Non-Small-Cell Lung Cancer With CNS Metastasis: Disparities From a Real-World Analysis (GBOT-LACOG 0417).

PURPOSE: Despite the advances in the approach to non-small-cell lung cancer (NSCLC) with CNS metastasis, access to timely diagnosis and treatment may not be optimal in many instances. Our main objective was to describe a cohort of patients with NSCLC with brain metastases from public and private cancer centers, and the differences between patients' presentation, treatment, and outcomes. METHODS: GBOT-LACOG 0417 is a multi-institutional retrospective cohort study of patients diagnosed with NSCLC and CNS metastasis in Brazil. All patients had confirmed diagnosis of NSCLC between January 2010 and December 2015. CNS metastases were identified by imaging. RESULTS: A total of 273 patients were included. Patients treated at public institutions were more often Black or Brown (38.8% v 15.4%), current or former smoker (88.6% v 60.0%), of squamous cell histology (25.0% v 9.1%), EGFR- and ALK-negative (95.9% v 74.9%), and were less frequently assessed by using brain magnetic resonance imaging (38.8% v 83.6%). At public institutions, patients were more often symptomatic (78.1% v 44.6%) and had worse performance status (Eastern Cooperative Oncology Group 2 or higher 61.5% v 10.3%). CNS metastases were larger (median size 25 v 15 mm) and more often surrounded by edema (67.7% v 55.2%) at public institutions. Patients at public institutions were more frequently treated with whole-brain radiation therapy (72.9% v 45.4%) and less frequently with radiosurgery (6.3% v 24.1%). Among patients from private care, median overall survival was 24.2 months (95% CI, 20.0 to 30.6), significantly higher than in public care (median 12.1 months; 95% CI, 6.7 to 13.6; P < .001). CONCLUSION: Our results demonstrate the discrepancy between public and private health care system in the critical setting of patients with CNS metastasis from NSCLC.

The impact of blood transfusion on morbidity and mortality after cardiac surgery.

OBJECTIVES: To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery. METHODS: Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05. RESULTS: Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9% vs. 2.2%, P <0.001), respiratory infection (27.8% vs 17.1%, P <0.001) and sepsis (6.2% vs. 2.5%, P <0.001). There were more episodes of atrial fibrillation (AF) (27% vs. 20.4%, P <0.001), acute renal failure (ARF) (14.5% vs 7.3%, P <0.001) and stroke (4.8% vs. 2.6%, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9% vs. 9.1%, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95% CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95% CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95% CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95% CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95% CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95% CI: 1.39-2.33, P <0.001). CONCLUSION: The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.

O impacto da hemotransfusão na morbimortalidade pós-operatória de cirurgias cardíacas / The impact of blood transfusion on morbidity and mortality after cardiac surgery

OBJETIVOS: Analisar o impacto da hemotransfusão sanguínea na incidência de desfechos clínicos no pós-operatório (PO) de cirurgias cardíacas. MÉTODOS: Estudo de coorte retrospectiva. Foram analisados 4.028 pacientes submetidos à cirurgia de revascularização miocárdica (CRM), troca valvar (TV) ou ambas, em hospital terciário universitário brasileiro, entre 1996 e 2009. Foram comparadas as complicações no PO entre os pacientes hemotransfundidos (n=916) e não-hemotransfundidos (n=3112). Foi realizada análise univariada através do teste t de Student, e análise multivariada com o uso de regressão logística Bivariada (Stepwise Forward). Foram consideradas significativas as variáveis com P<0,05. RESULTADOS: Os pacientes que receberam hemotransfusão apresentaram mais episódios infecciosos como mediastinite (4,9 por cento vs. 2,2 por cento, P<0,001), infecção respiratória (27,8 por cento vs 17,1 por cento, P<0,001), e sepse (6,2 por cento vs. 2,5 por cento, P<0,001). Ocorreram mais episódios de fibrilação atrial (FA) (27 por cento vs. 20,4 por cento, P<0,001), insuficiência renal aguda (IRA) (14,5 por cento vs. 7,3 por cento, P<0,001) e acidente vascular cerebral (AVC) (4,8 por cento vs. 2,6 por cento, P=0,001). O tempo de internação hospitalar no PO foi maior nos transfundidos (13±12,07 dias vs. 9,72±7,66 dias, P<0,001). Porém, a mortalidade não apresentou diferença entre os grupos (10,9 por cento vs. 9,1 por cento, P=0,112). A transfusão mostrou-se como fator de risco para: infecção respiratória (OR: 1,91; IC95 por cento: 1,59-2,29; P<0,001), FA (OR:1,35; IC95 por cento: 1,13-1,61; P=0,01), sepse (OR: 2,08; IC95 por cento: 1,4-3,07; P<0,001), mediastinite (OR: 2,14; IC95 por cento: 1,43-3,21; P<0,001), AVC (OR: 1,63; IC95 por cento: 1,1-2,41; P=0,014) e IRA (OR: 1,8; IC95 por cento: 1,39-2,33; P<0,001). CONCLUSÃO: A hemotransfusão está associada ao aumento do risco de eventos infecciosos, episódios de FA, IRA e AVC, bem como aumentou o tempo de permanência hospitalar, mas não a mortalidade.

