RESUMEN
PURPOSE: To compare hemodynamic instability during continuous, intermittent and hybrid renal replacement therapy (RRT) in critically ill patients, and its association with renal recovery and mortality. MATERIALS AND METHODS: The search was conducted in accordance with the PRISMA guidelines which was registered at the PROSPERO Database (CRD42018086504). Randomized clinical trials (RCTs) involving critically ill patients with acute kidney injury (AKI) treated with continuous, intermittent or hybrid RRT were included. The search was performed using PubMed, Embase and Cochrane databases. RESULTS: Out of 3442 citations retrieved, 12 RCTs were included in the systematic analysis, representing 1419 patients. Most studies (n = 8) did not report differences in hemodynamic parameters across different RTT modalities. The incidence of hypotensive episodes varied from 5 to 60% among the studies. Punctual differences on heart rate and blood pressure were observed among studies. However, studies presented high heterogeneity in terms of outcome definitions and measurement, thus making the conduction of meta-analysis impossible. CONCLUSIONS: There is very few information available regarding hemodynamic tolerance of renal replacement therapy methods. A better standardization of hemodynamic tolerance and further reports are needed before conclusions can be drawn.
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Lesión Renal Aguda , Terapia de Reemplazo Renal Híbrido , Enfermedades Vasculares , Femenino , Humanos , Masculino , Lesión Renal Aguda/terapia , Enfermedad Crítica/terapia , Hemodinámica , Ensayos Clínicos Controlados Aleatorios como Asunto , Terapia de Reemplazo Renal/métodosRESUMEN
ABSTRACT Introduction: Colorectal cancer is the third most common cancer worldwide, with about 15% of these tumours related with microsatellite instability, which confers distinct characteristics to these tumours, both clinicopathological and in the response to treatments. In fact, the poor response to chemotherapy in these tumours has led to the investigation for new treatments, with immunotherapy being the most successful one to date. The focus of this review is to assess the response of microsatellite unstable colorectal cancer to PD-1 blockade, and the mechanisms behind that response. Methods: A PubMed research was conducted, resulting in the inclusion of 47 articles in this review. Results: Microsatellite instability results in a high neoantigen load, leading to a highly active immune microenvironment of the tumour, mainly due to T-cells. To counteract this, there is an upregulation of PD-1, acting as a "brake" for immune cells, facilitating tumour growth and metastasis. This upregulation makes these tumours great candidates for treatment with PD-1 blockade, as seen in many clinical trials, where the overall responses and progression free survival rates were higher than those observed in microsatellite stable tumours. Conclusion: With the importance of colorectal cancer with microsatellite instability new treatments are necessary. Therefore, PD-1 blockade is a promising treatment for colorectal cancer with microsatellite instability, with improvement in survival rates and a better prognosis for these patients.
RESUMO Introdução: O câncer colorretal é o terceiro mais comum em todo o mundo, com cerca de 15% desses tumores relacionados com instabilidade dos microssatélites, o que confere características distintas a esses tumores, tanto clínico patológicas quanto na resposta aos tratamentos. De fato, a fraca resposta à quimioterapia nesses tumores levou à investigação de novos tratamentos, sendo a imunoterapia a mais bem sucedida até o momento. O foco desta revisão é avaliar a resposta do câncer colorretal com microssatélites instáveis ao bloqueio do PD-1 e os mecanismos por trás dessa resposta. Métodos: Foi realizada uma pesquisa na base de dados PubMed, resultando na inclusão de 47 artigos nesta revisão. Resultados: A instabilidade de microssatélites resulta em uma alta carga de neoantígenos, levando a um microambiente imunológico altamente ativo do tumor, principalmente devido às células T. Para neutralizar isso, há uma maior expressão do PD-1, atuando como um "freio" para as células imunes, facilitando o crescimento do tumor e suas metástases. Essa expressão faz desses tumores grandes candidatos ao tratamento com bloqueio PD-1, como demonstrado em vários ensaios clínicos, onde as respostas globais e as taxas de sobrevivência livres de progressão foram maiores do que as observadas em tumores com microssatélites estáveis. Conclusão: Com a importância do câncer colorretal com instabilidade de microssatélites, novos tratamentos são necessários. Portanto, o bloqueio do PD-1 é um tratamento promissor para o câncer colorretal com instabilidade de microssatélites, com melhora nas taxas de sobrevivência e melhor prognóstico para esses pacientes.
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Humanos , Masculino , Femenino , Neoplasias Colorrectales/patología , Receptor de Muerte Celular Programada 1/uso terapéutico , Inmunoterapia/métodos , Inestabilidad de MicrosatélitesRESUMEN
OBJECTIVE: To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. METHODS: We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. RESULTS: Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. CONCLUSION: In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.
