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Fernandes RRA, Barros BM, da Costa MR, Magliano CAS, Tura BR, Morais QCD, Santos M. Cost-Utility Model of Nirmatrelvir/Ritonavir in Brazil: Analysis of a Vaccinated Population. Value Health Reg Issues 2024; 40:74-80. [PMID: 37995417 DOI: 10.1016/j.vhri.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/13/2023] [Accepted: 09/11/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES The aim of this study is to conduct a cost-utility analysis of the use of the antiviral nirmatrelvir/ritonavir, applied to a vaccinated Brazilian population against COVID-19, from the perspective of the Brazilian Public Health System (SUS). METHODS A microsimulation model was created with individual-level data and daily cycles, with a 1-year time horizon, to compare the current scenario of standard care with a scenario in which nirmatrelvir/ritonavir is offered to the population. Adults of any age group that received ≥2 doses of the COVID-19 vaccine formed the investigated population. Direct medical costs of the outpatients and inpatients admitted to the ward or intensive care unit were included. The effectiveness of the model was measured in quality-adjusted life-years (QALYs). RESULTS In all simulations, the use of nirmatrelvir/ritonavir resulted in incremental costs per patient of US dollar (USD)245.86 and incremental effectiveness of 0.009 QALY, over a year. The incremental cost-utility ratio was USD27 220.70/QALY. The relative risk of the vaccinated population was the factor that affected the outcome most, according to the univariate sensitivity analysis. The probabilistic sensitivity analysis resulted in 100% of the simulations being more costly and effective, but that only 4% of them were below the established cost-effectiveness threshold of USD24 000.00/QALY. In the scenario considering only the population over 60 years old and immunosuppressed (of any age), the incremental cost-utility ratio was USD7589.37/QALY. CONCLUSIONS The use of nirmatrelvir/ritonavir in the treatment of COVID-19 in a vaccinated population was cost-effective only for immunosuppressed individuals and people over 60 years of age.
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Affiliation(s)
| | | | - Milene R da Costa
- National Cardiology Institute, Rio de Janeiro, Brazil; Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | - Marisa Santos
- National Cardiology Institute, Rio de Janeiro, Brazil
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De Lorenzo A, Kasal DA, Tura BR, Lamas CC, Rey HC. Acute cardiac injury in patients with COVID-19. Am J Cardiovasc Dis 2020; 10:28-33. [PMID: 32685261 PMCID: PMC7364273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Cardiac complications of COVID-19 are potentially life-threatening. The occurrence of myocardial injury in the context of COVID-19 is multifactorial and has generated increasing interest. METHODS A systematic review with a meta-analysis of the literature was performed. MEDLINE and EMBASE were searched. Two independent reviewers evaluated the selected manuscripts for the outcome "myocardial injury", defined by troponin elevation above the 99th percentile. The study heterogeneity and risk of bias were evaluated. RESULTS Eight studies, with a total of 1,229 patients, were included. The frequency of myocardial injury was 16% (95% CI: 9%-27%). The heterogeneity among the studies was high (93%). CONCLUSIONS Myocardial injury may occur in patients with COVID-19, with a frequency of 16% according to current studies. Continuous research is needed to update these findings as the pandemic evolves and to define the implications of myocardial injury in the context of this infection.
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Affiliation(s)
- Andrea De Lorenzo
- Instituto Nacional de Cardiologia, Research and Teaching Department Rio de Janeiro, RJ, Brazil
| | - Daniel Ab Kasal
- Instituto Nacional de Cardiologia, Research and Teaching Department Rio de Janeiro, RJ, Brazil
| | - Bernardo R Tura
- Instituto Nacional de Cardiologia, Research and Teaching Department Rio de Janeiro, RJ, Brazil
| | - Cristiane C Lamas
- Instituto Nacional de Cardiologia, Research and Teaching Department Rio de Janeiro, RJ, Brazil
| | - Helena Cv Rey
- Instituto Nacional de Cardiologia, Research and Teaching Department Rio de Janeiro, RJ, Brazil
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Arruda EF, Pereira BB, Thiers CA, Tura BR. Optimal testing policies for diagnosing patients with intermediary probability of disease. Artif Intell Med 2018; 97:89-97. [PMID: 30528359 DOI: 10.1016/j.artmed.2018.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 10/11/2018] [Accepted: 11/17/2018] [Indexed: 11/30/2022]
Abstract
This paper proposes a stochastic shortest path approach to find an optimal sequence of tests to confirm or discard a disease, for any prescribed optimality criterion. The idea is to select the best sequence in which to apply a series of available tests, with a view at reaching a diagnosis with minimum expenditure of resources. The proposed approach derives an optimal policy whereby the decision maker is provided with a test strategy for each a priori probability of disease, aiming to reach posterior probabilities that warrant either immediate treatment or a not-ill diagnosis.
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Affiliation(s)
- Edilson F Arruda
- Universidade Federal do Rio de Janeiro, Instituto Alberto Luiz Coimbra de Pós Graduação e Pesquisa de Engenharia, Programa de Engenharia de Produção, Caixa Postal 68507, Rio de Janeiro RJ 21941-972, Brazil.
| | - Basílio B Pereira
- Universidade Federal do Rio de Janeiro, Instituto Alberto Luiz Coimbra de Pós Graduação e Pesquisa de Engenharia, Programa de Engenharia de Produção, Caixa Postal 68507, Rio de Janeiro RJ 21941-972, Brazil; Americas Medical City, Hospital Samaritano, Departamento de Clinica Médica, Rio de Janeiro RJ, Brazil.
| | - Clarissa A Thiers
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Laranjeiras, Rio de Janeiro, RJ, 22.240-006, Brazil; Instituto do Coração Edson Saad, Rua Professor Rodolpho Paulo Rocco nº 255, 8º andar, Cidade Universitária, Ilha do Fundão, Rio de Janeiro RJ 21941-913, Brazil.
| | - Bernardo R Tura
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Laranjeiras, Rio de Janeiro, RJ, 22.240-006, Brazil.
