Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 5 uppsatser.

by Kai-Hang Choi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1998. / Includes bibliographical references (leaves 217-232). / Abstract also in Chinese. / ABSTRACT --- p.i / ACKNOWLEDGMENT --- p.iv / TABLE OF CONTENTS --- p.v / LIST OF FIGURES --- p.viii / LIST OF TABLES --- p.xiii / Chapter CHAPTER I --- INTRODUCTION --- p.1 / Chapter 1.1 --- Background --- p.1 / Chapter 1.2 --- Role of GIS in Health Studies --- p.4 / Chapter 1.3 --- Research Objectives --- p.5 / Chapter 1.4 --- Organization of the Thesis --- p.6 / Chapter CHAPTER II --- LITERATURE REVIEW --- p.8 / Chapter 2.1 --- Introduction --- p.8 / Chapter 2.2 --- Human cancer --- p.8 / Chapter 2.3 --- Environment and Cancer --- p.10 / Chapter 2.4 --- Cancer Etiology and Epidemiology --- p.13 / Chapter 2.5 --- Observational Cancer Epidemiology --- p.15 / Chapter 2.6 --- Geography of Cancer --- p.17 / Chapter 2.7 --- Geographical Epidemiology of Cancer --- p.19 / Chapter 2.7.1 --- Geographical Variation in Cancer Occurrence --- p.21 / Chapter 2.7.1.1 --- Cancer Mapping --- p.24 / Chapter 2.7.1.2 --- Spatial Autocorrelation --- p.26 / Chapter 2.7.2 --- Identifying Causal Association --- p.29 / Chapter 2.7.3 --- Environmental Factors of Cancer --- p.31 / Chapter 2.8 --- Geographical Information Systems --- p.40 / Chapter 2.9 --- GIS and Health --- p.41 / Chapter 2.9.1 --- GIS Applications in Health Planning --- p.42 / Chapter 2.9.2 --- GIS Applications in Health Research --- p.43 / Chapter 2.10 --- Cancer Studies with GIS --- p.45 / Chapter 2.11 --- Conclusion --- p.47 / Chapter CHAPTER III --- THE STUDY AREA AND RESEARCH METHODOLOGY --- p.49 / Chapter 3.1 --- Introduction --- p.49 / Chapter 3.2 --- Disease Transition in Hong Kong --- p.49 / Chapter 3.3 --- Cancer in Contemporary Hong Kong --- p.52 / Chapter 3.3.1 --- Trends of Cancer Mortality and Incidence --- p.52 / Chapter 3.3.2 --- The Common Types of Cancer --- p.55 / Chapter 3.3.3 --- Geographical Variation of Cancer in Hong Kong --- p.58 / Chapter 3.4 --- The Research --- p.61 / Chapter 3.4.1 --- Cartographic Analysis --- p.62 / Chapter 3.4.2 --- Statistical Analyses --- p.63 / Chapter 3.4.3 --- Cancer Variables --- p.67 / Chapter 3.4.4 --- Environmental Variables --- p.70 / Chapter 3.5 --- Conclusion --- p.71 / Chapter CHAPTER IV --- DATABASE CONSTRUCTION --- p.73 / Chapter 4.1 --- Introduction --- p.73 / Chapter 4.2 --- Data Collection --- p.73 / Chapter 4.2.1 --- Base Maps --- p.73 / Chapter 4.2.2 --- Cancer Data --- p.74 / Chapter 4.2.3 --- Socio-demographic Data --- p.75 / Chapter 4.2.4 --- Air Pollution --- p.76 / Chapter 4.2.5 --- ELF EMFs --- p.77 / Chapter 4.3 --- Data Input --- p.77 / Chapter 4.3.1 --- Spatial Data --- p.77 / Chapter 4.3.1.1 --- Base Maps --- p.78 / Chapter 4.3.1.2 --- Point Data --- p.78 / Chapter 4.3.1.3 --- Line Data --- p.79 / Chapter 4.3.2 --- Attribute Data --- p.79 / Chapter 4.4 --- Data Editing and Conversions --- p.80 / Chapter 4.4.1 --- Spatial Data --- p.80 / Chapter 4.4.1.1 --- Standard Coverage Editing Procedures --- p.80 / Chapter 4.4.1.2 --- Specific Coverage Editing Procedures --- p.81 / Chapter 4.4.2 --- Attribute Data --- p.83 / Chapter 4.4.2.1 --- Cancer Rates --- p.83 / Chapter 4.4.2.2 --- Socio-economic Status --- p.85 / Chapter 4.5 --- Data Pre-processing and Manipulation --- p.86 / Chapter 4.5.1 --- Socio-economic Variables --- p.86 / Chapter 4.5.1.1 --- Interpretation of Factor Scores --- p.97 / Chapter 4.5.2 --- Compromised Traffic Index --- p.99 / Chapter 4.5.3 --- ELFEMFs --- p.104 / Chapter 4.6 --- Conclusion --- p.106 / Chapter CHAPTER V --- RESULTS AND DISCUSSIONS --- p.111 / Chapter 5.1 --- Introduction --- p.111 / Chapter 5.2 --- Geographical Analysis of Cancer Patterns --- p.111 / Chapter 5.2.1 --- Results --- p.112 / Chapter 5.2.1.1 --- Total Cancer --- p.113 / Chapter 5.2.1.2 --- Cancer of the Female Breast --- p.118 / Chapter 5.2.1.3 --- Cancer of the Cervix Uteri (Cervical Cancer) --- p.121 / Chapter 5.2.1.4 --- Cancer of the Colon and Rectum (Colorectal Cancer) --- p.124 / Chapter 5.2.1.5 --- Cancer of the Stomach (Gastric Cancer) --- p.129 / Chapter 5.2.1.6 --- Leukaemia --- p.129 / Chapter 5.2.1.7 --- Cancer of the Liver --- p.134 / Chapter 5.2.1.8 --- Cancer of the Lung --- p.143 / Chapter 5.2.1.9 --- Cancer of the Nasopharynx (NPC) --- p.149 / Chapter 5.2.1.10 --- Cancer of the Oesophagus --- p.154 / Chapter 5.3 --- Correlation among Cancer Variables --- p.160 / Chapter 5.3.1 --- Correlation among Cancer types --- p.160 / Chapter 5.3.2 --- Temporal Correlation among Cancers --- p.168 / Chapter 5.3.3 --- Correlation between Cancer Mortality and Incidence --- p.170 / Chapter 5.4 --- Correlation between Cancer and Environmental Variables --- p.172 / Chapter 5.4.1 --- Results --- p.174 / Chapter 5.5 --- Weighted Stepwise Regression Modeling --- p.182 / Chapter 5.5.1 --- Results --- p.183 / Chapter 5.5.1.1 --- Total Cancer --- p.184 / Chapter 5.5.1.2 --- Cancer of the Female Breast --- p.186 / Chapter 5.5.1.3 --- Cancer of the Cervix Uteri (Cervical Cancer) --- p.188 / Chapter 5.5.1.4 --- Cancer of the Colon and Rectum --- p.189 / Chapter 5.5.1.5 --- Cancer of the Stomach (Gastric Cancer) --- p.191 / Chapter 5.5.1.6 --- Leukaemia --- p.193 / Chapter 5.5.1.7 --- Cancer of the Liver --- p.195 / Chapter 5.5.1.8 --- Cancer of the Lung --- p.197 / Chapter 5.5.1.9 --- Cancer of the Nasopharynx (NPC) --- p.199 / Chapter 5.5.1.10 --- Cancer of the Oesophagus --- p.201 / Chapter 5.6 --- Interpretations of Results --- p.203 / Chapter CHAPTER VI --- CONCLUSION --- p.207 / Chapter 6.1 --- Summary of Findings --- p.207 / Chapter 6.1.1 --- Summary on Geographical Analysis of Cancer Patterns --- p.207 / Chapter 6.1.2 --- Summary on Statistical Analysis of Cancer Variables --- p.209 / Chapter 6.1.3 --- Summary on Associations between Cancers and Environment --- p.211 / Chapter 6.2 --- Research Limitations --- p.212 / Chapter 6.3 --- Implications for Future Studies --- p.215 / BIBLIOGRAPHY --- p.217 / APPENDICES --- p.233 / Appendix I Community Map of hong Kong --- p.234 / Appendix II List of Communities and their Components --- p.236 / Appendix III Tertiary Planning Units (TPUs) - Community Conversion Lists --- p.240 / Appendix IV BASIC Program for Calculating Moran and Geary Indices --- p.244

by Siu-Fai Leung. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1998. / Includes bibliographical references (leaves 80-81). / Abstract also in Chinese. / Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Mortality and Socioeconomic Status --- p.1 / Chapter 1.2 --- Research Plan and Difficulties Encountered in the Study --- p.4 / Chapter 2 --- Imputation and File Merging --- p.8 / Chapter 2.1 --- Structure and Contents of Data Sets --- p.8 / Chapter 2.2 --- Imputation of Missing Values --- p.14 / Chapter 2.3 --- Merging Data Sets --- p.22 / Chapter 2.3.1 --- Merging Death Data and Census Data --- p.22 / Chapter 2.3.2 --- Merging Two Census Data Sets --- p.29 / Chapter 2.3.3 --- Final Data Set Used in Modeling --- p.31 / Chapter 3 --- Modeling and Estimation --- p.33 / Chapter 3.1 --- Discrete-Time Hazard Function Analysis --- p.33 / Chapter 3.1.1 --- The Hazard Function --- p.34 / Chapter 3.1.2 --- Logistic Regression --- p.36 / Chapter 3.2 --- Application of Discrete-Time Hazard Model on the Death Data Set --- p.37 / Chapter 3.2.1 --- Preparing the Person-Period Data Set --- p.38 / Chapter 3.2.2 --- Modeling the Person-Period Data Set --- p.41 / Chapter 3.3 --- Combining Results from different imputed data sets --- p.47 / Chapter 3.4 --- Estimation of Cell Probabilities --- p.51 / Chapter 4 --- Model Adequacy Checking --- p.52 / Chapter 4.1 --- The Definition of Residuals in Multiple Imputation --- p.52 / Chapter 4.2 --- Residual Analysis of The Cancer Mortality Model --- p.59 / Chapter 5 --- Conclusion --- p.63 / Chapter 5.1 --- The Cancer Mortality --- p.63 / Chapter 5.2 --- Competing Risk --- p.68 / Chapter 5.3 --- Discussion --- p.72 / Appendix A: Coding Description of District --- p.75 / Appendix B: Results of the Heart Diseases Mortality Model --- p.76 / Bibliography --- p.80

