-level interventions. O Acidente Vascular Cerebral (AVC) permanece como uma das principais causas de morte e incapacidade em todas as Américas, impactando desproporcionalmente os países de baixa e média renda e as populações vulneráveis. Nesta revisão, examinamos o estado atual da prevenção do AVC nas Américas. A prevenção é essencial; contudo, o acesso desigual aos cuidados de saúde resultou em disparidades significativas – especialmente entre populações rurais, minorias étnicas e indivíduos de baixo nível socioeconômico. Modelos como o Programa HEARTS da OMS demonstram que programas baseados em evidências podem ser adaptados aos contextos locais. A telessaúde e as ferramentas digitais desempenham um papel fundamental na capacitação dos pacientes, na educação das comunidades e no apoio aos profissionais de saúde. Apesar dos esforços crescentes, os desafios persistem devido às iniquidades em saúde, às lacunas entre a política e a implementação, e ao subfinanciamento. O fortalecimento da prevenção apoiará os países no alcance dos Objetivos de Desenvolvimento Sustentável das Nações Unidas, visando uma redução de um terço nas mortes prematuras por doenças crônicas não transmissíveis até 2030. Este artigo apresenta estratégias eficazes para a implementação da prevenção do AVC, enfatizando estilos de vida saudáveis, a detecção precoce de fatores de risco e intervenções em nível sistêmico. El ataque cerebrovascular sigue siendo una de las principales causas de muerte y discapacidad en las Américas, afectando de manera desproporcionada a los países de ingresos bajos y medianos, así como a las poblaciones desatendidas. En esta revisión, examinamos el estado de la prevención del accidente cerebrovascular en las Américas. La prevención es esencial; sin embargo, el acceso desigual a la atención sanitaria ha provocado disparidades importantes, especialmente entre las poblaciones rurales, las minorías étnicas y los grupos de nivel socioeconómico bajo. Modelos como la Iniciativa HEARTS de la OMS demuestran que los programas basados en evidencia pueden adaptarse a los contextos locales. La telesalud y las herramientas digitales desempeñan un papel fundamental en el empoderamiento de los pacientes, la educación de las comunidades y el apoyo a los trabajadores de la salud. A pesar de los crecientes esfuerzos, persisten los desafíos debido a las inequidades en salud, las brechas entre la política y la implementación, y la inversión insuficiente. El fortalecimiento de la prevención apoyará a los países en el logro de los Objetivos de Desarrollo Sostenible de las Naciones Unidas, con la meta de reducir en un tercio las muertes prematuras por enfermedades no transmisibles para el año 2030. Este artículo describe estrategias efectivas para implementar la prevención del accidente cerebrovascular, enfatizando los estilos de vida saludables, la detección temprana de factores de riesgo y las intervenciones a nivel sistémico.
Turnout, or external rotation of the lower limbs, is a fundamental skill in classical ballet. While the hip is turnout's main contributor, the coordinated roles of the knee and ankle remain unclear under dynamic and aerial tasks, such as jumps. Previous studies have focused on static or bipodal tasks, overlooking unipodal landings in jumps. The aim was to analyze the kinematic contributions of the hip, knee, and ankle to turnout during three ballet jumps from fifth position: Assemblé Dessus (bipodal, with lateral aerial body displacement), Sissone Ouvert En Avant (unipodal, with anterior displacement), and Sissone Ouvert Devant (unipodal, with lateral displacement). In this observational cross-sectional study, we assessed 30 female pre-professional dancers (20.1 ± 2.6 years; 11.7 ± 4.1 years ballet experience) using a cluster-based wedge-shaped marker protocol to improve accuracy of hip and knee axial rotation measurements. We used a six-degree-of-freedom model to calculate peak rotations and their timing, which were compared across joints and jump phases (preparation, flight, and landing) using repeated measures ANOVA (P < .05). The hip consistently exhibited the greatest external rotation across all jumps and phases (P < .001). In both Sissones, hip rotation remained stable from flight to landing, whereas in Assemblé, hip and knee rotations decreased upon landing (P < .001). Ankle rotation increased during landing (P < .001) and was the lowest during flight. Timing of rotation peaks varied across joints: the hip peaked earlier, while the ankle reached its maximum in late flight and late landing. The hip is the primary contributor to turnout in all jumps, whereas the knee and ankle act complementarily, with the knee reducing its contribution and the ankle increasing it from flight to landing. Jump type and landing support influence rotational contributions, reinforcing the need for training that optimizes coordination and joint alignment.
