Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation?

OBJECTIVE: The objective was to assess whether race/ethnicity is an independent predictor of failure to rescue (FTR) after orthotopic heart transplantation (OHT). SUMMARY BACKGROUND DATA: Outcomes following OHT vary by patient level factors; for example, non-White patients have worse outcomes than White patients after OHT. Failure to rescue is an important factor associated with cardiac surgery outcomes, but its relationship to demographic factors is unknown. METHODS: Using the United Network for Organ Sharing database, we included all adult patients who underwent primary isolated OHT between 1/1/2006 snd 6/30/2021. FTR was defined as the inability to prevent mortality after at least one of the UNOS-designated postoperative complications. Donor, recipient, and transplant characteristics, including complications and FTR, were compared across race/ethnicity. Logistic regression models were created to identify factors associated with complications and FTR. Kaplan Meier and adjusted Cox proportional hazards models evaluated the association between race/ethnicity and posttransplant survival. RESULTS: There were 33,244 adult, isolated heart transplant recipients included: the distribution of race/ethnicity was 66% (n=21,937) White, 21.2% (7,062) Black, 8.3% (2,768) Hispanic, and 3.3% (1,096) Asian. The frequency of complications and FTR differed significantly by race/ethnicity. After adjustment, Hispanic recipients were more likely to experience FTR than White recipients (OR 1.327, 95% CI[1.075-1.639], P =0.02). Black recipients had lower 5-year survival compared with other races/ethnicities (HR 1.276, 95% CI[1.207-1.348], P <0.0001). CONCLUSIONS: In the US, Black recipients have an increased risk of mortality after OHT compared with White recipients, without associated differences in FTR. In contrast, Hispanic recipients have an increased likelihood of FTR, but no significant mortality difference compared with White recipients. These findings highlight the need for tailored approaches to addressing race/ethnicity-based health inequities in the practice of heart transplantation.

A fase terminal do filho com câncer: percepções dos profissionais hospitalares / The terminal phase of children with cancer: perceptions of hospital professionals / La fase terminal del hijo con cáncer: percepciones de los profesionales del hospital

O confronto com o câncer de um filho e a percepção da sua morte como inevitável dão lugar a experiências parentais relevantes para a pesquisa científica. Este estudo teve como objetivo investigar, por meio da percepção dos profissionais hospitalares, o modo como os pais experienciam a fase terminal e fim de vida do filho com câncer para melhor compreender os processos psicoemocionais experienciados por esses pais diante da cronicidade da doença e da morte do filho. No sentido de alcançar esse objetivo, realizou-se um estudo qualitativo de tipo fenomenológico envolvendo 17 profissionais de dois hospitais portugueses de referência em oncologia pediátrica. Os dados foram recolhidos com recurso a um guia de entrevista semiestruturada. Na percepção dos profissionais hospitalares, os resultados evidenciam que esses pais experienciam múltiplas dificuldades e preocupações na fase terminal da doença do filho e no pós-morte, bem como um sofrimento extremo e desestruturação biopsicossocial e espiritual na família. O conhecimento aprofundado da fenomenologia desses processos é essencial para o desenho e a implementação de intervenções emocionais, cognitivas, comportamentais e sociais mais ajustadas às dificuldades e preocupações parentais vividas no fim de vida e pós-morte.(AU)

Coping with children's cancer and the perception of their inevitable death give rise to parental experiences that are important to study. This study aimed to investigate, based on hospital professionals' perspectives, how parents experience the terminal phase and end of life of their children suffering from cancer to better understand the psycho-emotional processes these parents experienced in face of the chronicity of the disease and their children's death. To achieve this objective, a qualitative phenomenological study was carried out involving 17 professionals of two Portuguese hospitals that are reference in pediatric oncology. Data were collected using a semi-structured interview guide. From the perspective of hospital professionals, results show that these parents experience multiple difficulties and concerns in the terminal phase of their children's disease and postmortem, as well as the extreme suffering and biopsychosocial and spiritual disruption of the family. A deeper understanding of the phenomenology of these processes is essential to design and implement better adjusted emotional, cognitive, behavioral, and social interventions aimed at the parental difficulties and concerns experienced at the end of life and after death.(AU)

El enfrentamiento del cáncer de un hijo y la percepción de su muerte como inevitable dan lugar a experiencias parentales importantes que deben ser estudiadas. Este estudio pretende identificar desde la percepción de los profesionales del hospital cómo los padres viven la fase terminal y el final de la vida de su hijo con cáncer con el fin de comprender mejor los procesos psicoemocionales que viven estos padres ante la cronicidad de la enfermedad y la muerte de su hijo. Para ello, se realizó un estudio cualitativo, con enfoque fenomenológico, en el que participaron 17 profesionales de dos hospitales portugueses de referencia en oncología pediátrica. Para recoger los datos se aplicó un guion de entrevista semiestructurada. En cuanto a la percepción de los profesionales del hospital, estos padres experimentaron múltiples dificultades y preocupaciones en la fase terminal de la enfermedad de su hijo y postmuerte, así como un sufrimiento extremo y una desestructuración biopsicosocial y espiritual en la familia. El conocimiento en profundidad de la fenomenología de estos procesos es esencial para elaborar e implementar intervenciones emocionales, cognitivas, conductuales y sociales más acordes a las dificultades y preocupaciones parentales que se experimentan al final de la vida y la postmuerte.(AU)

'Climate change concerns human survival and justice in our international community': A corpus-based positive discourse analysis (PDA) of the largest developing nation's global involve/engagement discourses (re)told in interpreting.

