Leila Beltrami Moreira

Research on the use of portable fundus cameras utilizing artificial intelligence (AI) for diabetic retinopathy (DR) screening in primary care remains limited. We aimed to evaluate the accuracy and reliability of DR screening in primary care using a smartphone-based, AI-assisted device in a small municipality in southern Brazil. The reference standard was classification of fundus images by a retina specialist. Patients with diabetes enrolled in the Brazilian Family Health Program were recruited for the study. A general ophthalmologist obtained fundus images from 134 patients, and a retina specialist validated the DR diagnosis by AI. The sample was predominantly female, with most patients having type 2 diabetes mellitus (T2DM). The age ranged from 17 to 81 years. Blood pressure was controlled in 34.9% of the sample. HbA1c levels ranged from 5.4% to 13.9%, and 35.3% of participants had levels below 7.0%. After excluding eight participants due to low image quality, the DR prevalence was 24.6%. The AI-based screening test for DR in primary care demonstrated a sensitivity of 100% (95% CI 88.8-100) and a specificity of 66.3% (95% CI 55.9-75.7). The negative predictive value (NPV) was 100% (95% CI 94.3-100), and the positive predictive value (PPV) was 49.2% (95% CI 36.4-62.1). The smartphone-based, AI-assisted device showed good accuracy and excellent performance for DR screening in primary care. It can avoid unnecessary medical referrals and help prioritize patients with advanced disease who require early treatment to prevent severe complications.

Background: Therapeutic drug monitoring (TDM) aims to prevent excessive immunosuppression, graft rejection, and the emergence of graft-versus-host disease (GVHD) and to control drug interactions. Estimates suggest that acute GVHD (aGVHD) occurs in 30-50% of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) and chronic GVHD (cGVHD) in 50 to 70%. Objective: To evaluate the effectiveness of TDM conducted by a clinical pharmacist on the quality of care for patients undergoing allogeneic HSCT to prevent GVHD and to improve clinical outcomes in comparison with historical controls. Methods: A cohort study of patients who underwent allogeneic HSCT was carried out from January 2015 to December 2017 (control group) and from January 2018 to December 2021 (TDM group). Patients were followed up for 2 years after HSCT. The exposed group received pharmaceutical TDM, considering the clinical pharmacokinetics of cyclosporine, tacrolimus, and busulfan, which was compared to a historical control group without TDM. Results: The control and TDM groups included 85 and 79 patients, respectively. Male patients predominated in this sample, the ages of whom ranged from 0 to 64 years. The incidence of GVHD in the overall cohort totaled 73.8% (n = 164). The incidence of aGVHD and cGVHD showed no significant difference between groups. Survival lasted for three more months (p = 0.04), and mortality was lower (risk ratio 0.55; p = 0.05) in the TDM group. Conclusion: TDM was associated with improved survival and reduced mortality, without significantly affecting the incidence of aGVHD or cGVHD.

Background: COVID-19 occurred in successive waves driven by different SARS-CoV-2 variants and shaped by vaccine availability and public health measures. This study analyzes differences in clinical characteristics and outcomes of hospitalized patients across three waves in Brazil. Methods: This retrospective cohort study included adult COVID-19 patients admitted to 41 hospitals across six Brazilian states from March 2020 to August 2022. Data on demographics, clinical characteristics, and outcomes were collected from medical records and compared across three pandemic waves. Categorical variables were analyzed using Chi-square or Fisher’s exact tests, with post hoc Z tests and Bonferroni correction. Continuous variables were analyzed using Analysis of Variance (ANOVA) with Tukey’s test or Kruskal-Wallis with Dunn’s test and Bonferroni correction. Results: Among 18,632 patients, 37% were hospitalized during the first wave, 55% in the second, and 8% in the third. The median age decreased during the second wave but increased in the third (60 vs 58 vs 66 years; P < 0.001). A higher proportion of patients with three or more comorbidities were admitted during the third wave (15.9% vs 11.9% vs 20.6%; P < 0.001). Anosmia, ageusia, and fever were less frequently reported in the third wave ( P < 0.001). Intensive care unit admissions (38.7% vs 37.1% vs 25.5%; P < 0.001) and in-hospital mortality (21.3% vs 23.7% vs 18.2%; P < 0.001) declined throughout the pandemic. Conclusion: Clinical manifestations and outcomes evolved across the pandemic waves. The third wave demonstrated fewer chemosensory symptoms, lower severity at admission, and reduced mortality, despite an older and more comorbid patient population. Graphical

