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Background: Currently, integrase inhibitors (INIs)-based ART regimens are the preferred initial therapy for AIDS patients. There is scarce information on the use of dolutegravir (DTG) among late-presenter people living with HIV (PLHIV). Objectives: To compare the effect of DTG- or efavirenz (EFV)-based regimens on the outcomes of patients with advanced AIDS. Methods: We compared two cohorts of consecutive symptomatic AIDS patients (WHO stage 4, CD4 count<50 cells/mL) starting therapy with DTG-based (2018-2021, prospective cohort) or EFV-based regimens (2013-2016, retrospective cohort) from five Brazilian cities. The main endpoints were early (all-cause) mortality, viral suppression at 24 and 48 weeks, changes in CD4 count, and changes in initial therapy (for any reason). Results: We included all eligible patients in a consecutive way (in both groups) until we reached 92 individuals per arm. The median baseline CD4 count (20 vs. 21 cells/mL) and the median HIV plasma viral load (5.5 copies/mL log10) were identical across the groups. Viral suppression rates were higher in the DTG group than in the EFV group at 24 (67.4% vs. 42.4%,) and 48 weeks (65.2% vs. 45.7%, p < 0.001 for both comparisons). More patients in the DTG group presented with CD4 > 200 cells/mL compared to the EFV group at 48 weeks (45% vs. 29%, p = 0.03). Treatment changes (ITT, M = F) were significantly more frequent in the EFV group (1% vs. 17%, p < 0.0001). The relative mortality rate was 25% lower in the DTG group, but without statistical significance. Conclusion: We detected a higher rate of virological suppression and greater treatment durability in patients with advanced AIDS treated with DTG than in those treated with EFV.
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ABSTRACT Introduction: Acute promyelocytic leukemia currently presents an excellent chance of cure with protocols based on all-trans-retinoic acid (ATRA) and anthracycline or only differentiation agents. However, high early mortality rates continue to be reported Methods: Between 2000 and 2018, patients were enrolled and retrospectively analyzed by medical records. A modified AIDA protocol, with a 1-year shortening of the treatment duration, reduction in the number of drugs and a strategy to reduce early mortality by the postponement of the initiation of anthracyclines were employed. Overall and event-free survival rates and toxicity were analyzed Results: Thirty-two patients were enrolled, of whom 56% were female, with a median age of 12 years and 34% belonged to the high-risk group. Two patients had the hypogranular variant and three had another cytogenetic alteration, in addition to the t(15;17). The median start of the first anthracycline dose was 7 days. There were two early deaths (6%) due to central nervous system (CNS) bleeding. All patients achieved molecular remission after the consolidation phase. Two children relapsed and were rescued by arsenic trioxide and hematopoietic stem cell transplantation. The presence of disseminated intravascular coagulation (DIC) at diagnosis (p = 0.03) was the only factor with survival impact. The five-year event-free survival (EFS) was 84% and 5-year overall survival (OS) was 90% Conclusion: The survival results were comparable to those found in the AIDA protocol, with a low rate of early mortality in relation to the Brazilian reality.
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INTRODUCTION: Acute promyelocytic leukemia currently presents an excellent chance of cure with protocols based on all-trans-retinoic acid (ATRA) and anthracycline or only differentiation agents. However, high early mortality rates continue to be reported METHODS: Between 2000 and 2018, patients were enrolled and retrospectively analyzed by medical records. A modified AIDA protocol, with a 1-year shortening of the treatment duration, reduction in the number of drugs and a strategy to reduce early mortality by the postponement of the initiation of anthracyclines were employed. Overall and event-free survival rates and toxicity were analyzed RESULTS: Thirty-two patients were enrolled, of whom 56% were female, with a median age of 12 years and 34% belonged to the high-risk group. Two patients had the hypogranular variant and three had another cytogenetic alteration, in addition to the t(15;17). The median start of the first anthracycline dose was 7 days. There were two early deaths (6%) due to central nervous system (CNS) bleeding. All patients achieved molecular remission after the consolidation phase. Two children relapsed and were rescued by arsenic trioxide and hematopoietic stem cell transplantation. The presence of disseminated intravascular coagulation (DIC) at diagnosis (pâ¯=â¯0.03) was the only factor with survival impact. The five-year event-free survival (EFS) was 84% and 5-year overall survival (OS) was 90% CONCLUSION: The survival results were comparable to those found in the AIDA protocol, with a low rate of early mortality in relation to the Brazilian reality.