Contributing to a much-needed 'outward turn' in interpreting studies, this intervention examines the role of interpreting and interpreters in (re)articulating the welcome 'voice' of a developing nation in the global South. Against the backdrop of reform and opening-up (ROU), China, the world's largest developing country, is increasingly open and keen to engage globally. Such elements as openness, integration, and international engagement represent vital components of the overarching ROU metadiscourse that justifies China's sociopolitical system and multifarious policies and decisions. As part of a series of digital humanities (DH) informed empirical studies exploring the part played by interpreting in rendering China's ROU metadiscourse, this study zooms in on the government interpreters' mediation of Beijing's international engagement and global involvement discourses. Unlike CDA which often foregrounds the negative themes (e.g. injustice, oppression, dominance, and hegemony), an innovative corpus-based positive discourse analysis (PDA) is introduced and applied, drawing on 20 years of China's press conferences. This article points to the interpreters' visibility and agency in facilitating and strengthening China's discourse through (over)producing core lexical items and salient collocational patterns. Following the trends of interdisciplinarity and digital humanities, this corpus-based PDA study illustrates ultimately how a major non-Western developing country from the global South communicates its discourse bilingually in front of the international community. The potential impact and implications of the interpreter-in(tro)duced discursive changes are discussed vis-à-vis the ever shifting and delicate East-West power balance from the perspective of (geo)politics.

Social inequalities in male cancer in a metropolis in the Southeast region of Brazil / Desigualdades sociais em câncer no sexo masculino em uma metrópole da região Sudeste do Brasil

ABSTRACT OBJECTIVE To analyze inequalities in incidence, mortality, and estimated survival for neoplasms in men according to social vulnerability. METHODS Analysis of cases and deaths of all neoplasms and the five most common in men aged 30 years or older in the city of Campinas (SP), between 2010 and 2014, using data from the Population-Based Cancer Registry (RCBP) and the Mortality Information System (SIM). The areas of residence were grouped into five social vulnerability strata (SVS) using São Paulo Social Vulnerability Index. For each SVS, age-standardized incidence and mortality rates were calculated. A five-year survival proxy was calculated by complementing the ratio of the mortality rate to the incidence rate. Inequalities between strata were measured by the ratios between rates, the relative inequality index (RII) and the angular inequality index (AII). RESULTS RII revealed that the incidence of all neoplasms (0.66, 95%CI 0.62-0.69) and colorectal and lung cancers were lower among the most socially vulnerable, who presented a higher incidence of stomach and oral cavity cancer. Mortality rates for stomach, oral cavity, prostate and all types of cancer were higher in the most vulnerable segments, with no differences in mortality for colorectal and lung cancer. Survival was lower in the most social vulnerable stratum for all types of cancer studied. AII showed excess cases in the least vulnerable and deaths in the most vulnerable. Social inequalities were different depending on the tumor location and the indicator analyzed. CONCLUSION There is a trend of reversal of inequalities between incidence-mortality and incidence-survival, and the most social vulnerable segment presents lower survival rates for the types of cancer, pointing to the existence of inequality in access to early diagnosis and effective and timely treatment.

RESUMO OBJETIVO Analisar as desigualdades segundo a vulnerabilidade social na incidência, mortalidade e estimativa de sobrevida de neoplasias no sexo masculino. MÉTODOS Foram analisados os casos e as mortes do total de neoplasias e das cinco mais incidentes em homens com 30 anos ou mais no município de Campinas (SP), entre 2010 e 2014, utilizando dados do Registro de Câncer de Base Populacional (RCBP) e do Sistema de Informação sobre Mortalidade (SIM). As áreas de residência foram agrupadas em cinco estratos de vulnerabilidade social (EVS) utilizando o Índice Paulista de Vulnerabilidade Social. Para cada EVS, foram calculadas as taxas de incidência e de mortalidade padronizadas por idade. Um proxy de sobrevida em cinco anos foi calculado pelo complemento da razão da taxa de mortalidade pela taxa de incidência. As desigualdades entre os estratos foram mensuradas pelas razões entre taxas, pelo índice relativo de desigualdade (IRD) e pelo índice angular de desigualdade. RESULTADOS O IRD revelou que a incidência do total de neoplasias (0,66, IC95% 0,62-0,69) e dos cânceres colorretal e de pulmão foram menores entre os socialmente mais vulneráveis, que apresentaram maior incidência dos cânceres de estômago e da cavidade oral. As taxas de mortalidade por câncer de estômago, cavidade oral, próstata e por todas as neoplasias foram superiores nos segmentos mais vulneráveis, sem diferenças na mortalidade por câncer colorretal e de pulmão. A sobrevida foi menor no estrato de maior vulnerabilidade social para todos os cânceres estudados. O índice angular de desigualdade (IAD) mostrou o excesso de casos nos menos vulneráveis e de óbitos nos mais vulneráveis. As desigualdades sociais revelaram-se distintas conforme a localização do tumor e o indicador analisado. CONCLUSÃO Constata-se uma tendência de inversão das desigualdades entre incidência e mortalidade e sobrevida, sendo esta última desfavorável ao segmento de maior vulnerabilidade social para os tipos de câncer, apontando a existência de inequidade no acesso ao diagnóstico precoce e ao tratamento efetivo e oportuno.

