RESUMEN

BACKGROUND AND PURPOSE: Fingolimod is a drug approved for treatment of relapsing-remitting multiple sclerosis (RRMS) that exerts its effects via sequestering lymphocytes within the lymph nodes. The drug, acting on the sphingosine-1-phosphate pathway, is involved in a plethora of processes and, to date, its mechanism of action is not completely understood. Recently, it has been demonstrated that Fingolimod increases the expression of transcription factor NR4A2 in murine brain. NR4A2 belongs to nuclear receptor family 4, group A (NR4A) along with NR4A1 and NR4A3. The role of NR4A2 in the pathogenesis of multiple sclerosis is already known and supported by its down-regulation observed in blood obtained from patients with RRMS compared with healthy controls (HCs). It is notable that NR4A2 impairment is reversed in patients with RRMS during pregnancy, which represents a transitory state of immune tolerance, associated with reduced disease activity. An inverse correlation between NR4A2 gene expression levels and clinical parameters indicates that more aggressive forms of the disease are characterized by lower levels of NR4A2. METHODS: Gene expression levels of NR4A in blood obtained from HCs, treatment-naive (T0) and Fingolimod-treated patients with RRMS were evaluated to determine their contribution to drug response. RESULTS: Gene expression levels of NR4A were down-regulated in T0 patients compared with HCs. Patients treated with Fingolimod for >2 years were characterized by higher levels of NR4A2 compared with the T0 group, approaching those of HCs. NR4A1 and NR4A3 levels were not altered. CONCLUSIONS: Involvement of the NR4A family in the pathogenesis of multiple sclerosis and a role of Fingolimod in the recovery from NR4A2 deficit can be hypothesized based on our data.

Asunto(s)

Clorhidrato de Fingolimod/uso terapéutico , Expresión Génica , Inmunosupresores/uso terapéutico , Esclerosis Múltiple/genética , Miembro 1 del Grupo A de la Subfamilia 4 de Receptores Nucleares/genética , Adolescente , Adulto , Anciano , Animales , Regulación hacia Abajo , Femenino , Humanos , Masculino , Ratones , Persona de Mediana Edad , Esclerosis Múltiple/tratamiento farmacológico , Adulto Joven

RESUMEN

The giant edible Placostylus snails of New Caledonia occur across a wide range of environmental conditions, from the dry southwest to the wetter central and northeastern regions. In large, slow-moving animals such as Placostylus, speciation could be assumed to be largely driven by allopatry and genetic drift as opposed to natural selection. We examined variation in shell morphology using geometric morphometrics and genetic structure within two species of Placostylus (P. fibratus, P. porphyrostomus), to determine the drivers of diversity in this group. Despite the current patchy distribution of snails on New Caledonia, both mtDNA and nuclear SNP data sets (>3000 loci) showed weak admixing between populations and species. Shell morphology was concordant with the genetic clusters we identified and had a strong relationship with local environment. The genetic data, in contrast to the morphological data, did not show concordance with climatic conditions, suggesting the snails are not limited in their ability to adapt to different environments. In sympatry, P. fibratus and P. porphyrostomus maintained genetic and morphological differences, suggesting a genetic basis of phenotypic variation. Convergence of shell shape was observed in two adjacent populations that are genetically isolated but experience similar habitat and climatic conditions. Conversely, some populations in contrasting environments were morphologically distinct although genetically indistinguishable. We infer that morphological divergence in the Placostylus snails of New Caledonia is mediated by adaptation to the local environment.

Asunto(s)

Exoesqueleto/anatomía & histología , Evolución Biológica , Clima , Selección Genética , Caracoles/genética , Adaptación Biológica/genética , Animales , ADN Mitocondrial/genética , Flujo Génico , Flujo Genético , Genética de Población , Modelos Lineales , Modelos Genéticos , Nueva Caledonia , Fenotipo , Polimorfismo de Nucleótido Simple , Análisis de Secuencia de ADN , Caracoles/anatomía & histología

