Validação do escore APACHE IV no transplante hepático pós‐operatório no sul do Brasil: estudo de coorte

BackgroundLiver transplantation is the only curative therapeutic modality available for individuals at end‐stage liver disease. There is no reliable method of predicting the early postoperative outcome of these patients. The Acute Physiology and Chronic Health Evaluation (APACHE) is a widely used model for predicting hospital survival and benchmarking in critically ill patients. This study evaluated the calibration and discrimination of APACHE IV in the postoperative period of elective liver transplantation in the southern Brazil.MethodsThis was a clinical prospective and unicentric cohort study that included 371 adult patients in the immediate postoperative period of elective liver transplantation from January 1, 2012 to December 31, 2016.ResultsIn this study, liver transplant patients who evolved to hospital death had a significantly higher APACHE IV score (82.7 ± 5.1 vs. 51.0 ± 15.8; p < 0.001) and higher predicted mortality (6.5% [4.4–20.2%] vs. 2.3% [1.4–3.5%]; p < 0.001). The APACHE IV score showed an adequate calibration (Hosmer‐Lemeshow – H‐L = 11.37; p = 0.181) and good discrimination (Receiver Operator Curve – ROC of 0.797; Confidence Interval 95% – 95% CI 0.713–0.881; p < 0.0001), although Standardized Mortality Ratio (SMR = 2.63), (95% CI 1.66–4.27; p < 0.001) underestimate mortality.ConclusionsIn summary, the APACHE IV score showed an acceptable performance for predicting a hospital outcome in the postoperative period of elective liver transplant recipients.     

Mutation screening in Angiotensin II receptors, AGTR1 and AGTR2, and evaluation of AGTR1 polymorphisms C573T and A1166C in patients with premature adrenarche

Precocious pubarche is the appearance of pubic hair before the age of 8 years in girls and 9 years in boys. The most frequent etiology is idiopathic precocious adrenarche, suggested, after long-term follow-up, to be associated with metabolic syndrome. One of the factors involved in the genesis of precocious adrenarche is Angiotensin II (Ang II), which promotes cell proliferation and steroidogenesis through type 1 (AT1) and type 2 (AT2) receptors. In order to study Ang II receptors mutations, 50 children with idiopathic precocious adrenarche were evaluated and compared to a control group of normal individuals. Mutations were not detected in the AGTR1 and AGTR2 genes; however, two polymorphisms were identified in the AGTR1 gene: the C573T (exon 5) and the A1166C (3' untranslated region). The polymorphic allele T573 was found in 35% of the patients and 38% of controls. The polymorphic allele C1166 was present in 24% of the patients and 26% of controls. There was no statistical difference between groups. There was also no correlation between the polymorphisms and clinical and laboratory findings, as well as their family history of metabolic syndrome.     

Pitfalls in integrated CT-PET of the thorax: implications in oncologic imaging

Integrated computed tomography-positron emission tomography (CT-PET) scanners improve localization of regions of increased [18F]-fluoro-2-deoxy-D-glucose (FDG) uptake and staging accuracy by allowing the near-simultaneous acquisition of coregistered, spatially matched functional and morphologic data in the same examination. However, many benign lesions can accumulate FDG and be potential pitfalls in interpretation. With the increased use of CT-PET in oncologic imaging, misinterpretation of these potential pitfalls can have significant clinical ramifications and alter staging and management. In this article, we review the physiologic uptake of FDG, normal variants, and potential pitfalls in the integrated CT-PET imaging of the thorax and their implications in oncologic imaging.     

Extrathoracic PET/CT findings in thoracic malignancies

The routine use of integrated positron emission tomography computed tomography in the staging and follow-up of patients diagnosed with non-small-cell lung cancer has improved diagnostic accuracy but many incidental extrathoracic findings are routinely encountered. These include physiologic fluorodeoxy glucose avid foci, normal computed tomography variants, and second primary malignancies, all of which have to be differentiated from extrathoracic metastatic disease. Knowledge of these findings is important for correct staging and identification of second primaries.     

