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1.
JAMA ; 326(2): 165-176, 2021 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-34255003

RESUMO

Importance: Alcohol-associated liver disease results in cirrhosis in approximately 10% to 20% of patients. In 2017, more than 2 million people had alcohol-associated cirrhosis in the US. Alcohol-associated liver disease is the primary cause of liver-related mortality and the leading indication for liver transplant, representing 40% to 50% of all liver transplant in high-income countries. Observations: Steatosis, alcoholic hepatitis, and fibrosis are the 3 pathologic findings that are associated with progression to cirrhosis, with highest risk in patients with alcoholic hepatitis. The amount and duration of alcohol consumption, female sex, obesity, and specific genetic polymorphisms such as patatin-like phospholipase domain protein 3, membrane bound O-acyltransferase, and transmembrane 6 superfamily member 2 genes are risk factors for alcohol-associated liver disease progression. Ten-year survival of patients with alcohol-associated liver disease is 88% among those who are abstinent and 73% for those who relapse to alcohol consumption. Symptomatic alcoholic hepatitis is characterized by rapid onset of jaundice and a 30% risk of mortality 1 year after diagnosis. Severe alcoholic hepatitis, defined as a modified discriminant function score greater than or equal to 32 or Model for End-Stage Liver Disease score (starts at 6 and capped at 40; worst = 40) greater than 20, is associated with the development of acute-on-chronic liver failure and multiorgan failure. Corticosteroid therapy is associated with improved 1-month survival from 65% in untreated patients to 80% in treated patients. Early liver transplant may be appropriate in highly select patients with severe alcoholic hepatitis who do not respond to medical therapy. In patients with decompensated cirrhosis, liver transplant should be considered if the Model for End-Stage Liver Disease score remains greater than 17 after 3 months of alcohol abstinence. Between 2014 and 2019, the proportion of patients waiting for liver transplantation who had alcohol-associated liver disease increased from 22% to 40%. Alcohol-associated cirrhosis accounted for approximately 27% of 1.32 million deaths worldwide related to cirrhosis in 2017. Conclusions and Relevance: Alcohol-associated liver disease is among the most common liver diseases and more than 2 million people in the US in 2017 had alcohol-associated cirrhosis. Corticosteroid therapy improves survival in select patients with severe alcoholic hepatitis. Liver transplantation is the most effective therapy in patients with decompensated liver disease.


Assuntos
Corticosteroides/uso terapêutico , Hepatopatias Alcoólicas , Transplante de Fígado , Fígado/patologia , Abstinência de Álcool , Consumo de Bebidas Alcoólicas/efeitos adversos , Feminino , Humanos , Fígado/metabolismo , Hepatopatias Alcoólicas/diagnóstico , Hepatopatias Alcoólicas/genética , Hepatopatias Alcoólicas/terapia , Masculino , Fatores de Risco , Índice de Gravidade de Doença
4.
Acta Biomed ; 92(3): e2021165, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34212932

RESUMO

To date, there is still a lack of unanimity regarding the definition of exacerbation of asthma and COPD and about objective measurements in the currently used criteria. The aim of our study was to conduct a survey among general practitioners (GPs) and pulmonologists regarding the clinical criteria arbitrarily considered as important to start a course of systemic corticoids and/or antibiotics in asthma and COPD. We conducted a survey enrolling 50 general practitioners (GPs) and 50 pulmonologists, that evaluated the clinical criteria arbitrated as essential to start a course of systemic corticosteroids or antibiotics during asthma and/or COPD exacerbations. Our results demonstrated incongruities between GPs and pulmonologist and within the same professional category concerning systemic corticosteroids. Conversely, we showed higher consensus between and within the groups about criteria to prescribe antibiotics.


