Correlation and validity of imputed PaO2/FiO2 and SpO2/FiO2 in patients with invasive mechanical ventilation at 2600m above sea level

OBJECTIVE

To establish the correlation and validity between PaO2/FiO2 obtained on arterial gases versus noninvasive methods (linear, nonlinear, logarithmic imputation of PaO2/FiO2 and SpO2/FiO2) in patients under mechanical ventilation living at high altitude.

DESIGN

Ambispective descriptive multicenter cohort study.

SETTING

Two intensive care units (ICU) from Colombia at 2600m a.s.l.

PATIENTS OR PARTICIPANTS

Consecutive critically ill patients older than 18 years with at least 24h of mechanical ventilation were included from June 2016 to June 2019.

INTERVENTIONS

None.

VARIABLES

Variables analyzed were demographic, physiological messures, laboratory findings, oxygenation index and clinical condition. Nonlinear, linear and logarithmic imputation formulas were used to calculate PaO2 from SpO2, and at the same time the SpO2/FiO2 by severe hypoxemia diagnosis. The intraclass correlation coefficient, area under the ROC curve, sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were calculated.

RESULTS

The correlation between PaO2/FiO2 obtained from arterial gases, PaO2/FiO2 derived from one of the proposed methods (linear, non-linear, and logarithmic formula), and SpO2/FiO2 measured by the intraclass correlation coefficient was high (greater than 0.77, p<0.001). The different imputation methods and SpO2/FiO2 have a similar diagnostic performance in patients with severe hypoxemia (PaO2/FiO2 <150). PaO2/FiO2 linear imputation AUC ROC 0,84 (IC 0.81-0.87, p<0.001), PaO2/FiO2 logarithmic imputation AUC ROC 0.84 (IC 0.80-0.87, p<0.001), PaO2/FiO2 non-linear imputation AUC ROC 0.82 (IC 0.79-0.85, p<0.001), SpO2/FiO2 oximetry AUC ROC 0.84 (IC 0.81-0.87, p<0.001).

CONCLUSIONS

At high altitude, the SaO2/FiO2 ratio and the imputed PaO2/FiO2 ratio have similar diagnostic performance in patients with severe hypoxemia ventilated by various pathological conditions.

Correlation and validity of imputed PaO2/FiO2 and SpO2/FiO2 in patients with invasive mechanical ventilation at 2600m above sea level

OBJECTIVE

To establish the correlation and validity between PaO2/FiO2 obtained on arterial gases versus noninvasive methods (linear, nonlinear, logarithmic imputation of PaO2/FiO2 and SpO2/FiO2) in patients under mechanical ventilation living at high altitude.

DESIGN

Ambispective descriptive multicenter cohort study.

SETTING

Two intensive care units (ICU) from Colombia at 2600m a.s.l.

PATIENTS OR PARTICIPANTS

Consecutive critically ill patients older than 18 years with at least 24h of mechanical ventilation were included from June 2016 to June 2019.

INTERVENTIONS

None.

VARIABLES

Variables analyzed were demographic, physiological messures, laboratory findings, oxygenation index and clinical condition. Nonlinear, linear and logarithmic imputation formulas were used to calculate PaO2 from SpO2, and at the same time the SpO2/FiO2 by severe hypoxemia diagnosis. The intraclass correlation coefficient, area under the ROC curve, sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were calculated.

RESULTS

The correlation between PaO2/FiO2 obtained from arterial gases, PaO2/FiO2 derived from one of the proposed methods (linear, non-linear, and logarithmic formula), and SpO2/FiO2 measured by the intraclass correlation coefficient was high (greater than 0.77, p<0.001). The different imputation methods and SpO2/FiO2 have a similar diagnostic performance in patients with severe hypoxemia (PaO2/FiO2 <150). PaO2/FiO2 linear imputation AUC ROC 0,84 (IC 0.81-0.87, p<0.001), PaO2/FiO2 logarithmic imputation AUC ROC 0.84 (IC 0.80-0.87, p<0.001), PaO2/FiO2 non-linear imputation AUC ROC 0.82 (IC 0.79-0.85, p<0.001), SpO2/FiO2 oximetry AUC ROC 0.84 (IC 0.81-0.87, p<0.001).

CONCLUSIONS

At high altitude, the SaO2/FiO2 ratio and the imputed PaO2/FiO2 ratio have similar diagnostic performance in patients with severe hypoxemia ventilated by various pathological conditions.

Preoperative color Doppler ultrasound parameters for surgical decision-making in upper arm arteriovenous fistula maturation

OBJECTIVE

Current scientific evidence is insufficient to determine the best vascular access for each patient. It is an unmet clinical need because vascular access dysfunction accounts for 20% to 30% of hospital admissions. Our aim was to evaluate preoperative color flow Doppler ultrasound (CDUS)-derived parameters (vein diameter and brachial artery flow and diameter) and their effect interaction with comorbidities as predictors of brachiocephalic (BC) and brachiobasilic (BB) arteriovenous fistula (AVF) maturation.

