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The increased production and expanding demand for cellulosic products have required companies to provide solutions for the proper disposal of generated residues without compromising soil quality. In this context, the current research aimed at evaluating the ecotoxicological impacts of dregs application in subtropical soils. The experiments were carried out with the earthworm Eisenia andrei, the springtail Folsomia candida, and the potworm Enchytraeus crypticus in two subtropical soils (Neosol and Cambisol) collected in the southern region of Brazil. The considerable differences in texture and organic matter content motivated the choosing of these soils. The reproductive rate of all organisms was influenced, with varying EC 50 values depending on the soil type. However, more pronounced effects were observed for Neosol. The springtail F. candida proved to be the most sensitive to contamination (EC 50  = 5.8 g kg -1 for Neosol and 48.5 g kg -1 for Cambisol), followed by the earthworm E. andrei (EC 50  = 62.4 g kg -1 for Neosol and 129.5 g kg -1 for Cambisol) and the potworm E. crypticus (EC 50  = 67.2 g kg -1 for Neosol and 230.4 g kg -1 for Cambisol). As a result, while dregs can be used to correct soil acidity, they have been shown to have negative effects on important organisms responsible for functions critical to maintaining ecosystem quality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This study aimed to investigate the impact of as-received biomass fly ashes (BFA) and green liquor dregs obtained from a pulp and paper plant in Brazil as substitutes for metakaolin in geopolymeric formulations. The properties of this type of waste material vary widely between different industrial plants. This study refrains from subjecting the waste materials to any form of pretreatment, taking into account their organic matter and particle size heterogeneity, requiring extensive characterization to evaluate their influence on the compressive strength, apparent open porosity, and water absorption of the geopolymeric samples. The objective was to assess their potential for upcycling purposes as an alternative to energy-intensive materials, such as ordinary Portland cement (OPC) and advanced ceramics. This potential arises from the ability of alkali-activated materials (AAM) to undergo curing at ambient temperatures, coupled with the possibility of compositions primarily derived from waste materials. To improve the sustainability of the products, the amorphous content of the raw material, which is more reactive than crystalline phases, was quantified and used as the base for mixture ratios. This approach aimed to reduce the requirement for alkaline activators, which have significant environmental impacts, while also increasing the waste content in the formulation. The incorporation of waste materials into the geopolymer matrix generally led to a reduction in the compressive strength compared to the benchmark metakaolin sample (19.4 MPa) but did not present a trend. The dregs led to values of 4.1 MPa at 25 wt% and 7.1 MPa at 50 wt%, a behavior that is somewhat counterintuitive, and BFA at 10 wt% presented 5.7 MPa. Nevertheless, the apparent open porosity remained at high levels for all the samples, close to 50%, and the compressive strength of most of them was over the values obtained for the metakaolin-only samples with mixture ratios calculated from the total composition instead of the amorphous composition. The decrease in strength and the increase in porosity were attributed to the specific characteristics of the waste materials, such as their high crystallinity, presence of organic matter, heterogeneous particle composition, and size. Overall, this study provides insight into the variations in geopolymerization based on the bulk and amorphous content of the aluminosilicate sources and how the characteristics of the waste materials influence the geopolymer matrix. It also highlights how calculating mixture ratios based on the amorphous composition improves the possibility of waste valorization through alkali activation. Additionally, it suggests that BFA and dregs might be effectively utilized in applications other than OPC substitution, such as adsorption, filtration, and catalysis. [ABSTRACT FROM AUTHOR]

Introduction: Distinguishing and categorizing the origin of garlic are highly significant, considering its widespread use as a flavoring agent. With billions of dollars annually in global trade, garlic is frequently susceptible to fraudulent practices., Methodology: Paper spray ionization mass spectrometry (PS-MS) was employed to quickly analyze garlic samples from distinct geographic origins: China and Brazil. The so-generated PS-MS data were treated with metabolomic multivariate approaches, and the garlic samples from these different geographic regions were easily discriminated., Results: Brazilian garlic was characterized to contain higher levels of amino acids, such as arginine, proline, and valine, and organosulfur compounds, such as allicin, alliin, and l-γ-glutamil-S-allyl-l-cysteine, compared to Chinese garlic. The PS-MS data were treated employing multivariate approaches, typically used in the metabolomics field, and this protocol was promptly able to discern among both types of samples., Conclusion: Hence, this combined strategy holds promise not only as an effective tool for the authentication of the geographical origin of garlic but also as a powerful means for biomarker discovery., (© 2024 John Wiley & Sons Ltd.)

