Adherencia a la terapia antiplaquetaria y a las estatinas por pacientes con síndrome coronario agudo tras el alta / Adherence to antiplatelet and statin therapy by patients with acute coronary syndrome following discharge

Objetivo: Evaluar los niveles de adherencia a la terapia antiplaquetaria y a las estatinas por pacientes con síndrome coronario agudo (SCA) a los 30 días tras el alta hospitalaria e identificar las principales barreras y las principales variables sociodemográficas y clínicas asociadas con la adherencia al tratamiento.Método:Estudio longitudinal cuantitativo. Se incluyó a pacientes ingresados en un hospital con SCA. Inicialmente, la recolección de datos se realizó mediante una entrevista semiestructurada durante la estancia hospitalaria. A los 30 días tras el alta hospitalaria se aplicó el Brief Medication Questionnarie por teléfono, para evaluar la adherencia al tratamiento. Se utilizó estadística descriptiva y se aplicaron pruebas para analizar la asociación entre la adherencia a la medicación y los datos clínicos y sociodemográficos.Resultados: Ciento sesenta y dos pacientes fueron evaluados. El Brief Medication Questionnarie mostró que el 49,3% presentaba probable baja adherencia al tratamiento. El estado civil, el ingreso familiar y el consumo de alcohol tuvieron asociación con la adherencia a la medicación.Conclusiones: Los hallazgos del presente estudio indican altas tasas de probable falta de adherencia a la medicación por los pacientes con SCA a los 30 días tras el alta hospitalaria. Esta información podría ayudar a las enfermeras a elegir intervenciones específicas que puedan mejorar la adherencia en las rutinas diarias del paciente.

Objective: To assess levels of medication adherence to antiplatelet and statins therapy among acute coronary syndrome (ACS) patients 30 days after hospital discharge and identify the main barriers to medication adherence and the main sociodemographic and clinical variables associated with treatment adherence.Method: This was a quantitative longitudinal study. Patients admitted to hospital with ACS were included. Initially, data collection was conducted using a semi-structured interview during the hospital stay. Thirty days after hospital discharge, the Brief Medication Questionnaire was applied by phone to assess treatment adherence. Descriptive statistics were used and tests were applied to analyze the association between medication adherence and clinical and sociodemographic data.Results: One hundred and sixty-two patients were assessed. The Brief Medication Questionnaire test showed that 49.3% presented probable low adherence to treatment. Marital status, household income and alcohol intake showed an association with medication adherence.Conclusions: The findings of the present study indicate high rates of probable nonadherence to medication among ACS patients 30 days after hospital discharge, this information could help nurses to choose specific nursing interventions that could improve adherence in patients’ daily routines.

When Can Nonrandomized Studies Support Valid Inference Regarding Effectiveness or Safety of New Medical Treatments?

The randomized controlled trial (RCT) is the gold standard for evaluating the causal effects of medications. Limitations of RCTs have led to increasing interest in using real-world evidence (RWE) to augment RCT evidence and inform decision making on medications. Although RWE can be either randomized or nonrandomized, nonrandomized RWE can capitalize on the recent proliferation of large healthcare databases and can often answer questions that cannot be answered in randomized studies due to resource constraints. However, the results of nonrandomized studies are much more likely to be impacted by confounding bias, and the existence of unmeasured confounders can never be completely ruled out. Furthermore, nonrandomized studies require more complex design considerations which can sometimes result in design-related biases. We discuss questions that can help investigators or evidence consumers evaluate the potential impact of confounding or other biases on their findings: Does the design emulate a hypothetical randomized trial design? Is the comparator or control condition appropriate? Does the primary analysis adjust for measured confounders? Do sensitivity analyses quantify the potential impact of residual confounding? Are methods open to inspection and (if possible) replication? Designing a high-quality nonrandomized study of medications remains challenging and requires broad expertise across a range of disciplines, including relevant clinical areas, epidemiology, and biostatistics. The questions posed in this paper provide a guiding framework for assessing the credibility of nonrandomized RWE and could be applied across many clinical questions.

The Net Benefit of a treatment should take the correlation between benefits and harms into account.