No major cost of evolved survivorship in Drosophila melanogaster populations coevolving with Pseudomonas entomophila.

Rapid exaggeration of host and pathogen traits via arms race dynamics is one possible outcome of host-pathogen coevolution. However, the exaggerated traits are expected to incur costs in terms of resource investment in other life-history traits. The current study investigated the costs associated with evolved traits in a host-pathogen coevolution system. We used the Drosophila melanogaster (host)-Pseudomonas entomophila (pathogen) system to experimentally derive two selection regimes, one where the host and pathogen both coevolved, and the other, where only the host evolved against a non-evolving pathogen. After 17 generations of selection, we found that hosts from both selected populations had better post-infection survivorship than controls. Even though the coevolving populations tended to have better survivorship post-infection, we found no clear evidence that the two selection regimes were significantly different from each other. There was weak evidence for the coevolving pathogens being more virulent than the ancestral pathogen. We found no major cost of increased post-infection survivorship. The costs were not different between the coevolving hosts and the hosts evolving against a non-evolving pathogen. We found no evolved costs in the coevolving pathogens. Thus, our results suggest that increased host immunity and pathogen virulence may not be costly.

Impacto da radioterapia adjuvante na sobrevida global e sobrevida livre de doença em pacientes do INCA / Impact of adjuvant radiotherapy on global survival and disease-free survival on INCA patients

Introdução: O câncer de mama é considerado o câncer com maior incidência e prevalência no sexo feminino e a sobrevida em países latino-americanos em geral encontra-se, em média, 20% abaixo daquela em países europeus e nos EUA. E dentre algumas das opções terapêuticas se encontra a radioterapia adjuvante com o objetivo de erradicar quaisquer depósitos tumorais remanescentes após a cirurgia para pacientes tratados por cirurgia conservadora da mama ou mastectomia. Alguns ensaios clínicos randomizados indicam um possível "efeito abscopal" em que a adição de radioterapia a cirurgia também pode reduzir o risco de recorrências distantes, diminuindo assim a mortalidade específica do câncer de mama. Objetivo: Analisar a incidência de recidiva, metástase e óbito, além de estimativa de sobrevida livre de doença e sobrevida global de acordo com a realização ou não de radioterapia adjuvante Método: Estudo do tipo coorte retrospectiva em mulheres com diagnóstico de câncer de mama no HCIII / INCA, no período de 2006 a 2010, do estádio I ao III e que foram submetidas a radioterapia adjuvante sendo realizado coleta de dados no Cadastro de Registro Hospitalar de Câncer do HCIII/INCA, complementadas por busca ativa nos prontuários físicos e eletrônicos, além de um instrumento de coleta de dados que foi elaborado exclusivamente para este estudo. Características sócio demográficas (idade do diagnostico, sexo, raça, escolaridade e estado civil), variáveis relacionadas ao tumor primário (data do diagnóstico, tipo histológico, estadiamento, status axilar, grau histológico, imunohistoquímica e terapia aplicadas) e evolução da doença (metástases, óbito e sobrevida global) foram avaliadas. Resultados: A população do estudo compreendeu 1771 mulheres. Nos estadiamentos iniciais (I a IIA) foram encontradas 964 mulheres (54,4%) e 807 (45,6%), em estadiamentos avançados (IIB ­ III). O tipo histológico mais prevalente foi carcinoma ductal infiltrante, em 81,3% das pacientes avaliadas e o subtipo molecular mais frequente foi luminal A, correspondendo a 65,3% das pacientes e o segundo mais frequente foi o triplo negativo com 12,9%. O grau histológico mais frequente foi grau 3, com 668 das pacientes (50,4%). Sobre os tratamentos concomitantes, no grupo que foi submetido a radioterapia, 35,5% foram submetidas também a quimioterapia neoadjuvante, 44% a quimioterapia adjuvante e 73,6% a hormonioterapia adjuvante. 27,4% não realizaram qualquer tipo de quimioterapia. Quanto ao tratamento cirúrgico da mama nas pacientes que realizaram radioterapia adjuvante, 65,5% foram submetidas à mastectomia e 34,5% a segmentectomia e em relação a abordagem axilar, 25,1% foram submetidas a biópsia do linfonodo sentinela e 60,4% fizeram linfadenectomia axilar. Considerando recidiva ou metástase, foi encontrado 29% nas que realizaram radioterapia adjuvante, e 22,9 % nas que não realizaram o procedimento. Em relação aos óbitos, relacionado ou não a evolução do câncer, foi encontrada taxa de 29,3% tanto nas que fizeram, como nas que não foram submetidas a radioterapia adjuvante. Para as pacientes que realizaram radioterapia adjuvante a média de sobrevida livre doença foi de cerca de 94 meses e sobrevida global de cerca de 100 meses, já em pacientes que não foram submetidas ao mesmo procedimento, a média de sobrevida livre de doença foi de cerca de 98 meses e sobrevida global em cerca de 100 meses. Conclusão: A radioterapia adjuvante já é tratamento bem estabelecido no cenário do câncer de mama, e a possibilidade de um efeito "abscopal" interferir positivamente na história natural da doença melhorando sobrevida livre de doença e sobrevida global não foi encontrada na avaliação dos nossos dados, bem como, não houve diferença na comparação dos dados em relação a presença de recidivas ou metástases em pacientes que realizaram ou não o procedimento.