This research focused on the molecular diversity of A. carambola collected from three Brazilian biomes (Cerrado, Amazônia, and Mata Atlântica), whose results revealed significant differences in metabolite profiles among these biomes through PSI-MS analysis. Chemometric analysis provided valuable insights into the clustering patterns and metabolic distinctions. Cerrado and Mata Atlântica biomes exhibited a 70 % similarity, indicating a notable degree of resemblance. In Cerrado, carambolaside A was notably abundant, while carambolaside M was low in Amazônia and moderate in Cerrado samples. Carambolaside B was abundant in Amazônia but relatively low in the Cerrado and Mata Atlântica. In contrast, the Amazônia biome samples appeared to be more dissimilar. In Cerrado, epicatechin, kaempferol, and procyanidin B showed lower abundance, while apigenin, quercetin, myricetin, and rutin displayed moderate levels. Mata Atlântica showed relatively higher levels of kaempferol, quercetin, and rutin. This study indicated the environmental influence on secondary metabolites production in A. carambola fruits., (© 2024 Wiley-VHCA AG, Zurich, Switzerland.)

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Drugs of abuse are psychoactive substances illicitly distributed and used worldwide. In Rio de Janeiro, Brazil, they represent a public health issue and are directly related to several social problems. The recent increase in appearances of new psychoactive substances (NPS), derived from structural modifications of existing psychoactive substances, poses a threat to public health and forensic laboratories worldwide, as little is known about these substances. This study aimed to chemically and geographically map drugs of abuse from blotter papers seized by the Civil Police of Rio de Janeiro State (PCERJ) between 2006 and 2019. High-performance analytical techniques, such as gas chromatography-mass spectrometry (GC-MS) and Orbitrap mass spectrometry (Orbitrap-MS), combined with statistical analyses, were employed to characterize the seized samples. The most common chemical compounds in NPS found in this study were synthetic phenethylamines, i.e., molecules from the 25I-NBOH (2-(((4-iodo-2,5-dimethoxyphenethyl)amino)methyl)phenol) and 25I-NBOMe (2-(4-iodo-2,5-dimethoxyphenyl)-N-(2-methoxybenzyl)ethanamine) families. Prior to 2014, the majority of seized blotter papers contained lysergic acid diethylamide (LSD) and were concentrated in the Metropolitan region. An upsurge in blotter paper seizures was observed from 2014 to 2017; the most common substances during this time were from the NBOMe family. NBOH compounds emerged in 2016 in coastal regions with high tourism, reaching over 1300 items only in 2017. Only one synthetic cannabinoid was found among the blotter papers seized in Rio de Janeiro between 2006 and 2019. The assembled chemical data and statistical analyses allowed the mapping and monitoring of the chemical profiles of the seized blotter papers, providing a strong foundation for the understanding of the origins and movement of these drugs around the RJ State., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Pulp and paper mill wastewater (PPMWW) contains high concentrations of recalcitrant compounds that cause toxicity to organisms. Advanced oxidation processes (AOPs) have the ability to degrade these compounds and reduce overall toxicity. Physicochemical characterization and Lactuca sativa toxicity test were conducted to compare the effectiveness of two post-treatments: UV/H 2 O 2 and photo-Fenton. A comparison of four phytotoxicity indexes was carried out. PPMWW from a Brazilian treatment plant was characterized by high values of phenols, color, integrated spectral area (ISA), and chemical oxygen demand (COD), and caused significant inhibition to seedling development. The use of both post-treatments allowed the removal of over 75% of phenols, color, ISA, and COD. Although UV/H 2 O 2 was more effective in removing phenols and ISA, photo-Fenton better reduced phytotoxicity. The most sensitive phytotoxicity indexes were RGIC 0.8 and GIC 80% , whereas SGC 0 , REC -0.25 and REC -0.50 better showed the effectiveness of the post-treatments. We suggest the combined use of two phytotoxicity indexes: one that evaluates the effects on seed germination and, another, on root elongation, e.g., SGC 0 and RGIC 0.8 . Additionally, we recommend the use of ISA for monitoring programs of wastewater treatments because it is a cost-effective approach that allows narrowing down