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- Higher mineralized bone volume is associated with a lower plain X-Ray vascular calcification score in hemodialysis patientsPublication . Adragao, Teresa; Ferreira, Anibal; Frazão, João; Papoila, Ana Luisa; Pinto, Iola; Monier-Faugere, Marie-Claude; Malluche, Hartmut H.Background and objectives In dialysis patients, there is an increasing evidence that altered bone metabolism is associated with cardiovascular calcifications. The main objective of this study was to analyse, in hemodialysis patients, the relationships between bone turnover, mineralization and volume, evaluated in bone biopsies, with a plain X-ray vascular calcification score. Design, setting, participants and measurements In a cross-sectional study, bone biopsies and evaluation of vascular calcifications were performed in fifty hemodialysis patients. Cancellous bone volume, mineralized bone volume, osteoid volume, activation frequency, bone formation rate/bone surface, osteoid thickness and mineralization lag time were determined by histomorphometry. Vascular calcifications were assessed by the simple vascular calcification score (SVCS) in plain X-Ray of pelvis and hands and, for comparison, by the Agatston score in Multi-Slice Computed Tomography (MSCT). Results SVCS >= 3 was present in 20 patients (40%). Low and high bone turnover were present in 54% and 38% of patients, respectively. Low bone volume was present in 20% of patients. In multivariable analysis, higher age (p = 0.015) and longer hemodialysis duration (p = 0.017) were associated with SVCS >= 3. Contrary to cancellous bone volume, the addition to this model of mineralized bone volume (OR = 0.863; 95% CI: 0.766, 0.971; p = 0.015), improved the performance of the model. For each increase of 1% in mineralized bone volume there was a 13.7% decrease in the odds of having SVCS >= 3 (p = 0.015). An Agatston score> 400 was observed in 80% of the patients with a SVCS >= 3 versus 4% of patients with a SVCS<3, (p<0.001). Conclusion Higher mineralized bone volume was associated with a lower plain X-ray vascular calcification. This study corroborates the hypothesis of the existence of a link between bone and vessel and reinforces the clinical utility of this simple and inexpensive vascular calcification score in dialysis patients.
- A multivariable prediction model to select colorectal surgical patients for co-managementPublication . Bayão Horta, A.; Brás-Geraldes, Carlos; Salgado, Cátia; Vieira, Susana; Xavier, Miguel; Papoila, Ana LuisaIntroduction: Increased life expectancy leads to older and frailer surgical patients. Co-management between medical and surgical specialities has proven favourable in complex situations. Selection of patients for co-management is full of difficulties. The aim of this study was to develop a clinical decision support tool to select surgical patients for co-management. Material and Methods: Clinical data was collected from patient electronic health records with an ICD-9 code for colorectal surgery from January 2012 to December 2015 at a hospital in Lisbon. The outcome variable consists in co-management signalling. A dataset from 344 patients was used to develop the prediction model and a second data set from 168 patients was used for external validation. Results: Using logistic regression modelling the authors built a five variable (age, burden of comorbidities, ASA-PS status, surgical risk and recovery time) predictive referral model for co-management. This model has an area under the curve (AUC) of 0.86 (95% CI: 0.81 - 0.90), a predictive Brier score of 0.11, a sensitivity of 0.80, a specificity of 0.82 and an accuracy of 81.3%. Discussion: Early referral of high-risk patients may be valuable to guide the decision on the best level of post-operative clinical care. We developed a simple bedside decision tool with a good discriminatory and predictive performance in order to select patients for comanagement. Conclusion: A simple bed-side clinical decision support tool of patients for co-management is viable, leading to potential improvement in early recognition and management of postoperative complications and reducing the ‘failure to rescue’. Generalizability to other clinical settings requires adequate customization and validation.
- The risk of chronic kidney disease and mortality are increased after community-acquired acute kidney injuryPublication . Soto, Karina; Campos, Pedro; Pinto, Iola; Rodrigues, Bruno; Frade, Francisca; Papoila, Ana Luisa; Devarajan, PrasadWe investigated whether community-acquired acute kidney injury encountered in a tertiary hospital emergency department setting increases the risk of chronic kidney disease (CKD) and mortality, and whether plasma biomarkers could improve the prediction of those adverse outcomes. In a prospective cohort study, we enrolled 616 patients at admission to the emergency department and followed them for a median of 62.1 months. Within this cohort, 130 patients were adjudicated as having acute kidney injury, 159 transient azotemia, 15 stable CKD, and 312 normal renal function. Serum cystatin C and plasma neutrophil gelatinase-associated lipocalin (NGAL) were measured at index admission. After adjusting for clinical variables, the risk of developing CKD stage 3, as well as the risk of death, were increased in the acute kidney injury group (hazard ratio [HR],5.7 [95% confidence interval, 3.8–8.7] and HR, 1.9 [95% confidence interval, 1.3–2.8], respectively). The addition of serum cystatin C increased the ability to predict the risk of developing CKD stage 3, and death (HR, 1.5 [1.1–2.0] and 1.6 [1.1–2.3], respectively). The addition of plasma NGAL resulted in no improvement in predicting CKD stage 3 or mortality (HR,1.0 [0.7–1.5] and 1.2 [0.8–1.8], respectively). The risk of developing CKD stage 3 was also significantly increased in the transient azotemia group (HR, 2.4 [1.5–3.6]). Thus, an episode of community acquired acute kidney injury markedly increases the risk of CKD, and moderately increases the risk of death. Our findings highlight the importance of follow-up of patients with community acquired acute kidney injury, for potential early initiation of renal protective strategies
- Optimizing risk stratification in heart failure and the selection of candidates for heart transplantationPublication . Pereira-da-Silva, Tiago; Soares, Rui M.; Papoila, Ana Luisa; Pinto, Iola; Feliciano, Joana; Morais, Luís Almeida; Abreu, Ana; Ferreira, Rui CruzIntroduction and Aims: Selecting patients for heart transplantation is challenging. We aimed to identify the most important risk predictors in heart failure and an approach to optimize the selection of candidates for heart transplantation. Methods: Ambulatory patients followed in our center with symptomatic heart failure and left ventricular ejection fraction <= 40% prospectively underwent a comprehensive baseline assessment including clinical, laboratory, electrocardiographic, echocardiographic, and cardiopulmonary exercise testing parameters. All patients were followed for 60 months. The combined endpoint was cardiac death, urgent heart transplantation or need for mechanical circulatory support, up to 36 months. Results: In the 263 enrolled patients (75% male, age 54 +/- 12 years), 54 events occurred. The independent predictors of adverse outcome were ventilatory efficiency (VE/VCO2) slope (HR 1.14, 95% CI 1.11-1.18), creatinine level (HR 2.23, 95% CI 1.14-4.36), and left ventricular ejection fraction (HR 0.96, 95% CI 0.93-0.99). VE/VCO2 slope was the most accurate risk predictor at any follow-up time analyzed (up to 60 months). The threshold of 39.0 yielded high specificity (97%), discriminated a worse or better prognosis than that reported for post-heart transplantation, and outperformed peak oxygen consumption thresholds of 10.0 or 12.0 ml/kg/min. For low-risk patients (VE/VCO2 slope <39.0), sodium and creatinine levels and variations in end-tidal carbon dioxide partial pressure on exercise identified those with excellent prognosis. Conclusions: VE/VCO2 slope was the most accurate parameter for risk stratification in patients with heart failure and reduced ejection fraction. Those with VE/VCO2 slope >= 39.0 may benefit from heart transplantation.