RESUMEN

The aim of this study was to investigate DNA damage in human dermal fibroblasts from a healthy subject and from a subject affected by Turner's syndrome that were exposed for 24 h to radiofrequency (RF) radiation at 900 MHz. The RF-radiation exposure was carried out alone or in combination with 3-chloro-4-(dichloromethyl)-5-hydroxy-2(5H)-furanone (MX), a well-known environmental mutagen and carcinogen produced during the chlorination of drinking water. Turner's syndrome fibroblasts were also exposed for a shorter time (1 h). A signal similar to that emitted by Global System for Mobile Communications (GSM) mobile phones was used at a specific absorption rate of 1 W/kg under strictly controlled conditions of temperature and dosimetry. To evaluate DNA damage after RF-radiation exposure alone, the alkaline comet assay and the cytokinesis-block micronucleus assay were used. In the combined-exposure experiments, MX was given at a concentration of 25 microM for 1 h immediately after the RF-radiation exposure, and the effects were evaluated by the alkaline comet assay. The results revealed no genotoxic and cytotoxic effects from RF radiation alone in either cell line. As expected, MX treatment induced an increase in DNA migration in the comet assay, but no enhancement of the MX-induced DNA damage was observed in the cells exposed to RF radiation.

Asunto(s)

Daño del ADN , ADN/efectos de la radiación , Fibroblastos/efectos de los fármacos , Fibroblastos/efectos de la radiación , Furanos/toxicidad , Mutágenos/toxicidad , Ondas de Radio/efectos adversos , Línea Celular , Proliferación Celular/efectos de los fármacos , Proliferación Celular/efectos de la radiación , Supervivencia Celular/efectos de los fármacos , Supervivencia Celular/efectos de la radiación , Células Cultivadas , Ensayo Cometa , ADN/efectos de los fármacos , Humanos , Pruebas de Micronúcleos , Temperatura , Síndrome de Turner/genética , Síndrome de Turner/patología

RESUMEN

In this study, the induction of apoptosis after exposure to 900 MHz radiofrequency radiation (GSM signal) was investigated by assessing caspase 3 activation in exponentially growing Jurkat cells and in quiescent and proliferating human peripheral blood lymphocytes (PBLs). The exposure was carried out at an average specific absorption rate of 1.35 W/kg in a dual wire patch cell exposure system where the temperature of cell cultures was accurately controlled. After 1 h exposure to the radiofrequency field, a slight but statistically significant increase in caspase 3 activity, measured 6 h after exposure, was observed in Jurkat cells (32.4%) and in proliferating human PBLs (22%). In contrast, no effect was detected in quiescent human PBLs. In the same experimental conditions, apoptosis was also evaluated in Jurkat cells by Western blot analysis and in both cell types by flow cytometry. To evaluate late effects due to caspase 3 activity, flow cytometry was also employed to assess apoptosis and viability 24 h after radiofrequency-radiation exposure in both cell types. Neither the former nor the latter was affected. Since in recent years it has been reported that caspases are also involved in processes other than apoptosis, additional cell cycle studies were carried out on proliferating T cells exposed to radiofrequency radiation; however, we found no differences between sham-exposed and exposed cultures. Further studies are warranted to investigate the biological significance of our findings of a dose-response increase in caspase 3 activity after exposure to radiofrequency radiation.

Asunto(s)

Caspasa 3/metabolismo , Teléfono Celular , Proliferación Celular/efectos de la radiación , Linfocitos/enzimología , Linfocitos/efectos de la radiación , Microondas , Animales , Apoptosis/efectos de la radiación , Línea Celular , Relación Dosis-Respuesta en la Radiación , Activación Enzimática/efectos de la radiación , Humanos , Células Jurkat , Linfocitos/citología , Dosis de Radiación

RESUMEN

This paper describes an innovative integrated micro flow cytometer that presents a new arrangement for the excitation/detection system. The sample liquid, containing the fluorescent marked particles/cells under analysis, is hydrodynamically squeezed into a narrow stream by two sheath flows so that the particles/cells flow individually through a detection region. The detection of the particles/cells emitted fluorescence is carried out by using a collection fiber placed orthogonally to the flow. The device is based on silicon hollow core antiresonant reflecting optical waveguides (ARROWs). ARROW geometry allows one to use the same channel to guide both the sample stream and the fluorescence excitation light, leading to a simplification of the optical configuration and to an increase of the signal-to-noise ratio. The integrated micro flow cytometer has been characterized by using biological samples marked with standard fluorochromes. The experimental investigation confirms the success of the proposed microdevice in the detection of cells.

