Caregivers of older adults in palliative care: level of burden and depressive symptoms / Cuidadores de idosos em cuidados paliativos: nível de sobrecarga e sintomas depressivos

Abstract Introduction The burden perceived by informal caregivers of older adult cancer patients in palliative care is an incessant daily repetitiveness, and can negatively affect their physical and mental health, as well as their social and family life. Objective To assess the level of burden and the intensity of depressive symptoms in caregivers, and the dependence of the older adults for basic and instrumental activities of daily living. Methods This was a cross-sectional and descriptive study, composed of 20 caregivers and 20 older adults with cancer in palliative care. Caregivers and older adults were administered the socio-economic and demographic profile assessment. For the caregivers, the International Physical Activity Questionnaire - IPAQ, the Zarit Burden Interview (ZBI), and the Beck Depression Inventory (BDI) were used. For the older adults, the Katz Index of Independence in Activities of Daily Living (Katz Index ADL) and the Lawton and Brody Instrumental Activities of Daily Living scales (Lawton and Brody IADL scales) were used. Data were represented in absolute and percentage values. Results Caregivers were predominantly female, mostly daughters of the older adults, married or with a partner, with elementary school education, income of 1 to 3 times the minimum wage, and had a sedentary lifestyle. A moderate level of burden was verified in 75% of the caregivers, and mild to moderate depressive symptoms in 45%. The assessment of ADL in older adults found that 55% were independent in all six functions, with greater dependence (75%) in ADL for housekeeping such as laundry (85%) and driving vehicles (90%). Conclusion Caregivers of older adults cancer patients in palliative care show moderate level of burden, and mild to moderate depressive symptoms.

Resumo Introdução A sobrecarga vivenciada por cuidadores informais de idosos com câncer em cuidados paliativos em uma repetitividade diária incessante pode afetar negativamente a saúde física e mental, bem como a vida social e familiar do cuidador. Objetivo Avaliar o nível de sobrecarga e a intensidade de sintomas depressivos nos cuidadores e a dependência para as atividades básicas e instrumentais de vida diária dos idosos. Métodos Estudo transversal e descritivo, composto por 20 cuidadores e 20 idosos com câncer em cuidados paliativos. Os cuidadores e os idosos foram submetidos à avaliação do perfil socioeconômico e demográfico. Quanto à avaliação dos cuidadores, utilizaram-se o Questionário Internacional de Atividade Física- IPAQ, a escala Zarit Burden Interview e o Inventário de Depressão de Beck. Para a avaliação dos idosos, o índice de Katz para as atividades básicas da vida diária (ABVD) e a escala de Lawton e Brody para atividades instrumentais de vida diária (AIVD). Os dados foram representados em valores absolutos e percentuais. Resultados Houve predomínio de cuidadores do sexo feminino, a maioria filha dos idosos, casadas ou com companheiro, com ensino fundamental I, renda de 1 a 3 salários mínimos e sedentárias, sendo constatado nível de sobrecarga moderado em 75% dos cuidadores e sintomas depressivos de leves a moderados em 45%. Quanto à avaliação das ABVD nos idosos, constatou-se que 55% eram independentes nas seis funções, com maior dependência (75%) em AIVD para trabalhos domésticos como lavar roupas (85%) e condução de veículos (90%). Conclusão Os cuidadores de idosos com câncer em cuidados paliativos apresentam nível de sobrecarga moderado e sintomas depressivos de leves a moderados.

