Missed diagnosis in hematological patients-an autopsy study.

Autopsy findings of missed diagnoses that would probably have changed management or prognosis occur in up to 29% of cases in general hospitals. Such proportions may be higher in subsets of patients with complex diseases. We reviewed 2908 consecutive autopsies performed over a period of 29 months in a large-volume hospital, analyzing 118 autopsies of patients with hematological malignancies or severe aplastic anemia. A review of macroscopic reports as well as microscopic examination of tissue samples was performed. Medical records were reviewed for clinical diagnoses. Discordances between clinical and autopsy diagnoses were classified using Goldman's criteria. Additionally, we searched for clinical parameters correlated with occurrence of class-I discrepancy using a multivariate method. Median age was 46.5 years, and 25.4% had received a hematopoietic stem-cell transplant. Overall, 11.9% (6.6-19.1%) of patients died before conclusion of the hematological diagnosis and 33% (24.6-42.3%) died with no active hematological disease. We found class-I discrepancy in 31.3% (23.1-40.5 %) of cases. The most common among these diagnoses were hematological disease, pneumonia and gastrointestinal bleeding. In a univariate analysis, being elderly (P=0.04) was positively correlated with the finding of class-I discrepancies; while, having received previous specific hematological treatment (P=0.0005) or hematopoietic stem-cell transplants (P=0.013), or being admitted to a specialized hematology unit (P=0.0006) were negatively correlated to the occurrence of such discrepancies. Multivariate analysis showed that care in a specialized hematology unit (OR 0.34, 0.12-0.93) was independently associated with lower occurrence of discrepancies. We concluded that critical diagnoses are often missed in highly complex hematological patients especially in the absence of admission to specialized hematology units.

Modulação da sinalização celular e do complexo de início de tradução como estratégias para o tratamento do carcinoma de células renais / Cell sinaling and translation initiation complex modulation as strategies to the treatment of renal cell carcinoma

O carcinoma de células renais (CCR) é uma causa crescente de morte por câncer. Melhor entendimento da biologia tumoral pode levar a terapias mais eficientes. Estudou-se a sinalização celular originada de EGFR em CCR e o efeito de um inibidor de EGFR (gefitinibe), um inibidor de MAPK (UO126) e um inibidor de mTOR (rapamicina) na fosforilação de intermediários da via de MAPK, em componentes do complexo de início de tradução (CIT) e no crescimento de culturas celulares. UO126 promoveu defosforilação de substratos de mTOR revelando comunicação entre MAPK e CIT. Gefitinibe bloqueou a sinalização entre EGFR e as vias PI3K e MAPK. Rapamicina foi um potente inibidor do crescimento na maioria das linhagens celulares e seu efeito foi frequentemente potencializado por UO126 ou gefitinibe. EGFR, MAPK e CIT são alvos promissores no tratamento do CCR / Summary Renal cell carcinoma (RCC) is a rising cause of cancer death. Better understanding of tumor biology may lead to more efficient therapy based on biological agents. We studied EGFR driven cell signaling in RCC as well as the effect of an EGFR inhibitor (gefitinib) a MAPK inhibitor (UO126) and a mTOR inhibitor (rapamycin) on phosphorylation of MAPK pathway intermediates, translation initiation complex (TIC) components and growth of cell cultures. UO126 caused dephosphorylation of downstream targets of mTOR revealing a cross talk between MAPK and TIC. Gefitinib blocked EGFR signaling though PI3K and MAPK pathways. Rapamycin was found to be a potent growth inhibitor in most cell lines and its effect was often potentiated by UO126 or gefitinib. EGFR, MAPK and TIC are suitable targets...

[Evaluation of non-oncologist physician's knowledge and attitude towards cancer screening and preventive actions]. / Estudo da atitude e do conhecimento dos médicos não oncologistas em relação às medidas de prevenção e rastreamento do câncer.

BACKGROUND: New cancer cases are most often diagnosed by non-oncologist physicians. It is therefore essential for all physicians to be aware of cancer preventive practices and use them appropriately with their patients. METHODS: Questionnaires were administered to 120 non-oncologist physicians of various specialties attending the "Faculdade de Medicina do ABC" who deal directly with adult patients. Replies were collected and classified as appropriate or not according to one of these three cancer prevention guidelines: INCA, American Cancer Society and Canadian Task Force. RESULTS: The percentage of replied questionnaires was 58.3% (70 questionnaires). Mean age of physicians was 33.9 years; 57.1% were women and 10% smokers. Most of the current preventive practices adopted by the participating physicians (45.72% to 100%) regarding the most common and preventable tumors (breast, cervix, prostate, colon and rectum and non-melanoma skin cancer) did not agree with any of the guidelines mentioned above. When questioned about possible impediments for the appropriate practice of cancer prevention, 82.86% reported absence of health education agents working with the population, 77.14% scarceness of knowledge or training concerning prevention, and 70.15% lack of financial support for ordering tests. Frequently, whenever there was disagreement between the guidelines and the physician's current practices, preventive tests were ordered in excess of those recommended by the guidelines. CONCLUSIONS: Physicians had a tendency to order excessive laboratory tests, an action which can be related to lack of knowledge and to divergence among guidelines. A more intensive educational effort regarding cancer prevention, directed towards teaching physicians in training, seems to be warranted.

