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1.
Sci Rep ; 9(1): 20064, 2019 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-31882805

RESUMO

In young patients with acute pulmonary embolism (PE), the predictive value of currently available prognostic tools has not been evaluated. Our objective was to compare prognostic value of 7 available tools (GPS, PESI, sPESI, Prognostic Algorithm, PREP, shock index and RIETE) in patients aged <50 years. We used the RIETE database, including PE patients from 2001 to 2017. The major outcome was 30-day all-cause mortality. Of 34,651 patients with acute PE, 5,822 (17%) were aged <50 years. Of these, 83 (1.4%) died during the first 30 days. Number of patients deemed low risk with tools was: PREP (95.9%), GPS (89.6%), PESI (87.2%), Shock index (70.9%), sPESI (59.4%), Prognostic algorithm (58%) and RIETE score (48.6%). The tools with a highest sensitivity were: Prognostic Algorithm (91.6%; 95% CI: 85.6-97.5), RIETE score (90.4%; 95%CI: 84.0-96.7) and sPESI (88%; 95% CI: 81-95). The RIETE, Prognostic Algorithm and sPESI scores obtained the highest overall sensitivity estimates for also predicting 7- and 90-day all-cause mortality, 30-day PE-related mortality, 30-day major bleeding and 30-day VTE recurrences. The proportion of low-risk patients who died within the first 30 days was lowest using the Prognostic Algorithm (0.2%), RIETE (0.3%) or sPESI (0.3%) scores. In PE patients less 50 years, 30-day mortality was low. Although sPESI, RIETE and Prognostic Algorithm scores were the most sensitive tools to identify patients at low risk to die, other tools should be evaluated in this population to obtain more efficient results.

2.
Sci Rep ; 9(1): 15810, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31676856

RESUMO

Global change exposes ecosystems to a myriad of stressors differing in their spatial (i.e. surface of stressed area) and temporal (i.e. exposure time) components. Among freshwater ecosystems, rivers and streams are subject to physical, chemical and biological stressors, which interact with each other and might produce diverging effects depending on exposure time. We conducted a manipulative experiment using 24 artificial streams to examine the individual and combined effects of warming (1.6 °C increase in water temperature), hydrological stress (simulated low-flow situation) and chemical stress caused by pesticide exposure (15.1-156.7 ng L-1) on river biofilms. We examined whether co-occurring stressors could lead to non-additive effects, and if these differed at two different exposure times. Specifically, structural and functional biofilm responses were assessed after 48 hours (short-term effects) and after 30 days (long-term effects) of exposure. Hydrological stress caused strong negative impacts on river biofilms, whereas effects of warming and pesticide exposure were less intense, although increasing on the long term. Most stressor combinations (71%) resulted in non-significant interactions, suggesting overall additive effects, but some non-additive interactions also occurred. Among non-additive interactions, 59% were classified as antagonisms after short-term exposure to the different stressor combinations, rising to 86% at long term. Our results indicate that a 30-day exposure period to multiple stressors increases the frequency of antagonistic interactions compared to a 48-hour exposure to the same conditions. Overall, the impacts of multiple-stressor occurrences appear to be hardly predictable from individual effects, highlighting the need to consider temporal components such as duration when predicting the effects of multiple stressors.

