Whole-Body Multiparametric PET in Clinical Oncology: Current Status, Challenges, and Opportunities.

The interpretation of clinical oncologic PET studies has historically used static reconstructions based on SUVs. SUVs and SUV-based images have important limitations, including dependence on uptake times and reduced conspicuity of tracer-avid lesions in organs with high background uptake. The acquisition of dynamic PET images enables additional PET reconstructions via Patlak modeling, which assumes that a tracer is irreversibly trapped by tissues of interest. The resulting multiparametric PET images capture a tracer's net trapping rate (Ki) and apparent volume of distribution (VD), separating the contributions of bound and free tracer fractions to the PET signal captured in the SUV. Potential benefits of multiparametric PET include higher quantitative stability, superior lesion conspicuity, and greater accuracy for differentiating malignant and benign lesions. However, the imaging protocols necessary for multiparametric PET are inherently more complex and time-intensive, despite the recent introduction of automated or semiautomated scanner-based reconstruction packages. In this Review, we examine the current state of multiparametric PET in whole-body oncologic imaging. We summarize the Patlak methodology and relevant tracer kinetics, discuss clinical workflows and protocol considerations, and highlight clinical challenges and opportunities. We aim to help oncologic imagers make informed decisions about whether to implement multiparametric PET in their clinical practices.

Mesenchymal Stem Cells Increase Resistance Against Ventricular Arrhythmias Provoked in Rats with Myocardial Infarction.

This study evaluated the role of the mesenchymal stem cells derived from adipose tissue (MSCs) in provoked ventricular arrhythmias (VAs) in animals with myocardial infarction (MI). The experimental groups were: sham, subjected to sham surgery and intramyocardial saline injection; MIV, infarcted rats subjected to intramyocardial saline injection; MI + MSCs, infarcted rats subjected to intramyocardial MSCs injection. Injections were performed two days after infarction and the arrhythmogenic inducibility experiment was performed the next day. Only 35% of the MI + MSCs group developed VAs, while the one in the MIV group was 65%. The proportion of nonsustained ventricular tachycardia, sustained tachycardia, and ventricular fibrillation was similar between the infarcted groups, but MSCs animals had shorter duration of nonsustained ventricular tachycardia. However, MSCs increased connexin 43 content in the remote area, even above the levels found in the sham group. MSCs prevented the increase of IL-1ß in the different areas of the myocardium. There was higher carbonylation and content of 4-hydroxynonenal (4-HNE, a marker of lipoperoxidation) in the myocardium of infarcted rats, but MSCs attenuated the increase of 4-HNE in the infarcted area. In conclusion, MSCs have a protective effect against the development of arrhythmias, but do not imply a significant benefit for animals that have developed VAs. It is possible to think that the cardioprotection of MSCs involves anti-inflammatory/oxidative actions and improvement in the formation of communicating junctions.Graphical abstract.

Prognostic significance of microsatellite instability in patients with resectable gastric cancer.

BACKGROUND: Microsatellite instability (MSI) gastric cancer (GC) generally has a better prognosis than microsatellite-stable (MSS) GC and has been associated with nonsurvival benefit with the addition of chemotherapy (CMT) compared with surgery alone. However, patients with MSI have distinct clinicopathological characteristics. This study aimed to compare the survival outcomes between patients with MSI GC and those with MSS GC. In addition, this study analyzed the survival outcomes of patients with MSI GC who received CMT. METHODS: This study reviewed all patients with GC who underwent curative gastrectomy. Patients were divided into MSI group and the MSS group. Propensity score matching (PSM) was used to match clinicopathological factors. RESULTS: Among the 378 patients enrolled, 78 (20.6%) had MSI. Older age (P < .001), subtotal gastrectomy (P = .008), pN0 (P = .020), and earlier pTNM stage (P = .012) were associated with MSI GC. Survival analysis showed better disease-free survival (DFS) and overall survival (OS) of patients in the MSI group (P = .012 and P = .019, respectively). After PSM, 78 patients were matched to each group. All variables assigned to the scores were well matched, and both groups became equivalent. After the matching, the differences in DFS and OS according to MSI/MSS status were estimated to be larger than before (DFS: 63.3% vs 41.4%; P = .002; OS: 65.8% vs 42.5%; P = .002). Regarding patients referred for CMT, there was no difference in DFS and OS between patients with MSI GC who underwent CMT and those who underwent surgery alone (P = .255 and P = .178, respectively). CONCLUSION: Even after controlling for clinicopathological characteristics, MSI was identified as a prognostic factor for patient survival. MSI GC showed no significant survival benefit with the addition of CMT.

