Evaluation of factors predicting the benefit from systemic oncological treatment for severely ill hospitalized patients: a retrospective study.

BACKGROUND: Patients with cancer in the disease's end-stage with poor performance represent a challenging clinical scenario, as they have high chance of a fatal outcome due to clinical conditions, oncological emergencies, and/or metastatic disease. This study examines the factors predicting the potential benefit of "urgent" chemotherapy during hospitalization in this setting, thus addressing a research gap. METHODS: This retrospective observational study was conducted in the largest cancer center in the outskirts of São Paulo. It identified factors predicting the benefit from antineoplastic treatment in severe in-hospital patients admitted during 2019-2020, considering post-chemotherapy survival time as the main dependent variable. Data were retrieved from medical records. All patients aged ≥ 18 years, with an ECOG-PS score ≥ 2, and undergoing non-elective systemic cancer treatment were included. RESULTS: This study evaluated 204 records, of which 89 were included in the final analysis. A statistically significant association with the worse outcome (death within 30 days of chemotherapy) was found with higher ECOG performance status; chemotherapy dose reduction; lower values of serum albumin, hemoglobin, and creatinine clearance; and higher values of leukocytes, neutrophils, direct bilirubin, urea, and C-reactive protein. In the multivariate analysis, only albumin remained statistically associated with the outcome (hazard ratio = 0.35; confidence interval: 0.14, 0.90; p = 0.034). CONCLUSIONS: Serum albumin and other clinical and laboratory variables might be associated with early post-treatment deaths in patients with cancer. The study data might help guide the decision to administer systemic treatment in this scenario and manage critically ill patients. This study adds to our knowledge of the factors predicting the objective benefits from "heroic" or "urgent" chemotherapy for hospitalized and severely ill patients with cancer.

Malignant pericardial effusion as a primary manifestation of metastatic colon cancer: a case report.

BACKGROUND: Pericardial neoplastic involvement is rarely related to primary tumors of the pericardium and is most often caused by spread from other primary sites, such as lung and breast carcinomas, hematological malignancies (lymphoma and leukemia), and melanoma. Although pericardial metastasis from infradiaphragmatic tumors (such as colon cancers) are rare and poorly described in literature, any neoplasm has the potential to metastasize to the pericardium and heart by either contiguity, lymphatic, or hematological spread. CASE PRESENTATION: A 44-year-old previously healthy male Causasian patient had a sudden onset of dyspnea and wheezing. During investigation with echocardiogram, computed tomography and repeated pericardiocentesis, the cause of malignant pericardial effusion was confirmed as primary manifestation of metastatic colon cancer. The patient was treated with appropriate chemotherapy and presented satisfactory disease control. CONCLUSIONS: This report emphasizes the importance of considering the diagnostic hypothesis of occult neoplasia in a patient with pericardial effusion.

The role of the radiologist in the assessment of thoracic changes after radiotherapy.

Radiotherapy plays a central role in the palliative and curative treatment of neoplasms of the chest wall or intrathoracic structures. However, despite technical advances, radiotherapy can alter previously normal organs and tissues, those alterations presenting as various types of imaging findings. Post-radiation alterations must be promptly recognized by radiologists, in order to avoid confusion between complications of radiotherapy and the recurrence of a tumor. This pictorial essay aims to illustrate different thoracic changes after radiotherapy.

A radioterapia tem papel fundamental no tratamento curativo ou paliativo de neoplasias da parede torácica ou intratorácicas. No entanto, mesmo com o avanço das técnicas, órgãos e tecidos vizinhos podem ser acometidos e apresentar alterações que devem ser reconhecidas pelos radiologistas, de maneira a evitar confusão com recidiva das lesões inicialmente tratadas, ou mesmo com outras complicações do tratamento oncológico. O objetivo deste ensaio iconográfico é ilustrar as diferentes consequências torácicas da radioterapia.

Staging liver fibrosis after severe yellow fever with ultrasound elastography in Brazil: A six-month follow-up study.