3.
Semin Thromb Hemost ; 45(8): 793-801, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31614388

RESUMO

Patients with cirrhosis are not only at an increased risk of bleeding but also at risk of venous thromboembolism (VTE). We sought to determine the clinical characteristics, management, and outcomes after VTE in patients with cirrhosis. We used the data from RIETE (Registro Informatizado de la Enfermedad TromboEmbolica), an international registry of patients with VTE, to compare the outcomes in patients with and without cirrhosis. Main outcomes included all-cause mortality, pulmonary embolism (PE)-related mortality, recurrent VTE, and bleeding. Among 43,611 patients with acute VTE, 187 (0.4%) had cirrhosis. Of these, 184 (98.4%) received anticoagulation for a median of 109 days (interquartile range [IQR]: 43-201 days), most commonly with enoxaparin (median dose: 1.77 [IQR: 1.38-2.00] mg/kg/day). Compared with patients without cirrhosis, those with cirrhosis had a higher rate of all-cause mortality (10.7 vs. 3.4%; odds ratio [OR]: 3.41; 95% confidence interval [CI]: 2.03-5.46) and fatal bleeding (2.1 vs. 0.2%; OR: 13.94; 95% CI: 3.65-37.90) but similar rates of fatal PE (0.5 vs. 0.5%; OR: 1.17; 95% CI: 0.03-6.70). Patients with cirrhosis had a higher rate of all-cause mortality per 100 patient-years of follow-up (58.9 vs. 16.0; hazard ratio [HR]: 3.70; 95% CI: 2.69-4.91). One-year hazard ratio of clinically relevant bleeding (HR: 2.86; 95% CI: 1.91-4.27), fatal bleeding (HR: 8.51; 95% CI: 3.5-20.7), or recurrent VTE (HR: 2.08; 95% CI: 1.00-4.36) was higher in patients with cirrhosis. Cirrhosis is a challenging comorbidity in patients with VTE. Most patients were treated with anticoagulation and had an elevated risk of recurrence, similar risk of fatal PE, and a very high risk of bleeding including fatal bleeds.

4.
Sci Total Environ ; 674: 401-411, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31005842

RESUMO

Urban wastewater inputs are a relevant pollution source to rivers, contributing a complex mixture of nutrients, organic matter and organic microcontaminants to these systems. Depending on their composition, WWTP effluents might perform either as enhancers (subsidizers) or inhibitors (stressors) of biological activities. In this study, we evaluated in which manner biofilms were affected by treated urban WWTP effluent, and how much they recovered after exposure was terminated. We used indoor artificial streams in a replicated regression design, which were operated for a total period of 56 days. During the first 33 days, artificial streams were fed with increasing concentration of treated effluents starting with non-contaminated water and ending with undiluted effluent. During the recovery phase, the artificial streams were fed with unpolluted water. Sewage effluents contained high concentrations of personal care products, pharmaceuticals, nutrients, and dissolved organic matter. Changes in community structure, biomass, and biofilm function were most pronounced in those biofilms exposed to 58% to 100% of WWTP effluent, moving from linear to quadratic or cubic response patterns. The return to initial conditions did not allow for complete biofilm recovery, but biofilms from the former medium diluted treatments were the most benefited (enhanced response), while those from the undiluted treatments showed higher stress (inhibited response). Our results indicated that the effects caused by WWTP effluent discharge on biofilm structure and function respond to the chemical pressure only in part, and that the biofilm dynamics (changes in community composition, increase in thickness) imprint particular response pathways over time.


Assuntos
Biofilmes/crescimento & desenvolvimento , Monitoramento Ambiental , Eliminação de Resíduos Líquidos/métodos , Poluentes Químicos da Água/análise , Ecossistema , Rios/microbiologia
5.
Water Res ; 151: 371-380, 2019 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-30616049

RESUMO

While wastewater treatment plant (WWTP) effluents have become increasingly recognized as a stressor for receiving rivers, their effects on river microbial communities remain elusive. Moreover, global change is increasing the frequency and duration of desiccation events in river networks, and we ignore how desiccation might influence the response of microbial communities to WWTP effluents. In this study, we evaluated the interaction between desiccation events and WWTP effluents under different dilution capacities. Specifically, we used artificial streams in a replicated regressional design, exposing first a section of the streams to a 7-day desiccation period and then the full stream to different levels of a realistic WWTP effluent dilution, from 0% to 100% of WWTP effluent proportion of the total stream flow. The microbial community response was assessed by means of high-throughput sequencing of 16S rRNA gene amplicons and quantitative PCR targeting ecologically-relevant microbial groups. Threshold Indicator Taxa Analysis (TITAN) was used, together with model fitting, to determine community thresholds and potential indicator taxa. Results show significant interactions between WWTP effluents and desiccation, particularly when sediment type is considered. Indicator taxa included members of Proteobacteria, Actinobacteria and Cyanobacteria, with abrupt changes in community structure at WWTP effluent proportion of the total flow above 50%, which is related to nutrient levels ranging 4.6-5.2 mg N-NO3-L-1, 0.21-0.32 mg P-PO43-L-1 and 7.09-9.00 mg DOC L-1. Our work indicates that situations where WWTP effluents account for >50% of the total river flow might risk of dramatic microbial community structure changes and should be avoided.


