Real-world Imatinib Mesylate Treatment in Patients with Chronic Myeloid Leukemia: The Importance of Molecular Monitoring and the Early Molecular Response.

INTRODUCTION: Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder characterized by the Philadelphia (Ph) chromosome. After the introduction of imatinib mesylate (IM) in 2000, the natural history of the disease changed. Data on the treatment of CML with IM are from randomized clinical trials. Establishing whether these results can be reproduced or if caution is needed when extrapolating data to the general population with CML is essential. OBJECTIVES: To evaluate the molecular response (MR) in patients with chronic-phase CML (CML-CP) not included in clinical studies and correlate them with the responses obtained in clinical trials. METHODS: Between January 2007 and January 2017, 227 patients newly diagnosed with CML-CP treated with IM as first-line treatment were included. This study is an observational, retrospective, and single-center study. RESULTS: At a median follow-up time of 7.3 years, 60.3% of the 227 patients who started IM were still on IM. Early molecular response (EMR) at 3 and 6 months was achieved by 74.2% and 65%, respectively. The median time to a MMR was nine months. The MR4.0 and MR4.5 were 67.2% and 51.1%, respectively. The overall survival (OS), progression-free survival (PFS), and event-free survival (EFS) of the patients who exclusively used IM were 91%, 91%, and 85.1%, respectively. CONCLUSION: The results presented are similar to those described in prospective and randomized trials, demonstrating that the outcomes are reproducible in the real world. EMR at 3 and 6 months reflects better long-term responses, including higher rates of deeper molecular responses. Considering treatment costs, the absence of literature evidence of an impact on overall survival demonstrated by first-line second-generation tyrosine kinase inhibitors (TKIs), and the global OS of 85.8%, imatinib mesylate (IM) is still an excellent therapeutic option.

Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians

ABSTRACT Introduction: Early integration between palliative care and other medical specialties in the care of patients with serious illnesses is consolidating itself as good medical practice, based on scientific and ethical evidence. Despite this, palliative care is still not part of the routine care of patients with hematological diseases, even in specialized centers. Objective and method: In this article, we review the benefits and the main barriers described in the literature for early integration of hematology and palliative care. We also point out the challenges encountered in clinical practice, such as end-of-life prognosis assessment in patients with hematological diseases and management of the most common symptoms in hematology. Finally, we review models of integration between palliative care and oncology centers in outpatient and inpatient settings. Results and conclusion: Patients with hematological diseases can greatly benefit from early integration with palliative care, with improvement in symptom control, quality of life, reduction of emotional distress and the development of advanced care directives. It is necessary to make hematologists aware of the benefits of palliative care, provide adequate training for multidisciplinary teams and encourage specific studies of palliative care in patients with hematological diseases.

Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians.

INTRODUCTION: Early integration between palliative care and other medical specialties in the care of patients with serious illnesses is consolidating itself as good medical practice, based on scientific and ethical evidence. Despite this, palliative care is still not part of the routine care of patients with hematological diseases, even in specialized centers. OBJECTIVE AND METHOD: In this article, we review the benefits and the main barriers described in the literature for early integration of hematology and palliative care. We also point out the challenges encountered in clinical practice, such as end-of-life prognosis assessment in patients with hematological diseases and management of the most common symptoms in hematology. Finally, we review models of integration between palliative care and oncology centers in outpatient and inpatient settings. RESULTS AND CONCLUSION: Patients with hematological diseases can greatly benefit from early integration with palliative care, with improvement in symptom control, quality of life, reduction of emotional distress and the development of advanced care directives. It is necessary to make hematologists aware of the benefits of palliative care, provide adequate training for multidisciplinary teams and encourage specific studies of palliative care in patients with hematological diseases.

Endoscopic and pharmacological secondary prophylaxis in children and adolescents with esophageal varices.

OBJECTIVE: The aim of this study was to describe the results of endoscopic secondary prophylaxis, alone or in combination with propranolol, used to prevent upper gastrointestinal bleeding (UGIB) in children and adolescents with esophageal varices. METHODS: This observational study followed 43 patients younger than 18 years who received secondary prophylaxis between August 2001 and December 2009. Sclerotherapy and/or band ligation were performed, and propranolol was used when no contraindications were present. The rebleeding rate, number of endoscopic sessions required for variceal eradication, rate of varix recurrence, the occurrence of varices at the gastric fundus, and the occurrence of portal hypertensive gastropathy were evaluated. RESULTS: Endoscopic prophylaxis in combination with propranolol was performed in 25 patients (58.1%) and endoscopic prophylaxis alone was performed in 18 patients (41.9%). Esophageal varices were eradicated in all of the patients after a median of 3 sessions. Varices recurred in 22 patients (51.2%). Rebleeding occurred in 13 patients (30.2%). Fundal varices and portal hypertensive gastropathy developed in 31% and 61.9% of patients, respectively. No deaths related to the endoscopic procedure or UGIB occurred. No statistically significant differences in any of the studied variables were observed when comparing endoscopic prophylaxis with propranolol and endoscopic prophylaxis alone. CONCLUSIONS: No significant differences were observed between sclerotherapy and band ligation. Secondary prophylaxis was effective in eradicating esophageal varices. The use of propranolol did not affect the results of the endoscopic prophylaxis. Furthermore, randomized studies will be necessary to assess the best form of prevention during childhood.

