Cerebral Venous Thrombosis in Patients With Traumatic Brain Injury: Epidemiology and Outcome

The natural history and epidemiological aspects of traumatic cerebral venous thrombosis (CVT) are not fully understood. Due to the concomitant occurrence with intracranial hemorrhages, guidelines for medical treatment have been highly controversial. In this study, our objective was to carry out an analysis description of the population and to conduct a literature review. A prospectively gathered radiology registry data of patients hospitalized at the tertiary hospital of Centro Hospitalar Universitário do São João, Porto, Portugal, between 2016 and 2021 was carried out. All patients with traumatic brain injury (TBI) and concomitant CVT were identified. CVT was confirmed by CT venogram. Demographic, clinical, and radiological data and their medical management were reported. In-hospital complications and treatment outcomes were compared between patients measured by the Glasgow Outcome Score Extended (GOSE) at discharge and GOSE at three months. There were 41 patients with traumatic CVT admitted to this study. The majority (45.2%) had a hyperdense signal near the lateral sinus at admission, and only 26.2% presented with skull fractures. Of this cohort, 95% had experienced lateral sinus thrombosis. Twenty-five patients (60%) had occlusive venous thrombosis. Venous infarct was the main complication following CVT. Thirty-two patients (78%) were anticoagulated after CVT and four developed complications. At the three-month follow-up after discharge, 28.2% had good recovery (GOSE > 6). This study revealed a higher incidence of CVT in severe TBI and a mild association with skull fractures. There is a higher incidence of CVT in the lateral sinus. Management was inconsistent, with no difference in outcome without or with anticoagulation. Larger, prospective cohort studies are required to better comprehend this condition and determine evidence-based guidelines.

From Pansinusitis to Cerebritis Due to Eikenella corrodens

Meningitis is a rare but possible complication of sinusitis. We present a case of a 21-year-old woman with a history of fever, headache and nasal obstruction who presented at the emergency department with psychomotor agitation. Orotracheal intubation and invasive mechanical ventilation were given to protect airway. Blood analysis showed leukocytosis and elevated C-reactive protein. Cerebral and maxillofacial computed tomography (CT) demonstrated pansinusitis with gas foci more prominent in the left frontal sinus with an area of ​​bone rarefaction on the posterior wall with possible communication with the cranial cavity. Lumbar puncture was performed. Empirical antibiotic and corticosteroid therapy were started. Neurosurgery (NC) and Ear Nose and Throat (ENT) surgeons declined indication for urgent surgery and she was admitted at General ICU. On the fourth day of hospitalization, a brain magnetic resonance imaging (CE-MRI) was performed, revealing subdural empyema and cerebritis adjacent to the frontal sinus. She was transferred to the reference neurosurgical center for surgical interventions and was admitted post-operatively at the Neurocritical Care Unit (NCCU). Reevaluation MRI showed residual anterior frontal empyema and absence of focus control in peri-nasal sinusitis, requiring a new ENT surgery. A Streptococcus spp was isolated from the blood, Eikenella corrodens from the pus collected from the sinuses, and the CSF was sterile. The patient completed 21 days of antibiotic therapy. She was extubated on the 19th day, with Broca's aphasia and right hemiparesis, and on the 23rd day transferred to the ENT Service and later to the Rehabilitation Service. We present a case of atypical central nervous system (CNS) infection by a rare agent, highlighting the importance of vigilance, focus control, and neurocritical care. In a severe and complex manifestation like this, the management typically involves medical and surgical interventions. Subdural empyema should be treated as a neurosurgical emergency due to the potential rapid deterioration in patient's neurological condition, attributed to secondary damage. In this case, brain multimodal monitoring, was very helpful in acute phase management. Neurocritical care teams should be involved early in patients with this presentation of CNS infection to provide optimal management, reducing complications and secondary brain lesions therefore improving patient outcomes.

Creatinine Clearance in Acute Brain Injury: A Comparison of Methods

BACKGROUND

Currently, the measurement of glomerular filtration rate is very complex and costly, so its daily evaluation is performed using endogenous markers, of which creatinine is the most frequently used. It allows the estimation of glomerular filtration rate by means of its clearance or by formulas based on its serum and urine concentration. Augmented renal clearance (ARC) is frequent among critically ill patients and is defined as creatinine clearance (CrCl) > 130 ml/min/1.73 m2. The aim of this study was to compare measured CrCl (MCC) and estimated CrCl obtained with the Cockcroft-Gault formula (CG), the Modification of Diet in Renal Disease Study equation (MDRD), and the Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) in patients with severe traumatic brain injury and nontraumatic subarachnoid hemorrhage. The second aim was to assess the incidence of ARC in this population of neurocritical patients.

METHODS

This was a prospective, observational, single center study from a cohort of 74 patients admitted to the neurocritical intensive care unit due to traumatic brain injury or subarachnoid hemorrhage. Serum creatinine (at 7 a.m.) and a 6-h urine collection were analyzed, and CrCl was measured and estimated by using CG, MDRD, and CKD-EPI. The intraclass correlation coefficient (ICC) was evaluated for each pair, and Bland-Altman plots were used to assess clinical significance.

RESULTS

Among 74 patients, the median age was 53 (interquartile range [IQR] 36-65), and the median Glasgow Coma Scale score at admission was 6. The median MCC at admission was 176 (IQR 135-214). The medians of CG, MDRD and CKD-EPI were, respectively, 129 ml/min/1.73 m2 (IQR 95-176), 158 (IQR 115-202), and 116 (97-132). An ICC was applied to evaluate the correlation between MCC and estimated methods and showed a weak correlation between MCC and estimated CrCl obtained with the three different methods. The strongest ICC statistical correlation was found between MCC and MDRD, and the weakest correlation was found between MCC and CKD-EPI. Bland-Altman plots showed that differences between each pair were not clinically acceptable. ARC was present in 78% of measurements, using MCC. A weak correlation was observed between MCC and calculated CrCl. CG, MDRD, and CKD-EPI overestimated MCC when MCC ≤ 130 ml/min/1.73 m2 and underestimated it when MCC > 130 ml/min/1.73 m2.

