RESUMO
BACKGROUND: Early assessment of response to chemotherapy in acute myeloid leukemia may be performed by examining bone marrow aspirate (BMA) or biopsy (BMB); a hypocellular bone marrow sample indicates adequate anti-leukemic activity. We sought to evaluate the quantitative and qualitative assessment of BMA performed on day 14 (D14) of chemotherapy, to verify the inter-observer agreement, to compare the results of BMA and BMB, and to evaluate the impact of D14 blast clearance on the overall survival (OS). METHODS: A total of 107 patients who received standard induction chemotherapy and had bone marrow samples were included. BMA evaluation was performed by two observers using two methods: quantitative assessment and a qualitative (Likert) scale. ROC curves were obtained correlating the BMA quantification of blasts and the qualitative scale, by both observers, with BMB result as gold-standard. RESULTS: There was a significant agreement between the two observers in both the qualitative and quantitative assessments (Kw = 0.737, p < 0.001, and rs = 0.798, p < 0.001; ICC = 0.836, p < 0.001, respectively). The areas under the curve (AUC) were 0.924 and 0.946 for observer 1 and 0.867 and 0.870 for observer 2 for assessments of the percentage of blasts and qualitative scale, respectively. The best cutoff for blast percentage in BMA was 6% and 7% for observers 1 and 2, respectively. A similar analysis for the qualitative scale showed the best cutoff as "probably infiltrated". Patients who attained higher grades of cytoreduction on D14 had better OS. CONCLUSIONS: Evaluation of D14 BMA using both methods had a significant agreement with BMB and between observers, identifying a population of patients with poor outcome.
Assuntos
Medula Óssea/patologia , Leucemia Mieloide Aguda/tratamento farmacológico , Leucemia Mieloide Aguda/patologia , Adolescente , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Área Sob a Curva , Biópsia por Agulha , Medula Óssea/efeitos dos fármacos , Criança , Feminino , Humanos , Quimioterapia de Indução , Estimativa de Kaplan-Meier , Leucemia Mieloide Aguda/mortalidade , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: To develop a simple score to predict early death in adult cancer patients with bloodstream infection. METHODS: A prediction score was developed by analyzing data collected from 361 episodes of BSI at an oncology cancer care center in Brazil. Early death was defined as all deaths occurring within 7 days of the first positive blood culture. RESULTS: Multivariate regression analysis identified poor Karnofsky performance status, uncontrolled cancer, hypotension, pulmonary infiltrates, associated infectious sites, and neutropenia as independently associated with death. Predictive scores were developed assigning points to each significant independent variable. The overall mortality was 20.5% and, the total weighted score ranged from 0 to 11 points, with a very good calibration (Hosmer-Lemeshow statistic, P=0.92) and discrimination (area under receiver operating characteristic curve=0.893). The cutoff value for the predictive score was 3 points, with a negative predictive value of 99% and sensitivity of 98.6%. CONCLUSION: The score model was able to identify adult cancer patients with bloodstream infection at lower risk for early death with an elevated degree of certainty as depicted by a very high negative predictive value. It is essential to prospectively validate the rule in a different group of patients.
Assuntos
Bacteriemia/mortalidade , Fungemia/mortalidade , Neoplasias/mortalidade , Adulto , Idoso , Bacteriemia/diagnóstico , Demografia , Feminino , Fungemia/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias/diagnóstico , Análise de Regressão , Fatores de RiscoRESUMO
PURPOSE: Patients with prolonged and profound neutropenia are at high risk to develop invasive mold infections (IMIs). We developed an index (D-index) that combines duration and severity of neutropenia. The aim of this study was to test the D-index as a predictor of IMI. PATIENTS AND METHODS: The D-index was based on a graph plotting the absolute neutrophil counts during neutropenia and was the area over the neutrophil curve. We tested the D-index in 11 patients with acute myeloid leukemia (AML) who developed IMI during neutropenia and 33 AML patients without IMI (controls). We also calculated a cumulative D-index (c-D-index), defined as the cumulative D-index from the start of neutropenia until the date of the first clinical manifestation of IMI in patient cases. We compared the D-index and c-D-index with duration of neutropenia and defined a cutoff for IMI using the receiver operating characteristic (ROC) curve. RESULTS: The median duration of neutropenia and profound neutropenia of patient cases were significantly higher compared with controls (P = .002 and P = .001, respectively), as were the D-index (P < .001) and c-D-index (P = .02). The D-index and c-D-index performed better than duration of neutropenia in ROC curve analysis. For a cutoff point of 5,800 of the c-D-index, the sensitivity and specificity were 91% and 58%, respectively, and for a prevalence of IMI of 5%, 10%, and 15%, the negative predictive values were 99%, 98%, and 97%, respectively. CONCLUSION: The high negative predictive value of the c-D-index may be of help in defining different risks for IMI in febrile neutropenic patients.