OBJECTIVE: The assessment of benefits and harms from experimental treatments often ignores the association between outcomes. In a randomized trial, generalized pairwise comparisons (GPC) can be used to assess a Net Benefit that takes this association into account. STUDY DESIGN AND SETTINGS: We use GPC to analyze a fictitious trial of treatment versus control, with a binary efficacy outcome (response) and a binary toxicity outcome, as well as data from two actual randomized trials in oncology. In all cases, we compute the Net Benefit for scenarios with different orders of priority between response and toxicity, and a range of odds ratios (ORs) for the association between these outcomes. RESULTS: The GPC Net Benefit was quite different from the benefit/harm computed using marginal treatment effects on response and toxicity. In the fictitious trial using response as first priority, treatment had an unfavorable Net Benefit if OR < 1, but favorable if OR > 1. With OR = 1, the Net Benefit was 0. Results changed drastically using toxicity as first priority. CONCLUSION: Even in a simple situation, marginal treatment effects can be misleading. In contrast, GPC assesses the Net Benefit as a function of the treatment effects on each outcome, the association between outcomes, and individual patient priorities.

Diabetes mellitus asociada al uso crónico de antipsicóticos atípicos / Diabetes mellitus association with chronic use of atypical antipsychotics

Resumen Los agentes antipsicóticos son considerados como el principal tratamiento farmacológico para el manejo de mantenimiento y el tratamiento de casos agudos de la esquizofrenia y otros trastornos mentales. Estos medicamentos están clasificados en dos grupos: los antipsicóticos de primera generación o antipsicóticos típicos (AT) y los antipsicóticos de segunda generación o antipsicóticos atípicos (AA). En relación con el uso de los antipsicóticos típicos (AT), se han descrito importantes efectos adversos, sobre todo síntomas extrapiramidales (EPS), lo cual ha relegado su uso y fomenta el mayor empleo en la práctica clínica de los antipsicóticos atípicos (AA) gracias a la adecuada efectividad clínica demostrada hasta el momento. Sin embargo, estos medicamentos están asociados con diferentes alteraciones metabólicas, entre las cuales se encuentra un mayor riesgo de diabetes; para lo cual se han propuesto varios mecanismos etiopatogénicos. En esta revisión narrativa, se presenta un resumen actualizado de la literatura de los últimos 5 años sobre el uso de antipsicóticos atípicos y la diabetes mellitus tipo 2, haciendo énfasis en las diferentes hipótesis reportadas hasta el momento que involucran el aumento de peso y diferentes efectos mediados por hormonas, receptores de neurotransmisores y neuropéptidos que impactan en la génesis de los estados hiperglucémicos y de insulinorresistencia.

Abstract Antipsychotic agents are currently considered as the main pharmacological treatment that helps the maintenance management of acute schizophrenia and other mental disorders. These drugs are classified into two groups: First-generation antipsychotics (FGAs) or typical antipsychotics, and Second-generation antipsychotics (SGAs) also known as atypical antipsychotics (AAP). In relation to the use of typical antipsychotics, some relevant adverse effects have been described, especially in terms of extrapyramidal side effects (EPS), which has downgraded their use and encourages the treatment of atypical antipsychotics (AAP) due to the adequate clinical effectiveness demonstrated so far in the practice. However, these drugs have been associated with different metabolic alterations such as the increased risk of suffering from diabetes; thus, several etiopathogenic mechanisms have been proposed. In this narrative review, we seek to present an updated summary of the literature of the last five years about the use of atypical antipsychotics and type 2 diabetes mellitus. Here it has been emphasized the different hypotheses reported so far that involve weight gain and different effects mediated by hormones, neurotransmitter receptors, and neuropeptides that impact on the genesis of hyperglycemia and insulin resistance states

Management of erectile dysfunction and LUTS/incontinence: the two most common, long-term side effects of prostate cancer treatment.

The two major long-term concerns associated with different options for the management of prostate cancer, (including surgery, radiotherapy, brachytherapy, cryotherapy, HIFU, etc.) include difficulties with lower urinary tract symptoms (LUTS) and/or erectile dysfunction. LUTS can be in the form of stress urinary incontinence (SUI), urge urinary incontinence (UUI), frequency/urgency, and/or voiding difficulties. While surgery is mostly associated with SUI and radiation mostly results in UUI, there can be an overlap. Incontinence rates after cryotherapy and high intensity focused ultrasound (HIFU) are generally very low. Voiding difficulties can also happen after the above-mentioned options. Treatment of SUI can start with pelvic floor muscle exercises (PFME), penile clamps or urethral plugs. If these fail to provide satisfactory results the surgical options could include: urethral bulking agents, male slings, and artificial urinary sphincter (AUS). Surgical options are usually not recommended during the first 6-12 months after radical prostatectomy. Management of frequency, urgency and/or UUI can also be started with lifestyle modifications and PFME. Oral agents (anticholinergics and ß3-agonists) are also considered before proceeding to third line options, such as Botox injection or sacral neuromodulation. The treatment options for ED resulting from the treatment of prostate cancer can include oral PDE5-I as the first line, local therapy as the second (such as MUSE, intracavernosal injections, and perhaps low intensity shock wave therapy) and finally surgery as the third line. Standard questionnaires and patient reported outcome measurement tools should be used for the assessment of LUTS and erectile dysfunction prior and after initiation of treatment to guide the management.