Assuntos
Águas Residuárias , Poluentes Químicos da Água , Dessecação , RNA Ribossômico 16S , Rios
6.
Support Care Cancer ; 26(9): 3233-3239, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29627861

RESUMO

INTRODUCTION: The previously reported Patients' Experience of LIving with CANcer-associated thrombosis (PELICAN) identified several areas of unmet clinical and support need for cancer patients diagnosed with venous thromboembolism (VTE) in the UK. It is not known whether such experiences are restricted to one particular country's healthcare system and culture. We therefore undertook an evaluation of patients' experience of cancer-associated thrombosis (CAT) within a Spanish setting. METHODS: Twenty consecutive Spanish patients with CAT were interviewed about their experiences of living with CAT as per the previous PELICAN study. Where possible, spouses were interviewed in conjunction. Semi-structured interviews were audio recorded, transcribed and translated into English. Transcripts were coded using Nvivo software and data were analysed using framework analysis. A pragmatic approach was undertaken to allow explication of the potential cultural and operational differences that were not apparent in the UK dataset. RESULTS: Several commonalities between the UK and Spanish patients were identified including the traumatic nature of the experience, the need for information and adaptive behaviors through ritualisation. Within the major themes lay new themes as follows. (1) The traumatic experience of CAT impacted on the family dynamic with respect to discussions within the family unit and support needs of individuals other than the patient. It also had a profound impact on the patient's concept of self with increased awareness of their mortality and seriousness of the cancer. (2) The need for information extended to the family as well as the patients. This was needed at the point of CAT diagnosis as well as an opportunity to later address unanswered questions. (3) Adaptive behaviors were common with similar ritualisations seen in the UK patients. CONCLUSION: The distress experienced by patients with CAT is not isolated to the UK alone but is similar in Spanish patients as well. The patient information provided regarding LMWH injections is important, but there is a need to for patients and their families to be given additional information about CAT itself and future prognosis. CAT also has a profound impact on the patient's family who has similar support needs. It appears that there are several commonalities between UK and Spanish patients, as well as specific local issues. This study justifies expansion of the sampling to other countries.


Assuntos
Coleta de Dados/métodos , Neoplasias/complicações , Trombose/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Espanha , Trombose/patologia
8.
PLoS One ; 13(3): e0194673, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29558509

RESUMO

The usefulness of a diagnostic workup for occult cancer in patients with venous thromboembolism (VTE) is controversial. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to perform a nested case-control study to validate a prognostic score that identifies patients with unprovoked VTE at increased risk for cancer. We dichotomized patients as having low- (≤2 points) or high (≥3 points) risk for cancer, and tried to validate the score at 12 and 24 months. From January 2014 to October 2016, 11,695 VTE patients were recruited. Of these, 1,360 with unprovoked VTE (11.6%) were eligible for the study. At 12 months, 52 patients (3.8%; 95%CI: 2.9-5%) were diagnosed with cancer. Among 905 patients (67%) scoring ≤2 points, 22 (2.4%) had cancer. Among 455 scoring ≥3 points, 30 (6.6%) had cancer (hazard ratio 2.8; 95%CI 1.6-5; p<0.01). C-statistic was 0.63 (95%CI 0.55-0.71). At 24 months, 58 patients (4.3%; 95%CI: 3.3-5.5%) were diagnosed with cancer. Among 905 patients scoring ≤2 points, 26 (2.9%) had cancer. Among 455 patients scoring ≥3 points, 32 (7%) had cancer (hazard ratio 2.6; 95%CI 1.5-4.3; p<0.01). C-statistic was 0.61 (95%CI, 0.54-0.69). We validated our prognostic score at 12 and 24 months, although prospective cohort validation is needed. This may help to identify patients for whom more extensive screening workup may be required.