Assuntos
Asma , Doença Pulmonar Obstrutiva Crônica , Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Asma/tratamento farmacológico , Humanos , Itália , Prescrições , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Pneumologistas
6.
Int J Mol Sci ; 22(12)2021 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-34205487

RESUMO

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been associated with excess mortality worldwide. The cardiovascular system is the second most common target of SARS-CoV-2, which leads to severe complications, including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism, as well as other major thrombotic events because of direct endothelial injury and an excessive systemic inflammatory response. This review focuses on the similarities and the differences of inflammatory pathways involved in COVID-19 and atherosclerosis. Anti-inflammatory agents and immunomodulators have recently been assessed, which may constitute rational treatments for the reduction of cardiovascular events in both COVID-19 and atherosclerotic heart disease.


Assuntos
Aterosclerose/patologia , COVID-19/patologia , Corticosteroides/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Aterosclerose/complicações , Aterosclerose/tratamento farmacológico , Aterosclerose/prevenção & controle , COVID-19/complicações , COVID-19/tratamento farmacológico , COVID-19/virologia , Quimiocinas/metabolismo , Síndrome da Liberação de Citocina/etiologia , Citocinas/metabolismo , Humanos , Prognóstico , SARS-CoV-2/isolamento & purificação , SARS-CoV-2/metabolismo
7.
Arch. argent. pediatr ; 119(3): e247-e251, Junio 2021. ilus
Artigo em Espanhol | LILACS, BINACIS | ID: biblio-1248216

RESUMO

La reacción a drogas con eosinofilia y síntomas sistémicos es una reacción adversa cutánea rara, potencialmente grave. Puede presentar fiebre, erupción cutánea polimorfa, edema facial y/o linfoadenopatías. La reactivación del virus herpes humano tipo 6 se asocia a un curso más grave y/o prolongado.Un lactante de 22 meses en tratamiento con fenobarbital presentó lesiones eritematopapulares, fiebre, leucocitosis, proteína C reactiva elevada y alteración de pruebas hepáticas. Se realizó biopsia de piel compatible con reacción adversa a drogas. Se trató con corticoides sistémicos e inmunoglobulina intravenosa sin respuesta. La reacción en cadena de la polimerasa para virus herpes humano tipo 6 resultó positiva. Se inició ciclosporina más prednisona, con buena respuesta. Existe poca evidencia del uso de ciclosporina en adultos, cuando los corticoides sistémicos son inefectivos. Este es el primer reporte pediátrico Podría ser una alternativa efectiva o un complemento de los corticosteroides sistémicos cuando no responde a tratamientos convencionales.


Drug reaction with eosinophilia and systemic symptoms is a rare and potentially serious skin adverse reaction, with fever, polymorphous skin rash, facial edema, and/or lymphadenopathy. Reactivation of human herpes virus type 6 has been associated with a more severe and/or prolonged course. A 22-month-old infant under phenobarbital treatment developed erythematous-papular lesions, fever, leukocytosis, elevated C-reactive protein, and abnormal liver tests. The skin biopsy was compatible with an adverse drug reaction. Treatment with systemic corticosteroids and intravenous immunoglobulin had no response. Polymerase chain reaction for human herpesvirus type 6 was positive, and cyclosporine plus prednisone was started with a good response. There is little evidence for the use of cyclosporine in adults when systemic corticosteroids are ineffective. This is the first report of pediatric drug reaction with eosinophilia and systemic symptoms treated with cyclosporine, which could be an effective alternative or an adjunct to systemic corticosteroid therapy unresponsive to conventional treatments.


Assuntos
Humanos , Masculino , Lactente , Herpesvirus Humano 6 , Síndrome de Hipersensibilidade a Medicamentos/diagnóstico , Ciclosporina/uso terapêutico , Corticosteroides/uso terapêutico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Eosinofilia , Síndrome de Hipersensibilidade a Medicamentos/complicações , Síndrome de Hipersensibilidade a Medicamentos/terapia
8.
Arch. argent. pediatr ; 119(3): e229-e233, Junio 2021. ilus
Artigo em Espanhol | LILACS, BINACIS | ID: biblio-1248132

