RESUMO
BACKGROUND: Racial and ethnic disparities in life expectancy in the United States have been widely documented. To date, there remains a paucity of similar data in patients with inborn errors of immunity (IEIs). OBJECTIVE: Our aim was to examine racial and ethnic differences in mortality due to an IEI in the United States. METHODS: We analyzed National Center for Health Statistics national mortality data from 2003 to 2018. We quantified age-adjusted death rate and age-specific death rate as a result of an IEI for each major racial and ethnic group in the United States and examined the association of race and ethnicity with death at a younger age. RESULTS: From 2003 to 2018, IEIs were reported as the underlying or contributing cause of death in 14,970 individuals nationwide. The age-adjusted death rate was highest among Black patients (4.25 per 1,000,000 person years), compared with 2.01, 1.71, 1.50, and 0.92 per 1,000,000 person years for White, American Indian/Alaska Native, Hispanic, and Asian/Pacific Islander patients, respectively. The odds of death before age 65 years were greatest among Black patients (odds ratio [OR] = 5.15 [95% CI = 4.61-5.76]), followed by American Indian/Alaska Native patients (OR = 3.58 [95% CI = 2.30-5.82]), compared with White patients. The odds of death before age 24 years were greater among Hispanic patients than among non-Hispanic patients (OR = 3.60 [95% CI = 3.08-4.18]). CONCLUSION: Our study highlights racial and ethnic disparities in mortality due to an IEI and the urgent need to further identify and systematically remove barriers in care for historically marginalized patients with IEIs.
Assuntos
Etnicidade , Disparidades nos Níveis de Saúde , Doenças do Sistema Imunitário , Grupos Raciais , Humanos , Estados Unidos/epidemiologia , Doenças do Sistema Imunitário/genética , Doenças do Sistema Imunitário/mortalidadeRESUMO
Wider use of checkpoint inhibitor therapy spurs efforts to predict and treat immune complications.
Assuntos
Inibidores de Checkpoint Imunológico , Doenças do Sistema Imunitário , Neoplasias , Humanos , Inibidores de Checkpoint Imunológico/efeitos adversos , Inibidores de Checkpoint Imunológico/toxicidade , Doenças do Sistema Imunitário/induzido quimicamente , Doenças do Sistema Imunitário/mortalidade , Neoplasias/tratamento farmacológicoRESUMO
Background: Immune-related adverse events (irAEs) caused by immune checkpoint inhibitors (ICIs) were associated with clinical benefit in cancer patients of melanoma, a lung cancer. In the present study, we investigated the correlation between irAE and ICI efficacy in hepatocellular carcinoma (HCC) patients. Methods: We divided the HCC patients who received the anti-PD-1 antibody into two groups as irAE group and non-irAE group according to the National Cancer Institute Common Terminology Criteria for Adverse Events ver. 4.03. The treatment efficacy of ICIs was evaluated with objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Result: Of the 65 HCC patients who received the anti-PD-1 antibody (monotherapy or combined with targeted medicine), median PFS in the irAE group was superior to that in the non-irAE group (302 days vs. 148 days, p = 0.004). Median OS in the irAE group was also better than that in the non-irAE group (374 days vs. 279 days, p = 0.038). Although the statistical difference for DCR in the irAE group and non-irAE group was not reached, the DCR of the irAE displayed a trend better than that of the non-irAE group (41.20% vs. 20.80%, p = 0.118). Multivariate analysis also demonstrated that the non-irAE group (HR = 6.410, 95% CI: 1.404 to 29.275) was associated independently with the poor prognosis. Conclusions: Development of irAEs was associated with clinical benefit for HCC patients who were treated with immune checkpoint inhibitors; irAE, particularly low-grade irAE, was a predictable marker for better ICI treatment efficiency in HCC patients.