Assuntos
Detecção Precoce de Câncer/métodos , Neoplasias/complicações , Neoplasias/diagnóstico , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Bases de Dados Factuais , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Primárias Desconhecidas/complicações , Neoplasias Primárias Desconhecidas/diagnóstico , Prognóstico , Sistema de Registros , Projetos de Pesquisa , Fatores de Risco
9.
Br J Cancer ; 118(8): 1056-1061, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29588512

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. Outpatients with cancer should be periodically assessed for VTE risk, for which the Khorana score is commonly recommended. However, it has been questioned whether this tool is sufficiently accurate at identifying patients who should receive thromboprophylaxis. The present work proposes a new index, TiC-Onco risk score to be calculated at the time of diagnosis of cancer, that examines patients' clinical and genetic risk factors for thrombosis. METHODS: We included 391 outpatients with a recent diagnosis of cancer and candidates for systemic outpatient chemotherapy. All were treated according to standard guidelines. The study population was monitored for 6 months, and VTEs were recorded. The Khorana and the TiC-Onco scores were calculated for each patient and their VTE predictive accuracy VTEs was compared. RESULTS: We recorded 71 VTEs. The TiC-Onco risk score was significantly better at predicting VTE than the Khorana score (AUC 0.73 vs. 0.58, sensitivity 49 vs. 22%, specificity 81 vs. 82%, PPV 37 vs. 22%, and NPV 88 vs. 82%). CONCLUSIONS: TiC-Onco risk score performed significantly better than Khorana score at identifying cancer patients at high risk of VTE who would benefit from personalised thromboprophylaxis.


Assuntos
Modelos Genéticos , Neoplasias/genética , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/genética , Adulto , Idoso , Quimioprevenção/métodos , Quimioprevenção/estatística & dados numéricos , Estudos de Coortes , Feminino , Predisposição Genética para Doença , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Neoplasias/epidemiologia , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle
10.
Eur Respir J ; 51(5)2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29563169
11.
Clin Appl Thromb Hemost ; 24(3): 489-495, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28681634

RESUMO

In patients with venous thromboembolism (VTE), male sex has been associated with an increased risk of occult cancer. The influence of sex on clinical characteristics, treatment, cancer sites, and outcome has not been thoroughly investigated yet. We used the Registro Informatizado Enfermedad TromboEmbólica registry to compare the clinical characteristics, treatment strategies, cancer sites, and clinical outcomes in patients with VTE having occult cancer, according to sex. As of June 2014, 5864 patients were recruited, of whom 444 (7.6%; 95% confidence interval: 6.8-8.2) had occult cancer. Of these, 246 (55%) were men. Median time elapsed from VTE to occult cancer was 4 months (interquartile range: 2-8.4), with no sex differences. Women were older, weighed less, and were less likely to have chronic lung disease than men. The most common cancer sites were the lung (n = 63), prostate (n = 42), and colorectal (n = 29) in men and colorectal (n = 38), breast (n = 23), uterine (n = 18), hematologic (n = 17), or pancreas (n = 15) in women. Men were more likely to have lung cancer than women (2.18% vs 0.30%; P < .01) and less likely to have pancreatic cancer (0.17% vs 0.5%; P = .03). Interestingly, breast cancer was more likely found in women aged ≥50 years than in those aged <50 years (0.97% vs 0.14%; P = .03). This study highlights the existence of sex differences in patients with VTE having occult cancer. One in every 2 men had lung, prostate, or colorectal cancer. In women, there is a heterogeneity of cancer sites, increasing risk of breast cancer in those aged >50 years.