Adenosine A2A receptor as a potential regulator of Mycobacterium leprae survival mechanisms: new insights into leprosy neural damage.

Background: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which can lead to a disabling neurodegenerative condition. M. leprae preferentially infects skin macrophages and Schwann cells-glial cells of the peripheral nervous system. The infection modifies the host cell lipid metabolism, subverting it in favor of the formation of cholesterol-rich lipid droplets (LD) that are essential for bacterial survival. Although researchers have made progress in understanding leprosy pathogenesis, many aspects of the molecular and cellular mechanisms of host-pathogen interaction still require clarification. The purinergic system utilizes extracellular ATP and adenosine as critical signaling molecules and plays several roles in pathophysiological processes. Furthermore, nucleoside surface receptors such as the adenosine receptor A2AR involved in neuroimmune response, lipid metabolism, and neuron-glia interaction are targets for the treatment of different diseases. Despite the importance of this system, nothing has been described about its role in leprosy, particularly adenosinergic signaling (AdoS) during M. leprae-Schwann cell interaction. Methods: M. leprae was purified from the hind footpad of athymic nu/nu mice. ST88-14 human cells were infected with M. leprae in the presence or absence of specific agonists or antagonists of AdoS. Enzymatic activity assays, fluorescence microscopy, Western blotting, and RT-qPCR analysis were performed. M. leprae viability was investigated by RT-qPCR, and cytokines were evaluated by enzyme-linked immunosorbent assay. Results: We demonstrated that M. leprae-infected Schwann cells upregulated CD73 and ADA and downregulated A2AR expression and the phosphorylation of the transcription factor CREB (p-CREB). On the other hand, activation of A2AR with its selective agonist, CGS21680, resulted in: 1) reduced lipid droplets accumulation and pro-lipogenic gene expression; 2) reduced production of IL-6 and IL-8; 3) reduced intracellular M. leprae viability; 4) increased levels of p-CREB. Conclusion: These findings suggest the involvement of the AdoS in leprosy neuropathogenesis and support the idea that M. leprae, by downmodulating the expression and activity of A2AR in Schwann cells, decreases A2AR downstream signaling, contributing to the maintenance of LD accumulation and intracellular viability of the bacillus.

Risk Scoring System to Predict Mortality in Gastric Cancer with Peritoneal Carcinomatosis.

Gastric cancer (GC) with peritoneal carcinomatosis (PC) has a particularly unfavorable prognosis. This limited survival raises doubts about which factors confer an extremely worse outcome and which patients could benefit from more aggressive treatments, in an attempt to improve survival and better control the disease. This study aimed to evaluate the survival outcomes of patients with PC due to GC and develop a prognostic score to predict 6-month mortality. We performed an analysis of clinical stage IV GC with PC. Scores were assigned to risk factors and calculated for each patient from nine variables. Among 326 IVB GC, 211 (64.7%) had PC and were included. After calculating the score, 136 (64.5%) GCs were classified as a low-risk group and 75 (35.5%) as a high-risk group. Median OS was 7.9 and 1.9 months for low- and high-risk patients (p < 0.001). In the high-risk group, 77.3% of the patients died in <6 mo (p < 0.001). Palliative surgery and chemotherapy were associated with better survival, and the prognostic groups maintained statistical significance even when the same type of treatment was performed. In conclusion, the scoring system developed with variables related to patient performance status and clinical data was able to distinguish GC with PC with a high risk of 6-month mortality. Accordingly, verifying and validating our findings in a large cohort of patients is necessary to confirm and guarantee the external validation of the results.

