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Comparison of Major Adverse Cardiac Events Between Instantaneous Wave-Free Ratio and Fractional Flow Reserve-Guided Strategy in Patients With or Without Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial.
No full textClinicalTrials.gov identifier: NCT02053038.IMPORTANCE:
Invasive physiologic indices such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are used in clinical practice. Nevertheless, comparative prognostic outcomes of iFR-guided and FFR-guided treatment in patients with type 2 diabetes have not yet been fully investigated.
OBJECTIVE:
To compare 1-year clinical outcomes of iFR-guided or FFR-guided treatment in patients with and without diabetes in the Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularization (DEFINE-FLAIR) trial.
DESIGN, SETTING, AND PARTICIPANTS:
The DEFINE-FLAIR trial is a multicenter, international, randomized, double-blinded trial that randomly assigned 2492 patients in a 1:1 ratio to undergo either iFR-guided or FFR-guided coronary revascularization. Patients were eligible for trial inclusion if they had intermediate coronary artery disease (40%-70% diameter stenosis) in at least 1 native coronary artery. Data were analyzed between January 2014 and December 2015.
INTERVENTIONS:
According to the study protocol, iFR of 0.89 or less and FFR of 0.80 or less were used as criteria for revascularization. When iFR or FFR was higher than the prespecified threshold, revascularization was deferred.
MAIN OUTCOMES AND MEASURES:
The primary end point was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. The incidence of MACE was compared according to the presence of diabetes in iFR-guided and FFR-guided groups.
RESULTS:
Among the total trial population (2492 patients), 758 patients (30.4%) had diabetes. Mean age of the patients was 66 years, 76% were men (1868 of 2465), and 80% of patients presented with stable angina (1983 of 2465). In the nondiabetes population (68.5%; 1707 patients), iFR guidance was associated with a significantly higher rate of deferral of revascularization than the FFR-guided group (56.5% [n = 477 of 844] vs 46.6% [n = 402 of 863]; P < .001). However, it was not different between the 2 groups in the diabetes population (42.1% [n = 161 of 382] vs 47.1% [n = 177 of 376]; P = .15). At 1 year, the diabetes population showed a significantly higher rate of MACE than the nondiabetes population (8.6% vs 5.6%; adjusted hazard ratio [HR], 1.88; 95% CI, 1.28-2.64; P < .001). However, there was no significant difference in MACE rates between iFR-guided and FFR-guided groups in both the diabetes (10.0% vs 7.2%; adjusted HR, 1.33; 95% CI, 0.78-2.25; P = .30) and nondiabetes population (4.7% vs 6.4%; HR, 0.83; 95% CI, 0.51-1.35; P = .45) (interaction P = .25).
CONCLUSIONS AND RELEVANCE:
The diabetes population showed significantly higher risk of MACE than the nondiabetes population, even with the iFR-guided or FFR-guided treatment. The iFR-guided and FFR-guided treatment showed comparable risk of MACE and provided equal safety in selecting revascularization target among patients with diabetes.info:eu-repo/semantics/publishedVersio
Vitamin D Deficiency in a Portuguese Cohort of Patients with Inflammatory Bowel Disease: Prevalence and Relation to Disease Activity
Get PDFBACKGROUND AND AIMS:
Vitamin D deficiency is more common in inflammatory bowel disease (IBD) patients than in the general population. However, there are conflicting data about predictive factors of vitamin D deficiency and its potential association with disease activity. The aims of this study were to determine the prevalence and predictive factors of vitamin D deficiency and to evaluate a possible association with disease activity.
METHODS:
A prospective observational study was conducted, including patients with IBD from January to July 2016. The Endocrine Society guidelines were considered for defining levels of serum 25-hydroxyvitamin D (25-OH-D) as follows: deficient ( 30 ng/mL).
RESULTS:
A total of 152 patients (52% men; 47.2 ± 17.3 years) were included, of whom 70% had Crohn's disease (CD). Thirty-seven percent of patients were on immunosuppressors and 17% were on biologics. The majority were outpatients (88.2%). Mean 25-OH-D levels were 17.1 ± 8 ng/mL (CD: 16.7 ± 8 ng/mL vs. ulcerative colitis: 17.6 ± 7 ng/mL, p = 0.1). Inadequate levels were present in 90.8% of patients (deficiency: 68.4%; insufficiency: 22.4%). A significant negative correlation between 25-OH-D levels and age (r = -0.2, p = 0.04), C-reactive protein (CRP) levels (r = -0.22, p = 0.004), and Harvey-Bradshaw index (HBi) (r = -0.32, p = 0.001) was found. Patients with severe deficiency showed a higher CRP (0.6 vs. 1.4 mg/dL, p = 0.03), erythrocyte sedimentation rate (ESR) (22 vs. 31 mm/h, p = 0.03), and HBi (2 vs. 5, p < 0.001) and lower hemoglobin (13.6 vs. 12.7 g/dL, p = 0.02). There was no association between vitamin D deficiency and gender, type, extent, and duration of disease, surgery, and other measures of disease activity, such as ESR, hemoglobin (these 2 items except for severe deficiency), fecal calprotectin, or Truelove and Witts classification.