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Bahia L, Kupfer R, Momesso D, Cabral DAP, Tschiedel B, Puñales M, Lavigne S, Façanha CFS, Forti AC, Mendes ADN, Tura BR. Health-related quality of life and utility values associated to hypoglycemia in patients with type 1 diabetes mellitus treated in the Brazilian Public Health System: a multicenter study. Diabetol Metab Syndr 2017; 9:9. [PMID: 28149328 PMCID: PMC5273819 DOI: 10.1186/s13098-017-0206-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/13/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hypoglycemia is a critical and limiting factor of a good metabolic control and can adversely affect the quality of life of diabetic patients. The aim of the study was to evaluate the health-related quality of life and calculate utilities values associated with hypoglycemia in patients with type 1 diabetes mellitus (T1DM). METHODS A multicenter, cross-sectional and observational study with T1DM patients from reference centers of the Brazilian public health system was conducted in three cities. Demographic and clinical data were collected, besides details on the frequency and severity of hypoglycemia. Health-related quality of life was assessed using EQ-5D instrument and utility values generated. RESULTS 221 patients (107 women, 114 men), aged 29.8 ± 11.6 and disease duration of 14.2 ± 9.1 years were included. Most patients (n = 214, 96.8%) reported at least one symptomatic hypoglycemia in the last three months, 68% (n = 150) reported nocturnal episodes and 34.8% (n = 77) reported severe episodes. High frequency (daily or weekly) was observed in 38.6 and 26% of those reporting nocturnal or severe hypoglycemia, respectively. The median visual analog scale was 70 [60-85] for all patients, with differences between those with and without severe hypoglycemia (70 [60-80] vs 80 [61-90]; p = 0.006) and those with high and low frequency (62.5 [50-72.25] vs 70 [60-80]; p = 0.007). The median utility values was 0.801 [0.756-1.000] for all patients, with difference between those with high and low frequency of severe episodes (0.737 [0.628-1.000] vs 0.801 [0.756-1.000]; p = 0.02). CONCLUSIONS This study shows the high frequency of hypoglycemia in a sample of T1DM patients treated in three reference centers of the Brazilian public health system and the impact of severe episodes on health-related quality of life. Utility values were generated and can be used in economic analysis for treatments that could decrease hypoglycemia and consequently improve quality of life.
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Affiliation(s)
- Luciana Bahia
- Universidade do Estado do Rio de Janeiro-UERJ, Rio de Janeiro, Brazil
- Visconde de Pirajá 547/501 Ipanema, Rio de Janeiro, 22410-003 Brazil
| | - Rosane Kupfer
- Instituto de Diabetes e Endocrinologia Luiz Capriglione-IEDE, Rio de Janeiro, Brazil
| | - Denise Momesso
- Instituto de Diabetes e Endocrinologia Luiz Capriglione-IEDE, Rio de Janeiro, Brazil
| | - Debora A. P. Cabral
- Instituto de Diabetes e Endocrinologia Luiz Capriglione-IEDE, Rio de Janeiro, Brazil
| | - Balduino Tschiedel
- Instituto da Criança com Diabetes do Rio Grande do Sul-ICDRS, Rio Grande do Sul, Brazil
| | - Marcia Puñales
- Instituto da Criança com Diabetes do Rio Grande do Sul-ICDRS, Rio Grande do Sul, Brazil
| | - Suzana Lavigne
- Instituto da Criança com Diabetes do Rio Grande do Sul-ICDRS, Rio Grande do Sul, Brazil
| | | | - Adriana C. Forti
- Centro de Diabetes e Hipertensão de Fortaleza-CIDH, Fortaleza, Brazil
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Serafim RB, Bozza FA, Soares M, do Brasil PEAA, Tura BR, Ely EW, Salluh JIF. Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review. J Crit Care 2015; 30:799-807. [PMID: 25957498 DOI: 10.1016/j.jcrc.2015.04.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of the study is to determine if pharmacologic approaches are effective in prevention and treatment of delirium in critically ill patients. MATERIALS AND METHODS We performed a systematic search to identify publications (from January 1980 to September 2014) that evaluated the pharmacologic interventions to treat or prevent delirium in intensive care unit (ICU) patients. RESULTS From 2646 citations, 15 studies on prevention (6729 patients) and 7 studies on treatment (1784 patients) were selected and analyzed. Among studies that evaluated surgical patients, the pharmacologic interventions were associated with a reduction in delirium prevalence, ICU length of stay, and duration of mechanical ventilation, but with high heterogeneity (respectively, I(2) = 81%, P = .0013; I(2) = 97%, P < .001; and I(2) = 97%). Considering treatment studies, only 1 demonstrated a significant decrease in ICU length of stay using dexmedetomidine compared to haloperidol (Relative Risk, 0.62 [1.29-0.06]; I(2) = 97%), and only 1 found a shorter time to resolution of delirium using quetiapine (1.0 [confidence interval, 0.5-3.0] vs 4.5 [confidence interval, 2.0-7.0] days; P = .001). CONCLUSION The use of antipsychotics for surgical ICU patients and dexmedetomidine for mechanically ventilated patients as a preventive strategy may reduce the prevalence of delirium in the ICU. None of the studied agents that were used for delirium treatment improved major clinical outcome, including mortality.
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Affiliation(s)
- Rodrigo B Serafim
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Hospital Copa D'Or, Rio de Janeiro, Brazil; Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Instituto de Pesquisa Clínica Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
| | | | - Bernardo R Tura
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
| | - E Wesley Ely
- Vanderbilt University School of Medicine, Nashville, TN, USA; Veteran Affairs Tennessee Valley Geriatric Research Education Clinical Center (VA-GRECC), Nashville, TN, USA.
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil.
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Costa MGSD, Santos MS, Tura BR, Goulart MC, Cintra MACT, Senna KMS. Study Of Costs Of The Cardiac And Diabetes Mellitus Patient In A Cardiology Hospital Of High Complexity. Value Health 2014; 17:A482. [PMID: 27201408 DOI: 10.1016/j.jval.2014.08.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - M S Santos
- National Institute of Cardiology, Rio de Janeiro, Brazil
| | - B R Tura
- National Institute of Cardiology, Rio de Janeiro, Brazil
| | - M C Goulart
- National Institute of Cardiology, Rio de Janeiro, Brazil
| | - M A C T Cintra
- National Institute of Cardiology, Rio de Janeiro, Brazil
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Benchimol-Barbosa PR, Tura BR, Barbosa EC, Kantharia BK. Utility of a novel risk score for prediction of ventricular tachycardia and cardiac death in chronic Chagas disease - the SEARCH-RIO study. Braz J Med Biol Res 2013; 46:974-984. [PMID: 24270912 PMCID: PMC3854332 DOI: 10.1590/1414-431x20133141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 08/06/2013] [Indexed: 11/22/2022] Open
Abstract
The SEARCH-RIO study prospectively investigated electrocardiogram (ECG)-derived variables in chronic Chagas disease (CCD) as predictors of cardiac death and new onset ventricular tachycardia (VT). Cardiac arrhythmia is a major cause of death in CCD, and electrical markers may play a significant role in risk stratification. One hundred clinically stable outpatients with CCD were enrolled in this study. They initially underwent a 12-lead resting ECG, signal-averaged ECG, and 24-h ambulatory ECG. Abnormal Q-waves, filtered QRS duration, intraventricular electrical transients (IVET), 24-h standard deviation of normal RR intervals (SDNN), and VT were assessed. Echocardiograms assessed left ventricular ejection fraction. Predictors of cardiac death and new onset VT were identified in a Cox proportional hazard model. During a mean follow-up of 95.3 months, 36 patients had adverse events: 22 new onset VT (mean±SD, 18.4±4/year) and 20 deaths (26.4±1.8/year). In multivariate analysis, only Q-wave (hazard ratio, HR=6.7; P<0.001), VT (HR=5.3; P<0.001), SDNN<100 ms (HR=4.0; P=0.006), and IVET+ (HR=3.0; P=0.04) were independent predictors of the composite endpoint of cardiac death and new onset VT. A prognostic score was developed by weighting points proportional to beta coefficients and summing-up: Q-wave=2; VT=2; SDNN<100 ms=1; IVET+ =1. Receiver operating characteristic curve analysis optimized the cutoff value at >1. In 10,000 bootstraps, the C-statistic of this novel score was non-inferior to a previously validated (Rassi) score (0.89±0.03 and 0.80±0.05, respectively; test for non-inferiority: P<0.001). In CCD, surface ECG-derived variables are predictors of cardiac death and new onset VT.