BACKGROUND: Yellow fever (YF) is a hemorrhagic disease caused by an arbovirus endemic in South America, with recent outbreaks in the last years. Severe cases exhibit fulminant hepatitis, but there are no studies regarding its late-term effects on liver parenchyma. Thus, the aim of this study was to determine the frequency and grade of liver fibrosis in patients who recovered from severe YF and to point out potential predictors of this outcome. METHODOLOGY/PRINCIPAL FINDINGS: We followed-up 18 patients who survived severe YF during a recent outbreak (January-April 2018) in Brazil using ultrasound (US) with shear-wave elastography (SWE) at 6 months after symptoms onset. No patient had previous history of liver disease. Median liver stiffness (LS) was 5.3 (4.6-6.4) kPa. 2 (11.1%) patients were classified as Metavir F2, 1 (8.3%) as F3 and 1 (8.3%) as F4; these two last patients had features of cardiogenic liver congestion on Doppler analysis. Age and cardiac failure were associated with increased LS (p = 0.036 and p = 0.024, respectively). SAPS-3 at ICU admission showed a tendency of association with significant fibrosis (≥ F2; p = 0.053). 7 patients used sofosbuvir in a research protocol, of which none showed liver fibrosis (p = 0.119). CONCLUSIONS/SIGNIFICANCE: We found a low frequency of liver fibrosis in severe YF survivors. US with SWE may have a role in the follow up of patients of age and / or with comorbidities after hospital discharge in severe YF, a rare but reemergent disease.

Arteriopathy in pediatric stroke: an underestimated clinical entity.

BACKGROUND: Pediatric arterial ischemic stroke (AIS), which was thought to be a rare disorder, is being increasingly recognized as an important cause of neurological morbidity, thanks to new advances in neuroimaging. OBJECTIVE: The aim of this study was to review the main etiologies of stroke due to arteriopathy in children. METHODS: Using a series of cases from our institution, we addressed its epidemiological aspects, physiopathology, imaging findings from CT, MR angiography, MR conventional sequences and MR DWI, and nuclear medicine findings. RESULTS: Through discussion of the most recent classification for childhood AIS (Childhood AIS Standardized Classification and Diagnostic Evaluation, CASCADE), we propose a modified classification based on the anatomical site of disease, which includes vasculitis, varicella, arterial dissection, moyamoya, fibromuscular dysplasia, Takayasu's arteritis and genetic causes (such as ACTA-2 mutation, PHACE syndrome and ADA-2 deficiency). We have detailed each of these separately. Conclusions: Prompt recognition of AIS and thorough investigation for potential risk factors are crucial for a better outcome. In this scenario, neurovascular imaging plays an important role in diagnosing AIS and identifying children at high risk of recurrent stroke.

Arteriopathy in pediatric stroke: an underestimated clinical entity / Arteriopatia em crianças com acidente vascular cerebral: uma entidade clínica subestimada

ABSTRACT Background: Pediatric arterial ischemic stroke (AIS), which was thought to be a rare disorder, is being increasingly recognized as an important cause of neurological morbidity, thanks to new advances in neuroimaging. Objective: The aim of this study was to review the main etiologies of stroke due to arteriopathy in children. Methods: Using a series of cases from our institution, we addressed its epidemiological aspects, physiopathology, imaging findings from CT, MR angiography, MR conventional sequences and MR DWI, and nuclear medicine findings. Results: Through discussion of the most recent classification for childhood AIS (Childhood AIS Standardized Classification and Diagnostic Evaluation, CASCADE), we propose a modified classification based on the anatomical site of disease, which includes vasculitis, varicella, arterial dissection, moyamoya, fibromuscular dysplasia, Takayasu's arteritis and genetic causes (such as ACTA-2 mutation, PHACE syndrome and ADA-2 deficiency). We have detailed each of these separately. Conclusions: Prompt recognition of AIS and thorough investigation for potential risk factors are crucial for a better outcome. In this scenario, neurovascular imaging plays an important role in diagnosing AIS and identifying children at high risk of recurrent stroke.