Fecal microbiota transplantation in disease therapy.

Fecal microbiota transplantation (FMT) is the introduction (transplantation) of gut microbiota obtained from the faeces of a healthy donor into the patient's gastrointestinal tract. Most often, such therapy is used the treatment of gastrointestinal diseases caused by the activity of pathogenic or conditionally pathogenic microorganisms, however, recently an increasing number of studies have reported the use of fecal microbiota transplantation for the treatment of diseases such as metabolic syndrome, diabetes, cancer and Parkinson's disease. This review article presents the results of studies concerning the impact of FMT on weight gain, immunological response and the treatment of neurological and gastrointestinal diseases and cancer. The procedure of fecal microbiota transplantation and possible side effects that may appear in FMT recipients are also described.

Effects of treatment with sitagliptin on hepatotoxicity induced by acetaminophen in mice

Up to date, the management of hepatotoxicity induced by a suicidal or unintentional overdose of acetaminophen (APAP) remains a therapeutic challenge. The present study aimed to elucidate the potential effect of sitagliptin, a DPP-4 inhibitor, to ameliorate the acute injurious effects of acetaminophen on the liver. APAP toxicity was induced in mice by an intraperitoneal injection of APAP (400 mg/kg). The effect of treatment with sitagliptin, initiated 5 days prior to APAP injection, was evaluated. Serum indices of hepatotoxicity, oxidative stress markers in liver tissues, serum IL-1ß, and TNF-α in addition to hepatic- NF-E2-related factor-2 (Nrf2) were determined. Our results showed that APAP induced marked hepatic injury as evidenced by an increase in serum levels of ALT and AST, in addition to the deterioration of histological grading. Oxidative stress markers, serum TNF-α, and IL-1ß were also elevated. Sitagliptin successfully ameliorated the histological changes induced by APAP, improving liver function tests and liver oxidant status accompanied with a marked increase in Nrf2 level in hepatic tissues. Thus, the hepatoprotective effects of sitagliptin in this animal model seem to involve Nrf2 modulation, coincidental with its anti-inflammatory and antioxidant effects

Perfil Epidemiológico dos Pacientes com câncer de Cabeça e Pescoço em um Centro Oncológico no Sul do Brasil / Epidemiological Profile of Patients with Head and Neck Cancer at a Cancer Center in Southern Brazil / Perfil Epidemiológico de Pacientes con Cáncer de Cabeza y Cuello en un Centro de Oncología en el Sur de Brasil

Introdução: O câncer de cabeça e pescoço aumentou significativamente na última década. Objetivo: Determinar o perfil epidemiológico dos pacientes com câncer de cabeça e pescoço atendidos em um Centro Oncológico de referência no Sul do Brasil no período de janeiro de 2013 a dezembro de 2018. Método: Estudo de caráter descritivo e retrospectivo realizado no Centro de Pesquisas Oncológicas (Cepon). Resultados: Foram obtidos dados preliminares de 133 pacientes. O gênero masculino foi o mais prevalente (65,4%), com média de idade acima dos 50 anos, baixa escolaridade (40%), baixa renda (77,3%), sendo sua grande maioria tabagistas (72%) e etilistas (58,1%). A região de cavidade oral (26,3%) foi o sítio mais prevalente, a cirurgia mais realizada foi a tireoidectomia total (19,4%) e o estadiamento mais observado foi T2 (30,8%) N2 (41,1%). Foram encontradas complicações pós-radioterapia como a radiodermite (82,7%) e, pós-quimioterapia, náuseas (81%). As fibroses cicatriciais foram mais frequentes após a cirurgia (18,2%), sendo avaliadas no pós-operatório tardio. Conclusão: Caracterizar o perfil dos pacientes com câncer de cabeça e pescoço permite conhecer os diversos acometimentos advindos do tratamento e possibilita, dessa maneira, maior qualidade e direcionamento das ações de reabilitação.

