A prediction rule to stratify mortality risk of patients with pulmonary tuberculosis

Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8-7.9), age >= 50 years (OR 2.9, 95% CI 1.7-4.8), bilateral lung involvement (OR 2.5, 95% CI 1.44.4), >= 1 significant comorbidity-HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease-(OR 2.3, 95% CI 1.3-3.8), and hemoglobin = 6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment.This work was supported by Fundacao Amelia de Mello/Jose de Mello Saude and Sociedade Portuguesa de Pneumologia (SPP). This work was developed under the scope of the project NORTE-01-0145-FEDER-000013, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER). NSO is a FCT (Fundacao para a Ciencia e Tecnologia) investigator. MS is an Associate FCT Investigator. The fundershad no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Nationwide access to endovascular treatment for acute ischemic stroke in portugal

Publisher Copyright: Copyright Ordem dos M dicos 2021.Introduction: Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts. Material and Methods: A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture. Results: A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity. Discussion: Overall endovascular treatment rates and procedural times in Portugal are comparable to other international registries. We found geographic heterogeneity, with lower endovascular treatment rates and longer onset-to-puncture time in southern and inner regions. Conclusion: The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitalspublishersversionpublishe

O método mãe-canguru nos recém-nascidos de baixo peso

Dissertação de mestrado em Medicina (Pediatria), apresentada á faculdade de Medicina da Universidade de CoimbraIntrodução: O elevado número de recém-nascidos de baixo peso constitui um importante problema de saúde pública e ainda representa uma taxa considerável de morbi-mortalidade neonatal. Deste modo, os cuidados aos recém-nascidos têm sido um foco primordial da atenção dos pediatras-neonatalogistas e outros profissionais de sáude que se dedicam a melhorar os cuidados neonatais. O Método Mãe-Canguru surgiu como um tipo de humanização e de assistência neonatal que implica o contacto entre a mãe/cuidador e o recém-nascido de baixo peso. Esta prática consiste no contacto “skin-to-skin” precoce, prolongado e contínuo, adoptando uma posição vertical e um decúbito prono do recém-nascido com o peito da mãe/cuidador. Além disso, o Método Mãe-Canguru promove a amamentação e a estabilização clínica. Objectivos: Este trabalho de revisão teve como objectivo realçar o crescente interesse da comunidade médica e científica em instituir esta prática nos recém-nascidos de baixo peso e compreender a sua importância na adaptação extra-uterina, bem como rever os seus efeitos sobre as respostas fisiológicas e comportamentais e sobre o desenvolvimento cognitivo-motor. Desenvolvimento: A promoção desta prática não só fortalece a necessidade precoce do vínculo afectivo e da amamentação, mas também contribui para a termoregulação, melhores padrões de sono e de alerta, redução da apneia, do choro e do stress, analgesia, redução das infecções, de outras morbilidades e da mortalidade. Sabe-se também que este método tem um grande impacte nas Unidades de Cuidados Neonatais, uma vez que permite a estabilização das respostas fisiológicas do recém-nascido: a frequência cardíaca, a frequência respiratória e a saturação periférica de oxigénio. Igualmente está associado a um maior ganho ponderal, o que O Método Mãe-Canguru nos Recém-nascidos de baixo peso 4 permite a alta precoce e um melhor crescimento e desenvolvimento. Contribui positivamente para as interacções sociais do recém-nascido e no ambiente familiar. O Método Mãe-Canguru tem sido comparado a muitas práticas adoptadas na Unidade de Cuidados Neonatais, demonstrando ser benéfico e seguro quando combinado com o suporte adequado que o recém-nascido necessita. Conclusões: Os benefícios do Método Mãe-Canguru no desenvolvimento psico-motor e na adaptação extra-uterina reflecte-se no prognóstico e na expectativa de sobrevivência dos recém-nascidos de baixo peso. A maioria dos estudos reporta resultados positivos e poucos efeitos deletérios. Além disso, esses benefícios parecem ter impacte a longo prazo. O Método Mãe-Canguru é uma prática neonatal recomendada nos recém-nascidos de baixo peso, empregue em todo o mundo, pelos ganhos fisiológicos, cognitivos e emotivos, embora sejam desejáveis mais estudos que o apoiem.Introduction: The increased number of low birth weight newborns is a relevant public health problem that accounts for a considerable neonatal morbidity and mortality rate. Thus, newborn care has been a major concern for both pediatricians and neonatologists as well as for other health professionals. The Kangaroo Mother Care has emerged as a humanization and neonatal care method involving the contact between the mother/caregiver and the low birth weight newborn. This technique consists in early, prolonged and continuous "skin-to-skin" contact by placing the newborn in upright and prone decubitus position with the mother's/caregiver's chest. In addition, the Kangaroo Mother Care promotes breastfeeding and clinical stabilization. Goals: This review aims to highlight the growing interest of the medical and scientific community in implementing this practice among low birth weight newborns, understand its importance in extrauterine adaptation and to review its effect on physiological and behavioral responses as well as on cognitive and motor development. Development: The promotion of this practice not only strengthens the need of an early emotional bond and breastfeeding, but also contributes to thermoregulation, better sleep and alert patterns, reduction of apnea, crying and stress, analgesia as well as the reduction of infections and other causes of mortality and morbidity. It is also known that this method has a major impact on Neonatal Care Units as it allows the stabilization of the physiological responses of newborns: heart rate, respiratory rate and oxygen saturation. This method is also associated with increased weight gain, allowing an early discharge from hospital as well as a better growth and development. It positively contributes to the social interactions between the O Método Mãe-Canguru nos Recém-nascidos de baixo peso 6 newborn and the family environment. The Kangaroo Mother Care has been compared to many practices adopted in Neonatal Care Units, proving to be beneficial and safe when combined with proper support to newborns. Conclusions: The benefits of Kangaroo Mother Care in psychomotor development and extrauterine adaptation are reflected on the prognosis and the expected survival of low weight newborns. Most studies report positive results with few deleterious effects. Moreover, these benefits appear to have a long-term impact. The Kangaroo Mother Care is a practice recommended for low birth weight newborns that is used worldwide due to its physiological, cognitive and emotional advantages, although further studies are needed to support i