Asunto(s)

Citometría de Flujo/instrumentación , Silicio/química , Electrodos , Diseño de Equipo , Análisis de Falla de Equipo , Tecnología de Fibra Óptica , Sensibilidad y Especificidad , Temperatura

RESUMEN

The effect of exposure to 50 Hz electromagnetic field on a human T-leukaemia cell line (Jurkat) was investigated by evaluating the reactive oxygen species (ROS) production and apoptosis, both spontaneous and induced by a specific anti Fas/CD95 monoclonal antibody (anti-Fas). Our results suggest that 1 h intermittent (5 min field on/10 min field off) exposure does not affect ROS formation, while a slight but statistically significant decrease of both spontaneous and anti-Fas-induced apoptosis was observed.

Asunto(s)

Apoptosis/fisiología , Apoptosis/efectos de la radiación , Campos Electromagnéticos , Estrés Oxidativo/fisiología , Estrés Oxidativo/efectos de la radiación , Especies Reactivas de Oxígeno/metabolismo , Humanos , Células Jurkat

RESUMEN

Lung cancer is a formidable worldwide health problem causing more deaths than breast, prostate, and colorectal cancer combined. Eighty percent are non-small cell type (NSCLC) and less than one in five patients can have a curative resection. Decisionmaking in treating cancer, and lung cancer specifically, requires an understanding of the basic ethical principles as well as a prioritization of values beyond medical knowledge alone. Choosing a treatment plan can be difficult because of the multiple confronting dilemmas occurring simultaneously. Economic analysis also is required of every major treatment strategy proposed. Active patient involvement is helpful in making these important and difficult choices at the same time clinicians must be mindful of their roles as healers, educators, and innovators of knowledge in a disease that has a five year mortality rate of nearly 90%. Finally, because end of life care issues are so common with this illness, clinicians must be aware of their importance in making dying easier for so many individuals.

Asunto(s)

Neoplasias Pulmonares , Carcinoma de Pulmón de Células no Pequeñas/prevención & control , Carcinoma de Pulmón de Células no Pequeñas/psicología , Carcinoma de Pulmón de Células no Pequeñas/terapia , Manejo de Caso , Costo de Enfermedad , Ética Médica , Eutanasia , Eutanasia Pasiva , Femenino , Humanos , Esperanza de Vida , Neoplasias Pulmonares/prevención & control , Neoplasias Pulmonares/psicología , Neoplasias Pulmonares/terapia , Masculino , Inutilidad Médica , Oncología Médica , Derechos del Paciente , Pacientes/psicología , Relaciones Médico-Paciente , Pronóstico , Calidad de Vida , Negativa al Tratamiento , Derecho a Morir , Fumar/efectos adversos , Prevención del Hábito de Fumar , Cuidado Terminal

RESUMEN

Gemcitabine (Gemzar) and irinotecan (CPT-11, Camptosar) are active cytotoxic drugs against pancreatic cancer. Preclinical data evaluating the combination of gemcitabine and irinotecan suggest dose-dependent synergistic interactions in SCOG small-cell lung cancer and MCF-7 breast cancer cell lines. Two phase I trials of this combination have been reported to date: the day 1 and 8 every-3-week schedule (IrinoGem trial), and the day 1, 8, and 15 every-4-week schedule (MSKCC trial). Both trials aimed to determine the maximum tolerated dose of irinotecan when administered as a 90-minute i.v. infusion either immediately after (IrinoGem) or before or immediately after (MSKCC) gemcitabine at 1,000 mg/m2 by 30-minute i.v. infusion in patients with solid tumors. The achieved maximum tolerated dose of IrinoGem has a higher dose intensity of irinotecan (100 mg/m2 on days 1 and 8, every-3-week cycle) compared with the MSKCC schedule (60 mg/m2 on days 1, 8, and 15, every-4-week trial). In IrinoGem, two of three previously untreated metastatic pancreas cancer patients had durable radiologic partial responses. The third had stable disease with clinical benefit for eight cycles. In addition, a patient with metastatic adenocarcinoma of unknown primary--potentially pancreatic--has had a durable response and is alive more than 30 months after the diagnosis. Preliminary results of a 45-patient multicenter phase II trial with IrinoGem in advanced and metastatic pancreas cancer were recently reported. Toxicity was modest, with no toxic deaths or neutropenic fever. Radiologic response rate was 20% of patients (9 out of 45), and a CA 19-9 decrease of more than 50% from baseline values occurred in 32.5% of patients (13 out of 40). Median survival was 6 months (range: 0.9 to 12.2+ months) and median time to treatment failure was 2.9 months (range: 0.1 to 11.3+ months). A pivotal international multicenter phase III trial comparing IrinoGem to single-agent gemcitabine in advanced and metastatic pancreas cancer is ongoing.