RESUMO

La pancreatitis recurrente ocurre en el 15-35% en la edad pediátrica. Se define como 2 o más episodios distintos de pancreatitis aguda con normalización de enzimas pancreáticas entre cada episodio. Una de sus causas es la pancreatitis autoinmune. En los últimos 10 años se controlaron, en el Hospital Garrahan, 10 pacientes con diagnóstico de pancreatitis recurrente, de los cuales solo uno tuvo diagnóstico de pancreatitis autoinmune. Se describe el caso clínico de una paciente, que, inicialmente, tenía estudios normales de función y anatomía pancreática y, en la evolución, luego de un episodio de pancreatitis aguda, desarrolló estenosis del conducto de Wirsung sugestiva de pancreatitis autoinmune. Se considera importante describir esta patología infrecuente en pediatría, pero que se encuentra en auge.


Introduction. Recurrent pancreatitis occurs in children between 15 and 35% of the cases. It is defined as two or more separate episodes of acute pancreatitis with normalization of the pancreatic enzymes between episodes. One of the causes is autoimmune pancreatitis. Over the last 10 years, 10 patients with recurrent pancreatitis were sent at our center. Only one was considered to have autoimmune pancreatitis. We described a clinical case about a patient, who had, at the beginning, normal functional and anatomical studies, and then was finally diagnosed with autoimmune disease based on findings on the magnetic resonance cholangiopancreatography with a duct of Wirsung abnormality. We considered important to describe this uncommon disorder in childhood, in spite of having an increasing incidence.


Assuntos
Humanos , Feminino , Criança , Pancreatite Autoimune/diagnóstico , Doenças Autoimunes , Prednisona/administração & dosagem , Corticosteroides/uso terapêutico , Pancreatite Autoimune/terapia
9.
BMC Infect Dis ; 21(1): 506, 2021 May 31.
Artigo em Inglês | MEDLINE | ID: mdl-34058989

RESUMO

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with acute respiratory distress syndrome, and corticosteroids have been considered as possible therapeutic agents for this disease. However, there is limited literature on the appropriate timing of corticosteroid administration to obtain the best possible patient outcomes. METHODS: This was a retrospective cohort study including patients with severe COVID-19 who received corticosteroid treatment from March 2 to June 30, 2020 in seven tertiary hospitals in South Korea. We analyzed the patient demographics, characteristics, and clinical outcomes according to the timing of steroid use. Twenty-two patients with severe COVID-19 were enrolled, and they were all treated with corticosteroids. RESULTS: Of the 22 patients who received corticosteroids, 12 patients (55%) were treated within 10 days from diagnosis. There was no significant difference in the baseline characteristics. The initial PaO2/FiO2 ratio was 168.75. The overall case fatality rate was 25%. The mean time from diagnosis to steroid use was 4.08 days and the treatment duration was 14 days in the early use group, while those in the late use group were 12.80 days and 18.50 days, respectively. The PaO2/FiO2 ratio, C-reactive protein level, and cycle threshold value improved over time in both groups. In the early use group, the time from onset of symptoms to discharge (32.4 days vs. 60.0 days, P = 0.030), time from diagnosis to discharge (27.8 days vs. 57.4 days, P = 0.024), and hospital stay (26.0 days vs. 53.9 days, P = 0.033) were shortened. CONCLUSIONS: Among patients with severe COVID-19, early use of corticosteroids showed favorable clinical outcomes which were related to a reduction in the length of hospital stay.


Assuntos
Corticosteroides/uso terapêutico , COVID-19/tratamento farmacológico , Idoso , COVID-19/diagnóstico , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , República da Coreia , Síndrome do Desconforto Respiratório , Estudos Retrospectivos
10.
J Assoc Physicians India ; 69(5): 50-55, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34189887