CONCLUSIONS

In this population, there was a weak statistical correlation between measured and estimated methods. In patients with ARC, formulas underestimated MCC. MCC should probably be the preferred methodology for renal function assessment in the clinical setting to better adjust drug dosage and guarantee drug effectiveness.

Outcomes of Head and Neck Cutaneous Angiosarcoma Treated in the IMRT Era

PURPOSE/OBJECTIVE(S)

Clinical behavior, natural history, and varied presentations of cutaneous angiosarcomas of the head and neck region (HN), in conjunction with its rarity, have rendered standardization of treatment elusive. We aimed to assess outcomes and patterns of failure for patients treated with surgery and radiation (Sx+RT), and radiation alone (RT).

MATERIALS/METHODS

A retrospective review of all HN angiosarcoma patients amenable for upfront Sx or RT in our institution between 2004-2018 was completed. Generally, treatment included Sx when feasible, and RT for large or extensive/ill-defined tumors. Demographic, tumor characteristics, local (LC), regional (RC), distant control (DC), and overall survival (OS), as well as patterns (in-field, marginal, out-of-field) of local failure at 5-year were estimated. Univariate analysis (UVA) was conducted to assess association with outcomes.

RESULTS

A total of 33 patients were eligible (14 Sx+RT and 19 RT). Tumor locations were: scalp (16, 48%). face (n = 12, 36%), and overlapping (5, 15%). Lesion types were: nodular (n = 23, 70%), flat (n = 4, 12%) and mixed (n = 6, 18%). Tumor size was larger in the RT group (median: 10.00 vs 2.85 cm, p<0.01). RT and Sx+RT patients had otherwise similar baseline characteristics: median age 74.3; male 70%; and ECOG performance status ≤1 85%. RT dose fractionations ranged from 50-70 Gy in 25-35 fractions in the RT group and 50-66 Gy in 25-33 fractions in the Sx+RT group. Four (12%) patients received neoadjuvant chemotherapy. Median follow up was 5.5 years. Five-year LC, RC, DC, and OS for RT vs Sx+RT groups were 68% vs 85% (p = 0.28); 95% vs 86% (p = 0.89); 79% vs 86% (p = 0.39); and 45% vs 55% (p = 0.71), respectively. The in-field/marginal/out-of-field local failure rate at 5 years were 16% vs 7% (p = 0.46), 26% vs 15% (p = 0.41), and 13% vs 0% (p = 0.24) for the RT vs Sx+RT groups, respectively. UVA showed that scalp location and ulceration/bleeding were strong adverse features for OS. Bone invasion was significantly associated with lower DC (Table). Lesion type (nodular/flat/mixed), tumor size, and treatment type (Sx+RT vs RT), were not significantly associated with LC or pattern of local failure.

CONCLUSION

Scalp tumors, as compared to face, portended poorer prognosis, and ulceration/bleeding and bone invasion were associated with increased distant metastases. Sx+RT was the preferred treatment modality when possible and typically used for smaller and better defined tumors. RT was reserved for larger and extensive/ill-defined disease; despite this, in the IMRT era, RT achieves reasonable rates of control, markedly superior to historical series.

Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy

Introduction

Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications.

Aim of the study

We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome.

Methods and results

Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO2/FiO2) was 305±88 and driving pressure 15.9±3.5cmH2O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found.

Conclusion

Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.

Neurocritical care management supported by multimodal brain monitoring after acute brain injury

OBJECTIVE

To evaluate the association between different intensive care units and levels of brain monitoring with outcomes in acute brain injury.

METHODS

Patients with traumatic brain injury and subarachnoid hemorrhage admitted to intensive care units were included. Neurocritical care unit management was compared to general intensive care unit management. Patients managed with multimodal brain monitoring and optimal cerebral perfusion pressure were compared with general management patients. A good outcome was defined as a Glasgow outcome scale score of 4 or 5.

RESULTS

Among 389 patients, 237 were admitted to the neurocritical care unit, and 152 were admitted to the general intensive care unit. Neurocritical care unit management patients had a lower risk of poor outcome (OR = 0.228). A subgroup of 69 patients with multimodal brain monitoring (G1) was compared with the remaining patients (G2). In the G1 and G2 groups, 59% versus 23% of patients, respectively, had a good outcome at intensive care unit discharge; 64% versus 31% had a good outcome at 28 days; 76% versus 50% had a good outcome at 3 months (p < 0.001); and 77% versus 58% had a good outcome at 6 months (p = 0.005). When outcomes were adjusted by SAPS II severity score, using good outcome as the dependent variable, the results were as follows: for G1 compared to G2, the OR was 4.607 at intensive care unit discharge (p < 0.001), 4.22 at 28 days (p = 0.001), 3.250 at 3 months (p = 0.001) and 2.529 at 6 months (p = 0.006). Patients with optimal cerebral perfusion pressure management (n = 127) had a better outcome at all points of evaluation. Mortality for those patients was significantly lower at 28 days (p = 0.001), 3 months (p < 0.001) and 6 months (p = 0.001).

CONCLUSION

Multimodal brain monitoring with autoregulation and neurocritical care unit management were associated with better outcomes and should be considered after severe acute brain injury.

Comparing the long-term prognosis of myocardial infarction with non-obstructive coronary arteries to myocardial infarction with obstructive coronary artery disease

Background

The long-term survival rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients is lower than in the general population. Nevertheless, there are conflicting results regarding the prognosis of MINOCA patients in comparison to myocardial infarction with obstructive coronary artery disease (MI-CAD) patients.

Purpose

The aim of this study was to assess the long-term all-cause mortality of MINOCA patients and compare it to MI-CAD patients.