Assuntos
Antineoplásicos Imunológicos/uso terapêutico , Carcinoma Hepatocelular/tratamento farmacológico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Inibidores de Checkpoint Imunológico/uso terapêutico , Doenças do Sistema Imunitário/diagnóstico , Neoplasias Hepáticas/tratamento farmacológico , Idoso , Antineoplásicos Imunológicos/efeitos adversos , Biomarcadores Tumorais , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidade , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/mortalidade , Feminino , Humanos , Inibidores de Checkpoint Imunológico/efeitos adversos , Doenças do Sistema Imunitário/mortalidade , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidade , Masculino , Estadiamento de Neoplasias , Prognóstico , Receptor de Morte Celular Programada 1/antagonistas & inibidores , Análise de Sobrevida , Resultado do TratamentoRESUMO
Age, sex and presence of comorbidities are risk factors associated with COVID-19. Hypertension, diabetes and heart disease are the most common comorbidities in patients with COVID-19. The objective of this study was to estimate the prevalence of patients with comorbidities who died of COVID-19 in Brazil. Searches of data were carried out on the official pages of the 26 State health departments and the federal district. The random-effect method was used to calculate the prevalence of patients with comorbidities who died. From the beginning of the pandemic in Brazil until May 20, 2020, 276,703 cases of COVID-19 were notified in Brazil, 6.4% died, 58.6% of whom were male. The prevalence of comorbidities among deaths was 83% (95% CI: 79 - 87), with heart disease and diabetes being the most prevalent. To our knowledge, this study represents the first large analysis of cases of patients with confirmed COVID-19 in Brazil. There is a high prevalence of comorbidities (83%) among patients who died from COVID-19 in Brazil, with heart disease being the most prevalent. This is important considering the possible secondary effects produced by drugs such as hydroxychloroquine.
Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Cardiopatias/mortalidade , Pandemias/estatística & dados numéricos , Pneumonia Viral/mortalidade , Brasil/epidemiologia , COVID-19 , Doença Crônica , Comorbidade , Diabetes Mellitus/mortalidade , Feminino , Humanos , Hipertensão/mortalidade , Doenças do Sistema Imunitário/mortalidade , Unidades de Terapia Intensiva/estatística & dados numéricos , Nefropatias/mortalidade , Pneumopatias/mortalidade , Masculino , Obesidade/mortalidade , Pneumonia/mortalidade , Prevalência , Fatores de Risco , SARS-CoV-2 , Distribuição por Sexo , Fatores Sexuais , Acidente Vascular Cerebral/mortalidadeRESUMO
Characterisation and prognostic impact of immunoparesis in relapsed multiple myeloma (MM) is lacking in the current literature. We evaluated 258 patients with relapsed MM, diagnosed from 2008 to 2015, to investigate the prognostic impact of deep immunoparesis on post-relapse survival. On qualitative immunoparesis assessment, no, partial and full immunoparesis was present in 9%, 30% and 61% of patients, respectively. Quantitative immunoparesis was assessed by computing the average relative difference (ARD) between polyclonal immunoglobulin(s) and corresponding lower normal limit(s), with greater negative values indicating deeper immunoparesis. The median ARD was -39%, with an optimal cut-off of -50% for overall survival (OS) by recursive partitioning analysis. Deep immunoparesis (ARD ≤-50%) was associated with a higher tumour burden at first relapse compared to none/shallow [ARD >-50%] immunoparesis. The OS (P = 0·007) and progression-free survival (PFS; P < 0·001) differed significantly between the deep and none/shallow immunoparesis groups. Kaplan-Meier estimates for 3-year OS were 36% and 46%, and for 2-year PFS were 17% and 27%, respectively. On multivariable analysis (MVA) for PFS, both qualitative and quantitative immunoparesis retained negative prognostic impact independently. However, only quantitative immunoparesis was independently prognostic for OS on MVA. Depth of immunoparesis in relapsed MM is an important prognostic factor for post-relapse survival in the era of novel agents and continuous therapy.