Introduction: Breast cancer is considered the cancer with the highest incidence and prevalence in females and survival in Latin American countries is, on average, 20% lower than in European countries and the USA. And among some of the therapeutic options is adjuvant radiotherapy with the aim of eradicating any tumor deposits remaining after surgery for patients treated by breast-conserving surgery or mastectomy. Some RCTs indicate a possible "abscopal effect" in which the addition of radiotherapy to surgery may also reduce the risk of distant recurrences, thus decreasing breast cancer-specific mortality. Objective: To analyze the incidence of recurrence, metastasis and death, in addition to estimating disease-free survival and overall survival according to whether or not adjuvant radiotherapy was performed Method: Retrospective cohort study in women diagnosed with breast cancer at HCIII/ INCA, in the period from 2006 to 2010, from stages I to III and who underwent adjuvant radiotherapy, with data collection being carried out in the Hospital Registry of Cancer of the HCIII/INCA, complemented by an active search in the physical and electronic records, in addition to of a data collection instrument that was designed exclusively for this study. Sociodemographic characteristics (age at diagnosis, sex, race, education and marital status), variables related to the primary tumor (date of diagnosis, histological type, staging, axillary status, histological grade, immunohistochemistry and therapy applied), and disease evolution ( metastases, death and overall survival) were evaluated. Results: The study population comprised 1771 women. In the initial stages (I to IIA), 964 women (54.4%) were found and 807 (45.6%) were in advanced stages (IIB ­ III). The most prevalent histological type was infiltrating ductal carcinoma, in 81.3% of the patients evaluated and the most frequent molecular subtype was luminal A, corresponding to 65.3% of the patients and the second most frequent was triple negative with 12.9% . The most frequent histological grade was grade 3, with 668 of the patients (50.4%). Regarding concomitant treatments, in the group that underwent radiotherapy, 35.5% were also submitted to neoadjuvant chemotherapy, 44% to adjuvant chemotherapy and 73.6% to adjuvant hormone therapy. 27.4% did not undergo any type of chemotherapy. Regarding the surgical treatment of the breast in patients who underwent adjuvant radiotherapy, 65.5% underwent mastectomy and 34.5% segmentectomy and in relation to the axillary approach, 25.1% underwent sentinel lymph node biopsy and 60.4 % underwent axillary lymphadenectomy. Considering recurrence or metastasis, 29% were found in those who underwent adjuvant radiotherapy, and 22.9% in those who did not undergo the procedure. Regarding deaths, related or not to the evolution of cancer, a rate of 29.3% was found both in those who underwent and in those who did not undergo adjuvant radiotherapy. For patients who underwent adjuvant radiotherapy, the mean disease-free survival was about 94 months and overall survival was about 100 months, whereas in patients who did not undergo the same procedure, the mean disease-free survival was about 100 months. 98 months and overall survival of about 100 months. Conclusion: Adjuvant radiotherapy is already a well-established treatment in the breast cancer scenario, and the possibility of an "abscopal" effect positively interfering with the natural history of the disease, improving disease-free survival and overall survival was not found in the evaluation of our data, as well as, there was no difference in the comparison of data regarding the presence of recurrences or metastases in patients who underwent the procedure or not

Description of a Lung Cancer Hotspot: Disparities in Lung Cancer Histology, Incidence, and Survival in Kentucky and Appalachian Kentucky.

INTRODUCTION: Kentucky is recognized as the state with the highest lung cancer burden for more than 2 decades, but how lung cancer differs in Kentucky relative to other US populations is not fully understood. PATIENTS AND METHODS: We examined lung cancer reported to the Surveillance, Epidemiology, and End Results (SEER) Program by Kentucky and the other SEER regions for patients diagnosed between 2012 and 2016. Our analyses included histologic types, incidence rates, stage at diagnosis, and survival in Kentucky and Appalachian Kentucky relative to other SEER regions. RESULTS: We found that both squamous cell carcinomas and small-cell lung cancers represent larger proportions of lung cancer diagnoses in Kentucky and Appalachian Kentucky than they do in the SEER registries. Furthermore, age-adjusted cancer incidence rates were higher in Kentucky for every subtype of lung cancer examined. Most notably, for Appalachian women the rate of small-cell carcinomas was 3.5-fold higher, and for Appalachian men the rate of squamous cell carcinoma was 3.1-fold higher, than the SEER rates. In Kentucky, lung cancers were diagnosed at later stages and lung cancer survival was lower for adenocarcinoma and neuroendocrine carcinomas than in SEER registries. Squamous cell carcinomas and small-cell carcinomas were most lethal in Appalachian Kentucky. CONCLUSION: Together, these data highlight the considerable disparities among lung cancer cases in the United States and demonstrate the continuing high burden and poor survival of lung cancer in Kentucky and Appalachian Kentucky. Strategies to identify and rectify causes of these disparities are discussed.