RESUMO Introdução: O acidente vascular cerebral (AVC) pediátrico, considerado um distúrbio raro, está sendo cada vez mais reconhecido como importante causa de morbidade neurológica, graças aos novos avanços na neuroimagem. Objetivo: Revisar as principais etiologias do AVC por arteriopatia em crianças. Métodos: Utilizando-se de uma série de casos de nossa instituição, abordamos seus aspectos epidemiológicos, fisiopatológicos e de imagem na angiotomografia computadorizada e angiorressonância magnética, sequências convencionais e avançadas de ressonância magnética e medicina nuclear. Resultados: Com base na classificação mais recente de AVC na infância (Classificação Padronizada e Avaliação Diagnóstica do AVC na Infância - CASCADE) propusemos uma classificação modificada com base no local anatômico da doença, que inclui vasculite, varicela, dissecção arterial, Moyamoya, displasia fibromuscular, arterite de Takayasu e causas genéticas (como mutação ACTA-2, síndrome PHACE e deficiência de ADA-2), detalhando cada uma separadamente. Conclusões: O reconhecimento imediato do AVC na infância e a investigação minuciosa de possíveis fatores de risco são cruciais para um melhor resultado. Nesse cenário, a imagem neurovascular desempenha papel importante no diagnóstico de AVC e na identificação de crianças com alto risco de recorrência.

Ultrasound Findings and Laboratory Predictors of Early Mortality in Patients With Severe Yellow Fever.

OBJECTIVE. Yellow fever is a hemorrhagic disease caused by an arbovirus endemic in South America; outbreaks have occurred in recent years. The purpose of this study was to describe abdominal ultrasound findings in patients with severe yellow fever and correlate them with clinical and laboratory data. MATERIALS AND METHODS. A retrospective cohort study was performed between January and April 2018. The subjects were patients admitted to an ICU with polymerase chain reaction-confirmed yellow fever. Bedside sonography was performed within 48 hours of admission. Images were independently analyzed by two board-certified radiologists. Laboratory test samples were collected within 12 hours of image acquisition. Multivariable logistic regression analysis was performed to identify 30-day mortality predictors; p < .05 was considered statistically significant. RESULTS. Forty-six patients (40 [87%] men, six [13%] women; mean age, 47.5 ± 15.2 years) were evaluated with bedside sonography. Laboratory tests showed high serum levels of aspartate aminotransferase (5319 U/L), total bilirubin (6.2 mg/dL), and creati-nine (4.3 mg/dL). Twenty-six (56.5%) patients died within 30 days of admission (median time to death, 5 days [interquartile range, 2-9 days]). The most frequent ultrasound findings were gallbladder wall thickening (80.4%), increased renal cortex echogenicity (71.7%), increased liver parenchyma echogenicity (65.2%), perirenal fluid (52.2%), and ascites (30.4%). Increased renal echogenicity was associated with 30-day mortality (84.6% versus 55.0%; p = .046) and was an independent predictor of this outcome after multivariate analysis (odds ratio, 10.89; p = .048). CONCLUSION. Reproducible abdominal ultrasound findings in patients with severe yellow fever may be associated with severity of disease and prognosis among patients treated in the ICU.

Imaging findings in COVID-19 pneumonia.

The coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city and was declared a pandemic in March 2020. Although the virus is not restricted to the lung parenchyma, the use of chest imaging in COVID-19 can be especially useful for patients with moderate to severe symptoms or comorbidities. This article aimed to demonstrate the chest imaging findings of COVID-19 on different modalities: chest radiography, computed tomography, and ultrasonography. In addition, it intended to review recommendations on imaging assessment of COVID-19 and to discuss the use of a structured chest computed tomography report. Chest radiography, despite being a low-cost and easily available method, has low sensitivity for screening patients. It can be useful in monitoring hospitalized patients, especially for the evaluation of complications such as pneumothorax and pleural effusion. Chest computed tomography, despite being highly sensitive, has a low specificity, and hence cannot replace the reference diagnostic test (reverse transcription polymerase chain reaction). To facilitate the confection and reduce the variability of radiological reports, some standardizations with structured reports have been proposed. Among the available classifications, it is possible to divide the radiological findings into typical, indeterminate, atypical, and negative findings. The structured report can also contain an estimate of the extent of lung involvement (e.g., more or less than 50% of the lung parenchyma). Pulmonary ultrasonography can also be an auxiliary method, especially for monitoring hospitalized patients in intensive care units, where transfer to a tomography scanner is difficult.

