Mário Reis Alvares-da-Silva

Hospital De Clínicas De Porto Alegre, Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil

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Publications (55)159.51 Total impact

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    ABSTRACT: . Transarterial chemoembolization alone or in association with radiofrequency ablation is an effective bridging strategy for patients with hepatocellular carcinoma awaiting for a liver transplant. However, cost of this therapy may limit its utilization. This study was designed to evaluate the outcomes of a protocol involving transarterial embolization, percutaneous ethanol injection, or both methods for bridging hepatocellular carcinomas prior to liver transplantation. Methods . Retrospective review of all consecutive adult patients who underwent a first liver transplant as a treatment to hepatitis C-related hepatocellular carcinoma at our institution between 2002 and 2012. Primary endpoint was patient survival. Secondary endpoint was complete tumor necrosis. Results . Forty patients were analyzed, age 58 ± 7 years. There were 23 males (57.5%). Thirty-six (90%) out of the total 40 patients were within Milan criteria. Complete necrosis was achieved in 19 patients (47.5%). One-, 3-, and 5-year patient survival were, respectively, 87.5%, 75%, and 69.4%. Univariate analysis did not reveal any variable to impact on overall patient survival. Conclusions . Transarterial embolization, ethanol injection, or the association of both methods followed by liver transplantation comprises effective treatment strategy for hepatitis C-related hepatocellular carcinoma. This strategy should be adopted whenever transarterial chemoembolization and/or radiofrequency ablation are not available options.
    Preview · Article · Jan 2016 · Gastroenterology Research and Practice
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    ABSTRACT: Introduction: Pegylated Interferon Alpha (Peg-IFN) in combination with other drugs is the standard treatment for chronic hepatitis C infection (HCV) and is related to severe painful symptoms. The aim of this study was access the efficacy of transcranial direct current stimulation (tDCS) in controlling the painful symptoms related to Peg-IFN side effects. Materials and Methods: In this phase II double-blind trial, twenty eight (n = 28) HCV subjects were randomized to receive either 5 consecutive days of active tDCS (n = 14) or sham (n = 14) during 5 consecutive days with anodal stimulation over the primary motor cortex region using 2 mA for 20 min. The primary outcomes were visual analogue scale (VAS) pain and brain-derived neurotrophic factor (BDNF) serum levels. Secondary outcomes were the pressure-pain threshold (PPT), the Brazilian Profile of Chronic Pain: Screen (B-PCP:S), and drug analgesics use. Results: tDCS reduced the VAS scores (P < 0.003), with a mean pain drop of 56% (p < 0.001). Furthermore, tDCS was able to enhance BDNF levels (p < 0.01). The mean increase was 37.48% in the active group. Finally, tDCS raised PPT (p < 0.001) and reduced the B-PCP:S scores and analgesic use (p < 0.05). Conclusions: Five sessions of tDCS were effective in reducing the painful symptoms in HCV patients undergoing Peg-IFN treatment. These findings support the efficacy of tDCS as a promising therapeutic tool to improve the tolerance of the side effects related to the use of Peg-IFN. Future larger studies (phase III and IV trials) are needed to confirm the clinical use of the therapeutic effects of tDCS in such condition. Trial registration: Brazilian Human Health Regulator for Research with the approval number CAAE 07802012.0.0000.5327.
    Full-text · Article · Jan 2016 · Frontiers in Neuroscience
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    ABSTRACT: Background: Topical hypothermia (TH) and ischemic preconditioning (IPC) are used to decrease I/R injury. The efficacy of isolated or combined use of TH and IPC in the liver regarding inflammation and cytoprotection in early ischemia/reperfusion (I/R) injury needs to be evaluated. Material and methods: Wistar rats underwent 70% liver ischemia for 90 min followed by 120 min of reperfusion. Livers of animals allocated in the sham, normothermic ischemia (NI), IPC, TH, and TH+IPC groups were collected for molecular analyses by ELISA and Western blot, aiming to compare proinflammatory, anti-inflammatory, and antioxidant profiles. Results: Compared with NI, TH presented decreased tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6 and IL-12 concentrations and increased IL-10 levels. TH animals displayed lower inducible nitric oxide synthase (iNOS) and higher endothelial nitric oxide synthase (eNOS) expressions. NAD(P)H-quinone oxidoreductase-1(NQO1) expression was also lower with TH. Isolated IPC and NI were similar regarding all these markers. TH+IPC was associated with decreased IL-12 concentration and reduced iNOS and NQO1 expressions, similarly to isolated TH. Expression of Kelch-like ECH-associated protein (Keap)-1 was increased and expression of nuclear and cytosolic nuclear erythroid 2-related factor 2 (Nrf2) was decreased with TH+IPC vs. NI. Conclusion: TH was the most effective method of protection against early I/R injury. Isolated IPC entailed triggering of second-line antioxidant defense enzymes. Combined TH+IPC seemed to confer no additional advantage over isolated TH in relation to the inflammatory process, but had the advantage of completely avoid second-line antioxidant defense enzymes.