CONCLUSIONS:
There is a high prevalence of inadequate levels of vitamin D in IBD patients, particularly deficiency (68.4%). There seems to exist an association between lower levels of vitamin D and higher disease activity, especially in CD.info:eu-repo/semantics/publishedVersio
Direct oral anticoagulants for the management of venous thromboembolism in patients with HIV - a single centre experience
No full textinfo:eu-repo/semantics/publishedVersio
Prescribing of Non-Steroidal Anti-Inflammatory Drugs to Patients with Diabetes Mellitus in Portugal
Get PDFINTRODUCTION:
Portugal presents the highest incidence of stage 5 chronic kidney disease in Europe. It is speculated that a high consumption of non-steroidal anti-inflammatory drugs (NSAIDS) may contribute to this high incidence. Our aim was to characterize the prescription of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus in Portugal.
MATERIAL AND METHODS:
We analyzed the national prescription database in triennium 2015 - 2017. In patients with diabetes mellitus, we evaluated the prescription of non-steroidal anti-inflammatory drugs according to age, gender and region of the patient and specialty of the prescribing physician. We evaluated the prescription of non-steroidal anti-inflammatory drugs in all patients with diabetes mellitus, in patients with presumed renal impairment, and in those with concomitant prescription of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.
RESULTS:
We analyzed 23 320 620 prescriptions, corresponding to 610 157 adults, including 104 306 patients with diabetes mellitus. The most prescribed non-steroidal anti-inflammatory drugs were ibuprofen (20.1%), metamizole (14.7%), and diclofenac (11.4%). The prescription of non-steroidal anti-inflammatory drugs was higher in females, in patients aged 51 - 70 years and in the Alentejo region. Non-steroidal anti-inflammatory drugs were prescribed to 70.6% of patients with diabetes mellitus, from which 10.6% were prescribed ≥ 10 packages during the three years. Among patients with diabetes mellitus on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and with presumed reduction in kidney function, 69.3% were prescribed non-steroidal anti-inflammatory drugs and 11.5% were prescribed ≥ 10 packages during the three years.
DISCUSSION:
The level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus is high. The concern of reducing non-steroidal anti-inflammatory drugs prescription to patients already on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and/or decreased renal function does not seem to exist.
CONCLUSION:
In Portugal, the level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus should be reduced, particularly in the subgroups identified with higher prescription and with higher risk of progression to stage 5 chronic kidney disease.info:eu-repo/semantics/publishedVersio
Mutational mechanism for DAB1 (ATTTC)n insertion in SCA37: ATTTT repeat lengthening and nucleotide substitution.
