Potential interactions between antineoplastic agents and medicines used to treat Covid-19.

INTRODUCTION: Cancer patients with Covid-19 are exposed to treatment combinations that can potentially result in interactions that adversely affect patient outcomes. This study aimed to identify potential drug-drug interactions between antineoplastic agents and medicines used to treat Covid-19. METHODS: We conducted a search for potential interactions between 201 antineoplastic agents and 26 medicines used to treat Covid-19 on the Lexicomp® and Micromedex® databases. The following data were extracted: interaction severity ("major" and "contraindicated") and interaction effects (pharmacokinetic and pharmacodynamic). We also sought to identify the therapeutic indication of the antineoplastic drugs involved in the potential drug-drug interactions. RESULTS: A total of 388 "major" or "contraindicated" drug-drug interactions were detected. Eight drugs or combinations (baricitinib, lopinavir/ritonavir, atazanavir, darunavir, azithromycin, chloroquine, hydroxychloroquine, and sirolimus) accounted for 91.5% of these interactions. The class of antineoplastic agents with the greatest potential for interaction was tyrosine kinase inhibitors (accounting for 46.4% of all interactions). The findings show that atazanavir, baricitinib, and lopinavir/ritonavir can affect the treatment of all common types of cancer. The most common pharmacokinetic effect of the potential drug-drug interactions was increased plasma concentration of the antineoplastic medicine (39.4%). CONCLUSIONS: Covid-19 is a recent disease and pharmacological interventions are undergoing constant modification. This study identified a considerable number of potential drug-drug interactions. In view of the vulnerability of patients with cancer, it is vital that health professionals carefully assess the risks and benefits of drug combinations.

Gynecological history to diagnosis and pregnancy outcomes in diagnosed Wilson's disease patients under therapy - A bicentric matched-control cohort study.

INTRODUCTION: most studies narrowly focus on pregnancy outcome comparisons between Wilson's disease (WD) patients on and off treatment. We aimed to identify menses irregularities in untreated WD, and to evaluate pregnancy outcomes in treated WD patients as compared to matched controls (with and without liver disease). METHODS: females with WD, hepatitis C (liver disease controls), and other gastrointestinal conditions (controls without liver disease) were identified at two tertiary hospital gastroenterology departments. Gynecological and obstetric data were retrospectively collected. A comparison of gynecological and obstetric outcomes was performed between the groups, and regression models were used to further assess obstetric outcomes. RESULTS: a total of 18 females with WD were identified, comprising 19 pregnancies under treatment in 11 patients, and 20 females were included in each control group. Age and liver disease stage were adjusted between groups. The incidence of menses irregularities was higher for WD (late menarche, 83 % vs. 10 % vs. 10 %, p < 0.01; irregular cycles, 100 % vs. 20 % vs. 20 %, p < 0.01; amenorrhea, 67 % vs. 10 % vs. 5 %, p < 0.01). Logistic regression models identified WD as a predictor of miscarriage and low birth weight (OR: 6.0; CI: 1.1-33.3; p < 0.05) but not of birth defects. Neither therapies (D-penicillamine 300 mg or zinc acetate 150 mg) nor disease presentation (hepatic and/or neurological) were associated with obstetric complications in WD subjects. CONCLUSION: there was a higher incidence of menses irregularities in untreated females with WD. In addition, our data suggest that treated WD still carries a higher risk of spontaneous abortion and low birth weight when compared to matched control groups with and without liver disease.

Association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma.

BACKGROUND: This study aimed to evaluate the association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma. METHODS: We enrolled, in a retrospective cohort, 239 women treated with carboplatin and paclitaxel between 2008 and 2017. Pretreatment computed tomography scans were used to quantify skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and subcutaneous adipose tissue index (SATI). Chemotherapy doses, related toxicities, potential drug-drug interactions (DDI), and clinical variables were collected from medical records. Outcomes were the number of adverse events ≥ grade 3 toxicity, toxicity-induced modification of treatment (TIMT), and three-year survival. RESULTS: Average age was 56.3 years and 35.1% had myopenia. Almost 33% had TIMT and 51.3% presented any grade 3 toxicity. Potential severe DDI occurred in 48.1% of the patients and 65.1% died three years after the first treatment. The SMD and SATI below the median were independent predictors for the number of adverse events ≥ grade 3 and TIMT. Also, SMD was the only body composition parameter able to predict reduced three-year survival. The SMI was not associated with any of the outcomes. CONCLUSION: Fewer amounts of SATI and low SMD were associated with the occurrence of toxicity to chemotherapy, and the low SMD increased the risk of death in the three years after oncologic treatment.

Cytotoxic effects of a chlorhexidine mouthwash and of an enzymatic mouthwash on human gingival fibroblasts.