    Full-text · Article · Dec 2015 · Annals of hepatology: official journal of the Mexican Association of Hepatology
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    ABSTRACT: This study sought to determine the role of physical training (PT) on body weight (BW), energy balance, histological markers of nonalcoholic fatty liver disease (NAFLD) and metabolic gene expression in the liver of ob/ob mice. Adult male ob/ob mice were assigned into groups sedentary (S; n = 8) and trained (T; n = 9). PT consisted in running sessions of 60 min at 60% of maximal speed conducted five days per week for eight weeks. BW of S group was higher from the 4(th) to 8(th) week of PT compared to their own BW at the beginning of the experiment. PT decreased daily food intake and increased resting oxygen consumption and energy expenditure in T group. No difference was observed in respiratory exchange ratio, but the rates of carbohydrate and lipids oxidation, and maximal running capacity were greater in T than S group. Both groups showed liver steatosis but not inflammation. PT increased CPT1a and SREBP1c mRNA expression in T group, but did not change MTP, PPAR-α, PPAR-γ, and NFKB mRNA expression. In conclusion, PT prevented body weight gain in ob/ob mice by inducing negative energy balance and increased physical exercise tolerance. However, PT did not change inflammatory gene expression and failed to prevent liver steatosis possible due to an upregulation in the expression of SREBP1c transcription factor. These findings reveal that PT has positive effect on body weight control but not in the liver steatosis in a leptin deficiency condition.
    Full-text · Article · Sep 2015 · International Journal of Clinical and Experimental Medicine
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    Catarina B A GOTTSCHALL · Thainá G PEREIRA · Estela I RABITO · Mário R ÁLVARES-DA-SILVA
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    ABSTRACT: Background - The hepatitis C virus is one of the main causes of liver disease worldwide and may develop nutritional defi­ciencies. Objective -The objective of this study was to assess and compare different nutritional status methods of adult patients with chronic hepatitis C virus, and to describe inadequacies in dietary intake. Methods - A cross-sectional study was conducted with adult outpatients with hepatitis C virus at a Brazilian hospital. Nutritional assessment included the 24-hour dietary recall, anthropometry (body weight, height, body mass index, triceps skinfold, mid-upper arm circumference, mid-arm muscle circumference, mid-upper arm muscle area, adductor policis muscle), Subjective Global Assessment, Royal Free Hospital Global Assessment and handgrip strength. Results -A total of 94 outpatients (ages 30 to 76 years), was included, 46 were men. The prevalence of malnutrition as measured by the different methods was 6.4% (body mass index); 60.6% (handgrip strength), and 53.2% (Royal Free Hospital Global Assessment). There was correlation between mid-upper arm circumference and mid-arm muscle circumference (r=0.821), mid-upper arm circumference and triceps skinfold (r=0.575) and mid-upper arm circumference and mid-upper arm muscle area (r=0.781). En­ergy and protein intakes were below recommended levels in 49 (52.1%) and 44 (46.8%) of patients, respectively. Inadequate calcium, potassium, zinc and vitamin C intakes occurred in 92.6%, 97.9%, 63.8% and 60.6% of patients. There was an association between dietary energy and protein intake with Royal Free Hospital Global Assessment (P<0.001) and a tendency for them to be associated with handgrip strength (P=0.076 and P=0.054). Conclusion -Malnutrition is frequently in hepatitis C virus patients. They have high prevalence of inadequate energy, protein and micronutrients intake, even in the absence of cirrhosis. © 2015, IBEPEGE - Inst. Bras. Estudos Pesquisas Gastroent. All rights reserved.