METHODS

A prospective analysis was performed of patients who underwent BC and BB AVF as primary definitive vascular access between January 2016 and May 2017. Variables included patients' demographics, comorbidities, medication, preoperative blood pressure, and CDUS-derived parameters. Outcomes were patency 48 hours after surgery and fistula maturation at 6 and 12 weeks. Nonparametric descriptive and univariate statistics were used. Logistic regression models and receiver operating characteristic curve analyses were performed.

RESULTS

There were 132 patients (91 with BC AVF and 41 with BB AVF) included. The 48-hour patency was 91.7%. AVF maturation at 6 weeks was observed in 71.3%, and AVF maturation at 12 weeks was observed in 66.3%. There were no associations in univariate and multivariate logistic regression analysis between AVF maturation and comorbidities. Systolic blood pressure was an independent predictor of 48-hour patency with an optimized cutoff of 154 mm Hg (area under the curve, 0.73; P = .013; Youden index, 0.40). Vein diameter with tourniquet was an independent predictor of AVF maturation at 6 and 12 weeks with an optimized cutoff of 3.9 mm (area under the curve, 0.74; P < .001; Youden index, 0.38).

CONCLUSIONS

AVF maturation was independent of comorbidities. Systolic blood pressure ≥154 mm Hg and vein diameter with tourniquet ≥3.9 mm were the associated conditions that better predicted BC and BB AVF maturation. There were no effect interactions between CDUS-derived parameters and associated comorbidities.

A Prognostic Model for the Outcome of Nobel Biocare Dental Implants with Peri-Implant Disease after One Year

Background: This investigation, based on a 1-year retrospective cohort study, aimed to estimate and validate a prognostic model for ailing and failing implants due to peri-implant disease. Methods: A total of 240 patients (male: 97; female: 143; average age of 57.3 years) with at least one ailing or failing implant were included: 120 patients for model derivation and 120 patients for model validation. The primary outcome measure was the implant status: success, defined as the arrest of the disease, or failure defined as implant extraction, prevalence or re-incidence of peri-implant disease). Potential prognostic risk indicators were collected at the baseline evaluation. The relative risk (RR) was estimated for the predictors through logistic regression and the c-statistic (95% confidence interval) was calculated for both derivation and validation sets. The significance level was set at 5%. Results: The risk model retrieved the prognostic factors age (RR = 1.04), history of Periodontitis (RR = 3.13), severe peri-implant disease status (RR = 3.26), implant length (RR = 3.52), early disease development (RR = 3.99), with good discrimination in both the derivation set (0.763 [0.679; 0.847]) and validation set (0.709 [0.616; 0.803]). Conclusions: A prognostic risk model for estimating the outcome of implants with peri-implant disease is available, with a good performance considering the c-statistic evaluation.

Combined effects of increased temperature and levonorgestrel exposure on zebrafish female liver, using stereology and immunohistochemistry against catalase, CYP1A, HSP90 and vitellogenin

Climate change and pharmaceuticals contamination constitute two of the most relevant stressors on the aquatic ecosystems, however, there is a huge lack of information regarding the interactive effects of both stressors. For that, a mesocosm experiment was implemented where adult zebrafish were exposed to combined temperature and the progestin levonorgestrel (LNG) for 21 days. Considering that the liver is one of the organs where there is a greater metabolization and accumulation of toxicants, the main objective of this work was to assess the effects of both stressors on the female zebrafish hepatocytes morphology and functioning, through stereological and immunohistochemical techniques. Our results revealed an increase of coefficient of variation of the number distribution of hepatocytes volume (CV_N(υ)) for individuals exposed to LNG, which denotes an increase of the hepatocytes size variability and is suggestive of functional impacts. This was corroborated by the signs of increased glycogen content with the exposure to increased LNG concentrations and temperature, indicating modified hepatocyte glycogen metabolism. Such disturbances can be considered indicators that the fish had to deal with impacts caused by the stress factors. Regarding the immunoreactivity, from the four proteins selected (catalase, CYP1A, HSP90 and Vtg), just in two of them (catalase and Vtg) were observed some responses to both stressors. For catalase there was a hormetic response, in which exposure to lower LNG concentrations caused a significant higher positive immunostaining than under higher LNG concentrations. While, for Vtg, significant effects of temperature and LNG existed, in which a decline in Vtg immunostaining was observed with exposure to higher temperature and lower LNG concentrations. These results should be seen as a warning sign about fine impacts of multiple stressors, such as temperature and progestogens, on the structure and functioning of zebrafish liver and potentially in other aquatic organisms, and on their health implications.