Introduction: Head and neck cancer has increased significantly in the last decade. Objective: To determine the epidemiological profile in patients with head and neck cancer treated at an oncological referral center in Brazil Southern region from january 2013 to december 2018. Method: Descriptive and retrospective study carried out at CEPON (Oncology Research Center). Results: Preliminary data were obtained from 133 patients. Male gender was the most prevalent (65.4%), with mean age above 50 years, low education (40%), low income (77.3%), many of them were smokers (72%) and alcoholics (58.1%). The oral cavity region (26.3%) was the most prevalent site, the most performed surgery was total thyroidectomy (19.4%) and the most observed staging was T2 (30.8%) and N2 (41.1%). Post-radiotherapy and post-chemotherapy complications as radiodermatitis (82.7%) and nausea (81%), respectively, were found. Scarring fibrosis was more frequent after surgery (18.2%) and were evaluated in the late postoperative period. Conclusion: Characterizing the profile of patients with head and neck cancer allows to know the several affections resulting from the treatment to ensure better quality and focus of rehabilitation actions.

Introducción: El cáncer de cabeza y cuello ha aumentado significativamente en la última década. Objetivo: Determinar el perfil epidemiológico en pacientes con cáncer de cabeza y cuello tratados en un centro de referencia en el sur de Brasil desde enero de 2013 hasta diciembre de 2018. Método: Estudio descriptivo y retrospectivo realizado en el Centro de Investigación Oncológica (Cepon). Resultados: Se obtuvieron datos preliminares de 133 pacientes. El sexo masculino fue el más prevalente (65.4%), con una edad promedio de más de 50 años, baja escolaridad (40%), bajos ingresos (77.3%), la mayoría de ellos fumadores (72%) y alcohólicos. (58.1%). La región de la cavidad oral (26.3%) fue el sitio más prevalente, la cirugía más realizada fue la tiroidectomía total (19.4%) y la estadificación más observada fue T2 (30.8%) y N2 (41.1%). Se encontraron complicaciones posteriores a la radioterapia, como radiodermatitis (82,7%) y después de la quimioterapia, náuseas (81%). La fibrosis cicatricial fue más frecuente después de la cirugía (18,2%) y se evaluó en el postoperatorio tardío. Conclusión: La caracterización del perfil de los pacientes con cáncer de cabeza y cuello nos permite conocer las diversas afecciones que surgen del tratamiento y, por lo tanto, permitir una mayor calidad y dirección de las acciones de rehabilitación.

A prática sexual de mulheres jovens em tratamento para o câncer de mama / La práctica sexual de mujeres jóvenes en tratamiento para el cáncer de mama / The sexual practice of young women in treatment for breast cancer

Resumo Objetivo compreender como ocorre a prática sexual (PS) de mulheres jovens com câncer de mama. Método pesquisa qualitativa, utilizando o Interacionismo Simbólico e a Teoria Fundamentada nos Dados. A coleta de dados ocorreu entre outubro de 2017 e agosto de 2019, em dois Centros de Alta Complexidade em Oncologia, seguindo-se um roteiro semiestruturado para entrevista. A pergunta norteadora foi: "Fale-me como era e como ficou agora sua vida sexual após o diagnóstico do câncer". Participaram 13 mulheres com companheiro sexual desde o diagnóstico da doença. Resultados primeiro diagrama: a prática sexual é afetada devido ao diagnóstico e tratamentos para a doença; segundo diagrama: fatores que contribuem para sua retomada são o apoio social e afetivo (principalmente); diagrama da categoria central: o companheiro (apoio afetivo) é o protagonista da rede de relacionamentos. Conclusão A PS é afetada pela doença/tratamentos e sua retomada ocorre mediante apoio do companheiro. Implicações para a prática: É necessário abordar sobre PS na assistência em saúde, evitando o distanciamento do casal, diminuindo as angústias e dúvidas das mulheres nesta condição.

