Background The efficacy and safety of azithromycin in the treatment of COVID-19 remain uncertain. We assessed whether adding azithromycin to standard of care, which included hydroxychloroquine, would improve clinical outcomes of patients admitted to the hospital with severe COVID-19. Methods We did an open-label, randomised clinical trial at 57 centres in Brazil. We enrolled patients admitted to hospital with suspected or confirmed COVID-19 and at least one additional severity criteria as follows: use of oxygen supplementation of more than 4 L/min flow; use of high-flow nasal cannula; use of non-invasive mechanical ventilation; or use of invasive mechanical ventilation. Patients were randomly assigned (1:1) to azithromycin (500 mg via oral, nasogastric, or intravenous administration once daily for 10 days) plus standard of care or to standard of care without macrolides. All patients received hydroxychloroquine (400 mg twice daily for 10 days) because that was part of standard of care treatment in Brazil for patients with severe COVID-19. The primary outcome, assessed by an independent adjudication committee masked to treatment allocation, was clinical status at day 15 after randomisation, assessed by a six-point ordinal scale, with levels ranging from 1 to 6 and higher scores indicating a worse condition (with odds ratio [OR] greater than 1·00 favouring the control group). The primary outcome was assessed in all patients in the intention-to-treat (ITT) population who had severe acute respiratory syndrome coronavirus 2 infection confirmed by molecular or serological testing before randomisation (ie, modified ITT [mITT] population). Safety was assessed in all patients according to which treatment they received, regardless of original group assignment. This trial was registered at ClinicalTrials.gov , NCT04321278 . Findings 447 patients were enrolled from March 28 to May 19, 2020. COVID-19 was confirmed in 397 patients who constituted the mITT population, of whom 214 were assigned to the azithromycin group and 183 to the control group. In the mITT population, the primary endpoint was not significantly different between the azithromycin and control groups (OR 1·36 [95% CI 0·94–1·97], p=0·11). Rates of adverse events, including clinically relevant ventricular arrhythmias, resuscitated cardiac arrest, acute kidney failure, and corrected QT interval prolongation, were not significantly different between groups. Interpretation In patients with severe COVID-19, adding azithromycin to standard of care treatment (which included hydroxychloroquine) did not improve clinical outcomes. Our findings do not support the routine use of azithromycin in combination with hydroxychloroquine in patients with severe COVID-19. Funding COALITION COVID-19 Brazil and EMS.

BackgroundAcute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival.MethodsThe study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study.ResultsA total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001).ConclusionsAcute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.

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Background During the SARS-CoV-2 pandemic, in order to protect the patient and to save hospital beds, cancelation of elective surgeries has become a great challenge. Considering that obesity is a chronic disease and the possible effect imposed by quarantine on weight gain with worsening rates of obesity and metabolic comorbidities, the creation of a protocol for a safe return to bariatric surgery became essential. Objective The aim of this study was to identify the incidence of new-onset severe acute respiratory syndrome coronavirus (SARS-CoV-2) symptoms in patients who underwent bariatric procedures during the declining curve period. Setting Private practice Methods A prospective observational cohort study was conducted and included patients with indications for bariatric surgery during the decreasing curve period of the SARS-CoV-2 pandemic who underwent surgery under a hospital security protocol. Patients were asked to answer a questionnaire and had a swab PCR test for SARS-CoV-2 detection. The primary outcome measure was the presence of 14-day and 30-day postoperative symptoms associated with COVID-19. Mortality was also analyzed. Results Three hundred patients with negative RT-PCR were operated on from May to June 2020. Seventeen patients had their surgery postponed because of a positive RT-PCR test or close contact. None of the patients developed new-onset SARS-CoV-2 symptomatic infection after 30 days of observation. No deaths were reported. Eleven had complications not related to SARS-CoV-2. Conclusions Even though this population may have a poorer outcome when infected with SARS-CoV-2, this security protocol has shown that the procedure can be safely performed during the outbreak.

These findings emphasize low eGFR prior to LTx as a predictor for ESRD or death. The consideration for kidney after liver transplant as a treatment modality should be taken into account for those who develop chronic kidney failure after LTx.

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Background Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain. Methods This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. Results Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01). Conclusion Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Endométrio superior a 5 mm deve ser sempre investigado, principalmente se não sangrar após o uso de progestógeno 1 . No caso presente, a investigação tornou-se ainda mais imperiosa, pois o tamoxifeno responsabiliza-se por hiperplasias atípicas do endométrio, que podem evoluir para câncer endometrial. As neoplasias malignas devem ser prevenidas, principalmente por meio de programas que visem à detecção precoce de lesões precursoras. Neste caso, outra constatação interessante foi o achado histeroscópio de atrofia endometrial em paciente cujo ultrasom revelava hiperplasia. O espessamento endometrial detectado na ultra-sonografia transvaginal é achado freqüente em exames de rotina na investigação da cavidade uterina e como menos de 10% desses espessamentos se relacionam ao câncer de endométrio, fica clara a necessidade de um método de triagem que seja pouco invasivo, de fácil acesso, baixo custo e boa sensibilidade 2,3 . Daí a inclusão da histeroscopia em associação à ultra-sonografia transvaginal na avaliação da cavidade uterina em mulheres após a menopausa. A encefalopatia hepática ou portosistêmica é uma síndrome clínica muito comum em portadores de doença hepá-tica crônica, acometendo de 50% a 70% dos cirróticos no curso da sua doença. Tem curso flutuante e caráter progressivo se não identificada e tratada adequadamente. É caracterizada por sinais e sintomas neurológicos em portadores de insuficiência hepática ou shunt porto-sistê-mico e que não podem ser atribuídos a outra causa. Tem graus variáveis de gravidade, desde manifestações subclínicas até o estupor e coma profundo. O diagnóstico de encefalopatia hepática é eminentemente clínico. As manifestações não são específicas; alteração de nível de consciência, asterix, hálito hepático e outros sintomas neuropsiquiátricos podem estar presentes em uma série de outras patologias que devem ser excluídas. Antecedentes de cirrose hepática e encefalopatia hepática prévia ou a presença de um evento precipitante óbvio, geralmente contribuem para o diagnóstico, porém, mesmo em hepatopatas, a alteração de nível de consciência pode estar relacionada a outras patologias como eventos vasculares cerebrais ou infecção no sistema nervoso central. Portanto, o diagnóstico de encefalopatia hepática é geralmente de exclusão, devendo-se atentar para a presença de sinais e sintomas que sugiram outra etiologia para alteração no nível de consciência, como déficits focais, alteração em pares cranianos ou irritação meníngea. Fatores predisponentes também auxiliam na suspeita diagnóstica e incluem: o aumento da produção de amônia ou da difusão de amônia pela barreira hemato-encefálica (por uremia, hemorragia digestiva, infecção, entre outras), o comprometimento da perfusão hepática (por hipovolemia, paracentese), drogas depressoras do sistema nervoso (benzodiazepínicos, opióides), shunt" portosistêmico (TIPS, cirúrgico) e diminuição da reserva funcional hepática (progressão da hepatopatia, hepatocarcinoma).Na maioria das vezes, existem fatores precipitantes que obrigatoriamente devem ser ...