Methods

Retrospective analysis of 2443 consecutively admitted patients for acute myocardial infarction (AMI), in a single coronary intensive care unit. Only patients with 5 years of follow-up and those who died before the 5-year mark were considered. Patients were divided into two groups according to the presence or absence of obstructive coronary artery disease on angiography (≥50% stenosis). Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were compared using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Five-year all-cause mortality was the target endpoint. Five-year survival was modelled through the Cox proportional hazard regression model. The variable of interest (MINOCA vs MI-CAD) and possible confounders that displayed statistically significant differences in the initial demographic analysis were included in univariable Cox regressions, and those with statistically significant associations were included in a multivariable model. Those that displayed non-significant associations in the multivariable model were subsequently removed until we were left with significant associations only, giving us an adjusted hazard ratio.

Results

Comparison between groups is presented in table 1. MINOCA patients were younger and more often women. They were less likely to have smoking habits, diabetes, or a previous history of AMI. They had a lower Killip class, as well as lower troponin I, serum creatinine and low-density lipoprotein cholesterol at admission. On the other hand, they had higher left ventricular ejection fractions. They were also less likely to have beta-blockers or aspirin prescribed at discharge.

All-cause mortality at 5 years was 13.1% among MINOCA patients and 28.3% among MI-CAD patients, with an unadjusted hazard ratio (HR) of 0.421 (95% CI 0.322–0.550), p&lt;0.001. Adjusting for known confounders, the HR was 0.461 (95% CI 0.261–0.816), p=0.008.

Conclusions

Compared with MI-CAD patients, those with MINOCA were slightly younger and had fewer comorbidities. In spite of having a worse long-term prognosis when compared to the general population, MINOCA patients have a significantly higher 5-year survival rate than MI-CAD patients, even after adjustment of confounding factors.

Funding Acknowledgement

Type of funding sources: None.

Maximum dose sacubitril/valsartan in heart failure with reduced ejection fraction: does atrial fibrillation compromise the benefits?

Background

In the PARADIGM-HF trial, sacubitril/valsartan (SV) was shown to be superior to enalapril in reducing hospitalizations for worsening heart failure (HF), cardiovascular mortality, and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). The 2021 ESC Guidelines recommends SV as a replacement for angiotensin-converting-enzyme inhibitors to reduce the risk of HF hospitalization and death. There is little information regarding the effects of SV according to atrial fibrillation (AF) status.

Purpose

The aim of this study was to compare the effects of maximum dose SV regarding symptomatic improvement, change in natriuretic peptides levels (NP) and left ventricular ejection fraction (LVEF) in patients with HFrEF with and without AF.

Methods

Retrospective analysis of 137 patients with HFrEF on maximum dose SV (97/103mg twice daily). Patients were divided into two groups according to AF status. Age, gender, relevant comorbidities, usual medication, baseline symptomatic status, NP levels and LVEF were assessed using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Variation in NYHA class, NP levels and LVEF between baseline and 6-month follow-up was evaluated and compared between groups.

Results

Comparison between groups is presented in Table 1. In our studied population, ischemic aetiology was more common in the sinus rhythm group (49.5% vs 30.4%; p 0.034). There were no significant differences between groups regarding age, gender, hypertension, diabetes, and beta-blocker and mineralocorticoid receptor antagonist usage. At baseline, the AF group had higher NT-proBNP levels [median 1421 mg/dL (IQR 743–3087) vs 467 mg/dL (IQR 140–797); p&lt;0.001]. There were no significant differences regarding baseline NYHA class or LVEF. After 6 months of follow-up, reductions in NYHA class [−1 (IQR −2, −1) for AF; −1 (IQR −1, 0) for SR; p=0.437] and NT-proBNP levels [−358 mg/dL (IQR −2275, −47) for AF; −162 mg/dL (IQR −364, 27) for SR; p=0.156], as well as LVEF improvement [11% (IQR 3–15) for AF; 12% (IQR 7–21) for SR; p=0.201], displayed no statistically significant differences between the two groups.

Conclusions

Our study shows that the beneficial effects of SV on symptomatic status, NP levels and LVEF were not compromised by the presence of AF at baseline.

Funding Acknowledgement

Type of funding sources: None.

Catatonia and dementia: a case report

Introduction

Catatonia is a neuropsychiatric disorder characterized by motor, behavioral and autonomic changes. It is associated with several psychiatric disorders, including dementia. Catatonia is an underdiagnosed syndrome, so it is important to draw attention to it. Here, we review a case of a patient admitted to our psychiatric department with a clinical presentation compatible with catatonia. After proper treatment, further assessment revealed dementia.

Objectives

This work aims to describe a case of catatonia in a patient with dementia.

Methods

Bibliographic research using Pubmed®. Clinical file consultation and patient interviews.

Results

Catatonia is a disorder that was already been described as part of several types of dementia. We present a 69-year-old female patient, admitted to our psychiatric department with clinical presentation compatible with catatonia. To admission, she presented some typical complications resulting from long immobility such as pressure ulcers and nutritional deficiencies. During the hospitalization, she developed a urinary infection and there was the need to tube feeding. She was treated with benzodiazepines and improved. Further assessment revealed dementia.

Conclusions

Catatonia in dementia is not uncommon, although it is an underdiagnosed syndrome, and when treated early and properly it has a good prognosis.

Disclosure

No significant relationships.

Cardiac resynchronization therapy: long-term impact of echocardiographic non-progression

Funding Acknowledgements

Type of funding sources: None.

Background

As heart failure (HF) is a progressive disease, there has been a raising idea that considering the absence of echocardiographic improvement as non-response to cardiac resynchronization therapy (CRT) may not be appropriate. In fact, in some classical echocardiographic non-responders, CRT might have prevented HF deterioration.

Purpose

Our aim was to compare the composite outcome of death and re-admissions due to HF according to a new classification of CRT response: responders, non-progressors and progressors.

Methods

We included 144 consecutive patients with HF, left ventricle (LV) ejection fraction &lt; 40% and QRS duration &gt; 120mseg submitted to CRT implantation. Patients were divided into 3 groups according to the variation of LV end-systolic volume (LVESV) at 6-month: ≥15% reduction in LVESV - responders (R); 0–15% reduction in LVESV – non-progressors (NPr); increase in LVESV – progressors (Pr). A long-term follow-up (4.9 ± 2.9 years) was performed targeting mortality and re-admissions due to HF.

