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Régis C, Abikhzer G, Harel F, Pelletier-Galarneau M. Molecular imaging of large vessel vasculitis. J Med Imaging Radiat Sci 2024; 55:S10-S16. [PMID: 38097449 DOI: 10.1016/j.jmir.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/27/2023] [Accepted: 11/27/2023] [Indexed: 05/29/2024]
Abstract
Large vessel vasculitis (LVV) affects mainly large arteries with giant cell arteritis (GCA) and Takayasu arteritis (TAK) being the two most frequent forms. Clinical symptoms can be non-specific, including headache, fatigue, weight loss, and change in vision. Untreated, LVV may also lead to serious complications such as blindness, aortic aneurysm and dissection. Therefore, rapid recognition of the disease leading to accurate diagnosis and appropriate treatment is essential. FDG-PET/CT imaging has emerged as a sensitive marker of active vascular inflammation and its use in the management of LVV is now integrated in guidelines. In this article, we will discuss the role of FDG-PET/CT for the diagnosis of LVV and monitoring of therapy, as well as review technical and interpretation parameters.
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Affiliation(s)
- Claudine Régis
- Department of Medical Imaging, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Gad Abikhzer
- Department of Medical Imaging, Jewish General Hospital, Montreal, Quebec, Canada
| | - Francois Harel
- Department of Medical Imaging, Montreal Heart Institute, Montreal, Quebec, Canada
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Luo B, Xiang D, Ji X, Chen X, Li R, Zhang S, Meng Y, Nieman DC, Chen P. The anti-inflammatory effects of exercise on autoimmune diseases: A 20-year systematic review. JOURNAL OF SPORT AND HEALTH SCIENCE 2024; 13:353-367. [PMID: 38341137 PMCID: PMC11117003 DOI: 10.1016/j.jshs.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The anti-inflammatory effect of exercise may be an underlying factor in improving several autoimmune diseases. The aim of this systematic review was to examine the evidence on the role of exercise training in mitigating inflammation in adolescents and adults with autoimmune disease. METHODS PubMed, Web of Science, and Embase databases were systematically reviewed for related studies published between January 1, 2003, and August 31, 2023. All randomized and non-randomized controlled trials of exercise interventions with autoimmune disease study participants that evaluated inflammation-related biomarkers were included. The quality of evidence was assessed using the Tool for the assEssment of Study qualiTy and reporting in EXercise scale and Cochrane bias risk tool. RESULTS A total of 14,565 records were identified. After screening the titles, abstracts, and full texts, 87 were eligible for the systematic review. These studies were conducted in 25 different countries and included a total of 2779 participants (patients with autoimmune disease, in exercise or control groups). Overall, the evidence suggests that inflammation-related markers such as C-reactive protein, interleukin 6, and tumor necrosis factor α were reduced by regular exercise interventions. Regular exercise interventions combined with multiple exercise modes were associated with greater benefits. CONCLUSION Regular exercise training by patients with autoimmune disease exerts an anti-inflammatory influence. This systematic review provides support for the promotion and development of clinical exercise intervention programs for patients with autoimmune disease. Most patients with autoimmune disease can safely adopt moderate exercise training protocols, but changes in inflammation biomarkers will be modest at best. Acute exercise interventions are ineffective or even modestly but transiently pro-inflammatory.
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Affiliation(s)
- Beibei Luo
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China; Shanghai Key Laboratory of Human Performance, Shanghai University of Sport, Shanghai 200438, China
| | - Dao Xiang
- Department of Diving and Hyperbaric Medicine, Naval Medical Center, Shanghai 200433, China; National Key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai 200433, China
| | - Xiaorong Ji
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China
| | - Xuan Chen
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China
| | - Rui Li
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China
| | - Shuxin Zhang
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China
| | - Yujun Meng
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China
| | - David C Nieman
- Human Performance Laboratory, Appalachian State University, North Carolina Research Campus, Kannapolis, NC 28081, USA.
| | - Peijie Chen
- School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China; Research Institute for Doping Control, Shanghai University of Sport, Shanghai 200438, China.