Resumen Objetivo Comprender cómo ocurre la práctica sexual (PS) de mujeres jóvenes con cáncer de mama. Método Investigación cualitativa; que utilizó el Interaccionismo Simbólico y la Teoría Fundamentada en Datos. La recopilación de datos tuvo lugar entre octubre de 2017 y agosto de 2019 en dos centros de alta complejidad en oncología, utilizando un guion semiestructurado para las entrevistas. La pregunta guía fue: "Dime cómo era y cómo está tu vida sexual después del diagnóstico de cáncer". Participaron trece mujeres con pareja sexual desde el diagnóstico de la enfermedad. Resultados Primer diagrama: la práctica sexual se ve afectada debido al diagnóstico y los tratamientos para la enfermedad; Segundo diagrama: los factores que contribuyen a su reanudación son el apoyo social y afectivo (principalmente); Diagrama de categoría central: el compañero (soporte afectivo) es el protagonista de la red de relaciones. Conclusión La PS es afectada por la enfermedad/los tratamientos y su continuación se produce con el apoyo de la pareja. Implicaciones para la práctica: Es necesario abordar la EP en la atención médica, evitando el alejamiento entre la pareja, reduciendo la angustia y las dudas de las mujeres en esta condición.

Abstract Objective To understand how the sexual practice (SP) of young women with breast cancer occurs. Method: Qualitative research; that used Symbolic Interactionism and Grounded Theory. Data collection took place between October/2017 and August/2019 in two Centers of High Complexity in Oncology, using a semi-structured guide for interviews. The guiding question was: "Tell me what it was like and what your sex life is like now after the cancer diagnosis". Participated thirteen women with a sexual partner since the diagnosis of the disease. Results: First diagram: sexual practice is affected due to diagnosis and treatments for the disease; Second diagram: factors that contribute to its resumption are social and (mainly) affective support; Central category diagram: the companion (affective support) is the protagonist of the relationship network. Conclusion: SP is affected by the disease/treatments and its resumption occurs with the support of the partner. Implications for practice: It is necessary to address SP in health care, avoiding the distance between of the couple, reducing the anxieties and doubts of women in this condition.

Association of a Crime Prevention Program for Boys With Mortality 72 Years After the Intervention: Follow-up of a Randomized Clinical Trial.

Importance: Mortality is an important outcome in evaluating crime prevention programs, but little is known about the effects on mortality during the full life course. Objective: To determine the long-term outcomes of a crime prevention program on mortality and whether the iatrogenic effects on mortality observed in middle age persist or change in old age. Design: This longitudinal follow-up was conducted in a cohort of boys included in a matched-pair randomized clinical trial (the Cambridge-Somerville Youth Study). Six hundred fifty boys aged 5 to 13 years who lived and attended public and parochial schools in working-class areas of Cambridge and Somerville, Massachusetts, and were identified as at risk for antisocial behavior were matched by age and demographic characteristics. One member of each pair was randomly allocated to the treatment condition. The original trial was performed from June 1, 1939, to December 1945. Follow-up in the present analysis was performed from January 2016 through June 2018. Interventions: Treatment group participants received individual counseling through a range of activities and home visits for an extended duration (mean, 5.5 years). Control group participants received no special services. Main Outcomes and Measures: The 4 outcomes of interest include age at mortality, mortality at latest follow-up, premature mortality (younger than 40 years), and cause of mortality (natural vs unnatural). Results: In the original analysis, 650 participants were matched and randomized to treatment or control conditions, of whom 506 were retained in the analysis (mean [SD] age, 9.8 [1.7] years). Through early 2018, records for 488 participants (96.4%) were located. A total of 446 participants were confirmed dead (88.1%) and 42 alive (8.3%). Matched-pairs analyses showed no significant differences between the treatment and control groups for mortality at latest follow-up (relative risk [RR], 1.05; 95% CI, 0.99-1.11), premature mortality (RR, 1.15; 95% CI, 0.55-2.43), or cause of mortality (RR, 1.19; 95% CI, 0.65-2.18) (P > .05 for all). Cox proportional hazard regression indicated no difference in time to death between groups (hazard ratio, 1.18; 95% CI, 0.98-1.41; P = .09). Conclusions and Relevance: Iatrogenic effects on mortality were not detected in this long-term follow-up. The longitudinal analysis provides information on the utility of life-long assessments of crime prevention programs and draws attention to the need for quality-of-life assessments of participants and their children.

Gay men's experiences of sexual changes after prostate cancer treatment-a qualitative study in Sweden.

