Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis.

BACKGROUND: Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS. OBJECTIVES: This study aimed to detail the role of GCS and GRS in ICI myocarditis. METHODS: In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death. RESULTS: Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002). CONCLUSIONS: GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.

Myocardial T1 and T2 Mapping by Magnetic Resonance in Patients With Immune Checkpoint Inhibitor-Associated Myocarditis.

BACKGROUND: Myocarditis is a potentially fatal complication of immune checkpoint inhibitor (ICI) therapy. Data on the utility of cardiovascular magnetic resonance (CMR) T1 and T2 mapping in ICI myocarditis are limited. OBJECTIVES: This study sought to assess the value of CMR T1 and T2 mapping in patients with ICI myocarditis. METHODS: In this retrospective study from an international registry of patients with ICI myocarditis, clinical and CMR findings (including T1 and T2 maps) were collected. Abnormal T1 and T2 were defined as 2 SD above site (vendor/field strength specific) reference values and a z-score was calculated for each patient. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. RESULTS: Of 136 patients with ICI myocarditis with a CMR, 86 (63%) had T1 maps and 79 (58%) also had T2 maps. Among the 86 patients (66.3 ± 13.1 years of age), 36 (41.9%) had a left ventricular ejection fraction <55%. Across all patients, mean z-scores for T1 and T2 values were 2.9 ± 1.9 (p < 0.001) and 2.2 ± 2.1 (p < 0.001), respectively. On Siemens 1.5-T scanner (n = 67), native T1 (1,079.0 ± 55.5 ms vs. 1,000.3 ± 22.1 ms; p < 0.001) and T2 (56.2 ± 4.9 ms vs. 49.8 ± 2.2 ms; p < 0.001) values were elevated compared with reference values. Abnormal T1 and T2 values were seen in 78% and 43% of the patients, respectively. Applying the modified Lake Louise Criteria, 95% met the nonischemic myocardial injury criteria and 53% met the myocardial edema criteria. Native T1 values had excellent discriminatory value for subsequent MACE, with an area under the curve of 0.91 (95% confidence interval: 0.84 to 0.98). Native T1 values (for every 1-unit increase in z-score, hazard ratio: 1.44; 95% confidence interval: 1.12 to 1.84; p = 0.004) but not T2 values were independently associated with subsequent MACE. CONCLUSIONS: The use of T1 mapping and application of the modified Lake Louise Criteria provides important diagnostic value, and T1 mapping provides prognostic value in patients with ICI myocarditis.

Avaliação das manifestações orais em crianças e adolescentes internos em um hospital submetidos à terapia antineoplásica / Oral manifestations in hospitalized children and adolescents subjected to antineoplastic therapy

Objetivo: Identificar a prevalência das alterações bucais decorrentes do tratamento antineoplásico e sua correlação com o hemograma em crianças e adolescentes internos pelo Sistema Único de Saúde (SUS) em um hospital em Maceió-AL. Método: Estudo transversal realizado na enfermaria da Oncologia Pediátrica de um hospital em Maceió-AL, com uma amostra de 40 pacientes oncológicos em terapia antineoplásica, com idade entre 1 e 17 anos, de ambos os gêneros, atendidos no período de fevereiro à setembro de 2011. Foi preenchido um prontuário com dados referentes à história médica, a doença atual, odontológica e nutricional, hábitos de higiene oral, hemogramas realizados, incluindo hematócritos, hemoglobina, plaquetas e leucócitos, bem como exame extra e intra-oral uma ou mais vezes. Foi realizada análise estatística descritiva e utilizado o teste não paramétrico de Mann-Whitney com nível de significância de 5%. Resultados: Houve maior prevalência no gênero masculino (57,5%) e dos tumores sólidos (45%). Em 80% houve alguma alteração oral, com predominância de petéquias (40%), seguida de mucosite (35,5%), boca seca (17,5%), úlcera (15%), sangramento gengival (15%), candidíase (10%), gengivite ulcerativa necrosante (10%) e palidez da mucosa (5%). Houve 15% dos internamentos por alterações orais. Houve relação positiva entre plaquetas e leucócitos e a presença de petéquias (p<0,05). Para sangramento gengival houve relação positiva entre todas as variáveis do hemograma (p<0,05). Para pacientes com mucosite grau III e IV houve relação positiva entre leucócitos e plaquetas. Houve diferença significativa entre as distribuições de idade dos pacientes com gengivite ulcerativa necrosante (GUN) e sem GUN (p<0,05). Conclusão: Houve alta ocorrência de alterações orais, significância para as variáveis do exame hematológico analisadas e a ocorrência de complicações orais e ocorrência de GUN nos adolescentes da pesquisa...