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Astley C, Leal GN, Gil S, Suguita P, Fink T, Bain V, Pereira MFB, Marques HH, Sieczkowska S, Prado D, Lima MS, Carneiro CG, Buchpiguel CA, Silva CA, Gualano B. Home-Based Exercise Training in the Recovery of Multisystem Inflammatory Syndrome in Children: A Case Series Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050889. [PMID: 37238437 DOI: 10.3390/children10050889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the potential therapeutic role of exercise on health-related quality of life, assessed by the Pediatric Outcomes Data Collection Instrument (PODCI), coronary flow reserve (CFR), cardiac function, cardiorespiratory fitness, and inflammatory and cardiac blood markers in multisystemic inflammatory syndrome in children (MIS-C) patients. METHODS This is a case series study of a 12-wk, home-based exercise intervention in children and adolescents after MIS-C diagnosis. From 16 MIS-C patients followed at our clinic, 6 were included (age: 7-16 years; 3 females). Three of them withdrew before the intervention and served as controls. The primary outcome was health-related quality of life, assessed PODCI. Secondary outcomes were CFR assessed by 13N-ammonia PET-CT imaging, cardiac function by echocardiography, cardiorespiratory fitness, and inflammatory and cardiac blood markers. RESULTS In general, patients showed poor health-related quality of life, which seemed to be improved with exercise. Additionally, exercised patients showed improvements in coronary flow reserve, cardiac function, and aerobic conditioning. Non-exercised patients exhibited a slower pattern of recovery, particularly in relation to health-related quality of life and aerobic conditioning. CONCLUSIONS Our results suggest that exercise may play a therapeutic role in the treatment of post-discharge MIS-C patients. As our design does not allow inferring causality, randomized controlled trials are necessary to confirm these preliminary findings.
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Affiliation(s)
- Camilla Astley
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, University of Sao Paulo, Sao Paulo 01246-903, Brazil
- Rheumatology Division, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Gabriela Nunes Leal
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Saulo Gil
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, University of Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Priscila Suguita
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Thais Fink
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Vera Bain
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Maria Fernanda Badue Pereira
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Heloisa Helena Marques
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Sofia Sieczkowska
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, University of Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Danilo Prado
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, University of Sao Paulo, Sao Paulo 01246-903, Brazil
| | - Marcos Santos Lima
- Department of Radiology and Oncology, Nuclear Medicine Division, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-911, Brazil
| | - Camila G Carneiro
- Department of Radiology and Oncology, Nuclear Medicine Division, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-911, Brazil
| | - Carlos Alberto Buchpiguel
- Department of Radiology and Oncology, Nuclear Medicine Division, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-911, Brazil
| | - Clovis Artur Silva
- Children and Adolescent Institute, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, University of Sao Paulo, Sao Paulo 01246-903, Brazil
- Rheumatology Division, Clinical Hospital, School of Medicine, University of Sao Paulo, Sao Paulo 01246-903, Brazil
- Food Research Center, University of Sao Paulo, Sao Paulo 05508-080, Brazil
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Kirienko M, Erba PA, Chiti A, Sollini M. Hybrid PET/MRI in Infection and Inflammation: An Update About the Latest Available Literature Evidence. Semin Nucl Med 2023; 53:107-124. [PMID: 36369091 DOI: 10.1053/j.semnuclmed.2022.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/13/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022]
Abstract