The aim of this study was to evaluate the cytotoxic effects of an enzymatic mouthwash and of a chlorhexidine mouthwash on human gingival fibroblasts. The metabolic activity of the fibroblasts exposed to each mouthwash was assessed by the MTT assay and the protein content was assessed by the SRB assay. The flow cytometry was used to evaluate the cell cycle and the types of cell death. The oxidative status was evaluated through the DCF and the DHE probes and the intracellular GSH concentration and the mitochondrial membrane potential through JC-1. The cytotoxicity of both mouthwashes was found to be dependent on the exposure time and on the concentration. However, the cytotoxicity of the enzymatic mouthwash was found to be lower than that of the chlorhexidine mouthwash. A trend towards increased oxidative stress was observed for both mouthwashes. After exposing the fibroblasts to the mouthwashes, a G2/M phase block was observed and cell death occurred predominantly by necrosis. The effects of chlorhexidine on fibroblasts were identified at lower concentrations than those used in clinical practice. Therefore, the use of chlorhexidine as an antiseptic in surgical and postoperative situations should be limited. In order to clarify the clinical significance of the enzymatic mouthwash cytotoxicity new clinical studies will be necessary.

Cancer care in Brazil: structure and geographical distribution.

BACKGROUND: The organisation and systematisation of health actions and services are essential to ensure patient safety and the effectiveness and efficiency of cancer care. The objective of this study was to analyse the structure of cancer care envisaged in Brazilian norms, describe the types of accreditations of cancer services and their geographic distribution, and determine the planning and evaluation parameters used to qualify the health units that provide cancer care in Brazil. METHODS: This observational study identified the current organisation of cancer care and other health services that are accredited by Brazil's national health system (SUS) for cancer treatment as of February 2017. The following information was collected from the current norms and the National Registry of Health Establishments: geographic location, type of accreditation, type of care, and hospital classification according to annual data of the number of cancer surgeries. The adequacy of the number of licensed units relative to population size was assessed. The analysis considered the facilitative or restrictive nature of policies based on the available rules and resources. RESULTS: The analysis of the norms indicated that these documents serve as structuring rules and resources for developing and implementing cancer care policies in Brazil. A total of 299 high-complexity oncology services were identified in facilities located in 173 (3.1%) municipalities. In some states, there were no authorised services in radiotherapy, paediatric oncology and/or haematology-oncology. There was a significant deficit in accredited oncology services. CONCLUSIONS: The parameters that have been used to assess the need for accredited cancer services in Brazil are widely questioned because the best basis of calculation is the incidence of cancer or disease burden rather than population size. The results indicate that the availability of cancer services is insufficient and the organisation of the cancer care network needs to be improved in Brazil.

Intramural hematoma of the esophagus after thrombolysis for ischemic stroke.

Intramural dissecting hematoma is an unusual esophageal condition with a threatening presentation but excellent prognosis when managed conservatively.We report the case of an 88-year-old woman who developed an intramural hematoma of the esophagus after intravenous thrombolysis for an acute ischemic stroke. Before thrombolysis, nasogastric intubation was attempted unsuccessfully. She was kept on nil by mouth, intravenous hydration, proton pump inhibitor, antiemetics,and an antibiotic initiated 2 days before for periodontal disease. The esophageal hematoma regressed, and she resumed oral diet asymptomatically.To our knowledge, this is the first report of this type of lesion after thrombolysis for an ischemic stroke. A brief discussion and literature review are presented.

Endoscopic Retrograde Cholangiopancreatography on Pediatric Patients: Experience of a Portuguese Adult Gastroenterology Department.

Introduction: Experience with endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population is limited. Few medical centers have experts specifically trained in pediatric therapeutic endoscopy. As a result, patients are generally referred to adult endoscopists with high experience in the procedure. The aim of this study was to characterize the experience of an adult endoscopy unit with ERCP on pediatric patients, with a special focus on very young patients. Methods: We retrospectively analyzed indications, technical success rate, final clinical diagnosis, and complications of ERCPs in children <18 years at our tertiary referral hospital center between January 1994 and June 2022. Results: Sixty-five ERCPs were performed on 57 children with a median age of 13 years (range 1-17 years). Eleven ERCPs were performed on 9 patients up to 5 years old. Indications for ERCP were as follows: biliary obstruction (n = 40), mainly due to choledocholithiasis, lithiasic acute pancreatitis (n = 19), recurrent pancreatitis (n = 3), stent extraction (n = 2), and post-operative biliary fistula (n = 1). The cannulation success rate was 95.1%. Therapeutic interventions were performed in 79% of ERCP. All patients were followed up as inpatients. Complications were recorded in two procedures (3.1%), and no procedure-related mortality occurred. Conclusion: In our experience, ERCP in children can be safely performed with high success rates by advanced adult-trained expert endoscopists at a high-volume center.

Introdução: Existe pouca experiência na realização de colangiopancreatografia retrógrada endoscópica (CPRE) na população pediátrica. A maioria dos centros carece de especialistas especificamente treinados em endoscopia terapêutica pediátrica, sendo os doentes geralmente referenciados para Gastroenterologistas de adultos com elevada experiência na técnica. O objectivo deste estudo foi caracterizar a experiência de um departamento de Gastrenterologia de adultos em CPRE pediátrica, com destaque particular nos doentes muito novos. Métodos: Foram analisadas retrospectivamente as indicações, sucesso técnico, diagnósticos e complicações das colangiopancreatografias retrógradas endoscópicas (CPREs) realizadas no nosso hospital terciário em crianças <18 anos, entre Janeiro de 1994 e Junho de 2022. Resultados: Foram realizadas 65 CPREs em 57 crianças com idade mediana 13 anos (1­17 anos). Doze procedimentos foram realizados em 9 crianças com idade até 5 anos. As indicações para CPRE foram: obstrução biliar (n = 40), sobretudo devido a coledocolitíase, pancreatite aguda litiásica (n = 19), pancreatite recorrente (n = 3), extracção de prótese (n = 2) e fístula biliar pós cirurgia (n = 1). A taxa de sucesso de canulação foi 95.4%. Foram realizados procedimentos terapêuticos em 80.0% das CPREs. Todos os doentes foram vigiados em regime de internamento, tendo-se registado complicações em dois exames (3.1%). Não existiram mortes relacionadas com a técnica. Discussão/ Conclusão: A CPRE pode ser realizada na população pediátrica com segurança e elevada taxa de sucesso por Gastrenterologistas de adultos com experiência na técnica, num centro com elevado volume de exames.