No full textAbstract
Dynamic mutations by microsatellite instability are the molecular basis of a growing number of neuromuscular and neurodegenerative diseases. Repetitive stretches in the human genome may drive pathogenicity, either by expansion above a given threshold, or by insertion of abnormal tracts in nonpathogenic polymorphic repetitive regions, as is the case in spinocerebellar ataxia type 37 (SCA37). We have recently established that this neurodegenerative disease is caused by an (ATTTC)n insertion within an (ATTTT)n in a noncoding region of DAB1. We now investigated the mutational mechanism that originated the (ATTTC)n insertion within an ancestral (ATTTT)n . Approximately 3% of nonpathogenic (ATTTT)n alleles are interspersed by AT-rich motifs, contrarily to mutant alleles that are composed of pure (ATTTT)n and (ATTTC)n stretches. Haplotype studies in unaffected chromosomes suggested that the primary mutational mechanism, leading to the (ATTTC)n insertion, was likely one or more T>C substitutions in an (ATTTT)n pure allele of approximately 200 repeats. Then, the (ATTTC)n expanded in size, originating a deleterious allele in DAB1 that leads to SCA37. This is likely the mutational mechanism in three similar (TTTCA)n insertions responsible for familial myoclonic epilepsy. Because (ATTTT)n tracts are frequent in the human genome, many loci could be at risk for this mutational process.info:eu-repo/semantics/publishedVersio
Resposta à Carta ao Editor Relativa ao Trabalho “Prescrição Inapropriada em Idosos numa Enfermaria de Medicina Interna” Mariana Alves, Marco Ribeiro Narciso, Teresa Fonseca, João Gorjão Clara” [Acta Med Port.2019;32:249-249]
Get PDFinfo:eu-repo/semantics/publishedVersio
Parental health literacy and the use of pediatric emergency services
Get PDFA literacia em saúde pode ser definida, entre outras, como o nível da capacidade dos indivíduos para obter, processar e perceber informação de saúde básica e os serviços necessários para realizar decisões apropriadas sobre a sua saúde. Neste sentido, o objetivo deste estudo é identificar qual a literacia em saúde dos pais e cuidadores das crianças utilizadoras dos serviços de urgência pediátrica (SUP). Para tal, realizou-se uma revisão integrativa da literatura nas bases de dados CINAHL, MEDLINE e PUBMED, para artigos com menos de cinco anos, com a seguinte equação de pesquisa: [(health literacy OR parental education OR caregiver education) AND (child* OR adolesc* OR paediatric) AND (emergency department OR emergency room OR emergency unit)]. Após aplicação dos critérios de inclusão e exclusão obteve-se uma amostra final de sete artigos. Da análise realizada verificou-se uma elevada prevalência de baixa literacia em saúde, representando em média 63,71% dos inquiridos, com IC 95% ]61-66[. Outros determinantes sociais da saúde, como o nível de rendimento, a etnia e o tipo de seguro de saúde estão também descritos como fatores adjacentes à reduzida literacia em saúde. A baixa literacia em saúde está presente em grande parte dos cuidadores das crianças utilizadores do SUP sendo que esta problemática pode influenciar fenómenos como a recorrência aos serviços de saúde e/ou a incorreta compreensão do tratamento necessário.info:eu-repo/semantics/publishedVersio
The Benefits of Mindfulness-Based Interventions on Burnout Among Health Professionals: A Systematic Review
No full textObjective: Healthcare professional burnout affects performance and has a negative impact on healthcare as a whole. Mindfulness-based Interventions (MIs), developed over the last 30 years, are increasingly used by healthcare professionals to reduce the risk of burnout. Yet the impact of MIs on burnout remains to be clarified. This review aimed to summarize and evaluate the existing literature on the potential benefits of MIs to minimize burnout risk.
Methods: We conducted a systematic review of the literature, reporting according to the PRISMA standards. PubMed, Psychinfo, Web of Science and Science Direct databases were screened for original articles. Articles in English assessing an MI in combination with burnout measures were included up to September 2018.
Results: Thirty-four articles were included. Only four randomised controlled trials concluded to burnout improvement after several weeks of MIs (11,8%). In the remaining five randomised controlled trials, results did not reach statistical significance. Of the four controlled, non-randomised studies, three showed significant improvements on burnout. Twenty-one studies did not report a controlled trial design. Overall the results appeared to be widely heterogeneous and several methodological concerns arose from the review.
Conclusion: This review shows the overall insufficient level of evidence offered by the literature assessing the effects of MIs on burnout in health professional populations. However, some studies have reported promising results and future research should address methodological issues and define more precise contexts of interventions and target populations that could benefit from MIs.info:eu-repo/semantics/publishedVersio
Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Patient Taking Lamotrigine
No full textDrug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare adverse drug reaction characterised by skin eruption and multiple organ involvement. Diagnosing this entity is challenging due to the variability of clinical manifestations, late onset and relapse even after stopping the causative drug. It is potentially life-threatening; thus, it must be promptly recognised and the causative drug withdrawn. We describe a case of a 50-year-old man with an acute diffuse rash, fever and eosinophilia 4 weeks after having started lamotrigine. The suspected eliciting drug was suspended and systemic corticoid treatment was initiated (prednisolone 0.5 mg/kg/day). Symptoms relapsed under corticoid tapering with greater severity. The patient developed an exuberant rash associated with peripheral lymphadenopathies, marked eosinophilia and hepatic cytolysis. The diagnosis of DRESS syndrome to lamotrigine was made. Prednisolone dosage was increased to 1 mg/kg/day, and the subsequent taper was performed slowly over the course of 10 weeks. Full clinical remission was observed.info:eu-repo/semantics/publishedVersio