Assuntos
Doenças do Sistema Imunitário , Mieloma Múltiplo , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Doenças do Sistema Imunitário/etiologia , Doenças do Sistema Imunitário/imunologia , Doenças do Sistema Imunitário/mortalidade , Doenças do Sistema Imunitário/patologia , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/imunologia , Mieloma Múltiplo/mortalidade , Mieloma Múltiplo/terapia , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
Immunoparesis is defined as a reduction in the levels of one, two, or three uninvolved immunoglobulins. However, there are very limited data on the incidence and prognostic significance of immunoparesis recovery 1 year after autologous stem cell transplantation (ASCT) in MM. We reviewed medical records of de novo MM patients who received ASCT at Beijing Chao Yang hospital. One hundred eight MM patients were included in the study. Conventional chemotherapy was administered as induction regimen in 16 patients (14.8%), whereas novel agents were used in 92 patients (85.2%). Most patients had immunoparesis at diagnosis (89.1%) and at the moment of ASCT as well (75%). After a median follow-up of 49 months, in the group with immunoglobulin recovery 1 year after ASCT, there was a trend towards longer progression-free survival (PFS) than in the group with immunoparesis (P = 0.054). And overall survival (OS) was significantly longer in patients with immunoparesis recovery (P = 0.004). In multivariate analysis, immunoparesis recovery 1 year after ASCT was independently associated with improved OS (P = 0.016). In conclusion, lack of immunoparesis recovery 1 year after ASCT in MM patients is associated with significantly shorter OS and this group of patients needs new treatment strategy to improve the prognosis.
Assuntos
Transplante de Células-Tronco Hematopoéticas , Doenças do Sistema Imunitário , Adulto , Idoso , Autoenxertos , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Doenças do Sistema Imunitário/etiologia , Doenças do Sistema Imunitário/imunologia , Doenças do Sistema Imunitário/mortalidade , Doenças do Sistema Imunitário/terapia , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/imunologia , Mieloma Múltiplo/mortalidade , Mieloma Múltiplo/terapia , Taxa de SobrevidaRESUMO
BACKGROUND: Sepsis is a leading cause of mortality and critical illness worldwide and is associated with an increased mortality rate in the months following hospital discharge. The occurrence of persistent or new organ dysfunction(s) after septic shock raises questions about the mechanisms involved in the post-sepsis status. The present study aimed to explore the immune profiles of patients one year after being discharged from the intensive care unit (ICU) following treatment for abdominal septic shock. METHODS: We conducted a prospective, single-center, observational study in the surgical ICU of a university hospital. Eighty-six consecutive patients admitted for septic shock of abdominal origin were included in this study. Fifteen different plasma biomarkers were measured at ICU admission, at ICU discharge and at one year after ICU discharge. Three different clusters of biomarkers were distinguished according to their functions, namely: (1) inflammatory response, (2) cell damage and apoptosis, (3) immunosuppression and resolution of inflammation. The primary objective was to characterize variations in the immune status of septic shock patients admitted to ICU up to one year after ICU discharge. The secondary objective was to evaluate the relationship between these biomarker variations and patient outcomes. RESULTS: At the onset of septic shock, we observed a cohesive pro-inflammatory profile and low levels of inflammation resolution markers. At ICU discharge, the immune status demonstrated decreased but persistent inflammation and increased immunosuppression, with elevated programmed cell death protein-1 (PD-1) levels, and a counterbalanced resolution process, with elevated levels of interleukin-10 (IL-10), resolvin D5 (RvD5), and IL-7. One year after hospital discharge, homeostasis was not completely restored with several markers of inflammation remaining elevated. Remarkably, IL-7 was persistently elevated, with levels comparable to those observed after ICU discharge, and PD-1, while lower, remained in the elevated abnormal range. CONCLUSIONS: In this study, protracted immune disturbances were observed one year after ICU discharge. The study results suggested the presence of long-lasting immune illness disorders following a long-term septic insult, indicating the need for long-term patient follow up after ICU discharge and questioning the use of immune intervention to restore immune homeostasis after abdominal septic shock.