Assuntos
Neoplasias/etiologia , Fatores Sexuais , Tromboembolia Venosa/complicações , Adulto , Fatores Etários , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Sistema de Registros , Fatores de Tempo
12.
TH Open ; 2(2): e210-e217, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31249944

RESUMO

Background The natural history of patients with lung cancer and venous thromboembolism (VTE) has not been consistently evaluated. Methods We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to assess the clinical characteristics, time course, and outcomes during anticoagulation of lung cancer patients with acute, symptomatic VTE. Results As of May 2017, a total of 1,725 patients were recruited: 1,208 (70%) presented with pulmonary embolism (PE) and 517 with deep vein thrombosis (DVT). Overall, 865 patients (50%) were diagnosed with cancer <3 months before, 1,270 (74%) had metastases, and 1,250 (72%) had no additional risk factors for VTE. During anticoagulation (median, 93 days), 166 patients had symptomatic VTE recurrences (recurrent DVT: 86, PE: 80), 63 had major bleeding (intracranial 11), and 870 died. The recurrence rate was twofold higher than the major bleeding rate during the first month, and over threefold higher beyond the first month. Fifty-seven patients died of PE and 15 died of bleeding. Most fatal PEs (84%) and most fatal bleeds (67%) occurred within the first month of therapy. Nine patients with fatal PE (16%) died within the first 24 hours. Of 72 patients dying of PE or bleeding, 15 (21%) had no metastases and 29 (40%) had the VTE shortly after surgery or immobility. Conclusion Active surveillance on early signs and/or symptoms of VTE in patients with recently diagnosed lung cancer and prescription of prophylaxis in those undergoing surgery or during periods of immobilization might likely help prevent VTE better, detect it earlier, and treat it more efficiently.

13.
Thromb Haemost ; 117(8): 1630-1636, 2017 07 26.
Artigo em Inglês | MEDLINE | ID: mdl-28517021

RESUMO

Treatment of patients with cancer-associated venous thromboembolism (VTE) remains a major challenge. The modified Ottawa score is a clinical prediction rule evaluating the risk of VTE recurrences during the first six months of anticoagulant treatment in patients with cancer-related VTE. We aimed to validate the Ottawa score using data from the RIETE registry. A total of 11,123 cancer patients with VTE were included in the analysis. According to modified Ottawa score, 2,343 (21 %) were categorised at low risk for VTE recurrences, 4,525 (41 %) at intermediate risk, and 4,255 (38 %) at high risk. Overall, 477 episodes of VTE recurrences were recorded during the course of anticoagulant therapy, with an incidence rate for low, intermediate, and high risk groups of 6.88 % (95 % CI 5.31-8.77), 11.8 % (95 % CI 10.1-13.6), and 21.3 % (95 % CI 18.8-24.1) patient-years, respectively. Overall mortality had an incidence rate of 21.1 % (95 % CI 18.2-24.3), 79.4 % (95 % CI: 74.9-84.1), and 134.7 % (95 % CI: 128.3-141.4) patient-years, respectively. The accuracy and discriminating power of the modified Ottawa score for VTE recurrence was modest, with low sensitivity, specificity and positive predictive value, and a C-statistics of 0.58 (95 % CI: 0.56-0.61). In our analysis, the modified Ottawa score did not accurately predict VTE recurrence among patients with cancer-associated thrombosis, thus hindering its use in clinical practice. It is time to define a new score including other clinical predictors.


Assuntos
Técnicas de Apoio para a Decisão , Neoplasias/complicações , Embolia Pulmonar/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Trombose Venosa/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Valor Preditivo dos Testes , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/mortalidade , Trombose Venosa/diagnóstico , Trombose Venosa/etiologia , Trombose Venosa/mortalidade
14.
Crit Rev Oncol Hematol ; 113: 83-89, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28427527

