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- Abdominal Hypoperfusion and Acute Kidney Injury in the Critically Ill Patient with Liver Cirrhosis: A Prospective Cohort Study.Publication . Pereira, Rui; Lopes, Diogo; Brandão Machado, Sara; Val-Flores, Luís; Caeiro, Fernando; Perdigoto, Rui; Marcelino, Paulo; Saliba, FaouziReduced abdominal perfusion pressure (APP) is an underdiagnosed potential pathophysiological mechanism for acute kidney injury (AKI) in the patient with liver cirrhosis and ascites. This study aimed to analyze the prevalence of abdominal hypoperfusion (AhP) (APP <60 mm Hg) and the impact of APP on AKI in critically ill patients with liver cirrhosis. This was a post hoc analysis from a prospective cohort study set in a general ICU at a tertiary university hospital. Patients were recruited between October 2016 and December 2021. Acute renal failure (ARF) was defined by stage 3 AKI according to the International Club of Ascites. Fifty-eight patients where included, with a mean age of 57 (±8.4) years, 79% were male, and 93% had acute-on-chronic liver failure at admission. The prevalence of AhP reached 75%, and 29% of cases had persisting AhP during the first week of ICU stay. Patients with baseline AhP had a higher 28-day mortality compared to those without AhP (respectively, 76% vs. 49%, = 0.03). Acute renal failure developed in 48% of patients. Higher serum urea (aOR: 1.01, 95% CI: 1.00-1.02, = 0.04) and white blood cell count (aOR: 1.1, 95% CI: 1.01-1.2, = 0.02) at ICU admission, as well as low persisting APP (aOR: 0.9, 95% CI: 0.86-0.98, = 0.02) were independent risk factors for ARF. Critically ill patients with liver cirrhosis presented a high prevalence of ARF, independently associated with higher baseline serum urea and WBC, and lower persisting APP. A structured clinical approach to optimize APP may reduce renal dysfunction in high-risk patients with cirrhosis.
- Acoustic and Clinical Data Analysis of Vocal Recordings: Pandemic Insights and Lessons.Publication . Carreiro-Martins, Pedro; Paixão, Paulo; Caires, Iolanda; Matias, Pedro; Gamboa, Hugo; Soares, Filipe; Gomez, Pedro; Sousa, Joana; Neuparth, NunoBackground/Objectives: The interest in processing human speech and other human-generated audio signals as a diagnostic tool has increased due to the COVID-19 pandemic. The project OSCAR (vOice Screening of CoronA viRus) aimed to develop an algorithm to screen for COVID-19 using a dataset of Portuguese participants with voice recordings and clinical data. Methods: This cross-sectional study aimed to characterise the pattern of sounds produced by the vocal apparatus in patients with SARS-CoV-2 infection documented by a positive RT-PCR test, and to develop and validate a screening algorithm. In Phase II, the algorithm developed in Phase I was tested in a real-world setting. Results: In Phase I, after filtering, the training group consisted of 166 subjects who were effectively available to train the classification model (34.3% SARS-CoV-2 positive/65.7% SARS-CoV-2 negative). Phase II enrolled 58 participants (69.0% SARS-CoV-2 positive/31.0% SARS-CoV-2 negative). The final model achieved a sensitivity of 85%, a specificity of 88.9%, and an F1-score of 84.7%, suggesting voice screening algorithms as an attractive strategy for COVID-19 diagnosis. Conclusions: Our findings highlight the potential of a voice-based detection strategy as an alternative method for respiratory tract screening.