Cost-effectiveness of nivolumab in advanced melanoma: a drug review.

Introduction: The immune checkpoint inhibitors, including nivolumab, and targeted agents have dramatically improved the outcome for patients with unresectable advanced melanoma. Areas covered: This is a narrative review of the published evidence on nivolumab in metastatic melanoma. Expert opinion: In ipilimumab pre-treated patients (CheckMate 037), nivolumab was associated with a higher response rate and a longer duration of response when compared to chemotherapy. In previously untreated patients, nivolumab improves survival when compared to chemotherapy (CheckMate 066) or to ipilimumab (CheckMate 067). The combination of nivolumab and ipilimumab also improves survival when compared to ipilimumab (CheckMate 067). CheckMate 067 was not designed to compare the nivolumab-ipilimumab combination to nivolumab alone. A modified regimen using a lower dose of ipilimumab in combination with standard dose nivolumab is better tolerated than nivolumab in combination with standard dose ipilimumab (CheckMate 511). In patients with previously untreated metastatic melanoma, the anti-PD-1 monoclonal antibodies nivolumab and pembrolizumab improve survival when compared to ipilimumab. Nivolumab is equally active in BRAF mutated and BRAF wild type melanoma. The optimal sequence of checkpoint inhibitors and BRAF/MEK inhibitors in BRAF mutated patients has not been established.

Necessidades Físicas, Emocionais e Socioeconômicas no Pós-tratamento do Câncer de Cabeça e Pescoço: um Estudo Qualitativo / Physical, Emotional and Socioeconomic Needs in the Post-Treatment of Head and Neck Cancer: a Qualitative Study / 2Necesidades Físicas, Emocionales y Socioeconómicas en el Postratamiento del Cáncer de Cabeza y Cuello: un Estudio Cualitativo

Introdução: Os pacientes com câncer de cabeça e pescoço constituem um grupo com necessidades complexas pouco estudadas na fase de pós-tratamento. Objetivo: Compreender a experiência e as necessidades da fase de sobrevivência ao câncer de cabeça e pescoço a partir da perspectiva dos próprios pacientes, seus familiares, e profissionais de saúde de serviços de oncologia. Método: Pesquisa qualitativa, exploratória descritiva, tendo como referencial metodológico a hermenêutica-dialética. Adotaram-se, como técnicas de produção de dados, a entrevista semiestruturada e o grupo focal. Resultados: O material empírico foi organizado em três categorias de necessidades físicas, emocionais e socioeconômicas e estruturado em três abrangentes sentidos envolvendo as consequências do impacto biológico, psíquico e socioeconômico da doença e seu tratamento. Destacam-se, para o primeiro, os aspectos relativos às adaptações do hábito alimentar, comunicação e manejo dos efeitos do tratamento; o apoio emocional para pacientes e familiares no segundo; e as informações sobre benefícios sociais para o terceiro. Conclusão: As necessidades físicas, emocionais e socioeconômicas da doença e seu tratamento se entrelaçam para formar uma complexa rede de desafios para as políticas públicas de controle do câncer no Brasil

Introduction: Head and neck cancer patients are a group with complex needs barely studied in the post-treatment phase. Objective: To understand the experience and needs of the head and neck cancer survival phase from the perspective of the patients themselves, their families, and health professionals from oncology services. Method: Qualitative, exploratory, and descriptive study, using the hermeneutic-dialectic methodological framework. Semi-structured interviews and focus group were adopted as data production techniques. Results: The empirical material was organized into three categories of needs physical, emotional and socioeconomic and structured in three broad senses involving the consequences of the biological, psychological, and socioeconomic impact of the disease and its treatment. The aspects related to the adaptations of eating habits, communication and management of the treatment effects stand out for the first; emotional support for patients and families in the second, and information about social benefits for the third impact. Conclusion: The physical, emotional, and socioeconomic needs of the disease and its treatment are intertwined to form a complex network of challenges for public cancer control policies in Brazil