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Introducción: El mieloma múltiple es una neoplasia maligna de células B caracterizada por una proliferación clonal incontrolada de células plasmáticas. Se define como mortalidad precoz en el mieloma múltiple de nuevo diagnóstico, al porcentaje de muerte que ocurre dentro de los primeros seis meses y afecta entre el 10 y 14 % de los casos. Los biomarcadores han evolucionado desde la caracterización del tumor hasta el reconocimiento de las aberraciones cromosómicas y moleculares que desempeñan un papel en la supervivencia. Objetivo: Describir los principales predictores identificados con relación a la mortalidad precoz y su función en la patogénesis de la enfermedad. Métodos: Se analizó la literatura científica publicada. Se utilizaron motores de búsqueda como Google Scholar, PubMed y ScienceDirect. Se consultaron un total de 80 artículos y se incluyeron 52, en su mayoría de los últimos cinco años. Análisis y síntesis de la información: Se evidenciaron mecanismos genéticos y epigenéticos que contribuyen de manera decisiva en la mortalidad precoz de pacientes con mieloma múltiple de nuevo diagnóstico. Conclusiones: El aumento del riesgo de mortalidad precoz en pacientes con mieloma múltiple de nuevo diagnóstico está asociado a factores clínicos y biológicos, por lo que existe la necesidad de estratificación de los pacientes para un manejo personalizado que impone el uso de datos clínicos y biológicos de una forma integrada.
Introduction: Multiple Myeloma is a malignant B-cell neoplasm characterized by uncontrolled clonal proliferation of plasma cells. Early mortality in newly diagnosed Multiple Mieloma is defined as the percentage of death that occurs six months or less after diagnosis and, it affects 10 to 14 % of the cases. Biomarkers have evolved from the characterization of tumor to the recognition of chromosomal and molecular aberrations that play a rol in survival. Objective: To describe the main predictors identified related to early mortality and their role in the pathogenesis of the disease. Methods: The scientific literature was analyzed using search engines such as Google Scholar, PubMed and ScienceDirect. Consulted articles were 80 and included articles were 52, mostly from the last five years. Analysis and information synthesis: Genetic and epigenetic mechanisms that contribute decisively in the early mortality in new diagnosis Multiple Myeloma patients were evidenced. Conclusions: The increased risk of early mortality in patients with newly diagnosed Multiple Myeloma is associated with clinical and biological factors and there is a need to stratify patients in terms of early mortality risk for personalized management, for which it is imposed the use of clinics and biological data in an integrative way.
Assuntos
HumanosRESUMO
RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.
ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.
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Adulto , Choque Hemorrágico/cirurgia , Choque Traumático/cirurgia , Acidose/mortalidade , Hipotermia/mortalidadeRESUMO
Outcomes in acute myeloid leukemia (AML) are dependent on patient- and disease-characteristics, treatment, and socioeconomic factors. AML outcomes between resource-constrained and developed countries have not been compared directly. We analyzed two cohorts: from São Paulo state, Brazil (USP, n = 312) and Oxford, United Kingdom (OUH, n = 158). USP cohort had inferior 5-year overall survival compared with OUH (29% vs. 49%, adjusted-p=.027). USP patients have higher early-mortality (23% vs. 6% p<.001) primarily due to multi-resistant Gram-negative bacterial and fungal infections. USP had higher 5-year cumulative incidence of relapse (60% vs. 50%, p=.0022), were less likely to undergo hematopoietic stem cell transplant (HSCT) (28% vs. 75%, p<.001) and waited longer for HSCT (median, 23.8 vs. 7.2 months, p<.001). Three-year survival in relapsed patients was worse in USP than OUH (10% vs. 39%, p<.001). Our study indicates that efforts to improve AML outcomes in Brazil should focus on infection prevention and control, and access to HSCT.
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Doença Enxerto-Hospedeiro , Transplante de Células-Tronco Hematopoéticas , Leucemia Mieloide Aguda , Brasil/epidemiologia , Humanos , Leucemia Mieloide Aguda/diagnóstico , Leucemia Mieloide Aguda/epidemiologia , Leucemia Mieloide Aguda/terapia , Estudos Retrospectivos , Reino UnidoRESUMO
BACKGROUND: Mexico City has one of the highest incidences and mortality rates of acute lymphoblastic leukemia (ALL) in the world and a high frequency of early relapses (17%) and early mortality (15%). Otherwise, childhood overweight and obesity are reaching epidemic proportions. They have been associated with poor outcomes in children with ALL. The aim of present study was to identify if overweight and obesity are predictors of early mortality and relapse in Mexican children with ALL. METHODS: A multicenter cohort study was conducted. ALL children younger than 15 years old were included and followed-up during the first 24 months after diagnosis. Overweight and obesity were classified according World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) criteria. Early mortality and early relapses were the main outcomes. RESULTS: A total of 1070 children were analyzed. Overweight/obesity at diagnosis were predictors of early mortality (WHO: HR = 1.4, 95%CI:1.0-2.0; CDC: HR = 1.6, 95%CI:1.1-2.3). However, no associations between overweight (WHO: HR = 1.5, 95%CI:0.9-2.5; CDC: HR = 1.0; 95% CI:0.6-1.6) and obesity (WHO: HR = 1.5, 95%CI:0.7-3.2; CDC: HR = 1.4; 95%CI:0.9-2.3) with early relapse were observed. CONCLUSIONS: Overweight and obese patients embody a subgroup with high risk of dying during leukemia treatment.
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Obesidade Infantil/epidemiologia , Obesidade Infantil/mortalidade , Leucemia-Linfoma Linfoblástico de Células Precursoras/epidemiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/mortalidade , Adolescente , Índice de Massa Corporal , Criança , Pré-Escolar , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Incidência , Lactente , Masculino , México/epidemiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Prognóstico , RecidivaRESUMO
Introducción: La forma de culminar la vida es una expresión de la manera en que se vivió. Las mujeres y los hombres no atraviesan su paso por el mundo igualmente y tampoco comparten las mismas características biológicas que son diferentes para cada sexo. Objetivos: identificar la tendencia del riesgo de morir entre los sexos en las principales causas de muerte entre 2005 y 2016 e identificar la tendencia del riesgo de morir prematuramente entre los sexos en las principales causas de muerte entre 2009 y 2016 en Cuba. Métodos: Se elaboraron series cronológicas de las principales causas de muerte conformadas con las razones hombres-mujeres y se analizó la tendencia mediante rectas de regresión o promedios móviles. Los posibles motivos se identificaron mediante entrevistas en profundidad a expertos de género y salud. Resultados: Se encontraron tres grupos de causas de muerte. En el primero clasificaron: tumores malignos, enfermedades del corazón, enfermedad cerebrovascular, influenza y neumonía, accidentes, enfermedades crónicas de las vías respiratorias y las de las arterias, arteriolas y vasos capilares. El segundo estuvo conformado por la cirrosis hepática y otras enfermedades del hígado y las lesiones autoinfligidas. En el último grupo constó la diabetes mellitus. La tendencia se mantuvo sin notable variación a lo largo del tiempo en casi todas las series analizadas. Las explicaciones referidas que trataron explicar las diferencias encontradas en las agrupaciones de causas de muerte transitaron desde las que atribuyeron la acción de factores biológicos hasta las relacionadas con las consecuencias de la identidad de género. Discusión: Los hombres presentaron una situación más desventajosa debido a que el riesgo de morir y el riesgo de morir prematuramente fue superior al de las mujeres en la mayoría de las causas de muerte estudiadas que estuvieron más afectadas, principalmente por la diabetes mellitus. Conclusiones: La tendencia de la mortalidad de la razón hombre-mujer de las principales causas de muerte y de la mortalidad prematura evidenció diferencias entre los sexos, fue el masculino el más afectado a lo largo del tiempo(AU)
Introduction: The way life ends it is an expression of the way it was lived. Women and men do not live life equally and they neither share the same biological characteristics, which are different for each sex. Objectives: To identify the trends related to the risk of dying among both sexes and the main causes of death from 2005 to 2016, and the risk of dying prematurely from 2009 to 2016. Methods: Time series with the main causes of death among men and women were made and it was analyzed the trend by means of straight regression or moving averages. The possible reasons were identified through in-depth interviews to experts in gender and health. Results: There were found three groups of causes of death. In the first, there were: malignant tumors, heart diseases, cerebrovascular diseases, influenza and pneumonia, accidents; respiratory, arteries, arterioles and capillary vessels chronic diseases. The second group was formed by liver cirrhosis and other diseases of the liver and self-inflicted injuries. The third group consisted in diabetes mellitus. The trend continued without an outstanding variation over time in almost all of the analyzed series. Various reasons were found that could affect the group of causes of death that went from the biological to those dealing with the consequences of gender identity. Discussion: Men are those who submitted a disadvantage since the risk of dying and the risk of dying prematurely was superior to the women in the majority of the studied causes, mainly because of diabetes mellitus. Conclusions: Mortality trends among men and women and the main causes of death and of premature mortality evidenced differences between the sexes being males the most affected in long term(AU)
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Humanos , Masculino , Feminino , Saúde de Gênero/história , Mortalidade Prematura/tendências , Equidade de Gênero , CubaRESUMO
Despite being recommended as first-line immunosuppressive therapy in severe aplastic anemia (SAA), horse antithymocyte globulin (ATG) is still unavailable in many countries outside the USA. Rabbit ATG is more lymphocytoxic than horse ATG, and this might result in a higher incidence of severe infections and early mortality. This study was designed to identify the risk factors for early mortality and overall survival (OS) after rabbit ATG in patients with SAA. We retrospectively reviewed 185 patients with SAA who underwent rabbit ATG and cyclosporine. The incidence of death in 3 months following rabbit ATG therapy was 15.1% (28/185). Early mortality was mainly related to infectious complications, despite adequate antibiotic and/or antifungal treatment. Age > 35 years (odds ratio [OR] 5.06, P = 0.001) and baseline absolute neutrophil count (ANC) ≤ 0.1 × 109/L (OR 7.64, P < 0.001) were independent risk factors for early mortality after immunosuppressive therapy with this agent. Hematological response at 6 months was observed in only 29.7% of all patients. OS at 1 year after rabbit ATG was 75.3%; and age > 35 years (OR 1.88, P = 0.03), baseline ANC ≤ 0.1 × 109/L (OR 2.65, P < 0.001), and lack of response to rabbit ATG (OR 11.40, P < 0.001) were independently associated with mortality. Alternative strategies are needed for the treatment of SAA patients in countries were horse ATG is unavailable, particularly for those at high risk for early mortality after rabbit ATG due to a higher age and very low pre-treatment neutrophil count.
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Anemia Aplástica/tratamento farmacológico , Anemia Aplástica/mortalidade , Soro Antilinfocitário/administração & dosagem , Imunossupressores/administração & dosagem , Índice de Gravidade de Doença , Adolescente , Adulto , Idoso , Anemia Aplástica/diagnóstico , Animais , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Coelhos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
ABSTRACTBACKGROUND AND OBJECTIVES: Although many recognize that the first year of life and specifically the neonatal period are associated with increased risk of anesthetic morbidity and mortality, there are no studies directed to these pediatric subpopulations. This systematic review of the scientific literature including the last 15 years aimed to analyze the epidemiology of morbidity and mortality associated with general anesthesia and surgery in the first year of life and particularly in the neonatal (first month) period.CONTENT: The review was conducted by searching publications in Medline/PubMed databases, and the following outcomes were evaluated: early mortality in the first year of life (<1 year) and in subgroups of different vulnerability in this age group (0-30 days and 1-12 months) and the prevalence of cardiac arrest and perioperative critical/adverse events of various types in the same subgroups.CONCLUSIONS: The current literature indicates great variability in mortality and morbidity in the age group under consideration and in its subgroups. However, despite the obvious methodological heterogeneity and absence of specific studies, epidemiological profiles of morbidity and mortality related to anesthesia in children in the first year of life show higher frequency of morbidity and mortality in this age group, with the highest peaks of incidence in the neonates' anesthesia.
RESUMOJUSTIFICATIVA E OBJETIVOS: Embora muitos reconheçam que a idade inferior a um ano e especificamente o período neonatal estejam associados a maior risco de morbimortalidade anestésica, não existem estudos dirigidos a essas subpopulações pediátricas. Esta revisão sistemática das publicações científicas dos últimos 15 anos teve como objetivo analisar o perfil epidemiológico da morbimortalidade relacionada com a anestesia geral e cirurgia no primeiro ano de idade e em particular no período neonatal (primeiro mês de idade).CONTEúDO: A revisão foi conduzida por pesquisa de publicações nas bases de dados Medline/PubMed. Foram avaliados os seguintes desfechos: mortalidade precoce no primeiro ano de idade (< 1A) e em subgrupos de diferente vulnerabilidade nesta faixa etária (0-30 dias e 1-12 meses) e prevalência de parada cardíaca e eventos críticos/adversos perioperatórios de diversos tipos nos mesmos subgrupos.CONCLUSÕES: A literatura corrente indica grande variabilidade nos índices de mortalidade e morbidade na faixa etária em análise, bem como nos seus subgrupos. No entanto, apesar da óbvia heterogeneidade metodológica e da ausência de estudos específicos, os perfis epidemiológicos de morbimortalidade relacionada com a anestesia de crianças no primeiro ano de idade mostram frequência mais alta de morbimortalidade nessa faixa etária, com os maiores picos de incidência na anestesia de neonatos.
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Sítios de Ligação , Ligação Proteica , Conformação Proteica , Proteínas/química , Proteínas/metabolismo , Biologia Computacional , Bases de Dados de Proteínas , Modelos Moleculares , Ressonância Magnética Nuclear BiomolecularRESUMO
BACKGROUND AND OBJECTIVES: Although many recognize that the first year of life and specifically the neonatal period are associated with increased risk of anesthetic morbidity and mortality, there are no studies directed to these pediatric subpopulations. This systematic review of the scientific literature including the last 15 years aimed to analyze the epidemiology of morbidity and mortality associated with general anesthesia and surgery in the first year of life and particularly in the neonatal (first month) period. CONTENT: The review was conducted by searching publications in Medline/PubMed databases, and the following outcomes were evaluated: early mortality in the first year of life (<1 Yr) and in subgroups of different vulnerability in this age group (0-30 days and 1-12 months) and the prevalence of cardiac arrest and perioperative critical/adverse events of various types in the same subgroups. CONCLUSIONS: The current literature indicates great variability in mortality and morbidity in the age group under consideration and in its subgroups. However, despite the obvious methodological heterogeneity and absence of specific studies, epidemiological profiles of morbidity and mortality related to anesthesia in children in the first year of life show higher frequency of morbidity and mortality in this age group, with the highest peaks of incidence in the neonates' anesthesia.
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BACKGROUND AND OBJECTIVES: Although many recognize that the first year of life and specifically the neonatal period are associated with increased risk of anesthetic morbidity and mortality, there are no studies directed to these pediatric subpopulations. This systematic review of the scientific literature including the last 15 years aimed to analyze the epidemiology of morbidity and mortality associated with general anesthesia and surgery in the first year of life and particularly in the neonatal (first month) period. CONTENT: The review was conducted by searching publications in Medline/PubMed databases, and the following outcomes were evaluated: early mortality in the first year of life (<1 year) and in subgroups of different vulnerability in this age group (0-30 days and 1-12 months) and the prevalence of cardiac arrest and perioperative critical/adverse events of various types in the same subgroups. CONCLUSIONS: The current literature indicates great variability in mortality and morbidity in the age group under consideration and in its subgroups. However, despite the obvious methodological heterogeneity and absence of specific studies, epidemiological profiles of morbidity and mortality related to anesthesia in children in the first year of life show higher frequency of morbidity and mortality in this age group, with the highest peaks of incidence in the neonates' anesthesia.