Interobserver and intraobserver variability of standardized uptake value measurements in non-small-cell lung cancer

OBJECTIVES: To assess interobserver and intraobserver variabilities in measuring the maximal standardized uptake value (SUV) of non-small-cell lung cancer. METHODS: Positron emission tomography-computed tomography examinations of 20 consecutive patients referred for initial evaluation of newly diagnosed non-small-cell lung cancer were retrospectively reviewed by 5 experienced positron emission tomography-computed tomography readers, who independently measured the maximal SUV/body weight of the primary tumors. Interobserver and intraobserver variabilities were assessed by using 4 statistical methods: correlation, regression analysis, Bland-Altman analysis, and analysis of variance. The SUV measurements derived in the study were compared with the SUV measurements documented in the original reports using correlation and regression analysis. The percentages of tumors whose retrospective SUV measurements were more than 20% different and more than 25% different from those in the original report were assessed. RESULTS: Both interobserver and intraobserver SUV measurements were highly reproducible. Pearson correlation coefficients were greater than 0.95 and 0.94, respectively. Good interobserver and intraobserver agreement was shown with regression analysis (F test P value >0.05), the Bland-Altman analysis, and analysis of variance (F test P value >0.95). The mean original SUV was much less than the mean study SUV (P<0.05). The study SUV differed from the SUV of the original report by more than 20% in 50% of the tumors, and by more than 25% in 45% of the tumors. CONCLUSIONS: There was excellent interobserver and intraobserver agreement in SUVs measured in the study environment but poor agreement between study SUVs and those documented in original reports, which can affect treatment decisions substantially.     

Psychological distress among marginalized women in the outskirts of Beirut: Determinants and association with health perception

The objective of this study was to determine the prevalence of psychological distress (PD) and its determinants in under-privileged women in the outskirts of Beirut, Lebanon. A cross-sectional survey of 1,869 ever-married women aged 15-59 was carried out. PD levels were determined using the 12-item General Health Questionnaire (Appendix). Health status, living conditions, social support, and physical symptoms as reported by women were recorded. Logistic regression was used to test the independent effect of each variable on PD. 46.6% of women had PD. Psychologically distressed women had more children, less education, lower income, less social support, an uncomfortable relationship with their husband, participated in the labor force and were more likely to reside in a predominantly Moslem community. Reporting a health or living problem were significant predictors of PD. The presence of limb, back and stomach pain, and headache were associated with PD. Compared to similar populations in other countries, our sample had a high prevalence of mental distress.     

Focal uptake of fluorodeoxyglucose by the thyroid in patients undergoing initial disease staging with combined PET/CT for non-small cell lung cancer

PURPOSE: To retrospectively evaluate the prevalence of focal fluorodeoxyglucose (FDG) uptake by the thyroid gland on combined positron emission tomographic (PET) and computed tomographic (CT) scans in patients undergoing staging of newly diagnosed non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Institutional review board approval was obtained, informed consent was waived, and the study was Health Insurance Portability and Accountability Act-compliant. Whole-body PET/CT scans and medical records of 140 consecutive patients with newly diagnosed NSCLC (80 men, 60 women; mean age, 66 years; range, 39-89 years) were retrospectively reviewed by two experienced PET/CT scan readers. Maximum standardized uptake value (SUV) was calculated for FDG-avid thyroid foci. Corresponding thyroid CT findings were recorded in patients with focal increased FDG thyroid uptake. RESULTS: PET results showed that six patients (4.3%) had seven foci of increased FDG uptake in the thyroid. Five of the seven foci (in four patients) corresponded to a low-attenuation thyroid lesion on the non-enhanced CT scan. Lesions ranged in diameter from 0.8 to 2.5 cm. Four of the lesions were found to be papillary thyroid cancers at fine-needle aspiration biopsy. The fifth lesion was found to be benign at thyroidectomy. The remaining two patients did not have histologic confirmation of their thyroid lesion because no specific biopsy site was visualized on CT or sonographic images and lesions were considered benign. Maximum SUV of the thyroid cancers ranged from 3.0 to 32.9 (mean, 13.7). Maximum SUV of benign thyroid lesions ranged from 4.6 to 6.2 (mean, 5.4). CONCLUSION: Focal thyroid FDG uptake found during the initial staging of NSCLC at PET/CT indicates a high likelihood of primary thyroid cancer.     