Effects of low dose computed tomography (LDCT) on lung cancer screening on incidence and mortality in regions with high tuberculosis prevalence: A systematic review.

BACKGROUND: Lung cancer screening (LCS) using low-dose computed tomography (LDCT) is a strategy for early-stage diagnosis. The implementation of LDCT screening in countries with a high prevalence/incidence of tuberculosis (TB) is controversial. This systematic review and meta-analysis aim to identify whether LCS using LDCT increases early-stage diagnosis and decreases mortality, as well as the false-positive rate, in regions with a high prevalence of TB. METHODS/DESIGN: Studies were identified by searching BVS, PUBMED, EMBASE, and SCOPUS. RCT and cohort studies (CS) that show the effects of LDCT in LC screening on mortality and secondary outcomes were eligible. Two independent reviewers evaluated eligibility and a third judged disagreements. We used the Systematic Review Data Repository (SRDR+) to extract the metadata and record decisions. The analyses were stratified by study design and incidence of TB. We used the Cochrane "Risk of bias" assessment tool. RESULTS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used. Thirty-seven papers were included, referring to 22 studies (10 RCTs and 12 cohorts). Few studies were from regions with a high incidence of TB (One RCT and four cohorts). Nonetheless, the evidence is compatible with European and USA studies. RCTs and CS also had consistent results. There is an increase in early-stage (I-II) diagnoses and reduced LC mortality in the LCDT arm compared to the control. Although false-positive rates varied, they stayed within the 20 to 30% range. DISCUSSION: This is the first meta-analysis of LDCT for LCS focused on its benefits in regions with an increased incidence/prevalence of TB. Although the specificity of Lung-RADS was higher in participants without TB sequelae than in those with TB sequelae, our findings point out that the difference does not invalidate implementing LDCT LCS in these regions. TRIAL REGISTRATION: Systematic review registration Systematic review registration PROSPERO CRD42022309581.

Smoking, mortality, access to diagnosis, and treatment of lung cancer in Brazil.

INTRODUCTION: Lung cancer (LC) is a relevant public health problem in Brazil and worldwide, given its high incidence and mortality. Thus, the objective of this study is to analyze the distribution of smoking and smoking status according to sociodemographic characteristics and disparities in access, treatment, and mortality due to LC in Brazil in 2013 and 2019. METHOD: Retrospective study of triangulation of national data sources: a) analysis of the distribution of smoking, based on the National Survey of Health (PNS); b) investigation of LC records via Hospital-based Cancer Registry (HCR); and c) distribution of mortality due to LC in the Mortality Information System (SIM). RESULTS: There was a decrease in the percentage of people who had never smoked from 2013 (68.5%) to 2019 (60.2%) and in smoking history (pack-years). This was observed to be greater in men, people of older age groups, and those with less education. Concerning patients registered in the HCR, entry into the healthcare service occurs at the age of 50, and only 19% have never smoked. While smokers in the population are mainly Mixed-race, patients in the HCR are primarily White. As for the initial stage (I and II), it is more common in White people and people who have never smoked. The mortality rate varied from 1.00 for people with higher education to 3.36 for people without education. Furthermore, White people have a mortality rate three times higher than that of Black and mixed-race people. CONCLUSION: This article highlighted relevant sociodemographic disparities in access to LC diagnosis, treatment, and mortality. Therefore, the recommendation is to strengthen the Population-Based Cancer Registry and develop and implement a nationwide LC screening strategy in Brazil since combined prevention and early diagnosis strategies work better in controlling mortality from the disease and continued investment in tobacco prevention and control policies.

Influence of solvents and composition of etch-and-rinse and self-etch adhesive systems on the nanoleakage within the hybrid layer.

AIM: The goal of this study was to evaluate nanoleakage within the hybrid layer yielded by etch-and-rinse and self-etch adhesive systems, with different solvents and compositions. MATERIALS AND METHODS: Four adhesives were applied onto 20 human dentin disks: group A: Adper Scotchbond 1XT(™) (3M ESPE), group B: One Coat Bond(®) (Coltène Whaledent), group C: AdheSE(®) (Ivoclar Vivadent) and group D: Xeno-V(®) (Dentsply). The samples were immersed in aqueous ammoniacal silver nitrate for 24 hour, prepared and observed under field-emission scanning electron microscopy with backscattered electrons. Microphotographs were scanned and data were processed. The mean value and standard deviation were calculated. Kruskal- Wallis and Mann-Whitney tests were used (p < 0.05). RESULTS: All the adhesives showed nanoleakage within the hybrid layer: Adper Scotchbond 1XT(™) (218.5 µm ± 52.6 µm), One Coat Bond(®) (139.6 µm ± 79.0 µm), AdheSE(®) (92.7 µm ± 64.8 µm) and Xeno-V(®) (251.0 µm ± 85.2 µm). AdheSE(®) yielded less nanoleakage than Adper Scotchbond-1XT(™) (p = 0.003) and than Xeno-V(®) (p = 0.007). No other statistically significant differences were detected. CONCLUSION: Two-step self-etch adhesive system (AdheSE(®)) might contribute for lower nanoleakage deposition and thus better performance in dentin adhesion. CLINICAL SIGNIFICANCE: The two-step self-etch adhesive system showed the lowest nanoleakage deposition compared with the other adhesive systems evaluated, which seems to indicate a better behavior when a restoration is performed in dentin and possibly can lead to a durable adhesion along time.