PET/MRI has been reported to be promising in the diagnosis and evaluation of infection and inflammation including brain disorders, bone and soft tissue infections and inflammations, cardiovascular, abdominal, and systemic diseases. However, evidence came out manly from anecdotal cases or small cohorts. The present review aimed to update the latest available evidence about the role of PET/MRI in infection and inflammation. The search (January, 1 2018-July, 8 2022) on PubMed produced 504 results. Sixty-five articles were selected and included in the qualitative synthesis. The number of publications on PET/MRI in the 3 years 2018-2020 was comparable, while it increased in 2021 and 2022 (from 11 to 17 and 15, respectively). [18F]FDG and 68Ga-DOTA-FAPI-04 were the most frequently used (42/65) and innovative radiopharmaceuticals, respectively. [18F]fluoride (9/65), translocator protein (TSPO)-targeted PET agents (6/65), CXCR4 receptor targeting tracer and β-amyloid plaques binding radiopharmaceuticals (2/65 and 2/65, respectively) were also used. Most PET/MRI studies in the period 2018-2022 focused on inflammation (55/65), and cardiovascular diseases represented the most frequent field of interest (30/65), also when considering each year singularly. An increasing trend in bone and joint publications was observed in the considered period (12/65). Other topics included neurology (11/65), inflammatory bowel disease (8/65), and other (4/65). PET/MRI technology demonstrated to be useful in infection and inflammation, being superior to each single modality and/or facilitating diagnosis in a number of conditions (eg, cardiac sarcoidosis, myocarditis, endocarditis), and/or allowing to provide insightful information about disease biology and apply innovative radiopharmaceuticals (eg, neurology, atherosclerosis). Publications focused on PET/MRI in large vessel vasculitis and aortic diseases include both diagnostic and discovery objectives. The current review corroborates the potential of PET/MRI - combining in a single examination the high soft tissue contrast, high resolution, and functional information of MRI, with molecular data provided by PET technology - to positively impact on the management of infectious diseases and inflammatory conditions.
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Affiliation(s)
| | - Paola A Erba
- Nuclear Medicine Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy.
| | - Martina Sollini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
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van Eeden C, Osman MS, Cohen Tervaert JW. Fatigue in ANCA-associated vasculitis (AAV) and systemic sclerosis (SSc): similarities with Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). A critical review of the literature. Expert Rev Clin Immunol 2022; 18:1049-1070. [PMID: 36045606 DOI: 10.1080/1744666x.2022.2116002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Persistent debilitating fatigue is a frequent complaint in patients with systemic autoimmune rheumatic diseases (SARDs). Fatigue is, however, frequently overlooked in the clinic, and patients who successfully achieve remission of their disease, often still have a lowered quality of life due to its persistence. How similar is this fatigue to Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), what is this fatigue associated with, and what tools/approaches (if any), have resulted in the improvement of fatigue in these patients is poorly defined. AREAS COVERED Similarities between the pathophysiology of ME/CFS, systemic sclerosis (SSc) and primary systemic vasculitides (PSV) are discussed, followed by an in-depth review of the prevalence and correlates of fatigue in these diseases. The authors reviewed literature from MEDLINE, APA PsycInfo, Embase, and CINAHL. EXPERT OPINION Persistent fatigue is a prominent feature in SARDs and may not be associated with components commonly associated with disease activity and/or progression. Immune and metabolic commonalities exist between ME/CFS, SSc, and PSVs - suggesting that common pathways inherent to the diseases and fatigue may be present. We suggest that patients with features of ME/CFS need to be identified by treating physicians, as they may require alternative approaches to therapy to improve their quality of life.
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Affiliation(s)
- Charmaine van Eeden
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed S Osman
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School for Mental Health and Neurosciences (MHeNs), Maastricht University, Maastricht, Netherlands
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the recent advances in Takayasu arteritis (TAK), mainly focusing on pathogenesis, imaging modalities, and management. RECENT FINDINGS Three novel clusters based on angiographic findings were identified in the Indian cohort and replicated in the North American cohorts. Different new imaging modalities have been tried in the assessment of arterial inflammation with promising results. There is more evidence on the long-term use of tocilizumab, but relapses are common. In light of the recent findings on the pathogenesis of TAK, Janus kinase inhibitors seem to be promising. SUMMARY Improvement in imaging modalities and in our understanding of the disease pathogenesis will allow us to better assess the disease activity and identify effective therapeutic agents.