OBJECTIVES: To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery. METHODS: Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05. RESULTS: Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9 percent vs. 2.2 percent, P <0.001), respiratory infection (27.8 percent vs 17.1 percent, P <0.001) and sepsis (6.2 percent vs. 2.5 percent, P <0.001). There were more episodes of atrial fibrillation (AF) (27 percent vs. 20.4 percent, P <0.001), acute renal failure (ARF) (14.5 percent vs 7.3 percent, P <0.001) and stroke (4.8 percent vs. 2.6 percent, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9 percent vs. 9.1 percent, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95 percent CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95 percent CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95 percent CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95 percent CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95 percent CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95 percent CI: 1.39-2.33, P <0.001). CONCLUSION: The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.

Tratamento adjuvante do melanoma com interferon / Adjuvant therapy of melanoma with interferon

Melanoma é um tumor maligno que cresce a partir de células melanocíticas, envolvendo principalmente a pele. Embora seja a neoplasia de pele menos freqüente, ela é responsável por 75% das mortes de câncer. Mesmo com as campanhas de prevenção, a incidência e a mortalidade por esta neoplasia continuam a aumentar. Atualmente, o diagnóstico precoce e a remoção cirúrgica adequada oferecem ao paciente a melhor chance de cura, mas as pessoas com alto risco de recorrência também devem realizar tratamento adjuvante, sendo o interferon o agente mais utilizado. Estudos evidenciam uma redução no risco de recorrência da doença e aumento na sobrevida global dos pacientes que utilizam este tratamento, embora este benefício esteja restrito a uma minoria. Análises de subgrupos apontam um maior benefício em pacientes que apresentam ulceração no tumor ou micrometástases linfonodais.

Suscetibilidade genética na lesão pulmonar aguda e síndrome da angústia respiratória aguda / Genetic susceptibility in acute lung injury and acute respiratory distress syndrome

A lesão pulmonar aguda e sua forma mais grave, a síndrome da angústia respiratória aguda, são o denominador comum de várias doenças que podem provocar uma inflamação exagerada nos pulmões. Nos últimos anos, essa variabilidade tem sido atribuída, pelo menos em parte, a fatores genéticos. O presente estudo tem por objetivos revisar o papel dos principais genes envolvidos na suscetibilidade, morbidade e mortalidade na lesão pulmonar aguda e na síndrome da angústia respiratória aguda. Através de pesquisa nas bases de dados PubMed e LiLACS, empregando-se os unitermos lesão pulmonar aguda, síndrome da angústia respiratória aguda e síndrome da angústia respiratória do adulto em combinação com polimorfismos genéticos, foram selecionados 69 artigos, dos quais 38 foram incluídos nesta revisão. Foram também considerados artigos relevantes extraídos das referências bibliográficas nos artigos selecionados das bases de dados. Os polimorfismos genéticos são variantes gênicas presentes em pelo menos 1 por cento da população. A presença destas variantes genéticas pode influenciar a expressão de mediadores da resposta inflamatória, afetando diretamente a suscetibilidade à lesão pulmonar aguda, a intensidade da inflamação no parênquima pulmonar, a evolução e o desfecho destes pacientes. Estudos de associação com grandes populações e passíveis de reprodução permitirão de modo definitivo a inclusão da genômica no arsenal diagnóstico, prognóstico e terapêutico de pacientes com lesão pulmonar aguda/síndrome da angústia respiratória aguda