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Affiliation(s)
- P R Benchimol-Barbosa
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de JaneiroRJ, Brasil
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Benchimol-Barbosa PR, Cordovil I, Campos PS, Tura BR, Barbosa-Filho J. Abstract 199: Renin-angiotensin-aldosterone System Polymorphisms-based Risk Score In Resistant Arterial Hypertension And Adverse Cardiovascular Events: The Genhart-rio SubStudy. Circ Cardiovasc Qual Outcomes 2013. [DOI: 10.1161/circoutcomes.6.suppl_1.a199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Renin-angiotensin-aldosterone system (RAAS) determines arterial pressure fluctuation. Resistant arterial hypertension (RAH) has increased risk for end organ damage. The aim of this study was to prospectively investigate, in subjects with RAH in a South American city: 1) Adverse cardiovascular events defined as fatal and non-fatal stroke or acute myocardial infarction (AMI); and 2) the association between RAAS polymorphisms and adverse cardiovascular events.
Methods:
Two hundred and twelve subjects under investigation for RAH were admitted. All subjects received standard drug therapy aiming at achieving <140/90mmHg, and were re-evaluated four weeks later, including 24h ambulatory arterial pressure monitoring. Subjects with secondary causes of RAH were excluded. Eighty eight subjects (age 57±10 y.o, 58 women) underwent genotyping to RAAS polymorphisms: renin (G1051A), angiotensinogen (M235T), angiotensin II type 1 receptor (A1166C) and aldosterone synthase (C344T). In this group, 65% were found RAH and 35% pseudo-RAH. Subjects were actively followed at scheduled clinical visits and phone contact. During follow-up, a composite of fatal and nonfatal stroke and/or AMI was assessed. A genetic score (GEN) based on allele risk was composed for each polymorphism (zero [low risk homozygosis], 1 [heterozygosis] to 2 [high risk homozygosis]), and summed up. Cox proportional-hazard model assessed both RAH and RAAS polymorphisms hazards for adverse events. (α<0.05)
Results:
During a median follow-up of 26 years, 40 subjects reached composite endpoint (median 22 years of follow-up). Hardy-Weinberg equilibrium was observed in all polymorphism. Optimal cutoff for GEN was >3 (AUC=0.66; p=0.006). In Cox proportional-hazard model, RAH and GEN>3 were independently associated with composite endpoint (RAH Hazard ratio [HR] 2.3; 95%CI [1.1-5.0]; p=0.027; and GEN>3 HR 3.4; 95%CI [1.2-9.6]; p=0.020). No significant differences according to age, gender, hypertension time were found.
Conclusion:
RAH determines an increased risk for a composite of stroke and AMI. A RAAS stratified genetic score identifies hypertensive subjects at increased risk for adverse cardiovascular events. (
NCT01173029
)
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Affiliation(s)
| | - Ivan Cordovil
- Instituto Nacional de Cardiologia, Rio De Janeiro, Brazil
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Ribeiro Dos Santos R, Rassi S, Feitosa G, Grecco OT, Rassi A, da Cunha AB, de Carvalho VB, Guarita-Souza LC, de Oliveira W, Tura BR, Soares MBP, Campos de Carvalho AC. Cell therapy in Chagas cardiomyopathy (Chagas arm of the multicenter randomized trial of cell therapy in cardiopathies study): a multicenter randomized trial. Circulation 2012; 125:2454-61. [PMID: 22523306 DOI: 10.1161/circulationaha.111.067785] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies suggested that transplantation of autologous bone marrow-derived mononuclear cells (BMNCs) improves heart function in chronic chagasic cardiomyopathy. We report the results of the first randomized trial of BMNC therapy in chronic chagasic cardiomyopathy. METHODS AND RESULTS Patients 18 to 75 years of age with chronic chagasic cardiomyopathy, New York Heart Association class II to IV heart failure, left ventricular ejection fraction (LVEF) <35, and optimized therapy were randomized to intracoronary injection of autologous BMNCs or placebo. The primary end point was the difference in LVEF from baseline to 6 and 12 months after treatment between groups. Analysis was by intention to treat and powered to detect an absolute between-group difference of 5. Between July 2005 and October 2009, 234 patients were enrolled. Two patients abandoned the study and 49 were excluded because of protocol violation. The remaining 183 patients, 93 in the placebo group and 90 in the BMNC group, had a trimmed mean age of 52.4 years (range, 50.8-54.0 years) and LVEF of 26.1 (range, 25.1-27.1) at baseline. Median number of injected BMNCs was 2.20×10(8) (range, 1.40-3.50×10(8)). Change in LVEF did not differ significantly between treatment groups: trimmed mean change in LVEF at 6 months, 3.0 (1.3-4.8) for BMNCs and 2.5 (0.6-4.5) for placebo (P=0.519); change in LVEF at 12 months, 3.5 (1.5-5.5) for BMNCs and 3.7 (1.5-6.0) for placebo (P=0.850). Left ventricular systolic and diastolic volumes, New York Heart Association functional class, Minnesota quality-of-life questionnaire, brain natriuretic peptide concentrations, and 6-minute walking test did also not differ between groups. CONCLUSION Intracoronary injection of autologous BMNCs does not improve left ventricular function or quality of life in patients with chronic chagasic cardiomyopathy.