Introducción: Los pacientes con cáncer de cabeza y cuello son un grupo con necesidades complejas poco estudiadas en la fase postratamiento. Objetivo: Conocer la experiencia y necesidades de la fase de supervivencia del cáncer de cabeza y cuello desde la perspectiva de los propios pacientes, sus familias y los profesionales sanitarios de los servicios de oncología. Método: Investigación cualitativa, exploratoria y descriptiva, utilizando el marco metodológico hermenéutico-dialéctico. Se adoptaron las entrevistas semiestructuradas y el grupo focal como técnicas de producción de datos. Resultados: El material empírico se organizó en tres categorías de necesidades físicas, emocionales y socioeconómicas y estructurado en tres amplios sentidos que involucran las consecuencias del impacto biológico, psicológico y socioeconómico de la enfermedad y su tratamiento. Los aspectos relacionados con la adaptación de los hábitos alimentarios, la comunicación y el manejo de los efectos del tratamiento destacan por el primero; apoyo emocional a pacientes y familiares en el segundo; e información sobre beneficios sociales para el tercero. Conclusión: Las necesidades físicas, emocionales y socioeconómicas de la enfermedad y su tratamiento se entrelazan para formar una compleja red de desafíos para las políticas públicas de control del cáncer en Brasil

Practical Guidance for Including Future Costs in Economic Evaluations in The Netherlands: Introducing and Applying PAID 3.0.

OBJECTIVES: A consensus has been reached in The Netherlands that all future medical costs should be included in economic evaluations. Furthermore, internationally, there is the recognition that in countries that adopt a societal perspective estimates of future nonmedical consumption are relevant for decision makers as much as production gains are. The aims of this paper are twofold: (1) to update the tool Practical Application to Include Future Disease Costs (PAID 1.1), based on 2013 data, for the estimation of future unrelated medical costs and introduce future nonmedical consumption costs, further standardizing and facilitating the inclusion of future costs; and (2) to demonstrate how to use the tool in practice, showing the impact of including future unrelated medical costs and future nonmedical consumption in a case-study where a life is hypothetically saved at different ages and 2 additional cases where published studies are updated by including future costs. METHODS: Using the latest published cost of illness data from the year 2017, we model future unrelated medical costs as a function of age, sex, and time to death, which varies per disease. The Household Survey from Centraal Bureau Statistiek is used to estimate future nonmedical consumption by age. RESULTS: The updated incremental cost-effectiveness ratios (ICERs) from the case studies show that including future costs can have a substantial effect on the ICER, possibly affecting choices made by decision makers. CONCLUSION: This article improves upon previous work and provides the first tool for the inclusion of future nonmedical consumption in The Netherlands.

Assessment of Studies Evaluating Incremental Costs, Effectiveness, or Cost-Effectiveness of Systemic Therapies in Breast Cancer Based on Claims Data: A Systematic Review.

OBJECTIVES: Large secondary databases, such as those containing insurance claims data, are increasingly being used to compare the effects and costs of treatments in routine clinical practice. Despite their appeal, however, caution must be exercised when using these data. In this study, we aimed to identify and assess the methodological quality of studies that used claims data to compare the effectiveness, costs, or cost-effectiveness of systemic therapies for breast cancer. METHODS: We searched Embase, the Cochrane Library, Medline, Web of Science, and Google Scholar for English-language publications and assessed the methodological quality using the Good Research for Comparative Effectiveness principles. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42018103992. RESULTS: We identified 1251 articles, of which 106 met the inclusion criteria. Most studies were conducted in the United States (74%) and Taiwan (9%) and were based on claims data sets (35%) or claims data linked to cancer registries (58%). Furthermore, most included large samples (mean 17 130 patients) and elderly patients, and they covered various outcomes (eg, survival, adverse events, resource use, and costs). Key methodological shortcomings were the lack of information on relevant confounders, the risk of immortal time bias, and the lack of information on the validity of outcomes. Only a few studies performed sensitivity analyses. CONCLUSIONS: Many comparative studies of cost, effectiveness, and cost-effectiveness have been published in recent decades based on claims data, and the number of publications has increased over time. Despite the availability of guidelines to improve quality, methodological issues persist and are often inappropriately addressed or reported.

All Children Thrive: Integration of Nutrition and Early Childhood Development.

Building on the successes of child survival, we review the evidence needed to ensure both that children who survive also thrive and that recommendations promote equity, with no child left behind. To illustrate the critical roles played by nutrition and child development, we revise the Conceptual Framework for the Causes of Malnutrition and Death and the Nurturing Care Framework to create the Conceptual Framework of All Children Surviving and Thriving. The revised framework highlights the goals of child growth and development, supported by health, nutrition, learning, responsive caregiving, and security and safety. We review the challenges posed by undernutrition, stunting, micronutrient deficiencies, overweight, and children not reaching their developmental potential. Although integrated nutrition-childhood development interventions have shown promising effects, most have not been implemented at scale. Implementation science that investigates how and why integrated interventions work in real life, along with the acceptability, feasibility, cost, coverage, and sustainability of the interventions, is needed to ensure equity for all children thriving.

Assessment of the Levels of Oxidative Stress, Muscle Damage, and Psychomotor Abilities of Special Force Soldiers during Military Survival Training.