A cidade ilustrada. Indelével: Centro do Mar

Desde dos primórdios da sua existência que o Homem utiliza a imagem como forma de comunicação, sendo apenas natural que, ao longo do tempo, a forma como a expõe e a própria sociedade evoluam em consonância. A imagem das cidades, em particular, é algo que se desenvolve através da malha urbana e da Arquitetura, arrecadando características que são intrínsecas aos locais e à forma como se desenvolveu a cidade. Por exemplo a cidade de Sines, na qual se centra o projecto prático associado a este trabalho, tem uma imagem fortemente industrializada, enquanto que a cidade de Odivelas, caso de estudo do presente trabalho, possui uma imagem com características muito mais rurais. Com o desenvolvimento da perceção da cidade e da forma como esta é vivida, surge a Arte Urbana. Esta está fortemente enraizada nas questões do local e utiliza os elementos arquitetónicos para se expor nas ruas da cidade, verificando-se que o seu desenvolvimento cria uma nova dimensão na urbe. Este desenvolvimento altera os fluxos da própria cidade, aderindo à complexidade da malha urbana. Por estar tão ligada à Arquitetura, no sentido em que esta se torna a sua tela, a Arte Urbana, coloca em questão a relação entre a Arte e a Arquitetura, dois elementos separados mas que podem ser unificados com propósito de melhorar a cidade. A Arte Urbana pode ser a chave para essa ligação, a ponte entre estes dois elementos que caracterizam tão fortemente a cidade. Esta faceta da Arte Urbana é o tópico em estudo neste trabalho.Since the dawn of ages Man has used images as a way of communicating, and it is natural that the way it shows those images and society evolve in accord with each other. Urban image, in particular, is something that developes through the Urban Mesh and Arquitecture, acquiring characteristics which are specific of the places and of the way the city has evolved. For instance, Sines, in which the pratical project associated to this work is based, has a strongly industrialized image while Odivelas, the case study of this work, has a image much more akin to the countryside. With the evolution of the way we see the city and the way we live it, Urban Art arises. It is strongly rooted in the local issues and uses architectonic elements to show itself in the city streets, which means that its own evolution adds a new dimension to the city. This evolution changes the city fluxes, becoming part of the Urban Mesh. Because of its strong connection to Architecture, in the sense that this last one becomes the canvas in which it is created, Urban Art questions the relation between Art and Architecture, which are two different objects but can unite in the search for improvement of the city. Urban Art can be the key to this connection, the bridge between those two important elements in the characterization of the city. This particular role of Urban Art is the main topic of discussion in this work