    Preview · Article · Sep 2015 · Arquivos de gastroenterologia
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    ABSTRACT: Transarterial chemoembolization (TACE) and transarterial embolization (TAE) have improved the survival rates of patients with unresectable hepatocellular carcinoma (HCC); however, the optimal TACE/TAE embolic agent has not yet been identified. The aim of this study was to compare the effect of two different embolic agents such as microspheres (ME) and polyvinyl alcohol (PVA) on survival, tumor response, and complications in patients with HCC submitted to transarterial embolization (TAE). Eighty HCC patients who underwent TAE between June 2008 and December 2012 at a single center were retrospectively studied. A total of 48 and 32 patients were treated with PVA and ME, respectively. There were no significant differences in survival ( P = 0.679 ) or tumoral response ( P = 0.369 ) between groups (PVA or ME). Overall survival rates at 12, 18, 24, 36, and 48 months were 97.9, 88.8, 78.9, 53.4, and 21.4% in the PVA-TAE group and 100, 92.9, 76.6, 58.8, and 58% in the ME-TAE group ( P = 0.734 ). Patients submitted to TAE with ME presented postembolization syndrome more frequently when compared with the PVA group ( P = 0.02 ). According to our cohort, the choice of ME or PVA as embolizing agent had no significant impact on overall survival.
    Preview · Article · Aug 2015
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    ABSTRACT: To investigate the survival rates after transarterial embolization (TAE). One hundred third six hepatocellular carcinoma (HCC) patients [90 barcelona clinic liver cancer (BCLC) B] were submitted to TAE between August 2008 and December 2013 in a single center were retrospectively studied. TAE was performed via superselective catheterization followed by embolization with polyvinyl alcohol or microspheres. The date of the first embolization until death or the last follow-up date was used for the assessment of survival. The survival rates were calculated using the Kaplan-Meier method, and the groups were compared using the log-rank test. The overall mean survival was 35.8 mo (95%CI: 25.1-52.0). The survival rates of the BCLC A patients (33.7%) were 98.9%, 79.0% and 58.0% at 12, 24 and 36 mo, respectively, and the mean survival was 38.1 mo (95%CI: 27.5-52.0). The survival rates of the BCLC B patients (66.2%) were 89.0%, 69.0% and 49.5% at 12, 24 and 36 mo, respectively, and the mean survival was 29.0 mo (95%CI: 17.2-34). The survival rates according to the BCLC B sub-staging showed significant differences between the groups, with mean survival rates in the B1, B2, B3 and B4 groups of 33.5 mo (95%CI: 32.8-34.3), 28.6 mo (95%CI: 27.5-29.8), 19.0 mo (95%CI: 17.2-20.9) and 13 mo, respectively (P = 0.013). The BCLC sub-staging system could add additional prognosis information for post-embolization survival rates in HCC patients.
    No preview · Article · Mar 2015 · World Journal of Hepatology
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    ABSTRACT: According to the current criteria, the diagnosis of early allograft dysfunction usually cannot be established before the end of the first week after liver transplantation. Thus, early predictive tests for detecting allograft dysfunction are still warranted to prevent allograft failure. This study was undertaken to assess the role of low serum factor V activity as an early prognostic factor (postoperative day 2) after liver transplantation. A retrospective review of all consecutive adult patients who underwent first orthotopic whole-graft liver transplant at our institution between March 2002 and June 2011 was undertaken. Primary endpoint was graft failure within 90 days after transplantation. Of all 105 patients analyzed in this study, 39 (37.1 %) were female and 66 (62.9 %) were male. Mean age was 52.7 ± 11.7 years, and median follow-up period was 2474 ± 164 days. There were overall 33 (31.4 %) deaths, 13 of those occurring on the first 90 post-transplant days. Multivariate analysis demonstrated that serum factor V lower than 41.5 % and female gender had a negative impact not only on allograft failure/death within 90 days after transplantation (RR = 5.30, CI = 1.40-20.2, p = 0.015 and RR = 5.23, CI = 1.53-21.33, p = 0.008) but also on overall mortality. For prediction of allograft failure/death occurring during the first 3 months, serum factor V level of 41.5 % or lower exhibited a specificity of 87.9 %, a sensitivity of 42.9 %, an accuracy of 81.9 %, a positive predictive value of 35.3 %, and a negative predictive value of 90.9 %. Assessment of serum factor V levels on postoperative day 2 might be a promising prognostic tool for early prediction of inferior outcomes after liver transplantation.