- Acute Symptomatic Seizures in Patients with Recurrent Ischemic Stroke: A Multicentric Study.Publication . Leal Rato, Miguel; Schön, Miguel; Zafra, Maria Paula; Aguiar de Sousa, Diana; Pinho E Melo, Teresa; Franco, Ana Catarina; Peralta, Ana Rita; Ferreira-Atuesta, Carolina; Mayor-Romero, Luis Carlos; Rouhl, Rob P W; Bentes, CarlaObjective: Epileptic seizures occur frequently after stroke due to changes in brain function and structure, and up to around 10% of stroke patients experience stroke recurrence in the first year. We aimed to establish the risk of acute symptomatic seizures in patients with recurrent stroke. Methods: Retrospective cohort study including consecutive admissions to a Stroke Unit due to acute ischemic stroke, during a 5-year period. Additional inclusion of patients admitted to two centers in different countries to corroborate findings (confirmatory cohort). We aimed to compare acute symptomatic seizure incidence in patients with and without previous stroke. Patients with history of epilepsy were excluded. Logistic regression modeling was performed to identify predictors in middle cerebral artery (MCA) stroke. Results: We included 1473 patients (1085 with MCA stroke), of which 117 had a recurrent ischemic stroke (84 with MCA stroke). Patients with recurrent stroke had a seizure risk during hospital stay similar to that of patients with a first-ever stroke (5.1% vs. 4.5%, OR 1.15, 95% CI .48-2.71, p = .75). Risk of acute symptomatic seizures was also similar (5.0% vs. 4.1, OR 1.22, 95% CI .29-5.27, p = .78). Older age, female sex, and hemorrhagic transformation were predictors of seizures in patients with a first MCA ischemic stroke, but not in recurrent stroke patients. Electrographic characteristics were similar between the two groups in patients who had an electroencephalogram (46 with first stroke, 5 with recurrent stroke). The low rate of seizures (1.5%) in the confirmatory cohort (n = 198) precluded full comparison with the initial cohort. Nevertheless, the rate of seizures was not higher in stroke recurrence. Significance: History of previous stroke was not associated with an increased risk of acute symptomatic seizures during hospital stay. Larger, prospective studies, with prospective electrophysiological evaluation, are needed to explore the impact of stroke recurrence on seizure risk.
- AI-Based Models to Predict Decompensation on Traumatic Brain Injury Patients.Publication . Ribeiro, Ricardo; Neves, Inês; Oliveira, Hélder P; Pereira, TaniaTraumatic Brain Injury (TBI) is a form of brain injury caused by external forces, resulting in temporary or permanent impairment of brain function. Despite advancements in healthcare, TBI mortality rates can reach 30%-40% in severe cases. This study aims to assist clinical decision-making and enhance patient care for TBI-related complications by employing Artificial Intelligence (AI) methods and data-driven approaches to predict decompensation. This study uses learning models based on sequential data from Electronic Health Records (EHR). Decompensation prediction was performed based on 24-h in-mortality prediction at each hour of the patient's stay in the Intensive Care Unit (ICU). A cohort of 2261 TBI patients was selected from the MIMIC-III dataset based on age and ICD-9 disease codes. Logistic Regressor (LR), Long-short term memory (LSTM), and Transformers architectures were used. Two sets of features were also explored combined with missing data strategies by imputing the normal value, data imbalance techniques with class weights, and oversampling. The best performance results were obtained using LSTMs with the original features with no unbalancing techniques and with the added features and class weight technique, with AUROC scores of 0.918 and 0.929, respectively. For this study, using EHR time series data with LSTM proved viable in predicting patient decompensation, providing a helpful indicator of the need for clinical interventions.
