Fatores associados a necessidade de otimização de dose de infliximabe em paciente com doença de Crohn

Introdução: A terapia biológica revolucionou o tratamento das doenças inflamatórias intestinais (DII) aumentando os índices de remissão de doença. Apesar disso, uma porcentagem significativa dos pacientes pode apresentar resposta parcial ou perda de resposta com o passar do tempo. Tais pacientes necessitam de otimização terapêutica, seja por aumento da dose ou redução do intervalo entre as infusões. Objetivos: Identificar os possíveis fatores relacionados a necessidade de otimização de dose de Infliximabe (IFX) em pacientes com Doença de Crohn (DC). Método: Foi conduzida uma coorte retrospectiva com segmento prospectivo, incluindo pacientes com diagnóstico de DC em acompanhamento no Centro de infusões do Hospital Dia do Hospital de Clínicas de Porto Alegre (HCPA). Foram coletados, através de revisão de prontuário e entrevista com o paciente, dados demográficos, variáveis clínicas, laboratoriais, endoscópicas e radiológicas em quatro momentos: no diagnóstico, na indicação do IFX, na semana 14 de tratamento e ao final de 1 ano de tratamento. Resultados: Foram avaliados 121 pacientes. Destes, 58 (47,93%), foram submetidos a otimização da dose de IFX. Ao avaliar se os fatores de pior prognóstico epidemiológicos, clínicos, laboratoriais e endoscópicos se relacionavam com a necessidade de otimização, observou-se diferença estatisticamente significativa entre os grupos (otimizados e não otimizados) em relação a anemia (p=0.019) e manutenção da elevação de proteína C reativa (PCR) na semana 14 (p=0.039). Após o ajuste pelo modelo multivariado apenas a manutenção da elevação da PCR na semana14 2 permaneceu estatisticamente significativa, com risco 119% maior de otimizar o tratamento quando comparados àqueles com PCR normal. Conclusão: Dentre todos os fatores analisados, apenas a manutenção da elevação de PCR acima do limite de normalidade na semana 14 foi associado à necessidade de otimização de dose de IFX. Isso é condizente com a literatura que descreve a semana 14 como um momento ideal de avaliação dos níveis sérico de imunobiológico como preditor de resposta sustentada. Assim, num contexto de saúde pública e na indisponibilidade de dosagem sérica, este marcador inflamatório sérico poderia auxiliar de uma forma fácil e barata a decisão terapêutica.Introduction: Biological therapy has revolutionized the treatment of inflammatory bowel diseases (IBD) by increasing disease remission rates. Despite this, a significant amount of patients may experience partial response or loss of response over time. Such patients need optimization of therapy, either by increasing the dose or reducing the interval between infusions. Objectives: To identify possible factors related to the need for infliximab (IFX) optimization in patients with Crohn's disease (CD). Method: Retrospective and prospective maintained database of CD patients under IFX treatment being followed up in the Infusion Center at the Day Hospital of the Hospital de Clínicas de Porto Alegre, Brazil. Demographic data, clinical, laboratory, endoscopic and radiological variables were collected in four moments: at diagnosis, at IFX indication, at week 14 of treatment and one year after the initiation of the treatment. Results: 121 patients were studied. Of these, 58 (47,93%) underwent IFX dose optimization. When analyzing epidemiological, clinical, laboratory and endoscopic factors related to a worse disease prognosis, there was a statistically significant difference between the groups (optimized and non-optimized) in relation to anemia (p = 0.019) and maintenance of elevated Creactive protein (CRP) at week 14 (p = 0.039). After adjusting for the multivariate model, only the maintenance of the increase in CRP in the week 14 remained statistically significant, with a 119% greater risk of optimizing treatment when compared to those with normal CRP. Conclusion: Among the factors analyzed, only maintaining CRP elevation at week 14 was associated with the need for IFX dose optimization. This is consistent with the literature that describes week 14 as an ideal time to assess serum levels of immunobiological as a predictor of sustained response. Thus, in a public health system and in the absence of serum dosage, this serum inflammatory marker could easily and cheaply guide the therapeutic decision

Management of anticoagulation with vitamin K antagonists in a tertiary hospital outpatient clinic

Introduction: atrial fibrillation (AF) is one of the main risk factors for stroke. Vitamin K antagonists (VKA) reduce this risk, and the effectiveness of this treatment is directly related to time in therapeutic range (TTR). This study aimed to report the TTR in patients with non-valvular AF at an anticoagulation outpatient clinic; and to describe the profile of this population of patients in terms of risk of stroke, as well as the occurrence of adverse events during the follow-up. Methods: Retrospective cohort study involving patients of the anticoagulation outpatient clinic of the Department of Internal Medicine at Hospital de Clínicas de Porto Alegre. We evaluated outpatient visits, hospital admissions, and emergency visits from January to December 2011. TTR was calculated using the Rosendaal method. Results: Sixty-three patients were investigated. Their mean age was 74.3±10.9 years. The CHADS2 score was ≥ 4 in 44.5% of the patients; 63.5% of them had a CHA2DS2-VASc score ≥ 5. The TTR was 64.8%. During follow-up, the incidence of overall bleeding was 31.7%, with major and minor bleeding rates of 4.8% and 34.9%, respectively. There were no other complications related to AF or anticoagulation. Conclusion: The patients achieved a TTR of 64.8% during follow-up, which is deemed appropriate and in agreement with the literature. Patients had high risk for stroke, and the incidence of minor bleeding was higher than the rate found in the literature, whereas the incidence of major bleeding was similar to the one found in previous studies

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2