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Basto ST, Villela-Nogueira CA, Tura BR, Coelho HSM, Ribeiro J, Fernandes ESM, Schmal AF, Victor L, Luiz RR, Perez RM. Risk factors for long-term mortality in a large cohort of patients wait-listed for liver transplantation in Brazil. Liver Transpl 2011; 17:1013-20. [PMID: 21604358 DOI: 10.1002/lt.22344] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver donor shortage and long waiting times are observed in many liver transplant programs worldwide. The aim of this study was to evaluate the wait list in a developing country, before and after the introduction of the MELD scoring system. In addition, the MELD score ability to predict mortality in this setting was assessed. A single-center retrospective study of patients wait-listed for liver transplantation between 1997 and 2010 was undertaken. There were 1339 and 762 patients on the list in pre-MELD and MELD era, respectively. A competitive risk analysis was performed to assess age, gender, disease diagnosis, serum sodium, MELD, Child-Pugh, ABO type, and body mass index. Also, MELD score predictive ability at 3, 6, 12, and 24 months after list enrollment was evaluated. The overall mortality rates on waiting list were 31.0% and 28.1% (P = 0.16), and the median waiting times were 412 and 952 days (P < 0.001), in pre and MELD eras, respectively. The competitive risk analysis yielded the following significant P values for both eras: HCC (0.03 and <0.001), MELD (<0.001 and 0.002), sodium level (0.002 and <0.001), and Child-Pugh (0.02 and <0.001). The MELD mortality predictions at 3, 6, 12, and 24 months were similar. In conclusion, in a liver transplant program with long waiting times, the MELD system introduction did not improve mortality rate. In either pre and MELD eras, HCC diagnosis, serum sodium, Child-Pugh, and MELD were significant predictors of prognosis. Short- and long-term MELD based mortality predictions were similarly accurate. Strategies for increasing the liver donor pool should be implemented to improve mortality.
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Affiliation(s)
- Samanta T Basto
- Division of Hepatology, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Martino HF, Oliveira PS, Souza FC, Costa PC, Assunção E Silva E, Villela R, Gaze M, Weitzel LH, Oliveira A, Muccillo FB, Arvelo SNS, Sá R, Guimarães TCF, Tura BR, Campos de Carvalho AC. A safety and feasibility study of cell therapy in dilated cardiomyopathy. Braz J Med Biol Res 2010; 43:989-95. [PMID: 20878013 DOI: 10.1590/s0100-879x2010007500093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 09/01/2010] [Indexed: 02/08/2023] Open
Abstract
The aim of this study was to determine if bone marrow mononuclear cell (BMMC) transplantation is safe for moderate to severe idiopathic dilated cardiomyopathy (IDC). Clinical trials have shown that this procedure is safe and effective for ischemic patients, but little information is available regarding non-ischemic patients. Twenty-four patients with IDC, optimized therapy, age 46 ± 11.6 years, 17 males, NYHA classes II-IV, and left ventricular ejection fraction <35% were enrolled in the study. Clinical evaluation at baseline and 6 months after stem cell therapy to assess heart function included echocardiogram, magnetic resonance imaging, cardiopulmonary test, Minnesota Quality of Life Questionnaire, and NYHA classification. After cell transplantation 1 patient showed a transient increase in enzyme levels and 2 patients presented arrhythmias that were reversed within 72 h. Four patients died during follow-up, between 6 and 12 weeks after therapy. Clinical evaluation showed improvement in most patients as reflected by statistically significant decreases in Minnesota Quality of Life Questionnaire (63 ± 17.9 baseline vs 28.8 ± 16.75 at 6 months) and in class III-IV NYHA patients (18/24 baseline vs 2/20 at 6 months). Cardiopulmonary exercise tests demonstrated increased peak oxygen consumption (12.2 ± 2.4 at baseline vs 15.8 ± 7.1 mL·kg⁻¹·min⁻¹ at 6 months) and walked distance (377.2 ± 85.4 vs 444.1 ± 77.9 m at 6 months) in the 6-min walk test, which was not accompanied by increased left ventricular ejection fraction. Our findings indicate that BMMC therapy in IDC patients with severe ventricular dysfunction is feasible and that larger, randomized and placebo-controlled trials are warranted.
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Affiliation(s)
- H F Martino
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brasil
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Lessa AS, Paredes BD, Dias JV, Carvalho AB, Quintanilha LF, Takiya CM, Tura BR, Rezende GFM, Campos de Carvalho AC, Resende CMC, Goldenberg RCS. Ultrasound imaging in an experimental model of fatty liver disease and cirrhosis in rats. BMC Vet Res 2010; 6:6. [PMID: 20113491 PMCID: PMC2835689 DOI: 10.1186/1746-6148-6-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 01/29/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Domestic dogs and cats are very well known to develop chronic hepatic diseases, including hepatic lipidosis and cirrhosis. Ultrasonographic examination is extensively used to detect them. However, there are still few reports on the use of the ultrasound B-mode scan in correlation with histological findings to evaluate diffuse hepatic changes in rodents, which represent the most important animal group used in experimental models of liver diseases. The purpose of this study was to determine the reliability of ultrasound findings in the assessment of fatty liver disease and cirrhosis when compared to histological results in Wistar rats by following up a murine model of chronic hepatic disease. RESULTS Forty Wistar rats (30 treated, 10 controls) were included. Liver injury was induced by dual exposure to CCl4 and ethanol for 4, 8 and 15 weeks. Liver echogenicity, its correlation to the right renal cortex echogenicity, measurement of portal vein diameter (PVD) and the presence of ascites were evaluated and compared to histological findings of hepatic steatosis and cirrhosis. Liver echogenicity correlated to hepatic steatosis when it was greater or equal to the right renal cortex echogenicity, with a sensitivity of 90%, specificity of 100%, positive and negative predictive values of 100% and 76.9% respectively, and accuracy of 92.5%. Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. PVD was significantly increased in both steatotic and cirrhotic rats; however, the later had greater diameters. PVD cut-off point separating steatosis from cirrhosis was 2.1 mm (sensitivity of 100% and specificity of 90.5%). One third of cirrhotic rats presented with ascites. CONCLUSION The use of ultrasound imaging in the follow-up of murine diffuse liver disease models is feasible and efficient, especially when the studied parameters are used in combination. The potential implication of this study is to provide a non-invasive method that allows follow-up studies of fatty liver disease and cirrhosis of individual rats for pre-clinical drug or cell based therapies.