INTRODUÇÃO: Neutropenia febril (NF) é frequente complicação quimioterapia para tumores sólidos e é de suma importância a identificação dos pacientes de alto risco para o seu desenvolvimento. OBJETIVOS: Caracterização clínica, laboratorial e dos fatores de risco para NF em pacientes admitidos para antibioticoterapia. MATERIAL E MÉTODOS: Estudo retrospectivo de todos os pacientes consecutivamente internados com NF no ICESP (Instituto do Câncer do Estado de São Paulo) entre maio de 2008 e maio de 2012. Critérios de inclusão: idade >= 16 anos, diagnóstico de NF (temperatura axilar >= 37,8ºC e neutrófilos < 500/mm3 ou entre 500-1000/mm³ com tendência à queda) em pacientes portadores de tumor sólido. Dados clínico-laboratoriais e de evolução foram coletados; realizada análise univariada e multivariada a fim de investigar a relação entre os fatores de risco e o desenvolvimento de complicações. RESULTADOS: 333 episódios de NF em 295 pacientes com tumores sólidos foram avaliados. Idade mediana de 57 anos (16-88), 150 do sexo feminino (51%). Os sítios primários das neoplasias mais frequentes foram mama (15%), pulmão (14%), sarcomas (13%), colorretal (10%), estômago (9%), cabeça e pescoço (8%) e testículo (5%). 31 pacientes (10%) apresentaram mais de um episódio de NF. À admissão, a mediana de contagem de neutrófilos foi 690/mm3, e a mediana de MASCC atribuído 19 (7-26). Sítios de infecção mais comumente identificados foram pulmão (19%), trato urinário (15%), corrente sanguínea (13%), abdominal (10%) e partes moles (8%); quanto à etiologia, bacilos Gram-negativos isolados em 36 (11%) episódios e cocos Gram-positivos em 15 (9%). Mediana de internação de 10 dias (0-106 dias). Alguma complicação grave foi identificada em 248 (74%) episódios, sendo que hipotensão (47%), admissão em UTI (35%), insuficiência renal (30%), insuficiência respiratória (19%) e alteração do estado mental (17%) as mais comuns (> 10%). A mortalidade foi 14% (46 pacientes). A análise univariada revelou como fatores de risco para complicações idade >= 60 anos (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controle sistêmico da neoplasia (OR 0.51, 95%CI 0.31-0.85, p 0.01), DPOC (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presença de sintomas ao diagnóstico (OR 2.16, CI95% 1.26-3.69, p 0.0063), desidratação (OR 4.63, CI95% 2.57-8.31, p<0.0001) e regular ou mau estado geral (OR 3.31, CI95% 1.93-5.68, p<0.0001). Na análise multivariada, permaneceram como fatores de risco a desidratação (OR 3.7, CI95% 2.09-6.78, p 0.000009), DPOC (OR 3.7, CI 95% 1.27-11.04, p 0.0166) e idade >= 60 anos (OR 2.5, CI95% 1.37-4.58, p 0.0029). O modelo multivariado corretamente classificou os episódios como de alto risco em 75% dos eventos. Elaboramos um novo escore de risco baseado nos valores de OR, onde pacientes desidratados receberam quatro pontos, aqueles com DPOC três pontos e aqueles com idade >= 60 anos, dois pontos. O escore final corresponde à soma das parcelas acima. Consideramos os pacientes como de alto risco com escore > 5 pontos (sensibilidade 72%, especificidade 64%). CONCLUSÕES: Complicações clínicas graves são comuns durante os episódios de NF, em pacientes com tumores sólidos. DPOC, idade >= 60 anos e desidratação representam fatores de risco para o desenvolvimento de complicações. Um novo escore de fácil execução foi proposto, o qual deverá ser validado prospectivamente / BACKGROUND: Febrile neutropenia (FN) is a frequent complication during chemotherapy in solid tumors, and to identify those patients (pts) with higher risk of developing complications during FN episodes is important. Here we aimed to characterize those risk factors for severe complications during FN episodes in pts with solid tumors, admitted for intravenous antibiotics. MATERIAL AND METHODS: It is a retrospective study of all consecutive pts admitted with FN at ICESP (Instituto do Câncer do Estado de São Paulo) between May/2008 and May/2012. Eligibility criteria included: age >= 16y, the diagnosis of FN (documented