ABSTRACT
OBJECTIVES: A comparative analysis of three major clinical trials with factor Xa inhibitor oral anticoagulant (XOAC) drugs versus warfarin in atrial fibrillation-Rocket-AF (rivaroxaban), Aristotle (apixaban) and Engage AF Timi 48 (edoxaban; two different doses and sets of data)-was carried out. METHODS: Data were extracted from the original reports (study level) and a meta-analysis was carried out. RESULTS: When compared with warfarin, XOAC therapy was associated with a decrease in haemorrhagic stroke, with a similar pattern for all regimens and meta-analysis showing a risk ratio of 0.488 (95% CI 0.396 to 0.601). Regarding total mortality, a favourable pattern was seen for all four regimens and meta-analysis showed a risk ratio of 0.892 (95% CI 0.840 to 0.947). Major bleeding and gastrointestinal bleeding provided two examples regarding which heterogeneity would seem to exist, when XOAC drugs are compared with warfarin. In what concerns the incidence of myocardial infarction, the primary end point (stroke plus systemic embolism) and ischaemic stroke, the situation is less clear. These results are inconsistent with a putative 'group effect' for all the seven parameters under study, and for some of them it would probably be best to look at each of the individual trial data rather than at the meta-analysis data (which seem to lack a clear biological meaning). CONCLUSIONS: Apixaban, rivaroxaban and edoxaban have shown interesting effects, when compared with warfarin in clinical trials, in patients with atrial fibrillation, particularly with regard to haemorrhagic stroke and to the mortality rate. No other consistent conclusions concerning a putative 'group effect' can be reached at the present stage. Concerns regarding adherence to therapy, possible drug interactions, cost and current absence of antidotes may be taken into consideration when choosing an anticoagulant drug.
ABSTRACT
BACKGROUND: Early warning score (EWS) is a system that assists in the timely recognition of hospitalized patients outside critical care areas with potential or established critical illness at risk of deteriorating and who may be receiving suboptimal care. No such systems have been implemented in Portuguese National Health Service's wards. We performed a preliminary study to assess the potential outcome of applying the EWS in our hospital setting. METHODS: An observational retrospective study was conducted based on 100 patients assessed by the outreach team due to an acute event. The EWS was calculated a posteriori on three preceding periods from the acute deterioration (-12, -24, and -72 h). RESULTS: In 35 patients, there was insufficient recording of vital signs. The final sample of 65 patients includes 62.0% men, and the mean age (±SD) was 67 ± 16 years old. Respiratory problems were the main cause of deterioration (44.6%). The EWS score increased from -72 to -12 h. More than half of cases (63.0%) were admitted into high care units, and their mean (±SD) score was higher in comparison to those remaining in general wards (Intermediate Care Units 3.75 ± 1.9, Intensive Care Units 4.2 ± 1.5, wards 3.5 ± 1.4). Score at -24 and -12 h seemed to predict length of stay (LoS; p < 0.05) and mortality, respectively. The EWS would have incremented early medical attention by 40.0% if a threshold of ≥3 was used. CONCLUSIONS: EWS systems are not widely used in Portuguese health service. Our data suggests that the EWS would allow early recognition for a higher number of patients in comparison to current ward care. Clinical worsening, lengths of stay, admission into high care units, and mortality may be predicted by the EWS. Prospective studies with multivariable analysis are needed to clarify the global outcome of the EWS implementation in national wards.
ABSTRACT
BACKGROUND: Neurosyphilis became a rare disease after the introduction of antibiotics. The resurgence of syphilis in association with human immunodeficiency virus infection in the past decades increased the incidence of this tertiary form of the disease. However, in immunocompetent patients neurosyphilis remains uncommon and accurate diagnosis is challenging as the clinical presentation is unspecific and the validity of supportive laboratory tests is unclear. CASE REPORT: We describe the case of a 60-year-old man who presented with a 6-month clinical picture of depression-like symptoms and recent sudden unilateral blindness. Medical history uncovered a primary syphilitic event 20 years before. The investigation led to the diagnosis of neurosyphilis with optical involvement in a patient who did not present with any signs of secondary syphilis. Treatment with penicillin G and topical steroids resulted in significant clinical improvement and resolution of the visual loss. CONCLUSION: In the well-established natural history of syphilis, primary syphilis is almost always followed by manifestation of the secondary form, which in turn precedes a period of latency. This case emphasizes the need for a high index of suspicion of neurosyphilis in an immunocompetent patient with nonspecific neuropsychiatric manifestations and an atypical course of syphilis infection.
ABSTRACT
The prevalence of carbon monoxide intoxication in the World shows that this is a common situation. In Portugal, there are no concrete data available in literature and its incidence remains unknown. Currently, the use of hyperbaric oxygen is a valid therapeutic for carbon monoxide poisoning management. However, its effectiveness and its proper handling are still controversial. The first aim of this study was to estimate the incidence of carbon monoxide intoxication in Portugal and to analyze its demographic characteristics. The second objective of this work was to evaluate the possible change in the type of treatment applied in areas near de hyperbaric chamber of Unidade Local de Saúde de Matosinhos, since its opening in June 2006. To achieve these objectives, we conducted a survey on admissions data for carbon monoxide intoxication occured between January first, 2000 and December 31, 2007. These data was collected in seven hospitals and in the Administração Central do Sistema de Saúde, I.P. Nationally, 621 hospitalizations were recorded, which represents an incidence of 5,86/100000 in 8 years. In the seven hospitals, there were 93 hospitalizations due to carbon monoxide intoxication during the same period of time. There was a peak of incidence during winter, between November and March and there was a similar distribution in men (47,3%) and women (52,7%). Since June 2006, date of opening of the hyperbaric chamber, the Unidade Local de Saúde de Matosinhos, E.P.E. recorded a sharp increase in the number of hospitalization for carbon monoxide intoxication. The number of admissions in the 19 months after the chamber opening was double the number of all cases occurred in that institution in the 65 months prior. We concluded that, in Portugal, carbon monoxide intoxication is an uncommon situation but it´s still an important cause of hospitalization. The referral of cases to the Unidade Local de Saúde de Matosinhos, E.P.E. since the opening of hyperbaric chamber objectively increased. Thus, we can assume that peripheral hospitals are aware of the existence of hyperbaric chamber and its potential in treatment of carbon monoxide poisoning.
