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- Critical Care Admission Following Elective Surgery Was Not Associated With Survival Benefit: Prospective Analysis of Data From 27 CountriesPublication . Kahan, BC; Koulenti, D; Arvaniti, K; Beavis, V; Campbell, D; Chan, M; Moreno, R; Pearse, RMPURPOSE: As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. METHODS: Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. RESULTS: 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10-5.21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. CONCLUSIONS: We did not identify any survival benefit from critical care admission following surgery.
- Validação da “Subjective Happiness Scale” em Pessoas com Doença Renal CrónicaPublication . Mota de Sousa, LM; Marques-Vieira, CM; Severino, S; Pozo-Rosado, JL; José, HMObjetivo: Validar as propriedades psicométricas da Subjective Happiness Scale (SHS) em pessoas com Doença Renal Crônica (DRC) em programa de hemodiálise. Método: Trata-se de um estudo metodológico. A amostra randomizada foi constituída por 171 pessoas com DRC submetida a hemodiálise em duas clinicas na região de Lisboa, Portugal. Os dados foram colhidos de maio a junho de 2015. Foram avaliadas as propriedades psicométricas: validade (construto, convergente e discriminativa), fidedignidade por meio da consistência interna (α de Cronbach) e estabilidade (Coeficiente de Correlação Intraclasse e Coeficiente de Correlação de Spearman-Brown). Resultados: Os resultados suportam a estrutura unifatorial, com uma confiabilidade (α=0,90). Além disso, esta escala está positivamente correlacionada com a Escala de Satisfação com a Vida (r=0,60; p<0,001), apoiando assim a sua validade de critério. Conclusões: A versão portuguesa da SHS é válida e reprodutível em pessoas com DRC.
- Serum Fetuin-A Levels Are Associated with Serum Triglycerides Before and 6 Months after Bariatric SurgeryPublication . Verras, CG; Christou, GA; Simos, YV; Ayiomamitis, GD; Melidonis, AJ; Kiortsis, DNOBJECTIVE: The elucidation of the changes of fetuin-A in the context of bariatric surgery. DESIGN: Twenty obese patients (8 males, 12 females; body mass index = 42.5±3.4 kg/m2) were studied at baseline and 6 months after bariatric surgery. RESULTS: Serum fetuin-A levels did not differ with regard to the presence of each individual component of the Metabolic Syndrome (MetS) at baseline, except for hypertriglyceridaemia [increased serum fetuin-A levels (p=0.011)]. Circulating fetuin-A was positively correlated with serum triglycerides (TG) (r=0.461, p=0.047) and negatively correlated with serum globulins (r=-0.477, p=0.033) and C-reactive protein (CRP) (r=-0.604, p=0.010), while it independently predicted TG at baseline. Circulating fetuin-A did not change during the 6 months either in the whole population or in the subgroups of patients who were positive for each individual component of MetS at baseline and negative for this component at 6 months of follow-up, except for hypertriglyceridaemia [reduction of serum fetuin-A levels (p=0.046)]. The subgroup of patients with a decrease in circulating fetuin-A during the 6 months was characterized by a smaller reduction of serum globulins (p=0.003) and CRP (p=0.049). The change in serum fetuin-A levels over the 6 months was positively correlated with the change in TG (r=0.592, p=0.006) and negatively correlated with the change in serum globulins (r=-0.523, p=0.018) and CRP (r=-.494, p=0.037). CONCLUSIONS: Circulating fetuin-A predicted serum triglycerides before as well as 6 months after bariatric surgery.
- Low Serum Chromium Is Rare in Patients That Underwent Endoscopic Gastrostomy For Long Term Enteral FeedingPublication . Santos, CA; Fonseca, J; Carolino, E; Sousa Guerreiro, ABACKGROUND: Patients that underwent Percutaneous Endoscopic Gastrostomy (PEG) present with protein-energy malnutrition. Trace elements are required in small quantities and Chromium (Cr) displays a major role in the metabolism. OBJECTIVE: This study aims to evaluate Cr levels and its relationship with serum proteins, BMI and underlying diseases during the first 3 months of PEG feeding. METHODS: Prospective observational study during 3-months, when PEG was performed (T0), after 4 (T1), and 12 weeks (T3). Initial evaluation included: age, gender, underlying disease, NRS-2002, BMI, serum albumin, transferrin and Cr concentration. At T1 and T3 a blood sample was collected for Cr, albumin and transferrin. A Graphite Furnace Atomic Absorption Spectroscopy was used to assess Cr. According with the underlying disease, patients were divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). All patients were fed with homemade meals. RESULTS: A one hundred and twenty-nine patients (80 males), 26-95 years old were studied: HNC-52; ND-77. The observed data included low mean values of BMI from 71 patients; low Cr-8, low albumin-70, low transferrin-85 and 57 with both proteins low. Albumin was associated with survival time ( P =0.024) and there was a significant correlation between albumin and Cr (r=0.217, P =0.012). A good evolution of Cr and proteins values was observed, with no low Cr levels at T3. CONCLUSION: Low serum Cr is rare in PEG-patients, with no relationship to other studied parameters. For the minority of patients displaying low Cr before gastrostomy, homemade PEG meals seem to be effective.