Ischemic lesions in acute and subacute perimesencephalic subarachnoid hemorrhage

© American Roentgen Ray SocietyObjective: Perimesencephalic hemorrhage (PMH) is a subtype of nonaneurysmal subarachnoid hemorrhage (SAH). In patients with aneurysmal SAH, the occurrence of acute ischemic lesions is associated with severity and poor outcome. We investigated the frequency of ischemic lesions on DWI in patients with PMH and compared it with the frequency of ischemic lesions in patients with aneurysmal SAH. Subjects and methods: From a prospective cohort of 80 patients with acute spontaneous SAH, we included 15 patients with PMH and 39 patients with aneurysmal SAH who were matched on the basis of their clinical condition (World Federation of Neurological Societies grade 1 or 2). MRI was performed less than 72 hours after SAH, 8-10 days after SAH, or at both points in time. The number and distribution of lesions previously seen on DWI that were also seen on a second MRI examination were assessed. Nonparametric tests were used to compare groups. Results: Early acute ischemic lesions (those identified < 72 hours after SAH) were found in 46.2% of patients with PMH and in 62.9% of patients with aneurysmal SAH. No significant differences in the number of acute ischemic lesions between groups were noted less than 72 hours after SAH (median, 0.5 lesion [interquartile range {IQR}, two lesions] in patients with PMH vs one lesion [IQR, three lesions] in patients with aneurysmal SAH [p = 0.48] or 8-10 days after SAH (median, 0.5 lesion [IQR, four lesions] in patients with PMH vs 1.5 lesions [IQR, three lesions] in patients with aneurysmal SAH [p = 0.26]). However, 58.3% of patients with aneurysmal SAH had new infarcts at 8-10 days, compared with 7.1% of patients with PMH. Patients with PMH had diffuse ischemic lesions, whereas patients with aneurysmal SAH in the anterior circulation had mainly supratentorial lesions. Conclusion: Early ischemic lesions appeared on DWI both in patients with PMH and in patients with aneurysmal SAH. The number of lesions increased during the time window for vasospasm, mainly in patients with aneurysmal SAH. Further studies are required to better understand the pathophysiologic mechanisms behind early ischemia in patients with PMH and their impact on prognosis.info:eu-repo/semantics/publishedVersio

TNF-R1 Correlates with Cerebral Perfusion and Acute Ischemia Following Subarachnoid Hemorrhage