Although lactate levels and lactate clearance are associated with outcomes in shock states, their prognostic value in brain-dead potential organ donors remains unclear and is not mentioned in clinical guidelines as a perfusion marker to guide clinical intervention. We aimed to evaluate whether lactate levels and lactate clearance may predict losses of brain-dead potential organ donors to cardiac arrest. This was a secondary analysis embedded within the cluster-randomized DONORS trial. Participants were stratified according to baseline lactate level: <2 mmol/L and ≥2 mmol/L. Individuals with lactate measurements at enrollment and after 6 h were classified according to lactate clearance: <10% or ≥10%. The primary outcome was loss of potential donors to cardiac arrest prior to organ procurement. Among 1043 participants, those with baseline lactate ≥2 mmol/L were more likely to develop cardiac arrest (53/386 [13.7%] vs. 62/657 [9.4%]; p = 0.016) and less likely to become actual donors (151/386 [39.1%] vs. 308/657 [46.9%]; p = 0.022). In adjusted analyzes, baseline lactate ≥2.0 mmol/L was associated with increased risk of cardiac arrest (OR, 1.59; 95% CI, 1.09-2.33; p = 0.016). High lactate clearance was associated with more cardiac arrests (OR, 3.44; 95% CI, 1.61-7.14; p = 0.001). Elevated baseline lactate identifies brain-dead potential donors at increased risk of cardiac arrest, whereas a lactate clearance <10% was associated with a higher risk.
Myasthenia gravis is an antibody-mediated disorder of the neuromuscular junction. Fatigability and fluctuations are hallmarks of the disease, posing a challenge: evaluation through a single physical examination may not reflect disease control. A shift towards patient-reported Outcomes is a new paradigm in the current practice, and these outcomes are usually assessed through validated scales. In the present paper, we discuss some of the most used scales in the clinical practice, such as the Myasthenia Gravis Foundation of America (MGFA) scale, the Myasthenia Gravis Activities of Daily Living (MG-ADL) scale, and the 15-Item Myasthenia Gravis Quality of Life (MG-QOL15) scale. Definitions of remission, minimal manifestation, high-burden disease, highly-active disease, and others are reviewed, and correlations involving these definitions and the scales are presented. Guidance on how to assess disease severity, therapeutic response, and a rationale for treatment escalation are explored.
The MOUSEION-11 systematic review and meta-analysis aimed to assess the rates of asthenia in patients receiving immune checkpoint inhibitors (ICIs) compared with those who received non-immunotherapeutic regimens or placebo ones. The MOUSEION-11 was recorded with PROSPERO n. CRD420250654013 and carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). For any-grade asthenia, 39 studies were included. The pooled prevalence was 15.6% (95% CI: [10.4%; 22.7%]) under a random-effects model, with significant very high heterogeneity (P < 0.001; tau2 = 2.15; I2 = 93.5%. No evidence of publication bias was detected (Egger's test P = 0.538). For grade ≥ 3 asthenia, 36 studies showed a pooled prevalence of 1.5% (95% CI: [0.6%; 3.4%]), with very high heterogeneity (I2 = 85.1%, P < 0.001) and evidence of publication bias (Egger's test P < 0.001). In comparative analyses, 14 studies demonstrated that immunotherapy was associated with significantly higher odds of any-grade asthenia compared with placebo (OR = 7.18; 95% CI: [3.82; 13.49]; P < 0.001; I2 = 63.3%), without significant publication bias (P = 0.077). Conversely, in 15 studies, immunotherapy was associated with significantly lower odds of grade ≥ 3 asthenia compared with placebo (OR = 0.06; 95% CI: [0.04; 0.09]; P < 0.001; I2 = 20.8%), with no evidence of funnel plot asymmetry (Egger's test P = 0.084). Despite the incidence of asthenia in patients receiving ICI, no treatments have been tested to palliate ICIs-induced asthenia.