- Diastolic Dysfunction in HypertensionPublication . Nazário Leão, R; Marques da Silva, PHypertension and coronary heart disease, often coexisting, are the most common risk factors for heart failure. The progression of hypertensive heart disease involves myocardial fibrosis and alterations in the left ventricular geometry that precede the functional change, initially asymptomatic. The left ventricular diastolic dysfunction is part of this continuum being defined by the presence of left ventricular diastolic dysfunction without signs or symptoms of heart failure or poor left ventricular systolic function. It is highly prevalent in hypertensive patients and is associated with increased cardiovascular morbidity and mortality. Despite its growing importance in clinical practice it remains poorly understood. This review aims to present the epidemiological fundamentals and the latest developments in the pathophysiology, diagnosis and treatment of left ventricular diastolic dysfunction.
- Epilepsia Partialis Continua After an Anterior Circulation Ischaemic StrokePublication . Bentes, C; Franco, AC; Peralta, A; Viana, P; Martins, H; Morgado, C; Casimiro, C; Fonseca, C; Geraldes, R; Canhão, P; Pinho e Melo, T; Paiva, T; Ferro, JMBackground and purpose: Although cerebrovascular disorders are the main cause of epilepsia partialis continua (EPC) in adulthood, the frequency of EPC after stroke is unknown. The aim was to prospectively ascertain its frequency 1 year after an ischaemic stroke. Methods: This was a prospective study of consecutive acute anterior circulation ischaemic stroke patients, previously independent, with an admission National Institutes of Health Stroke Scale score ≥4, an acute ischaemic lesion on imaging and no previous epileptic seizures. During admission patients received standardized diagnostic and medical care and were submitted to a neurophysiological evaluation protocol. One year after stroke, patients were re-evaluated by an epilepsy expert neurologist and performed a video-electroencephalogram with electromyography co-registration whenever myoclonus was observed during neurological examination for jerk-locked back averaging analysis (JLBA). EPC was defined as continuously repeated fragments of epileptic seizures, with preserved consciousness, lasting at least 1 h, and representing locally restricted epileptic activity. Results: In all, 151 acute anterior circulation stroke patients were consecutively included and prospectively evaluated, but 23 died in the first year. One year after stroke, from 127 patients alive, 117 (92.1%) underwent clinical and neurophysiological evaluation. In two (1.7%) patients, EPC diagnosis was made both by clinical and electroencephalographic criteria, namely JLBA. Both patients had a history of remote symptomatic seizures and one of them acute symptomatic seizures and non-convulsive status epilepticus criteria during the first 7 days after stroke. Conclusions: Despite its low frequency, the high stroke incidence makes post-stroke EPC relevant. This study draws attention to this recognizable condition with therapeutic and eventually prognostic implications.
- Higher Mineralized Bone Volume Is Associated with a Lower Plain X-Ray Vascular Calcification Score in Hemodialysis PatientsPublication . Adragao, T; Ferreira, A; Frazao, JM; Papoila, AL; Pinto, I; Monier-Faugere, MC; Malluche, HHBACKGROUND AND OBJECTIVES: In dialysis patients, there is an increasing evidence that altered bone metabolism is associated with cardiovascular calcifications. The main objective of this study was to analyse, in hemodialysis patients, the relationships between bone turnover, mineralization and volume, evaluated in bone biopsies, with a plain X-ray vascular calcification score. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: In a cross-sectional study, bone biopsies and evaluation of vascular calcifications were performed in fifty hemodialysis patients. Cancellous bone volume, mineralized bone volume, osteoid volume, activation frequency, bone formation rate/bone surface, osteoid thickness and mineralization lag time were determined by histomorphometry. Vascular calcifications were assessed by the simple vascular calcification score (SVCS) in plain X-Ray of pelvis and hands and, for comparison, by the Agatston score in Multi-Slice Computed Tomography (MSCT). RESULTS: SVCS≥3 was present in 20 patients (40%). Low and high bone turnover were present in 54% and 38% of patients, respectively. Low bone volume was present in 20% of patients. In multivariable analysis, higher age (p = 0.015) and longer hemodialysis duration (p = 0.017) were associated with SVCS≥3. Contrary to cancellous bone volume, the addition to this model of mineralized bone volume (OR = 0.863; 95%CI: 0.766, 0.971; p = 0.015), improved the performance of the model. For each increase of 1% in mineralized bone volume there was a 13.7% decrease in the odds of having SVCS≥3 (p = 0.015). An Agatston score>400 was observed in 80% of the patients with a SVCS≥3 versus 4% of patients with a SVCS<3, (p<0.001). CONCLUSION: Higher mineralized bone volume was associated with a lower plain X-ray vascular calcification. This study corroborates the hypothesis of the existence of a link between bone and vessel and reinforces the clinical utility of this simple and inexpensive vascular calcification score in dialysis patients.