Lung Cancer Screening in Brazil Comparing the 2013 and 2021 USPSTF Guidelines.

Importance: It is estimated that, from 2023 to 2025, lung cancer (LC) will be the second most frequent cancer in Brazil, but the country does not have an LC screening (LCS) policy. Objective: To compare the number of individuals eligible for screening, 5-year preventable LC deaths, and years of life gained (YLG) if LC death is averted by LCS, considering 3 eligibility strategies by sociodemographic characteristics. Design, Setting, and Participants: This comparative effectiveness research study assessed 3 LCS criteria by applying a modified version of the LC-Death Risk Assessment Tool (LCDRAT) and the LC-Risk Assessment Tool (LCRAT). Data are from the 2019 Brazilian National Household Survey. Participants included ever-smokers aged 50 to 80 years. Data analysis was performed from February to May 2023. Exposures: Exposures included ever-smokers aged 50 to 80 years, US Preventive Services Task Force (USPSTF) 2013 guidelines (ever-smokers aged 55 to 80 years with ≥30 pack-years and <15 years since cessation), and USPSTF 2021 guidelines (ever-smokers aged 50 to 80 years with 20 pack-years and <15 years since cessation). Main Outcomes and Measures: The primary outcomes were the numbers of individuals eligible for LCS, the 5-year preventable deaths attributable to LC, and the number of YLGs if death due to LC was averted by LCS. Results: In Brazil, the eligible population for LCS was 27 280 920 ever-smokers aged 50 to 80 years (13 387 552 female [49.1%]; 13 249 531 [48.6%] aged 50-60 years; 394 994 Asian or Indigenous [1.4%]; 3 111 676 Black [11.4%]; 10 942 640 Pardo [40.1%]; 12 830 904 White [47.0%]; 12 428 536 [45.6%] with an incomplete middle school education; and 12 860 132 [47.1%] living in the Southeast region); 5 144 322 individuals met the USPSTF 2013 criteria for LCS (2 090 636 female [40.6%]; 2 290 219 [44.5%] aged 61-70 years; 66 430 Asian or Indigenous [1.3%]; 491 527 Black [9.6%]; 2 073 836 Pardo [40.3%]; 2 512 529 [48.8%] White; 2 436 221 [47.4%] with an incomplete middle school education; and 2 577 300 [50.1%] living in the Southeast region), and 8 380 279 individuals met the USPSTF 2021 LCS criteria (3 507 760 female [41.9%]; 4 352 740 [51.9%] aged 50-60 years; 119 925 Asian or Indigenous [1.4%]; 839 171 Black [10.0%]; 3 330 497 Pardo [39.7%]; 4 090 687 [48.8%] White; 4 022 784 [48.0%] with an incomplete middle school education; and 4 162 070 [49.7%] living in the Southeast region). The number needed to screen to prevent 1 death was 177 individuals according to the USPSTF 2013 criteria and 242 individuals according to the USPSTF 2021 criteria. The YLG was 23 for all ever-smokers, 19 for the USPSTF 2013 criteria, and 21 for the USPSTF 2021 criteria. Being Black, having less than a high school education, and living in the North and Northeast regions were associated with increased 5-year risk of LC death. Conclusions and Relevance: In this comparative effectiveness study, USPSTF 2021 criteria were better than USPSTF 2013 in reducing disparities in LC death rates. Nonetheless, the risk of LC death remained unequal, and these results underscore the importance of identifying an appropriate approach for high-risk populations for LCS, considering the local epidemiological context.

Factors associated with late-stage diagnosis and overall survival for lung cancer: An analysis of patients treated in a Brazilian hospital and a US-hospital from 2009 to 2019.