The optimal management of concomitant coronary artery disease (CAD) during transcatheter aortic valve implantation (TAVI) remains controversial due to conflicting data from randomized controlled trials (RCTs). A systematic review and Bayesian meta-analysis of RCTs (through April 2026) compared pre-TAVI percutaneous coronary intervention (PCI) versus conservative management in TAVI patients with CAD. Effect measures were risk ratios (RRs) with 95% credible intervals (CrIs) using a Bayesian random-effects model. Three RCTs involving 1,156 patients were included, with 579 (50%) randomized to pre-TAVI PCI. No evidence of benefit was observed for myocardial infarction (RR, 0.83; 95% CrI, 0.44 to 1.60), all-cause mortality (RR, 0.92; 95% CrI, 0.62 to 1.35), acute kidney injury (RR, 1.01; 95% CrI, 0.41 to 2.73), rehospitalization (RR, 1.08; 95% CrI, 0.67 to 1.75), cardiovascular death (RR, 0.74; 95% CrI, 0.44 to 1.24) or stroke (RR, 0.71; 95% CrI, 0.42 to 1.20). Although pre-TAVI PCI was associated with fewer subsequent revascularizations (RR, 0.27; 95% CrI, 0.11 to 0.66), this outcome is vulnerable to ascertainment and treatment bias. Conversely, point estimates favored conservative management for major bleeding (RR, 1.57; 95% CrI, 0.96 to 2.57). Pre-TAVI PCI yielded no hard clinical benefits and likely increased major bleeding risk. While it reduced subsequent revascularizations, a soft, clinician-driven endpoint, this did not improve hospital-free survival. These findings strongly support a selective, lesion-guided approach over routine intervention.
The therapeutic landscape of metastatic hormone-sensitive prostate cancer (mHSPC) has expanded significantly with triplet regimens, raising questions about their real-world applicability. This study evaluates the efficacy and safety of darolutamide- and abiraterone-based triplets using real-world data from the ARON-3 study. A retrospective analysis was conducted on 247 mHSPC patients treated with DARO+DOCE+ADT or ABI+DOCE+ADT across 37 institutions in 14 countries. Key outcomes included progression-free survival (PFS), overall survival (OS), PSA kinetics, and safety. A propensity score was estimated based on key clinical variables and included as a covariate in Cox regression models to adjust for baseline imbalances between treatment groups. Data from 247 patients receiving triplet therapy were analyzed. The median OS for the entire cohort was not reached (NR). The median PFS was 24.8 months (95% CI: 18.7-33.6), with NR for DARO+DOCE+ADT and 21.5 months (95% CI: 13.1-25.2) for ABI+DOCE+ADT (P=0.007). In patients with visceral metastases, DARO+DOCE+ADT demonstrated superior outcomes, achieving higher OS rates at 6 months (97% vs. 83%, P=0.002) and 12 months (92% vs. 74%, P<0.001) compared to ABI+DOCE+ADT. The safety profiles of both regimens were comparable, although grade 3-4 fatigue was more frequently observed in the ABI+DOCE+ADT group. After adjusting for baseline imbalances through propensity score inclusion in multivariate models, the differences in OS (P=0.103) and PFS (P=0.135) between treatment groups did not reach statistical significance, although a numerical trend favoring DARO+DOCE+ADT was observed. Both regimens demonstrate efficacy, with DARO+DOCE+ADT offering superior outcomes in high-volume disease, especially visceral metastases. Nonetheless, the limited sample size and potential biases highlight the need for further follow-up and biomarker-driven studies in larger cohorts to refine treatment strategies.
To map strategies, technologies and management practices reported in the literature that contribute to improving operational efficiency in operating theatres. A scoping review conducted according to the Joanna Briggs Institute methodology and reported following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Searches were conducted in March 2025 in PubMed, ScienceDirect, Scopus, Embase, CINAHL and the Virtual Health Library, as well as grey literature sources including Google Scholar and the CAPES. Studies published within the last 5 years addressing technologies to improve operational efficiency were included. Fifteen studies were included (11 articles and 4 theses/dissertations), most of which were conducted in the United States (40%). Identified strategies included Lean Six Sigma, scheduling automation, digital communication platforms and artificial intelligence, demonstrating improvements in indicators such as turnover time, surgical delays and theatre room idle time. Technological and process-improvement strategies show potential to optimise operating theatre performance and support safer, more efficient use of health care resources.
