FM-CEMBE-Artigos em Revistas Nacionais
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- In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018Publication . Calé, R.; Ascenção, Raquel; Bulhosa, C.; Pereira, Helder; Borges, Margarida; Costa, J.; Caldeira, DanielBackground: The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known. Methods: Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases. Results: From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70). Conclusion: In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.
- Expert perspectives on strategic factors for the management and prevention of heart failure in PortugalPublication . Caldeira, Daniel; Brito, Dulce; Aguiar, Carlos; Silva Cardoso, José; Fonseca, Cândida; Franco, Fátima; Macedo, Filipe; Moura, Brenda; Pinto, Fausto J.; Carneiro, António VazIntroduction and objectives: Heart failure (HF) has significant morbidity and mortality, and its prevalence will continue to increase in the future. This unfavorable evolution requires reflection as well as recommendations and decisions based on expert critical and strategic appraisal. Methods: In the Acceleration on Heart Failure Empowerment and Awareness - the Portuguese Challenge (ATHENA-PT) study, a range of strategic factors that represent the strengths, weaknesses, threats, and opportunities (SWOT) of HF in Portugal were established. These factors were assessed quantitatively by experts, to create a final SWOT matrix for the management and prevention of HF in Portugal and to outline recommendations. Results: For HF management, the panel emphasized the following strategic recommendations: (i) reimbursement of natriuretic peptides testing in primary healthcare; (ii) reimbursement of Doppler assessment in echocardiographic studies and promotion of detailed information in reports; (iii) intervention to improve the prognosis of patients with HF with preserved ejection fraction; (iv) ensuring effective healthcare transition between hospital and ambulatory units, using checklists/protocols; and (v) reinforcement and commitment to the training of primary health physicians and to the cardiac rehabilitation of patients. For the prevention of HF, the following recommendations/proposals were proposed: (i) campaigns to raise awareness of cardiovascular disease risk factors; (ii) promotion of physical exercise and healthy eating; and (iii) avoidance of therapeutic inertia in the management of risk factors. Conclusions: The acknowledgment of various strategic factors and their prioritization by experts made it possible to create and reinforce a range of new strategic recommendations for the management and prevention of HF.
- Análise da revisão Cochrane: o papel dos antiagregantes plaquetários para prevenir a pré-eclâmpsia e as suas complicações: Cochrane Database Syst Rev. 2019;10:CD004659Publication . Reis-de-Carvalho, Catarina; Vieira, Miguel Bigotte; Costa, João; Carneiro, António VazPre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia. This Cochrane review aimed to assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing preeclampsia. A systematic review of literature was carried out by searching the following databases up to September 2019: Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. Seventy-seven trials were included, including 40 249 women at risk of developing pre-eclampsia. About 80% of these women were evaluated in nine of the 77 trials included, with eight of these nine trials providing individual data. Interventions were administration of an antiplatelet agent, and comparisons were either placebo or no antiplatelet. The present review provides high-quality evidence that administering low-dose aspirin (50 - 150 mg) to pregnant women led to small-to-moderate benefits, including reductions in the risk of pre-eclampsia, preterm birth, small-for-gestational age fetus, and fetal or neonatal death. Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes.
- Direct oral anticoagulants in chronic thromboembolic pulmonary hypertension: more high-quality and multinational trials are needed!Publication . Calé, Rita; Caldeira, DanielChronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease which, although rare, is associated with significant morbidity and mortality when left untreated. It is characterized by the obstruction of the pulmonary arterial vasculature by organized thrombotic material, with consequent fibrotic reaction, intimal thickening, vascular remodeling, and plexiform lesions, leading to increased resistance and pressure in pulmonary circulation, right heart overload, right ventricular failure, and death.1 Pulmonary arterial endarterectomy (PEA) surgery is the first-line therapy which, when performed in experienced centers, has hospital mortality of less than 5% and provides hemodynamic and functional improvement with good long-term survival.2 Balloon pulmonary angioplasty (BPA) is an alternative approach in inoperable or residual/recurrent CTEPH patients after PEA, with favorable results in terms of functional clinical improvement, exercise capacity, haemodynamics and survival.
- Atherosclerosis in the primary health care setting: a real-word data studyPublication . Ascenção, Raquel; Alarcão, Joana; Araujo, Francisco; Costa, João; Fiorentino, Francesca; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Mello e Silva, Alberto; Carneiro, António Vaz; Borges, MargaridaIntroduction and objectives: To characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region. Methods: A cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests. Results: A total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p<0.001). Mean blood pressure, LDL-C and glycated hemoglobin values were lower in the subpopulation with manifestations (142/74 vs. 146/76 mmHg, 101 vs. 108 mg/dl, and 6.80 vs. 6.84%, respectively; p<0.001). Each user with atherosclerosis attended 4.1±2.9 face-to-face medical consultations and underwent 8.6±10.0 laboratory test panels, with differences in subpopulations with and without clinical manifestations (4.4±3.2 vs. 4.0±2.8 and 8.3±10.3 vs. 8.7±9.8, respectively; p<0.001). Conclusions: About one in three adult primary health care users with atherosclerosis have clinical manifestations. The results suggest that control of cardiovascular risk factors is suboptimal in patients with atherosclerosis.