Results

In our population, 78 patients (54.2%) were classified as R, 21 (14.5%) as NPr and 45 (31.3%) as Pr. Baseline comparison between groups is presented in table 1. Compared with R, N-Pr had ischemic aetiology more frequently. The prescription of digoxin was more common in Pr. The Kaplan-Meier curves (figure 1) demonstrate that the composite outcome of death and re-admission due to HF had a lower incidence in R, but was similar between N-Pr and Pr. After adjustment of possible confounders (ischemic aetiology and digoxin use), the type of response to CRT remained as the only predictor of outcomes (OR 0.61; CI 0.41-0.90). 144

Conclusion

In our population, patients without progression of HF had a similarly negative prognosis to the ones that deteriorated. Hence, positive LV remodelling, and not only stabilization seems to be necessary to improve long-term prognosis.

Tachydysrhythmias in patients admitted with COVID-19 pneumonia: prevalence and impact on in-hospital mortality

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality.

Purpose

Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality.

Methods

A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR).

Results

A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p &lt;0.001) and had more hypertension (p 0.034), heart failure (HF) (p &lt;0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA).

Patients with HF had the highest risk of tachyarrhythmia (OR 3.539; 95% CI 2.666-4.698; p &lt;0.001), followed by severe VHD (OR 1.990; 95% CI 1.192-3.365; p 0.009) and CAD (OR 1.575; 95% CI 1.040-2.386; p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819; 95% CI 1.272-2.602; p 0.001)

Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820; 95% CI 2.151-3.695; p &lt;0.001).

Conclusions

Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed.

Prevalence and impact of dysrhythmias in COVID-19 intensive care patients

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias.

Purpose

To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality.

Methods

A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables.

Results

The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016).

When adjusted for confounding variables, prone was the most significant predictor (OR 2.800; 95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484; 95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440; 95% CI 0.950-6.310; p 0.065).

Conclusions

COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias.

Inflammation in acute coronary syndrome: prognostic significance

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with acute coronary syndrome (ACS) the acute phase reactant, C-reactive protein (CRP), might be significantly elevated. Several reports suggest that CRP may play a direct pathophysiological role on the development and progression of atherosclerosis, and CRP values correlate with infarct size when measured by magnetic resonance imaging.

Purpose

The aim of the present study was to evaluate the prognostic value of CRP in patients presenting with an ACS.

Methods

Retrospective analysis of 635 consecutively admitted patients due to ACS in a single coronary intensive care unit. CRP levels were measured at admission. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether CRP was an independent predictor of outcome.

Results

In the studied sample, 75% were male. Median age was 69 [interquartile range (IQR) 57–78]. ST-elevation myocardial infarction (STEMI) occurred in 39.6%, non-ST segment elevation myocardial infarction in 44.9% and unstable angina in 15.5% of the patients. Median left ventricular ejection fraction (LVEF) was 48% (IQR 40–55%) and median CRP level at admission 0.7 mg/dL (IQR 0.5–1.9 mg/dL). Regarding important comorbidities and past medical history, 75.9% had hypertension (HTN), 34.0% diabetes, 20.3% chronic kidney disease (CKD), 68.6% dyslipidaemia and 17.3% heart failure (HF). The median follow-up was 34 months (IQR 22–72). In univariate analysis, CRP was significantly associated with all-cause mortality (HR 1.06 per 1 mg/dL increase, 95% CI 1.04–1.08, p&lt;0.001), as was gender, age, LVEF, STEMI and previous history of diabetes, HTN, CKD or HF. In multivariate analysis, CRP remained significantly associated with the primary endpoint (HR 1.02, 95% CI 1.00–1.05, p=0.033), as did age, LVEF and previous history of HF.

Conclusions

In our study, CRP at admission was an independent risk factor for all-cause mortality following an ACS. This finding indicates that inflammation associated with the acute event has a significant impact in the long-term prognosis. More evidence is needed to determine if treating inflammation (and when, in the course of the disease) could result in better outcomes.

Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p&lt;0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.

Impact of the COVID-19 pandemic on emergent pacemaker implantation during lockdown and its aftermath

Background

COVID-19 was first considered a pandemic on the 11th of March of 2020 by the World Health Organization. Its impact comprised not only the direct consequences of the disease but a decrease in the follow-up and interventions of patients with cardiovascular (CV) disease. In Portugal and the World, the consequences of this complex paradigm shift on emergent pacemaker implantation rates during and after this pandemic is largely unknown.

Purpose

We sought to analyse the impact of COVID-19 pandemic on emergent pacemaker implantation rate and patient profile in a tertiary hospital during the first Portuguese lockdown and subsequent post-lockdown period.

Methods

We retrospectively reviewed the clinical profile of patients who had pacemakers implanted in our hospital in an urgent/emergent setting from March 18, 2020 to May 17, 2020 (lockdown) and May 19 to July 17, 2020 (post-lockdown). This data was then directly compared to the homologous periods from the year before (H1 and H2, respectively).

Results

A total of 180 patients submitted to emergent pacemaker implantation were included.

The cohort was comprised of 29 patients who had a pacemaker implanted during lockdown, 60 post-lockdown, 38 in H1 (+31% vs lockdown) and 53 in H2. Average age and gender proportion were similar for all groups.

When comparing lockdown and post-lockdown periods, the number of cases significantly increased in the second period (+106.9%) and there was a tendency for a higher number of temporary pacemaker use (3.4% vs 16.7%; p=0.076). Patients admitted during lockdown were 7.57 times more likely to present with hypotension/shock (odds ratio (OR) 7.57; p=0.013).

Regarding lockdown and its homologous 2019 period, there was a decrease in the number of patients admitted (−23.7%). Again, there was a higher tendency for hypotension on presentation during lockdown (p=0.054).