the search and identification of compounds present in complex mixtures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs., Aims: To emphasize the most important points of a multimodal perioperative care protocol., Methods: Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients., Results: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures., Conclusions: This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Pulp and paper industries are very important for developing the Brazilian economy. During production processes, many effluents are generated with high polluting potential. The objective of this study is to conduct an extensive literature review on the characteristics of effluents and treatment forms adopted by Brazilian mills in this industrial sector. Most consulted studies address raw (without treatment) and secondary (after biological treatment) effluents, considering their main characteristics like pH, chemical and biochemical oxygen demands (COD and BOD, respectively), color, solids, organochlorines, toxicity, estrogenic activity, and phenols. Raw effluents differ considerably in composition, depending on the type of paper produced, the pulping process employed, and other steps, like pulp bleaching. Raw effluent characteristics indicate that this effluent cannot be directly disposed of into water bodies, because it does not comply with federal and state disposal standards. Secondary effluents normally comply with Brazilian legislations, although some studies have reported COD and total phenol concentrations higher than disposal standards, suggesting that additional treatments are necessary. Treated effluent reuse was verified in some Brazilian mills, while its disposal in eucalyptus plantations has been considered a promising alternative for irrigation purposes., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Bisphenol A (BPA) is a high-production-volume chemical with endocrine disrupting properties commonly used as color developer in thermal paper. Concerns about the potential hazards of human BPA exposure have led to the increasing utilization of alternatives such as bisphenol S (BPS) and bisphenol F (BPF). This study was designed to assess: (i) BPA, BPS, and BPF concentrations in 112 thermal paper receipts from Brazil, France, and Spain by liquid chromatography coupled to mass spectrometry (LC-MS); and (ii) hormone-like activities of these receipts using two receptor-specific bioassays, the E-Screen for (anti-)estrogenicity and PALM luciferase assay for (anti-)androgenicity. BPA was present in 95.3% of receipts from Spain, 90.9% of those from Brazil, and 51.1% of those from France at concentrations up to 20.27 mg/g of paper. Only two samples from Brazil, two from Spain, and ten from France had a BPS concentration ranging from 6.46 to 13.29 mg/g; no BPA or BPS was detected in 27.7% of French samples. No BPF was detected in any receipt. Estrogenic activity was observed in all samples from Brazil and Spain and in 74.5% of those from France. Anti-androgenic activity was observed in > 90% of samples from Brazil and Spain and in 53.2% of those from France. Only 25.5% of French samples were negative for both estrogenic and anti-androgenic activity. Estrogenic and anti-androgenic activities per gram of paper were up to 1.411 µM estradiol (E 2 ) equivalent units (E 2 eq) and up to 359.5 mM procymidone equivalent units (Proceq), respectively. BPA but not BPS concentrations were positively correlated with both estrogenic and anti-androgenic activities. BPA still dominates the thermal paper market in Brazil and Spain, and BPS appears to be one of the main alternatives in France. There is an urgent need to evaluate the safety of alternatives proposed to replace BPA as developer in thermal printing. The large proportion of samples with hormonal activity calls for the adoption of preventive measures., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This essay studies the cultural consequences that the spread of paper money had in late nineteenth-century Brazil. First, I examine how these tensions are called into question through the analysis of a political scandal that took place in Rio de Janeiro, in 1900, concerning a two thousand reales banknote. Second, I offer a close reading of Machado de Assis' "Anedota pecuniária", a short-story included in Histórias sem data (1884). My goal is to interrogate the relation between paper money and the economy of credit work, and the narrative devices of literary fiction. [ABSTRACT FROM AUTHOR]