THE VALUE OF PREOPERATIVE PROGNOSTIC NUTRITIONAL INDEX IN GASTRIC CANCER AFTER CURATIVE RESECTION.

BACKGROUND: Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries. AIMS: To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients. METHODS: A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI. RESULTS: Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival. CONCLUSIONS: Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.

Robotic versus laparoscopic gastrectomy for gastric cancer: A Western propensity score matched analysis.

BACKGROUND: Robot-assisted gastrectomy (RG) has been shown to be safe and feasible in the treatment of gastric cancer (GC). However, it is unclear whether RG is equivalent to laparoscopic gastrectomy (LG), especially in the Western world. Our objective was to compare the outcomes of RG and LG in GC patients. METHODS: We reviewed all gastric adenocarcinoma patients who underwent curative gastrectomy by minimally invasive approach in our institution from 2009 to 2022. Propensity score matching (PSM) analysis was conducted to reduce selection bias. DaVinci Si platform was used for RG. RESULTS: A total of 156 patients were eligible for inclusion (48 RG and 108 LG). Total gastrectomy was performed in 21.3% and 25% of cases in LG and RG, respectively. The frequency of stage pTNM II/III was 48.1%, and 54.2% in the LG and RG groups (p = 0.488). After PSM, 48 patients were matched in each group. LG and RG had a similar number of dissected lymph nodes (p = 0.759), operative time (p = 0.421), and hospital stay (p = 0.353). Blood loss was lower in the RG group (p = 0.042). The major postoperative complications rate was 16.7% for LG and 6.2% for RG (p = 0.109). The 30-day mortality rate was 2.1% and 0% for LG and RG, respectively (p = 1.0). There was no significant difference between the LG and RG groups for disease-free survival (79.6% vs. 61.2%, respectively; p = 0.155) and overall survival (75.9% vs. 65.7%, respectively; p = 0.422). CONCLUSION: RG had similar surgical and long-term outcomes compared to LG, with less blood loss observed in RG.

Dynamic whole-body [18F]FES PET/CT increases lesion visibility in patients with metastatic breast cancer.

BACKGROUND: Correct classification of estrogen receptor (ER) status is essential for prognosis and treatment planning in patients with breast cancer (BC). Therefore, it is recommended to sample tumor tissue from an accessible metastasis. However, ER expression can show intra- and intertumoral heterogeneity. 16α-[18F]fluoroestradiol ([18F]FES) Positron Emission Tomography/Computed Tomography (PET/CT) allows noninvasive whole-body (WB) identification of ER distribution and is usually performed as a single static image 60 min after radiotracer injection. Using dynamic whole-body (D-WB) PET imaging, we examine [18F]FES kinetics and explore whether Patlak parametric images ( K i ) are quantitative and improve lesion visibility. RESULTS: This prospective study included eight patients with metastatic ER-positive BC scanned using a D-WB PET acquisition protocol. The kinetics of [18F]FES were best characterized by the irreversible two-tissue compartment model in tumor lesions and in the majority of organ tissues. K i values from Patlak parametric images correlated with K i values from the full kinetic analysis, r2 = 0.77, and with the semiquantitative mean standardized uptake value (SUVmean), r2 = 0.91. Furthermore, parametric K i images had the highest target-to-background ratio (TBR) in 162/164 metastatic lesions and the highest contrast-to-noise ratio (CNR) in 99/164 lesions compared to conventional SUV images. TBR was 2.45 (95% confidence interval (CI): 2.25-2.68) and CNR 1.17 (95% CI: 1.08-1.26) times higher in K i images compared to SUV images. These quantitative differences were seen as reduced background activity in the K i images. CONCLUSION: [18F]FES uptake is best described by an irreversible two-tissue compartment model. D-WB [18F]FES PET/CT scans can be used for direct reconstruction of parametric K i images, with superior lesion visibility and K i values comparable to K i values found from full kinetic analyses. This may aid correct ER classification and treatment decisions. Trial registration ClinicalTrials.gov: NCT04150731, https://clinicaltrials.gov/study/NCT04150731.