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Enfermedad Crítica , Neoplasias Esofágicas/terapia , Unidades de Cuidados Intensivos/estadística & datos numéricos , Enfermedad Aguda , Anciano , Estudios de Cohortes , Neoplasias Esofágicas/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/epidemiología , Estudios Retrospectivos , Sepsis/epidemiología , Choque Séptico/epidemiologíaRESUMEN
RESUMO Objetivo: Mostrar o quadro clínico e os desfechos de uma coorte de pacientes críticos com câncer esofágico. Métodos: Conduzimos um estudo multicêntrico retrospectivo que incluiu pacientes com câncer esofágico admitidos a unidades de terapia intensiva em razão de doença aguda entre setembro de 2009 e dezembro de 2017. Colhemos os dados demográficos e as características clínicas de todos os pacientes incluídos, assim como as medidas de suporte a órgãos e os desfechos no hospital. Realizamos uma análise de regressão logística para identificar os fatores associados de forma independente com mortalidade hospitalar. Resultados: Dentre os 226 pacientes incluídos no estudo, 131 (58,0%) faleceram antes de receber alta hospitalar. O carcinoma espinocelular foi mais frequente do que o adenocarcinoma, e 124 (54,9%) pacientes tinham câncer metastático. As principais razões para admissão foram sepse/choque séptico e insuficiência respiratória aguda. Uso de ventilação mecânica (RC = 6,18; IC95% 2,86 - 13,35) e doença metastática (RC = 7,10; IC95% 3,35 - 15,05) tiveram associação independente com mortalidade hospitalar. Conclusão: Nesta coorte de pacientes com câncer esofágico admitidos à unidades de terapia intensiva em razão de doença aguda, a taxa de mortalidade hospitalar foi muito elevada. A necessidade de utilizar ventilação mecânica invasiva e a presença de doença metastática foram fatores independentes de prognóstico e devem ser levados em conta nas discussões a respeito dos desfechos destes pacientes em curto prazo.
ABSTRACT Objective: To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. Methods: We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. Results: Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. Conclusion: In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Neoplasias Esofágicas/terapia , Enfermedad Crítica , Unidades de Cuidados Intensivos/estadística & datos numéricos , Pronóstico , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/epidemiología , Choque Séptico/epidemiología , Neoplasias Esofágicas/mortalidad , Enfermedad Aguda , Estudios Retrospectivos , Estudios de Cohortes , Mortalidad Hospitalaria , Sepsis/epidemiologíaRESUMEN
Background Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. Objectives This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PRE dicting bleeding Complications in patients undergoing stent Implantation and Sub sequent Dual Anti Platelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. Methods Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. Results Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: −3.86%; 95% confidence interval: −7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: −1.14%; 95% confidence interval: −2.26 to −0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. Conclusions Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT. (AU)
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Humanos , Enfermedades Cardiovasculares/prevención & control , Evaluación Nutricional , Nutrición, Alimentación y DietaRESUMEN
RESUMO Objetivo: descrever a prevalência de fibrilação atrial, o perfil epidemiológico e o tratamento utilizado em pacientes submetidos à hemodiálise contínua. Método: estudo quantitativo, transversal, realizado em 2017, com 110 pacientes internados num Centro de Terapia Intensiva de hospital privado de grande porte de Porto Alegre. Resultados: evidenciaram-se 36 (32,7%) ocorrências de fibrilação atrial durante a hemodiálise, com predominância da raça branca, sexo masculino em 25 (69,4%) e idade média de 75,2 ± 10,5. Verificou-se que 22 (61,1%) desencadearam o primeiro episódio de Fibrilação Atrial. A hipertensão arterial sistêmica e a obesidade foram as comorbidades de maior prevalência. Houve evidência maior de cardioversão química em 30 e elétrica em seis pacientes. Conclusão: evidenciou-se alta prevalência de fibrilação atrial em pacientes submetidos à hemodiálise contínua, o que denota a necessidade de competências específicas dos profissionais para a identificação, manejo das intercorrências cardiológicas e registros de qualidade acerca dos eventos.
RESUMEN Objetivo: describir la prevalencia de fibrilación auricular, el perfil epidemiológico y el tratamiento que se utiliza en pacientes sometidos a la hemodiálisis constante. Método: estudio cuantitativo, trasversal, que se realizó en 2017, con 110 pacientes ingresados en un Centro de Terapia Intensiva de un gran hospital particular en Porto Alegre. Resultados: se evidenciaron 36 (32,7%) ocurrencias de fibrilación auricular durante la hemodiálisis, con predominancia de la raza blanca, sexo masculino en 25 (69,4%) y promedio de edad de 75,2 ± 10,5. Se verificó que 22 (61,1%) presentaron el primero episodio de Fibrilación Auricular. La hipertensión arterial sistémica y la obesidad fueron las comorbilidades de más prevalencia. Hubo evidencia mayor de cardioversión farmacológica en 30 y eléctrica en seis pacientes. Conclusión: se evidenció alta prevalencia de fibrilación auricular en pacientes sometidos a la hemodiálisis constante, lo que apunta para la necesidad de competencias específicas de los profesionales para la identificación, la administración de las complicaciones cardiológicas y los registros de cualidad acerca de los eventos.
ABSTRACT Objective: to describe the prevalence of atrial fibrillation, the epidemiological profile and the treatment used in patients undergoing continuous hemodialysis. Method: Quantitative cross-sectional study conducted in 2017 with 110 patients admitted to an intensive care center of a large private hospital in Porto Alegre. Results: The study found 36 (32.7%) episodes of atrial fibrillation during hemodialysis. Most patients were white males: 25 (69.4%) with a mean age of 75.2 ± 10. Also, 22 (61.1%) experienced their first episode of atrial fibrillation. Systemic arterial hypertension and obesity were the most prevalent comorbidities. There was evidence of chemical cardioversion in 30 patients and electrical cardioversion in six patients. Conclusion: There was a high prevalence of atrial fibrillation in patients receiving continuous hemodialysis. Thus, health professionals must have specific skills for the identification and management of heart disorders and accurate and complete records about the events.