Assuntos
Doenças do Sistema Imunitário/complicações , Choque Séptico/complicações , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/análise , Biomarcadores/sangue , Ácidos Docosa-Hexaenoicos/análise , Ácidos Docosa-Hexaenoicos/sangue , Feminino , Humanos , Doenças do Sistema Imunitário/sangue , Doenças do Sistema Imunitário/mortalidade , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Interleucina-10/análise , Interleucina-10/sangue , Interleucina-7/análise , Interleucina-7/sangue , Masculino , Pessoa de Meia-Idade , Paris , Prognóstico , Receptor de Morte Celular Programada 1/análise , Receptor de Morte Celular Programada 1/sangue , Estudos Prospectivos , Choque Séptico/mortalidadeRESUMO
BACKGROUND: The increased risk for early death owing to anti-programmed cell death 1 inhibitors is a major disadvantage that requires special management. We evaluated the frequency, causes, and risk factors of early death during nivolumab treatment for non-small cell lung cancer (NSCLC) in a Japanese clinical setting. PATIENTS AND METHODS: The medical records of patients with NSCLC who started receiving nivolumab between December 17, 2015 and July 31, 2016 in 3 Japanese institutes were collected. Early death was defined as any death within 3 months from the start of nivolumab treatment, irrespective of its cause. Treatment response was evaluated using the Response Evaluation Criteria In Solid Tumors criteria, version 1.1. RESULTS: A total of 201 patients with NSCLC were enrolled, and 38 (18.9%) died within the first 3 months. Thirty-one (81.6%) patients who experienced early death developed progressive disease, whereas 14 (36.8%) patients who experienced early death demonstrated nivolumab-induced immune-related adverse events, which required corticosteroid intervention, including interstitial lung disease in 7 (18.4%) patients. Multivariate logistic regression demonstrated that an Eastern Cooperative Oncology Group performance status score ≥ 2 (odds ratio [OR], 5.66; 95% confidence interval [CI], 2.01-15.61; P < .001), C-reactive protein-to-albumin ratio > 0.3 (OR, 10.56; 95% CI, 3.61-30.86; P < .001), and the response to prior treatment (OR, 2.07; 95% CI, 1.03-4.14; P = .041) were independent predictors for early death. CONCLUSION: Disease progression and immune-related adverse events are 2 major causes of early death with nivolumab in patients with NSCLC. An Eastern Cooperative Oncology Group performance status score ≥ 2, pretreatment C-reactive protein-to-albumin ratio > 0.3, and poor response to prior treatment were associated with early death.
Assuntos
Antineoplásicos/efeitos adversos , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Doenças do Sistema Imunitário/epidemiologia , Imunoterapia/efeitos adversos , Neoplasias Pulmonares/epidemiologia , Nivolumabe/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/mortalidade , Feminino , Humanos , Doenças do Sistema Imunitário/etiologia , Doenças do Sistema Imunitário/mortalidade , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Mortalidade Prematura , Nivolumabe/uso terapêutico , Receptor de Morte Celular Programada 1/imunologia , Risco , Análise de SobrevidaRESUMO
BACKGROUND: Immunodysregulation polyendocrinopathy enteropathy x-linked (IPEX) syndrome is a monogenic autoimmune disease caused by FOXP3 mutations. Because it is a rare disease, the natural history and response to treatments, including allogeneic hematopoietic stem cell transplantation (HSCT) and immunosuppression (IS), have not been thoroughly examined. OBJECTIVE: This analysis sought to evaluate disease onset, progression, and long-term outcome of the 2 main treatments in long-term IPEX survivors. METHODS: Clinical histories of 96 patients with a genetically proven IPEX syndrome were collected from 38 institutions worldwide and retrospectively analyzed. To investigate possible factors suitable to predict the outcome, an organ involvement (OI) scoring system was developed. RESULTS: We confirm neonatal onset with enteropathy, type 1 diabetes, and eczema. In addition, we found less common manifestations in delayed onset patients or during disease evolution. There is no correlation between the site of mutation and the disease course or outcome, and the same genotype can present with variable phenotypes. HSCT patients (n = 58) had a median follow-up of 2.7 years (range, 1 week-15 years). Patients receiving chronic IS (n = 34) had a median follow-up of 4 years (range, 2 months-25 years). The overall survival after HSCT was 73.2% (95% CI, 59.4-83.0) and after IS was 65.1% (95% CI, 62.8-95.8). The pretreatment OI score was the only significant predictor of overall survival after transplant (P = .035) but not under IS. CONCLUSIONS: Patients receiving chronic IS were hampered by disease recurrence or complications, impacting long-term disease-free survival. When performed in patients with a low OI score, HSCT resulted in disease resolution with better quality of life, independent of age, donor source, or conditioning regimen.
