Implications of the use of total parenteral nutrition (TPN) in allogenic hematopoietic cell transplantation

Introdução: Dentre as complicações que acometem os pacientes submetidos ao transplante alogênico de células tronco hematopoéticas destacam-se aquelas que afetam o desempenho nutricional. Esses pacientes apresentam hipermetabolismo conseqüente à quimioterapia e ou radioterapia e cursam com distúrbios do trato gastrointestinal como náusea, vômito, diarréia, mucosite, alteração do paladar, salivação e anorexia, havendo com isso uma redução ou mínima ingestão oral que resulta em déficit nutricional importante. Freqüentemente, os transplantados de células tronco hematopoéticas demandam de suporte nutricional adicional para adequada manutenção de aporte calórico e protéico. A nutrição parenteral total (NPT) é a forma de nutrição mais comumente utilizada uma vez que a alimentação enteral é desaconselhada por riscos de aspiração, sinusite e vômito, além de alterações de trânsito gastrointestinal presentes na terapia anti-neoplásica. A NPT acarreta distúrbios de função hepática, do metabolismo da glicose e rico de infecção, dentre outras complicações. Objetivos: Avaliar as implicações clínicas do uso de NPT em transplante alogênico de células tronco hematopoéticas, correlacionando-as às principais complicações do transplante como doença venoclusiva hepática, doença do enxerto contra hospedeiro aguda e infecções. Analisamos a relação entre NPT e alterações da glicemia, função hepática, enxertia de leucócitos e plaquetas, dependência de hemocomponentes e sobrevida geral. Métodos: Nesse estudo retrospectivo e comparativo foram incluídos 199 pacientes adultos de duas instituições hospitalares com características semelhantes, portadores de doenças onco-hematológicas submetidos a transplante alogênico de células tronco hematopoéticas, dividindo-os em dois grupos: pacientes que receberam nutrição parenteral total (NPT+) e pacientes que não necessitaram de NPT (NPT-). Resultados: O uso de NPT demonstrou ser um fator de risco isolado para doença venoclusiva hepática (p= 0, 005, IC: 1,6-15,6) quando analisado conjuntamente com a data do transplante e tipo de regime de condicionamento mieloablativo. A idade inferior à mediana de 34 anos mostrou-se significante para o uso de NPT (p=0, 0001). Entre a comparação dos grupos, a enxertia plaquetária mostrou significante piora no grupo NPT+ (p= 0, 0004) e conseqüente dependência de transfusão de plaquetas neste grupo (p=0, 003). A hiperglicemia (p= 0, 0001), a bilirrubina total xvi (p=0, 002) e a bilirrubina direta (p=0, 003) foram os exames laboratoriais que se mostraram significantes no mesmo grupo. A NPT foi fator de risco para mortalidade relacionada ao transplante (p=0, 009, IC: 1,2-2,8) quando analisada conjuntamente com o sexo, data do transplante e idade maior que a mediana. Conclusões: Concluímos que a NPT, quando utilizada de forma profilática, aumentou as complicações pós-transplante, a exemplo da doença venoclusiva hepática, doença do enxerto contra hospedeiro aguda e taxa de mortalidade precoce relacionada ao transplante.Introduction: Among complications that affect patients undergoing allogeneic hematopoetic stem cell transplantation, those concerning nutritional performance are emphasized. These patients show hypermetabolism consequent to chemotherapy and/or radiotherapy, leading to gastrointestinal disorders such as nausea, vomiting, diarrhea, mucositis, taste alterations, salivation and anorexia, bringing to a reduction or minimal oral intake which results in significant nutritional deficiency. Frequently, hematopoetic stem cell transplanted patients require additional nutritional support for proper maintenance of caloric and protein demands. The total parenteral nutrition (TPN) is the most common form of nutrition used. Enteral nutrition is not advisable due to the risk of aspiration, sinusitis and vomiting, and changes in gastrointestinal transit in the antineoplastic therapy. The TPN causes disturbances of liver function, glucose metabolism and risk of infection, among other complications. Objectives: Evaluating clinical implications of using TPN in allogeneic hematopoetic stem cell transplantation, correlating them with the main transplant complications such as veno-occlusive disease, graft-versus-host disease and acute infections. We analyzed the relationship between TPN and glycemic alterations, liver function, engraftment of leukocytes and platelets, dependence on hemocomponents and overall survival. Methods: This retrospective and comparative study included 199 adult patients suffering from onco-hematological diseases and having been submitted to allogeneic hematopoetic stem cell transplantation from two hospitals with similar characteristics. Patients and transplant data were analyzed into two groups: patients receiving total parenteral nutrition (TPN + ) and patients who did not require TPN (TPN-). Results: Using TPN proved to be a risk factor for isolated veno-occlusive liver disease (p = 0, 005, CI: 1,6-15,6) when analyzed together with the date and type of transplantation scheme of myeloablative conditioning. The age lower than the median of 34 years old proved to be significant for the use of TPN (p = 0, 0001). Among the comparison of groups, the engrafting platelet proved to be significant worsening in the group TPN + (p = 0, 0004) and consequent dependence on platelets transfusion in this group (p = 0, 003). The hyperglycemia (p = 0, 0001), the total bilirubin (p = 0, 002) and direct bilirubin enhancement (p = 0, 003) were the laboratory tests which were significant in that group. The TPN was a risk factor for mortality related to transplantation (p = 0, 009, CI: 1,2-2,8) when considered together with the sex, transplantation date and age above the median. Conclusions: We conclude that when TPN was used as a prophylactic measure, it caused an increase in post-transplant complications such as the veno-occlusive liver disease, acute graftversus-host disease and early mortality rate related to transplantation.BV UNIFESP: Teses e dissertaçõe