Asunto(s)

Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Pancreáticas/tratamiento farmacológico , Camptotecina/administración & dosificación , Camptotecina/análogos & derivados , Desoxicitidina/administración & dosificación , Desoxicitidina/análogos & derivados , Humanos , Irinotecán , Gemcitabina

RESUMEN

The authors report the results of a phase I clinical study using semiallogeneic cancer vaccines formulated with granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat patients with metastatic adenocarcinomas of the gastrointestinal tract. A specially engineered cell line, FO1-12, was used to generate semiallogeneic hybrids by fusion with patient-derived tumor cells; the hybrids express HLA class I and II haplotypes derived from both parental cells. For treatment, the vaccine was mixed with GM-CSF, irradiated, and injected intradermally into patients at weekly or biweekly intervals. Vaccinations were associated with minimal or no toxicity and showed that semiallogeneic hybrids formulated with GM-CSF can induce a specific antitumor immune response in some patients, as measured by a delayed-type hypersensitivity response to autologous tumor cells. Because of the simplicity, feasibility, and flexibility of this immunotherapeutic approach, semiallogeneic hybrid vaccines have the potential to be used in the treatment of virtually any type of cancer.

Asunto(s)

Adenocarcinoma/secundario , Adenocarcinoma/terapia , Vacunas contra el Cáncer/uso terapéutico , Neoplasias Gastrointestinales/terapia , Factor Estimulante de Colonias de Granulocitos y Macrófagos/uso terapéutico , Adenocarcinoma/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Vacunas contra el Cáncer/efectos adversos , Vacunas contra el Cáncer/genética , Femenino , Neoplasias Gastrointestinales/inmunología , Factor Estimulante de Colonias de Granulocitos y Macrófagos/efectos adversos , Factor Estimulante de Colonias de Granulocitos y Macrófagos/metabolismo , Humanos , Células Híbridas/metabolismo , Células Híbridas/trasplante , Inmunoterapia Adoptiva/métodos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Células Tumorales Cultivadas/metabolismo , Células Tumorales Cultivadas/trasplante , Vacunas Sintéticas/efectos adversos , Vacunas Sintéticas/genética , Vacunas Sintéticas/uso terapéutico

RESUMEN

Docetaxel (Taxotere), gemcitabine (Gemzar), and irinotecan (Camptosar, CPT-11) are active single agents in a variety of solid tumors. In combination, synergism may be schedule dependent. Preclinical studies suggested synergistic interactions when docetaxel was administered 24 hours before gemcitabine or irinotecan. The objective of this phase I trial in patients with refractory solid tumors was to determine the maximum tolerated dose of docetaxel followed 24 hours later by gemcitabine and irinotecan. Two different schedules were tested: docetaxel escalated by 5 mg/m2/cohort from an initial dose of 20 mg/m2 on days 1 and 8 (schedule A) or escalated by 15 mg/m2/cohort from 45 mg/m2 on day 8 only (schedule B). In both schedules, docetaxel was given over 1 hour. Gemcitabine and irinotecan were given on days 2 and 9 (arm A) or 1 and 9 (arm B) at fixed doses of 1,000 mg/m2 over 30 minutes and 100 mg/m2 over 90 minutes, respectively. Escalation of docetaxel was planned in groups of three patients, with three additional patients added at the first indication of dose-limiting toxicity. Four dose levels in arm A and one dose level in arm B have been tested. Seventeen patients were evaluable in arm A; one died of an unrelated cause on cycle 1, and another withdrew consent before beginning treatment. Five of six patients were evaluable in arm B; one patient inadvertently received G-CSF on cycle 1. Forty-two cycles have been delivered in arm A (mean; 2.2 cycles/patient), and 25 cycles in arm B (mean, 4.2 cycles/patient); the maximum tolerated dose of docetaxel on arm A was 20 mg/m2. The dose-limiting toxicities were grade 3 diarrhea in one patient, grade 3 infection in two patients, and grade 4 neutropenia for > 4 days in one patient at the 25 mg/m2 level. The dose-limiting toxicities on arm B occurred at the first dose level and included grade 3 diarrhea in one patient, grade 4 diarrhea in one patient, and grade 4 neutropenia for 4 days in another patient. Accrual to schedule B was closed after testing the cohort 1 dose level because testing of a single deescalated docetaxel dose given on day 8 was not considered clinically relevant.