Background: Early cerebral hypoperfusion and ischemia occur after subarachnoid hemorrhage (SAH) and influence clinical prognosis. Pathophysiological mechanisms possibly involve inflammatory mediators. TNF-α has been associated with complications and prognosis after SAH. We investigated the relation of perfusion parameters and ischemic lesions, with levels of TNF-α main receptor, TNF-R1, after SAH, and their association with prognosis. Methods: We included consecutive SAH patients admitted within the first 72 h of SAH onset. Blood samples were simultaneously collected from a peripheral vein and from the parent artery of the aneurysm. Levels of TNF-R1 were measured using ELISA (R&D Systems Inc., USA). CT perfusion and MRI studies were performed in the first 72 h. Correlation and logistic regression analysis were used to identify outcome predictors. Results: We analyzed 41 patients. Increased levels of TNF-R1 correlated with increased T (arterial: r = −0.37, p = 0.01) and prolonged MTT (arterial: r = 0.355, p = 0.012; venous: r = 0.306, p = 0.026). Increased levels of both arterial and venous TNF-R1 were associated with increased number of lesions on DWI (p = 0.006). In multivariate analysis, venous TNFR1 levels > 1742.2 pg/mL (OR 1.78; 95%CI 1.18–2.67; p = 0.006) and DWI lesions (OR 14.01; 95%CI 1.19–165.3; p = 0.036) were both independent predictors of poor outcome (mRS ≥ 3) at 6 months. Conclusion: Increased levels of TNF-R1 in arterial and venous blood correlate with worse cerebral perfusion and with increased burden of acute ischemic lesions in the first 72 h after SAH. Venous levels of TNF-R1 and DWI lesions were associated with poor outcome at 6 months. These results highlight the pathophysiological role of TNF-α pathways in SAH and suggest a possible role of combined imaging and laboratorial markers in determining prognosis in acute SAH.Dr Fragata was supported by Sociedade Portuguesa de AVC/Tecnifar. Dr Bustamante is supported by a Juan Rodes research contract (JR16/00008) from Instituto de Salud Carlos III

Venous and arterial TNF-R1 predicts outcome and complications in acute subarachnoid hemorrhage

© 2019 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care SocietyBackground: There is increasing evidence for the role of inflammation in clinical outcome after subarachnoid hemorrhage (SAH). Specifically, the TNF-alfa(α) pathway seems to be relevant after SAH. Although the TNF-α main receptor, TNF-R1 is associated with aneurysm growth and rupture, its relation to prognosis is unknown. We sought to compare TNF-R1 levels in peripheral venous blood and arterial blood closer to the ruptured aneurysm to study the association of TNF-R1 blood levels with poor prognosis (modified Rankin Scale > 2 at discharge, 3 and 6 months) and complications (hydrocephalus or delayed cerebral ischemia/DCI) following SAH. Methods: We included consecutive SAH patients admitted in the first 72 h of symptoms. Blood samples were simultaneously collected from a peripheral vein and from the main parent artery of the aneurysm. Levels of TNF-R1 were measured using enzyme-linked immunosorbent assays. Results: We analyzed 58 patients. Arterial and venous levels of TNF-R1 were correlated (R = 0.706, p < 0.001). In multivariate regression analysis, venous TNF-R1 was an independent predictor of poor outcome at 6 months after adjusting by age and sex [odds ratio (OR) 11.63; 95% CI 2.09-64.7, p = 0.005] and after adjusting by Glasgow Coma Scale and Fisher scales (OR 8.74; 95% CI 1.45-52.7, p = 0.018). There was no association of TNF-R1 with DCI. A cut-off for arterial TNF-R1 of 1523.7 pg/mL had 75% sensitivity/66% specificity for the prediction of hydrocephalus. Conclusion: Levels of venous TNF-R1 are associated with poor outcome in SAH. A specific association was found between levels of arterial TNF-R1 and hydrocephalus. These results are consistent with the role of TNF-α pathway in SAH and need to be validated in larger cohorts.Dr Fragata was supported by Sociedade Portuguesa de AVC/Tecnifar. Dr Bustamante is supported by a Juan Rodes research contract (JR16/00008) from Instituto de Salud Carlos III.info:eu-repo/semantics/publishedVersio

Evolution of diffusion tensor imaging parameters after acute subarachnoid haemorrhage : a prospective cohort study