RESUMO

Introduction: Steroids are recommended as the standard of care in managing severe COVID-19. However, several questions remain unanswered regarding the prescription of steroids which led to differing opinions and practice. We surveyed practice patterns of critical care physicians in India for the use of corticosteroids in COVID-19. Methods: This was a nationwide, cross-sectional, online, knowledge attitude practice-based survey, among intensivists for corticosteroid use in COVID-19. The survey questionnaire had seven questions for demographic data and 14 questions in the core survey. Results: 384 responses were analyzed from different parts of the country. A majority (81.2%) agreed that steroids improved oxygenation and survival chances. 88.3% agreed that steroids are indicated because of their anti-inflammatory properties, and should be prescribed in patients with moderate (75.8%), severe (59.9%), or critical (41.1%) COVID-19. 68.8% of physicians start steroids on the basis of "need for oxygen therapy" and hyperglycemia (85.2%) was the most commonly reported complication. 59.1% prefer prescribing methylprednisolone followed by Dexamethasone (38.8%). 51.8% preferred to use low dose steroids, and 59.1% have used "pulse steroids''. Rather than a fixed duration of therapy, 66.9% of the respondents rely on "clinical improvement" before stopping steroids, even if it meant continuing steroids for prolonged periods beyond 14 days (34.1%). 57.8% always taper steroids before stopping. Conclusions: We found wide variation in the practice patterns of critical care physicians in India for use of Corticosteroids in COVID-19. The dilemma regarding when to initiate, type of steroid, dose, and duration of therapy still persist emphasizing the need for further research.


Assuntos
COVID-19 , Médicos , Corticosteroides/uso terapêutico , Cuidados Críticos , Estudos Transversais , Humanos , Índia , Padrões de Prática Médica , SARS-CoV-2
11.
J Wound Care ; 30(6): 492-496, 2021 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-34121430

RESUMO

OBJECTIVE: Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. METHODS: A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. RESULTS: A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. CONCLUSIONS: SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.


Assuntos
Corticosteroides/uso terapêutico , Queimaduras/terapia , Imunoglobulinas Intravenosas/uso terapêutico , Imunossupressores/uso terapêutico , Síndrome de Stevens-Johnson/tratamento farmacológico , Cicatrização , Adulto , Idoso , Unidades de Queimados , Queimaduras/mortalidade , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Síndrome de Stevens-Johnson/mortalidade , Resultado do Tratamento
13.
PLoS One ; 16(6): e0252576, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34081722

RESUMO

Inhaled Corticosteroids (ICS) are commonly prescribed to patients with severe COPD and recurrent exacerbations. It is not known what impact ICS cause in terms of COVID-19 positivity or disease severity in COPD. This study examined 27,810 patients with COPD from the Cleveland Clinic COVID-19 registry between March 8th and September 16th, 2020. Electronic health records were used to determine diagnosis of COPD, ICS use, and clinical outcomes. Multivariate logistic regression was used to adjust for demographics, month of COVID-19 testing, and comorbidities known to be associated with increased risk for severe COVID-19 disease. Amongst the COPD patients who were tested for COVID-19, 44.1% of those taking an ICS-containing inhaler tested positive for COVID-19 versus 47.2% who tested negative for COVID-19 (p = 0.033). Of those who tested positive for COVID-19 (n = 1288), 371 (28.8%) required hospitalization. In-hospital outcomes were not significantly different when comparing ICS versus no ICS in terms of ICU admission (36.8% [74/201] vs 31.2% [53/170], p = 0.30), endotracheal intubation (21.9% [44/201] vs 16.5% [28/170], p = 0.24), or mortality (18.4% [37/201] vs 20.0% [34/170], p = 0.80). Multivariate logistic regression demonstrated no significant differences in hospitalization (adj OR 1.12, CI: 0.90-1.38), ICU admission (adj OR: 1.31, CI: 0.82-2.10), need for mechanical ventilation (adj OR 1.65, CI: 0.69-4.02), or mortality (OR: 0.80, CI: 0.43-1.49). In conclusion, ICS therapy did not increase COVID-19 related healthcare utilization or mortality outcome in patients with COPD followed at the Cleveland Clinic health system. These findings should encourage clinicians to continue ICS therapy for COPD patients during the COVID-19 pandemic.