In comparison to its homologous 2019 period, post-lockdown saw a slight increase in the number of patients (+13.2%) and more patients presented with bradycardia (16.7% vs 3.8%; p=0.026).

Also of note, no patients were admitted to the emergency department during lockdown for anomalies detected on ambulatory tests (Holter, electrocardiogram or implanted loop recorder).

Conclusion

During lockdown, clinical presentation was generally more severe, with a greater number of patients presenting with hypotension/shock. In addition, there appears to be a lockdown effect on emergent bradyarrhtmias admissions in the post-lockdown period with a profound impact: higher admission rates and more severe presentations including a higher need of temporary pacemaker. Patients with symptoms suggestive of bradyarrhythmias should be advised to present promptly regardless of the pandemic.

Funding Acknowledgement

Type of funding sources: None. Pacemakers during lockdown/post-lockdownPacemakers implanted by diagnosis

Brain Multimodal Monitoring in Severe Acute Brain Injury: Is It Relevant to Patient Outcome and Mortality?

INTRODUCTION

Advanced multimodal monitoring (MMM) of the brain is recommended as a tool to manage severe acute brain injury in intensive care units (ICUs) and prevent secondary lesions. The aim of this study was to determine if MMM has implications for patient outcome and mortality.

METHODS

We analyzed data on 389 patients admitted with a subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI) to two general ICUs and one neurocritical care ICU (NCCU) between March 2014 and October 2016, and their subsequent outcomes.

RESULTS

The study population consisted of 259 males and 130 females. Group 1, which comprised 69 patients with MMM admitted to the NCCU, was compared with group 2, which comprised patients managed without MMM. With the exceptions of the Simplified Acute Physiology Score (SAPS II) and Glasgow Coma Scale (GCS) scores, there were no differences between the two groups. Group 1 had significantly better outcomes at ICU discharge, at 28 days, and at 3 months, and also had a lower mortality rate (P < 0.05). When outcomes were adjusted for SAPS II scores, patients who had MMM had better outcomes (odds ratios 0.215 at ICU discharge, 0.234 at 28 days, 0.338 at 3 months, and 0.474 at 6 months) but no difference in mortality.

CONCLUSION

Use of MMM in patients with SAH or TBI is associated with better outcomes and should be considered in the management of these patients.

Integrating Health Information Systems: A Critical Appraisal

Objectives: The aim of this paper is to critically assess some of the underlying assumptions behind these initiatives and analyze the dominant expressions, forms and mechanisms of integration.

Methods: This paper employs a discourse analysis to elicit the notion of integration of information systems and its consequences for electronic patient record systems.

Results and Conclusions: An alternative strategy is outlined, encouraging a more decentralized, multi-vocal approach acknowledging the productive role of related and duplicated information and preserving the existing variety of information systems.

Big is Beautiful: Electronic Patient Records in Large Norwegian Hospitals 1980s – 2001

Objectives: This paper aims to describe and analyze the prolonged efforts – spanning close to two decades – of developing and using electronic patient records in the large, university-based hospitals in Norway.

Methods: This study belongs to an interpretative approach to the development and use of information systems.

Results: The increase in organizational, institutional, political and technological complexity has been seriously underestimated. This paper describes and analyses the prolonged efforts – spanning close to two decades – of developing and using EPRs in the large, university-based hospitals in Norway. The investments involved were considerable, implying that a crucial aspect of these efforts has been the way alliances have been forged with public institutions and agendas.

Conclusions: The conditions for small-scale, bottom-up and evolutionary approaches never succeeded in constructing themselves as a viable alternative to the larger, more sweeping electronic patient record initiative, reiterating a more general tendency to privilege the more comprehensive and daring projects.

Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study

BACKGROUND

Guidelines recommend cerebral perfusion pressure (CPP) values of 50-70 mmHg and intracranial pressure lower than 20 mmHg for the management of acute traumatic brain injury (TBI). However, adequate individual targets are still poorly addressed, since patients have different perfusion thresholds. Bedside assessment of cerebral autoregulation may help to optimize individual CPP-guided treatment.

OBJECTIVE

To assess staff compliance and outcome impact of a new method of autoregulation-guided treatment (CPPopt) based on continuous evaluation of cerebrovascular reactivity (PRx).

METHODS

Prospective pilot study of severe TBI adult patients managed with continuous multimodal brain monitoring in a single Neurocritical Care Unit (NCCU). Every minute CPPopt was automatically estimated, based on the previous 4-h window, as the CPP with the lowest PRx indicating the best cerebrovascular pressure reactivity. Patients were managed with CPPopt targets whenever possible and otherwise CPP was managed following general/international guidelines. In addition, other offline CPPopt estimates were calculated using cerebral oximetry (COx-CPPopt), brain tissue oxygenation (ORxs-CPPopt), and cerebral blood flow (CBFx-CPPopt).

RESULTS

Eighteen patients with a total multimodal brain monitoring time of 5,520 h were enrolled. During the total monitoring period, 11 patients (61 %) had a CPPopt U-shaped curve, 5 patients (28 %) had either ascending or descending curves, and only 2 patients (11 %) had no fitted curve. Real CPP correlated significantly with calculated CPPopt (r = 0.83, p < 0.0001). Preserved autoregulation was associated with greater Glasgow coma score on admission (p = 0.01) and better outcome (p = 0.01). We demonstrated that patients with the larger discrepancy (>10 mm Hg) between real CPP and CPPopt more likely have had adverse outcome (p = 0.04). Comparison between CPPopt and the other estimates revealed similar limits of precision. The lowest bias (-0.1 mmHg) was obtained with COx-CPPopt (NIRS).

CONCLUSION

Targeted individual CPP management at the bedside using cerebrovascular pressure reactivity seems feasible. Large deviation from CPPopt seems to be associated with adverse outcome. The COx-CPPopt methodology using non-invasive CO (NIRS) warrants further evaluation.