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Affiliation(s)
- Andréia S Lessa
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rua Prof. Rodolpho Paulo Rocco, 255, Rio de Janeiro, 21941-913, Brasil
| | - Bruno D Paredes
- Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G, Sala G2-053, Rio de Janeiro, RJ, 21941-902, Brasil
| | - Juliana V Dias
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rua Prof. Rodolpho Paulo Rocco, 255, Rio de Janeiro, 21941-913, Brasil
| | - Adriana B Carvalho
- Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G, Sala G2-053, Rio de Janeiro, RJ, 21941-902, Brasil
| | - Luiz Fernando Quintanilha
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255, Rio de Janeiro, 21941-913, Brasil
| | - Christina M Takiya
- Department of Histology and Embryology, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco F2-024, Rio de Janeiro, RJ, 21941-902, Brasil
| | - Bernardo R Tura
- National Institute of Cardiology, Rua das Laranjeiras, 374, 2° andar, Rio de Janeiro, RJ, 22240-006, Brasil
| | - Guilherme FM Rezende
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rua Prof. Rodolpho Paulo Rocco, 255, Rio de Janeiro, 21941-913, Brasil
| | - Antonio C Campos de Carvalho
- Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G, Sala G2-053, Rio de Janeiro, RJ, 21941-902, Brasil
- National Institute of Cardiology, Rua das Laranjeiras, 374, 2° andar, Rio de Janeiro, RJ, 22240-006, Brasil
| | - Célia MC Resende
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255, Rio de Janeiro, 21941-913, Brasil
| | - Regina CS Goldenberg
- Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G, Sala G2-053, Rio de Janeiro, RJ, 21941-902, Brasil
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Azevedo VMP, Albanesi Filho FM, Santos MA, Castier MB, Tura BR, Amino JG, Da Cunha MOM. Is myocardial performance index an independent echocardiographic marker of death in children with idiopathic dilated cardiomyopathy? Clin Cardiol 2008; 31:424-30. [PMID: 18781602 PMCID: PMC6652866 DOI: 10.1002/clc.20264] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 08/06/2007] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Myocardial performance index (MPI) was reported as a parameter of ventricular systolic and diastolic function, as well as a useful tool to predict the outcome in patients with ventricular dysfunction. HYPOTHESIS To compare MPI with classical echocardiographic parameters as an independent marker of death in children with idiopathic dilated cardiomyopathy (IDCM). METHODS Fifty-five children (13 deaths) underwent 104 echocardiograms from January 1996 to May 2005. Right ventricle (RV) MPI and left ventricle (LV) MPI, and 9 classical echocardiographic parameters (left atrium [LA]/body surface area [BSA], distance between mitral E point and ventricular septum, LV mass/body surface area, RV shortening fraction, LV end-systolic and end-diastolic dimensions/body surface area, LV ejection fraction, fiber circumferential shortening velocity, and mitral deceleration time) were compared. Statistical analysis was performed by chi-square, Pearson's correlation and Student t-test, Kaplan-Meier method, Cox's method, and receiver operating curve (ROC). Statistical significance was considered with alpha<0.05 and p=0.80]. RESULTS Univariate analysis showed that all studied parameters were markers of death. There was a high correlation between RVMPI and LVMPI (r=0.847]-p=0.0001]); therefore, to avoid bias, RVMPI was discharged from multivariate analysis. In the deceased group, moderate/severe mitral regurgitation was frequent (76.9%; confidence interval [CI[ 95%=46.2%- 94.9%) and it was considered in multivariate analysis. In Cox's multivariate analysis, LVMPI was the only independent marker of death (p=0.0213]). The ideal cut-off was 0.63 with 92.3% sensitivity, 66.7% specificity, and fitted ROC area=0.918]. CONCLUSIONS In children with IDCM, LVMPI is an independent marker of death.
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Rocha RM, Bittencourt MI, Correa LA, Tura BR, Albuquerque DC, Albanesi Filho FM. Influence of Spironolactone and Loop-Diuretic on Thiamin Blood Levels in Patients with Heart Failure. J Card Fail 2008. [DOI: 10.1016/j.cardfail.2008.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dohmann HFR, Silva SA, Sousa ALS, Braga AMS, Branco RVC, Haddad AF, Oliveira MA, Moreira RC, Tuche FAA, Peixoto CM, Tura BR, Borojevic R, Ribeiro JP, Nicolau JC, Nóbrega AC, Carvalho ACC. Multicenter double blind trial of autologous bone marrow mononuclear cell transplantation through intracoronary injection post acute myocardium infarction - MiHeart/AMI study. Trials 2008; 9:41. [PMID: 18598362 PMCID: PMC2486263 DOI: 10.1186/1745-6215-9-41] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 07/03/2008] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Myocardial infarction remains as a major cause of mortality worldwide and a high rate of survivors develop heart failure as a sequel, resulting in a high morbidity and elevated expenditures for health system resources. We have designed a multicenter trial to test for the efficacy of autologous bone marrow (ABM) mononuclear cell (MC) transplantation in this subgroup of patients. The main hypothesis to be tested is that treated patients will have a significantly higher ejection fraction (EF) improvement after 6 months than controls. METHODS A sample of 300 patients admitted with ST elevation acute myocardial infarction (STEMI) and left ventricle (LV) systolic dysfunction, and submitted to successful mechanical or chemical recanalization of the infarct-related coronary artery will be selected for inclusion and randomized to either treated or control group in a double blind manner. The former group will receive 100 x 106 MC suspended in saline with 5% autologous serum in the culprit vessel, while the latter will receive placebo (saline with 5% autologous serum). IMPLICATIONS Many phase I/II clinical trials using cell therapy for STEMI have been reported, demonstrating that cell transplantation is safe and may lead to better preserved LV function. Patients with high risk to develop systolic dysfunction have the potential to benefit more. Larger randomized, double blind and controlled trials to test for the efficacy of cell therapies in patients with high risk for developing heart failure are required. TRIAL REGISTER This trial is registered at the NIH registry under the number NCT00350766.