Background: The needs of gay men after prostate cancer treatment are becoming visible. This patient group reports a more negative impact of treatment than heterosexual men. Yet, gay men's experiences of post-treatment sexual changes are still little explored. This study aims to determine specific concerns of gay men's post-treatment sexual practices. Methods: A qualitative study design was deployed using semi-structured interviews as data. Participants were purposefully sampled through advertisements and the snowball method. Eleven self-identifying gay men aged 58-81 years and treated for prostate cancer participated in interviews during 2016-2017. The interviews were transcribed, coded and thematically analysed. Results: The analysis highlights sexual changes in relation to the physical body, identity and relations. Problematic physical changes included loss of ejaculate and erectile dysfunction. Some respondents reported continued pleasure from anal stimulation and were uncertain about the role of the prostate. These physical changes prompted reflections on age and (dis)ability. Relationship status also impacted perception of physical changes, with temporary sexual contacts demanding more of the men in terms of erection and ejaculations. Conclusions: Gay prostate cancer survivors' narratives about sexual changes circle around similar bodily changes as heterosexual men's, such as erectile problems and weaker orgasms. The loss of ejaculate was experienced as more debilitating for gay men. Men who had anal sex were concerned about penetration difficulties as well as sensations of anal stimulation. Additional studies are required to better understand the role of the prostate among a diversity of men, regardless of sexuality.

Waldenström macroglobulinemia: 2019 update on diagnosis, risk stratification, and management.

DISEASE OVERVIEW: Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with immunoglobulin M (IgM) monoclonal protein. Clinical features include anemia, thrombocytopenia, hepatosplenomegaly, lymphadenopathy, and rarely hyperviscosity. DIAGNOSIS: Presence of IgM monoclonal protein associated with ≥10% clonal lymphoplasmacytic cells in bone marrow confirms the diagnosis. The L265P mutation in MYD88 is detectable in >90% of patients and is found in the majority of IgM monoclonal gammopathy of undetermined significance patients. RISK STRATIFICATION: Age, hemoglobin level, platelet count, ß2 microglobulin, and monoclonal IgM concentrations are characteristics that are predictive of outcomes. RISK-ADAPTED THERAPY: Not all patients who fulfill WM criteria require therapy; these patients can be observed until symptoms develop. Rituximab-monotherapy is inferior to regimens that combine it with bendamustine, an alkylating agent, a proteosome inhibitor, or ibrutinib. Purine nucleoside analogs are active but usage is declining for less toxic alternatives. The preferred Mayo Clinic induction is rituximab and bendamustine. Potential for stem cell transplantation should be considered in selected younger patients. MANAGEMENT OF REFRACTORY DISEASE: Bortezomib, fludarabine, thalidomide, everolimus, ibrutinib, carfilzomib, lenalidomide, and bendamustine have all been shown to have activity in relapsed WM. Given WM's natural history, reduction of therapy toxicity is an important part of treatment selection.

[Mortality due to medical and surgical complications, economic crisis and health spending in Spain, 2002-2013]. / Mortalidad por complicaciones médicas y quirúrgicas, impacto de la crisis y gasto sanitario en España, 2002-2013.

OBJECTIVE: To describe the evolution of mortality risks for complications due to medical care or surgery between the periods prior to (2002-2007) and after (2008-2013) the beginning of the economic crisis for Spain and by autonomous region, and to analyse the relationship between the changes in the risks of death and the socioeconomic impact of the crisis and the variation in health spending. METHOD: Ecological study based on age-standardized mortality rates, synthetic index of vulnerability as a socioeconomic indicator and variation in health expenditure as an indicator of health expenditure. The relative risk of death between periods was estimated with Poisson regression models. RESULTS: The number of deaths increased for Spain in the period studied. Although the relationship between the increase in public investment in health and the decrease in mortality due to this cause has not been clearly demonstrated, it was possible to determine that the autonomous regions with the lowest increase in health expenditure had rates higher than the rest throughout the period, and that the most vulnerable to the crisis and with the lowest increase in spending presented the greatest increase in the risk of death between the periods. CONCLUSIONS: Given the increase in these deaths, due to avoidable failures of the system, it is necessary to continue investigating this cause of mortality.