Assuntos
Corticosteroides/uso terapêutico , COVID-19/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Corticosteroides/administração & dosagem , Corticosteroides/farmacologia , Agonistas de Receptores Adrenérgicos beta 2/efeitos adversos , Adulto , Idoso , COVID-19/complicações , Teste para COVID-19 , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas Muscarínicos/uso terapêutico , Nebulizadores e Vaporizadores , Pandemias , Doença Pulmonar Obstrutiva Crônica/complicações , Sistema de Registros , SARS-CoV-2/efeitos dos fármacos , SARS-CoV-2/patogenicidade
14.
Medicine (Baltimore) ; 100(22): e25919, 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34087834

RESUMO

ABSTRACT: Most of the reports about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children reported mild-to-moderate disease manifestations. However, recent reports explored a rare pediatric multisystem syndrome possibly associated with SARS-CoV-2 infection termed multisystem inflammatory syndrome in children (MIS-C).The study prospectively enrolled 5 patients with clinical and laboratory evidence of MIS-C associated with SARS-CoV-2 infection. They were admitted to the pediatric intensive care unit (PICU). Their clinical presentation, laboratory, and outcome were described.All patients shared similar clinical presentations such as persistent documented fever for more than 3 days, respiratory symptoms, gastrointestinal involvement, and increased inflammatory markers (CRP, ESR, and ferritin). Three patients had concurrent positive coronavirus disease 2019 (COVID-19) infection, and the other 2 patients had contact with suspected COVID-19 positive patients. They were all managed in the PICU and received intravenous immunoglobulin, systemic steroid, and hydroxychloroquine. The hospital stays ranged between 3 and 21 days. One patient died due to severe multiorgan failures and shock, and the other 4 patients were discharged with good conditions.Pediatric patients with SARS-CoV-2 are at risk for MIS-C. MIS-C has a spectrum of clinical and laboratory presentations, and the clinicians need to have a high index of suspicion for the diagnosis and should initiate its early treatment to avoid unfavorable outcomes. Long-term follow-up studies will be required to explore any sequelae of MIS-C, precisely the cardiovascular complications.


Assuntos
COVID-19/epidemiologia , COVID-19/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia , Corticosteroides/uso terapêutico , Anti-Inflamatórios/uso terapêutico , COVID-19/tratamento farmacológico , Criança , Pré-Escolar , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Imunoglobulinas/uso terapêutico , Mediadores da Inflamação/metabolismo , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação , Masculino , Estudos Prospectivos , SARS-CoV-2 , Arábia Saudita/epidemiologia , Índice de Gravidade de Doença , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico
15.
Medicine (Baltimore) ; 100(22): e26090, 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34087853

RESUMO

RATIONALE: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a chronic inflammatory disorder of the central nervous system. It is characterized by the appearance on magnetic resonance imaging of punctate and curvilinear gadolinium enhancement in the pons and cerebellum, and is exquisitely responsive to steroid treatment. The etiology of CLIPPERS remains unclear, although its pathogenesis reflects immune-mediated processes. The accurate diagnosis of this disease is very important for both its management and prognosis. PATIENT CONCERNS: A 43-year-old woman presented with clinical and radiological features suggestive of CLIPPERS. Whole-exome sequencing of the patient's DNA revealed 76 mutations. DIAGNOSES: The patient was clinically diagnosed with CLIPPERS. INTERVENTIONS: Hormone therapy was administered intravenously upon hospitalization and then gradually reduced to an oral dose. OUTCOMES: The clinical symptoms and imaging manifestations of the patient improved rapidly. This patient was followed up for more than 1 year, and there has been no recurrence or aggravation. LESSONS: A gene variation library of CLIPPERS syndrome was established, which lays the foundation for the further accumulation of data, and will allow the etiology and pathogenesis of the disease to be explored.