BACKGROUND: Lung cancer is a major public health problem due to its high incidence and mortality rates worldwide. Histology, socioeconomic conditions, access, quality of healthcare, and regional aspects are associated with lung cancer stages at diagnosis and survival outcomes. This paper aims to examine and contrast the factors associated with late-stage diagnosis of lung cancer and overall survival rates in two different settings: a Brazilian hospital and a US hospital, spanning from 2009 to 2019. METHODS: This is a retrospective cohort study of the incidence of lung cancer cases at the institution's cancer registry from a Brazilian and a US-based cohort. Descriptive analyses are presented using either the mean and standard deviation or the median and interquartile interval. Frequency is used to present categorical variables. Factors associated with late-stage lung cancer diagnosis were identified through bivariate and multivariable forward stepwise logistic regression. One-year overall survival and its associated factors were identified by Kaplan-Meier curves and Cox's proportional hazards model. RESULTS: Between January 2009 and December 2019, a total of 5286 individuals were diagnosed with LC in the Brazilian cohort, and out of these cases, 85.6% were diagnosed with late-stage disease. The US-cohort consisted of 3594 individuals, of whom 60.3% were diagnosed with late-stage disease in lung cancer. The one-year overall survival was 8.6 months for the US cohort and 6.4 months for the Brazilian cohort. In both cohorts, late-stage diagnosis emerged as the most significant factor influencing overall survival. However, the factors associated with late-stage diagnosis differed between the US and Brazilian cohorts. In the Brazilian cohort, being male and belonging to black or brown ethnic groups, along with having a lower education level, were linked to late-stage diagnosis. On the other hand, in the US-based cohort, the factors related to late-stage diagnosis were being male, having been diagnosed before 2015, and possessing private insurance coverage. CONCLUSION: Late-stage diagnosis was associated with the worst survival in both the US and Brazilian cohorts. This study provides valuable information on inequities and barriers to access for lung patients with cancer from upper-middle-income and high-income countries.

First use of antineoplastic agents in women with breast cancer in the state of Rio de Janeiro, Brazil.

Context: Breast cancer is the most common cancer, except for non-melanoma skin cancer, among women in Brazil and worldwide. Breast cancer treatment involves surgery, radiotherapy and chemotherapy, which is used in 70% of patients. This study analyzes the utilization of antineoplastic agents among women undergoing their first round of chemotherapy in Brazil's public health system (SUS) in the state of Rio de Janeiro. Methods: Data from the SUS Outpatient Information System's authorizations for high-complexity outpatient procedures (APACs) billed between January 2013 and December 2019 were extracted, and three datasets were created: all type 1 and type 2 APACs (including all chemotherapy procedures performed); all type 1 APACs; and first type 1 APACs (containing data only for the first round of breast cancer chemotherapy). Names of antineoplastic agents were standardized to enable the subsequent classification of therapy regimens, mitigating limitations related to data quality. Absolute and relative frequencies were used to describe sociodemographic, clinical and treatment characteristics, therapy regimen and supportive drugs. Results: We analyzed 23,232 records of women undergoing their first round of chemotherapy. There was a progressive increase in the number of procedures over time. Women were predominantly white, lived in the capital and close to the treatment center. Most had stage 3 cancer at diagnosis (50.51%) and a significant proportion had regional lymph node invasion (37.9%). The most commonly used chemotherapy regimens were TAC (docetaxel, doxorubicine, cyclophosphamide) (21.05%) and and cyclophosphamide (17.71%), followed by tamoxifen (15.65%) and anastrozole (12.94%). Supportive drugs were prescribed to 386 women and zoledronic acid was predominant (59.58%). Conclusion: The findings point to important bottlenecks and possible inequities in access to treatment and medicine utilization for breast cancer patients in Brazil. Efforts to improve breast cancer treatment and prevention should not only focus on interventions at the individual level but address the disease as a public health problem. The study focused on women undergoing their first round of treatment, providing valuable insight into patient and treatment characteristics to inform policy decisions.

[Strategies adopted to ensure the rights of people with cancer in the Brazilian Unified Health System (SUS)]. / Estratégias adotadas para a garantia dos direitos da pessoa com câncer no âmbito Sistema Único de Saúde (SUS).

This study was based on Giddens' Structuration Theory and aimed to analyze strategies adopted to ensure the rights of people with cancer in five Brazilian municipalities, anchored on the experience of managers and health professionals within the Brazilian Unified Health System (SUS). A multiple-case study design was conducted. The municipality was the unit of analysis and oncology care-certified facilities were established as analytical sub-units. We analyzed the strategic behavior of ten managers and 15 health professionals from interviews. The results were systematized according to care, legal and social dimensions. The relevant elements expressed were the need to expand and organize the diagnostic and therapeutic cancer care network; the concern with the large number of lawsuits, both in light of economic sustainability of the health system and because of the promotion of inequalities; and the low resoluteness of social benefits, as they do not meet all people's needs. The adopted measures are considered insufficient to ensure the rights of people with cancer in the Brazilian Unified Health System.

Este estudo, fundamentado na Teoria da Estruturação de Giddens, buscou analisar as estratégias adotadas para garantir os direitos das pessoas com câncer em cinco municípios brasileiros, a partir da experiência de gestores e profissionais de saúde no contexto do Sistema Único de Saúde. Foi conduzido um estudo de casos múltiplos. A unidade de análise foi o município e a subunidade foi a unidade habilitada de atenção oncológica. Foi realizada a análise de conduta estratégica de dez gestores e 15 profissionais de saúde, a partir de entrevistas. Os resultados foram sistematizados em três dimensões: assistencial, judicial e social. Destacaram-se: a necessidade de expansão e organização da rede assistencial diagnóstica e terapêutica; a preocupação com o grande número de demandas judiciais, tanto pela sustentabilidade econômica do sistema de saúde, quanto pela promoção de iniquidades; a pouca resolutividade dos benefícios sociais, uma vez que não atendem a todos aqueles que necessitam. A percepção é de que as medidas adotadas são insuficientes para garantir os direitos da pessoa com câncer no sistema de saúde brasileiro.

Effect of municipal and state regulation on access and outcomes for cervical cancer patients in Rio de Janeiro, Brazil: An interrupted time series analysis.