- Atherosclerosis: the cost of illness in PortugalPublication . Costa, João; Alarcão, Joana; Amaral-Silva, Alexandre; Araujo, Francisco; Ascenção, Raquel; Caldeira, Daniel; Cardoso, Marta Ferreira; Correia, Manuel; Fiorentino, Francesca; Gavina, Cristina; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Mello E Silva, Alberto; Pedro, Luís M; Morais, João; Carneiro, António Vaz; Veríssimo, Manuel Teixeira; Borges, MargaridaIntroduction and objectives: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease-related costs. Methods: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real-world data from primary care, the 2014 National Health Interview Survey, and expert opinion. Results: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). Conclusions: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.
- Análise da revisão Cochrane : administração suplementar de vitamina D para prevenção de cancro em adultos : Cochrane database syst rev. 2014, 6:cd007469Publication . Cardoso, André Torres; Nanji, Liliana Sousa; Costa, João; Carneiro, António VazVitamin D has been mentioned in the literature has a potentially important agent for preventing the development of tumors, namely breast, colon, prostate and ovary tumors. However, the currently available evidence on the subject is contradictory and inconclusive. In this Cochrane systematic review, patients taking supplemental vitamin D on its various forms (cholecalciferol, ergocalciferol, alfacalcidol or calcitriol), regardless the dose, duration and route of administration, were compared with placebo, healthy adults without any intervention or adults with a disease in a stable phase, non-related with vitamin D metabolism. The results showed that currently, there is no firm evidence that vitamin D supplementation increases or decreases the risk of cancer occurrence, mainly in elderly community-dwelling women. Though at risk of type I errors due to small samples and substantial dropout of participants during the trials, the administration of supplemental cholecalciferol led to a 12% (CI 95%: 2 a 22%) decreased in cancer mortality, while the administration of supplemental vitamin D decreased all-cause mortality by 7% (CI 95%: 2 a 12%). The combined administration of supplements of cholecalciferol and calcium induced an increased incidence of nephrolithiasis.
- Os custos da insuficiência cardíaca em Portugal e a sua evolução previsível com o envelhecimento da populaçãoPublication . Gouveia, Miguel Rebordão de Almeida; Ascenção, Raquel; Fiorentino, Francesca; Costa, João; Broeiro-Gonçalves, Paula; Fonseca, Maria Cândida Faustino Gamito da; Borges, MargaridaIntroduction and Objectives: Heart failure (HF) is a growing public health problem. This study estimates the current and future costs of HF in mainland Portugal. Methods: Costs were estimated based on prevalence and from a societal perspective. The annual costs of HF included direct costs (resource consumption) and indirect costs (productivity losses). Estimates were mostly based on data from the Diagnosis-Related Groups database, real-world data from primary care, and the opinions of an expert panel. Costs were estimated for 2014 and, taking population aging into account, changes were forecast up to 2036. Results: Direct costs in 2014 were D 299 million (39% for hospitalizations, 24% for medicines, 17% for exams and tests, 16% for consultations, and the rest for other needs, including emergencies and long-term care). Indirect costs were D 106 million (16% for absenteeism and 84% for reduced employment). Between 2014 and 2036, due to demographic dynamics, total costs will increase from D 405 to D 503 million. Per capita costs are estimated to rise by 34%, which is higher than the increase in total costs (+24%), due to the expected reduction in the resident population. Conclusions: HF currently has a significant economic impact, representing around 2.6% of total public health expenditure, and this is expected to increase in the future. This should be taken into account by health policy makers, alerting them to the need for resource management in order to mitigate the impact of this disease.
- Cochrane corner : perioperative beta-blockers for preventing surgery-related mortality and morbidityPublication . Alegria, Sofia; Costa, João; Carneiro, António Vaz; Caldeira, DanielRandomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality. This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events. Eighty-eight randomized controlled trials with 19 161 participants were included (53 trials on cardiac surgery and 35 trials on non-cardiac surgery). In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction (AMI), stroke, heart failure, hypotension or bradycardia. In non-cardiac surgery, beta-blockers had a protective effect against AMI and arrhythmias, but this was counterbalanced by an increased risk of death and stroke. In conclusion, perioperative use of beta-blockers appears overall to be beneficial in cardiac surgery. However, in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke, and so the systematic use of beta-blockers in this setting is not recommended.
- Perceção e atitudes sobre prescrição racional durante a formação médica : resultados de grupos focais com estudantes de medicina e médicos internosPublication . Boaventura, Isabel; Costa, João; Fernandes, Ricardo M.; Ferreira, Joaquim J.Introduction: Clinical pharmacology educational strategies for medicine students seek to foster skills that range from technical knowledge to the development of behaviors that ensure rational prescribing decisions. The authors present the results of a study to evaluate the perceptions, attitudes and behaviors linked with rational prescribing throughout training. Material and Methods: Four focus groups were held with first, third and fifth year medical students and residents from the first years of various specialties, with a total of 29 participants. A semi-structured questionnaire with open-ended questions was used to facilitate interaction between the participants, alongside case-studies to explore the behaviors associated with therapeutic decisions. Results: The analysis of the references showcased an evolution of concepts throughout academic training. References regarding guidelines and effectiveness emerge during the third year; safety and treatment personalization emerge during the fifth year and specialist training. Efficacy studies, systematic reviews, regulatory documents and online platforms were considered the most relevant sources of information. Discussion: The literature review showcases the need to implement strategies dedicated to the development of adequate skills for rational prescribing. The use of focus groups may be a useful methodology to engage students in self-evaluation of their skills and inform faculty of the perceptions and behaviors of students. Conclusion: This analysis illustrates the awareness of students and young physicians to the need to adapt therapeutic approaches to the characteristics of the patient. These concepts should be reinforced so that young doctors feel more prepared for rational prescription in complex clinical situations.