- Albumin-Bilirubin Grade and Tumor Burden Score Predict Outcomes Among Patients with Intrahepatic Cholangiocarcinoma After Hepatic Resection: a Multi-Institutional Analysis.Publication . Munir, Muhammad Musaab; Endo, Yutaka; Lima, Henrique A; Alaimo, Laura; Moazzam, Zorays; Shaikh, Chanza; Poultsides, George A; Guglielmi, Alfredo; Aldrighetti, Luca; Weiss, Matthew; Bauer, Todd W; Alexandrescu, Sorin; Kitago, Minoru; Maithel, Shishir K; Pinto Marques, Hugo; Martel, Guillaume; Pulitano, Carlo; Shen, Feng; Cauchy, François; Koerkamp, Bas Groot; Endo, Itaru; Pawlik, Timothy M; SpringerBackground: The prognostic role of tumor burden score (TBS) relative to albumin-bilirubin (ALBI) grade among patients undergoing curative-intent resection of ICC has not been examined. Methods: We identified patients who underwent curative-intent resection for ICC between 1990 and 2017 from a multi-institutional database. Multivariable analysis was performed to assess the effect of TBS relative to ALBI grade on both short- and long-term outcomes. Results: Among 724 patients, 360 (49.7%) patients had low TBS and low ALBI grade, 142 (19.6%) patients had low TBS and high ALBI grade, 138 (19.1%) patients had high TBS and low ALBI grade, and 84 patients (11.6%) had high TBS and high ALBI grade. Decreased tumor burden was associated with better long-term outcomes among patients with both low (5-year OS; low TBS vs. high TBS: 52.4% vs 21.4%; p < 0.001) and high ALBI grade (5-year OS; low TBS vs. high TBS: 40.7% vs 12.0%; p < 0.001). On multivariable analysis, higher ALBI grade was associated with greater odds of an extended hospital LOS (> 10 days) (OR 2.80, 95%CI 1.62-4.82; p < 0.001), perioperative transfusion (OR 2.04, 95%CI 1.25-3.36; p = 0.005), 90-day mortality (OR 2.56, 95%CI 1.12-5.81; p = 0.025), as well as a major complication (OR 1.99, 95%CI 1.13-3.49; p = 0.016) among patients with similar tumor burden. Of note, patients with high TBS and high ALBI grade had markedly worse overall survival compared with patients who had low TBS and low ALBI grade disease (HR 2.27; 95%CI 1.44-3.59; p < 0.001). Importantly, high TBS and high ALBI grade were strongly associated with both early recurrence (88.1%%) and 5-year risk of death (96.4%). Conclusion: Both TBS (i.e., tumor morphology) and ALBI grade (i.e., hepatic function reserve) were strong predictors of outcomes among patients undergoing ICC resection. There was an interplay between TBS and ALBI grade relative to patient prognosis after hepatic resection of ICC with high ALBI grade predicting worse outcomes among ICC patients with different TBS.
- Amyotrophic Lateral Sclerosis with SOD1 Mutation Presenting with Progressive Cerebellar Ataxia.Publication . Sequeira, Marta; Godinho, Filipe; Lourenço, JoãoAmyotrophic lateral sclerosis is a fatal neurodegenerative disorder that affects upper and lower motor neurons. SOD1 mutations are the second most commonly found in familial and sporadic cases. We describe a patient with a homozygous pathogenic mutation in SOD1 gene that presented with a progressive cerebellar ataxia and ultimately developed a complex phenotype of cerebellar ataxia and motor neuron disease. The linkage between the cerebellum and ALS is shortly discussed.
- Association Between COVID-19 and the Incidence of Type 1 Diabetes in Portugal - a Registry StudyPublication . Bjerregaard-Andersen, Morten; Da Silva, Jessica; Diogo, Rui; Claro, Ana Raquel; Ferro, Inês; Romana, Andreia; Rocha, Patrícia; Sá, Beatriz; Lobarinhas, Goreti; Rolim, Sara; Juhl, Claus Bogh; Højlund, Kurt; Fernandes, Isabel; Antunes, Sónia; Félix Calha, Maria Manuela; Gama, Guida; Amálio, Sofia; Figueiras, Mariana; Silva, Teresa; Rosado, Margarida; Ferrão, Estela; Arez, Luísa; Baptista, Ana; Martins Ferreira, Adriana; Alba, Diana; Godinho, Carlos; Leite, Ana Luísa; Lopes, Lurdes; Sampaio, Maria Lurdes; Serra-Caetano, Joana; Carvalho, EugeniaBackground: Viral respiratory infections may precipitate type 1 diabetes (T1D). A possible association between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, and the incidence of T1D is being determined. This study was carried out using Portuguese registries, aiming at examining temporal trends between COVID-19 and T1D. Methods: Hospital data, comparing the incidence before and during the COVID-19 pandemic, from children and young adults diagnosed with new-onset T1D, was acquired beginning in 2017 and until the end of 2022. Data was obtained from nine different Portuguese hospital units. The impact of the COVID-19 pandemic, beginning in March 2020, was assessed comparing the annual numbers of new-onset T1D cases. The annual median levels of glucose, glycated hemoglobin (HbA1c) and fasting C-peptide at T1D diagnosis were compared. The annual number of diabetic ketoacidosis (DKA) episodes among new T1D cases was also assessed at two centers. Results: In total, data from 574 newly diagnosed T1D patients was analyzed, including 530 (92.3%) children. The mean ages for child and adult patients were 9.1 (SD 4.4) and 32.8 (SD 13.6) years, respectively. 