Prognostic implications of tumor-infiltrating lymphocytes within the tumor microenvironment in gastric cancer.

BACKGROUND: Tumor-infiltrating lymphocytes (TILs) play a regulatory role in the tumor-associated immune response and are important in the prognosis and treatment response of several cancers. However, because of its heterogeneity, the prognostic value of TILs in gastric cancer (GC) is still controversial. Thus, this study aimed to investigate the association between the density of TILs and patients' outcomes in GC. METHODS: Patients with gastric adenocarcinoma who underwent curative intent gastrectomy were retrospectively investigated. The groups for analysis were determined on the basis of TIL intensity and percentage of CD3+ T-cell infiltration by immunohistochemical. Furthermore, Epstein-Barr virus (EBV), microsatellite instability (MSI), T-cell ratio of CD4 to CD8, and programmed death protein ligand 1 (PD-L1) status were evaluated. RESULTS: A total of 345 patients were enrolled: 124 patients with GCs (35.9%) were classified as the low-CD3+ TIL group, and 221 patients with GCs (64.1%) were classified as the high-CD3+ TIL group. Poorly differentiated histology (P = .014), EBV-positive status (P < .001), PD-L1-positive status (P = .001), and CD4 < CD8 (P < .001) were associated with high-CD3+ GC. There was no difference regarding MSI status, the degree of tumor invasion (pT), the presence of lymph node metastasis, and pTNM stage between low- and high-CD3+ groups. In survival analysis, the high-CD3+ group had better disease-free survival and overall survival rates than had the low-CD3+ group (P = .055 and P = .041, respectively). In the multivariate analysis, total gastrectomy, lymph node metastasis, advanced pT stage, and low CD3+ levels were independent factors related to worse survival. CONCLUSION: High CD3+ TILs levels were significantly associated with improved survival and could serve as prognostic biomarkers in GC. In addition, CD3+ T-cell infiltration was related to both EBV-positive and PD-L1-positive GC and may assist in the investigation of targets in immunotherapy.

Incidental [18F]FDG-avid focuses in parotid glands on PET/CT.

BACKGROUND: The number of unexpected focal [18F]FDG-avid findings (incidentalomas) within the parotid gland (PGI) continues to increase with the expanding use of PET/CT scanning. The prevalence of malignancy in PGIs is uncertain and appropriate management is unsettled. AIMS: We aimed to explore the underlying pathologies associated with PGI. MATERIALS AND METHODS: A retrospective review of all patients with parotid gland incidentaloma(s) treated at the Ear-Nose-Throat Department, Aarhus University Hospital, Denmark in the period 2012-2021, was performed. RESULTS: In total, 94 patients with one (n = 86) or two (n = 8) PGI(s) were included. In patients with one PGI, 72 (84%) focuses were benign, two (2%) focuses were malignant (both malignant melanoma metastases), and 12 (14%) focuses were undiagnosed. In patients with two PGIs, all 12 lesions with pathological examinations were benign (4 PGIs were undiagnosed). The median SUVmax found in benign lesions was higher (12.0) compared to malignant lesions (5.5) (p = .043). CONCLUSIONS AND SIGNIFICANCE: The prevalence of malignancy was low (2/94, 2.4%) in PGIs. Based on our findings, PGI in patients without a history of parotid malignancy, who undergo PET/CT scanning for reasons other than head and neck cancer (including malignant melanoma), may be managed similarly to patients with asymptomatic parotid gland tumors.