Asunto(s)

Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Camptotecina/análogos & derivados , Neoplasias/tratamiento farmacológico , Paclitaxel/análogos & derivados , Taxoides , Camptotecina/administración & dosificación , Ensayos Clínicos como Asunto , Desoxicitidina/administración & dosificación , Desoxicitidina/análogos & derivados , Docetaxel , Femenino , Factor Estimulante de Colonias de Granulocitos/administración & dosificación , Humanos , Irinotecán , Masculino , Dosis Máxima Tolerada , Persona de Mediana Edad , Paclitaxel/administración & dosificación , Tasa de Supervivencia , Gemcitabina

RESUMEN

Synergy with no overlapping toxicities has been demonstrated for the combination of irinotecan (Camptosar, CPT-11) and gemcitabine (Gemzar) in vitro. Results of a single-institution phase I study in which patients with previously untreated pancreatic cancer were given irinotecan and gemcitabine were promising, with two of three patients achieving a partial response. Because of the favorable outcome of the phase I study, a multicenter phase II trial was undertaken in previously untreated patients with pancreatic carcinoma. Data from other sites entering patients in this phase II study have been analyzed, and a multicenter phase III trial of single-agent gemcitabine vs the irinotecan combination in first-line treatment of patients with locally advanced or metastatic pancreatic cancer is underway.

Asunto(s)

Antineoplásicos Fitogénicos/uso terapéutico , Camptotecina/análogos & derivados , Camptotecina/uso terapéutico , Neoplasias Pancreáticas/tratamiento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Ensayos Clínicos Fase I como Asunto , Ensayos Clínicos Fase II como Asunto , Ensayos Clínicos Fase III como Asunto , Terapia Combinada , Humanos , Irinotecán , Estudios Multicéntricos como Asunto

RESUMEN

The authors surveyed 1,137 physicians, nurses, and social workers (overall response = 48%) to characterize the willingness to endorse assisted suicide. Willingness to endorse varied among disciplines and was negatively correlated with level of religious belief (r = -0.35, P < 0.0001), knowledge of symptom management (r = -0.21, P < 0.0001), and time managing symptoms (r = -0.21, P < 0.0001). On multivariate analysis, the significant predictors were lesser religious belief (P < 0.0001), greater concern about analgesic toxicity (P = 0.001), diminished empathy (P = 0.03), lesser knowledge of symptom management (P < 0.04), and the interaction between religious belief and knowledge of symptom management (P = 0.04). Professionals' attitudes toward assisted suicide are influenced by diverse personal attributes, among which may be competence in symptom management and burnout.