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Affiliation(s)
- Hans FR Dohmann
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Suzana A Silva
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca/FioCruz, Rio de Janeiro, Brasil
| | - André LS Sousa
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Alcione MS Braga
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Rodrigo VC Branco
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Andréa F Haddad
- Departamento de Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Mônica A Oliveira
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Rodrigo C Moreira
- Departamento de Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Fabio AA Tuche
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Cíntia M Peixoto
- Departamento de Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Bernardo R Tura
- Departamento de Pesquisa Clínica, Instituto Nacional de Cardiologia/INC, Rio de Janeiro, Brasil
| | - Radovan Borojevic
- Departamento de Embriologia e Histologia, Universidade Federal do Rio de Janeiro, Brasil
| | - Jorge P Ribeiro
- Departamento de Cardiologia, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil
| | - José C Nicolau
- Departamento de Cardiologia, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Antonio C Nóbrega
- Departamento de Pesquisa Clínica, Centro de Ensino e Pesquisa do Pró-Cardíaco/PROCEP, Rio de Janeiro, Brasil
| | - Antonio CC Carvalho
- Departamento de Pesquisa Clínica, Instituto Nacional de Cardiologia/INC, Rio de Janeiro, Brasil
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Sogayar AMC, Machado FR, Rea-Neto A, Dornas A, Grion CMC, Lobo SMA, Tura BR, Silva CLO, Cal RGR, Beer I, Michels V, Safi J, Kayath M, Silva E. A multicentre, prospective study to evaluate costs of septic patients in Brazilian intensive care units. Pharmacoeconomics 2008; 26:425-434. [PMID: 18429658 DOI: 10.2165/00019053-200826050-00006] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Sepsis has a high prevalence within intensive care units, with elevated rates of morbidity and mortality, and high costs. Data on sepsis costs are scarce in the literature, and in developing countries such as Brazil these data are largely unavailable. OBJECTIVES To assess the standard direct costs of sepsis management in Brazilian intensive care units (ICUs) and to disclose factors that could affect those costs. METHODS This multicentre observational cohort study was conducted in adult septic patients admitted to 21 mixed ICUs of private and public hospitals in Brazil from 1 October 2003 to 30 March 2004. Complete data for all patients admitted to the ICUs were obtained until their discharge or death. We collected only direct healthcare-related costs, defined as all costs related to the ICU stay. Enrolled patients were assessed daily in terms of cost-related expenditures such as hospital fees, operating room fees, gas therapy, physiotherapy, blood components transfusion, medications, renal replacement therapy, laboratory analysis and imaging. Standard unit costs (year 2006 values) were based on the Brazilian Medical Association (AMB) price index for medical procedures and the BRASINDICE price index for medications, solutions and hospital consumables. Medical resource utilization was also assessed daily using the Therapeutic Intervention Scoring System (TISS-28). Indirect costs were not included. RESULTS With a mean (standard deviation [SD]) age of 61.1 +/- 19.2 years, 524 septic patients from 21 centres were included in this study. The overall hospital mortality rate was 43.8%, the mean Acute Physiology And Chronic Health Evaluation II (APACHE II) score was 22.3 +/- 5.4, and the mean Sequential Organ Failure Assessment (SOFA) score at ICU admission was 7.5 +/- 3.9. The median total cost of sepsis was $US 9632 (interquartile range [IQR] 4583-18 387; 95% CI 8657, 10 672) per patient, while the median daily ICU cost per patient was $US 934 (IQR 735-1170; 95% CI 897, 963). The median daily ICU cost per patient was significantly higher in non-survivors than in survivors, i.e. $US 1094 (IQR 888-1341; 95% CI 1058, 1157) and $US 826 (IQR 668-982; 95% CI 786, 854), respectively (p < 0.001). For patients admitted to public and private hospitals, we found a median SOFA score at ICU admission of 7.5 and 7.1, respectively (p = 0.02), and the mortality rate was 49.1% and 36.7%, respectively (p = 0.006). Patients admitted to public and private hospitals had a similar length of stay of 10 (IQR 5-19) days versus 9 (IQR 4-16) days (p = 0.091), and the median total direct costs for public ($US 9773; IQR 4643-19 221; 95% CI 8503, 10 818) versus private ($US 9490; IQR 4305-17 034; 95% CI 7610, 11 292) hospitals did not differ significantly (p = 0.37). CONCLUSIONS The present study provides the first economic analysis of direct costs of sepsis in Brazilian ICUs and reveals that the cost of sepsis treatment is high. Despite similar ICU management, there was a significant difference regarding patient outcome between private and public hospitals. Finally, the median daily costs of non-survivor patients were higher than survivors during ICU stay.
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Moreira P, Filho PMS, Silva EA, Weksler C, Drable SG, Tura BR, Fonseca MDG, Cunha AB, Fischer RG. Effect of periodontal treatment on oral anticoagulation in patients with heart disease. Rev Port Cardiol 2007; 26:977-989. [PMID: 18232621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
UNLABELLED In recent decades, there have been several studies on the correlation between periodontal disease (PD) and cardiovascular disease, but the influence of PD on the effect of oral anticoagulant drugs has not been reported. OBJECTIVE To assess the influence of PD on oral anticoagulation in patients with heart disease. METHODS Dental treatment for patients of the Anticoagulation Clinic of the Instituto Nacional de Cardiologia Laranjeiras (INCL), receiving warfarin as a prophylactic treatment for thromboembolic events, was performed without suspending the drug and according to the INCL's "Protocol of dental treatment for patients with acquired coagulopathy". A therapeutic anticoagulation level was maintained and was assessed using the international normalized ratio (INR) on the of the patient's visit. The patient was thus protected against thromboembolic events and could undergo dental treatment, even oral surgery. Our study comprised 40 patients who underwent prospective oral assessment and were divided into two groups: Group I--20 patients with PD; and Group II--20 patients without PD. Dental treatment was performed in the two groups as follows: PD control in Group I and treatment of dental caries in Group II. The INR of the patients was assessed before each dental consultation, to guarantee hemostasis during the procedures and to monitor the anticoagulation level obtained. INR prior to the dental intervention was then compared with that after the intervention in both groups. An INR increase of > or =50% was considered significant. RESULTS In Group I, all patients showed an increase in INR after the dental treatment, which was significant in 15 (75%). In Group II, only 8 patients had increased INR, which was significant in 5 (25%) (p = 0.002). Considering the oral health of the two groups,. the extent of tissue injury in the oral cavity was not significant compared to the INR increase; however, comparison between the two groups showed significant INR increase mainly in patients with PD (p = 0.002). CONCLUSION This study showed that dental treatment in patients with any type of PD significantly increases INR.
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Affiliation(s)
- Paula Moreira
- Universidade Federal Fluminense-Rio de Janeiro, RJ, Brasil.