    No preview · Article · Feb 2015 · Langenbeck s Archives of Surgery
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    ABSTRACT: Background/aims:: Nonalcoholic fatty liver disease (NAFLD) has emerged as an important cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC). The Barcelona Clinic Liver Cancer (BCLC) system is the preferred staging system to evaluate patients with HCC and links prognosis assessment with treatment recommendation. The aim of this retrospective study was to evaluate whether the BCLC staging system and its treatment algorithm are suitable for patients with HCC arising from NAFLD. Methods:: Forty-two patients with HCC related to either to NAFLD or cryptogenic cirrhosis were retrieved retrospectively from 2 centers in Brazil. Patients were classified according to BCLC staging system. If the proposed HCC therapy could not be applied, the case was considered to represent deviations from the recommended BCLC guideline. Causes of treatment deviations were investigated. Results:: There were 4 patients without evidence of cirrhosis according to liver biopsy and/or clinical evaluation. One (2%), 21 (50%), 10 (24%), 5 (12%), and 5 patients (12%) were classified initially to the very early (0), early (A), intermediate (B), advanced (C), and terminal (D) BCLC stages, respectively. Thirty-five patients (83%) were treated according to BCLC recommendations. There were 3 cases (of 5) of protocol deviation in BCLC C patients. The 1- and 2-year overall survival rates were 81% and 66%, respectively. Conclusions:: The BCLC system is applied in most cases of NAFLD-related HCC cases. Deviation of BCLC is found more frequently in BCLC C stage patients.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.
    Full-text · Article · Sep 2014 · American Journal of Clinical Oncology
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    ABSTRACT: The mechanisms involved in organ protection by volatile anaesthetics are not completely understood. In the liver transplant setting, there is a lack of information in the literature about whether sevoflurane anaesthesia has a superior hepatoprotective effect when compared with isoflurane.
    No preview · Article · Aug 2014 · European Journal of Anaesthesiology
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    ABSTRACT: & Aims: Transient elastometry is a non-invasive procedure used to measure fibrosis when patients are diagnosed with liver disease; it might be used to monitor changes over time. We investigated whether there are short-term variations in stiffness measurements not attributable to changes in fibrosis by studying patients with stable liver disease.
    Full-text · Article · Jul 2014 · Clinical Gastroenterology and Hepatology
  • Alexandre de Araujo · Mario Reis Alvares-da-Silva
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    ABSTRACT: Background and aims: Spontaneous bacterial peritonitis (SBP) often triggers acute-on-chronic liver failure (ACLF). Acute kidney injury (AKI) is frequent and correlates with higher mortality in such cases. The aim of this study is to evaluate the Acute Kidney Injury Network (AKIN) criteria in the prediction of death in cirrhotic patients after an episode of SBP. Material and methods: Forty-six cirrhotic patients with SBP were included in a cohort study. Renal injury was estimated by AKIN criteria (grades 1, 2 or 3) to examine the association between AKI severity and mortality. Patients were followed-up for a mean of 13.22 months. Kaplan-Meier survival curve and the hazard ratio of mortality by Cox regression model were calculated accordingly to the AKIN criteria. Results: The mean age of the included patients was 56.94 ± 9.49; 29 (63%) were male. Mean MELD score was 19.46 ± 6.16; 78.3% were Child-Pugh C. AKI occurred in 43.5% of patients (8.7, 17.4 and 17.4% respectively for AKIN criteria 1, 2 and 3). Inpatient mortality for AKIN 1, 2 and 3 was 50, 37.5 and 62.5 vs. 3.8% for patients without renal injury (p = 0.002, 0.001 and < 0.001 respectively). Patients with AKIN grades 1, 2 or 3 had no significant differences regarding MELD score (p = 0.893). The hazard ratio and 95% confidence interval of mortality for patients with AKI (AKIN grades 1, 2 and 3 grouped) were 3.41 (1.58-7.36). Conclusions: AKIN criteria are useful to predict mortality in patients with SBP.