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Affiliation(s)
| | - Gulen Hatemi
- Department of Medicine, Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Fink TT, Marques HH, Gualano B, Lindoso L, Bain V, Astley C, Martins F, Matheus D, Matsuo OM, Suguita P, Trindade V, Paula CS, Farhat SC, Palmeira P, Leal GN, Suzuki L, Odone V, Carneiro-Sampaio M, Duarte AJS, Antonangelo L, Batisttella LR, Polanczyk GV, Pereira RMR, Carvalho CRR, Buchpiguel CA, Xavier ACL, Seelaender M, Silva CA, Pereira MFB. Persistent symptoms and decreased health-related quality of life after symptomatic pediatric COVID-19: A prospective study in a Latin American tertiary hospital. Clinics (Sao Paulo) 2021; 76:e3511. [PMID: 34852145 PMCID: PMC8595593 DOI: 10.6061/clinics/2021/e3511] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/25/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To prospectively evaluate demographic, anthropometric and health-related quality of life (HRQoL) in pediatric patients with laboratory-confirmed coronavirus disease 2019 (COVID-19). METHODS This was a longitudinal observational study of surviving pediatric post-COVID-19 patients (n=53) and pediatric subjects without laboratory-confirmed COVID-19 included as controls (n=52) was performed. RESULTS The median duration between COVID-19 diagnosis (n=53) and follow-up was 4.4 months (0.8-10.7). Twenty-three of 53 (43%) patients reported at least one persistent symptom at the longitudinal follow-up visit and 12/53 (23%) had long COVID-19, with at least one symptom lasting for >12 weeks. The most frequently reported symptoms at the longitudinal follow-up visit were headache (19%), severe recurrent headache (9%), tiredness (9%), dyspnea (8%), and concentration difficulty (4%). At the longitudinal follow-up visit, the frequencies of anemia (11% versus 0%, p=0.030), lymphopenia (42% versus 18%, p=0.020), C-reactive protein level of >30 mg/L (35% versus 0%, p=0.0001), and D-dimer level of >1000 ng/mL (43% versus 6%, p=0.0004) significantly reduced compared with baseline values. Chest X-ray abnormalities (11% versus 2%, p=0.178) and cardiac alterations on echocardiogram (33% versus 22%, p=0.462) were similar at both visits. Comparison of characteristic data between patients with COVID-19 at the longitudinal follow-up visit and controls showed similar age (p=0.962), proportion of male sex (p=0.907), ethnicity (p=0.566), family minimum monthly wage (p=0.664), body mass index (p=0.601), and pediatric pre-existing chronic conditions (p=1.000). The Pediatric Quality of Live Inventory 4.0 scores, median physical score (69 [0-100] versus 81 [34-100], p=0.012), and school score (60 [15-100] versus 70 [15-95], p=0.028) were significantly lower in pediatric patients with COVID-19 at the longitudinal follow-up visit than in controls. CONCLUSIONS Pediatric patients with COVID-19 showed a longitudinal impact on HRQoL parameters, particularly in physical/school domains, reinforcing the need for a prospective multidisciplinary approach for these patients. These data highlight the importance of closer monitoring of children and adolescents by the clinical team after COVID-19.
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Affiliation(s)
- Thais T. Fink
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Heloisa H.S. Marques
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Bruno Gualano
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Livia Lindoso
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vera Bain
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Camilla Astley
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fernanda Martins
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Denise Matheus
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Olivia M. Matsuo
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Priscila Suguita
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vitor Trindade
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Camila S.Y. Paula
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sylvia C.L. Farhat
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Patricia Palmeira
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Gabriela N. Leal
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lisa Suzuki
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vicente Odone
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Magda Carneiro-Sampaio
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alberto José S. Duarte
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leila Antonangelo
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Linamara R. Batisttella
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme V. Polanczyk
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rosa Maria R. Pereira
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Carlos A. Buchpiguel
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ana Claudia L. Xavier
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marilia Seelaender
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Clovis Artur Silva
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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