BACKGROUND: Cervical cancer (CC) is one of Brazil's most prevalent neoplasms, and organizing health care flows that guarantee adequate and timely referral is a challenge. This paper analyzes the effect of municipal and state regulation on access and outcomes for CC patients treated in Rio de Janeiro. METHODS: Retrospective, quasi-experimental study, applying interrupted time series, using data from Cancer Registry from January-2012 to December-2017. We analyzed the implementation of the municipal (August-2013) and state (June-2015) regulation systems for the treatment of CC. The primary outcomes were 1. Time from diagnosis to the first Specialist Visit (TSV); 2. Time from a specialist visit to Treatment Initiation (TSV-TTI); 3. Time from diagnosis to treatment initiation (DTTI); 4. Percentage of patients with adequate Time to Treatment Initiation (PATTI); 5. Percentage of patients with a positive outcome (PPO). RESULTS: were included 4119 women. 71.04 % were between 30 and 59 years old, 55.57 % were black or brown, and 50.52 % had completed elementary school. The monthly average TSV was 43 days in 2012. After the first intervention, TSV increased by seven days, with a decreasing trend of 1 day per month until December-2017. Similarly, after June-2015, DTTI increased to 63 days, decreasing by one day per month until December-2017. After both interventions, there was an increase of 11.98 % in PATTI, with an increasing monthly trend of 0.18 %. PPO remained stable throughout the analyzed period. CONCLUSION: the results suggest that regulation organized access flow for specialized care. However, other relevant issues must be addressed, such as an internal backlog at the institutions, which compromises a timely start of treatment. POLICY SUMMARY: To improve access to the diagnosis and treatment of CC in its early stages, it is necessary to invest in health policies to adjust the supply to the required demand and thus reduce mortality from this pathology.

Burden of Liver Cirrhosis in Portugal between 2010 and 2017.

INTRODUCTION: Liver cirrhosis is a prevalent disease in Portugal. Recent changes in alcohol consumption, as well as the wide use of direct-acting antivirals for hepatitis C since 2015, may be contributing to changes in the national burden of liver cirrhosis in the last few years. OBJECTIVES: We aim to characterize the burden of cirrhosis in Portugal between 2010 and 2017. PATIENTS AND METHODS: We analyzed all hospital admission episodes due to cirrhosis in Portugal Mainland between 2010 and 2017, registered in the national Diagnosis-Related Group database, according to etiology of cirrhosis. We also analyzed data on mortality and potential years of life lost from liver cirrhosis and chronic liver disease, retrieved from Statistics Portugal (National Institute for Statistics). RESULTS: Between 2010 and 2017, a total of 51,438 admissions for liver cirrhosis occurred in Portugal. The annual number of admissions decreased (p = 0.044) during the analyzed period. The most frequent cause of cirrhosis was alcoholic liver disease, present in 78.9% of all admissions (n = 40,595), followed by chronic hepatitis C virus infection, present in 11.3% (n = 5,823). A male predominance was identified in the admissions for every analyzed cause of cirrhosis. Annual admissions for alcoholic cirrhosis remained stable (p = 0.075) during the 8-year period. The same stable tendency was observed in the number of admissions for cirrhosis caused by hepatitis C virus (p = 0.861) and alcohol plus hepatitis C virus infection (p = 0.082), although these admissions for hepatitis C-related cirrhosis increased until 2014-2015 and steadily decreased thereafter. Annual deaths due to liver cirrhosis and chronic liver disease decreased from 1,357 in 2010 to 1,038 in 2017 (p = 0.002). The number of potential years of life lost decreased as well in the period (p = 0.001). CONCLUSION: The burden of cirrhosis, evaluated by hospital admissions, mortality, and potential years of life lost, decreased in Portugal between 2010 and 2017.

INTRODUÇÃO: A cirrose hepática é uma patologia prevalente em Portugal. Alterações recentes no consumo de álcool, assim como o uso generalizado de antivíricos de ação direta para a hepatite C desde 2015, podem estar a contribuir para alterações no peso nacional da cirrose hepática nos últimos anos. OBJETIVOS: Pretendemos caracterizar o impacto da cirrose em Portugal entre 2010 e 2017. DOENTES E MÉTODOS: Analisámos todos os episódios de internamento hospitalar por cirrose em Portugal Continental entre 2010 e 2017, registados na base de dados dos Grupo de Diagnósticos Homogéneos, de acordo com a etiologia da cirrose. Também analisámos dados de mortalidade e anos de vida potencialmente perdidos por cirrose e doença hepática crónica, disponibilizados pelo Instituto Nacional de Estatística. RESULTADOS: Entre 2010 e 2017 ocorreram 51 438 internamentos por cirrose hepática em Portugal. O número total de internamentos diminuiu (p = 0,044) durante o período analisado. A causa mais frequente de cirrose foi doença hepática alcoólica, presente em 78,9% de todos os internamentos (n = 40 595), seguido da infeção crónica pelo vírus da hepatite C, presente em 11,3% (n = 5 823). Verificou-se predominância de doentes do género masculino em todas as causas de cirrose analisadas. O número de internamentos anual por cirrose alcoólica manteve-se estável (p = 0,075) durante os 8 anos. A mesma tendência foi observada no número de internamentos por infeção por vírus de hepatite C (p = 0,861) e álcool mais infeção por vírus de hepatite C (p = 0,082) − embora estes internamentos por cirrose relacionada com hepatite C tenham aumentado até 2014­2015 e depois diminuído sustentadamente. O número anual de óbitos por cirrose e doença hepática crónica diminuiu de 1357 em 2010 para 1038 em 2017 (p = 0,002). O número de anos potenciais de vida perdidos diminuiu também (p = 0,001) nesse período. Conclusão: O impacto da cirrose, avaliado através dos internamentos hospitalares, mortalidade e anos potenciais de vida perdidos, diminuiu em Portugal entre 2010 e 2017.