Disordered Eating Behaviors, Perfectionism And Perseverative Negative Thinking–study In a Clinical Sample

Introduction

In a recent study developed with a community sample, we have found that although PNT mediated the relationship between perfectionist cognitions and bulimic behavior, the effect of perfectionism on other disordered eating dimensions, such as diet, was independent of the PNT levels (Monteiro et al., 2015).

Objective

To investigate if PNT mediates the relationship between perfectionism and disordered eating behaviors in a clinical sample.

Methods

Fifty-two patients with eating disorders/ED (mean age = 22.54 ± 7.637; mean BMI = 20.07 ± 4.192; 14.5% Anorexia Nervosa cases; 7.8% Bulimia Nervosa and 9.0% EDNOS) were assessed with the ED section of the Diagnostic Interview for Genetic Studies and fill in the Portuguese validated versions of Eating Attitudes Test/EAT-25 (to evaluate Bulimic behaviors/BB, Diet and Social pressure to eat), Multidimensional Perfectionism Scales (to evaluate perfectionism composite dimensions Evaluative Concerns/EC and Perfectionistic Strivings/PS) and Perseverative Thinking Questionnaire/PTQ-15 (to evaluate Repetitive Thought/RT, Cognitive interference and unproductiveness/CIU). Only variables significantly correlated with the outcomes (EAT-25_Total and its dimensions) were entered in the regression models. Mediation analyses using Preacher and Hayes bootstrapping methodology were performed.

Results

EC, PS, CIU and RT were significant predictors of EAT_Total. PA, CIU and PR were significant predictors of BB. EC and PS were significant predictors of Diet. CIU partially mediated the relationship between EC and EAT_Total (95% CI = 0.0025–0.3296) and between EC and BB (95% CI = 0.0037–0.1877).

Conclusion

Also in a clinical sample, CII, the most pernicious dimension of PNT, mediates the relationship between perfectionism and disordered eating behavior, particularly bulimic behavior; diet is predicted by perfectionism independently of PNT.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Kidney-brain link in traumatic brain injury patients? A preliminary report

BACKGROUND

Kidney hyperfiltration with augmented renal clearance is frequently observed in patients with traumatic brain injury. The aim of this study is to report preliminary findings about the relationship between brain autoregulation impairment, estimated kidney glomerular filtration rate and outcome in critically ill patients after severe traumatic brain injury.

METHODS

Data collected from a cohort of 18 consecutive patients with severe traumatic brain injury managed with ICP monitoring in a Neurocritical Care Unit, were retrospectively analyzed. Early morning blood tests were performed for routine chemistry assessments and we analyzed creatinine and estimated creatinine clearance, osmolarity, and sodium. Daily norepinephrine dose, protein intake, and water balance were documented. Time average of brain monitoring data (intracranial pressure, cerebral perfusion pressure, and cerebrovascular reactivity pressure index--PRx) were calculated for 6 h before blood sample tests. Patient outcome was evaluated using Glasgow outcome scale at 6-month follow-up, considering nonfatal outcome if GOS ≥ 3 and fatal outcome if GOS < 3. Multiple linear regression models were used to study the crude and adjusted effects of the above variables on PRx throughout time.

RESULTS

A total of 199 complete daily observations from 18 adult consecutive multiple trauma patients with severe traumatic brain injury were analyzed. At hospital admission, the median post-resuscitation Glasgow coma score was 6 (range 3-12), mean SAPSII score was 44.65 with predicted mortality of 36 %. Hospital mortality rate was 27 % and median GOS at 6 month after discharge was 3. Creatinine clearance (CrCl) was found to have a negative correlation with PRx (Pearson correlation--0.82), with statistically significant crude (p < 0.001) and adjusted (p = 0.001) effects. For each increase of 10 ml/min in CrCl (estimated either by the Cockcroft-Gault or by Modification of Diet in Renal Disease Study equations) a mean decrease in PRx of approximately 0.01 was expected. Amongst possible confounders only norepinephrine was shown to have a significant effect. Mean PRx value for outcome fatal status was greater than mean PRx for nonfatal status (p < 0.05), regardless of the model used for the CrCl estimation.

CONCLUSIONS

Better cerebral autoregulation evaluated with cerebrovascular PRx is significantly correlated with augmented renal clearance in TBI patients and associates with better outcome.

Liver metastasis of ethmoid sinus adenocarcinoma

INTRODUCTION

Sinonasal cancer is an uncommon neoplasm, often associated with exposure to occupational hazards and delayed diagnosis.

CASE REPORT

The authors report a rare case of solitary liver metastasis from ethmoid sinus adenocarcinoma treated by surgical resection. No clinical or radiological sign of recurrence was observed with a follow-up of 3 months.

DISCUSSION

Adenocarcinoma of the ethmoid sinus is characterized by its aggressiveness and its tendency to recurrence. Metastases are rare and can be found in unexpected organs due to dissemination via collateral venous plexuses. The role of chemotherapy has not been clearly established. Due to their rarity, the treatment of metastases has not yet been defined.

Peptide receptor radionuclide therapy in head and neck paragangliomas – Report of 14 cases

BACKGROUND

Peptide receptor radionuclide therapy (PRRT) is a very promising treatment option in neuroendocrine tumours, with good results, but there are only few reports regar­ding its use in paragangliomas.

METHODS

The authors conduc­ted a retrospective study during the period of May 2011 to February 2014 in an Oncological Centre. Ten patients with jugular-tympanic paragangliomas and four with carotid body paragangliomas were treated with three cycles of Lutetium labelled peptide (177 Lu-DOTATATE). Treatment response was assessed with a PET-CT with 68 Ga-DOTANOC and clinical crite­ria.

RESULTS

Ten of the fourteen patients showed a decrea­se in the tumor standard uptake value (SUV) after treat­ment. 90% of patients with Jugulotympanic paraganglio­mas had symptomatic improvement or stabilization. Patients with carotid body paragangliomas and patients with a low uptake of 68 Ga-DOTANOC had a worse response to the treatment. The tumor SUV value was a predictor of treatment response [R= 0,64; F= 8,212; p= 0,014].