Objective: To identify the prevalence of oral manifestations subsequentto antineoplastic therapy and its correlation with complete blood countin children and adolescents admitted in a public hospital in the city ofMaceió, AL, Brazil.Method: This cross-sectional study was undertaken in the PediatricOncology outpatient service of a hospital located in Maceió, AL, Brazil.Forty male and female 1-17-year-old oncologic patients subjected toantineoplastic therapy between February and September 2011 wereenrolled. A clinical chart was filled out containing data on the medicalhistory, the current disease, dental and nutritional history, oral hygienehabits, results of complete blood counts, including hematocrit,hemoglobin, platelet and leukocyte counts, as well as extra- andintraoral examination performed once or more times. Descriptivestatistical analysis was performed using the non-parametric Mann-Whitney test with a significance level of 5%.Results: There was prevalence of males (57.5%) and solid tumors (45%).Eighty percent of the patients presented some type of oral alterationwith predominance of petechiae (40%), followed by mucositis (35.5%),dry mouth (17.5%), ulcers (15%), gingival bleeding (15%), candidiasis(10%), necrotizing ulcer gingivitis (NUG) (10%) and pale mucosa (5%).In 15% of the cases, oral alterations resulted in hospitalizations. Therewas positive correlation between platelet and leukocyte counts and thepresence of petechiae (p<0.05). Gingival bleeding had positivecorrelation with all complete blood count variables. Patients with gradeIII and IV mucositis presented positive correlation between leukocytesand platelets. There was a statistically significant difference betweenthe age distribution of patients with or without NUG (p<0.05).Conclusion: There was high incidence of oral alterations, significancebetween the hematological exam variables and occurrence oralcomplications and NUG in the adolescents in this study...

Polineuropatia no paciente crítico: um diagnóstico comum em medicina intensiva?: [revisão] / Polyneuropathy in the critical ill patient: a common diagnosis in intensive care medicine?: [review]

JUSTIFICATIVA E OBJETIVOS: A polineuropatia axonal difusa, hoje mais conhecida como polineuropatia do paciente crítico (PPC), tem sido relatada por autores há décadas, porém, apenas nos últimos 30 anos, ocupa maior importância como causa de dependência prolongada de ventilação mecânica, em pacientes gravemente enfermos internados em Unidades de Terapia Intensiva. Esta revisão teve por objetivo apresentar os princípios tópicos que norteiam a fisiopatologia, diagnóstico e tratamento desta doença em Medicina intensiva. CONTEÚDO: A importância da PPC como complicação inicial do choque séptico e em pacientes com disfunção de múltiplos de órgãos e sistemas (DMOS) está claramente descrita como responsável pelo prolongamento da permanência na UTI e, também pela redução gradativa da probabilidade de sobrevida. Sugere-se que a polineuropatia esteja relacionada com as citocinas envolvidas na sepse, além de outros mediadores que aumentariam a permeabilidade dos vasos, resultando em edema endoneural e lesão axonal. Seu início é de difícil diagnóstico, geralmente sendo possível apenas quando as complicações da sepse ou falência de múltiplos órgãos tenham sido adequadamente controladas. O diagnóstico é feito através da eletroneuromiografia. Apesar de ainda não haver nenhum tratamento medicamentoso efetivo, além do controle da doença de base, é censo comum, entre equipes multidisciplinares que o desenvolvimento da PPC não deve ser entendido como forma de reduzir os esforços do tratamento. CONLUSÕES: A despeito de sua prevalência, ainda permanecem desconhecidos os fatores claramente associados à sua fisiopatologia, bem como adequada terapia para o manuseio desta condição.

