Introduction: Combination of doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) is the standard of care in frontline therapy for classic Hodgkin lymphoma (cHL). Since 2018, bleomycin shortages have been reported in Brazil, with severe consequences for cHL patients. In the private setting, many institutions chose to use A+AVD, in which bleomycin is replaced by brentuximab-vedotin, or to import bleomycin from vendors not registered at the national drug agency. For public institutions, however, these costly strategies are largely unattainable. Methods: We conducted a single-arm open-label study to evaluate the substitution of bleomycin with etoposide 100 mg/m2 on days 1 and 15 of every 28-day cycle (AEVD) in previously untreated cHL, at Hospital Municipal São José, in Joinville, Brazil. Here we present preliminary data on the safety and efficacy of this combination in a scenario of lack of approved treatment options for this patient population. Results: Twenty-five patients aged 18 or more with cHL diagnosed between June 2018 and November 2020 were included. Fourteen patients (56%) were male, with median age of 27 years (range: 18-66). Most patients were stage II (60%, n=15), presented with B symptoms (56%, n=14) and high lactate dehydrogenase (LDH, n=13, 52%). For stage III-IV (n=5), high-risk IPS was present in 3 patients (score >2; 60%). For localized disease (n=20), unfavorable features according to the GHSG were seen in 16 patients (n=80%). All patients received between 3 and 6 chemotherapy cycles, with no recorded adverse event requiring hospitalization, treatment interruption or discontinuation. PET-CT was performed solely outside of our institution. Eight patients had access to interim PET-CT, all with Deauville scores (DS) 1-3. Overall response rate was 96%, with one disease progression after 5 cycles. Seven patients had CT scan-alone end-of-treatment (EOT) assessment, with 5 complete responses (CR) and 2 partial responses (PR), with both PR patients sustaining remissions after 10 and 12 months. EOT assessment with PET-CT (n=18) resulted in DS 1-3 in 72% (n=13), 4 in 22% (n=4) and 5 in one (6%). All 5 patients with DS 4-5 underwent biopsy after EOT assessment, with confirmation of relapsed or refractory (RR) cHL in 4 cases (22 year-old, stage IV high-risk female with progressive disease; 65 year-old, stage III low-risk male with relapse 11 months after EOT; 26 year-old, stage II high-risk male with relapse 6 months after EOT; 25 year-old, stage II high-risk female with relapse 4 months after EOT). Two RR cHL patients (50%) had treatment delays exceeding 30 days due to psychosocial or financial impacts emerging from the COVID-19 pandemic. All RR cHL patients had access to salvage treatments. At a median follow-up of 16 months (range: 8-36), no death was recorded and 12-month progression-free survival probability was 86% (95%CI: 72%-100%). Conclusions: Drug shortages impacting chemotherapy treatments have been a recurring problem worldwide, most noticeably among cytotoxic agents without in-class validated substitutions, as is the case with bleomycin. AEVD, as a novel approach to newly diagnosed cHL, appears to be safe, feasible and highly active in a population composed mostly of high-risk patients. Figure 1 Figure 1. Disclosures Boettcher: Novartis: Speakers Bureau.
Background: Transverse myelitis (TM) is most often triggered by an autoimmune reaction due to infections and perhaps vaccines. During the current coronavirus disease 2019 (COVID-19) pandemic, some case reports have shown a temporal association between TM and COVID-19 vaccine. We aimed to report a case of TM with a temporal association with ChAdOx1 nCoV-19 (AZD1222, Oxford/AstraZeneca) vaccine in a Brazilian public hospital. Case Presentation: A 27-year-old woman experienced fever, low back pain and urinary retention 3 weeks after the first dose of the ChAdOx1 nCoV-19 vaccine. Two days later, she experienced decreased strength of the lower limbs associated with paresthesia of the distal extremities. At the hospital, there was progression of weakness associated with anesthesia in T4-L1. Magnetic resonance imaging findings were suggestive of demyelination and acute inflammation. Cerebrospinal fluid analysis showed monomorphonuclear pleocytosis, increased protein and decreased glucose.Gram stain, oligoclonal bands, anti-aquaporin-4 antibody, and screening for infectious agents and connective tissue disease were all negative. During treatment, the patient received 5-day pulse therapy with methylprednisolone, acyclovir and 7-day plasmapheresis. Despite all treatments, she persisted with lower limb plegia, areflexia and anesthesia at the level of T4. She was discharged with a monthly cyclophosphamide plan and outpatient follow up. Conclusions:In the absence of other causes, the diagnosis of TM was made with evidence of a possible temporal association with ChAdOx1 nCoV-19 vaccine. It is important to emphasize that it is a temporal association only and the benefits of vaccination continue to outweigh the risk of TM.