Assuntos
Antifúngicos/uso terapêutico , Antineoplásicos/efeitos adversos , Micoses/etiologia , Micoses/prevenção & controle , Neutropenia/induzido quimicamente , Neutropenia/complicações , Neutrófilos , Adolescente , Adulto , Antineoplásicos/administração & dosagem , Área Sob a Curva , Feminino , Humanos , Leucemia Mieloide Aguda/tratamento farmacológico , Contagem de Leucócitos , Masculino , Computação Matemática , Pessoa de Meia-Idade , Micoses/microbiologia , Neutropenia/patologia , Seleção de Pacientes , Valor Preditivo dos Testes , Curva ROC , Medição de Risco/métodos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
Sickle cell disease is a hereditary illness of high prevalence in black population, and involved patients frequently have multiple hospitalizations. Our objective was to describe and to analyze the clinical course of hospitalizations in patients with sickle cell disease. Cross-sectional study of 78 patients submitted to 230 hospital admissions due to acute complications of sickle cell disease, from 2000 to 2004 in a public teaching hospital in Rio de Janeiro city, RJ, Brazil. Outcomes variables were length of hospital stay and death. Main covariables were age, gender, chronic renal failure, causes of hospitalization and use of medicines. Proportions were compared using the chi-square or the Fischer test, and for the continuous variables, Mann-Whitney test was used. The median age in years was 20.3 (15-53) and the most frequent clinical event was acute painful episode (73.5 percent). Mean length of stay was significantly higher in admissions caused by different reasons than acute painful episode (p < 0.001), in those with chronic renal failure (p = 0.006) or with bacterial infection (p = 0.002). The number of deaths was higher in admissions with bacterial infection (p = 0.049) or chronic renal failure (p = 0.014). Gram-negative bacteria isolated from febrile patients included Pseudomonas sp and Acinetobacter sp. This study allowed a larger knowledge concerning morbidity and mortality among adolescent and adult patients hospitalized with sickle cell disease. As few studies with data from hospital admissions are avaiable, the findings can be useful in public health area, especially on healthcare planning to the population with sickle cell disease.
A doença falciforme é uma doença hereditária, de alta prevalência na população negra, que leva a múltiplas internações hospitalares. Nosso objetivo foi descrever e analisar o curso clínico de pacientes com doença falciforme hospitalizados.Realizou-se estudo transversal de 78 pacientes submetidos a 230 internações hospitalares devido a complicações agudas da doença falciforme, de 2000 a 2004, em um hospital universitário no Rio de Janeiro-RJ, Brasil. Os desfechos estudados foram tempo de permanência hospitalar e óbito. As principais co-variáveis foram idade, sexo, presença de insuficiência renal crônica, causas de hospitalização e uso de medicamentos. Proporções foram comparadas utilizando-se o teste qui-quadrado ou teste de Fischer, e, para as variáveis contínuas, o teste de Mann-Whitney foi utilizado. A mediana da idade foi 20,3 anos (15-23) e o evento clínico mais freqüente foi o episódio doloroso agudo (73,5 por cento). O tempo médio de permanência hospitalar foi maior nas internações por causas distintas do episódio doloroso agudo (p<0,001), e naquelas com o diagnóstico de insuficiência renal crônica (p=0,006) ou infecção bacteriana (p=0,002). O número de óbitos foi maior nas internações com o diagnóstico de infecção bacteriana (p=0,049) ou insuficiência renal crônica (p=0,014). Os germes gram-negativos isolados nos pacientes com febre incluíram Pseudomonas sp e Acinetobacter sp. O presente estudo permitiu um maior conhecimento acerca da morbi-mortalidade entre adolescentes e adultos hospitalizados com doença falciforme. Como poucos estudos sobre internações hospitalares estão disponíveis, os achados podem ser úteis no campo da saúde pública, em especial na área de planejamento de saúde da população de pacientes com doença falciforme.