© Springer-Verlag Berlin Heidelberg 2016.Introduction: Few studies assessed diffusion tensor imaging (DTI) changes in the acute phase of subarachnoid haemorrhage (SAH). We prospectively evaluated DTI parameters in the acute phase of SAH and 8-10 days after and analysed whether changes could be related to SAH severity or to the development of delayed cerebral ischemia (DCI). Methods: Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) changes over time were assessed in a prospective cohort of patients with acute SAH. Two MRI studies were performed at <72 h (MRI-1) and 8-10 days (MRI-2). DTI parameters were recorded in 15 ROIs. Linear mixed regression models were used. Results: Forty-two patients were included. Subtle changes in DTI parameters were found between MRI-1 and MRI-2. At the posterior limb of internal capsule (PLIC), a weak evidence of a 0.02 mean increase in FA (p = 0.064) and a 17.55 × 10-6 mm2/s decrease in ADC (p = 0.052) were found in MRI-2. Both FA and ADC changed over time at the cerebellum (increase of 0.03; p = 0.017; decrease of 34.73 × 10-6 mm2/s; p = 0.002, respectively). Patients with DCI had lower FA values on MRI-1 and lower ADC on MRI-2, although not reaching statistical significance, compared to non-DCI patients. DTI parameters on MRI-1 were not correlated to clinical admission scales. Conclusion: ADC and FA values show subtle changes over time in acute SAH at the PLIC and cerebellum although not statistically associated with the severity of SAH or the occurrence of DCI. However, DTI changes occurred mainly in DCI patients, suggesting a possible role of DTI as a marker of DCI.info:eu-repo/semantics/publishedVersio

Temporal evolution of cerebral computed tomography perfusion after acute subarachnoid hemorrhage : a prospective cohort study

© The Foundation Acta Radiologica 2019Background: Changes in cerebral perfusion occur in subarachnoid hemorrhage that possibly relate to clinical presentation and complications. Purpose: To evaluate changes in computed tomography perfusion (CTP) parameters between the acute and subacute stage of subarachnoid hemorrhage. To analyze correlation of these parameters to SAH severity and delayed cerebral ischemia. Material and Methods: Cerebral CT perfusion was assessed in a prospective cohort of 44 patients with acute subarachnoid hemorrhage at < 72 h (CTP1) and 8–10 days (CTP2), using the mean of all regions of interest. Regions of interest were located at arterial territories of the anterior, middle, and posterior cerebral artery and basal ganglia and midpons cerebellar hemispheres. Linear regression models (univariable and multivariable) were used to explore the association between changes in perfusion parameters (absolute and relative differences) and relevant clinical data. Results: Worse perfusion parameters on the first 72 h were correlated with poor admission clinical scores: cerebral blood flow positively correlated with Glasgow Coma Scale (rS ¼ 0.398, P ¼ 0.008), and negatively correlated with Hunt & Hess scale (rS ¼ 0.348, P ¼ 0.020) and World Federation of Neurosurgeons scale (rS ¼ 0.384, P ¼ 0.010). Cerebral blood volume positively correlated with Glasgow Coma Scale (rS ¼ 0.332, P ¼ 0.028) and negatively correlated with World Federation of Neurosurgeons scale (rS ¼ 0.353, P ¼ 0.019). Mean transit time negatively correlated with Glasgow Coma Scale (rS ¼ 0.415, P ¼ 0.005) and positively correlated with Hunt & Hess scale (rS ¼ 0.471, P ¼ 0.001) and World Federation of Neurosurgeons scale (rS ¼ 0.386, P ¼ 0.010) scores. There were no differences between absolute CTP1/CTP2 parameters. Patients with delayed cerebral ischemia had DTmax mean decrease of 2.08 s (95% CI ¼ 4.04–0.12; P ¼ 0.038). Conclusion: Early cerebral hypoperfusion correlates with poor clinical grade at admission in subarachnoid hemorrhage and with higher amounts of blood. Tmax was decreased at 8–10 days, in patients with delayed cerebral ischemia, which may favor the application value of Tmax in signaling delayed cerebral ischemia.info:eu-repo/semantics/publishedVersio