INTRODUÇÃO: Com o envelhecimento da população Brasileira, dimensionar e avaliar o perfil da população vulnerável a ter a Síndrome da Fragilidade no Idoso (SFI) e entender seus fatores associados é de grande importância. OBJETIVO: Analisar o perfil de idosos que correspondem às informações referentes aos indicadores de fragilidade do questionário de fragilidade de Edmonton, em uma clínica especializada em geriatria. MÉTODO: O presente estudo é do tipo transversal, analítico, com idosos da Unidade especializada de atenção geriátrica em Joinville, Brasil. Foram analisados perfil social econômico (escolaridade, renda, raça, sexo) e a avaliação para a SFI e as comorbidades no idoso. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da UNIVILLE sob parecer de n⁰ 40940020.6.0000.5366. RESULTADO: Os resultados do estudo foram a partir dos 141 idosos entrevistados, com uma média de 74 anos de idade. A maioria (60%) do sexo feminino, de cor branca (90,1%), de baixa escolaridade (56%) e casados ou em união estável (53,2%). A prevalência de algum nível de fragilidade foi de 17,7% (IC95%). DISCUSSÃO: Apesar da discussão sobre os critérios para definição da SFI, o presente estudo baseou-se no questionário de fragilidade de Edmonton - Edmonton Frail Scale. A amostra local da população representa como discussão sobre a escolaridade, tabagismo, renda e o grande número de comorbidades predispõe a SFI e, dessa forma, também uma prevalência maior de queda do idoso. Isso converge com estudos prévios na literatura que ilustram maior prevalência de queda em pacientes com esse perfil epidemiológico. Conclusão: Apesar de algumas limitações do estudo como de ter sido realizado em um serviço de referência em geriatria, o estudo molda o perfil local da população idosa acometida pela SFI.
Objective: Breaking bad news (BBN) has a big influence in patients' lives, but still a lot of health care providers struggle when doing it with efficiency and empathy. Methods: This study is a prospective cohort that evaluated the knowledge and the evolution of fifth year medical students in breaking bad news, and investigated which factors had a positive or negative influence on their scores. Two simulations were conducted during the year in the model of Objective Structured Clinical Examination (OSCE), the students' scores were acquired through a checklist based on the SPIKES protocol. Posteriorly, an online questionnaire was filled by the students, containing objective and open questions relevant to the BBN scenario. Results: Participated in this study 85 undergraduates, in the first OSCE 52% (n = 44) scored above the minimum institutional average, in the second OSCE 59% (n = 50) scored above the minimum institutional average. Comparing both activities there were isolated differences between isolated items at the checklist, but without statistical significance. The factor that had a positive influence for scoring higher was having previous experience in BBN, during the second OSCE the group that had experience scored an average of 3,11 points, the other group had an average of 2,57 only (p = 0,012). Conclusion: The performance was median, and no score evolution was observed between the activities. Previous experience was the more important factor for a better score.
Avaliar os desfechos adversos perinatais relacionados ao uso de álcool na gestação. MÉTODOS: Trata-se de um estudo observacional transversal, realizado na Maternidade Darcy Vargas em Joinville-SC, período de março de 2018 a fevereiro de 2019 através de amostra randomizada composta de 722 puérperas maiores de 18 anos, que realizaram o acompanhamento pré-natal exclusivamente em Atenção Primária à Saúde, divididas em 2 grupos: pacientes que fizeram uso de álcool na gestação e que não utilizaram. Os fatores de confusão foram uso de tabaco e drogas. O intervalo de confiança foi de 95%.
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