Assuntos
Diabetes Mellitus Tipo 1/congênito , Diarreia , Fatores de Transcrição Forkhead , Doenças Genéticas Ligadas ao Cromossomo X , Transplante de Células-Tronco Hematopoéticas , Doenças do Sistema Imunitário/congênito , Terapia de Imunossupressão , Mutação , Adolescente , Adulto , Aloenxertos , Criança , Pré-Escolar , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 1/imunologia , Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 1/terapia , Diarreia/genética , Diarreia/imunologia , Diarreia/mortalidade , Diarreia/terapia , Intervalo Livre de Doença , Feminino , Seguimentos , Fatores de Transcrição Forkhead/genética , Fatores de Transcrição Forkhead/imunologia , Doenças Genéticas Ligadas ao Cromossomo X/genética , Doenças Genéticas Ligadas ao Cromossomo X/imunologia , Doenças Genéticas Ligadas ao Cromossomo X/mortalidade , Doenças Genéticas Ligadas ao Cromossomo X/terapia , Humanos , Doenças do Sistema Imunitário/genética , Doenças do Sistema Imunitário/imunologia , Doenças do Sistema Imunitário/mortalidade , Doenças do Sistema Imunitário/terapia , Lactente , Masculino , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
There is no consensus approach to safety screening for immune intervention in clinical neuroimmunology. An immunosuppression risk evaluation checklist was used as an audit tool to assess real-world immunosuppression risk management and formulate recommendations for quality improvements in patient safety. Ninety-nine patients from two centres with 27 non-MS diagnoses were included. An average of 1.9 comorbidities with the potential to adversely impact morbidity and mortality associated with immunosuppression were identified. Diabetes and smoking were the most common, however a range of rarer but potentially life-threatening co-morbid disorders in the context of immunosuppression were identified. Inadequate documentation of risk mitigation tasks was common at 40.1% of total tasks across both cohorts. A routine, systematic immunosuppression checklist approach should be considered to improve immunosuppression risk management in clinical neuroimmunology practice.
Assuntos
Lista de Checagem , Auditoria Clínica , Doenças do Sistema Imunitário/epidemiologia , Doenças do Sistema Imunitário/fisiopatologia , Terapia de Imunossupressão , Austrália , Auditoria Clínica/métodos , Auditoria Clínica/normas , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Doenças do Sistema Imunitário/mortalidade , Masculino , Gestão de Riscos , Reino UnidoAssuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Doenças do Sistema Imunitário/etiologia , Insuficiência Respiratória/terapia , Adolescente , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Transplante de Células-Tronco Hematopoéticas/mortalidade , Humanos , Doenças do Sistema Imunitário/complicações , Doenças do Sistema Imunitário/mortalidade , Masculino , Pediatria , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Análise de SobrevidaRESUMO
PURPOSE: The clinical implications for patients who survive serious infections are not well understood. It has been hypothesized that the excess mortality for survivors of sepsis observed in epidemiological studies is due to increased vulnerability to subsequent infections. We undertook this study to identify characteristics of patients who are at high risk for death after surviving a common type of blood-stream infection. MATERIALS AND METHODS: At a single academic medical center, 237 patients with Staphylococcus aureus bacteremia admitted during a three-year period were retrospectively identified. The primary outcomes were 30-day and 31 to 90-day mortality after the first positive blood culture. The primary predictor variable of interest was clinical immune dysfunction prior to bacteremia. RESULTS: The 30-day mortality was not significantly different for patients with and without prior immune dysfunction. However, during days 31 to 90, 11 patients (20%) with prior immune dysfunction compared to 10 patients (8.6%) without prior immune dysfunction died (OR 2.59, 95% CI 1.03-6.53, pâ=â0.04). In a Cox-proportional hazard model controlling for age, there was a significant association between prior immune dysfunction and greater 31 to 90 day mortality (HR 2.44, 95% CI 1.01-5.90, pâ=â0.05) and a non-significant trend towards occurrence of subsequent infections and greater 31 to 90 day mortality (HR 2.12, 95% CI 0.89-5.07, pâ=â0.09). CONCLUSIONS: Patients with prior immune dysfunction are at high risk for death 31 to 90 days, but not <30 days, after S. aureus bacteremia. Further investigation is needed to determine if this finding is due to poor prognosis of chronic disease or increased vulnerability to subsequent infections.