    No preview · Article · Apr 2014 · Annals of hepatology: official journal of the Mexican Association of Hepatology
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    ABSTRACT: Minimal hepatic encephalopathy (MHE) is common in cirrhotic. Its optimal treatment is still under investigation. To assess efficacy/safety of oral l-ornithine-l-aspartate (LOLA) in controlling MHE. Consecutive cirrhotic outpatients with MHE - psychometric tests (PHES) - NCT-A/B and DSST> 2 standard deviation, were randomized to 60-day oral LOLA (5g t.i.d) or placebo. Critical Flicker test (CFF), quantitative EEG (qEEG), arterial ammonia (NH3), Beck's anxiety-depression forms and LD-QOL were assessed. Patients were followed by 6 months after the end of the study to assess LOLA prophylactic role on overt hepatic encephalopathy (OHE). 64 patients were included - 63 (98.4%) with MHE. In 6/63 CFF was <39Hz (9.52%); NH3 was increased in 32 (50.8%); 25% had abnormal qEEG. Age, sex, scholarship, Child-Pugh (CP), MELD, NCT-A/B, DSST, CFF and NH3 were similar in both groups at the baseline. LOLA led to a significant improvement in NCT-B age-controlled z-score (3.4 ± 3.4 vs. 1.5 ± 2.3 - P=0.01) and CFF (42.2 ± 5.8 vs. 45.2 ± 5.8 - P=0.02), comparing the first and the last visit, but there were no differences between LOLA and placebo regarding the whole PHES battery, CFF, LD-QOL and Beck's forms. No serious adverse effects occurred. Patients taking LOLA had fewer episodes of OHE at 6-month (5% vs. 37.9% - P=0.016), as they have significant improvement on liver function assessed by CP (P<0.001). A 60-day oral LOLA course was not better than placebo on treating MHE, but was useful on preventing further episodes of OHE. Clinical Trials (NCT-00896831).
    No preview · Article · Sep 2013 · Hepatology Research
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    Full-text · Article · Sep 2013 · Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery
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    Claudia Pinto Marques Souza de Oliveira · Jose Tadeu Stefano · Mário Reis Alvares-da-Silva
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    ABSTRACT: Liver transplantation is the standard of care for acute and chronic end-stage liver disease. Advances in medical therapy and surgical techniques have transformed the long-term survival of liver-transplant (LT) recipients. The prevalence of post-transplant cardiovascular complications has been rising with increased life expectancy after liver transplantation. Currently, deaths related to cardiovascular complications are one of the main causes of long-term mortality in LT recipients, as cardiovascular disease is the reason of 19-42% of non-liver-related mortality after transplant. On the other hand, metabolic syndrome is common among LT recipients before and after transplantation. In fact, their components (abdominal obesity, diabetes mellitus, hypertension and dyslipidemia) are often exacerbated by transplant-specific factors, such as immunosuppression, inappropriate diet, smoking and a sedentary lifestyle, and add a significant risk of developing atherosclerosis. These aspects are discussed in this article.
    Full-text · Article · May 2013 · Expert review of gastroenterology & hepatology
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    ABSTRACT: The role of hepatitis C virus (HCV) in the pathogenesis of atherosclerosis and cardiovascular events is unclear. The aim of this study was to evaluate the direct effect of HCV on cardiovascular risk and correlate it with pro and anti-inflammatory cytokines in patients with HCV. HCV monoinfected patients, genotype 1, naive, non-obese (BMI<30) and non-diabetics were included and compared to controls (blood donors). Patients with prior diagnosis of cardiovascular diseases, hypertension, chronic renal failure, cancer and chronic use of lipid-lowering drugs or immunosuppressants were excluded. Age, BMI, systolic blood pressure (SBP) and diastolic (DBP), fasting glucose and lipid levels were determined. Serum cytokines (IL-6, IL-10 and TNF-α) and Framingham score were also evaluated. 62 HCV patients, 34 (54.8%) were males and none of them was smoking. The Framingham scores (median and 25th and 75th percentiles) were 12% (6.5-14%), showing an intermediate cardiovascular risk in patients with HCV. There was significant direct correlation between Framingham and total cholesterol (p=0.043) and DBP (p=0.007). HDL-C (p=0.002) was inversely correlated with the Framingham score. HCV patients had higher levels of proinflammatory cytokines (IL-6 and TNF-α) compared to controls (p<0.0001) and the relation of proinflammatory/anti-inflammatory TNF-α/IL10 and IL-6/IL10 were higher in HCV patients (p<0.01). The Framingham score was directly correlated to IL-6 and TNF-α, but differences were not statistically significant. Patients with HCV monoinfected, nonobese, naïve and non diabetic have an intermediate cardiovascular risk, as measured by the Framingham score and high levels of proinflammatory cytokines (IL-6 and TNF).