Genotoxic effects of combined multiple stressors on Gammarus locusta haemocytes: Interactions between temperature, pCO2 and the synthetic progestin levonorgestrel

Climate change and pharmaceutical contamination are two priority research topics due to their impacts in the aquatic ecosystems and in the food chain structure. In the bottom of many food chains are the invertebrates, like the amphipods, which are important environmental and ecotoxicological models. In this study, we combined the increase of temperature [ambient and warming temperature], pCO₂ [normocapnia and hypercapnia] and the synthetic progestin levonorgestrel (LNG) [environmentally relevant concentration (10 ng L^-1) and 100-fold higher (1000 ng L^-1)] to evaluate the genotoxic effects on the amphipod Gammarus locusta haemocytes, using the comet assay technique. Additionally, the study examined protective/potentiating effects of the three tested factors against hydrogen peroxide (H₂O₂)-induced DNA damage in haemocytes after ex vivo exposure. Our data revealed no significant effects of any of the three stressors on DNA damage of G. locusta haemocytes or protection against H₂O₂-induced DNA damage after twenty-one days exposure. Only a significant effect of the solvent was visible, since it was able to induce higher DNA damage (i.e. strand breaks) on exposed individuals. On the other hand, LNG exposure seemed to induce a slight increase of DNA damage after H₂O₂ exposure. Our findings suggest that more short-term studies to conclude about the genotoxicity and/or protective effects of the stress factors in G. locusta should be made, attending to the fast turnover rate of repairing cells that could have masked impacts seen only after the end of the experiment.

Histopathological Evaluation of Combined Impacts of the Synthetic Progestin Levonorgestrel and Temperature on the Female Zebrafish Maturation Using a Semi-quantitative Grading Analysis-Is it Enough?

Pharmaceuticals contamination (e.g., synthetic progestins), and global climate change, represent two of the most stressful factors affecting aquatic species. To our knowledge, there is huge gap of data regarding the combined effects of both stressors on vertebrates' reproduction. Thus, it is crucial to implement rapid screenings of measurable histopathological alterations in fish gonads. For that, we propose: (1) an evaluation of the combined effects of progestin (levonorgestrel) and temperature on maturation of zebrafish female gonads, using a semi-quantitative method (i.e., grading) and (2) testing the robustness of the grading analysis comparatively to a quantitative method (i.e., stereology). Grading analysis showed a decrease on maturation stage of ovaries exposed to both stressors. Although grading is less robust than stereological analysis, it is recommended for a preliminary approach, since it gives a correct idea on trends and it is fast and cost-effective. For a detailed histological assessment, we recommend a stereological study.

Endotoxin-Induced Intravascular Coagulation in Rabbits:Effect of Tissue Plasminogen Activator vs Urokinase on PAI Generation, Fibrin Deposits and Mortality

We have evaluated the effect of plasminogen activators (t-PA and urokinase) on an experimental model of disseminated intravascular coagulation (DIC) in rabbits by injection of 20 μg/kg/h of E. coli lipopolysaccharide during 6 h t-PA (0.2 mg/kg and 0.7 mg/kg), urokinase (3000 U/kg/h) and saline (control) were given simultaneously with endotoxin. Results indicated that urokinase and low dose of t-PA significantly reduced the increase of plasminogen activator inhibitor (PAI) activity observed 2 h after endotoxin (p <0.001). High t-PA dose also diminished the PAI levels at 6 h (p <0.0001). A significant reduction of fibrin deposits in kidneys was observed in both t-PA treated groups as compared with findings in the group of rabbits infused with saline solution (p <0.005), whereas urokinase had no significant effect on the extent of fibrin deposition. Finally, the mortality rate in the control group (70%) was reduced to 50% in rabbits receiving high doses of t-PA. In conclusion, treatment with t-PA resulted in reduced PAI generation, fibrin deposits and mortality in endotoxin-treated rabbits

Postoperative Changes in the Plasmatic Levels of Tissue-Type Plasminogen Activator and Its Fast-Acting Inhibitor - Relationship to Deep Vein Thrombosis and Influence of Prophylaxis

Fibrinogen, euglobulin lysis time (ELT), tissue-type plasminogen activator (t-PA) antigen, plasminogen activator inhibitor activity (PA-inhibitor) and α2-antiplasmin (a2-AP) were measured pre- and postoperatively in 60 patients undergoing total hip replacement. Reduced fibrinolytic activity as assessed by the prolongation of euglobulin lysis time, decrease of t-PA and increase of PA-inhibitor and β2-AP could be demonstrated. These changes did not correlate with the postoperative deep vein thrombosis (DVT) diagnosed with the 125I-fibrinogen test. However, preoperative PA-inhibitor activity was significantly higher in patients with postoperative DVT (p <0.01). The prophylactic treatment with aspirin (20 patients) and with heparin plus dihy-droergotamine (20 patients) induced significant changes in some of those parameters.