BACKGROUND AND OBJECTIVES: The diffuse axonal polyneuropathy, more commonly known as Critical Illness Polyneuropathy (CIP), has been discussed by authors by decades; however, it has only been deeply studied over the last thirty years, becoming more important as an important cause of long term dependence on mechanical ventilation by seriously ill patients in intensive care medicine. CONTENTS: A significant reason for such interest is due to the importance of the CIP as complication of the septic shock and in patients with multiple organ failure, as much as responsible for the prolonging hospitalization in the Intensive Care Unit, as for the gradual reduction of the chance of survival. It has been suggested that the polyneuropathy is related with cytokines and other mediators which would increase the permeability of the vases, resulting in endoneural edema and causing the axonal injury. It is difficult to do the initial diagnostic, which, in general, are only possibly recognized when the sepsis complications or the multiple organs failure have been satisfactorily controlled. The diagnosis is made through the eletroneuromiography exam, and although there is still no effective drug treatment other than the control of the basic illness, it is consensus among multidisciplinary team that the development of the CIP does not have to be understood as a way to reduce the intensity of treatment. CONCLUSIONS: Spit of your prevalence, it is still unknown the mainly factors which are physiopathology associated as soon as your correct therapy.

[Polyneuropathy in the critical ill patient: a common diagnosis in intensive care medicine?]. / Polineuropatia no paciente crítico: um diagnóstico comum em medicina intensiva?

BACKGROUND AND OBJECTIVES: The diffuse axonal polyneuropathy, more commonly known as Critical Illness Polyneuropathy (CIP), has been discussed by authors by decades; however, it has only been deeply studied over the last thirty years, becoming more important as an important cause of long term dependence on mechanical ventilation by seriously ill patients in intensive care medicine. CONTENTS: A significant reason for such interest is due to the importance of the CIP as complication of the septic shock and in patients with multiple organ failure, as much as responsible for the prolonging hospitalization in the Intensive Care Unit, as for the gradual reduction of the chance of survival. It has been suggested that the polyneuropathy is related with cytokines and other mediators which would increase the permeability of the vases, resulting in endoneural edema and causing the axonal injury. It is difficult to do the initial diagnostic, which, in general, are only possibly recognized when the sepsis complications or the multiple organs failure have been satisfactorily controlled. The diagnosis is made through the eletroneuromiography exam, and although there is still no effective drug treatment other than the control of the basic illness, it is consensus among multidisciplinary team that the development of the CIP does not have to be understood as a way to reduce the intensity of treatment. CONCLUSIONS: Spit of your prevalence, it is still unknown the mainly factors which are physiopathology associated as soon as your correct therapy.

Carcinoma adenoescamoso primário de estômago: relato de caso / Primary adenosquamous carcinoma of the stomach: a case report

O carcinoma adenoescamoso primário do estômago é um tumor raro, cuja incidência não excede 1 por cento dos tumores gástricos. Esse tumor mostra dois tipos celulares distintos: um escamoso e outro adenocarcinomatoso. É discutido um caso de um tumor raro e interessante do estômago, com relação à sua patogênese, diagnóstico e aspectos clínico-patológicos. Material e método: Reporta-se um caso de carcinoma adenoescamoso primário do estômago em uma paciente de cor branca de 51 anos, cuja patologia, exame endoscópico e histopatológico mostram a presença dos dois tipos celulares: adenocarcinomatoso e escamoso