Assuntos
Bacteriemia/complicações , Doenças do Sistema Imunitário/complicações , Infecções Estafilocócicas/complicações , Staphylococcus aureus/isolamento & purificação , Adulto , Idoso , Bacteriemia/sangue , Bacteriemia/mortalidade , Feminino , Humanos , Doenças do Sistema Imunitário/mortalidade , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Infecções Estafilocócicas/sangue , Infecções Estafilocócicas/mortalidadeRESUMO
BACKGROUND: The status of immunocompromised patients is well recognized in end stage renal disease (ESRD). As described recently, this acquired immune dysfunction in the uremic milieu may be one of the main pathogenic factors for mortality in ESRD. The aim of this study was to determine the relationship between the immune response following a hepatitis B vaccination (HBV vaccination) and the survival of maintenance dialysis patients. METHODS: A total of 156 patients (103 on hemodialysis and 53 on continuous ambulatory peritoneal dialysis) were recruited. After receiving a full dose of the HBV vaccination, all patients were followed up for to 5 years to evaluate the association of patient survival, cause of mortality, and immune response. RESULTS: The response rate to the hepatitis B vaccination was 70.5%. There was no significant association between the immune response and the 5-year survival rate (p =0.600) or between the post-vaccination anti-HBs titers and the 5-year survival rate (p = 0.201). The logistic prediction model with the coefficient as non-response following HBV vaccination, diabetes mellitus, old age, and low albumin level could significantly predict infection-cause mortality (sensitivity = 0.842, specificity = 0.937). CONCLUSION: There was no significant association between the immune response to HBV vaccination and the 5-year survival rate. However, non-response following HBV vaccination might be associated with infection-cause mortality in dialysis patients.
Assuntos
Vacinas contra Hepatite B/imunologia , Vacinas contra Hepatite B/uso terapêutico , Doenças do Sistema Imunitário/mortalidade , Diálise Renal/mortalidade , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/reabilitação , Vacinação/mortalidade , Causalidade , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Taiwan/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Previous studies have shown that high fiber intake is associated with lower mortality. However, little is known about the association of dietary fiber with specific causes of death other than cardiovascular disease (CVD). OBJECTIVE: The aim of this study was to assess the relation between fiber intake, mortality, and cause-specific mortality in a large European prospective study of 452,717 men and women. DESIGN: HRs and 95% CIs were estimated by using Cox proportional hazards models, stratified by age, sex, and center and adjusted for education, smoking, alcohol consumption, BMI, physical activity, total energy intake, and, in women, ever use of menopausal hormone therapy. RESULTS: During a mean follow-up of 12.7 y, a total of 23,582 deaths were recorded. Fiber intake was inversely associated with total mortality (HR(per 10-g/d increase): 0.90; 95% CI: 0.88, 0.92); with mortality from circulatory (HR(per 10-g/d increase): 0.90 and 0.88 for men and women, respectively), digestive (HR: 0.61 and 0.64), respiratory (HR: 0.77 and 0.62), and non-CVD noncancer inflammatory (HR: 0.85 and 0.80) diseases; and with smoking-related cancers (HR: 0.86 and 0.89) but not with non-smoking-related cancers (HR: 1.05 and 0.97). The associations were more evident for fiber from cereals and vegetables than from fruit. The associations were similar across BMI and physical activity categories but were stronger in smokers and participants who consumed >18 g alcohol/d. CONCLUSIONS: Higher fiber intake is associated with lower mortality, particularly from circulatory, digestive, and non-CVD noncancer inflammatory diseases. Our results support current recommendations of high dietary fiber intake for health maintenance.