This study shows that the decrease of t-PA and the increase of PA-inhibitor may contribute to the reduced postoperative fibrinolytic activity after total hip replacement. PA-inhibitor level might be a useful marker in evaluating the risk of developing DVT in patients undergoing total hip replacement.

Prophylaxis of Thromboembolic Disease and Platelet-Related Changes Following Total Hip Replacement: A Comparative Study of Aspirin and Heparin-Dihydroergotamine

A prospective study involving 120 consecutive patients undergoing total hip replacement was performed to compare the effectiveness of aspirin (high and low dose) or a combination of heparin plus dihydroergotamine (heparin-DHE) in preventing isotopic and phlebographic deep vein thrombosis (DVT), and to evaluate their effect on postoperative platelet changes. Phlebographic DVT was demonstrated in 9 cases (30%) in control group, in 1 (3.3%) in aspirin (high-dose) group (p <0.01), in 1 (3.3%) in aspirin (low-dose) group (p <0.01) and in 5 (16.6%) in heparin-DHE group (p = NS). Aspirin was able to reduce the postoperative increase in circulating platelet aggregates, platelet factor 4 and p-thromboglobulin observed in control group. This study shows that aspirin is effective in the prevention of DVT for patients undergoing total hip replacement. Small aspirin dose (250 mg/day) represents an effective form of prophylaxis in these patients.

Effect of DDAVP on Endotoxin-Induced Intravascular Coagulation in Rabbits

We have evaluated the effect of l-Deamino-8D-arginine vasopressin (DDAVP) on an experimental model of intravascular coagulation (DIC) induced in rabbits by injection of 20 µg kg–1 h–1 during 6 h of E. coli lipopolysaccharide. DDAVP significantly ameliorated the platelet drop and fibrinogen decrease (p <0.01) induced by endotoxin in control animals. A significant reduction in factor XII consumption (p <0.01) and a decrease in the generation of endotoxin induced PAI-1 activity in rabbits circulation was also observed (p <0.005). Moreover, fibrin deposition in kidneys of rabbits receiving DDAVP was significantly reduced as compared to control animals. Finally, the mortality rate in the control group was significantly higher than in DDAVP-treated rabbits (p <0.01). The hemostatic changes induced by DDAVP correlated with lower fibrin deposition and reduction in mortality rates.

Fibrinolytic Potential and Antiphospholipid Antibodies in Systemic Lupus Erythematosus and Other Connective Tissue Disorders

We studied the fibrinolytic response before and after venous occlusion (VO) in 30 patients with systemic lupus erythematosus (SLE), 25 with rheumatoid arthritis (RA) and 25 with different connective tissue disorders. Results were compared in patients with and without antiphospholipid antibodies (APA) and a history of either thrombosis or abortions. Before occlusion plasma levels of tissue-type plasminogen activator (t-PA) antigen and its inhibitor (PAI-1) were significantly higher in the patient group (p <0.001). After occlusion, a low fibrinolytic activity on fibrin plates (p <0.005) was observed in the same group. t-PA capacity and t-PA release were similar in relation to controls. The plasma PAI-1 activity was significantly elevated in each group of patients (p <0.005) as compared to the control group. No significant differences with respect to t-PA and PAI-1 were observed in patients as to the presence or absence of thrombosis. There was also no correlation between the fibrinolytic changes and the presence of APA. It is concluded that an impairment of the fibrinolytic system, mainly related to increased PAI-1 levels, is present in most patients with connective tissue disorders, although these changes did not correlate with the presence of APA or the incidence of thrombosis.

Plasminogen Activator Inhibitor Activity in Bacterial Infection

It has been experimentally shown that endotoxin induces a marked increase in the levels of a fast-acting inhibitor of plasminogen activator (PAI). The plasma PAI activity and tissuetype plasminogen activator (t-PA) concentrations were measured in 61 patients with human septicaemia and results were compared with those observed in healthy controls. There was a markedly significant increase of PAI in plasma and platelet extracts of patients with septicaemia as compared to controls (p <0.0001). No correlation between PAI and endotoxin concentration was observed. Fibrin autography of plasma samples confirmed that activator inhibition was associated with the formation of an enzyme-inhibitor complex. t-PA activity was similar in patients and controls, whereas t-PA Ag showed a significant increase in patients (p <0.0001). A significant inverse correlation between t-PA activity and PAI was observed (p <0.05). PAI activity was higher in patients with positive blood cultures (p <0.0001) and gram-negative septicaemia (p <0.0001). There was also a significant increase of PAI levels in patients with disseminated intravascular coagulation (DIC) as compared with patients without DIC (p <0.001). We conclude that there is a marked increase of PAI in patients with sepsis. Increased PAI activity may contribute to the pathogenesis of DIC associated with septicaemia.