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Azevedo VMP, Santos MA, Albanesi Filho FM, Castier MB, Tura BR, Amino JGC. Outcome factors of idiopathic dilated cardiomyopathy in children - a long-term follow-up review. Cardiol Young 2007; 17:175-84. [PMID: 17244382 DOI: 10.1017/s1047951107000170] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND Idiopathic dilated cardiomyopathy in children has a high rate of mortality. Cardiac transplantation is the treatment of choice in those who fail to respond to therapeutics. Several studies have been carried out to determine unfavourable prognoses, and to provide an early indication for cardiac transplantation. Nevertheless, no consensus has been reached on the matter. OBJECTIVE To propose predictors of death in children with idiopathic dilated cardiomyopathy. METHODS We reviewed data extending over 22 years from 142 consecutive children with idiopathic dilated cardiomyopathy, of whom 36 died. The criteria for inclusion were the presence of congestive heart failure or cardiomegaly in a routine chest X-ray, confirmed by enlargement and hypo kinesis of the left ventricle in the echocardiogram. We included asymptomatic children in functional class I. Based on Cox's analysis of clinical and laboratory data, we sought any predictors of death. RESULTS In univariate analysis, the predictors were functional class IV at presentation (p equal to 0.0001), dyspnoea (p equal to 0.0096), and reduced pedal pulses (p equal to 0.0413). In chest X-ray, they were maximal cardiothoracic ratio (p equal to 0.0001) and pulmonary congestion (p equal to 0.0072). In the electrocardiogram, right atrium overload (p equal to 0.0118), ventricular arrhythmias (p equal to 0.0148) and heart rate (p equal to 0.027). In the echocardiogram, mitral regurgitation of grade 3 to 4 (p equal to 0.002), the left atrial to aortic ratio (p equal to 0.0001), and left ventricle ejection fraction (p equal to 0.0266). In multivariate analysis, the independent predictors were maximum cardiothoracic ratio (p equal to 0.0001), left ventricle ejection fraction (p equal to 0.0013), mitral regurgitation of grade 3 or 4 (p equal to 0.0017), functional class IV at presentation (p equal to 0.0028), and ventricular arrhythmias (p equal to 0.0253). CONCLUSION Children, who have these predictors of death should be considered for early heart transplantation when no improvement is observed in clinical treatment.
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Affiliation(s)
- Vitor Manuel P Azevedo
- Department of Research, National Institute of Cardiology Laranjeiras, Rio de Janeiro, Brazil.
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Tura BR, Martino HF, Gowdak LH, dos Santos RR, Dohmann HF, Krieger JE, Feitosa G, Vilas-Boas F, Oliveira SA, Silva SA, Bozza AZ, Borojevic R, de Carvalho ACC. Multicenter randomized trial of cell therapy in cardiopathies - MiHeart Study. Trials 2007; 8:2. [PMID: 17233910 PMCID: PMC1783861 DOI: 10.1186/1745-6215-8-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2006] [Accepted: 01/18/2007] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cardiovascular diseases are the major cause of death in the world. Current treatments have not been able to reverse this scenario, creating the need for the development of new therapies. Cell therapies have emerged as an alternative for cardiac diseases of distinct causes in experimental animal studies and more recently in clinical trials. METHOD/DESIGN We have designed clinical trials to test for the efficacy of autologous bone marrow derived mononuclear cell therapies in four different cardiopathies: acute and chronic ischemic heart disease, and Chagasic and dilated cardiomyopathy. All trials are multicenter, randomized, double-blind and placebo controlled. In each trial 300 patients will be enrolled and receive optimized therapy for their specific condition. Additionally, half of the patients will receive the autologous bone marrow cells while the other half will receive placebo (saline with 5% autologous serum). For each trial there are specific inclusion and exclusion criteria and the method for cell delivery is intramyocardial for the chronic ischemic heart disease and intracoronary for all others. Primary endpoint for all studies will be the difference in ejection fraction (determined by Simpson's rule) six and twelve months after intervention in relation to the basal ejection fraction. The main hypothesis of this study is that the patients who receive the autologous bone-marrow stem cell implant will have after a 6 month follow-up a mean increase of 5% in absolute left ventricular ejection fraction in comparison with the control group. DISCUSSION Many phase I clinical trials using cell therapy for cardiac diseases have already been performed. The few randomized studies have yielded conflicting results, rendering necessary larger well controlled trials to test for efficacy of cell therapies in cardiopathies. The trials registration numbers at the NIH registry are the following: Chagasic cardiomyopathy (NCT00349271), dilated cardiomyopathy (NCT00333827), acute myocardial infarction (NCT00350766) and Chronic Ischemic Heart Disease (NCT00362388).
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Affiliation(s)
- Bernardo R Tura
- Instituto Nacional de Cardiologia Laranjeiras, Rio de Janeiro, Brazil
| | - Helena F Martino
- Instituto Nacional de Cardiologia Laranjeiras, Rio de Janeiro, Brazil
| | - Luis H Gowdak
- Instituto do Coração da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - José E Krieger
- Instituto do Coração da Universidade de São Paulo, São Paulo, Brazil
| | - Gilson Feitosa
- Hospital Santa Izabel-Santa Casa de Misericórida da Bahia, Salvador, Brazil
| | - Fábio Vilas-Boas
- Hospital Santa Izabel-Santa Casa de Misericórida da Bahia, Salvador, Brazil
| | - Sérgio A Oliveira
- Instituto do Coração da Universidade de São Paulo, São Paulo, Brazil
| | | | - Augusto Z Bozza
- Instituto Nacional de Cardiologia Laranjeiras, Rio de Janeiro, Brazil
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Albuquerque DC, Rocha RM, Esporcatt R, Gouvea EP, Oliveira AP, Tura BR, Albanesi Fo FM. Renal Dysfunction and ST Depression Were Strong Predictors of Death in Patients with Acute Coronary Syndrome and Heart Failure. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Mattos M, Toledo D, Mattos C, de Deus F, Assad M, Tura B. Crit Care 2005; 9:P75. [DOI: 10.1186/cc3619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Pereira K, Viegas M, Gomes G, Gomes N, Potch A, Tura B, Mendonca-filho H. Crit Care 2005; 9:P4. [DOI: 10.1186/cc3548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rocha RM, Albuquerque DC, Gouvea EP, Esporcatte R, Almeida GLG, Tura BR, Santos VM, Amaral BV, Albanesi Filho FM. Differential expression of tumoral necrosis factor α and interleukin 6 in patients with severe heart failure. J Card Fail 2004. [DOI: 10.1016/j.cardfail.2004.06.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Azevedo VMP, Albanesi Filho FM, Santos MA, Castier MB, Tura BR. [The impact of malnutrition on idiopathic dilated cardiomyopathy in children]. J Pediatr (Rio J) 2004; 80:211-6. [PMID: 15192764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE To analyze the prognostic value of malnutrition in children with idiopathic dilated cardiomyopathy. METHODS This is a retrospective study of 165 patients with idiopathic dilated cardiomyopathy, diagnosed from September 1979 to March 2003. It analyzed the following variables: gender, age, previous viral illness in the preceding 3 months, functional class according to the New York Heart Association (NYHA), evaluation of nutritional status (normal vs. malnutrition), percentile and standard deviation (z index) of weight. Weight was measured 744 times during the first 72 months, 93 during the first month. Statistical analysis was performed by Chi Squared, Student t test and analysis of variance for repeated measures (ANOVA). Ninety-five percent confidence intervals (CI95) and odds ratios (OR) were calculated. An alpha value of 0.05 and beta of 0.80 were used. RESULTS Mean age at presentation was 2.2+/-3.2 years with higher incidence in those younger than 2 years (75.8%-CI95 = 68.5% to 82.1%) (p < 0.0001). NYHA classes III and IV were observed in 81.2% (CI95 = 74.4% to 86.9%) (p < 0.0001) and all 40 deaths were this group (p = 0.0008). At presentation, myocarditis occurred in 39.4% (CI95 = 31.9% to 47.3%) (p = 0.0001) and a high level of association between myocarditis and previous viral illness was observed (p = 0.0005) (OR = 3.15-CI95 = 1.55 to 6.44). Malnutrition at presentation did not influence death (p = 0.10), however progressive malnutrition was a marker for death (p = 0.02) (OR = 3.21-CI95 = 1.04 to 9.95). No significant differences weight percentiles (p = 0.15) or in z scores (p = 0.14) were observed. Observed mean weight percentiles (34.9+/-32.6 vs. 8.6+/-16.0) (p < 0.0001) and z scores (-0.62+/-1.43 vs. -2.02+/-1.12) (p < 0.0001) during the study period were greater among survivors. ANOVA demonstrated significant differences in weight percentile progression (p = 0.0417) and z scores (p = 0.0005) from the first month onwards. CONCLUSION The evaluation of nutritional status is easy to perform, it does not imply additional costs and should become routine for children with chronic heart failure.