Clinical and pharmacokinetic study of TNP-470, an angiogenesis inhibitor, in combination with paclitaxel and carboplatin in patients with solid tumors

Purpose Preclinical studies have demonstrated a synergistic effect with the angiogenesis inhibitor TNP-470 and several cytotoxic agents. A recent clinical trial with the combination of paclitaxel and TNP-470 has shown promising effects. The present study was designed to determine the toxicity and pharmacokinetics of carboplatin in combination with TNP-470 in comparison with the doublet regimen of paclitaxel and carboplatin in patients with solid tumors.Experimental design Enrolled in the study were 17 patients with lung (11), head/neck (3), sarcoma (2) and thymoma (1). The patients received intravenous paclitaxel and carboplatin on day 1 followed by TNP-470 (60 mg/m² i.v. over 1 h administered thrice weekly on Monday, Wednesday, and Friday). Each cycle of therapy consisted of 3 weeks. The initial cohort of three patients received carboplatin at AUC 5 mg/ml×min. No dose-limiting toxic effects occurred, thus the subsequent cohort received carboplatin at AUC 6 mg/ml×min. In addition to toxicity, the pharmacokinetics of carboplatin were evaluated, and tumor response and patient survival rates were assessed.Results The administered regimen of paclitaxel (225 mg/m² i.v. over 3 h) and carboplatin (AUC 6 mg/ml×min i.v. over 1 h) on day 1 followed by TNP-470 (60 mg/m² i.v. over 1 h administered thrice weekly on Monday, Wednesday, and Friday) was defined as both the maximum tolerated and optimal dose. Hematological toxic effects were similar to those expected with the chemotherapy doublet. All neurocognitive impairments were graded as mild to moderate and reversed after discontinuation of TNP-470 administration. No alterations in the pharmacokinetic disposition of carboplatin were noted. Overall, the median survival duration was 297 days. Four patients (24%) had a partial response, and eight (47%) had stable disease.Conclusions The combination of TNP-470, paclitaxel, and carboplatin is a reasonably well tolerated regimen. Further randomized studies of TNP-470 with this doublet regimen are now warranted for non-small-cell lung carcinoma and other solid tumors.     

Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty

OBJECTIVE: The purpose of this study was to determine the frequency, radiographic findings, and clinical significance of a pulmonary embolism of cement occurring during percutaneous vertebroplasty or kyphoplasty as detected on conventional chest radiography. MATERIALS AND METHODS: Chest radiographs were obtained after 69 percutaneous vertebroplasty procedures in 64 patients. Chest radiographs were reviewed retrospectively for the presence of pulmonary emboli of cement, and findings were assessed. The frequency was calculated from the cases treated. Medical records were reviewed for procedure-related complications. RESULTS: The emboli of cement were noted radiographically in three (4.6%) of 65 procedures performed in our institution. All patients with cement emboli had multiple myeloma. The chest radiographic findings were multiple radiographically dense opacities with a tubular and branching shape that were scattered sporadically or distributed diffusely throughout the lungs. All patients with cement pulmonary embolism remained asymptomatic. A correlation of embolism of cement to lungs was found with paravertebral venous cement leak (p < 0.001) but not with the number of vertebral bodies treated (p = 0.185) or with the type of procedure performed-kyphoplasty versus vertebroplasty (p = 0.98). CONCLUSION: Pulmonary embolism of cement is seen in 4.6% of patients after percutaneous vertebroplasty or kyphoplasty. The characteristic radiographic findings should be recognized by radiologists.     

Bronchioalveolar cell carcinoma: radiologic appearance and dilemmas in the assessment of response

Bronchioalveolar cell carcinomas (BACs), a subset of primary lung adenocarcinomas, are uncommon. Histologically, they are a diverse group of malignancies. The diagnosis is restricted to adenocarcinomas that grow in a lepidic manner and that have no stromal, vascular, or pleural invasion. Their histologic diversity leads to varied radiologic manifestations that are often indistinguishable from those of other primary non-small-cell lung cancers (NSCLC). However, typical manifestations, many of which can be attributed to lepidic growth, have been reported. Radiologic manifestations include a solitary peripheral pulmonary nodule, airspace disease, and multiple nodules and a combination of these findings can be present in a single patient. The most common manifestation, a solitary pulmonary nodule, is usually indistinguishable from other primary NSCLC. However, pseudocavitation and air bronchograms within the nodule can be useful in suggesting the correct diagnosis. In addition to aiding in the diagnosis of BAC, radiologic imaging is an important component in the evaluation of the therapeutic efficacy of treatment; serial measurements of tumor size before and after treatment are commonly used to assess response. However, BACs that are consolidative or ground-glass in nature present challenges in tumor-response determination. Other imaging modalities, such as positron emission tomography scanning, may prove helpful in assessing the metabolic response to therapy but have yet to be proven effective.