Interactive effects of increased temperature, pCO2 and the synthetic progestin levonorgestrel on the fitness and breeding of the amphipod Gammarus locusta

Given the lack of knowledge regarding climate change-chemical exposure interactions, it is vital to evaluate how these two drivers jointly impact aquatic species. Thus, for the first time, we aimed at investigating the combined effects of increased temperature, pCO₂ and the synthetic progestin levonorgestrel on survival, growth, consumption rate and reproduction of the amphipod Gammarus locusta. For that, a full factorial design manipulating temperature [ambient temperature and warming (+4 °C)], pCO₂ [normocapnia and hypercapnia (Δ pH 0.5 units)] and the progestin levonorgestrel (LNG: L1 - 10 ngLL^-1 and L2 - 1000 ngLL^-1, control - no progestin and solvent control - vehicle ethanol (0.01%)) was implemented for 21 days. G. locusta was strongly negatively affected by warming, experiencing higher mortality rates (50-80%) than in any other treatments. Instead, growth rates were significantly affected by interactions of LNG with temperature and pCO₂. It was observed, in the short-term (7d) that under ambient temperature (18 °C) and hypercapnic conditions (pH 7.6), the LNG presence promoted the amphipod's growth, while in the medium-term (21d) this response was not observed. Relative consumption rates (RCRs), during the first week were higher than in the third week. Furthermore, in the first week, RCRs were negatively affected by higher temperature while in the third week, RCRs were negatively affected by acidification. Furthermore, it was observed a negative effect of higher temperature and acidification on G. locusta fecundity, contrarily to LNG. Concluding, the impact of increased temperature and pCO₂ was clearly more adverse for the species than exposure to the synthetic progestin, however, some interactions between the progestin and the climate factors were observed. Thus, in a future scenario of global change, the presence of LNG (and other progestins alike) may modulate to a certain level the effects of climate drivers (and vice-versa) on the gammarids fitness and reproduction.

Preoperative Identification of Patients at High Risk of Deep Venous Thrombosis Despite Prophylaxis in Total Hip Replacement

Clinical and laboratory variables were measured on the day before operation in 111 patients who underwent total hip replacement prophylactically treated with acetylsalicilic acid or heparin-dihydroergotamine. Postoperative deep vein thrombosis (DVT) was deteced in 16 patients by ascending venography. Stepwise logistic discriminant analysis was used to identify DVT predicting factors. Three such factors, fibrinogen degradation products (FDP), plasminogen activator inhibitor (PA-inhibitor) and tissue type plasminogen activator (t-PA), were found to be significantly associated with DVT and were used to construct a predictive index. The predictive index, I = —2.09 + 0.46 (FDP) +1.39 (PA-inhibitor)-0.24 (t-PA), was 100% sensitive and 95% specific in the prediction of DVT. This index would allow for identification of those patients in whom routine prophylaxis would be sufficient and for selecting those in whom more effective prophylactic regimens would be necessary.

Comparison of Three Criteria for Interpretation of Electrocardiogram in the Military

BACKGROUND

Screening of competitive athletes and other individuals exposed to regular and intense physical exercise, such as military personnel, can lead to an early and preclinical identification of cardiac conditions associated with a higher risk for sudden cardiac death. The electrocardiogram (ECG) has been recommended for the precompetitive screening, but its interpretation remains controversial. The aim of this study was to compare three different standardized criteria for interpretation of athletes' ECG applied in military.

METHODS

Prospective study of 1,380 consecutive healthy military, 249 (18%) also involved in competitive sport, screened with clinical history, physical examination, and ECG. The ECG was interpreted according to the European Society of Cardiology (ESC) recommendations, the Seattle Criteria (SC), and the Refined Criteria (RC).

FINDINGS

Independently of the criteria used, the majority of the individuals included had ECG changes, mainly physiological: ESC 55.1%, SC 63.6%, and RC 64.4%. The rate of pathological ECGs was significantly higher with the ESC criteria when compared to SC and RC (ESC 14.8%, SC 5.0% and RC 4.5%; p < 0.001). A significant cardiac abnormality was diagnosed with additional investigations in 4 patients (Brugada syndrome Type 1, mitral valve prolapse, bicuspid aortic valve, and Wolff-Parkinson-White pattern).