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Affiliation(s)
- Vitor M P Azevedo
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil.
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Azevedo VMP, Albanesi Filho FM, Santos MA, Castier MB, Tura BR. [Prognostic value of chest roentgenograms in children with idiopathic dilated cardiomyopathy]. J Pediatr (Rio J) 2004; 80:71-6. [PMID: 14978553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE To analyze the prognostic value of cardiomegaly, pulmonary congestion and cardiothoracic ratio as indicators of death and survival in children with idiopathic dilated cardiomyopathy. METHODS We carried out a retrospective review of 152 patients with idiopathic dilated cardiomyopathy diagnosed between September 1979 and March 2003. In the first 72 months, 722 exams were performed (100 in the first 15 days). STATISTICAL ANALYSIS chi-square, Student's t test, ANOVA and Kaplan-Meier curves. Alpha = 0.05; beta = 0.80. RESULTS The mean age at presentation was 2.2+/-3.2 years. Idiopathic dilated cardiomyopathy incidence was higher in children younger than 2 years (76.3% - 95% CI = 68.7% to 82.8%) (p < 0.0001). Sex (p = 0.07) and color (p = 0.11) were not significant and mortality was not influenced by age (p = 0.73), sex (p = 0.78) or color (p = 0.20). Most patients were severely ill (84.2% - 95% CI = 77.4% to 89.6%; functional class III and IV; p < 0.0001). All 43 deaths occurred in this group (p = 0.0008). Cardiomegaly at presentation was observed in 94.1% (95% CI = 89.1% to 97.2%) (p < 0.0001), and pulmonary congestion in 75.6% (95% CI = 68.0% to 82.2%) (p < 0.0001). Pulmonary congestion and cardiomegaly were more frequent in functional class III/IV patients (RC = 8.03 - 95% CI = 2.85% to 23.1%) (p < 0.0001). Pulmonary congestion was a marker of death (RC = 3.16 - 95% CI = 1.06% to 10.07) (p = 0.0222), but not cardiomegaly (p = 0.1185). Survival was influenced by both cardiomegaly (p = 0.0189) and pulmonary congestion (p = 0.0050). Mean and maximum cardiothoracic ratio were higher in the death group (0.749+/-0.053 vs. 0.662+/-0.080) (p < 0.0001) and (0.716+/-0.059 vs. 0.620+/-0.085) (p < 0.0001). ANOVA revealed a progressive decrease in cardiothoracic ratio in the survival group (p < 0.0001). CONCLUSIONS In children with idiopathic dilated cardiomyopathy, the presence of pulmonary congestion at presentation and increased cardiothoracic ratio are associated with poor survival.
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Affiliation(s)
- Vitor M P Azevedo
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil.
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Tura B, Gomes R, Pontes A, Vegni R, Weksler A, Silva Filho D, Campos L, Fernandes M, Nogueira P, Dohmann H. Crit Care 2003; 7:P95. [DOI: 10.1186/cc2291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Levy RA, Vilela VS, Cataldo MJ, Ramos RC, Duarte JL, Tura BR, Albuquerque EM, Jesús NR. Hydroxychloroquine (HCQ) in lupus pregnancy: double-blind and placebo-controlled study. Lupus 2002; 10:401-4. [PMID: 11434574 DOI: 10.1191/096120301678646137] [Citation(s) in RCA: 288] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We conducted a randomized, controlled study to assess the need for hydroxychloroquine (HCQ) during lupus pregnancy and to assess safety. Twenty consecutive pregnant patients with similar characteristics were enrolled. The HCQ group included eight patients with systemic lupus erythematosus (SLE) and two with discoid lupus erythematosus (DLE). The placebo (PL) group included nine patients with SLE and one with DLE. The HCQ group had no flare-ups. SLEPDAI scores were similar at study entry, and at conclusion the placebo group had significantly higher scores. One patient had improvement of skin lesions and another of arthritis, allowing a decrease of prednisone dose. There were no retinal effects. Three patients in the PL group flared up, two with skin rashes, one also with arthritis and uveitis, and one (previously in remission on HCQ) with hemolytic anemia, polyserositis and anti-dsDNA antibody. Toxemia was diagnosed in only three patients in the PL group (one fetal death). Comparing prednisone dosage change, we noted a decrease in the HCQ and an increase in the PL group. Delivery age and Apgar scores were higher in the HCQ group. Neonatal examination did not reveal congenital abnormalities, nor did a neuro-ophthalmological and auditory evaluation at 1.5-3 y of age. In spite of the small number of patients studied, we noted beneficial effects of HCQ during lupus pregnancy, as measured by SLEPDAI and decrease in prednisone dose with no detriment to patients' health.
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Affiliation(s)
- R A Levy
- Department of Rheumatology, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
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