Background: The comparison of left ventricular mass (LVM) at different BP levels and the effects of antihypertensive drug treatment on LVM are unknown. Objective: To compare the LVM of individuals with prehypertension and Stage 1 hypertension and assess the effects of treatment on LVM at these stages of hypertension. Methods: We estimated LVM in the PREVER-Prevention trial using Sokolow–Lyon and Cornell voltage and voltage–duration products before and after randomization to 18 months of treatment with low doses of chlorthalidone and amiloride or placebo in adults with JNC 7 “prehypertension” (systolic BP [SBP] of 120–139 mm Hg and diastolic BP [DBP] of 80–89 mm Hg). Similarly, in the PREVER-Treatment trial, we assessed these indices before and after randomization to 18 months of treatment with the chlorthalidone/amiloride combination or losartan in adults with JNC 7 “stage 1” hypertension (140–159 mm Hg or DBP of 90–99 mm Hg). Results: At baseline, the participants in the stage I hypertension trial exhibited higher mean LVM indices than those in the prehypertension trial. In the PREVER-Prevention trial, those randomized to the chlorthalidone/amiloride combination experienced a significant reduction in Sokolow–Lyon LVM indices compared to placebo (p = 0.02). In the PREVER-Treatment trial, those randomized to the chlorthalidone/amiloride combination or losartan experienced a similar reduction in electrocardiographic LVM during the 18 months of treatment (p < 0.01). Conclusions: The institution of low-dose antihypertensive drug therapy in prehypertension and treatment of patients with stage 1 hypertension has the potential to interrupt the progress of hypertensive cardiomyopathy.

The 2017 US guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults proposed the diagnosis of hypertension at 130/80 mmHg, while the European Society of Cardiology and 2020 Brazilian Guidelines of Hypertension maintain the 140/90 mmHg cut-off. We aimed to evaluate how the cut-off established by the American Heart Association guidelines would impact the prevalence of hypertension in the ELSA-Brasil cohort and compare the clinical characteristics among these subgroups. The participants were part of the ongoing ELSA-Brasil multicenter cohort, with baseline data collected between 2008 and 2010, consisting of 15,105 public servants of both sexes aged 35 to 74 years. Hypertension (≥140 or ≥90 mmHg or use of antihypertensive drugs in the last two weeks if below these values) prevalence was 36.2% (95%CI: 35.4-36.9, n=5,456) with the Brazilian cut-off and 51.4% (95%CI: 50.6-52.1, n=7,756) when considering the US cut-off (SBP≥130 or DBP≥80 mmHg). In general, those with high blood pressure (HBP) presented an intermediate-risk profile compared to the hypertension group. Lowering the hypertension cut-off caused an absolute increase of 15.2% in the prevalence of hypertension in the sample of public servants studied. HBP individuals showed intermediate-risk profile between normal blood pressure and hypertension and represented a large fraction of the population who may benefit from treatment.

The Covid-19 pandemic caused a negative impact on other infectious diseases control, prevention, and treatment. Consequently, low and middle-income countries suffer from other endemic diseases, such as tuberculosis. This study was designed to compare Covid-19 manifestations and outcomes between patients with previously treated tuberculosis and controls without this condition. We performed a matched case-control study drawn from the Brazilian Covid-19 Registry data, including in-hospital patients aged 18 and over with laboratory-confirmed Covid-19 from March 1, 2020, to March 31, 2022. Cases were patients with a past history of tuberculosis. Controls were Covid-19 patients without a tuberculosis history. Patients were matched by hospital, sex, presence of HIV, and number of comorbidities, with a 1:4 ratio. Of 13,636 patients with laboratory-confirmed diagnoses of Covid-19 enrolled in this study, 80 had a history of tuberculosis. Statistical differences in history of chronic pulmonary obstructive disease (15% vs. 3.2%), psychiatric disease (10% vs. 3.5%,), chronic kidney disease (11.2% vs. 2.8%), and solid-organ transplantation; (5% vs. 0.9%, p < 0.05 for all) were higher in patients with a past history of tuberculosis. Prior use of inhalatory medications (5% vs. 0.6%,), oral corticoids (8.8% vs. 1.9%), immunosuppressants (8.8% vs. 1.9%,) and the use of illicit drugs were more common in the case group (6.2% vs. 0.3% p < 0.05for all). There were no significant differences in in-hospital mortality, mechanical ventilation, need for dialysis, and ICU admission. Patients with a history of tuberculosis infection presented a higher frequency of use of illicit drugs, chronic pulmonary obstructive disease, psychiatric disease, chronic kidney disease, solid-organ transplantation, prior use of inhalatory medications, oral corticoids, and immunosuppressants. The outcomes were similar between cases and controls.