CONCLUSION

Peptide receptor radio­nuclide therapy can be a therapeutic option in selected cases of head and neck paragangliomas.

Adenocarcinomas of the sinonasal tract: a case series from an Oncology Centre in Northern Portugal

Sinonasal malignant neoplasms are rare and adenocarcinomas account for 10-20 % of these cancers. Our aim is to characterise the clinical presentation, risk factors and outcomes of patients with adenocarcinoma treated at our institution. Retrospective review of medical records of patients with sinonasal adenocarcinomas, treated at IPO-Porto from January 2008 until December 2012. Twenty-eight patients with adenocarcinomas were selected from a total of 53 patients with sinonasal cancers. There was a male predominance (93 %), a mean age at diagnosis of 56 years and a rate of occupational wood dust exposure of 71 %. The most common treatment option was surgery followed by adjuvant radiotherapy. The 5 year disease-free and cancer-specific survival was 58 and 60 %, respectively. The following factors had negative impact on disease-free survival: advanced AJCC stage (p = 0.014); skull base invasion (p = 0.002); poorly differentiated or mucinous subtypes histology (p = 0.034) and imaging findings of residual tumour before adjuvant radiotherapy (p < 0.001). Endoscopic tumour resection was not associated with adverse outcomes. The role of volume-modulated arch therapy in the treatment of sinonasal tumours has to be clarified. The higher rate of adenocarcinomas among sinonasal cancers in this series comparing with previous reports, even from our institution, suggests that this pathology is rising in Northern Portugal. Despite substantial local failure, sinonasal adenocarcinomas have a relatively favourable prognosis in terms of cancer-specific survival.

Central nervous system–immune reconstitution inflammatory syndrome presenting as varicella zoster virus-mediated vasculitis causing stroke

Varicella zoster virus (VZV)-mediated vasculitis is a rare cause of stroke, but should be considered in HIV patients where vasculitis can occur in association with central nervous system – immune reconstitution inflammatory syndrome (CNS-IRIS). A literature search revealed 7 reports of VZV vasculitis over the years with no unifying management strategy, highlighting the difficulty in managing rare conditions in the absence of clear guidelines. This is the first documented case of VZV-mediated vasculitis presenting as stroke in the United Kingdom. Our patient made a full recovery with multidisciplinary input from HIV, neurology and radiology specialists.

[Fracture of the carpal scaphoid in children. Case report and literature review]

OBJECTIVE

To conduct a bibliographic review of the infrequent fractures of the carpal scaphoid in pediatric cases based on a clinical case. The diagnosis is usually a difficult one and treatment should be stringent in order to minimize the chance of delayed healing or pseudoarthrosis.

MATERIAL AND METHODS

Ten year-old child with a carpal scaphoid fracture visible in the plain films. The patient did not comply with treatment and removed the cast at three weeks. Despite this healing occurred without any clinical sequelae.

DISCUSSION

This case is especially infrequent given the excellent result obtained despite the fact that the immobilization period was considerably shorter than the minimum recommended.

Strain Field Measurement on 3D Surfaces: Application to Petaloid Base of PET Bottles under Pressure

Validation of stretched blown bottles of polyethylene terephthalate (PET) by using numerical simulation is an important industrial goal. This necessitates the identification of the PET material characteristics. Because the biaxial elongation of macromolecules induces great modifications of the mechanical properties of the material, it is difficult to manage an accurate simulation: properties are not well known in the base or neck region of the bottles.

The aim of the work presented here is to provide an identification tool for the orthotropic elastic properties in the 3D regions of PET bottles of carbonated soft drinks. More specifically, we focus on the behavior of the petaloid bases when bottles are submitted to internal pressure like during burst or ESC (environmental stress cracking) tests. A stereo correlation tool has been developed in order to build digital 3D surface; comparing the initial surface with the same surface when the bottle is under pressure, it is possible to evaluate the membrane strains at each point of the petaloid surface. Two bases, one with large valleys (LV) between the five feet and one with small valleys (SV) which highlight very different behavior at the ESC test, are compared with this tool. Coupled with a finite element simulation managed on the same bases, these results allow the identification of the induced mechanical properties. The LV case presents specific characteristics that are discussed in the last section of the paper.

PET/CT in the management of metastatic cervical lymphadenopathy from unknown primary site: a seven years retrospective study

OBJECTIVES

To evaluate the accuracy of PET/CT for the diagnostic evaluation of patients presenting cervical node metastasis of suspected unknown primary; furthermore to understand its relative clinical utility and relevance when compared to classic endoscopic investigation approach.

MATERIALS & METHODS

A retrospective study was pursued, collecting information from clinical files of all patients who presented to the Portuguese Institute of Oncology - Oporto, from January 2005 to December 2011, with cervical node metastases whose primary hadn't been found, despite clinical examination and standard imaging (CT scan or MRI) and therefore were submitted to a PET/CT. Among those presenting with non-supraclavicular metastasis patients were subsequently analyzed according to: histopathology; those who performed examination under anaesthesia (EUA) for biopsies either before of after PET/CT.

RESULTS

Eighty nine patients were included in the study. Detection rate was 32.6% with no statistically difference between those with supraclavicular metastases and those with metastases in higher cervical levels (p = 0.24). In this last group (n = 76), 43% patients had had PET/CT and an endoscopy associated with biopsies of the upper aerodigestive tract in different orders, to complete diagnostic workup in cases where the first performed was inconclusive. No statistically difference was found between these two methods (p = 0.25). Most of noticed false negatives were microscopic lesions located deep in the palatine tonsils.

CONCLUSIONS

PET/CT showed to be an useful tool when searching for primary tumours whether metastasis were supraclavicular or located in higher levels of the neck. Despite its good accuracy and detection of tumours previously undetected by EUA with biopsies (missed mainly due to sampling error), up-front negative scan shouldn't preclude performing endoscopies. Being evident that both tools are helpful. It was not possible in this study to find any evidence that could show which one of these two exams should be performed first.