In 2021, Brazil updated its Clinical Protocol and Therapeutic Guidelines (PCDT) for multiple sclerosis (MS), expanding first-line eligibility for natalizumab (NTZ) in patients with highly active disease and incorporating alemtuzumab (ALE). Evidence on temporal changes in disease-modifying therapy (DMT) dispensation within the Brazilian public health system (SUS) after this update is lacking. Using big data, we analyzed 1711,342 DMT dispensation authorizations for MS from the national outpatient registry (SIA/SUS) between 2019 and 2023. DMTs were categorized as: high-efficacy (NTZ, ALE), intermediate/moderate-efficacy (FNG), and platform therapies (IFN, GA, DMF, TERI). Quasi-Poisson space-time regression models compared pre-PCDT (2019-2021) and post-PCDT (2022-2023) periods at national and regional levels, while state-level variation was assessed relative to the national mean. Treatment switches were evaluated across periods and regions. From 2019 to 2023, the number of MS patients treated through the SUS increased by 25.9%. Nationwide, dispensation of NTZ (+44.5%, p < 0.001), DMF (+53.1%, p < 0.001), TERI (+32.5%, p < 0.001), and FNG (+15.8%, p < 0.001) increased, while IFN (-40.3%, p < 0.001) and GA (-27.6%, p < 0.001) decreased. NTZ increased across all regions, with the largest growth in the North (+82.0%, p = 0.042), whereas IFN reduced only in the North (-41.9%, p = 0.049). State-level analyses showed heterogeneous NTZ uptake, with higher rates in parts of the Northeast (Ceará, Paraíba, Sergipe), Center-West (Federal District, Goiás), North (Pará), and Southeast (São Paulo), and lower rates across all Southern states. Most treatment switches occurred within the same efficacy class, with no differences between pre- and post-PCDT periods or across regions. ALE dispensation was limited to the late post-PCDT period. In this nationwide observational analysis, DMT dispensation patterns in Brazil were characterized by higher NTZ and increased dispensation of FNG, DMF, and TERI in the post-PCDT period. However, persistent regional disparities and conservative switching patterns may suggest barriers to equitable access to HE DMTs. These findings highlight the role of national guidelines in shaping real-world therapeutic practices and the value of administrative data for monitoring treatment patterns and healthcare organization in MS.
This multicenter study aims to investigate associations between body mass index (BMI) and sociodemographic and clinical characteristics in a clinical sample of individuals with obsessive-compulsive disorder (OCD). Data were analyzed from 947 adults diagnosed with OCD, recruited through the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. BMI was calculated from self-reported weight and height and categorized according to WHO definitions. Sociodemographic and clinical data were obtained using standardized instruments. Associations between BMI and sociodemographic/clinical variables were examined using linear regression models. The mean BMI in the sample was 24.55 kg/m2 (SD = 4.65), with 5.5% of participants classified as underweight, 58% as normal weight, 25% as overweight, and 11.5% as obese. In the multivariate linear regression model, higher BMI was significantly associated with older age (β = 0.09, p < 0.001), current psychiatric treatment (β = 1.4, p < 0.001), and binge eating disorder (β = 4.4, p < 0.001). Lower BMI was significantly associated with female sex (β = - 1.6, p < 0.001) and body dysmorphic disorder (β = - 1.2, p = 0.005). No significant associations were found with educational level, OCD severity, comorbid depression, anxiety, bulimia, or anorexia. Although BMI was unrelated to OCD severity, it was associated with demographic, clinical, and treatment-related variables, underscoring the need for evaluation beyond symptom-based assessment. III, as it is based on an observational analytic design using a large cross-sectional multicenter sample.
To analyze social needs documentation across structured electronic sources in Johns Hopkins Health System, describing practices, patient characteristics, and utility for care, research, and population health. Retrospective study of electronic health records (EHR) data, 2016-2023. Social needs domains were extracted from flowsheets, ICD-10/SNOMED codes, the Social Needs Registry, and the Wellness Registry. A 6-step process refined and aggregated flowsheet entries; regression models assessed associations between documentation and demographic/clinical factors. Among 1 042 184 patients, overall, 63 595 unique patients (6.1%) had social needs documented in at least one data source. Demographically, patients with documented social needs were more likely to be Black or African American (40.2%) or Hispanic/Latino (10%) and had higher comorbidity (Charlson Comorbidity Index scores of 2.31 vs 0.84) and healthcare utilization (69.5 vs 6.1% hospitalized). Among patients with 3 or more domains of documented social needs, residential instability was the most prevalent, affecting 85.2% of this subgroup. Regression models showed African American race, Hispanic or Latino ethnicity, legal separation, and clinical severity were associated with greater documentation. Documentation of social needs in structured fields was sparse and inconsistent across sources, reflecting variable workflows and limited integration of structured data. These gaps hinder measurement, intervention, and equity goals. Given the inconsistencies we observed in social needs documentation across EHR components and need for properly harmonizing extracted values, we identified practices and workflows that enhance usability for clinical care, research, and population health, and to support equity. Standardized screening, staff training, and reporting are always needed to improve data interoperability and quality.