Assuntos
Fibras na Dieta/administração & dosagem , Doenças do Sistema Digestório/mortalidade , Promoção da Saúde , Doenças do Sistema Imunitário/mortalidade , Política Nutricional , Adulto , Idoso , Estudos de Coortes , Doenças do Sistema Digestório/prevenção & controle , Grão Comestível/química , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Frutas/química , Humanos , Doenças do Sistema Imunitário/prevenção & controle , Masculino , Pessoa de Meia-Idade , Mortalidade , Estudos Prospectivos , Risco , Verduras/químicaRESUMO
OBJECTIVE: To define the relationship between worsening oxygenation status (worst PaO(2)/FiO(2) ratio in the first 24 hours after intensive care unit admission) and mortality in immunosuppressed and immunocompetent ICU patients in the presence and absence of mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Data were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. PARTICIPANTS: Adult patients admitted to 129 ICUs in Australasia, 2000-2010. MAIN OUTCOME MEASURES: In hospital and ICU mortality; relationship between mortality and declining PaO(2)/FiO(2) ratio by ventilation status and immune status. RESULTS: 457 750 patient records were analysed. Worsening oxygenation status was associated with increasing mortality in all groups. Higher mortality was seen in immunosuppressed patients than immunocompetent patients. After multivariate analysis, in mechanically ventilated patients, declining PaO(2)/FiO(2) ratio in the first 24 hours of ICU admission was associated with a more rapidly rising mortality rate in immunosuppressed patients than non-immunosuppressed patients. Immunosuppression did not affect the relationship between oxygenation status and mortality in non-ventilated patients. CONCLUSION: Immunosuppression increases the risk of mortality with progressively worsening oxygenation status, but only in the presence of mechanical ventilation. Further research into the impact of mechanical ventilation in immunosuppressed patients is required.
Assuntos
Doenças do Sistema Imunitário/sangue , Doenças do Sistema Imunitário/mortalidade , Oxigênio/sangue , Respiração Artificial/estatística & dados numéricos , Idoso , Austrália/epidemiologia , Estudos de Coortes , Feminino , Hong Kong , Mortalidade Hospitalar , Humanos , Doenças do Sistema Imunitário/fisiopatologia , Doenças do Sistema Imunitário/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Pressão Parcial , Estudos RetrospectivosRESUMO
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, occurring as either a familial disorder or a sporadic condition, in association with a variety of triggers. This immune dysregulatory disorder is prominently associated with cytopenias and a unique combination of clinical signs and symptoms of extreme inflammation. Prompt initiation of immunochemotherapy is essential for survival, but timely diagnosis may be challenging because of the rarity of HLH, its variable presentation, and the time required to perform diagnostic testing. Therapy is complicated by dynamic clinical course, high risk of treatment-related morbidity, and disease recurrence. Here, we review the clinical manifestations and patterns of HLH and describe our approach to the diagnosis and therapy for this elusive and potentially lethal condition.
Assuntos
Doenças do Sistema Imunitário/diagnóstico , Doenças do Sistema Imunitário/terapia , Imunoterapia/métodos , Linfo-Histiocitose Hemofagocítica/diagnóstico , Linfo-Histiocitose Hemofagocítica/terapia , Humanos , Doenças do Sistema Imunitário/sangue , Doenças do Sistema Imunitário/imunologia , Doenças do Sistema Imunitário/mortalidade , Inflamação/sangue , Inflamação/diagnóstico , Inflamação/imunologia , Inflamação/mortalidade , Inflamação/terapia , Linfo-Histiocitose Hemofagocítica/sangue , Linfo-Histiocitose Hemofagocítica/imunologia , Linfo-Histiocitose Hemofagocítica/mortalidadeRESUMO
Parainfluenza virus (PIV) infections cause significant mortality in adults undergoing hematopoietic stem cell transplantation (HSCT). Children are more prone to PIV infections than adults; however, data on the epidemiology of these infections in children undergoing HSCT are limited. This study examined the incidence of symptomatic PIV infections, risk factors for lower respiratory tract infection (LRTI), and the impact on mortality after pediatric HSCT. A total of 1028 children who underwent HSCT between 1995 and 2009 were studied. PIV infections were detected in 46 of the 738 patients tested for respiratory infection (6.2%). PIV infection was the most common symptomatic respiratory viral infection in this population. On multivariate logistic regression analysis, receipt of an allogeneic transplant (P < .0001) and total body irradiation-based conditioning (P < .0001) were associated with increased risk of acquiring symptomatic PIV infection. Of the 46 HSCT patients with PIV infection, 18 (39%) had an LRTI. LRTI was associated with PIV infection in the first 100 days post-HSCT (P = .006), use of steroids (P = .035), and absolute leukocyte count (ALC) <100 cells/µL at the onset of infection (P < .0001). An ALC of <500 cells/µL was associated with prolonged viral shedding (P = .045). Six (13%) HSCT patients died of PIV infection. Mortality was associated with African-American ethnicity (P = .013), LRTI (P = .002), use of steroids (P < .0001), mechanical ventilation (P < .0001), and ALC <100 cells/µL at the onset of infection (P = .01). PIV infection causes significant morbidity and mortality in children undergoing HSCT.