Imaging findings in COVID-19 pneumonia

The coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city and was declared a pandemic in March 2020. Although the virus is not restricted to the lung parenchyma, the use of chest imaging in COVID-19 can be especially useful for patients with moderate to severe symptoms or comorbidities. This article aimed to demonstrate the chest imaging findings of COVID-19 on different modalities: chest radiography, computed tomography, and ultrasonography. In addition, it intended to review recommendations on imaging assessment of COVID-19 and to discuss the use of a structured chest computed tomography report. Chest radiography, despite being a low-cost and easily available method, has low sensitivity for screening patients. It can be useful in monitoring hospitalized patients, especially for the evaluation of complications such as pneumothorax and pleural effusion. Chest computed tomography, despite being highly sensitive, has a low specificity, and hence cannot replace the reference diagnostic test (reverse transcription polymerase chain reaction). To facilitate the confection and reduce the variability of radiological reports, some standardizations with structured reports have been proposed. Among the available classifications, it is possible to divide the radiological findings into typical, indeterminate, atypical, and negative findings. The structured report can also contain an estimate of the extent of lung involvement (e.g., more or less than 50% of the lung parenchyma). Pulmonary ultrasonography can also be an auxiliary method, especially for monitoring hospitalized patients in intensive care units, where transfer to a tomography scanner is difficult.

Association of Tuberculosis Status with Neurologic Disease and Immune Response in HTLV-1 Infection.

The human T cell lymphotropic virus type 1 (HTLV-1) is the etiologic agent of HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). HTLV-1 infected individuals have increased susceptibility to Mycobacterium tuberculosis infection but the influence of tuberculosis (TB) on the course of HTLV-1 infection is unknown. The aim of this study was to evaluate the influence of TB on immunological, virologic, and neurologic features of HTLV-1 infection. This is a retrospective analysis of individuals enrolled in a cohort study from an HTLV-1 clinic who were evaluated for past or latent tuberculosis (LTB) and classified clinically as HTLV-1 carriers, probable HAM/TSP and definite HAM/TSP. Spontaneous cytokine production (interferon-gamma [IFN-γ], tumor necrosis factor [TNF], and interleukin[IL]-10), serum chemokines (CXCL9 and CXCL10) and HTLV-1 proviral load were evaluated. Of 172 participants, 64 did not have histories of TB (TB- group), 81 had LTB and 27 had TB in the past (TB+ group). In the TB+ group, there was a higher frequency of HAM/TSP patients (35%) than in HTLV-1 carriers (10%) (OR = 3.8, p = .0001). HAM/TSP patients with histories of TB had higher IFN-γ/IL-10 and TNF/IL-10 ratios when compared with HAM/TSP patients without histories of TB. There were no differences in serum chemokine production and proviral load across TB groups stratified on HTLV-1 clinical status. In conclusion, TB may influence the development of HAM/TSP, and patients with these two diseases have an impairment in the modulation of immune response.

Characteristics of training and motivation of physicians working in emergency medicine.

INTRODUCTION:: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. OBJECTIVE:: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. METHOD:: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. RESULTS:: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p<0.001). Thirteen percent said they were completely satisfied with the activity, while 81.3% expressed a desire to stop working in emergency units in the next 15 years, mentioning stress levels as the main reason. CONCLUSION:: The physicians interviewed had taken few emergency immersion courses. A low motivational level was registered in physicians who work in the emergency departments of medium and large hospitals in Salvador.

Characteristics of training and motivation of physicians working in emergency medicine

Summary Introduction: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. Objective: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. Method: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. Results: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p<0.001). Thirteen percent said they were completely satisfied with the activity, while 81.3% expressed a desire to stop working in emergency units in the next 15 years, mentioning stress levels as the main reason. Conclusion: The physicians interviewed had taken few emergency immersion courses. A low motivational level was registered in physicians who work in the emergency departments of medium and large hospitals in Salvador.