Bipolar affective disorder: pharmacotherapeutic profile and adherence to medication

Este estudo teve como objetivos verificar a adesão de portadores de transtorno afetivo bipolar (TAB) à terapêutica medicamentosa e identificar possíveis causas de adesão e não adesão ao medicamento de acordo com o perfil farmacoterapêutico. Trata-se de estudo transversal, descritivo, realizado em Núcleo de Saúde Mental de um município do interior paulista. Participaram do estudo 101 pacientes com TAB. Para coleta dos dados, utilizou-se a entrevista estruturada e o teste de Morisky-Green e, para a análise dos mesmos, o programa Statistical Package for the Social Science. Os resultados mostraram que a maioria (63%) dos sujeitos investigados não adere ao medicamento. Apesar de não ter ocorrido diferenças significativas entre o grupo de aderentes e não aderentes, para as variáveis investigadas, foi possível verificar a utilização de polifarmacoterapia e regimes terapêuticos complexos no tratamento do TAB. Permanece como desafio a implementação de estratégias que possam melhorar, na prática, a adesão de pacientes ao tratamento medicamentoso.Se objetivó verificar la adhesión de afectados por transtorno afectivo bipolar (TAB) a la terapéutica medicamentosa e identificar posibles causas de adhesión y no adhesión, de acuerdo al perfil fármaco-terapéutico. Estudio transversal, descriptivo, realizado en Núcleo de Salud Mental de municipio del interior paulista. Participaron 101 pacientes con TAB. Datos recolectados mediante entrevista estructurada y test de Morisky-Green, analizados con software Statitistical Package for the Social Science. Los resultados demostraron que la mayoría (63%) de los sujetos investigados no adhiere a la medicación. A pesar de no haberse determinado diferencias significativas entre el grupo de adherentes y no adherentes para las variables investigadas, fue posible verificar la utilización de polifarmacoterapia y regímenes terapéuticos complejos en el tratamiento del TAB. Permanece como desafío la implementación de estrategias que puedan mejorar en la práctica la adhesión del paciente al tratamiento medicamentoso.This cross-sectional and descriptive study aimed to verify the adherence of patients with Bipolar Affective Disorder (BAD) to medication and to identify possible causes of adherence and non-adherence to medication according to the pharmacotherapeutic profile. The study was carried out in a mental health service in a city in the interior of the state of São Paulo. Participants included 101 patients with BAD. Structured interviews and the Morisky-Green test were used for data collection, and the Statistical Package for Social Science was employed for data analysis. Most subjects (63%) did not adhere to medication. Although there were no significant differences between the adherent and non-adherent groups for the researched variables, the use of polypharmacotherapy and complex treatment regimens was observed in treatment for BAD. In practice, implementing strategies to improve the adherence of patients to medication treatment remains a challenge

Transtorno afectivo bipolar: perfil fármaco-terapéutico y adhesión a la medicación