RESUMO

BACKGROUND: Cancer patients are at high risk of venous thromboembolism, particularly during cancer treatment. Conversely to chemotherapy, data on the epidemiology and clinical features of venous thromboembolism during radiation therapy are scarce. There is lack of evidence on the influence of radiation therapy (RT) on outcome in cancer patients with acute venous thromboembolism (VTE). METHODS: We used the RIETE (Registro Informatizado de Enfermedad ThromboEmbolica) database to assess the clinical characteristics and outcome of prospectively-collected consecutive patients with cancer-associated thrombosis occurred during the course of radiation therapy for cancer. Death, venous thromboembolism recurrences and major bleeding rates during long-term follow-up according to cancer site and treatment were compared RESULTS: 9284 Patients with active cancer and VTE were enrolled in RIETE: 4605 with pulmonary embolism (PE) and 4679 with deep vein thrombosis (DVT). In all, 1202 (13%) were receiving RT. This last sub-population had a higher rate of PE recurrences and a similar rate of DVT recurrences or major bleeding than those not receiving RT. Patients on RT had a higher rate of cerebral bleeding. CONCLUSIONS: In this cohort of cancer patients with VTE, a significant proportion of them received RT before VTE, the latter experienced a higher risk of cerebral bleeding.


Assuntos
Neoplasias/radioterapia , Sistema de Registros , Tromboembolia Venosa/etiologia , Idoso , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Estudos Prospectivos , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Embolia Pulmonar/patologia , Radioterapia/efeitos adversos , Radioterapia/mortalidade , Recidiva , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/patologia , Trombose Venosa/epidemiologia , Trombose Venosa/etiologia , Trombose Venosa/patologia
15.
Oncotarget ; 8(13): 21930-21937, 2017 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-28423537

RESUMO

PAM50/Prosigna gene expression-based assay identifies three categorical risk of relapse groups (ROR-low, ROR-intermediate and ROR-high) in post-menopausal patients with estrogen receptor estrogen receptor-positive (ER+)/ HER2-negative (HER2-) early breast cancer. Low risk patients might not need adjuvant chemotherapy since their risk of distant relapse at 10-years is below 10% with endocrine therapy only. In this study, 517 consecutive patients with ER+/HER2- and node-negative disease were evaluated for Ki67 and Prosigna. Most of Luminal A tumors (65.6%) and ROR-low tumors (70.9%) had low Ki67 values (0-10%); however, the percentage of patients with ROR-medium or ROR-high disease within the Ki67 0-10% group was 42.7% (with tumor sizes ≤2 cm) and 33.9% (with tumor sizes > 2 cm). Finally, we found that the optimal Ki67 cutoff for identifying Luminal A or ROR-low tumors was 14%. Ki67 as a surrogate biomarker in identifying Prosigna low-risk outcome patients or Luminal A disease in the clinical setting is unreliable. In the absence of a well-validated prognostic gene expression-based assay, the optimal Ki67 cutoff for identifying low-risk outcome patients or Luminal A disease remains at 14%.


Assuntos
Biomarcadores Tumorais/genética , Neoplasias da Mama/tratamento farmacológico , Recidiva Local de Neoplasia/diagnóstico , Receptor ErbB-2/genética , Receptores Estrogênicos/genética , Medição de Risco/métodos , Tamoxifeno/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/genética , Quimioterapia Adjuvante , Feminino , Seguimentos , Perfilação da Expressão Gênica , Humanos , Incidência , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/genética , Prognóstico , Estudos Prospectivos
16.
Eur J Radiol ; 87: 66-75, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28065377

RESUMO

OBJECTIVE: To analyze the prognostic value of pulmonary artery obstruction versus right-ventricle (RV) dysfunction radiologic indices in cancer-related pulmonary embolism (PE). METHODS: We enrolled 303 consecutive patients with paraneoplastic PE, evaluated by computed tomography pulmonary angiography (CTPA) between 2013 and 2014. The primary outcome measure was serious complications at 15days. Multivariate analyses were conducted by using binary logistic and robust regressions. Radiological features such as the Qanadli index (QI) and RV dysfunction signs were analyzed with Spearman's partial rank correlations. RESULTS: RV diameter was the only radiological variable associated with an adverse outcome. Subjects with enlarged RV (diameter>45mm) had more 15-day complications (58% versus 40%, p=0.001). The QI correlated with the RV diameter (r=0.28, p<0.001), left ventricle diameter (r=-0.19, p<0.001), right ventricular-to-left ventricular diameter ratio (r=0.39, p<0.001), pulmonary artery diameter (r=0.22, p<0.001), and pulmonary artery/ascending aorta ratio (r=0.27, p<0.001). A QI≥50% was only associated with 15-day complications in subjects with enlarged RV, inverted intraventricular septum, or chronic cardiopulmonary diseases. The central or peripheral PE location did not affect the correlations among radiological variables and was not associated with clinical outcomes. CONCLUSIONS: Right ventricular dysfunction signs in CTPA are more useful than QI in predicting cancer-related PE outcome.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Neoplasias/complicações , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Artéria Pulmonar/diagnóstico por imagem , Reprodutibilidade dos Testes , Estudos Retrospectivos , Disfunção Ventricular Direita/fisiopatologia
17.
Eur Respir J ; 49(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28052954