The aim of this study was to analyze the changes in biochemical markers of oxidative stress and muscle damage, as well as psychomotor abilities during a military survival training. The study included 15 soldiers of special unit (SU), that completed 48 h military survival training combined with sleep deprivation. Before the training (P1), after 24 h (P2), and after 48 h of training (P3), blood samples were taken to measure biochemical markers. At the same time points, the measurements of divided attention and handgrip strength were conducted. Glutathione peroxidase activity decreased significantly at P3, in comparison with P1 and P2 (p < 0.0001), however, no changes were observed in other biochemical markers (i.e., lipid hydroperoxides, creatine kinase and superoxide dismutase activity) throughout the survival training (p > 0.05). The divided attention index was improved significantly at P2 and P3, as compared to P1 (p < 0.05). A tendency to change in maximum strength was found during the training period (main time effect; p = 0.08). Moreover, the strength differentiation (i.e., 50% maximum strength; 50%max) was higher at P3 than at P1 and P2 (p < 0.05). In conclusion, the 48 h survival training in the SU soldiers does not cause oxidative stress or muscle tissue damage, as well as any deterioration, and even improvement in psychomotor abilities. However, the change in strength differentiation (i.e., the production above 60%max instead of target 50%max) after the training may point to deterioration in motor control. Although it should be confirmed in further study with a more numerous group of soldiers, our findings indicate that the special unit soldiers will be able to perform, in a correct manner, specialized tasks related to their long-term activities, especially those which require divided attention. However, participation in long-term survival training, even with low workload, combined with sleep deprivation, results in a deterioration in motor control which may indicate the relevance of monitoring coordination motor abilities/skills in the training process of special unit soldiers.

[Risk assessment and early predictors of survival after out-of-hospital cardiac arrest in the province of Trento, Italy]. / La valutazione del rischio e predittori precoci di sopravvivenza dopo arresto cardiaco extraospedaliero in provincia di Trento.

BACKGROUND: Early prognostication of patients experiencing out-of-hospital cardiac arrest (OHCA) remains difficult, with no recommended risk assessment tool. The aim of this study was to determine and assess the association between available variables with survival at discharge of patients with OHCA in our regional reality. METHODS: We conducted a retrospective observational study in a single-center cohort of 236 consecutive patients with OHCA and return of spontaneous circulation admitted to the S. Chiara Hospital (Trento, Italy) from 2012 to 2015. We applied a backward stepwise multivariable logistic regression performed on 26 variables significantly related to outcome to identify predictors. The final model was evaluated for discrimination with area under the curve (AUC) of a receiver operating characteristic curve and for calibration with Hosmer-Lemeshow test and with calibration belt. RESULTS: We identified four independent factors predictive of outcome: age, arterial blood pH, coronary angiography execution and intervention of helicopter. The final model presented good discrimination with an average AUC of 0.78 (95% confidence interval 0.72-0.84) and was well calibrated, as confirmed by the Hosmer-Lemeshow test (p=0.45) and the calibration belt plot (p=0.597). CONCLUSIONS: Age, arterial blood pH, coronary angiography execution and intervention of helicopter were variables predictive of outcome. Identified predictors are in agreement with the literature and relate to local reality. Accurate prognostic assessment would facilitate an earlier identification of patients who may benefit from intensive advanced post-resuscitation care.

Definitive-intent radiotherapy for sinonasal carcinoma in cats: A multicenter retrospective assessment.

Treatment of epithelial sinonasal tumours in cats is not commonly reported. In the newer reports, palliative radiation protocols have been described more often than definitive-intent protocols. In this multi-institutional retrospective study, we included 27 cats treated with single-modality radiotherapy. Cats were irradiated using 10 daily fractions of 4.2 Gy. Three cats (11.1%) experienced a complete clinical response and 17 (63%) had a partial clinical response. Stable clinical disease was noted in three cats (11.1%). Four cats (14.8%) showed progression within 3 months following treatment. The median time to progression for all cases was 269 days (95 % confidence intervals [CI]: 225; 314). The proportion of cats free of progression at 1 and 2 years was 24% (95% CI: 22%; 26%) and 5% (95% CI: 5%; 6%), respectively. None of the prognostic factors evaluated were predictive of outcome (anaemia, tumour volume at the time of staging, modified Adams stage, intracranial involvement, facial deformity, epistaxis, inappetence or weight loss). Median overall survival (OS) for all deaths was 452 days (95% CI: 334; 571). The proportion of cats alive at 1 and 2 years was 57% (95% CI: 37%; 77%) and 27% (95% CI: 25%; 29%), respectively. Surprisingly, cats with epistaxis had a longer median OS of 828 days (95% CI: 356; 1301) compared to 296 days (95% CI: 85; 508) in cats without epistaxis, (P = .04, Breslow). Radiation therapy used as a single modality for the treatment of feline sinonasal carcinoma improved clinical signs and was well tolerated but progression within a year was common.

Survival and costs of colorectal cancer treatment and effects of changing treatment strategies: a model approach.