Increased lesion detectability in patients with locally advanced breast cancer-A pilot study using dynamic whole-body [18F]FDG PET/CT.

BACKGROUND: Accurate diagnosis of axillary lymph node (ALN) metastases is essential for prognosis and treatment planning in breast cancer. Evaluation of ALN is done by ultrasound, which is limited by inter-operator variability, and by sentinel lymph node biopsy and/or ALN dissection, none of which are without risks and/or long-term complications. It is known that conventional 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) has limited sensitivity for ALN metastases. However, a recently developed dynamic whole-body (D-WB) [18F]FDG PET/CT scanning protocol, allowing for imaging of tissue [18F]FDG metabolic rate (MRFDG), has been shown to have the potential to increase lesion detectability. The study purpose was to examine detectability of malignant lesions in D-WB [18F]FDG PET/CT compared to conventional [18F]FDG PET/CT. RESULTS: This study prospectively included ten women with locally advanced breast cancer who were referred for an [18F]FDG PET/CT as part of their diagnostic work-up. They all underwent D-WB [18F]FDG PET/CT, consisting of a 6 min single bed dynamic scan over the chest region started at the time of tracer injection, a 64 min dynamic WB PET scan consisting of 16 continuous bed motion passes, and finally a contrast-enhanced CT scan, with generation of MRFDG parametric images. Lesion visibility was assessed by tumor-to-background and contrast-to-noise ratios using volumes of interest isocontouring tumors with a set limit of 50% of SUVmax and background volumes placed in the vicinity of tumors. Lesion visibility was best in the MRFDG images, with target-to-background values 2.28 (95% CI: 2.04-2.54) times higher than target-to-background values in SUV images, and contrast-to-noise values 1.23 (95% CI: 1.12-1.35) times higher than contrast-to-noise values in SUV images. Furthermore, five imaging experts visually assessed the images and three additional suspicious lesions were found in the MRFDG images compared to SUV images; one suspicious ALN, one suspicious parasternal lymph node, and one suspicious lesion located in the pelvic bone. CONCLUSIONS: D-WB [18F]FDG PET/CT with MRFDG images show potential for improved lesion detectability compared to conventional SUV images in locally advanced breast cancer. Further validation in larger cohorts is needed. CLINICAL TRIAL REGISTRATION: The trial is registered in clinicaltrials.gov, NCT05110443, https://www. CLINICALTRIALS: gov/study/NCT05110443?term=NCT05110443&rank=1 .

Projeto Terapêutico Singular: relato de experiência da construção da prática da ESF no ensino da medicina

A disciplina Integração-Ensino-Serviço-Comunidade III (IESC III) faz parte do itinerário curricular da Universidade do Grande Rio ­ Professor José de Souza Herdy (UNIGRANRIO-AFYA) e, por ter caráter obrigatório, deve ser cursada por todos os graduandos ao decorrer do curso. Como parte da metodologia de ensino-aprendizagem, acompanhados pelos professores atribuídos ao curso, os discentes, como parte das atividades da disciplina, realizam, em sua prática, um Projeto Terapêutico Singular (PTS), seguindo as normas da Equipe de Saúde da Família (ESF), tendo a oportunidade de acompanhar uma família por meio dessa ação. Este artigo tem como objetivo relatar as experiências vivenciadas pelos discentes durante os quatro meses de IESC III em que foi posto em prática o desenvolvimento do PTS. Na percepção dos estudantes, tal ação formativa foi substancial para a construção dos futuros médicos, haja vista o contato mais próximo com a família em questão, que proporcionou a familiarização com o trabalho que é desenvolvido diariamente pelos Agentes Comunitários de Saúde. Ademais, atesta-se pelo próprio sucesso obtido ao final do trabalho, que ele oportunizou o conhecimento de realidades completamente distintas daquelas vivenciadas por cada integrante do grupo.