axillary temperature greater than 37.8°C, and neutrophil count < 500/mm3 or expected to fall below 500/mm3) as an adverse event of chemotherapy for a solid tumor. Potentially life-threatening complications during FN episodes were collected and univariate and multivariate logistic regression analyses were performed to assess the relationship between risk factors and these complications. RESULTS: 333 FN episodes in 295 pts with solid tumors were studied. Median age was 57 y (16-88), 150 female (51%). Most frequent primary sites included: breast (15%), lung (14%), bone/soft tissues (13%), colorectal (10%), stomach (9%), head & neck (8%) and testis (5%). 31 pts (10%) presented more than 1 FN episode. At admission, median neutrophil count was 690/mm3, and the median MASCC score was 19 (7-26). Infection sites were identified as pulmonary (19%), urinary tract (15%), bloodstream (13%), abdominal (10%) and soft tissues (8%), and regarding etiology, Gram-negative bacilli could be isolated in 36 (11%) and Gram-positive cocci in 15 FN episodes (9%). All pts were admitted with a median duration of hospital stay of 10 d (0-106 d). Overall, a severe complication as a consequence of FN was detected in 248 episodes (74%), being hypotension (47%), ICU admission (35%), renal failure (30%), respiratory failure (19%) and altered mental state (17%) the most common (> 10%), and 46 pts died (14%). A univariate analysis revealed age >= 60y (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controlled cancer (OR 0.51, 95%CI 0.31-0.85, p 0.01), previous COPD (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presence of symptoms (OR 2.16, CI95% 1.26-3.69, p 0.0063) or dehydration (OR 4.63, CI95% 2.57-8.31, p < 0.0001) and regular or bad general condition (OR 3.31, CI95% 1.93-5.68, p < 0.0001) as risk factors for complications. On multivariate analysis, only dehydration (OR 3.7, CI95% 2.09-6.78, p 0.000009), previous COPD (OR 3.7, CI 95% 1.27-11.04, p 0.0166) and age >= 60y (OR 2.5, CI95% 1.37-4.58, p 0.0029) were associated with severe complications. The multivariate model correctly classified 75% of all FN episodes as complicated. We elaborated a new risk score based on the OR, where dehydrated pts scored 4 points, those with COPD 3 points and those with age >= 60y 2 points. The final score was calculated by the sum of all above. We have considered as high risk pts those who scored > 5 points (sensitivity 72%, specificity 64%). CONCLUSIONS: Severe complications were common during febrile neutropenic episodes in pts with solid tumors. COPD, age >= 60 y and dehydration represent clinically significant risk factors for severe complications in FN pts. A new score was proposed, though it should be prospectively validated

Introdução: Pacientes portadores de câncer estão sobrevivendo mais devido aos avanços no diagnóstico precoce e tratamento dos tumores. A diminuição da mortalidade relacionada ao câncer e o envelhecimento da população acarretaram um número crescente de pacientes oncológicos internados em UTI. Objetivos: Identificar a prevalência e os fatores de risco para IRA nos pacientes oncológicos críticos. Métodos: Foram avaliados, prospectivamente, 371 pacientes oncológicos internados nas UTIs do Instituto do Câncer do Estado de São Paulo e do Hospital AC Camargo, entre novembro de 2011 a março de 2013. Os pacientes foram avaliados na admissão, 24h e 48h da internação na UTI. Foram coletados os parâmetros demográficos, clínicos e laboratoriais os quais foram analisados para os desfechos IRA, conforme o critério AKIN (Cr > 0,3 mg/dl ou aumento de 50% sobre a Cr basal em 48h) e óbito na UTI. Os dados foram submetidos à análise bivariada e multivariada. Resultados: A incidência de IRA nos pacientes oncológicos foi de 45,1%, sendo que apenas 5,2% necessitaram de tratamento dialítico. Os pacientes com IRA apresentaram mais frequentemente admissão cirúrgica (49% IRA vs 34% sem IRA; p=0,022). Na admissão à UTI, os fatores associados ao desenvolvimento de IRA (IRA vs sem IRA) foram: ventilação mecânica (26,6% vs 