Asunto(s)

Actitud Frente a la Muerte , Enfermeras y Enfermeros , Médicos , Servicio Social , Suicidio Asistido , Adulto , Anciano , Agotamiento Profesional , Recolección de Datos , Eutanasia Activa Voluntaria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Religión

Asunto(s)

Prácticas Clínicas , Cuidados Paliativos al Final de la Vida , Cuidados Paliativos/métodos , Connecticut , Guías como Asunto , Humanos , Grupo de Atención al Paciente , Estudiantes de Medicina

RESUMEN

This study tested the feasibility of standardized pain assessment instruments in a population of patients with far advanced cancer at the time of admission to a specialty hospital. As pain is a symptom, pain control must be based on patients' self-report. Cognitive impairment and severe physical illness, however, limited the ability to use these tools. Almost one-half (44.8%) of the patients were unable to use the McGill-Melzack Pain Questionnaire, the Memorial Pain Assessment Card, or the Faces Pain Rating Scale. Patients with far advanced cancer fall into three groups: those who report pain, those who report no pain, and those who are unable to state whether or not they have pain. This study demonstrates the need to undertake pain assessment while the patient is able to respond and to monitor behaviors that could be indicative of changes in pain.

Asunto(s)

Neoplasias/fisiopatología , Dimensión del Dolor/métodos , Anciano , Trastornos del Conocimiento/complicaciones , Humanos , Neoplasias/complicaciones , Encuestas y Cuestionarios

Asunto(s)

Cuidados Paliativos al Final de la Vida/normas , Servicios de Atención de Salud a Domicilio , Hospitales para Enfermos Terminales , Humanos , Estados Unidos

RESUMEN

Pain is a common, feared, but treatable component of malignancy. The ability, however, to successfully relieve the difficult symptoms of progressive disease, including pain, require an understanding of tumor behavior, complications, and cancer therapy. Despite the treatability of cancer pain and multiple clinical options, the clinician faces many challenges to adequate pain management.

Asunto(s)

Neoplasias/terapia , Cuidados Paliativos , Cuidado Terminal , Humanos , Neoplasias/psicología , Cuidados Paliativos/psicología , Filosofía Médica , Cuidado Terminal/psicología

RESUMEN

PURPOSE: Pain is a common and feared symptom for patients with incurable cancer. Comprehensive assessment provides the foundation for effective pain management, and data that clarify the relationship between pain and other relevant factors also facilitate this process. The main objective of the study was to develop a clinical data base for advanced cancer patients and to survey data to determine (1) pain severity at admission, (2) opioid use at admission, (3) change in opioid use during the hospital stay, and (4) survival in the hospital. PATIENTS AND METHODS: Information was collected prospectively on 1,103 patients admitted and on 1,017 patients who died within 6 months of the study's end. Demographic and clinical data were recorded 72 hours after admission and soon after death or discharge. RESULTS: Seventy-three percent of patients had pain at admission. Cancer of the cervix was frequently (68%) associated with severe pain, as were prostate (52%) and rectal/sigmoid tumors (49%). Severe pain was more probable in those with bone metastasis, those admitted from home, and in those younger than 55 years of age. The majority (71.7%) of patients had a stable dosing pattern, and only 4.2% of the patients required dose increases of at least 10% per day. CONCLUSION: This study demonstrated the wide variability in opioid doses required. No reliable predictor of opioid requirement was identified, and this lack of predictability of cancer pain severity underscores the need for ongoing assessment.

Asunto(s)

Analgésicos Opioides/administración & dosificación , Hospitalización , Neoplasias/complicaciones , Dolor/tratamiento farmacológico , Dolor/etiología , Adulto , Anciano , Anciano de 80 o más Años , Intervalos de Confianza , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Análisis de Supervivencia

Asunto(s)

Eutanasia , Cuidado Terminal , Actitud Frente a la Muerte , Humanos , Principios Morales

Asunto(s)

Objetivos , Cuidados Paliativos , Cuidado Terminal , Ética Médica , Hospitales para Enfermos Terminales , Humanos

RESUMEN

More than half of all individuals diagnosed with cancer will not be cured and will require supportive care for some period. Nonetheless, few large scale studies have documented the prevalence and complexity of the problems of advanced disease. This study examined the demographic treatment and outcome variables for 1,103 admissions to a specialty acute care hospital devoted to the care of patients with advanced cancer. The population is profiled, and significant relationships among these variables are identified. The prevalence of major symptoms is documented. This data base study provides a foundation for further research.

Asunto(s)

Instituciones Oncológicas , Hospitales Especializados , Neoplasias/fisiopatología , Actividades Cotidianas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/mortalidad , Dolor/epidemiología , Dolor/etiología , Prevalencia , Tasa de Supervivencia