Sarcoma de Kaposi em Paciente Jovem Imunocompetente: uma Quinta Variante Epidemiológica? ­ Relato de Caso / Kaposi's Sarcoma in Young Immunocompetent Patient: a Fifth Epidemiological Variant? ­ Case Report / Sarcoma de Kaposi em Paciente Joven Inmunocompetente: ¿una Quinta Variante Epidemiológica? ­ Informe de Caso

Introdução: O sarcoma de Kaposi apresenta, classicamente, quatro tipos de variantes: clássico, endêmico, associado à imunossupressão (ou iatrogênico) e epidêmico (ou relacionado à Aids). Todos esses subtipos estão relacionados ao herpes-vírus humano 8. Uma quinta variante clínico-epidemiológica vem sendo proposta na literatura, que inclui uma apresentação visceral da doença no grupo de homens que fazem sexo com homens sem fatores de imunossupressão identificados. Relato de caso: Descreve-se o caso de um paciente masculino de 24 anos de idade, de orientação homossexual, sem fatores de imunossupressão, com apresentação linfonodal de sarcoma de Kaposi, e sem outros fatores que o incluam dentro das classificações da doença atualmente conhecidas. O paciente recebeu tratamento quimioterápico com paclitaxel, atingindo resposta completa e mantida até o momento, 42 meses após o término do tratamento. Conclusão: Esse caso reforça que a patogênese do sarcoma de Kaposi ainda é pouco clara, e que provavelmente múltiplos fatores, tanto do vírus como do hospedeiro, interajam entre si para desencadear a carcinogênese. É possível que o hábito sexual não encerre relação com essa patogênese, comportando-se apenas como fator confundidor. O paciente apresentou toxicidade mínima durante o tratamento com paclitaxel e atingiu resposta completa e mantida.

Introduction: Kaposi sarcoma classically presents four types of variants: classic, endemic, immunosuppression-associated (or iatrogenic) and epidemic (or AIDS-associated). All subtypes are invariably linked to human herpesvirus-8. A fifth clinical-epidemiological variant has been proposed in the literature, which includes a visceral presentation of the disease in the group of men who have sex with men without detected immunosuppressive factors. Case Report: We report the case of a 24-year-old male patient with a homosexual orientation without immunosuppressive factors, diagnosed with KS, with lymph node involvement, and without other disease characteristics that could include him within the currently known four types of Kaposi sarcoma classification. The patient received chemotherapy with paclitaxel, evolving with complete and sustained reponse until now, 42 months after the ending of treatment. Conclusion: This case reinforces that the pathogenesis of KS is still unclear, and that probably multiple factors, both virus and host, interact with each other to trigger carcinogenesis. It is possible that the sexual habit does not influence this pathogenesis, behaving only as a confounding factor. The patient had minimal toxicity during treatment with paclitaxel and achieved a complete and sustained response.

Introducción: El sarcoma de Kaposi presenta, clásicamente, cuatro tipos de variantes: clásico, endémico, asociado a inmunosupresión (o iatrogénico) y epidémico (o relacionado a SIDA). Todos estos subtipos están relacionados con el virus del herpes humano tipo 8 (HHV-8). Una quinta variante clínica-epidemiológica está en estudio, incluye una presentación visceral de la enfermedad en un grupo de hombres que tienen sexo con hombres sin factores de inmunosupresión de causa detectada. Informe de Caso: Se desarrolló un estudio sobre un paciente masculino de 24 años de edad, de orientación homosexual, sin factores de inmunosupresión, presentando diagnóstico de sarcoma de Kaposi con característica linfonodal de la enfermedad, y sin otros factores que incluyan dentro de las clasificaciones de sarcoma de Kaposi actualmente conocidas. El paciente recibió tratamiento quimioterápico con paclitaxel, alcanzando respuesta completa y sostenida hasta el momento, 42 meses después del término del tratamiento. Conclusión: Este caso refuerza que la patogénesis del sarcoma de Kaposi es poco clara, y que probablemente múltiples factores, tanto del virus y del hospedador, interactúan entre sí para desencadenar La carcinogénesis. Es posible que el hábito sexual no encierre relación con esa patogénesis, comportándose apenas como factor confundidor. El paciente presentó toxicidad mínima durante el tratamiento y alcanzó una respuesta completa y sostenida hasta el momento, pudiendo, el paclitaxel, ser considerado una opción sólida para el tratamiento del sarcoma de Kaposi en ese grupo de pacientes con esa variante de presentación.

KRAS mutation associated with CD44/CD166 immunoexpression as predictors of worse outcome in metastatic colon cancer.