16,0%; p=0,031), frequência cardíaca (88 bpm vs 82 bpm; p=0,029), balanço hídrico (575 ml vs 275 ml; p = 0,0002), lactato (19 mg/dL vs 17 mg/dL; p= 0,046) e fósforo (3,9 mg/dL vs 3,4 mg/dL; p < 0,0001). A taxa de óbito hospitalar foi de 37,3% sendo que 25,3% ocorreu na UTI. A mortalidade foi mais prevalente em pacientes com câncer hematológico (8,6% sobreviventes vs 19,5% óbitos; p = 0,008), procedentes do pronto atendimento (23,5% sobreviventes vs 34,1% óbitos; p = 0,002), admissão clínica (50,4% sobreviventes vs 84,1% óbitos; p < 0,0001) e internação não planejada (59,9% vs 86,6% óbitos; p < 0,0001). Outros fatores relacionados ao óbito foram: sinais de congestão, uso de drogas vasoativas, choque séptico e infecção respiratória (p < 0,0001). Os dias de internação prévios à admissão na UTI também se relacionaram ao óbito (6 dias óbitos vs 2 dias sobreviventes; p < 0,0001). Os exames laboratoriais que se relacionaram ao óbito foram (sobreviventes vs óbitos): hipoalbuminemia (2,7 g/dL vs 2,4 g/dL; p= 0,003), aumento do INR (1,3 vs 1,5; p < 0,0001); aumento do lactato (17 mg/dL vs 20,5 mg/dL; p = 0,037), PCR (41,8 mg/dL vs 148,4 mg/dL; p < 0,0001) e TP (69% vs 59,5%; p = 0,001). Conclusão: A IRA é frequente em pacientes oncológicos admitidos na UTI e apresenta alta mortalidade. As ocorrências de IRA e óbito encontram-se mais relacionados com a gravidade das disfunções orgânicas no momento da admissão à UTI, do que às características da neoplasia de base / Introduction: Cancer patients are currently presenting longer survival due to advances in diagnosis and treatment. Mortality reduction related to cancer and aging of population had led to an increased admission of cancer patients in the ICU. Objectives: Evaluation of the prevalence and risk factors for AKI in critically ill cancer patients. Methods: It was prospectively evaluated 371 cancer patients admitted to the ICU in Instituto do Câncer do Estado de São Paulo and Hospital AC Camargo, from November 2011 until March 2013. Patients were evaluated at admission, 24h and 48h in the ICU. Demographic, clinical and laboratory parameters were collected which were correlated with the outcome AKI (AKIN I - Cr > 0.3 mg/dL or 50% increase over baseline in 48h) and mortality in the ICU. Statistical analysis was performed using bivariate and multivariate analysis. Results: The incidence of AKI in cancer patients was 45.1% but only 5.2% were dialysed. AKI patients were more frequently admitted due to surgical admission (AKI 53% vs. 49% non-AKI, p=0.022). At ICU admission, factors associated with AKI development (AKI vs. non-AKI) were: mechanical ventilation (26.6% vs. 16%, p =0.031), heart beats (88 bpm vs. 82 bpm, p=0.029), fluid balance (575 ml vs. 275 ml, p=0.0002), lactate (19 mg/dLvs. 17 mg/dL, p=0.046) and phosphorus (3.9 mg/dL vs. 3.4 mg/dL, p < 0.0001). Hospital mortality rate was 37.3% whereas ICU mortality was 25.3%. Mortality was more prevalent in patients with hematological cancer (8.6% survivors vs. 19.5% non-survivors, p = 0.008), patients from emergency room (23.5% survivors vs. 34.1% non-survivors, p = 0.002), patients with clinical admission (50.4% survivors vs. 84.1% non-survivors, p < 0.0001) and non-elective admission (59.9% vs. 86.6% non-survivors, p < 0.0001). Other factors related to mortality were: volume overload, vasoactive drugs use, septic shock and pulmonary infection (p < 0.0001). Hospitalization period before ICU admission also correlated with mortality (6 days survivors vs. 2 days non-survivors, p 0.0001). The laboratory parameters that correlated to mortality were (survivors vs. non-survivors): hypoalbuminemia (2.7 g/dL vs. 2.4 g/dL, p=0.003), increased INR (1.3 vs. 1.5, p < 0.0001), increased lactate (17 mg/dL vs. 20.5 mg/dL, p=0.037), PCR (41.8 mg/dL vs 148.4 mg/dL, p < 0.0001) e PT (69% vs. 59.5%, p = 0.001). Conclusions: AKI is a frequent complication in cancer patients admitted to ICU, presenting high mortality rate. AKI and mortality outcomes are more related to the severity of organs dysfunction at ICU admission than the patient´s cancer disease