Pregnancy as a Period of Enhanced Risk for Non-Cavitated Caries Lesions.

PURPOSE: To investigate if pregnancy represents a period of increased risk of non-cavitated dental caries related to changes in saliva and oral health behaviours. MATERIALS AND METHODS: A non-randomised longitudinal study was performed with 27 pregnant women and 25 non-pregnant women, who were evaluated twice with the same time gap (24 weeks on average). At the first visit sociodemographic and oral health-related behaviours were assessed through a structured questionnaire. At the second visit changes related to eating sweet snacks and oral hygiene habits were also assessed. In both visits the surface-related caries status was evaluated according to ICDAS II criteria. Calculation of D0 (Sound), D1-2 (visual changes) and D3-4 (precavitated caries lesions) Index was based on data collected from clinical examination. Saliva pH and saliva flow rate were also assessed. RESULTS: Throughout pregnancy, a statistically significant increase of eating sweet snacks between main meals was reported, with no effective adaptation of oral hygiene habits. In comparison to the non-pregnant group, pregnant women presented a lower saliva pH at both the first and second visit, p < 0.0005. During the follow-up period, a decrease in the frequency of caries-free surfaces was observed in the pregnant women (p = 0.004) and an increase in precavitated caries lesions (p = 0.011). CONCLUSION: The main results support the hypothesis that during pregnancy women are prone to enamel demineralisation, namely, to exhibiting additional lesions characterised by precavitated caries lesions.

Endoscopic Management of Sigmoid Volvulus in a Debilitated Population: What Relevance?

BACKGROUND: Colonic volvulus, mainly from the sigmoid, is a relatively common cause of intestinal obstruction, particularly in the elderly and in patients with debilitating conditions. The high morbi-mortality of emergency surgery places the endoscopic approach as the first-line treatment for the resolution of this acute obstructive condition. OBJECTIVES: To assess the importance of endoscopic treatment for the resolution of colonic volvulus in a debilitated population. METHOD: This is a retrospective analysis of emergency lower gastrointestinal endoscopies in patients with colonic volvulus as diagnosis, performed over a 9-year period (2009-2018), as well as population characterization and follow-up after the first exam. RESULTS: We performed 88 procedures in 52 patients (56.4% males, median age 83 years, range 33-94). Endoscopic resolution was effective in 86.4% (76/88) of the exams, without procedure complications. Eighty-one percent of patients presented with volvulus recurrence, 50% of which occurred during the 3 months after the initial procedure. Twenty-one were submitted to surgery, 12 of which were emergency procedures after endoscopic failure as the primary treatment (5 of which had mucosal necrosis at endoscopy). There was no mortality in elective surgery. In the emergency plus necrosis group, mortality was 60% (3/5) and 14.3% (1/7) in the emergency without necrosis group. CONCLUSIONS: Despite the high recurrence of volvulus after endoscopic treatment, it seems to be an adequate and low-risk first-line therapy for sigmoid volvulus in debilitated patients, allowing improvement of surgical conditions.

INTRODUÇÃO: O volvo cólico, particularmente da sigmoideia, é uma causa relativamente comum de obstrução intestinal, sobretudo em idosos ou doentes com condições debilitantes. A elevada morbi-mortalidade do procedimento cirúrgico de urgência coloca a abordagem endoscópica como primeira linha na tentativa de resolução do quadro obstrutivo agudo. OBJETIVOS: Avaliar a importância da terapêutica endoscópica na resolução do volvo sigmoideu (inaugural ou de repetição) numa população debilitada. MÉTODOS: Análise retrospetiva dos procedimentos endoscópicos realizados em contexto de urgência e com diagnóstico de volvo cólico, durante um período de 9 anos (2009-2018) num Serviço de Urgência de um Hospital Central, bem como caracterização demográfica da população e curso clínico após procedimento endoscópico inicial. RESULTADOS: Realizados 88 procedimentos em 52 doentes (56.4% do sexo masculino, idade mediana 83 anos, intervalo 33-94). A resolução endoscópica foi conseguida em 86.4% dos procedimentos (76/88), não se registando complicaçõs associadas ao procedimento. Um total de 81% dos doentes apresentaram recidiva de volvo após procedimento endoscópico, 50% dos quais nos 3 meses após procedimento inicial. Vinte e um doentes foram operados, 12 de urgência por não ter havido resolução endoscópica (5 destes com necrose da mucosa na endoscopia). Não se registou mortalidade nos doentes operados eletivamente. No grupo de doentes operados em urgência com necrose da mucosa cólica a mortalidade foi de 60% (3/5), e de 14.3% (1/7) no grupo de urgência sem necrose da mucosa. CONCLUSÃO: Apesar da elevada taxa de recorrência, a terapêutica endoscópica parece apresentar-se como uma opção de primeira linha adequada e de baixo risco na resolução de volvo cólico em doentes debilitados, permitindo melhorar condições clínicas para a realização de intervendo cirúrgica eletiva.