Acesso e qualidade da alimentação: percepção da população em situação de rua / Acceso y calidad de la alimentación: percepción de personas en situación de calle / Access to food and food quality: perception of the homeless population

Resumo Objetivo Compreender a percepção do acesso e da qualidade da alimentação para a população em situação de rua. Métodos Estudo descritivo qualitativo, realizado em um Centro de Referência da População de Rua na região centro-sul de Belo Horizonte (MG). Utilizou-se roteiro semiestruturado para a realização das entrevistas de 18 participantes. A coleta de dados ocorreu entre dezembro de 2020 e janeiro de 2021. A análise temática do material, proposta por Bardin, possibilitou a elaboração de três categorias empíricas. Resultados O público entrevistado era masculino, com idade média de 43 anos e tempo médio de situação de rua de 44,6 meses. O acesso à alimentação foi proveniente das doações de alimentos, refeições em instituições governamentais e aquisições ao dispor de renda. Foram relatadas dificuldades quanto à quantidade e qualidade dos alimentos, à aquisição das refeições nos fins de semana, aos sentimentos de medo e angústia perante a fome, à falta do alimento e pelo estigma social, agravados pela COVID-19. Conclusão Diante do cenário de iniquidades sociais, o direito ao acesso à alimentação não é garantido, sendo necessária a implementação de políticas públicas de proteção social que garantam os direitos básicos.

Resumen Objetivo Comprender la percepción del acceso y de la calidad de la alimentación según personas en situación de calle. Métodos Estudio descriptivo cualitativo, realizado en un Centro de Referencia de Personas de la Calle en la región centro-sur de Belo Horizonte (Minas Gerais). Se utilizó un guion semiestructurado para realizar entrevistas a 18 participantes. La recopilación de datos se realizó entre diciembre de 2020 y enero de 2021. El análisis temático del material, propuesto por Bardin, permitió la elaboración de tres categorías empíricas. Resultados El público entrevistado era masculino, de 43 años de edad promedio y tiempo promedio de situación de calle de 44,6 meses. El acceso a la alimentación fue proveniente de donaciones de alimentos, comidas en instituciones gubernamentales y adquisiciones al disponer de ingresos. Las personas relataron dificultades con relación a la cantidad y calidad de los alimentos, a la adquisición de comida los fines de semana, a los sentimientos de miedo y angustia ante el hambre, a la falta de alimentos y al estigma social, agravados por el COVID-19. Conclusión Ante el escenario de iniquidades sociales, el derecho al acceso a la alimentación no está garantizado, por lo cual es necesario implementar políticas públicas de protección social que garanticen los derechos básicos.

Abstract Objective To understand the perception of access to food and food quality for the street population. Methods This qualitative descriptive study was performed in a Reference Center for the Homeless Population in the south-central region of Belo Horizonte (MG). A semi-structured script was used to conduct interviews with 18 participants. Data collection occurred between December 2020 and January 2021. The thematic analysis of the material, as proposed by Bardin, made it possible to elaborate three empirical categories. Results The public interviewed was male, with a mean age of 43 years, and a mean time on the streets of 44.6 months. Access to food came from donations, meals at government institutions, and acquisition when income was available. Difficulties were reported regarding the quantity and quality of food, acquisition of meals on weekends, feelings of fear and anguish in the face of hunger, lack of food, and social stigma, which were aggravated by COVID-19. Conclusion As in this scenario of social inequalities the access to food is not guaranteed, implementing public policies of social protection is necessary to guarantee basic rights.

O valor do índice nutricional prognóstico pré-operatório no câncer gástrico após ressecção curativa / The value of preoperative prognostic nutritional index in gastric cancer after curative resection

ABSTRACT BACKGROUND: Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries. AIMS: To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients. METHODS: A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI. RESULTS: Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival. CONCLUSIONS: Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.