Introdução: Pacientes portadores de câncer estão sobrevivendo mais devido aos avanços no diagnóstico precoce e tratamento dos tumores. A diminuição da mortalidade relacionada ao câncer e o envelhecimento da população acarretaram um número crescente de pacientes oncológicos internados em UTI. Objetivos: Identificar a prevalência e os fatores de risco para IRA nos pacientes oncológicos críticos. Métodos: Foram avaliados, prospectivamente, 371 pacientes oncológicos internados nas UTIs do Instituto do Câncer do Estado de São Paulo e do Hospital AC Camargo, entre novembro de 2011 a março de 2013. Os pacientes foram avaliados na admissão, 24h e 48h da internação na UTI. Foram coletados os parâmetros demográficos, clínicos e laboratoriais os quais foram analisados para os desfechos IRA, conforme o critério AKIN (Cr > 0,3 mg/dl ou aumento de 50% sobre a Cr basal em 48h) e óbito na UTI. Os dados foram submetidos à análise bivariada e multivariada. Resultados: A incidência de IRA nos pacientes oncológicos foi de 45,1%, sendo que apenas 5,2% necessitaram de tratamento dialítico. Os pacientes com IRA apresentaram mais frequentemente admissão cirúrgica (49% IRA vs 34% sem IRA; p=0,022). Na admissão à UTI, os fatores associados ao desenvolvimento de IRA (IRA vs sem IRA) foram: ventilação mecânica (26,6% vs 16,0%; p=0,031), frequência cardíaca (88 bpm vs 82 bpm; p=0,029), balanço hídrico (575 ml vs 275 ml; p = 0,0002), lactato (19 mg/dL vs 17 mg/dL; p= 0,046) e fósforo (3,9 mg/dL vs 3,4 mg/dL; p < 0,0001). A taxa de óbito hospitalar foi de 37,3% sendo que 25,3% ocorreu na UTI. A mortalidade foi mais prevalente em pacientes com câncer hematológico (8,6% sobreviventes vs 19,5% óbitos; p = 0,008), procedentes do pronto atendimento (23,5% sobreviventes vs 34,1% óbitos; p = 0,002), admissão clínica (50,4% sobreviventes vs 84,1% óbitos; p < 0,0001) e internação não planejada (59,9% vs 86,6% óbitos; p < 0,0001). Outros fatores relacionados ao óbito foram: sinais de congestão, uso de drogas vasoativas, choque séptico e infecção respiratória (p < 0,0001). Os dias de internação prévios à admissão na UTI também se relacionaram ao óbito (6 dias óbitos vs 2 dias sobreviventes; p < 0,0001). Os exames laboratoriais que se relacionaram ao óbito foram (sobreviventes vs óbitos): hipoalbuminemia (2,7 g/dL vs 2,4 g/dL; p= 0,003), aumento do INR (1,3 vs 1,5; p < 0,0001); aumento do lactato (17 mg/dL vs 20,5 mg/dL; p = 0,037), PCR (41,8 mg/dL vs 148,4 mg/dL; p < 0,0001) e TP (69% vs 59,5%; p = 0,001). Conclusão: A IRA é frequente em pacientes oncológicos admitidos na UTI e apresenta alta mortalidade. As ocorrências de IRA e óbito encontram-se mais relacionados com a gravidade das disfunções orgânicas no momento da admissão à UTI, do que às características da neoplasia de base / Introduction: Cancer patients are currently presenting longer survival due to advances in diagnosis and treatment. Mortality reduction related to cancer and aging of population had led to an increased admission of cancer patients in the ICU. Objectives: Evaluation of the prevalence and risk factors for AKI in critically ill cancer patients. Methods: It was prospectively evaluated 371 cancer patients admitted to the ICU in Instituto do Câncer do Estado de São Paulo and Hospital AC Camargo, from November 2011 until March 2013. Patients were evaluated at admission, 24h and 48h in the ICU. Demographic, clinical and laboratory parameters were collected which were correlated with the outcome AKI (AKIN I - Cr > 0.3 mg/dL or 50% increase over baseline in 48h) and mortality in the ICU. Statistical analysis was performed using bivariate and multivariate analysis. Results: The incidence of AKI in cancer patients was 45.1% but only 5.2% were dialysed. AKI patients were more frequently admitted due to surgical admission (AKI 53% vs. 49% non-AKI, p=0.022). At ICU admission, factors associated with AKI development (AKI vs. non-AKI) were: mechanical ventilation (26.6% vs. 16%, p =0.031), heart beats (88 bpm vs. 82 bpm, p=0.029), fluid