INTRODUCTION: Multiple stages of carcinogenesis in colon cancer encompass subpopulations of cancer stem cells (CSC), responsible for tumor cell transformation, growth and proliferation. CD44 and CD166 proteins are CSC markers associated with cell signaling, adhesion, migration, metastasis and lymphocytic response. The expression of CSC may be modulated by some factors, such as the KRAS gene mutation. OBJECTIVE: Correlate the expression of CD44 and CD166 markers in metastatic colon adenocarcinoma and KRAS mutation status (wild-type/mutated) with clinical pathological features and patients' outcome. MATERIAL AND METHODS: Fifty-eight samples of tumor tissue samples of metastatic colon adenocarcinoma were collected from patients treated with CapeOx at the HCFMRP-USP Clinical Oncology Service. Clinical and survival data were collected from medical records. KRAS status was determined by the polymerase chain reaction (PCR) technique, and analysis of immunohistochemical expression of CD44 and CD166 proteins was performed by tissue microarray. RESULTS: The expression of CD44 and CD166 were positive in 41% and 43% of patients, respectively, and mutated KRAS was detected in 48% of patients. A significant association was found between CD166 and CD44 expression (p= 0.016), mainly in the wild-type KRAS group (p= 0.042) and patients over 65 years (p= 0.001). CD44-positive patients had 3.7-fold and 5.3-fold greater risk of liver metastasis and lung metastasis, respectively (p< 0.01), compared with CD44-negative patients. CD166-negative patients had 2.7 greater risk of lymph node involvement (0.03), compared with CD166-positive patients. KRAS mutation increased the risk of liver metastasis by 8 times (p< 0.01), and the risk of lung metastasis by 5 times (p= 0.04) in CD44-positive patients. KRAS mutation increased the risk of lymph node involvement by 8 times in CD166-negative patients (p= 0.0007). CONCLUSION: An association between CD44 and CD166 expression was demonstrated in this study. Analysis of KRAS mutation combined with immunohistochemical expression of CD44 and CD166 identified subgroups of patients with colon adenocarcinoma at higher risk of lymph node involvement by the tumor and development of liver and lung metastasis.

Clinical-Pathological Correlation of KRAS Mutation Status in Metastatic Colorectal Adenocarcinoma.

BACKGROUND: KRAS gene mutations play an important role in the carcinogenesis of colorectal tumors. However, studies that have assessed the association between KRAS gene mutation status and disease characteristics report conflicting results. To assess KRAS gene status (mutated or wild-type) and its association with the clinical, epidemiological, and histopathological features of metastatic colorectal adenocarcinoma as well its association with clinical outcomes. METHODS: Cross-sectional descriptive study in which clinical and histopathological data were collected from the medical records of 65 patients diagnosed with metastatic colorectal adenocarcinoma at the Clinical Oncology Service of the Teaching Hospital of the School of Medicine of Ribeirao Preto, University of Sao Paulo (Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo -HCFMRP-USP) between 2005 and 2012 and analyzed based on their KRAS gene status. RESULTS: KRAS gene mutations were found in 49.2% of the tumors, and G/A (25.5%) and Gly12Asp (34.37%) were the most frequent mutations. Among the investigated clinical features (gender, ECOG (Eastern Cooperative Oncology Group), histology, degree of cell differentiation, lymph node ratio, primary tumor site, staging, presence of synchronous metastasis, lung metastasis, and liver metastasis), the association between age less than 65 years with KRAS mutation was statistically significant (P = 0.046). KRAS mutation status did not exhibit a significant correlation with the overall survival of the patients (P = 0.078); however, the cases with KRAS mutation exhibited shorter survival. In the multivariate analysis, synchronous metastasis (P = 0.03) and liver metastasis (P = 0.008) behaved as independent factors of poor prognosis relative to the overall survival of the patients. CONCLUSION: The KRAS mutation status did not exhibit prognostic value in the investigated sample. Among the older patients (> 65 years old), wild-type KRAS was more frequently observed compared to mutated KRAS.