A Reproducible and Standardised Clinical Registry for Clinical and Economic Outcomes of Heart Transplantation Patients

This study describes the creation and implementation of a prospective, reproducible and standardised clinical registry of outpatients who underwent heart transplantation.  Methods and Results: The following steps were carried out: i) data were standardised in accordance with national and international standard data elements, ii) an initial data collection and clinical research workflow was developed, iii) electronic case reports were developed in accordance with the HIPAA privacy rule using REDCap, iv) pilot testing and validation of the data collection, clinical research workflows and case report forms was undertaken, and v) an automated data quality report was developed using REDCap. All patients undergoing heart transplantation in a reference cardiology hospital were included. Patients were excluded if they did not agree to participate in the study. The registry was designed to become multicentre in the future. Data were collected from the moment of the inclusion (hospital admission), at hospital discharge, and 1, 3 and 6 months and yearly after surgery. Clinical and cost-related outcomes included all-causes mortality, cardiovascular mortality, non-fatal myocardial infarction, stroke, hospital admissions, visits to the emergency department, organ rejection, infection, need for re-operation, any adverse event, costs related to treatment and procedures, and quality of life.   Conclusions: This registry represents a powerful tool for assisting quality improvement, healthcare services management, technology assessment, health policies and clinical research since it contains comprehensive and representative data of the clinical practice and allows for interoperability and data integration with other datasets

Universality in Bibliometrics

Many discussions have enlarged the literature in Bibliometrics since the Hirsh proposal, the so called $h$-index. Ranking papers according to their citations, this index quantifies a researcher only by its greatest possible number of papers that are cited at least $h$ times. A closed formula for $h$-index distribution that can be applied for distinct databases is not yet known. In fact, to obtain such distribution, the knowledge of citation distribution of the authors and its specificities are required. Instead of dealing with researchers randomly chosen, here we address different groups based on distinct databases. The first group is composed by physicists and biologists, with data extracted from Institute of Scientific Information (ISI). The second group composed by computer scientists, which data were extracted from Google-Scholar system. In this paper, we obtain a general formula for the $h$-index probability density function (pdf) for groups of authors by using generalized exponentials in the context of escort probability. Our analysis includes the use of several statistical methods to estimate the necessary parameters. Also an exhaustive comparison among the possible candidate distributions are used to describe the way the citations are distributed among authors. The $h$-index pdf should be used to classify groups of researchers from a quantitative point of view, which is meaningfully interesting to eliminate obscure qualitative methods.Comment: To appear in Physica A (8 pages, 6 figures and 2 tables

Do Diabetic Patients with Acute Coronary Syndromes Have a Higher Threshold for Ischemic Pain?

Background: Data from over 4 decades have reported a higher incidence of silent infarction among patients with diabetes mellitus (DM), but recent publications have shown conflicting results regarding the correlation between DM and presence of pain in patients with acute coronary syndromes (ACS). Objective: Our primary objective was to analyze the association between DM and precordial pain at hospital arrival. Secondary analyses evaluated the association between hyperglycemia and precordial pain at presentation, and the subgroup of patients presenting within 6 hours of symptom onset. Methods: We analyzed a prospectively designed registry of 3,544 patients with ACS admitted to a Coronary Care Unit of a tertiary hospital. We developed multivariable models to adjust for potential confounders. Results: Patients with precordial pain were less likely to have DM (30.3%) than those without pain (34.0%; unadjusted p = 0.029), but this difference was not significant after multivariable adjustment, for the global population (p = 0.84), and for subset of patients that presented within 6 hours from symptom onset (p = 0.51). In contrast, precordial pain was more likely among patients with hyperglycemia (41.2% vs 37.0% without hyperglycemia, p = 0.035) in the overall population and also among those who presented within 6 hours (41.6% vs. 32.3%, p = 0.001). Adjusted models showed an independent association between hyperglycemia and pain at presentation, especially among patients who presented within 6 hours (OR = 1.41, p = 0.008). Conclusion: In this non-selected ACS population, there was no correlation between DM and hospital presentation without precordial pain. Moreover, hyperglycemia correlated significantly with pain at presentation, especially in the population that arrived within 6 hours from symptom onset

Evaluation of the metabolism of high energy phosphates in patients with Chagas' disease