This paper investigates retracted articles indexed in the Scientific Electronic Library Online (SciELO) Brazil, using bibliometric techniques to identify the characteristics of these retractions and relevant citation trends. All records of retracted articles from the first record in October 2004 to April 2022 were included. Sixty-seven retractions and 870 citations pre- and post-retraction were analyzed. Results indicate a change of scenario that began in 2015, with recurrences of retracted articles allegedly produced by paper mills. The prevalence of retractions derived from professional misconduct in health research and the frequency of post-retraction citations in health sciences raise concerns in the chain of stakeholders, public health, and scientific development. [ABSTRACT FROM AUTHOR]

Purpose: With the COVID-19 pandemic, online high-stakes exams have become a viable alternative. This study evaluated the feasibility of computer-based testing (CBT) for medical residency applications in Brazil and its impacts on item quality and applicants' access compared to paper-based testing., Methods: In 2020, an online CBT was conducted in a Ribeirao Preto Clinical Hospital in Brazil. In total, 120 multiple-choice question items were constructed. Two years later, the exam was performed as paper-based testing. Item construction processes were similar for both exams. Difficulty and discrimination indexes, point-biserial coefficient, difficulty, discrimination, guessing parameters, and Cronbach's alpha coefficient were measured based on the item response and classical test theories. Internet stability for applicants was monitored., Results: In 2020, 4,846 individuals (57.1% female, mean age of 26.64 ± 3.37 years) applied to the residency program, versus 2,196 individuals (55.2% female, mean age of 26.47 ± 3.20 years) in 2022. For CBT, there was an increase of 2,650 (120.7%) applicants, albeit with significant differences in demographic characteristics. There was a significant increase in applicants from more distant and lower-income Brazilian regions, such as the North (5.6% vs. 2.7%) and Northeast (16.9% vs. 9.0%). No significant differences were found in difficulty and discrimination indexes, point-biserial coefficients, and Cronbach's alpha coefficients between the 2 exams., Conclusion: Online CBT with multiple-choice questions was a viable format for a residency application exam, improving accessibility without compromising exam integrity and quality.

This article discusses Conservation Units in the conservationist perspective, as instruments to protect nature, assuring the maintenance of Brazilian biodiversity and biomes, in order to build an ecologically balanced environment under the terms of the Federal Constitution of 1988. Through deductive method, exploratory, documental, and bibliographic research, and indirect analysis of Environmental Ministry and Environmental, Sustainable Development State Office data, it makes a legal-theoretical appreciation of the issue in Brazil. By looking at the Brazilian scenario, it notices that most part of the Conservation Units were created by the States and were focused, respectively, on Mata Atlântica, Cerrado, and the Amazon, and had sustainability as a legal-political fundament. The conjuncture of Goiás indicates that stating the Conservation Units existence is not enough, since more than half of Conservation Units lack landing regularization. Also, six out of twenty-five Conservation Units still do not have an Administrative Counsel. Twenty Conservation Units do not have a working plan, which, added to financial and staff difficulties may compromise the expected protection of nature. [ABSTRACT FROM AUTHOR]