Acute lung injury and its most severe presentation, acute respiratory distress syndrome, are a common denominator for several diseases which can lead to exaggerated lung inflammation. In the last years this variability has been ascribed, at least partially, to genetic issues. This study aims to review the role of the main genes involved in acute lung injury and acute respiratory distress syndrome susceptibility, morbidity and mortality. By search on PubMed and LiLACS databases, using the key words acute lung injury, acute respiratory distress syndrome and adult acute respiratory distress syndrome in combination with genetic polymorphisms, 69 papers were selected, from which 38 were included in this review. Were also considered relevant articles extracted from the reference lists in the articles selected from the databases. Genetic polymorphisms are gene variations in at least 1 percent population. These gene variations may influence the inflammatory response mediators' expression, directly affecting the susceptibility to acute lung injury, the intensity of lung parenchyma inflammation, the development clinical course and outcome. Association studies reproducible in large populations will definitely allow genomics to be included into the diagnostic and therapeutic armamentarium for acute lung injury/acute respiratory distress syndrome patients.

Sepse: uma visão atual: [revisão] / Sepsis: current aspects: [review]

Objetivos: esta revisão tem por objetivo discutir a epidemiologia, os mecanismos fisiopatológicos, os critérios diagnósticos e o tratamento da sepse em adultos. Fonte de dados: a pesquisa foi feita a partir dos descritores sepse, sepse grave e choque séptico, através da base de dados PubMed/Medline. Síntese dos dados: a sepse resulta de uma complexa interação entre o microorganismo infectante e a resposta imune, pró e anti-inflamatória e pró-coagulante do hospedeiro. A resposta do hospedeiro e as características do organismo infectante são as principais variáveis fisiopatológicas da doença. Seu tratamento sofreu profundas e significativas modificações na última década, principalmente a partir de uma campanha mundial, Surviving Sepsis Campaign, onde se estabeleceu uma rotina padrão para o atendimento desses pacientes. As medidas para o manejo da sepse grave incluem ressuscitação inicial, identificação do agente infeccioso, antibioticoterapia, controle do foco de infecção e suporte hemodinâmico em todos os casos. Corticosteróides, transfusão sanguínea e proteína C ativada devem ser empregados em casos selecionados. Conclusões: a sepse é a resposta complexa do hospedeiro à agressão de um patógeno. Seu tratamento baseia-se no controle do foco e no suporte hemodinâmico e das funções orgânicas.

Aims: This review aims to discuss the epidemiology, the pathophysiologic mechanisms, diagnosis criteria and treatment in adult population. Source of data: A search in PubMed/Medline was made, including sepsis, severe sepsis, and septic shock, as the key words. Summary of findings: Sepsis results from a complex interaction between the microorganism and the immune, pro and anti-inflammatory response and coagulation activation cascade of the host. The host response and the characteristics of the casual agent are the main pathophysiologic variables of the syndrome. The approach of the sepsis patients has suffered profound changes in the last decade, mainly after the Surviving Sepsis Campaign, with the standardization of management of these patients. The recommend treatment for these patients included a vigorous initial resuscitation, identification of the infectious agent, antibiotics, source control and hemodynamic support for all patients. Corticosteroid therapy, transfusion, and recombinant activated protein C should be used in selected cases. Conclusions: Sepsis is the complex response of the host to the invading microorganism. Its treatment consists in source control, and the support of hemodynamics and organ function.

Genetic susceptibility in acute lung injury and acute respiratory distress syndrome. / Suscetibilidade genética na lesão pulmonar aguda e síndrome da angústia respiratória aguda.

Acute lung injury and its most severe presentation, acute respiratory distress syndrome, are a common denominator for several diseases which can lead to exaggerated lung inflammation. In the last years this variability has been ascribed, at least partially, to genetic issues. This study aims to review the role of the main genes involved in acute lung injury and acute respiratory distress syndrome susceptibility, morbidity and mortality. By search on PubMed and LiLACS databases, using the key words acute lung injury, acute respiratory distress syndrome and adult acute respiratory distress syndrome in combination with genetic polymorphisms, 69 papers were selected, from which 38 were included in this review. Were also considered relevant articles extracted from the reference lists in the articles selected from the databases. Genetic polymorphisms are gene variations in at least 1% population. These gene variations may influence the inflammatory response mediators' expression, directly affecting the susceptibility to acute lung injury, the intensity of lung parenchyma inflammation, the development clinical course and outcome. Association studies reproducible in large populations will definitely allow genomics to be included into the diagnostic and therapeutic armamentarium for acute lung injury/acute respiratory distress syndrome patients.