This cross-sectional and descriptive study aimed to verify the adherence of patients with Bipolar Affective Disorder (BAD) to medication and to identify possible causes of adherence and non-adherence to medication according to the pharmacotherapeutic profile. The study was carried out in a mental health service in a city in the interior of the state of Sao Paulo. Participants included 101 patients with BAD. Structured interviews and the Morisky-Green test were used for data collection, and the Statistical Package for Social Science was employed for data analysis. Most subjects (63%) did not adhere to medication. Although there were no significant differences between the adherent and non-adherent groups for the researched variables, the use of polypharmacotherapy and complex treatment regimens was observed in treatment for BAD. In practice, implementing strategies to improve the adherence of patients to medication treatment remains a challenge.Este estudo teve como objetivos verificar a adesão de portadores de transtorno afetivo bipolar (TAB) à terapêutica medicamentosa e identificar possíveis causas de adesão e não adesão ao medicamento de acordo com o perfil farmacoterapêutico. Trata-se de estudo transversal, descritivo, realizado em Núcleo de Saúde Mental de um município do interior paulista. Participaram do estudo 101 pacientes com TAB. Para coleta dos dados, utilizou-se a entrevista estruturada e o teste de Morisky-Green e, para a análise dos mesmos, o programa Statistical Package for the Social Science. Os resultados mostraram que a maioria (63%) dos sujeitos investigados não adere ao medicamento. Apesar de não ter ocorrido diferenças significativas entre o grupo de aderentes e não aderentes, para as variáveis investigadas, foi possível verificar a utilização de polifarmacoterapia e regimes terapêuticos complexos no tratamento do TAB. Permanece como desafio a implementação de estratégias que possam melhorar, na prática, a adesão de pacientes ao tratamento medicamentoso.Se objetivó verificar la adhesión de afectados por transtorno afectivo bipolar (TAB) a la terapéutica medicamentosa e identificar posibles causas de adhesión y no adhesión, de acuerdo al perfil fármaco-terapéutico. Estudio transversal, descriptivo, realizado en Núcleo de Salud Mental de municipio del interior paulista. Participaron 101 pacientes con TAB. Datos recolectados mediante entrevista estructurada y test de Morisky-Green, analizados con software Statitistical Package for the Social Science. Los resultados demostraron que la mayoría (63%) de los sujetos investigados no adhiere a la medicación. A pesar de no haberse determinado diferencias significativas entre el grupo de adherentes y no adherentes para las variables investigadas, fue posible verificar la utilización de polifarmacoterapia y regímenes terapéuticos complejos en el tratamiento del TAB. Permanece como desafío la implementación de estrategias que puedan mejorar en la práctica la adhesión del paciente al tratamiento medicamentoso

Marginal adaptation of lithium disilicate crowns obtained by scanning techniques (CAD/CAM): in vitro confocal microscopy analysis

Objetivo. El objetivo de este estudio fue evaluar la adaptación marginal de coronas de disilicato de litio obtenidas mediante técnicas de escaneo (CAD/CAM), antes y después de la cristalización, a través de análisis in vitro con microscopía confocal (MC). Métodos. Fueron confeccionadas 16 réplicas en poliuretano a partir de la pieza 1.4, de modelo typodont, tallada para corona total. Las réplicas fueron divididas en dos grupos, de acuerdo a la técnica de escaneo: Técnica Indirecta (Grupo IND, n=08), donde modelos de yeso fueron escaneados con escáner de laboratorio (inEos X5, Sirona Dental Systems) y Técnica Directa (Grupo DIR, n=08), donde modelos typodont fueron escaneados con escáner intraoral (CEREC BlueCam, Sirona Dental Systems). A seguir, se fresaron (inLab MC XL, Sirona Dental Systems) coronas en disilicato de litio (IPS e.max CAD, Ivoclar Vivadent) y se adaptaron a las réplicas. Se evaluó la adaptación marginal con análisis de MC en dos momentos, antes y después de la cristalización del disilicato de litio. Los datos fueron analizados con la prueba de Mann-Whitney, t de Student y Wilcoxon (α= 0,05). Resultados. Hubo una diferencia estadísticamente significativa en la adaptación marginal horizontal entre los grupos IND y DIR después de la cristalización (p=0,05). En el grupo IND, la comparación de la adaptación marginal vertical antes y después de la cristalización mostró una diferencia estadísticamente significativa (p=0,038). Conclusiones. Las coronas de disilicato de litio obtenidas mediante escaneo directo (CAD/CAM) presentaron menor desajuste marginal vertical. La etapa de cristalización afectó la adaptación marginal de las coronas.Objective. This study aimed to evaluate lithium disilicate marginal adaption on crowns by scanning techniques (CAD/CAM), before and after crystallization, through confocal microscopy (CM) in vitro analysis. Methods. Sixteen polyurethane replicas were performed from tooth 1.4, of a typodont model, prepared for a full crown. The replicas were divided into two groups, according to the scanning technique: Indirect Technique (Group IND, n=08), where dental stone models were scanned with a laboratory scanner (inEos X5, Sirona Dental Systems) and Direct Technique (Group DIR, n=08), where typodont models were scanned with an intraoral scanner (CEREC BlueCam, Sirona Dental Systems). Then, the lithium disilicate crowns (IPS e.max CAD, Ivoclar Vivadent) were milled (inLab MC XL, Sirona Dental Systems) and adapted to the replicas. Marginal adaptation was evaluated with CM analysis before and after lithium disilicate crystallization. Data were analyzed with the Mann-Whitney, t test, and Wilconxon test (α=0.05). Results. There was a statistically significant difference in horizontal marginal adaptation between IND and DIR groups after crystallization (p=0.05). In IND group, the comparison of vertical marginal adaptation before and after crystallization showed a statistically significant difference (p=0.038). Conclusions. Lithium disilicate crowns obtained by direct scanning technique (CAD/CAD) showed less vertical marginal maladjustment. The crystallization stage affected the crown’s marginal adaptation