RESUMO RACIONAL: Estimar os desfechos de curto e longo prazo das terapias contra o câncer é crucial para o desenvolvimento de estratégias de tratamento eficazes. A desnutrição e o estado imunológico do hospedeiro afetam significativamente os desfechos em cirurgias de grande porte. OBJETIVOS: Avaliar o valor do índice nutricional prognóstico pré-operatório (INP) na predição de desfechos em pacientes com câncer gástrico. MÉTODOS: Foi realizada uma análise de coorte retrospectiva de pacientes submetidos à cirurgia com intenção curativa para adenocarcinoma gástrico entre 2009 e 2020. O INP foi calculado da seguinte forma: INP=(10 x albumina [g/dL])+(0.005 x linfócitos [nº/mm3]). O valor de corte ideal foi determinado pela curva característica de operação do receptor (ponto de corte do INP=52), e os pacientes foram agrupados em INP baixo ou alto. RESULTADOS: Dos 529 pacientes incluídos, 315 (59,5%) foram classificados como grupo de baixo INP (INP<52) e 214 (40,5%) como grupo de alto INP (INP>52). Idade mais avançada (p=0,050), sexo masculino (p=0,003), escore da Sociedade Americana de Anestesiologistas (ASA) III/IV (p=0,001), menor nível de hemoglobina (p<0,001), menor índice de massa corpórea (p=0,001), maior relação neutrófilos-linfócitos (p<0,001), linfadenectomia D1, estágio pT avançado, pN+ e estágio pTNM mais avançado foram relacionados ao paciente com baixo INP. Além disso, as taxas de mortalidade em 30 dias (1,4 vs. 4,8%; p=0,036) e em 90 dias (3,3 vs. 10,5%; p=0,002) foram maiores no grupo com baixo PNI em comparação ao grupo com alto INP. A sobrevida livre de doença e a sobrevida global foram piores em pacientes com baixo INP em comparação com pacientes com alto INP (p<0,001 para ambos). Escore ASA III/IV, baixo INP, pT3/T4 e pN+ foram fatores de risco independentes para pior sobrevida. CONCLUSÕES: O INP pré-operatório pode predizer desfechos de curto e longo prazo de pacientes com câncer gástrico após gastrectomia curativa. Baixo INP é um fator independente relacionado a piores sobrevida livre de doença e sobrevida global.

Nursing care protocol for critical users with tracheostomy under mechanical ventilation / Protocolo de atención de enfermería al usuario crítico con traqueotomía en ventilación mecánica / Protocolo de cuidados de enfermagem para usuários críticos com traqueostomia em ventilação mecânica

ABSTRACT Objectives: to develop and assess a nursing care protocol for critically ill users with tracheostomy under mechanical ventilation. Methods: a methodological study, developed through two phases, guided by the 5W2H management tool: I) target audience characterization and II) technology development. Results: thirty-four nursing professionals participated in this study, who presented educational demands in relation to care for critical users with tracheostomy, with an emphasis on standardizing care through a protocol and carrying out continuing education. Final Considerations: the creation and validity of new technologies aimed at this purpose enhanced the participation of nursing professionals and their empowerment in the health institution's microsectoral actions and in macrosectoral actions, highlighting the need for public policies that guarantee the conduct of a line of care for users with tracheostomy.

RESUMEN Objetivos: desarrollar y evaluar un protocolo de atención de enfermería a usuarios críticos con traqueostomía y ventilación mecánica. Métodos: estudio metodológico, desarrollado a través de dos fases, guiado por la herramienta de gestión 5W2H: I) caracterización del público objetivo y II) desarrollo tecnológico. Resultados: participaron de este estudio 34 profesionales de enfermería, quienes presentaron demandas educativas en relación al cuidado de usuarios críticos con traqueotomía, con énfasis en estandarizar los cuidados a través de un protocolo y realizar educación permanente. Consideraciones Finales: la creación y validación de nuevas tecnologías orientadas a este propósito han potenciado la participación de los profesionales de enfermería y su empoderamiento en las acciones microsectoriales y macrosectoriales de la institución de salud, por resaltar la necesidad de políticas públicas que garanticen la conducción de una línea de atención a usuarios con traqueotomía.