    Full-text · Article · Apr 2013 · International journal of cardiology

  • No preview · Article · Apr 2013 · Journal of Hepatology
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    ABSTRACT: Various ocular lesions are associated with hepatitis C virus (HCV). Few studies have focused on untreated patients. This study aims to describe ocular lesions in untreated HCV-infected patients without ophthalmic symptoms by means of a comprehensive ophthalmologic examination. Ninety-five consecutive naive HCV chronically infected patients and 54 controls (blood donors) were enrolled in a prospective, cross-sectional, single-center study. The following variables were analyzed: age, sex, HCV viral load and genotype, liver fibrosis, visual acuity, biomicroscopy of the anterior segment, lacrimal function (tear break-up time) and Schirmer's tests), posterior segment examination, and intraocular pressure. HCV-infected patients presented an almost four times higher risk of lacrimal function involvement by tear break-up time [odds ratio (OR)=3.76; 95% confidence interval (CI) 1.75-8.04, P=0.001] and Schirmer's test (OR=4.17; 95% CI 1.83-9.50, P=0.001) than the controls. The chances of palpebral biomicroscopic lesions (blepharitis) were also higher (OR=3.21; 95% CI 1.49-6.94, P=0.003). Mean tonometry was higher in HCV patients (right eye 14.4±2.3 vs. 12.2±1.5, P<0.001 and left eye 14.5±2.3 vs. 12.0±1.4, P<0.001). Naive HCV patients even with no ophthalmic complaints presented a greater prevalence of lacrimal function abnormalities and a higher frequency of blepharitis compared with the control group. As never formerly described, intraocular pressure in HCV patients was higher than that in controls.
    Full-text · Article · Apr 2013 · European journal of gastroenterology & hepatology
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    Full-text · Article · Dec 2012
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    ABSTRACT: Protein-calorie malnutrition (PCM) is a prognostic factor increasing complications and mortality in chronic liver diseases. Objectives: To quantify the dietary intake and compare different methods of nutritional assessment in patients with chronic liver diseases. Ninety seven outpatients of Hospital de Clínicas de Porto Alegre, with chronic hepatits (CH) and cirrhosis (CIR), were assessed from April 2009 to January 2010. The CH patients presented higher calorie and protein intake (p<0.05) than the CIR patients. Malnutrition prevalence in CH and CIR groups by the Royal Free Hospital-Global Assessment (RFH) was 51.2 vs 84%, Hand Grip Strength 61 vs 82.1%, Subjective Global Assessment 14.6 vs 32.1%, Adductor Pollices Muscle 7.3 vs 14.3%, Arm Muscle Circumference 4.9 vs 14.3% and Body Mass Index2.4 vs 3.6% (p<0.05), respectively. HGS and RFH were the best methods to identify malnutrition and present concordance with each other.
    Full-text · Article · Dec 2012 · Revista Chilena de Nutricion

Publication Stats

421 Citations
159.51 Total Impact Points

Institutions

  • 2000-2016
    • Hospital De Clínicas De Porto Alegre
      Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil
  • 2004-2015
    • Universidade Federal do Rio Grande do Sul
      • Faculty of Medicine
      Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil
  • 2012
    • University of São Paulo
      San Paulo, São Paulo, Brazil
  • 2001
    • Santa Casa de Porto Alegre
      Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil