O uso de inibidores da aromatase na profilaxia do câncer de mama e no tratamento da doença metastática / The use of aromatase inhibitors in the prevention of breast cancer and in the treatment of metastatic disease

O uso do tamoxifeno como tratamento convencional para o câncer de mama estrogênio-dependente possui efeitos colaterais indesejáveis, o que motivou o desenvolvimento de fármacos inibidores da aromatase. O artigo apresenta estudos que demonstram as vantagens e desvantagens do uso de inibidores da aromatase no câncer de mama metastático. Ademais, há uma abordagem de estudos demostrando o uso profilático tanto dos inibidores de aromatase como do tamoxifeno para o câncer de mama. Essas pesquisas demonstram a redução considerável da incidência da doença em pacientes que apresentam fatores de risco aumentados. A ooforectomia também é relatada como profilaxia para o câncer de mama

Atendimento humanizado à vítima de queimadura

A queimadura interrompe a continuidade da pele, corrompe a primeira barreira do corpo contra agentes infecciosos, ainda promove modificações na homeostase hidroeletrolítica, controle da temperatura interna, flexibilidade e lubrificação da superfície corporal, que são funções da pele. Neste cenário de sofrimento físico e psíquico, é necessário que os profissionais de saúde saibam preparar o paciente para o que ele poderá ver, quando for ser realizado algum cuidado ou procedimento. Objetivo: compreender com base em evidências científicas acerca do atendimento humanizado à vítima de queimadura. Metodologia: Revisão Integrativa da Literatura com coleta de dados em fontes disponíveis online, a busca foi realizada entre maio e junho de 2021. Resultados e discussão: Foram incluídos 13 artigos na revisão que discutem sobre o atendimento à vítima de queimadura tiveram, destacando principalmente as características das queimaduras e atribuições do enfermeiro nos cuidados às vítimas e a importância da enfermagem no atendimento. Conclusão: O atendimento à vítima de queimadura compreende ações sistematizadas, desde o Pré-atendimento hospitalar a interrupção do processo lesivo, portanto, é uma área que requer autonomia e aprofundamento científico dos profissionais

Reação anafilactoide por Vancomicina: uma revisão de literatura sobre a Síndrome do Homem Vermelho (SHV)

Red Man Syndrome (RMS), or Vancomycin Flushing Syndrome, is characterized by allergic manifestations to the use of Vancomycin, an antibiotic of the beta-lactam class used in the treatment of bacterial infections. This study aimed to analyze the pharmacological mechanisms of Vancomycin in association with the RMS clinical aspects, in addition to a review of the pathophysiology, epidemiology, clinical manifestations, diagnosis and treatment, as well as new perspectives and scientific advances that can improve the management of the anaphylactoid reaction. A search was performed in the SciELO, PubMed and Google Scholar databases using the keywords “Vancomycine”, “Adverse Reactions” and “Red Man Syndrome”, with a time range from 2003 to 2024. The syndrome is characterized by an anaphylactoid reaction after infusion rapid dose of Vancomycin, manifesting itself in a similar way to anaphylaxis, but without the mediation of Immunoglobulin E (IgE), with histamine being the main substance responsible for the manifestations. Some research indicates that the incidence of the condition is around 5–13%, especially when the infusion is administered in less than 1 hour. However, other literature disagrees, pointing out that the incidence of the syndrome can reach 47%. The most common clinical manifestation is the association between generalized itching and erythematous skin eruptions, mainly affecting the face, neck and body. The diagnosis of the syndrome is clinical, based on the observation of signs and symptoms that appear during or shortly after intravenous administration. Treatment consists of antihistamine pre-treatment for mild and moderate cases and reducing the infusion rate by 50%, or at least 1 gram in 2 hours, while for more severe cases rapid desensitization must be performed, which consists of administering small doses of vancomycin until reaching the therapeutic dose, in addition to ceasing the use of opioids. Finally, it is concluded that RMS corresponds to an extremely complex condition, requiring caution regarding the infusion of the drug and that it deserves a close look at its main particularities.El Síndrome del Hombre Rojo se caracteriza por manifestaciones alérgicas al uso de vancomicina, un antibiótico de la clase de los betalactámicos utilizado para tratar infecciones bacterianas. Este estudio tuvo como objetivo analizar los mecanismos farmacológicos de la Vancomicina en asociación con los aspectos clínicos de la ERM, además de una revisión de la fisiopatología, epidemiología, manifestaciones clínicas, diagnóstico y tratamiento, así como nuevas perspectivas y avances científicos que puedan mejorar el manejo. Se realizó una búsqueda en las bases de datos SciELO, PubMed y Google Scholar utilizando los descriptores “Vancomycin”, “Adverse Reactions” y “Red Man Syndrome”, con un rango temporal de 2003 a 2024. El síndrome se caracteriza por una reacción anafiláctica posterior una dosis de infusión rápida de Vancomicina, manifestándose de forma similar a la anafilaxia, pero sin la mediación de Inmunoglobulina E (IgE), siendo la histamina la principal sustancia responsable de las manifestaciones. Algunas investigaciones indican que la incidencia de la afección ronda el 5-13%, especialmente cuando la infusión se administra en menos de 1 hora. Sin embargo, otra literatura no está de acuerdo, señalando que la incidencia del síndrome puede alcanzar el 47%. La manifestación clínica más común es la asociación entre prurito generalizado y erupciones cutáneas eritematosas, afectando principalmente a cara, cuello y cuerpo. El diagnóstico del síndrome es clínico, basado en la observación de los signos y síntomas que aparecen durante o poco después de la administración intravenosa. El tratamiento consiste en un pretratamiento con antihistamínicos para los casos leves y moderados y reducir la velocidad de infusión en un 50%, o al menos 1 gramo en 2 horas, mientras que para los casos más graves se debe realizar una desensibilización rápida, que consiste en administrar pequeñas dosis de vancomicina. hasta alcanzar la dosis terapéutica, además de suspender el uso de opioides. Finalmente, se concluye que el RMS corresponde a una condición extremadamente compleja, que requiere precaución en la infusión del medicamento y que merece una mirada cercana a sus principales particularidades.A Síndrome do Homem Vermelho (SHV) se caracteriza por manifestações alérgicas ao uso da Vancomicina, antibiótico da classe dos beta-lactâmicos utilizado no tratamento de infecções bacterianas. Este estudo teve o objetivo de analisar os mecanismos farmacológicos da Vancomicina em associação à clínica da SHV, além de uma revisão da fisiopatologia, epidemiologia, manifestações clínicas, diagnóstico e tratamento, como também das novas perspectivas e avanços científicos que possam melhorar o manejo da reação anafilactoide. Realizou-se uma busca nas bases SciELO, PubMed e Google Scholar utilizando as palavras chaves “Vancomycine”, “Adverse Reactions” e “Red Man Syndrome”, com recorte temporal de 2003 a 2024. A síndrome se caracteriza por uma reação anafilactoide após infusão rápida de Vancomicina, manifestando-se de forma semelhante à anafilaxia, porém sem a mediação de Imunoglobulina E (IgE), sendo a histamina a principal substância responsável pelas manifestações da síndrome. Algumas pesquisas apontam que a incidência da condição está em torno de 5–13%, especialmente quando a infusão é administrada em menos de 1 hora. Entretanto, outras literaturas divergem apontando que a incidência da síndrome pode chegar a 47%. A manifestação clínica mais comum é a associação entre prurido generalizado e erupções eritematosas cutâneas, acometendo principalmente a face, o pescoço e a parte superior do tronco. O diagnóstico da síndrome é essencialmente clínico, baseado na observação dos sinais e sintomas que surgem durante ou logo após a administração intravenosa de Vancomicina. O tratamento consiste para os casos leves e moderados em pré-tratamento anti-histamínico e redução da taxa de infusão em 50%, ou, pelo menos, 1 grama em 2 horas, enquanto que para os quadros mais graves deve ser feita a dessensibilização rápida, que consiste na administração de pequenas doses da vancomicina até atingir a dose terapêutica, além de cessar o uso de opioides. Conclui-se, por fim, que a SHV corresponde a um quadro de extrema complexidade, exigindo cautela quanto à infusão do fármaco e que merece um olhar atento às suas principais particularidades

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

A multi-country test of brief reappraisal interventions on emotions during the COVID-19 pandemic.

The COVID-19 pandemic has increased negative emotions and decreased positive emotions globally. Left unchecked, these emotional changes might have a wide array of adverse impacts. To reduce negative emotions and increase positive emotions, we tested the effectiveness of reappraisal, an emotion-regulation strategy that modifies how one thinks about a situation. Participants from 87 countries and regions (n = 21,644) were randomly assigned to one of two brief reappraisal interventions (reconstrual or repurposing) or one of two control conditions (active or passive). Results revealed that both reappraisal interventions (vesus both control conditions) consistently reduced negative emotions and increased positive emotions across different measures. Reconstrual and repurposing interventions had similar effects. Importantly, planned exploratory analyses indicated that reappraisal interventions did not reduce intentions to practice preventive health behaviours. The findings demonstrate the viability of creating scalable, low-cost interventions for use around the world

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK.

BACKGROUND: A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials. METHODS: This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674. FINDINGS: Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0-75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4-97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8-80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3-4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation. INTERPRETATION: ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials. FUNDING: UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, Bill & Melinda Gates Foundation, Lemann Foundation, Rede D'Or, Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

Background A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials. Methods This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674. Findings Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0–75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4–97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8–80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3–4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation. Interpretation ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030