DISCUSSION

Electrical cardiac adaptations are frequent in military personnel, similar to competitive athletes. Some ECG changes, previously considered pathological, could in fact correspond to physiological adaptations. The refinement of the ECG interpretation in this athletic population seems to reduce the rate of false-positive cases. This may have a favorable socioeconomic impact, especially by reducing the health cost burden and number of disability days.

Warming modulates the effects of the endocrine disruptor progestin levonorgestrel on the zebrafish fitness, ovary maturation kinetics and reproduction success

Interactive effects between multiple stressors, namely climate drivers (e.g., temperature) and chemical pollution (e.g., endocrine disruptors) are poorly studied. Here, it was for the first time evaluated the combinatory effects of temperature and a synthetic progestin, levonorgestrel (LNG), on the fitness and reproductive-related endpoints of zebrafish (Danio rerio). A multi-factorial design was implemented by manipulating both temperature [setting as baseline an ambient temperature of 27 °C, against warming (+3 °C)] and LNG levels (10 ngL^-1 and 1000 ngL^-1). Groups of males and females were exposed sub-acutely, for 21-days. Increased temperature caused an overall decrease in the females' gonadosomatic index (GSI), during the pre-reproduction phase, LNG did not affect GSI. In addition, fecundity (number of ovulated eggs) was negatively affected by both temperature and LNG, being the effect of the latter more intense. Fish exposed to the highest LNG concentration (at both temperatures) did not reproduce, but also in those exposed to the lowest dose of progestin at a higher temperature, a complete reproductive failure occurred. These results reflect what was observed in the stereological analysis of the ovary maturation stages prior to reproduction. Accordingly, the higher the LNG concentration, the lower the degree of maturation of the ovary. This was exacerbated by the higher temperature. As to embryonated eggs, they hatched significantly faster at higher temperatures, but exposure to 10 ngL^-1 of LNG (at 27 °C) reduced significantly the hatching rate, comparing to control. Further, the recrudescence of the ovary 48 h after spawning seems to be not affected by both stressors. Our data suggest that in a future scenario of global warming and synthetic hormones exposure, the reproduction of fish species, such as the zebrafish, can be endangered, which can put at risk their success, and consequently affect the structure and functioning of associated aquatic ecosystems.

Impact of Introducing Full-time In-house Coordinators on Referral and Organ Donation Rates in Rio de Janeiro Public Hospitals: A Health Care Innovation Practice

Establishing an organization to promote organ donation and a good organ procurement team assure quality and improve performance on organ donation rates. Brazil's organ procurement structure is based on 2 models disseminated worldwide: the "Spanish model," based on in-house coordinators, and the "American organ procurement organization (OPO) model," with extra-hospital coordinators. In 2006, Brazil's Federal Government had formally introduced the in-house coordination model for every hospital equipped with a mechanical ventilator bed. In January 2012, the Rio de Janeiro State OPO, Programa Estadual de Transplantes, introduced an innovation in the organization of the in-house coordination model in 4 selected public hospitals with high organ donation potential. It consisted in launching full-time in-house coordination teams, with ≥1 physician and 2 nurses per hospital fully dedicated to organ procurement. The objectives were to observe the impact of this innovation in referral and organ donor conversion rates and to analyze the importance of middle managers in health care innovation implementation. Comparing the year before implementation (2011) and the year of 2014 showed that this innovation led to an overall increase in referrals-from 131 to 305 per year (+132%) and conversion rates-from 20% to 42% per year-resulting in an increase in number of donors from 26 to 128 per year (+390%). Despite wide variations among hospitals in the outcomes, our results seem very encouraging and express a positive impact of this model, suggesting that dissemination to other hospitals may increase the number of donors and transplants in our region.

Attributable fractions, modifiable risk factors and risk stratification using a risk score for peri-implant pathology

PURPOSE

This study aimed to estimate the impact of risk factors for peri-implant pathology, to identify potentially modifiable factors, and to evaluate the accuracy of the risk algorithm, risk scores and risk stratification.

METHODS

This retrospective case-control study with 1275 patients (255 cases; 1020 controls) retrieved a model according to the predictors: history of Periodontitis, bacterial plaque, bleeding, bone level, lack of passive fit or non-optimal screw joint, metal-ceramic restoration, proximity to other implants/teeth, and smoking habits. Outcome measures were the attributable fraction; the positive and negative likelihood ratios at different disease cut-off points illustrated by the area under the curve statistic.

RESULTS

Six predictors may be modified or controlled directly by either the patient or the clinician, accounting for a reduction in up to 95% of the peri-implant pathology cases. The positive and negative likelihood ratios were 9.69 and 0.13, respectively; the area under the curve was 0.96; a risk score was developed, making the complex statistical model useful to clinicians.