RESUMO

The study aimed to identify predictors of overall 30-day mortality in cancer patients with pulmonary embolism including suspected pulmonary embolism (SPE) and unsuspected pulmonary embolism (UPE) events. Secondary outcomes included 30- and 90-day major bleeding and venous thromboembolism (VTE) recurrence.The study cohort included 1033 consecutive patients with pulmonary embolism from the multicentre observational ambispective EPIPHANY study (March 2006-October 2014). A subgroup of 497 patients prospectively assessed for the study were subclassified into three work-up scenarios (SPE, truly asymptomatic UPE and UPE with symptoms) to assess outcomes.The overall 30-day mortality rate was 14%. The following variables were associated with the overall 30-day mortality on multivariate analysis: VTE history, upper gastrointestinal cancers, metastatic disease, cancer progression, performance status, arterial hypotension <100 mmHg, heart rate >110 beats·min-1, basal oxygen saturation <90% and SPE (versus overall UPE).The overall 30-day mortality was significantly lower in patients with truly asymptomatic UPE events (3%) compared with those with UPE-S (20%) and SPE (21%) (p<0.0001). Thirty- and 90-day VTE recurrence and major bleeding rates were similar in all the groups.In conclusion, variables associated with the severity of cancer and pulmonary embolism were associated with short-term mortality. Our findings may help to develop pulmonary embolism risk-assessment models in this setting.


Assuntos
Neoplasias/complicações , Neoplasias/mortalidade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hemorragia/epidemiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Medição de Risco , Fatores de Risco , Espanha/epidemiologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Adulto Jovem
18.
Heliyon ; 3(1): e00229, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28119956

RESUMO

BACKGROUND: In cancer patients with symptomatic venous thromboembolism (VTE) (deep-vein thrombosis (DVT) and/or pulmonary embolism (PE)), clinical factors that influence the benefit-risk balance of anticoagulation need to be identified so treatment intensity and duration can be optimally adjusted for the individual patient. METHODS: Using clinical data for cancer patients with VTE obtained from the RIETE registry, we compared how rates of fatal PE and fatal bleeding during and after anticoagulation vary depending on patients' clinical characteristics. RESULTS: Data were analysed from the 10,962 cancer patients with VTE (5,740 with PE with or without DVT; 5,222 with DVT alone) in RIETE registry as of March 2016. Fatal PE occurred in 2.18% of patients, while fatal bleedings occurred in 1.55%. During the 12 months from initial VTE, fatal PE was the most common cause of death, after disseminating cancer, and bleeding the fourth most common. In patients initially presenting with PE, fatal PE during anticoagulation was 4-fold more frequent than fatal bleeding (204 vs 51 deaths) and occurred mostly during the first month of treatment (196/223, 88%). In patients initially presenting with DVT, fatal PE was 3-fold lower than fatal bleeding during (25 vs 85 deaths) and after anticoagulation treatment (8 vs 37 deaths). During the 12-month follow-up, other characteristics of cancer patients with VTE were identified as more common in fatal cases of PE and/or bleeding than in surviving cases. INTERPRETATION: Baseline clinical characteristics may determine anticoagulation outcomes in cancer patients with VTE and should be further investigated as possible factors for guiding changes in current practices of anticoagulation, such as adjusting anticoagulation intensity and duration in selected patients.