balance (575 ml vs. 275 ml, p=0.0002), lactate (19 mg/dLvs. 17 mg/dL, p=0.046) and phosphorus (3.9 mg/dL vs. 3.4 mg/dL, p < 0.0001). Hospital mortality rate was 37.3% whereas ICU mortality was 25.3%. Mortality was more prevalent in patients with hematological cancer (8.6% survivors vs. 19.5% non-survivors, p = 0.008), patients from emergency room (23.5% survivors vs. 34.1% non-survivors, p = 0.002), patients with clinical admission (50.4% survivors vs. 84.1% non-survivors, p < 0.0001) and non-elective admission (59.9% vs. 86.6% non-survivors, p < 0.0001). Other factors related to mortality were: volume overload, vasoactive drugs use, septic shock and pulmonary infection (p < 0.0001). Hospitalization period before ICU admission also correlated with mortality (6 days survivors vs. 2 days non-survivors, p 0.0001). The laboratory parameters that correlated to mortality were (survivors vs. non-survivors): hypoalbuminemia (2.7 g/dL vs. 2.4 g/dL, p=0.003), increased INR (1.3 vs. 1.5, p < 0.0001), increased lactate (17 mg/dL vs. 20.5 mg/dL, p=0.037), PCR (41.8 mg/dL vs 148.4 mg/dL, p < 0.0001) e PT (69% vs. 59.5%, p = 0.001). Conclusions: AKI is a frequent complication in cancer patients admitted to ICU, presenting high mortality rate. AKI and mortality outcomes are more related to the severity of organs dysfunction at ICU admission than the patient´s cancer disease

INTRODUÇÃO: Neutropenia febril (NF) é frequente complicação quimioterapia para tumores sólidos e é de suma importância a identificação dos pacientes de alto risco para o seu desenvolvimento. OBJETIVOS: Caracterização clínica, laboratorial e dos fatores de risco para NF em pacientes admitidos para antibioticoterapia. MATERIAL E MÉTODOS: Estudo retrospectivo de todos os pacientes consecutivamente internados com NF no ICESP (Instituto do Câncer do Estado de São Paulo) entre maio de 2008 e maio de 2012. Critérios de inclusão: idade >= 16 anos, diagnóstico de NF (temperatura axilar >= 37,8ºC e neutrófilos < 500/mm3 ou entre 500-1000/mm³ com tendência à queda) em pacientes portadores de tumor sólido. Dados clínico-laboratoriais e de evolução foram coletados; realizada análise univariada e multivariada a fim de investigar a relação entre os fatores de risco e o desenvolvimento de complicações. RESULTADOS: 333 episódios de NF em 295 pacientes com tumores sólidos foram avaliados. Idade mediana de 57 anos (16-88), 150 do sexo feminino (51%). Os sítios primários das neoplasias mais frequentes foram mama (15%), pulmão (14%), sarcomas (13%), colorretal (10%), estômago (9%), cabeça e pescoço (8%) e testículo (5%). 31 pacientes (10%) apresentaram mais de um episódio de NF. À admissão, a mediana de contagem de neutrófilos foi 690/mm3, e a mediana de MASCC atribuído 19 (7-26). Sítios de infecção mais comumente identificados foram pulmão (19%), trato urinário (15%), corrente sanguínea (13%), abdominal (10%) e partes moles (8%); quanto à etiologia, bacilos Gram-negativos isolados em 36 (11%) episódios e cocos Gram-positivos em 15 (9%). Mediana de internação de 10 dias (0-106 dias). Alguma complicação grave foi identificada em 248 (74%) episódios, sendo que hipotensão (47%), admissão em UTI (35%), insuficiência renal (30%), insuficiência respiratória (19%) e alteração do estado mental (17%) as mais comuns (> 10%). A mortalidade foi 14% (46 pacientes). A análise univariada revelou como fatores de risco para complicações idade >= 60 anos (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controle sistêmico da neoplasia (OR 0.51, 95%CI 0.31-0.85, p 0.01), DPOC (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presença de sintomas ao diagnóstico (OR 2.16, CI95% 1.26-3.69, p 0.0063), desidratação (OR 4.63, CI95% 2.57-8.31, p<0.0001) e regular ou mau estado geral (OR 3.31, CI95% 1.93-5.68, p<0.0001). Na análise multivariada, permaneceram como fatores de risco a desidratação (OR 3.7, CI95% 2.09-6.78, p 0.000009), DPOC (OR 3.7, CI 95% 1.27-11.04, p 0.0166) e idade >= 60 anos (OR 2.5, CI95% 1.37-4.58, p 0.0029). O modelo multivariado corretamente