57.8% (331/573) were male, one patient had unknown sex. The overall median (25-75 percentiles) levels of glucose, HbA1c and fasting C-peptide at diagnosis were 454 mg/dL (356-568), 11.8% (10.1-13.4) and 0.50 µg/L (0.30-0.79), respectively. DKA at T1D diagnosis was present in 48.4% (76/157). For eight centers with complete 2018 to 2021 data (all calendar months), no overall significant increase in T1D cases was observed during the COVID-19 pandemic, i.e. 90 cases in 2018, 90 cases in 2019, 112 in 2020 and 100 in 2021 (P for trend = 0.36). Two of the centers, Faro (CHUA) and Dona Estefânia (CHULC) hospitals, did however see an increase in T1D from 2019 to 2020. No significant changes in glucose (P = 0.32), HbA1c (P = 0.68), fasting C-peptide (P = 0.20) or DKA frequency (P = 0.68) at the time of T1D diagnosis were observed over the entire study period. Conclusion: The T1D incidence did not increase significantly, when comparing the years before and during the COVID-19 pandemic, nor did key metabolic parameters or number of DKA episodes change.
- Biochemical Clusters as Substitutes of Bone Biopsies in Kidney Transplant Patients.Publication . Ferreira, Ana Carina; Mendes, Marco; Silva, Cecília; Cotovio, Patrícia; Aires, Inês; Navarro, David; Caeiro, Fernando; Salvador, Rute; Correia, Bruna; Cabral, Guadalupe; Nolasco, Fernando; Ferreira, AníbalBone and mineral metabolism abnormalities are frequent in kidney transplant recipients and have been associated with cardiovascular morbidity. The primary aim of this study was to analyse the association between routine clinically available biochemical evaluation, non-routine histomorphometric bone evaluation, and vascular disease in kidney transplanted patients. A cross-sectional analysis was performed on 69 patients, 1-year after kidney transplantation. Laboratory analysis, radiography of hands and pelvis, bone biopsy, bone densitometry, and coronary CT were performed. One-year post-transplantation, nearly one-third of the patients presented with hypercalcemia, 16% had hypophosphatemia, 39.3% had iPTH levels > 150 pg/mL, 20.3% had BALP levels > 40 U/L, and 26.1% had hypovitaminosis D. Evaluation of extraosseous calcifications revealed low Adragão and Agatston scores. We divided patients into three clusters, according to laboratory results routinely used in clinical practice: hypercalcemia and hyperparathyroidism (Cluster1); hypercalcemia and high BALP levels (Cluster2); hypophosphatemia and vitamin D deficiency (Cluster 3). Patients in clusters 1 and 2 had higher cortical porosity (p = 0.001) and osteoid measurements, although there was no difference in the presence of abnormal mineralization, or low volume. Patients in cluster 2 had a higher BFR/BS (half of the patients in cluster 2 had high bone turnover), and most patients in cluster 1 had low or normal bone turnover. Cluster 3 has no differences in volume, or turnover, but 60% of the patients presented with pre-osteomalacia. All three clusters were associated with high vascular calcifications scores. Vascular calcifications scores were not related to higher bone mineral density. Instead, an association was found between a higher Adragão score and the presence of osteoporosis at the femoral neck (p = 0.008). In conclusion, inferring bone TMV by daily clinical biochemical analysis can be misleading, and bone biopsy is important for assessing both bone turnover and mineralization after kidney transplantation, although hypophosphatemia combined with vitamin D deficiency is associated with abnormal mineralization. The presence of hypercalcemia with high levels of PTH or high levels of BALP, or hypophosphatemia and vitamin D deficiency should remind us to screen vascular calcification status of patients.Clinical Research: ClinicalTrials.gov ID NCT02751099.