This paper is aimed to develop a hybrid model (PCA-ANN) to predict the extractive content in eucalyptus wood clones. The input variables to the virtual analyzer are planting parameters available from the forest inventory, therefore the prediction does not rely on laboratory analysis of the wood samples, affording a quick estimate of the extractive contents. This study further bridges the literature gap on the investigation of the cause of variability of extractive content in eucalyptus wood. The PCA-ANN was identified from experimental data to predict and monitor the extractive content, since laboratory measurements can take several days and become available only after wood processing. The experimental data contained information on ten species of eucalyptus clones from five regions in the extreme south of Bahia, Brazil. Principal Component Analysis (PCA) firstly assessed the impact of planting variables on the extractives content. The variability of the data was represented by eight principal components and the variables that mostly contribute to the extractive content are: potential acidity, iron, saturation of aluminum, magnesium, pH, base saturation, remaining phosphorus, zinc, manganese and copper. The artificial neural network (ANN) with the 8 principal components in the input layer showed that the PCA could effectively reduce the dimensionality of the data. For practical purposes, though, the ANN with 10 input variables and 16 neurons in the hidden layer, presenting an average relative deviation of 1.5%, is recommended. The prediction of the extractive content is essential to allow preventive management practices toward the improvement of yield and quality of the cellulosic pulp. [ABSTRACT FROM AUTHOR]

Hypericum perforatum L. (St. John's wort) is one of the world's most consumed medicinal plants for treating depression and psychiatric disorders. Counterfeiting can occur in the medicinal plant trade, either due to the lack of active ingredients or the addition of substances not mentioned on the labels, often without therapeutic value or even harmful to health. Hence, 43 samples of St. John's wort commercially acquired in different Brazilian regions and other countries were analyzed by paper spray ionization mass spectrometry (PS-MS) and modeled by principal component analysis. Hence, samples (plants, capsules, and tablets) were extracted with ethanol in a solid-liquid extraction. For the first time, PS-MS analysis allowed the detection of counterfeit H. perforatum samples containing active principles typical of other plants, such as Ageratum conyzoides and Senna spectabilis. About 52.3% of the samples were considered adulterated for having at least one of these two species in their composition. Furthermore, out of 35 samples produced in Brazil, only 13 were deemed authentic, having only H. perforatum. Therefore, there is a clear need to improve these drugs' quality control in Brazil., (© 2023 John Wiley & Sons Ltd.)

This article describes how The Language Center at the Espirito Santo Federal University changed from using traditional pencil-andpaper tests to performance testing, based on authentic tasks. The change was prompted because people thought that their testing did not reflect a communicative approach to language teaching. The Assessment Project lasted for two years; the author discusses its participants, goals, stages (including pilot testing), and results. Content and construct validity improved, leading to positive washback. Learning objectives and criteria for passing were clarified.

The retraction of health sciences publications is a growing concern. To understand the patterns in a particular country-context and design specific measures to address the problem, it is important to describe and characterize retractions. We aimed to assess the evolution of health science retractions in Brazil and Portugal and to describe their features. We conducted a cross-sectional study including all health sciences retracted articles with at least one author affiliated to a Portuguese or Brazilian institution identified through Retraction Watch database. A total of 182 retracted articles were identified. The number of retractions increased over time, but the proportion related to the whole of publications remained stable. A total of 50.0% and 60.8% of the Portuguese and Brazilian retracted articles, respectively, were published in first and second quartile journals. Scientific misconduct accounted for 60.1% and 55.9% of retractions in Brazil and Portugal. In both countries, the most frequent cause of misconduct was plagiarism. The time from publication to retraction decreases as the journal quartile increases. The retraction of health sciences articles did not decrease over time in Brazil and Portugal. There is a need to develop strategies aimed at preventing, monitoring and managing scientific misconduct according to the country context.

Silicon (Si) is a chemical element that is not yet considered essential for plants. However, over the past few decades, an increasing number of scientifi c studies have focused on the role of Si in soil-plant interactions. At the same time, many countries are leading the development and use of silicon-based fertilizers. Si can be taken up by plants predominantly in a mobile form (H4SiO4) in the soil through both passive and active uptake mechanisms. Therefore, Scopus data from 2012 to 2022 were used to understand the implementation and current status of research on the benefi cial effects of silicon fertilizers on soil and plants and the role of soil forms of silicon in improving soil quality. A bibliometric study of articles published in the database on the role of Si in soil and silicon fertilizers was carried out. Various tools, such as Microsoft Offi ce Excel 2021, VOS Viewer and Mapchart.net were used in this study. The fi nal literature includes 440 articles, 82% of which are scientifi c. Over the past decade, the number of published articles has increased signifi cantly. For example, in the years 2021–2022, a total of 91 articles were published, which is six times higher than the number of articles published in 2012–2013 (15 articles). This signifi cant increase in publications highlights the growing interest in the role Si and Si fertilizer research. It was found around 32.04% of China, 13.2% of the USA and 9.8% of Brazil the reviewed publications focused on the role of Si and Si fertilizers studies. Among the authors who published the most articles on this topic during the selected period are Wang X. (with 12 articles), Liang Yu., Rizwan M. and Ali S. (each with 8 articles). [ABSTRACT FROM AUTHOR]