Assuntos
Doenças do Sistema Nervoso Central/patologia , Inflamação/patologia , Corticosteroides/uso terapêutico , Adulto , Doenças do Sistema Nervoso Central/tratamento farmacológico , Doenças do Sistema Nervoso Central/genética , Feminino , Humanos , Inflamação/tratamento farmacológico
16.
J Clin Neurosci ; 89: 381-388, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34083111

RESUMO

Primary central nervous system lymphoma (PCNSL) is a rare and aggressive form of extra-nodal non-Hodgkin's lymphoma. Corticosteroids cause transient regression of PCNSL at the radiological and histological level. A growing number of case reports describe histologically confirmed neuroinflammation (sentinel lesions) heralding the development of PCNSL. We present two further cases of sentinel lesions contextualised by a review of past literature. Our aims are to collate existing knowledge on sentinel lesions in PCNSL and explore their pathophysiological significance. Two cases were identified (n = 2) from a cohort of 104 patients with PCNSL referred to a tertiary neurosurgery centre. A literature search identified previously reported cases (n = 14). Median age was 57.5 (range; 26-72); pre-biopsy corticosteroid administration was reported in 50% of cases (n = 8); mean time between biopsies was 10 months (range; 3-60). Common MRI features were homogenous enhancement (10;71.4%) and T2-hyperintensity (11;100%). Histochemical analysis of sentinel lesion biopsy revealed inflammatory CD3/4/5/8-positive T-cells (14; 100%), demyelination (13; 81.3%), rare/scattered CD20-postive B-cells (11;78.6%) and CD68-positive macrophages (10;71.4%). Repeat biopsy confirmed PCNSL in all cases. Waxing and waning CNS inflammation has been identified in 16 patients ultimately diagnosed with PCNSL. Neuro-specialists should be aware of this atypical presentation and maintain a high index of suspicion for lymphoma despite histopathology negative for lymphoma when clinical or radiological features indicate PCNSL.


Assuntos
Neoplasias do Sistema Nervoso Central/patologia , Linfoma não Hodgkin/patologia , Corticosteroides/uso terapêutico , Adulto , Idoso , Anti-Inflamatórios/uso terapêutico , Biópsia , Neoplasias do Sistema Nervoso Central/sangue , Neoplasias do Sistema Nervoso Central/diagnóstico por imagem , Feminino , Humanos , Inflamação/sangue , Inflamação/tratamento farmacológico , Inflamação/patologia , Linfoma não Hodgkin/sangue , Linfoma não Hodgkin/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Radiografia , Linfócitos T/metabolismo , Linfócitos T/patologia
17.
Int J Chron Obstruct Pulmon Dis ; 16: 1461-1475, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34103906

RESUMO

Background: The long-acting anticholinergic (LAMA) aclidinium was approved in Europe in 2012 to relieve symptoms in adults with chronic obstructive pulmonary disease (COPD). A Post-Authorisation Safety Study (PASS) was initiated to assess potential cardiovascular safety concerns for aclidinium. Objective: To estimate the adjusted incidence rate ratio (IRR) for hospitalisation for heart failure in patients with COPD who were new users of aclidinium, tiotropium, other LAMA, long-acting beta-agonists/inhaled corticosteroids (LABA/ICS), and LAMA/LABA were compared with initiators of LABA. Methods: This population-based cohort study included patients with COPD aged ≥40 years initiating COPD medications in the Clinical Practice Research Datalink (CPRD) GOLD in the United Kingdom from 2012 to 2017. Medications were identified via general practice prescriptions. The first-ever hospitalisations for heart failure were identified in the Hospital Episode Statistics, and general practitioner records from the CPRD. Poisson regression models were used to estimate the IRR for hospitalisation for heart failure in users of COPD medications versus LABA, adjusting for clinically relevant covariates. Results: The study included 4350 new users of aclidinium, 23,405 of tiotropium, 6977 of other LAMAs, 3122 of LAMA/LABA, 26,093 of LABA/ICS, and 5678 of LABA. Mean age was 69-70 years across medication groups. Aclidinium users had the highest proportion of severe COPD, and LABA users had the lowest (35% vs 19%, respectively). Crude incidence rates per 1000 person-years for the first-ever hospitalisation for heart failure ranged from 6.9 in LABA to 9.5 in aclidinium. Using LABA as reference, adjusted IRRs (95% confidence interval) for first-ever hospitalisation for heart failure were 0.90 (0.53-1.53) for aclidinium, 1.02 (0.69-1.51) for tiotropium, 0.86 (0.50-1.47) for other LAMAs, 1.09 (0.41-2.92) for LAMA/LABA, and 1.01 (0.69, 1.48) for LABA/ICS. Conclusion: The study did not find increased risks of hospitalisations for heart failure in new users of aclidinium, tiotropium, other LAMAs, LAMA/LABA, and LABA/ICS compared with LABA.


