Single and combination immunotherapy with chemotherapy and the risk of AKI in patients with solid cancer.

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) has emerged as an important toxicity among patients with advanced cancer treated with immune checkpoint inhibitors. The aim of this study was to describe the incidence, risk factors and mortality of AKI in patients receiving immune checkpoint inhibitors alone or in combination with another form of immunotherapy or chemotherapy. DESIGN, SETTING AND PARTICIPANTS: We included all patients who received immune checkpoint inhibitors alone or in combination with another form of immunotherapy or chemotherapy at AC Camargo Cancer Center from January 2015 to December 2019. AKI was defined as a ≥ 1.5 fold increase in creatinine from baseline within 12 months of immune checkpoint inhibitor initiation. We assessed the association between baseline demographics, comorbidities, medications and risk of AKI using a competing risk model, considering death as a competing event. RESULTS: We included 614 patients in the analysis. The mean age was 58.4 ± 13.5 years, and the mean baseline creatinine was 0.8 ± 0.18 mg/dL. AKI occurred in 144 (23.5%) of the patients. The most frequent AKI etiologies were multifactorial (10.1%), hemodynamic (8.8%) and possibly immunotherapy-related (3.6%). The likelihood of AKI was greater in patients with genitourinary cancer (sHR 2.47 95% CI 1.34-4.55 p < 0.01), with a prior AKI history (sHR 2.1 95% CI 1.30-3.39 p < 0.01) and taking antibiotics (sHR 2.85 95% CI 1.54-5.27 p < 0.01). CONCLUSIONS: In this study, genitourinary cancer, previous AKI and antibiotics use were associated with a higher likelihood of developing AKI.

In-hospital mortality and one-year survival of critically ill patients with cancer colonized or not with carbapenem-resistant gram-negative bacteria or vancomycin-resistant enterococci: an observational study.

BACKGROUND: Patients with cancer are at risk of multidrug-resistant bacteria colonization, but association of colonization with in-hospital mortality and one-year survival has not been established in critically ill patients with cancer. METHODS: Using logistic and Cox-regression analyses adjusted for confounders, in adult patients admitted at intensive care unit (ICU) with active cancer, we evaluate the association of colonization by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci with in-hospital mortality and one-year survival. RESULTS: We included 714 patients and among them 140 were colonized (19.6%). Colonized patients more frequently came from ward, had longer hospital length of stay before ICU admission, had unplanned ICU admission, had worse performance status, higher predicted mortality upon ICU admission, and more hematological malignancies than patients without colonization. None of the patients presented conversion of colonization to infection by the same bacteria during hospital stay, but 20.7% presented conversion to infection after hospital discharge. Colonized patients had a higher in-hospital mortality compared to patients without colonization (44.3 vs. 33.4%; p < 0.01), but adjusting for confounders, colonization was not associated with in-hospital mortality [Odds ratio = 1.03 (0.77-1.99)]. Additionally, adjusting for confounders, colonization was not associated with one-year survival [Hazard ratio = 1.10 (0.87-1.40)]. CONCLUSIONS: Adult critically ill patients with active cancer and colonized by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci active cancer have a worse health status compared to patients without colonization. However, adjusting for confounders, colonization by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci are not associated with in-hospital mortality and one-year survival.

Excess mortality by specific causes of deaths in the city of São Paulo, Brazil, during the COVID-19 pandemic.

BACKGROUND: To investigate the excess of deaths by specific causes, in the first half of 2020 in the city of São Paulo-Brazil, during the COVID-19 pandemic. METHODS: Ecological study conducted from 01/01 to 06/30 of 2019 and 2020. Population and mortality data were obtained from DATASUS. The standardized mortality ratio (SMR) by age was calculated by comparing the standardized mortality rate in 2020 to that of 2019, for overall and specific mortality. The ratio between the standardized mortality rate due to COVID-19 in men as compared to women was calculated for 2020. Crude mortality rates were standardized using the direct method. RESULTS: COVID-19 was responsible for 94.4% of the excess deaths in São Paulo. In 2020 there was an increase in overall mortality observed among both men (SMR 1.3, 95% CI 1.17-1.42) and women (SMR 1.2, 95% CI 1.06-1.36) as well as a towards reduced mortality for all cancers. Mortality due to COVID-19 was twice as high for men as for women (SMR 2.1, 95% CI 1.67-2.59). There was an excess of deaths observed in men above 45 years of age, and in women from the age group of 60 to 79 years. CONCLUSION: There was an increase in overall mortality during the first six months of 2020 in São Paulo, which seems to be related to the COVID-19 pandemic. Chronic health conditions, such as cancer and other non-communicable diseases, should not be disregarded.