RESUMO Objetivos: desenvolver e avaliar um protocolo de cuidados de enfermagem para usuários críticos com traqueostomia em ventilação mecânica. Métodos: estudo metodológico, desenvolvido mediante duas fases, guiadas pela ferramenta gerencial 5W2H: I) caracterização do público-alvo e II) desenvolvimento da tecnologia. Resultados: participaram deste estudo 34 profissionais de enfermagem, que apresentaram demandas educacionais em relação aos cuidados com o usuário crítico com traqueostomia, com ênfase na padronização dos cuidados mediante um protocolo e realização de educação permanente. Considerações Finais: a criação e a validação de novas tecnologias voltadas para este fim potencializaram a participação dos profissionais de enfermagem e o seu empoderamento nas ações microssetoriais da instituição de saúde e nas ações macrossetoriais, por evidenciar a necessidade de políticas públicas que garantam a condução de uma linha de cuidado para usuários com traqueostomia.

Pancreatoduodenectomy with Venous Resection or Palliative Therapy? A Meta-Analysis.

This review evaluated the risks and survival benefits of pancreatoduodenectomy associated with venous resection compared with palliative surgery. A systematic review with meta-analysis was performed. Higher overall survival was observed in the pancreatic resection group (HR = 4.000; 95% CI 2.800 to 5.200). However, the palliative group had fewer complications (RD = -0.170; 95% CI -0.260 to -0.070). There was no significant difference in the mortality rates (RD = 0.000; 95% CI -0.030 to 0.030). In centres with experience in pancreatic surgery, resection may be considered for locally advanced cancer and major venous invasion. Pancreaticoduodenectomy with vascular resection may improve survival for periampullary tumours compared with palliation therapy. However, pancreaticoduodenectomy with major venous resection has potentially higher morbidity than palliation therapy. Key Words: Pancreatoduodenectomy, Pancreatic neoplasms, Vascular surgical procedures.

FAILURE TO RESCUE AFTER GASTRECTOMY: A NEW INDICATOR OF SURGICAL QUALITY.

BACKGROUND: The main treatment modality for gastric cancer is surgical resection with lymphadenectomy. Despite advances in perioperative care, major surgical complications can occur in up to 20% of cases. To determine the quality of surgical care employed, a new indicator called failure to rescue (FTR) was proposed, which assesses the percentage of patients who die after complications occur. AIMS: To assess the rate of FTR after gastrectomy and factors associated with its occurrence. METHODS: Patients with gastric cancer who underwent gastrectomy with curative intent were retrospectively evaluated. According to the occurrence of postoperative complications, patients were divided into FTR group (grade V complications) and rescued group (grade III/IV complications). RESULTS: Among the 731 patients, 114 had major complications. Of these patients, 76 (66.7%) were successfully treated for the complication (rescued group), while 38 (33.3%) died (FTR group). Patients in the FTR group were older (p=0.008; p<0.05), had lower levels of hemoglobin (p=0.021; p<0.05) and albumin (p=0.002; p<0.05), and a higher frequency of ASA III/IV (p=0.033; p<0.05). There were no differences between the groups regarding surgical and pathological characteristics. Clinical complications had a higher mortality rate (40.0% vs 30.4%), with pulmonary complications (50.2%) and infections (46.2%) being the most lethal. Patients with major complications grade III/IV had worse survival than those without complications. CONCLUSIONS: The FTR rate was 33.3%. Advanced age, worse performance, and nutritional parameters were associated with FTR.