Assuntos
Insuficiência Cardíaca , Doença Pulmonar Obstrutiva Crônica , Administração por Inalação , Corticosteroides/uso terapêutico , Agonistas de Receptores Adrenérgicos beta 2/efeitos adversos , Adulto , Idoso , Broncodilatadores/efeitos adversos , Estudos de Coortes , Quimioterapia Combinada , Europa (Continente)/epidemiologia , Insuficiência Cardíaca/induzido quimicamente , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização , Humanos , Antagonistas Muscarínicos/efeitos adversos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Reino Unido/epidemiologia
18.
PLoS One ; 16(6): e0252591, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34115801

RESUMO

INTRODUCTION: During the early months of the COVID-19 pandemic, mortality associated with the disease declined in the United States. The standard of care for pharmacological interventions evolved during this period as new and repurposed treatments were used alone and in combination. Though these medications have been studied individually, data are limited regarding the relative impact of different medication combinations. The objectives of this study were to evaluate the association of COVID-19-related mortality and observed medication combinations and to determine whether changes in medication-related practice patterns and measured patient characteristics, alone, explain the decline in mortality seen early in the COVID-19 pandemic. METHODS: A retrospective cohort study was conducted at a multi-hospital healthcare system exploring the association of mortality and combinations of remdesivir, corticosteroids, anticoagulants, tocilizumab, and hydroxychloroquine. Multivariable logistic regression was used to identify predictors of mortality for both the overall population and the population stratified by intensive care and non-intensive care unit admissions. A separate model was created to control for the change in unmeasured variables over time. RESULTS: For all patients, four treatment combinations were associated with lower mortality: Anticoagulation Only (OR 0.24, p < 0.0001), Anticoagulation and Remdesivir (OR 0.25, p = 0.0031), Anticoagulation and Corticosteroids (OR 0.53, p = 0.0263), and Anticoagulation, Corticosteroids and Remdesivir (OR 0.42, p = 0.026). For non-intensive care unit patients, the same combinations were significantly associated with lower mortality. For patients admitted to the intensive care unit, Anticoagulation Only was the sole treatment category associated with decreased mortality. When adjusted for demographics, clinical characteristics, and all treatment combinations there was an absolute decrease in the mortality rate by 2.5% between early and late periods of the study. However, when including an additional control for changes in unmeasured variables overtime, the absolute mortality rate decreased by 5.4%. CONCLUSIONS: This study found that anticoagulation was the most significant treatment for the reduction of COVID-related mortality. Anticoagulation Only was the sole treatment category associated with a significant decrease in mortality for both intensive care and non-intensive care patients. Treatment combinations that additionally included corticosteroids and/or remdesivir were also associated with decreased mortality, though only in the non-intensive care stratum. Further, we found that factors other than measured changes in demographics, clinical characteristics or pharmacological interventions accounted for an additional decrease in the COVID-19-related mortality rate over time.


Assuntos
Monofosfato de Adenosina/análogos & derivados , Corticosteroides/uso terapêutico , Alanina/análogos & derivados , Anticorpos Monoclonais Humanizados/uso terapêutico , Anticoagulantes/uso terapêutico , Antivirais/uso terapêutico , COVID-19/tratamento farmacológico , Hidroxicloroquina/uso terapêutico , Pandemias , SARS-CoV-2/isolamento & purificação , Monofosfato de Adenosina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Alanina/uso terapêutico , COVID-19/epidemiologia , COVID-19/mortalidade , COVID-19/virologia , Atenção à Saúde/métodos , Quimioterapia Combinada , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologia
19.
PLoS One ; 16(6): e0253465, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34161387