FOXP3 expression in papillary thyroid carcinoma with and without Hashimoto's thyroiditis / Expressão do FOXP3 no carcinoma papilífero da tireoide com e sem tireoidite de Hashimoto

INTRODUCTION: The forkhead box P3 (FOXP3) plays a role in cell development and control. In the presence of abnormal FOXP3 expression, tumor cells may evade the immunosurveillance of lymphoid cells, the first step for the maintenance of cancer cells in the thyroid tissue. OBJECTIVE: To identify the presence of FOXP3 in papillary thyroid carcinoma (PTC) with and without Hashimoto's Thyroiditis (HT). METHODS: We conducted a series study of cases collected from 2000 to 2008, when 1,438 thyroidectomies were performed. We selected those diagnosed with PTC, comprising 466 cases. 30 patients were randomly selected for purposes of immunohistochemistry with antibodies against FOXP3. RESULT: FOXP3 revealed high positivity for PTC and positive immunostaining was present in 21 (72.4%) from all analyzed cases. There was no difference regarding coexistent HT or not. DISCUSSION AND CONCLUSION: In the present study, it was evidenced that the focal or diffuse FOXP3 expression was commonly observed in neoplastic cells from PTC, hence indicating that the assessment of this molecule expression in suspected cases of thyroid cancer may contribute to its diagnosis.

INTRODUÇÃO: O forkhead box P3 (FOXP3) tem o seu papel no desenvolvimento e no controle celular. Na presença de alterações da sua expressão, células tumorais podem escapar da imunovigilância das células linfoides, sendo o primeiro passo para perpetuação das células cancerígenas no tecido tireoidiano. OBJETIVO: Identificar a presença do FOXP3 no carcinoma papilífero da tireoide (CPT), com e sem tireoidite de Hashimoto (TH). MÉTODOS: Foi realizado um estudo de série de casos coletados no período de 2000 a 2008, quando foram realizadas 1.438 tireoidectomias. Destes, foram selecionados aqueles que apresentaram diagnóstico de CPT, perfazendo um total de 466 casos. Desse total, 30 casos de CPT foram selecionados aleatoriamente para fins de exame imuno-histoquímico com o anticorpo contra o FOXP3. RESULTADO: O FOXP3 apresentou alta positividade no CPT; a marcação positiva na imuno-histoquímica esteve presente em 21 (72,4%) de todos os casos analisados. Não houve diferença com relação à coexistência ou não de TH. DISCUSSÃO E CONCLUSÃO: No presente estudo, foi documentado que a expressão difusa ou focal de FOXP3 foi intensamente observada nas células neoplásicas do CPT, indicando que a avaliação da expressão dessa molécula em casos suspeitos de neoplasia da tireoide pode contribuir para o seu diagnóstico.

Evaluation of atopy in patients with COPD.

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood.

Evaluation of atopy in patients with COPD / Avaliação de atopia em portadores de DPOC

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood. .

OBJETIVO: Determinar a prevalência de atopia e avaliar o perfil clínico, laboratorial e radiológico de pacientes com DPOC. MÉTODOS: Estudo de corte transversal com pacientes ambulatoriais portadores de DPOC estável (definida pela história clínica e relação VEF1/CVF < 70% do previsto após broncodilatador). Os pacientes responderam um questionário clínico e de atopia e foram submetidos a citologia de lavado nasal, teste cutâneo de alergia, radiografia de tórax, hemogasometria arterial e dosagem de IgE total. RESULTADOS: Dos 149 indivíduos avaliados, 53 (35,6%), 49 (32,8%) e 88 (59,1%), respectivamente, apresentavam eosinofilia no lavado nasal, teste cutâneo positivo e sintomas de rinite alérgica. A análise de correspondência confirmou esses achados, evidenciando dois perfis distintos de doença: a presença de atopia em pacientes com estágios mais leves de DPOC, e a ausência de características de atopia em pacientes com aspectos de doença mais grave (VEF1 reduzido e hiperinsuflação). Houve uma associação estatisticamente significante entre eosinofilia no lavado nasal e prova farmacodinâmica positiva. CONCLUSÕES: Este estudo identificou uma alta frequência de atopia em pacientes com DPOC, utilizando ferramentas simples e reprodutíveis. A monitorização inflamatória de vias aéreas parece ser uma ferramenta útil para avaliar as doenças respiratórias em idosos, assim como em pacientes com sobreposição de asma e DPOC, entidade clínica ainda pouco compreendida. .