FUNDAMENTO: Anormalidades do metabolismo miocárdico têm sido observadas em pacientes com insuficiência cardíaca de diferentes etiologias. A espectroscopia por ressonância magnética (ERM) com fósforo 31 é uma técnica não invasiva que permite a detecção de alterações metabólicas miocárdicas. OBJETIVO: Determinar o metabolismo de repouso dos fosfatos de alta energia em pacientes portadores de doença de Chagas (DC) pela ERM com fósforo 31. MÉTODOS: Foram estudados 39 pacientes com DC, sendo 23 com função ventricular preservada (Grupo FP) e 16 com disfunção ventricular (Grupo DV), avaliados pela ecodopplercardiografia. A ERM da região anterosseptal foi realizada nos 39 pacientes e em 8 indivíduos normais (Grupo C), por meio de um aparelho Phillips de 1,5 Tesla, obtendo-se a relação fosfocreatina/trifosfato de adenosina beta (PCr/&#946;-ATP) miocárdicos. RESULTADOS: Os níveis cardíacos de PCr/&#946;-ATP estavam reduzidos no Grupo DV em relação ao Grupo FP, e estes apresentaram níveis reduzidos em relação ao Grupo C (Grupo DV: 0,89 ± 0,31 vs Grupo FP: 1,47 ± 0,34 vs Grupo C: 1,88 ± 0,08, p < 0,001). Houve correlação entre a fração de ejeção do ventrículo esquerdo e a PCr/&#946;-ATP nos 39 pacientes estudados (r = 0,64, p < 0,001). Os pacientes em classe funcional I (n = 22) apresentaram PCr/&#946;-ATP de 1,45 ± 0,35, e aqueles em classes funcionais II e III (n = 17), PCr/&#946;-ATP de 0,94 ± 0,36 (p < 0,001). CONCLUSÃO: A ERM permitiu detectar de forma não invasiva alterações no metabolismo energético em pacientes com DC, mesmo sem disfunção sistólica; tais alterações estavam relacionadas com a gravidade do comprometimento cardíaco.BACKGROUND: Abnormalities in myocardial metabolism have been observed in patients with heart failure of different etiologies. Magnetic resonance spectroscopy (MRS) with phosphorus-31 is a noninvasive technique that allows detection of myocardial metabolic changes. OBJECTIVE: To determine the resting metabolism of high-energy phosphates in patients with Chagas' disease (CD) by MRS with phosphorus-31. METHODS: We studied 39 patients with CD, 23 with preserved ventricular function (PF Group) and 16 with ventricular dysfunction (VD Group), assessed by Doppler echocardiography. MRS of the anterosseptal region was performed in 39 patients and 8 normal subjects (C Group) through a Phillips 1.5 Tesla device, obtaining the phosphocreatine/beta-adenosine triphosphate myocardial ratio (PCr/&#946;-ATP). RESULTS: The levels of cardiac PCr/&#946;-ATP were reduced in VD Group in relation to PF Group, and the latter presented reduced levels compared to C Group (VD Group: 0.89 ± 0.31 vs PF Group: 1.47 ± 0.34 vs C Group: 1.88 ± 0.08, p < 0.001). A correlation was found between left ventricular ejection fraction and PCr/&#946;-ATP in 39 patients (r = 0.64, p < 0.001). Patients under functional class I (n = 22) presented PCr/&#946;-ATP of 1.45 ± 0.35, and those in functional classes II and III (n = 17), PCr/&#946;-ATP of 0.94 ± 0.36 (p < 0.001). CONCLUSION: The 31-phosphorus MRS was able to detect non-invasively changes in the rest energy metabolism of patients with Chagas' disease, with and without systolic dysfunction. These changes were related to the severity of heart impairment

The five-point Likert scale for dyspnea can properly assess the degree of pulmonary congestion and predict adverse events in heart failure outpatients

OBJECTIVES: Proper assessment of dyspnea is important in patients with heart failure. Our aim was to evaluate the use of the 5-point Likert scale for dyspnea to assess the degree of pulmonary congestion and to determine the prognostic value of this scale for predicting adverse events in heart failure outpatients. METHODS: We undertook a prospective study of outpatients with moderate to severe heart failure. The 5-point Likert scale was applied during regular outpatient visits, along with clinical assessments. Lung ultrasound with ≥15 B-lines and an amino-terminal portion of pro-B-type natriuretic peptide (NT-proBNP) level >;1000 pg/mL were used as a reference for pulmonary congestion. The patients were then assessed every 30 days during follow-up to identify adverse clinical outcomes. RESULTS: We included 58 patients (65.5% male, age 43.5±11 years) with a mean left ventricular ejection fraction of 27±6%. In total, 29.3% of these patients had heart failure with ischemic etiology. Additionally, pulmonary congestion, as diagnosed by lung ultrasound, was present in 58% of patients. A higher degree of dyspnea (3 or 4 points on the 5-point Likert scale) was significantly correlated with a higher number of B-lines (p = 0.016). Patients stratified into Likert = 3-4 were at increased risk of admission compared with those in class 1-2 after adjusting for age, left ventricular ejection fraction, New York Heart Association functional class and levels of NT-proBNP >;1000 pg/mL (HR = 4.9, 95% CI 1.33-18.64, p = 0.017). CONCLUSION: In our series, higher baseline scores on the 5-point Likert scale were related to pulmonary congestion and were independently associated with adverse events during follow-up. This simple clinical tool can help to identify patients who are more likely to decompensate and whose treatment should be intensified

The Role of Invasive Therapies in Elderly Patients with Acute Myocardial Infarction

INTRODUCTION: In elderly patients with acute myocardial infarction, very little is known about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive therapies - IT), especially in the context of long-term outcomes after hospital discharge. METHODS: We analyzed 1588 patients with MI who had been included prospectively in a databank and followed for up to 7.5 years. In this population, 548 patients were >70 years old (elderly group - EG), and 1040 were <70 years of age (younger group - YG); 1088 underwent IT during hospitalization, and the remaining 500 were treated medically (conservative therapy - CT). Patients were monitored either by visit or by phone at least once a year. A standard questionnaire was administered to all patients. The impact of IT was analyzed with both non-adjusted and adjusted models. RESULTS: By the end of the follow-up period, the survival rates for the IT and CT groups were, respectively, 71.9% versus 47.2% in the global population (hazard ratio=0.55, P<0.001), 81.5% versus 66.6% in the YG (hazard ratio=0.68, P=0.018) and 48.8% versus 20.3% in the EG (hazard ratio=0.58, P<0.001). In the adjusted models, the hazard ratios were 0.62 (P<0.001) in the global population, 0.74 in the YG (P=0.073) and 0.64 (P=0.001) in the EG. CONCLUSION: Long-term follow-up of patients with myocardial infarction revealed that IT during the in-hospital phase was at least as effective in elderly patients as in younger patients