classificou os episódios como de alto risco em 75% dos eventos. Elaboramos um novo escore de risco baseado nos valores de OR, onde pacientes desidratados receberam quatro pontos, aqueles com DPOC três pontos e aqueles com idade >= 60 anos, dois pontos. O escore final corresponde à soma das parcelas acima. Consideramos os pacientes como de alto risco com escore > 5 pontos (sensibilidade 72%, especificidade 64%). CONCLUSÕES: Complicações clínicas graves são comuns durante os episódios de NF, em pacientes com tumores sólidos. DPOC, idade >= 60 anos e desidratação representam fatores de risco para o desenvolvimento de complicações. Um novo escore de fácil execução foi proposto, o qual deverá ser validado prospectivamente / BACKGROUND: Febrile neutropenia (FN) is a frequent complication during chemotherapy in solid tumors, and to identify those patients (pts) with higher risk of developing complications during FN episodes is important. Here we aimed to characterize those risk factors for severe complications during FN episodes in pts with solid tumors, admitted for intravenous antibiotics. MATERIAL AND METHODS: It is a retrospective study of all consecutive pts admitted with FN at ICESP (Instituto do Câncer do Estado de São Paulo) between May/2008 and May/2012. Eligibility criteria included: age >= 16y, the diagnosis of FN (documented axillary temperature greater than 37.8°C, and neutrophil count < 500/mm3 or expected to fall below 500/mm3) as an adverse event of chemotherapy for a solid tumor. Potentially life-threatening complications during FN episodes were collected and univariate and multivariate logistic regression analyses were performed to assess the relationship between risk factors and these complications. RESULTS: 333 FN episodes in 295 pts with solid tumors were studied. Median age was 57 y (16-88), 150 female (51%). Most frequent primary sites included: breast (15%), lung (14%), bone/soft tissues (13%), colorectal (10%), stomach (9%), head & neck (8%) and testis (5%). 31 pts (10%) presented more than 1 FN episode. At admission, median neutrophil count was 690/mm3, and the median MASCC score was 19 (7-26). Infection sites were identified as pulmonary (19%), urinary tract (15%), bloodstream (13%), abdominal (10%) and soft tissues (8%), and regarding etiology, Gram-negative bacilli could be isolated in 36 (11%) and Gram-positive cocci in 15 FN episodes (9%). All pts were admitted with a median duration of hospital stay of 10 d (0-106 d). Overall, a severe complication as a consequence of FN was detected in 248 episodes (74%), being hypotension (47%), ICU admission (35%), renal failure (30%), respiratory failure (19%) and altered mental state (17%) the most common (> 10%), and 46 pts died (14%). A univariate analysis revealed age >= 60y (OR 3.1, 95%CI 1.75-5.47, p 0.0001), controlled cancer (OR 0.51, 95%CI 0.31-0.85, p 0.01), previous COPD (OR 4.45, CI95% 1.71 - 11.54, p 0.0016), presence of symptoms (OR 2.16, CI95% 1.26-3.69, p 0.0063) or dehydration (OR 4.63, CI95% 2.57-8.31, p < 0.0001) and regular or bad general condition (OR 3.31, CI95% 1.93-5.68, p < 0.0001) as risk factors for complications. On multivariate analysis, only dehydration (OR 3.7, CI95% 2.09-6.78, p 0.000009), previous COPD (OR 3.7, CI 95% 1.27-11.04, p 0.0166) and age >= 60y (OR 2.5, CI95% 1.37-4.58, p 0.0029) were associated with severe complications. The multivariate model correctly classified 75% of all FN episodes as complicated. We elaborated a new risk score based on the OR, where dehydrated pts scored 4 points, those with COPD 3 points and those with age >= 60y 2 points. The final score was calculated by the sum of all above. We have considered as high risk pts those who scored > 5 points (sensitivity 72%, specificity 64%). CONCLUSIONS: Severe complications were common during febrile neutropenic episodes in pts with solid tumors. COPD, age >= 60 y and dehydration represent clinically significant risk factors for severe complications in FN pts. A new score was proposed, though it should be prospectively validated