- Biópsias Percutâneas Vertebrais – Experiência do nosso CentroPublication . Gonçalves, J; Kuroedov, D; Pamplona, J; Fragata, I; Reis, JIntrodução: A biópsia percutânea vertebral tem substituído a biópsia cirúrgica aberta nos últimos 50 anos. A biópsia não-invasiva é mais custo-efetiva e tem menos complicações quando comparada com procedimentos abertos. Realizou-se uma revisão das biópsias percutâneas vertebrais realizadas no nosso centro para avaliar o yield diagnóstico e a segurança. Métodos: Analisou-se retrospetivamente 240 biópsias vertebrais percutâneas realizadas no nosso centro terciário durante 4 anos. As variáveis adquiridas incluíram técnica diagnóstica de imagem, segmento vertebral, localização da biópsia, resultados histopatológicos, tratamento adjuvante e complicações. Resultados: 102 (42,5%) dos pacientes eram mulheres, com uma média de 68 anos. A técnica mais utilizada foi a fluoroscopia (99%, n=237). A maioria dos procedimentos foi realizado no segmento lombar, representando 47% (n=112), seguido do segmento torácico (42%, n=100). Obtivemos amostra suficiente para análise histológica em 93%. Das 240 biópsias, 18 (7,5%) tiveram de ser repetidas, tendo-se obtido um diagnóstico em 14 (78%). Histologicamente, em 28% (n=67) das amostras não se obteve alterações patológicas e em 27% (n=65) confirmou-se doença metastática. Realizou-se vertebroplastia em 19% (n=46) dos casos após a biópsia. Apenas um paciente teve uma complicação clinicamente significativa secundária ao procedimento. Conclusão: A biópsia vertebral percutânea é uma importante ferramenta na avaliação de lesões vertebrais e dos tecidos paravertebrais adjacentes, e pode ser realizada com baixa morbilidade e alta taxa de deteção como um procedimento de ambulatório. Em conformidade com a literatura, a maior parte das nossas amostras eram adequadas para análise histopatológica e o achado mais comum foi lesão metastática.
- Cerebral Venous Sinus Thrombosis in Traumatic Brain Injury: a Systematic Review of its Complications, Effect on Mortality, Diagnostic and Therapeutic Management, and Follow-Up.Publication . Netteland, Dag Ferner; Sandset, Else Charlotte; Mejlænder-Evjensvold, Magnus; Aarhus, Mads; Jeppesen, Elisabeth; Aguiar de Sousa, Diana; Helseth, Eirik; Brommeland, Tor; FrontiersObjective: Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its management remains uncertain. Here, we systematically review the currently available evidence on the complications, effect on mortality and the diagnostic and therapeutic management and follow-up of CVST in the setting of TBI. Methods: Key clinical questions were posed and used to define the scope of the review within the following topics of complications; effect on mortality; diagnostics; therapeutics; recanalization and follow-up of CVST in TBI. We searched relevant databases using a structured search strategy. We screened identified records according to eligibility criteria and for information regarding the posed key clinical questions within the defined topics of the review. Results: From 679 identified records, 21 studies met the eligibility criteria and were included, all of which were observational in nature. Data was deemed insufficiently homogenous to perform meta-analysis and was narratively synthesized. Reported rates of venous infarctions ranged between 7 and 38%. One large registry study reported increased in-hospital mortality in CVSP and TBI compared to a control group with TBI alone in adjusted analyses. Another two studies found midline CVST to be associated with increased risk of mortality in adjusted analyses. Direct data to inform the optimum diagnostic and therapeutic management of the condition was limited, but some data on the safety, and effect of anticoagulation treatment of CVST in TBI was identified. Systematic data on recanalization rates to guide follow-up was also limited, and reported complete recanalization rates ranged between 41 and 86%. In the context of the identified data, we discuss the diagnostic and therapeutic management and follow-up of the condition. Conclusion: Currently, the available evidence is insufficient for evidence-based treatment of CVST in the setting of TBI. However, there are clear indications in the presently available literature that CVST in TBI is associated with complications and increased mortality, and this indicates that management options for the condition must be considered. Further studies are needed to confirm the effects of CVST on TBI patients and to provide evidence to support management decisions.