RESUMO

INTRODUCTION: This study was aimed to identify risk factors associated with unfavorable outcomes (composite outcome variable: mortality and need for mechanical ventilation) in patients hospitalized in Galicia with COVID-19 pneumonia. METHODS: Retrospective, multicenter, observational study carried out in the 8 Galician tertiary hospitals. All Patients admitted with confirmed COVID-19 pneumonia from 1st of March to April 24th, 2020 were included. A multivariable logistic regression analysis was performed in order to identify the relationship between risk factors, therapeutic interventions and the composite outcome variable. RESULTS: A total of 1292 patients (56.1% male) were included. Two hundred and twenty-five (17.4%) died and 327 (25.3%) reached the main outcome variable. Age [odds ratio (OR) = 1.03 (95% confidence interval (CI): 1.01-1.04)], CRP quartiles 3 and 4 [OR = 2.24 (95% CI: 1.39-3.63)] and [OR = 3.04 (95% CI: 1.88-4.92)], respectively, Charlson index [OR = 1.16 (95%CI: 1.06-1.26)], SaO2 upon admission [OR = 0.93 (95% CI: 0.91-0.95)], hydroxychloroquine prescription [OR = 0.22 (95%CI: 0.12-0.37)], systemic corticosteroids prescription [OR = 1.99 (95%CI: 1.45-2.75)], and tocilizumab prescription [OR = 3.39 (95%CI: 2.15-5.36)], significantly impacted the outcome. Sensitivity analysis using different alternative logistic regression models identified consistently the ratio admissions/hospital beds as a predictor of the outcome [OR = 1.06 (95% CI: 1.02-1.11)]. CONCLUSION: These findings may help to identify patients at hospital admission with a higher risk of death and may urge healthcare authorities to implement policies aimed at reducing deaths by increasing the availability of hospital beds.


Assuntos
Antivirais/uso terapêutico , COVID-19/mortalidade , COVID-19/terapia , Corticosteroides/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , Comorbidade , Feminino , Hospitais/estatística & dados numéricos , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Resultado do Tratamento
20.
Yonsei Med J ; 62(7): 608-614, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34164958

RESUMO

PURPOSE: We aimed to investigate clinical outcomes between top-down (TD) and conventional step-up (SU) therapies in pediatric patients with moderate to severe ulcerative colitis (UC). MATERIALS AND METHODS: All patients underwent clinical and endoscopic evaluation at diagnosis and 4 months and 1 year after treatment. Patients who started treatment with corticosteroid were grouped in the SU group, while those that initiated early infliximab (IFX) were grouped in the TD group. Among the SU group, patients who eventually changed to IFX treatment due to steroid resistance or dependency were included in the SU(R) group. RESULTS: In total, 44 children with moderate to severe UC were included for analysis. Twenty-one patients were included in the SU group, 23 were included in the TD group, and 10 were enrolled in the SU(R) group. Relapse rates were 47.6% (10/21) in the SU group and 17.4% (4/23) in the TD group (p=0.033). Among relapsed patients, the durations from remission to relapse were 17.3 months (0.9-46.9) in the SU group and 24.3 months (1.8-44.9) in the TD group. There was no statistically significant difference in the sustained durations of remission after IFX administration between the SU(R) and TD groups [3.9 (1.4-6.3) and 2.3 (0.3-5.2) years, respectively (p>0.05)]. CONCLUSION: According to our study, early use of IFX without corticosteroid treatment for children with moderate to severe UC helps to lower relapse rates. We also found that IFX was a very effective treatment for pediatric UC, with a sustained duration of remission similar between TD and SU(R) groups.


Assuntos
Colite Ulcerativa , Corticosteroides/uso terapêutico , Criança , Colite Ulcerativa/tratamento farmacológico , Fármacos Gastrointestinais/uso terapêutico , Humanos , Infliximab/uso terapêutico , Indução de Remissão , Estudos Retrospectivos , Resultado do Tratamento
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