Fatores de risco de paratireoidectomia acidental em tireoidectomia

Incidental parathyroidectomy is a common event in thyroid surgery. The literature shows a finding of parathyroid glands ranging from 6.4% to 31% in pathological specimens of the thyroid gland.Objective: To collect the amount of parathyroid glands found in surgical specimens of thyroidectomy and correlate with the histopathological and demographic variables.Methods: Retrospective study based on pathological reports of thyroidectomy from January 2007 to December 2008.Results: 442 patients were submitted to total thyroidectomy, and 2.93% had parathyroid glands, which corresponded to 13 of this total. The presence of papillary thyroid carcinoma associated with incidental parathyroidectomy was 10.11%, compared to the benign lesion: 1.4%.Conclusion: Papillary thyroid carcinoma was the variable associated with increased number of incidental parathyroidectomy.Metropolitan Univ Santos UNIMES, Sch Med, Santos, SP, BrazilUniv Metropolitana Santos, Santos, SP, BrazilFed Univ Sao Paulo UNIFESP, Sao Paulo, BrazilMetropolitan Univ Santos UNIMES, Dept Otorhinolaryngol & Head & Neck Surg, Santos, SP, BrazilMetropolitan Univ Santos UNIMES, Dept Sci Initiat, Santos, SP, BrazilFed Univ Sao Paulo UNIFESP, Sao Paulo, BrazilWeb of Scienc

Fusion Cell Markers in Circulating Tumor Cells from Patients with High-Grade Ovarian Serous Carcinoma

Cancer is primarily a disease in which late diagnosis is linked to poor prognosis, and unfortunately, detection and management are still challenging. Circulating tumor cells (CTCs) are a potential resource to address this disease. Cell fusion, an event discovered recently in CTCs expressing carcinoma and leukocyte markers, occurs when ≥2 cells become a single entity (hybrid cell) after the merging of their plasma membranes. Cell fusion is still poorly understood despite continuous evaluations in in vitro/in vivo studies. Blood samples from 14 patients with high-grade serous ovarian cancer (A.C. Camargo Cancer Center, São Paulo, Brazil) were collected with the aim to analyze the CTCs/hybrid cells and their correlation to clinical outcome. The EDTA collected blood (6 mL) from patients was used to isolate/identify CTCs/hybrid cells by ISET. We used markers with possible correlation with the phenomenon of cell fusion, such as MC1-R, EpCAM and CD45, as well as CEN8 expression by CISH analysis. Samples were collected at three timepoints: baseline, after one month (first follow-up) and after three months (second follow-up) of treatment with olaparib (total sample = 38). Fourteen patients were included and in baseline and first follow-up all patients showed at least one CTC. We found expression of MC1-R, EpCAM and CD45 in cells (hybrid) in at least one of the collection moments. Membrane staining with CD45 was found in CTCs from the other cohort, from the other center, evaluated by the CellSearch® system. The presence of circulating tumor microemboli (CTM) in the first follow-up was associated with a poor recurrence-free survival (RFS) (5.2 vs. 12.2 months; p = 0.005). The MC1-R expression in CTM in the first and second follow-ups was associated with a shorter RFS (p = 0.005). CEN8 expression in CTCs was also related to shorter RFS (p = 0.035). Our study identified a high prevalence of CTCs in ovarian cancer patients, as well as hybrid cells. Both cell subtypes demonstrate utility in prognosis and in the assessment of response to treatment. In addition, the expression of MC1-R and EpCAM in hybrid cells brings new perspectives as a possible marker for this phenomenon in ovarian cancer