Fatores Associados à Qualidade de Vida Relacionada à Saúde de Pacientes com Câncer em Tratamento Clínico / Factors Associated with Health-Related Quality of Life of Cancer Patients Undergoing Clinical Treatment / Factores Asociados con la Calidad de Vida Relacionada con la Salud de los Pacientes con cáncer en Tratamiento Clínico

Introdução: Estado nutricional, qualidade de vida relacionada à saúde (QVRS) e apetite preservados proporcionam maior sobrevida aos pacientes oncológicos. Suas oscilações são comuns durante o tratamento, mas pouco se conhece sobre os fatores interferentes na QVRS. Objetivo: Avaliar os fatores associados à QVRS de pacientes com câncer. Método: Estudo transversal com 110 pacientes com câncer em tratamento clínico. Foram coletadas as variáveis sociodemográficas, clínicas, QVRS, estado nutricional e apetite. Os instrumentos utilizados foram o European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, a Avaliação Subjetiva Global (ASG) e o Cancer Appetite and Symptom Questionnaire. Para análise estatística, considerou-se o nível de significância de 5%. Resultados: A maioria era do sexo feminino (62,72%) com média de idade igual a 74,41±24,54 anos, casada (70,0%), sem atividade de trabalho (51,82%) e pertencente à classe econômica B (54,54%). O tipo de câncer mais prevalente nessa população foi o câncer de mama (30,0%), com estadiamento IV (34,44%) e ausência de metástases (53, 64%). O comprometimento do apetite foi identificado como fator associado à QVRS, apresentando diferença significativa na saúde global e na QV (p<0,001). A função emocional foi a mais prejudicada. A fadiga foi o sintoma que apresentou maior pontuação. Conclusão: O comprometimento do apetite apresentou associação com a saúde global e a QV dos pacientes em tratamento oncológico.

Introduction: Protected nutritional status, health-related quality of life (HRQOL) and appetite provide longer survival for cancer patients. Oscillations are common during treatment, but little is known about factors interfering with HRQOL. Objective: To assess the factors associated with the HRQOL of patients with cancer. Method: A cross-sectional study with 110 cancer patients undergoing clinical treatment. Sociodemographic, clinical, HRQOL, nutritional status and appetite variables were collected. The instruments used were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the Subjective Global Assessment (SGA) and the Cancer Appetite and Symptom Questionnaire. For statistical analysis, the level of significance was 5%. Results: The majority were female (62.72%) with a mean age of 74.41±24.54 years, married (70.0%), without working activity (51.82%) and belonging to economic class B (54.54%). The most prevalent type of cancer in this population was breast cancer (30.0%), with staging IV (34.44%) and absence of metastasis (53.64%). The appetite impairment was identified as a factor associated with HRQOL, presenting significant difference in the global health and QoL (quality of life). Emotional function was the most damaged. Fatigue was the symptom that presented the highest score. Conclusion: Appetite impairment was associated with the global health and QoL of cancer patients in oncologic treatment.

Introducción: Estado nutricional, calidad de vida relacionada con la salud (CVRS) y apetito conservado proporcionan una supervivencia más larga para los pacientes con cáncer. Sus oscilaciones son comunes durante el tratamiento, pero se sabe poco sobre los factores de interferencia en la CVRS. Objetivo: Evaluar los factores asociados con la CVRS de los pacientes con cáncer. Método: estudio transversal con 110 pacientes con cáncer en tratamiento clínico. Incluimos variables sociodemográficas, clínicas, de CVRS, estado nutricional y apetito. Los instrumentos utilizados fueron el Cuestionario básico 30 de la Organización Europea para la Investigación y el Tratamiento del Cáncer, la Evaluación global subjetiva (EGS) y el cuestionario sobre el apetito y los síntomas del cáncer. Se consideró nivel de significancia del 5%. Resultados: La mayoría era mujeres (62,72%) con una edad media de 74,41±24,54 años, casada (70,0%), sin actividad laboral (51,82%) y perteneciente a clase económica B (54,54%). El tipo de cáncer más frecuente era el cáncer de mama (30,0%), estadificación IV (34,44%) y sin metástasis (53,64%). El deterioro del apetito fue identificado como factor asociado con la CVRS, mostrando diferencia significativa en lo generale de salud y CV. La función emocional fue la más deteriorada. Fatiga fue el síntoma con el puntaje más alto. Conclusión: El deterioro del apetito se asoció con la salud general y CV de los pacientes en tratamiento contra el cáncer.