Criança entre oito e doze anos: uma oportunidade a ser explorada para identificação e abordagem de problemas sociais / Children at age of 8 to 12 years: An opportunity to identify and approach social problems

Objetivo: chamar a atenção para a necessidade de busca ativa que possibilite a identificação de crianças ainda na idade escolar que já apresentem riscos de transgressão, a partir do relato de dois casos. Métodos: no ano de 2009, todas as crianças entre oito e 12 anos atendidas no Projeto Social Conviver no Carmo foram avaliadas pelos alunos de Medicina da UFMG. As crianças eram levadas à consulta médica e atendidas individualmente ou em grupo de três. Foram identificadas algumas com problemas sociais graves e até já iniciando atividades contraventoras. A abordagem das crianças envolveu acompanhamento multidisciplinar: médico, psicológico e com assistente social, além das ações afirmativas (esportes, música, dança, artes). Resultados: a partir da análise do discurso dos pacientes antes e depois da abordagem observou-se que houve mudança da perspectiva de vida, planejamentos para o futuro e comportamento social adequado dos indivíduos abordados. Conclusões: este trabalho demonstra a necessidade e a eficácia de ações voltadas para a criança e o adolescente na idade escolar, especificamente na faixa etária entre oito e 13 anos. Ressalta também a importância de busca ativa por esses jovens em situações de risco social e sugere mais eficácia da intervenção quando realizada precocemente, ao início da adolescência.

Objective: To introduce two case reports to draw the attention to the need of proactively seeking out school-age children that are prone to commit future transgressions. Methods: In 2009 UFMG medicine students assessed all children aging from 8 to 12 years that attended the Social Project ?Conviver?. Children were scheduled medical appointmentsand assessed individually or in groups of three. Some were diagnosed with serious social problems and some had already committed infractions. Children were followed up through a multidisciplinary approach: medical, psychological, and social work, as well as affirmative actions (sports, music, dance, arts). Results: The analysis of patients? discourse before and after intervention pointed to change of perspective of life, development of future plans, and adequate social behavior. Conclusions: This case report shows the need and efficiency of actions aimed at school-age children and teenagers (more specifically those aging from 8 to 13 years). It also points to the importance of proactively seeking out children living at social risk and suggests that intervention tends to be more effective when carried out early in adolescence.

Profilaxia secundária endoscópica e medicamentosa em crianças e adolescentes com varizes esofágicas / Endoscopic and pharmacologic secondary prophylaxis in children and adolescents with esophageal varices

Hipertensão porta é uma síndrome clínica decorrente de doenças hepáticas e hepáticas, tendo como principal complicação a hemorragia digestiva alta por sangramento de varizes esofagianas. O objetivo deste artigo é apresentar revisão atualizada sobre profilaxia secundária de varizes esofagianas em crianças e adolescentes, a partir de revisão da literatura dos últimos 30 anos, A profilaxia secundária está indicada a todos os pacientes com sangramento de varizes esofagianas. Em adultos, o método considerado de melhor eficácia é o uso combinado de beta-bloqueador e ligadura elástica. Na infância, não existe consenso sobre a melhor forma de profilaxia e a maioria dos estudos são relatos de séries de casos. A terapia endoscópica tem apresentado eficácia de 80 a 100% em erradicar as varizes esofágicas. O único estudo randomizado em pediatria que comparou os métodos endoscópicos foi mais favorável à ligadura elástica. Poucos estudos relatam o uso do propranolol na infância. Somente um estudo, não randomiza- do, comparou escleroterapia isolada ou associada ao propranolol e não foi observado benefício com a associação. Desta forma, não há consenso sobre a melhor forma de realizar profilaxia secundária na criança. A terapia endoscópica tem se mostrado eficaz em erradicar as varizes esofágicas, porém, o papel do propranolol em pediatria ainda precisa ser definido.

Portal hypertension is a clinical syndrome resulting from hepatic and extra-hepatic diseases. Its main complication is high digestive hemorrhage from esophageal varices bleeding. The aim of this work is to present an updated revision on secondary prophylaxis of esophageal varices bleeding in children and adolescents through a revision of the literature from the past thirty years. The secondary prophylaxis is appropriated to ali the patients with esophageal varices bleeding. In adults, the method of better efficiency is considered to be the combined use of betablockers and endoscopic band ligation. As for childhood, there is not a consensus on the best form of prophylaxis and most of the studies are reports of series of cases. The endoscopic treatment has been presenting efficiency in eradicating from 80 to 100 % of the esophageal varices. The only randomized study in pediatrics that compared the endoscopics methods was more favorable to the endoscopic band ligation. Few studies report the use of propranolol in the childhood. Only one study, not randomized, compared endoscopic sclerotherapy isolated ar associated to propranolol and benefit was not observed with the association. Thus, there is no consensus on the best form of carrying out secondary prophylaxis in the child. The endoscopic therapy has shown itself efficient in eradicating the esophageal varices. The role of propranolol in pediatrics still needs to be defined.