We evaluated the influence of single-nucleotide polymorphisms in cytokine, renin-angiotensin-aldosterone system, and uromodulin genes on COVID-19 severity and the persistence of symptoms in the post-COVID phase. Two cross-sectional cohort studies were conducted: a retrospective cohort (cohort 1) from early phase of the pandemic and a prospective cohort (cohort 2) including patients with symptoms in the post-COVID phase. Single-nucleotide polymorphism detection was performed using real-time and conventional polymerase chain reaction. Cohort 1 included 112 patients (mean age 57.4±17.5 years, 42% male). ACE rs4646994, ACE2 rs2285666, IL1A rs1800587, and TNF rs1800629 were associated with COVID-19 severity. However, when evaluating more specific outcomes such as intensive care unit admission and the need for invasive mechanical ventilation, associations were observed only for ACE2 and TNF. In women, the ACE2 rs2285666 GG genotype (p=0.003) and G allele (p=0.013) were associated with intensive care unit admission. In addition the A allele of TNF rs1800629 was associated with a higher risk of invasive mechanical ventilation (p<0.001). Cohort 2 included 107 patients (mean age 54.7±15.18 years 27.2% male). The TNF GA genotype was a risk factor for cough (p=0.03) and exertional fatigue (p=0.049). Lastly, IL1A rs1800587 was associated with the risk of persistent respiratory symptoms. Our results suggest that single-nucleotide polymorphisms in ACE2, IL1A, and TNF may be associated with an increased risk of severe COVID-19 and persistence of symptoms in affected patients.
Peripheral nerve sheath tumors (PNSTs) of the head and neck (H&N) show histopathological overlap. Although convolutional neural networks (CNNs) have demonstrated feasibility in soft tissue tumor classification, limited intra-class variability related to perineurioma remains a critical constraint for rare tumor subtypes. This retrospective diagnostic accuracy study with internal validation included 30 patients diagnosed with PNSTs. Whole-slide images were digitized at 20× magnification and partitioned using a strict patient-wise split. Synthetic perineurioma patches were generated using a modified Pix2Pix-based Generative Adversarial Network (GAN) incorporating a bottleneck architecture and self-attention modules. Two morphology-driven augmentation strategies were evaluated: (1) intra-phenotypic expansion by cross-patient patch pairing within the sclerosing subtype and (2) inter-phenotypic interpolation by cross-phenotype patch pairing between sclerosing and intraneural variants. EfficientNetV2-B0 pre-trained on ImageNet was trained under three configurations: original dataset only, original + Experiment A synthetic patches, and original + Experiment B synthetic patches. All performance metrics were computed exclusively on an independent yet internal test set composed of original images. GAN-based augmentation improved global classification performance compared with the baseline model trained on original images only (accuracy 0.733). Intra-phenotypic expansion increased accuracy to 0.767 and achieved the highest balanced accuracy (0.750) and macro-F1 (0.740). Inter-phenotypic interpolation yielded the highest overall accuracy and competitive multiclass agreement metrics. Perineurioma recall improved from 0.34 (baseline) to 0.51 with intra-phenotypic augmentation and 0.47 with inter-phenotypic interpolation, while specificity remained ≥ 0.999 across all strategies. Structured, pathology-informed GAN augmentation improved CNN classification of PNSTs, particularly for the morphologically heterogeneous perineurioma class. Intra-phenotypic expansion primarily improved rare-class sensitivity, whereas inter-phenotypic interpolation improved multiclass agreement and global robustness. These findings support morphology-driven synthetic enrichment as a clinically meaningful strategy to improve AI performance in underrepresented tumor entities and potentially support diagnostic decision-making in digital pathology environments.