Recycled paper has the potential to be used as a mulch for vegetable production and can be adopted for the cultivation of Italian zucchini. However, there have been no studies about the water savings or crop coefficient values used in irrigation management in this system; therefore, there is a need for more research. In view of the above, this study aimed to evaluate the effects of recycled paper mulch on evaporation and evapotranspiration in Italian zucchini and to determine the crop coefficients in its developmental stages. The study was carried out in two cultivation cycles conducted at the Lysimetric Station in Viçosa, MG, Brazil. The experiments were installed in a randomized block design with four replicates. Four lysimeter cultivation treatments were applied: without mulch (C); with recycled paper as mulch (CP); with only recycled paper (P); and with Bahia grass (G). Irrigation and drainage measurements were performed daily to calculate the crop and reference evapotranspiration, and thus the crop coefficient (Kc) values. The following characteristics were evaluated: fruit yield, NDVI and water productivity. For the cultivation of Italian zucchini using paper as mulch, Kc values of 0.54, 0.77 and 0.44 and Kcb values of 0.15, 0.45 and 0.18 are recommended for the initial, intermediate and final stages, respectively. NDVI can be used to estimate the Kc values for Italian zucchini. The use of recycled paper as mulch reduces the water consumption of Italian zucchini. [ABSTRACT FROM AUTHOR]

In the 21st century, there is a growing Brazilian academic interest from professors and students in researching realities from Asia, especially in postgraduate courses in Language Arts, Philosophy and Human Science. The paper aims not only to point to a broader panorama of Centers, Nuclei, Programs, Research, Study and Work Groups, Thematic Sessions and Events with Asian themes in the aforementioned academic areas in Brazil, but also to make a brief analysis of the papers carried out in Work Groups and Thematic Sessions of the ANPTECRE and PPCIR (CONACIR) national congresses dedicated to realities of Asian origin, taking into account three criteria, i.e. Religious Studies methodologies used, the genres of authorship, and the religious traditions that were approached by these papers. [ABSTRACT FROM AUTHOR]

Background: Surgical antibiotic prophylaxis is an essential component of perioperative care. The use of prophylactic regimens of antibiotics is a well-established practice that is encouraged to be implemented in preoperative/perioperative protocols in order to prevent surgical site infections., Aims: The aim of this study was to emphasize the crucial aspects of antibiotic prophylaxis in abdominal surgery., Results: Antibiotic prophylaxis is defined as the administration of antibiotics before contamination occurs, given with the intention of preventing infection by achieving tissue levels of antibiotics above the minimum inhibitory concentration at the time of surgical incision. It is indicated for clean operations with prosthetic materials or in cases where severe consequences may arise in the event of an infection. It is also suitable for all clean-contaminated and contaminated operations. The spectrum of action is determined by the pathogens present at the surgical site. Ideally, a single intravenous bolus dose should be administered within 60 min before the surgical incision. An additional dose should be given in case of hemorrhage or prolonged surgery, according to the half-life of the drug. Factors such as the patient's weight, history of allergies, and the likelihood of colonization by resistant bacteria should be considered. Compliance with institutional protocols enhances the effectiveness of antibiotic use., Conclusion: Surgical antibiotic prophylaxis is associated with reduced rates of surgical site infection, hospital stay, and morbimortality.

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.