- Validation of the Subjective Happiness Scale in People with Chronic Kidney DiseasePublication . Mota de Sousa, LM; Marques-Vieira, CM; Severino, S; Pozo-Rosado, JL; José, HMObjective: To explore the psychometric properties of the Subjective Happiness Scale (SHS) in patients with Chronic Kidney Disease (CKD) undergoing hemodialysis. Methods: This is a methodological study. The random sample included 171 patients with CKD under hemodialysis program in two clinics in the region of Lisbon, Portugal. Data was collected between May and June 2015. The following psychometric properties were evaluated: validity (construct, convergent and discriminant), reliability through internal consistency (Cronbach α) and stability (intraclass correlation coefficient and Spearman-Brown correlation coefficient). Results: The results support the unifactorial structure, with reliability (α = 0.90). In addition, this scale is positively correlated with the Satisfaction Life Scale (r = 0.60; p <0.001), supporting the validity criteria. Conclusions: The Portuguese version of the SHS is valid and reproducible in patients with CKD.
- Modified Continuity Equation Using Left Ventricular Outflow Tract Three-Dimensional Imaging for Aortic Valve Area EstimationPublication . Teixeira, P; Ramos, R; Rio, P; Branco, LM; Portugal, G; Abreu, A; Galrinho, A; Marques, H; Figueiredo, L; Cruz Ferreira, RPURPOSE: Aortic valve area (AVA) is usually estimated by the continuity equation (CE) in which the left ventricular outflow tract (LVOT) area is calculated assuming a circular shape. This study aimed to compare measurements of LVOT area using standard 2D transthoracic echocardiography (2DTTE), 3D transesophageal echocardiography (3DTEE), and multidetector computed tomography (MDCT) and assess their relative impact on AVA estimated by the CE. METHODS AND RESULTS: We prospectively enrolled 60 patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR) who systematically underwent 2DTTE, 3DTEE, and MDCT. Mean LVOT areas obtained by 2DTTE (3.28±0.66 cm2 ) and 3DTEE (3.95±0.90 cm2 ) were significantly underestimated when compared to the mean MDCT LVOT area (4.31±0.99 cm2 ). LVOT was rather elliptical than round, with a mean eccentricity index of 1.47 (ratio of maximum to minimum LVOT diameters) assessed by MDCT. Mean TTE AVA estimated by the CE was 0.62±0.20 cm2 . Substitution of 2DTTE LVOT area by 3DTEE LVOT area in the CE resulted in AVA of 0.74±0.24 cm2 , while using MDCT LVOT area held an AVA of 0.80±0.24 cm2 . MDCT-derived AVA was similar to MDCT planimetric AVA and allowed 24% of patients to be reclassified from severe to moderate AS. CONCLUSIONS: 2DTTE and 3DTEE underestimate LVOT area when compared to MDCT with significant impact on AVA estimation. Assessment through MDCT fusion AVA may be of incremental value in patients with discrepant severity criteria for AS.
- Multifocal Septic Arthritis, Gluteal Abscess and Spondylodiscitis by Streptococcus Dysgalactiae Subspecies Equisimilis After an Intramuscular InjectionPublication . Pocinho, R; Antunes, L; Pires, P; Baptista, IWe present the case of a 63-year-old man, admitted for hand cellulitis and acute kidney injury. A Streptococcus dysgalactiae subsp equisimilis (SDSE) was isolated in blood cultures and despite directed intravenous antibiotherapy, the patient evolved unfavourably, with dorsolumbar spondylodiscitis, multifocal septic arthritis and abscesses. CT also showed densification of the gluteal muscles, multiple air bubbles in the psoas, paraspinal muscles and spinal canal that were associated with an intramuscular injection administered 1 week earlier for a backache. After escalation of the antibiotherapy and intensive supportive measures, the patient showed improvement and was discharged after 8 weeks of antibiotherapy.The incidence of invasive SDSE infections has been growing, especially in immunosupressed patients. In this case, despite no predisposing factor identified, it evolved to severe sepsis. The intramuscular injection, a trivialised but not harmless procedure, was the assumed port of entry, as previously described in another case report.