New and emerging advances in colorectal cancer (CRC) treatment combined with limited healthcare resources highlight the need for detailed decision-analytic models to evaluate costs, survival and quality-adjusted life years. The objectives of this article were to estimate the expected lifetime treatment cost of CRC for an average 70-year-old patient and to test the applicability and flexibility of a model in predicting survival and costs of changing treatment scenarios. The analyses were based on a validated semi-Markov model using data from a Norwegian observational study (2049 CRC patients) to estimate transition probabilities and the proportion resected. In addition, inputs from the Norwegian Patient Registry, guidelines, literature, and expert opinions were used to estimate resource use. We found that the expected lifetime treatment cost for a 70-year-old CRC patient was €47,300 (CRC stage I €26,630, II €38,130, III €56,800, and IV €69,890). Altered use of palliative chemotherapy would increase the costs by up to 29%. A 5% point reduction in recurrence rate for stages I-III would reduce the costs by 5.3% and increase overall survival by 8.2 months. Given the Norwegian willingness to pay threshold per QALY gained, society's willingness to pay for interventions that could result in such a reduction was on average €28,540 per CRC patient. The life years gained by CRC treatment were 6.05 years. The overall CRC treatment costs appear to be low compared to the health gain, and the use of palliative chemotherapy can have a major impact on cost. The model was found to be flexible and applicable for estimating the cost and survival of several CRC treatment scenarios.

Providing Dignified Palliative Care Services in Liberia.

Background: Liberia faces a critical shortage of palliative care services, particularly for persons with advanced-stage HIV/AIDS, tuberculosis, diabetes, and cancers. Access to healthcare services is especially limited in rural areas, along with a lack of supportive social and economic resources. Home of Dignity (HoD) Health Center was established in 2013 in Yarbah's Town to fill a last-option palliative care gap. The mission emphasizes patient wellbeing and worth. HoD integrates health, agriculture, and education on-site for immediate medical needs, broader sustainable development, and reducing disease-associated stigma in local communities. Objective: We aimed to describe the Center's integrated approach and conduct a descriptive analysis of the HoD patient population. Methods: We reviewed patient characteristics (sex, age distribution, mobility status, and CD4 count on arrival) and outcomes (survival rate and community reintegration) for patients with HIV seeking care at the Center between 2013-2017. Findings: Of 182 patients (ages 3 months-50 years), over half arrived to the facility bedridden and over 82% had CD4 counts between <100-350. Of the 182 patients, 66% survived, 27% died, and 7% were lost to follow-up. Of surviving patients, 90% were successfully reintegrated into their communities. The clinic also served over 365 chronically ill patients that had been rejected by other health providers during the 2014-2015 Ebola outbreak. Conclusions: The Center is providing last-option palliative care services in the country. As a trusted healthcare center, patients also seek care for acute conditions, resulting in unanticipated resource demands. HoD's experience underscores the need for development of training programs for medical professionals, supply chains, community outreach, and resourcing channels to ensure adequate and sustainable service provision for hospice and palliative care services and reduce stigma in the country. There is an urgent need to invest in holistic palliative and overall healthcare services in Liberia.

Assessment of Survival of Pediatric Patients With Hepatoblastoma Who Received Chemotherapy Following Liver Transplant or Liver Resection.

Importance: The incidence of hepatoblastoma is increasing, and liver transplant (LT) provides a potential cure for pediatric patients with unresectable hepatoblastoma; however, the use of LT for hepatoblastoma has not been examined in a modern cohort. Moreover, data are lacking on the association between the type of surgical management received and overall risk of death among pediatric patients with hepatoblastoma. Objectives: To examine the receipt of LT among pediatric patients with hepatoblastoma and to assess overall survival of pediatric patients with hepatoblastoma who were treated with chemotherapy after LT or liver resection (LR) using data from a national cancer registry. Design, Setting, and Participants: This cohort study used data for 443 pediatric patients with histologically confirmed hepatoblastoma who received chemotherapy and surgical therapies, as documented in the Surveillance, Epidemiology, and End Results database of the National Cancer Institute, from 2004 to 2016, with follow-up through December 31, 2018. Multivariable logistic regression was used to determine factors associated with the use of LT. Cox proportional hazards models were used to assess factors associated with overall survival. Data analysis was performed from April 18, 2019, to July 25, 2019. Main Outcomes and Measures: Overall survival. Results: Among 443 patients receiving chemotherapy (mean [SD] age, 1.8 [2.6] years; 167 [37.7%] female), 350 (79%) underwent LR and 93 (21%) underwent LT. Multivariable analysis showed that patients with multiple lesions were more likely to undergo LT than LR (31% vs 13%; P < .001) and that patients with higher stage tumors were more likely to undergo LT than LR (local disease, 20% vs 58%; regional disease, 58% vs 24%; distant disease, 22% vs 18%; P < .001). There was a statistically significant 19% increase in the receipt of LT from 8% in 1998 to 27% 2016 (trend test, P = .02). Overall survival at 10 years was not significantly different for the 2 surgical management strategies (87.2% [95% CI, 78.3%-97.1%] for patients undergoing LT vs 87.8% [95% CI, 83.5%-92.4%] for those undergoing LR; P = .92). The overall risk of death was not significantly different for LT compared with LR (hazard ratio, 0.716; 95% CI, 0.309-1.657; P = .44). Conclusions and Relevance: The use of LT for the management of hepatoblastoma has increased significantly over time. Among pediatric patients with hepatoblastoma receiving chemotherapy, LT was not associated with improved overall survival compared with LR. There was no significant different between treatments with regard to the outcome variable, but this finding cannot be interpreted as indicating equivalence or lack of superiority.