[Profile of antineoplastic medication among indigenous people treated in the Brazilian Unified National Health System]. / Perfil de utilização de medicamentos antineoplásicos entre indígenas atendidos pelo Sistema Único de Saúde.

Brazil has an estimated 900,000 indigenous people (0.4% of the country's population), belonging to more than 300 different ethnic groups. However, information is scarce on cancer epidemiology and the antineoplastic drugs used in treatment of these individuals. The study's objectives are to identify the antineoplastic drugs used and to describe the profile of use of these drugs in the indigenous population treated in Brazil, as well as to describe the patients' epidemiological profile. An ecological study was performed involving outpatient chemotherapy care from January 2014 to December 2018 throughout Brazil. The data source was the Outpatient Information System of the Brazilian Health Informatics Department, considering only Authorizations for High-Complexity Chemotherapy Procedures. We identified 2,425 authorizations for chemotherapy procedures for treatment of indigenous patients. Of these, 2,292 authorizations for a total of 210 individuals were analyzed. We found an increase in the number of authorizations and of indigenous persons receiving chemotherapy over the period, with a higher concentration of individuals living in and receiving treatment in the South of Brazil, plus a wide diversity in the types of diagnosed tumors (n = 63) and of treatment regimen used during the treatment (n = 107). The current study provided a new overview of the epidemiological profile of indigenous patients receiving chemotherapy in the Brazilian Unified National Health System. The findings help fill a current knowledge gap on indigenous people's health in Brazil.

Estima-se que no Brasil existam cerca de 900 mil indígenas (0,4% da população do país) pertencentes a mais de 300 etnias diferentes. Porém, informações sobre a epidemiologia do câncer e sobre os medicamentos antineoplásicos utilizados no tratamento desses indivíduos são escassas. Os objetivos do presente estudo são identificar os medicamentos antineoplásicos utilizados e descrever o perfil de utilização deles na população indígena tratada no Brasil, além de descrever o perfil epidemiológico dos usuários. Foi realizado um estudo do tipo ecológico que envolveu os atendimentos ambulatoriais de quimioterapia, realizados no período de janeiro de 2014 e dezembro de 2018, em todo o Brasil. A fonte de coleta dos dados utilizada foi o Sistema de Informação Ambulatorial, do Departamento de Informática do SUS, considerando apenas as Autorizações de Procedimentos de Alta Complexidade para Quimioterapia. Foram identificadas 2.425 autorizações para procedimentos de quimioterapia destinadas ao tratamento de pacientes indígenas. Um total de 2.292 autorizações, para um total de 210 indivíduos, foram analisadas. Observou-se um aumento do número de autorizações e de indígenas em uso de quimioterapia ao longo do período, maior concentração de indivíduos residentes e em tratamento na Região Sul do país, diversidade de tipos de tumores diagnosticados (n = 63) e de esquemas terapêuticos utilizados durante o tratamento (n = 107). O presente estudo trouxe um novo panorama sobre o perfil epidemiológico dos usuários indígenas sob tratamento quimioterápico no Sistema Único de Saúde. Os achados contribuem para o preenchimento da atual lacuna de conhecimento a respeito da saúde indígena no Brasil.

Se estima que en Brasil existan cerca de 900 mil indígenas (0,4% de la población del país) pertenecientes a más de 300 etnias diferentes. No obstante, la información sobre la epidemiología del cáncer y medicamentos antineoplásicos utilizados en el tratamiento de esos individuos es escasa. Los objetivos del presente estudio son identificar los medicamentos antineoplásicos utilizados, y describir el perfil de utilización de esos medicamentos en la población indígena tratada en Brasil, así como describir el perfil epidemiológico de los usuarios. Se realizó un estudio de tipo ecológico, implicando la atención ambulatoria con quimioterapia, realizada en el período de enero de 2014 y diciembre de 2018 en todo Brasil. La fuente de recogida de datos utilizada fue el Sistema de Información Ambulatoria, del Departamento de Informática del SUS, considerando solamente las Autorizaciones de Procedimientos de Alta Complejidad para Quimioterapia. Se identificaron 2.425 autorizaciones para procedimientos de quimioterapia, destinadas al tratamiento de pacientes indígenas. Se analizaron 2.292 autorizaciones para un total de 210 individuos. Se observó un aumento del número de autorizaciones y de indígenas en el tratamiento de quimioterapia a lo largo del período, con una mayor concentración de individuos residentes y en tratamiento en la región sur del país, con una diversidad de tipos de tumores diagnosticados (n = 63) y de esquemas terapéuticos utilizados durante el tratamiento (n = 107). El presente estudio presentó un nuevo panorama sobre el perfil epidemiológico de los usuarios indígenas bajo tratamiento quimioterápico en el Sistema Único de Salud. Los hallazgos contribuyen a llenar la actual laguna de conocimiento con respecto a la salud indígena en Brasil.

Interventional Algorithm in Gastrointestinal Bleeding-An Expert Consensus Multimodal Approach Based on a Multidisciplinary Team.

The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.