19.
Am J Med ; 130(3): 337-347, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27884650

RESUMO

BACKGROUND: We hypothesized that the clinical course of venous thromboembolism in patients with active cancer may differ according to the specificities of primary tumor site. AIM AND METHODS: We used data from RIETE (international registry of patients with venous thromboembolism) to compare the clinical venous thromboembolism-related outcomes during the course of anticoagulation in patients with one of the 4 more frequent cancers (breast, prostate, colorectal, or lung cancer). RESULTS: As of September 2014, 3947 cancer patients were recruited, of whom 938 had breast, 629 prostate, 1189 colorectal, and 1191 lung cancer. Overall, 55% had metastatic disease (42%, 36%, 53%, and 72%, respectively). During the course of anticoagulant therapy (mean duration, 139 days), the rate of thromboembolic recurrences was similar to the rate of major bleeding in patients with breast (5.6 [95% confidence interval (CI), 3.8-8.1] vs 4.1 [95% CI, 2.7-5.9] events per 100 patient-years) or colorectal cancer (10 [95% CI, 7.6-13] vs 12 [95% CI, 9.4-15] per 100 patient-years). In contrast, in patients with prostate cancer, the rate of venous thromboembolic recurrences was half the rate of major bleeding (6.9 [95% CI, 4.4-10] vs 13 [95% CI, 9.2-17] events per 100 patient-years), whereas in those with lung cancer, the rate of thromboembolic recurrences was twofold higher than the rate of major bleeding (27 [95% CI, 22-23] vs 11 [95% CI, 8.6-15] per 100 patient-years). CONCLUSIONS: Significant differences in the clinical profile of venous thromboembolic-related outcomes were observed according to the site of cancer. These findings suggest the development of cancer-specific anticoagulant strategies as an area for further research.


Assuntos
Neoplasias/complicações , Tromboembolia Venosa/etiologia , Idoso , Anticoagulantes/uso terapêutico , Neoplasias da Mama/complicações , Neoplasias da Mama/patologia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/patologia , Progressão da Doença , Feminino , Hemorragia/etiologia , Humanos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/complicações , Neoplasias da Próstata/patologia , Recidiva , Sistema de Registros , Resultado do Tratamento , Tromboembolia Venosa/patologia , Tromboembolia Venosa/terapia
20.
Eur Respir J ; 48(5): 1360-1368, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27660517

RESUMO

Current guidelines suggest treating cancer patients with incidental pulmonary embolism comparably to patients with symptomatic pulmonary embolism.We used the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) registry to compare the rate of major bleeding and symptomatic pulmonary embolism during the course of anticoagulation and after its discontinuation in cancer patients with incidental pulmonary embolism.As of March 2016, 715 cancer patients with incidental pulmonary embolism had been enrolled in RIETE. During the course of anticoagulant therapy (mean 235 days), the rate of major bleeding was higher than the rate of symptomatic pulmonary embolism (10.1 (95% CI 7.48-13.4) versus 3.17 (95% CI 1.80-5.19) events per 100 patient-years, respectively), and the rate of fatal bleeding was higher than the rate of fatal pulmonary embolism (2.66 (95% CI 1.44-4.52) versus 0.66 (95% CI 0.17-1.81) deaths per 100 patient-years, respectively). After discontinuing anticoagulation (mean follow-up 117 days), the rate of major bleeding was lower than the rate of symptomatic pulmonary embolism (3.00 (95% CI 1.10-6.65) versus 8.37 (95% CI 4.76-13.7) events per 100 patient-years, respectively); however, there were no differences in the rate of fatal events at one death each.The risk/benefit ratio of anticoagulant therapy in cancer patients with incidental pulmonary embolism is uncertain and must be evaluated in further studies.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Embolia Pulmonar/complicações , Embolia Pulmonar/tratamento farmacológico , Idoso , Anticoagulantes/efeitos adversos , Feminino , Hemorragia , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/prevenção & controle , Sistema de Registros , Medição de Risco , Terapia Trombolítica , Resultado do Tratamento
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