CONCLUSIONS

Based on the results, six predictors for the incidence of peri-implant pathology can be modified to significantly improve the outcome. It was possible to stratify patients per risk category according to the risk score, providing a tool for clinicians to support their decision-making process.

[Hypertension Control at the Primary Health Care: A Comparison Among Portuguese Natives and Portuguese Speaking African Coutries Immigrants]

INTRODUCTION

In Portugal, the frequency of patient with treated and controlled hypertension is low. It is unknown the relation of socio-economic determinants with hypertension control, particularly in African immigrants.

AIMS

To compare frequency of control in treated hypertension and to identify characteristics associated with uncontrolled and treated hypertension between Portuguese natives (Caucasian) and Portuguese Speaking African Coutries immigrants (black).

MATERIAL AND METHODS

Cross-sectional study of patients with treated hypertension, 40-80 years old, randomized from Primary Health Care of Lisbon Region. We collected sociodemographic, clinical and health care data through structured interviews. We compared the frequency of patients with uncontrolled hypertension, and identified related factors through univariate and multivariate analysis.

RESULTS

In this study participated 786 patients with treated hypertension (participation rate: 71%): 449 natives and 337 immigrants. Of these, 46% had controlled hypertension. Diastolic blood pressure was higher in younger immigrants. Were associated with no control, in natives, male sex, low education, going to emergency and / or nursing services and not looking for the family doctor; on immigrants, being single, using the pharmacist, the number of years of illness and intentional non-adherence.

DISCUSSION

Treated hypertension control has been increasing for last years. Natives and immigrants differ, regarding blood pressure control, relatively to the frequency of family doctor consultation, and resorting to other services and health professionals. These differences didn't reflect in statistically different control rates.

CONCLUSIONS

It is needed to define strategies to control hypertension in primary health care specific for ethnic groups.

Effects of the PPARα agonist WY-14,643 on plasma lipids, enzymatic activities and mRNA expression of lipid metabolism genes in a marine flatfish, Scophthalmus maximus

Fibrates and other lipid regulator drugs are widespread in the aquatic environment including estuaries and coastal zones, but little is known on their chronic effects on non-target organisms as marine fish. In the present study, turbot juveniles were exposed to the PPARα model agonist WY-14,643 for 21 days by repeated injections at the concentrations of 5mg/kg (lo-WY) and 50mg/kg (hi-WY), and samples taken after 7 and 21 days. Enzyme activity and mRNA expression of palmitoyl-CoA oxidase and catalase in the liver were analyzed as first response, which validated the experiment by demonstrating interactions with the peroxisomal fatty acid oxidation and oxidative stress pathways in the hi-WY treatment. In order to get mechanistic insights, alterations of plasma lipids (free cholesterol, FC; HDL associated cholesterol, C-HDL; triglycerides, TG; non-esterified fatty acids, NEFA) and hepatic mRNA expression of 17 genes involved in fatty acid and lipid metabolism were studied. The exposure to hi-WY reduced the quantity of plasma FC, C-HDL, and NEFA. Microsomal triglyceride transfer protein and apolipoprotein E mRNA expression were higher in hi-WY, and indicated an increased formation of VLDL particles and energy mobilization from liver. It is speculated that energy depletion by PPARα agonists may contribute to a higher susceptibility to environmental stressors.

Ocular and parotid sarcoidosis - panda sign

Sarcoidosis is a multisystem disease with ocular involvement in 25-50% of patients, parotid and other salivary glands involvement in 6%, resulting in this characteristic panda sign in Gallium-67 scan, present in a 16 year old male with a history of bilateral recurrent uveitis.

[PRAdA intervention: effects on weight of dietary intervention among treated hypertensive Portuguese natives and African immigrants]

INTRODUCTION

Blood pressure is significantly improved with weight loss. Behavioral interventions for weight loss seem to be less successful in African immigrants. Our main aims were to assess the effect of a dietary and lifestyle intervention on weight among hypertensive Portuguese natives and immigrants and to identify success factors for weight loss, and also to evaluate changes in knowledge and compliance with food recommendations.

MATERIAL AND METHODS

Hypertensive medicated patients followed in primary care setting were randomly enrolled in a two phase study, observational (15-months) and behavioral intervention (six months). Participants were divided in two groups: immigrants from African Countries of Portuguese Official Language and Portuguese natives. Participants were given dietary and life styles recommendations in individual face-to-face and telephone sessions.

RESULTS

Of 110 participants with a mean BMI of 31.6 ± 3.7 Kg/m(2), 60 were immigrants. The number of dietary recommendations known and followed at the end was significantly greater than at baseline; however natives performed a greater number of recommendations. Weight loss during intervention was in average 1.4 ± 2.7% in natives and 0.8 ± 3.6% in immigrants and was greater than in the observational period. Being male and consuming more than 2 servings of low-fat dairy products/day was associated with higher weight loss, independently of age and ethnicity.