Estudo da atitude e do conhecimento dos médicos não oncologistas em relação às medidas de prevenção e rastreamento do câncer / Evaluation of non-oncologist physician's knowledge and attitude towards cancer screening and preventive actions

OBJETIVO: Avaliar o nível de informação e as atitudes preventivas em uso corrente pelos médicos ligados à FMABC. MÉTODOS: Foram entregues questionários para 120 médicos não oncologistas que lidam diretamente com pacientes adultos. RESULTADOS: A taxa de resposta foi de 58,3 por cento. A idade média dos médicos foi de 33,9 anos, sendo 57,1 por cento mulheres e 10 por cento tabagistas. As práticas preventivas para os cânceres mais comuns (mama, colo de útero, próstata, colorretal e pele não-melanoma) foram analisadas e comparadas com as recomendadas pelos consensos adotados (INCA, Sociedade Americana de Cancerologia e Força-Tarefa Canadense). Observou-se que a maioria das práticas (45,72 por cento a 100 por cento) não se adequou a nenhum deles. Sobre possíveis barreiras para o adequado exercício da prevenção do câncer, 82,86 por cento considerou falta de agentes educadores em saúde para a população, 77,14 por cento poucos conhecimento ou treinamento e 70,15 por cento falta de verba para custear exames. Houve uma tendência ao excesso de pedidos de exames de rastreamento. CONCLUSÕES: As práticas preventivas utilizadas pelos médicos entrevistados são heterogêneas e, em sua maioria, não preconizadas pelos consensos de condutas preventivas consultados, o que pode ser relacionado tanto à sua falta de conhecimento em relação a estes consensos como às divergências entre eles. Dessa forma, faz-se necessário um esforço educativo enfatizando a importância da prevenção do câncer no aprendizado e na prática médica.

Weight changes during chemotherapy for breast cancer.

CONTEXT: Patients receiving adjuvant chemotherapy for breast cancer have a tendency to gain weight. This tendency has determining factors not completely defined and an unknown prognostic impact. OBJECTIVE: To evaluate weight change during chemotherapy for breast cancer in a defined population and to identify its predisposing factors and possible prognostic significance. DESIGN: Observational, retrospective cohort study. SETTING: Private clinical oncology service. PARTICIPANTS: 106 consecutive patients with breast cancer treated between June 1994 and April 2000, who received neoadjuvant (n = 8), adjuvant (n = 74) or palliative (n = 24) chemotherapy. INTERVENTION: Review of medical records and gathering of clinical information, including patients' body weights before treatment and at follow-up reviews. MAIN MEASUREMENTS: Body weight change, expressed as percentage of body weight per month in treatment; role of clinical data in weight change; and influence of weight change in overall survival and disease-free survival. RESULTS: There was a mean increase of 0.50 +/- 1.42% (p = 0.21) of body weight per month of treatment. We noted a negative correlation between metastatic disease and weight gain (r = -0.447, p < 0.0001). In the adjuvant and neoadjuvant therapy groups there was a mean weight gain of 0.91 +/- 1.19 % (p < 0.00001) per month, whereas in the metastatic (palliative) group, we observed a mean loss of 0.52 +/- 1.21% (p = 0.11) of body weight per month during the treatment. We did not observe any statistically significant correlation between weight changes and disease-free survival or overall survival. CONCLUSIONS: Women with breast cancer undergoing adjuvant or neoadjuvant chemotherapy gain weight, whereas metastatic cancer patients will probably lose weight during palliative chemotherapy. Further studies are needed in order to evaluate the prognostic significance of weight changes during chemotherapy.

Weight changes during chemotherapy for breast cancer

CONTEXT: Patients receiving adjuvant chemotherapy for breast cancer have a tendency to gain weight. This tendency has determining factors not completely defined and an unknown prognostic impact. OBJECTIVE: To evaluate weight change during chemotherapy for breast cancer in a defined population and to identify its predisposing factors and possible prognostic significance. DESIGN: Observational, retrospective cohort study. SETTING: Private clinical oncology service. PARTICIPANTS: 106 consecutive patients with breast cancer treated between June 1994 and April 2000, who received neoadjuvant (n = 8), adjuvant (n = 74) or palliative (n = 24) chemotherapy. INTERVETION: Review of medical records and gathering of clinical information, including patientsÆ body weights before treatment and at follow-up reviews. MAIN MEASUREMENTS: Body weight change, expressed as percentage of body weight per month in treatment; role of clinical data in weight change; and influence of weight change in overall survival and disease-free survival. RESULTS: There was a mean increase of 0.50 ± 1.42 percent (p = 0.21) of body weight per month of treatment. We noted a negative correlation between metastatic disease and weight gain (r = -0.447, p < 0.0001). In the adjuvant and neoadjuvant therapy groups there was a mean weight gain of 0.91 ± 1.19 percent (p < 0.00001) per month, whereas in the metastatic (palliative) group, we observed a mean loss of 0.52 ± 1.21 percent (p = 0.11) of body weight per month during the treatment. We did not observe any statistically significant correlation between weight changes and disease-free survival or overall survival. CONCLUSIONS: Women with breast cancer undergoing adjuvant or neoadjuvant chemotherapy gain weight, whereas metastatic cancer patients will probably lose weight during palliative chemotherapy. Further studies are needed in order to evaluate the prognostic significance of weight changes during chemotherapy