Limitación del esfuerzo terapéutico: experiencias de enfermeras en una unidad de cuidados intensivos / Limitation of therapeutic effort: Experiences of nurses in an intensive care unit

El propósito de este estudio fue comprender cómo es la experiencia de las enfermeras en cuanto a vivenciar la limitación del esfuerzo terapéutico (LET) en unidades de paciente crítico de un hospital público de la región de Valparaíso. Se opta por un estudio de tipo cualitativo, de trayectoria fenomenológica, se realizó entrevista en profundidad a 3 enfermeras, con la pregunta orientadora ¿Qué experiencia tiene usted como enfermera de Unidad de Cuidados Intensivos (UCI) con respecto a la LET? Los discursos fueron interpretados bajo el referencial de Fenómeno Situado de Joel Martins. En los relatos se evidencia el uso de las palabras "manejo proporcional" como sinónimo, el rol de enfermería es confuso en la toma de decisión respecto a la LET pero se releva al momento del cuidado al final de la vida. Se concluye que las enfermeras son quienes deben asumir un rol más protagónico en el cuidado de la persona en esta situación, participando activamente en la toma de decisiones del binomio familia-paciente. Se recomienda la creación de protocolos para la LET, detallando la definición de la LET junto con el rol de enfermería y del equipo de salud, con el objetivo de no prolongar la vida innecesariamente, no aumentar la esperanza familiar y asegurar el cuidado al final de la vida.

The purpose of this study was to understand the experience of nurses in terms of experiencing limitation of therapeutic effort (LET) in critical patient units of a public hospital in Valparaíso. We opted for a qualitative study, a phenomenological trajectory, an in-depthinterview with 3 nurses, with the guiding question. What experience do you have as an Intensive Care Unit (ICU) nurse regarding LET? The speeches were interpreted under the referential of Located Phenomenon of Joel Martins. In the stories the use of the words "proportional management" is evidenced as synonymous, the nursing role is confusing in the decision making regarding the LET but it is relieved at the moment of care at the end of life. It is concluded that nurses are the ones who must assume a more protagonic role in the care of the person in this situation, participating actively in the decision making of the family-patient binomial. It is recommended the creation of protocols for the LET, detailing the definition of the LET along with the role of nursing and the health team, with the aim of not prolonging life unnecessarily, not increasing family hope and ensuring care at the end of life.

Recent advances in managing brain metastasis.

Brain metastases are the most common malignancy encountered in the central nervous system (CNS), with up to 30-40% of cancer patients developing brain metastases at some point during the course of their disease. The management of brain metastasis is rapidly evolving and the roles of local therapies such as whole-brain radiation therapy, stereotactic radiosurgery, and resection along with systemic therapies are in flux. An emphasis on the neurocognitive side effects associated with treatment has gained prominence. Novel molecular studies have demonstrated important evolutionary patterns underpinning the development of brain metastasis and leptomeningeal disease, which may be key to unlocking new therapeutic strategies. This article provides a framework for incorporating the results of recent randomized radiotherapy clinical trials into practice, expounds upon the emphasis on cognition being an important driver in therapeutic selection, describes the importance of CNS-penetrating systemic therapies, and provides an overview of the novel molecular insights that will likely set the stage for future developments in this field.

Incidence and mortality from adverse effects of medical treatment in the UK, 1990-2013: levels, trends, patterns and comparisons.

OBJECTIVE: To present an update on incidence and mortality from adverse effects (AEs) of medical treatment in the UK, its four countries and nine English regions between 1990 and 2013. DESIGN: Descriptive epidemiological study on AEs of medical treatment. AEs are shown as a single cause-of-injury category from the Global Burden of Disease (GBD) 2013 study. DATA SOURCES: The GBD 2013 interactive data visualisation tools 'Epi Visualisation' and 'GBD Compare'. OUTCOME MEASURES: The means of incidence and mortality rates with 95% uncertainty intervals (UIs). The estimates are age-standardised. RESULTS: Incidence rate was 175 and 176 cases per 100 000 men, 173 and 174 cases per 100 000 women in 1990 and 2013, in the UK (UI 170-180). The mortality from AEs declined from 1.33 deaths (UI 0.99-1.5) to 0.92 deaths (UI 0.75-1.2) per 100 000 individuals in the UK between 1990 and 2013 (30.8% change). Although mortality trends were descending in every region of the UK, they varied by geography and gender. Mortality rates in Scotland, North East England and West Midlands were highest. Mortality rates in South England and Northern Ireland were lowest. In 2013, age-specific mortality rates were higher in males in all 20 age groups compared with females. CONCLUSIONS: Despite gains in reducing mortality from AEs of medical treatment in the UK between 1990 and 2013, the incidence of AEs remained the same. The results of this analysis suggest revising healthcare policies and programmes aimed to reduce incidence of AEs in the UK.