Assuntos
Transplante de Células-Tronco Hematopoéticas , Infecções por Paramyxoviridae/metabolismo , Infecções Respiratórias/mortalidade , Condicionamento Pré-Transplante , Adolescente , Criança , Pré-Escolar , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Doenças do Sistema Imunitário/mortalidade , Doenças do Sistema Imunitário/terapia , Masculino , Doenças Metabólicas/mortalidade , Doenças Metabólicas/terapia , Neoplasias/mortalidade , Neoplasias/terapia , Infecções por Paramyxoviridae/etnologia , Infecções por Paramyxoviridae/terapia , Infecções Respiratórias/etnologia , Infecções Respiratórias/terapia , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Transplante Autólogo , Transplante Homólogo , Irradiação Corporal TotalRESUMO
Multiple myeloma (MM) is characterized by the presence of osteolytic bone disease, renal impairment, anemia, and immune dysfunction. Adequate supportive care is considered an essential part of anti-myeloma therapy. The administration of bisphosphonates has been shown to reduce skeletal related events and hypercalcemia. Bisphosphonates are well tolerated, but preventive steps should be taken to avoid renal impairment and osteonecrosis of the jaw (ONJ). Adequate pain control is of crucial importance for the quality of life of MM patients. Local radiotherapy may rapidly ameliorate symptoms of painful MM bone lesions, and vertebroplasty and kyphoplasty are able to control symptoms and restore the original height of vertebral fractures. Symptomatic chemotherapy-induced anemia should preferentially be treated with erythropoietic growth factors, but further studies are required to confirm the long-term safety of this approach. Light-chain-induced renal impairment should be treated without delay with a highly effective anti-myeloma regimen consisting of novel drugs. Prophylaxis of infections should be considered particularly in patients with poorly controlled disease and documented infections should be treated aggressively as they contribute significantly to morbidity and mortality. The concerted action of these supportive therapies can significantly improve the quality of life of MM patients during the different phases of their disease.
Assuntos
Anemia/terapia , Doenças do Sistema Imunitário/terapia , Controle de Infecções , Nefropatias/terapia , Mieloma Múltiplo/complicações , Osteólise/terapia , Anemia/etiologia , Anemia/mortalidade , Doenças do Sistema Imunitário/etiologia , Doenças do Sistema Imunitário/mortalidade , Nefropatias/etiologia , Nefropatias/mortalidade , Mieloma Múltiplo/mortalidade , Mieloma Múltiplo/terapia , Osteólise/etiologia , Osteólise/mortalidadeRESUMO
BACKGROUND: The aim of this study was to analyze the incidence of new cases, survival of HIV-1-infected patients with progressive multifocal leukoencephalopathy (PML), and the characteristics of PML-associated immune reconstitution inflammatory syndrome (IRIS). METHODS: Multicenter observational cohort study of all HIV-1-infected patients newly diagnosed of PML in 7 hospitals in Barcelona (Spain) from 2002 to 2006. The annual incidence of PML was calculated. Survival was estimated using the Kaplan-Meier method. IRIS was defined as new onset or rapid worsening of PML shortly after initiation of highly active antiretroviral therapy together with a decline in HIV-1 viral load and rising of CD4 lymphocytes. RESULTS: Sixty-one new cases of PML were diagnosed. The mean survival time was 15 months [95% confidence interval (CI), 11 to 19]. The Kaplan-Meier estimates of the probability of survival were 47.7% (95% CI, 35 to 59) at 6 months, 38.6% (95% CI, 25 to 51) at 12 months, 35.1% (95% CI, 22 to 48) at 24 months, and 25.1% (95% CI, 10 to 40) at 36 months. IRIS was diagnosed in 14 (23%) cases. Mortality was similar in patients with and without IRIS. CONCLUSIONS: PML continues to be one of the deadliest opportunistic infections in acquired immunodeficiency syndrome patients. The development of PML-associated IRIS has no influence on prognosis.