Mental health and quality of life in alcoholic liver disease patients after liver transplantation: a prospective controlled study

OBJECTIVE

Alcoholic liver disease (ALD) is one of the most important indications for liver transplantation. Discordant conclusions have been found concerning quality of life and mental health after transplantation in this particular group. The aim of this work was to investigate improvements in mental health and quality of life among transplanted patients for ALD.

METHODS

We studied 45 consecutive transplant candidates with ALD, attending the outpatient clinics. Among these patients we transplanted 24 with the control candidates remaining in wait for transplantation.

RESULTS

There was a significant improvement in all mental health and quality of life dimensions among the transplanted ALD group. We also observed a favorable evolution of coping mechanisms (CM) in this group.

CONCLUSION

There is a favorable adjustment of ALD patients after transplantation as shown in CM evolution, which might explain the improved mental health and quality-of-life dimensions.

Psychiatric and psychosocial predictors of medical outcome after liver transplantation: a prospective, single-center study

OBJECTIVE

Recognizing the potential impact of psychiatric and psychosocial factors on liver transplant patient outcomes is essential to apply special follow-up for more vulnerable patients. The aim of this article was to investigate the psychiatric and psychosocial factors predicted medical outcomes of liver transplanted patients.

METHODS

We studied 150 consecutive transplant candidates, attending our outpatient transplantation clinic, including 84 who had been grafted 11 of whom died and 3 retransplanted.

RESULTS

We observed that active coping was an important predictor of length of stay after liver transplantation. Neuroticism and social support were important predictors of mortality after liver transplantation.

CONCLUSION

It may be useful to identify patients with low scores for active coping and for social support and high scores for neuroticism to design special modes of follow-up to improve their medical outcomes.

A therapeutic “innovation”…

Domestic violence, particularly violence against women, is a scourge that has killed this year in Portugal more than twenty women.

Our aim is to present a case study on the issue of gender violence on a 49 years old woman with a prior diagnosis of bipolar disorder and its (terrible) consequences.

The multiple injuries sustained over several years “treated” the bipolar disorder. Apart from a frontal lesion on CT there is now a set of neurological and psychiatric symptoms compatible with a diagnosis of chronic traumatic encephalopathy (CTE) “boxer's dementia” like.

Survival of the thriftiest: restricted nurture reveals the thrifty nature of a growth gene in Bos indicus

Growth hormone (GH) is a part of the somatotropic axis that controls metabolism, growth, development and aging in a wide range of animals. Mutations that reduce GH signaling have been associated with extended life spans and increased longevity in ways similar to what is observed in dietary restriction (DR) models. However, the mechanism by which DR works is not well understood. Here, we show that DR works as a factor in the evolution of the genetic make-up of domestic cattle. In a series of 6864 bovines of seven Bos indicus and tropically adapted Bos taurus breeds, the frequency of a short, wild-type allele of the promoter region of the bovine GH gene, G1 allele, varied from 2.7 to 17.7%. The frequency of the long, domestic G2 allele increased from 88 to 95% along 20 calf crops of commercial Bos indicus cattle of the Nelore breed undergoing selection for increasing post-weaning weight gain with ad libitum nutrient intake. Under DR, however, the G1 allele sustained growth better than the G2 allele, as observed in a series of feeding tests. The G2 allele was even detrimental or abiotropic, as it caused rapid body decay under DR. We observed a reflection symmetry of GH allele substitution effects on body weight under different dietary schemes. The G2 allele is featured as the "demanding allele", because it is optimally fitted to ad libitum nutrient intake. The G1 allele is featured as the "thrifty allele" because it is optimally fitted to DR. Our results show that dietary regimens need not extend lifespan or increase longevity in the sense of age-specific fitness. Instead, adaptation to any particular dietary regimen is just as much a consequence of selection as its cause; dietary regimens work as do any selection force, optimizing genotypic fitness to nutritional conditions.

Identification and quantitative analysis of human transthyretin variants in human serum by Fourier transform ion-cyclotron resonance mass spectrometry

Transthyretin (TTR) is a homotetrameric protein involved in thyroid hormone transport in blood and in retinol binding in the central nervous system. More than 80 point mutations in this protein are known to be associated with the formation of amyloid deposits and systemic amyloidotic pathologies. Age at onset varies according to the mutation but considerable variations also occur for subjects carrying the same mutation. Moreover, wild-type TTR forms amyloid deposits in systemic senile amyloidosis, a geriatric disorder. An accurate diagnostic and the choice of therapeutic options depend on the identification of the specific mutation. Previous characterization of TTR variants by mass spectrometry required the use of antibodies for sample enrichment. We developed a novel assay based on ultra high-resolution mass spectrometry to identify human TTR variants. The method, requiring a very low sample amount, is based on SDS-PAGE fractionation of human serum, followed by peptide mass fingerprinting by MALDI-FTICR-MS (matrix assisted laser desorption ionization coupled to Fourier transform ion cyclotron resonance mass spectrometry). Moreover, it is possible to perform a relative quantification of wild type and mutant TTR forms by mass spectrometry. The method was tested and validated with the V30M mutant, involved in familial amyloidotic neuropathy of Portuguese type.

Adherence correlates in liver transplant candidates

The study sought to investigate the psychiatric and psychosocial correlates of multidimensional adherence among liver transplant candidates. A liver transplant candidate sample (N = 100), comprising consecutive patients attending outpatient clinics of a liver transplantation central unit, was assessed by means of the Multidimensional Adherence Questionnaire (MAQ; Telles-Correia 2007), the Diagnostic and Statistical Manual of Mental Disorders, Revised 4th Edition (DSM-IV-TR) criteria, the Toronto Alexithymia Scale (TAS), the NEO Five-Factor Inventory (NEO-FFI) personality inventory, the Hospital Anxiety and Depression Scale (HADS), the Brief COPE, and the Psychological Assessment of Candidates for Transplantation (PACT). We found that multidimensional adherence positively correlated with personality traits (agreeableness), good social support, and coping strategies (planning).