SAPS 3, APACHE IV or GRACE: which score to choose for acute coronary syndrome patients in intensive care units? / SAPS 3, APACHE IV ou GRACE: qual escore escolher para pacientes com sindromes coronarianas agudas na unidade de terapia intensiva?

CONTEXT AND OBJECTIVE Acute coronary syndromes (ACS) are a common cause of intensive care unit (ICU) admission. Specific prognostic scores have been developed and validated for ACS patients and, among them, GRACE (Global Registry of Acute Coronary Events) has had the best performance. However, intensive care clinicians generally use prognostic scores developed from heterogeneous populations of critically ill patients, such as APACHE IV (Acute Physiologic and Chronic Health Evaluation IV) and SAPS 3 (Simplified Acute Physiology Score 3). The aim of this study was to evaluate and compare the performance of these three scores in a non-selected population of ACS cases. DESIGN AND SETTING Retrospective observational study to evaluate three prognostic scores in a population of ACS patients admitted to three general ICUs in private hospitals in São Paulo. METHODS All patients with ACS admitted from July 2008 to December 2009 were considered for inclusion in the study. Score calibration and discrimination were evaluated in relation to predicting hospital mortality. RESULTS A total of 1065 patients were included. The calibration was appropriate for APACHE IV and GRACE but not for SAPS 3. The discrimination was very good for all scores (area under curve of 0.862 for GRACE, 0.860 for APACHE IV and 0.804 for SAPS 3). CONCLUSIONS In this population of ACS patients admitted to ICUs, GRACE and APACHE IV were adequately calibrated, but SAPS 3 was not. All three scores had very good discrimination. GRACE and APACHE IV may be used for predicting mortality risk among ACS patients. .

CONTEXTO E OBJETIVO Síndromes coronarianas agudas (SCA) são causa comum de admissão à unidade de terapia intensiva (UTI). Escores prognósticos específicos foram desenvolvidos e validados para pacientes com SCA e, dentre esses, o GRACE (Registro Global de Eventos Coronarianos Agudos) tem tido a melhor performance. No entanto, os intensivistas normalmente usam escores desenvolvidos para populações heterogêneas de pacientes graves, como o APACHE IV (Avaliação de Saúde Crônica e Fisiologia Aguda IV) e o SAPS 3 (Escore Fisiológico Agudo Simplificado 3). O presente estudo objetiva avaliar e comparar a performance desses três escores em uma população não selecionada admitida com diagnóstico de SCA. TIPO DE ESTUDO E LOCAL Estudo retrospectivo observacional para a avaliação de três escores prognósticos em uma população admitida com SCA em três UTIs gerais de hospitais particulares em São Paulo. MÉTODOS Todos os pacientes admitidos com SCA de julho de 2008 a dezembro de 2009 foram avaliados para inclusão no estudo. Foram avaliadas a calibração e a discriminação dos escores em predizer a mortalidade hospitalar. RESULTADOS Um total de 1.065 pacientes foi incluído. A calibração foi adequada para o APACHE IV e para o GRACE, mas não para o SAPS 3. A discriminação foi muito boa para todos os escores (área sob a curva de 0,862; 0,860 e 0,804 para GRACE, APACHE IV e SAPS 3). CONCLUSÕES Nesta população de pacientes com SCA admitidos à UTI, os escores GRACE e APACHE IV apresentaram uma calibração adequada, mas o SAPS 3 não. Todos os escores tiveram uma discriminação muito boa. O GRACE e o APACHE IV podem ser usados para pre...