DISCUSSION

In general the proposed intervention was efficacious especially in Portuguese natives, confirming other studies.

CONCLUSION

The intervention increased knowledge and adherence to recommendations, highlighting the relevance of nutrition education, culturally adapted in primary care.

Adjuvant therapy with bemiparin in patients with limited-stage small cell lung cancer: results from the ABEL study

INTRODUCTION

The haemostatic system plays an important role in the process of cancer development and spread. Anticoagulants, mainly low molecular weight heparins, could prolong survival in cancer patients, particularly in patients with lung cancer, beyond prevention of thromboembolic events.

METHODS

In a multicenter, investigator-initiated, open-label, randomized, sequential study, 38 patients with newly-diagnosed, limited-stage small-cell lung cancer were randomized to receive standard chemoradiotherapy or the same therapy plus 3,500 IU daily of bemiparin for a maximum of 26 weeks. The primary outcome was progression-free survival.

RESULTS

The study was terminated early due to slow recruitment. Median progression-free survival was 272 days with chemoradiotherapy alone and 410 days in the bemiparin group; hazard ratio, 2.58 (95% confidence interval [CI], 1.15-5.80); p=0.022. Median overall survival was 345 days with chemoradiotherapy alone and 1133 days in the bemiparin group; hazard ratio, 2.96 (95% CI, 1.22-7.21); p=0.017. The rate of tumor response was similar in both study arms. There was no significant between-group difference in the rates of major bleeding. Toxicity related with the experimental treatment was minimal.

CONCLUSION

The addition of bemiparin to first line therapy with chemoradiotherapy significantly increases survival in patients with newly-diagnosed, limited-stage small-cell lung cancer. (Funded by the Instituto Científico y Tecnológico, University of Navarra. ClinicalTrials.gov identifier: NCT00324558).

Tissue expression of PPAR-α isoforms in Scophthalmus maximus and transcriptional response of target genes in the heart after exposure to WY-14643

Peroxisome proliferator-activated receptors (PPARs) are involved in the regulation of lipid and carbohydrate metabolism and can be activated either by natural ligands as fatty acids or by synthetic ligands including several environmental chemicals. In this study, two PPARα isoforms (α1 and α2) were analyzed in turbot (Scophthalmus maximus) for a different tissue distribution. PPARα1 was ubiquitously expressed, while the PPARα2 was predominantly expressed in the heart. Following this result, turbot juveniles were exposed by injection to a synthetic selective PPARα agonist, WY-14643, for 14 days. Suppression subtractive hybridization (SSH) was performed with pools of heart samples of control and exposed fish to get insights into PPARα-regulated genes in the heart of juvenile turbot. Four genes were positively identified in the forward-subtracted and 12 genes in the reverse-subtracted cDNA SSH library, corresponding to the down-regulated and up-regulated genes in response to the WY-14643 treatment, respectively. The confirmation of these results in individual samples of juvenile turbot exposed to WY-14643 revealed a statistically significant mRNA induction of two cardiac muscle proteins (myosin light chain 2 and tropomyosin 4), which were shown to be involved in heart contraction and heartbeat regulation in other teleost species. Herewith, we showed for the first time that PPARα2 is predominantly expressed in the heart and that a PPARα agonist can induce the mRNA expression of cardiac muscle proteins in teleosts.

[Economic evaluation of dabigatran for stroke prevention in patients with non-valvular atrial fibrillation]

INTRODUCTION AND OBJECTIVES

To estimate the cost-effectiveness and cost-utility of dabigatran in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in Portugal.

METHODOLOGY

A Markov model was used to simulate patients' clinical course, estimating the occurrence of ischemic and hemorrhagic stroke, transient ischemic attack, systemic embolism, myocardial infarction, and intra- and extracranial hemorrhage. The clinical parameters are based on the results of the RE-LY trial, which compared dabigatran with warfarin, and on a meta-analysis that estimated the risk of each event in patients treated with aspirin or with no antithrombotic therapy.

RESULTS

Dabigatran provides an increase of 0.331 life years and 0.354 quality-adjusted life years for each patient. From a societal perspective, these clinical gains entail an additional expenditure of 2978 euros. Thus, the incremental cost is 9006 euros per life year gained and 8409 euros per quality-adjusted life year.

CONCLUSIONS

The results show that dabigatran reduces the number of events, especially the most severe such as ischemic and hemorrhagic stroke, as well as their long-term sequelae. The expense of dabigatran is partially offset by lower event-related costs and by the fact that INR monitoring is unnecessary. It can thus be concluded that the use of dabigatran in clinical practice in Portugal is cost-effective.