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- Prediction of short-term prognosis in elderly patients with spontaneous intracerebral hemorrhagePublication . Batista, António; Osório, Rui; Varela, Ana; Guilherme, Patrícia; Marreiros, Ana; Pais, Sandra; Nzwalo, HipólitoAim The incidence of spontaneous intracerebral hemorrhage (SICH) increases with age. Data on SICH mortality in the very old are sparse. We aimed to describe the predictors of 30-day SICH mortality in the very elderly in southern Portugal. Methods A total of 256 community representative SICH patients aged >= 75 years (2009-2016) were included. Multiple logistic regression was used to identify predictors of 30-day mortality. Results Mean age was 82.1 years; 57.4% males. The 30-day case fatality was 38.7%. The frequency of patients taking anticoagulants (29.3% vs. 11.5%); comatose (46.9% vs. 2.5%); with hematoma volume >= 30 mL (64.6% vs. 13.4%); intraventricular dissection (78.8% vs. 27.4%) was higher in deceased patients (p < 0.05). Survivors were more often admitted to stroke unit (SU) (68.2 vs. 31.3%) and had lower mean admission glycaemia values (p < 0.05). The likelihood of death was increased in patients with higher admission hematoma volume (>= 30 mL) (OR: 8.817, CI 1.753-44.340, p = 0.008) and with prior to SICH history of >= 2 hospitalizations OR = 1.022, CI 1.009-1.069, p = 0.031). Having higher Glasgow coma scale score, OR: 0.522, CI 0.394-0.692, p < 0.001, per unit was associated with reduced risk of death. Age was not an independent risk factor of short-term death. Conclusions The short-term mortality is high in very elderly SICH. Prior to SICH history of hospitalization, an indirect and gross marker of coexistent functional reserve, not age per se, increases the risk of short-term death. Other predictors of short-term death are potentially manageable reinforcing the message against any defeatist attitude toward elderly patients with SICH. Key summary pointsAim Identification of predictors of short-term death after spontaneous intracerebral hemorrhage (SICH) in the elderly. Findings The short-term case fatality (38.7%) after SICH is high in the elderly. Hematoma volume, decreased level of consciousness and functional reserve, but not age per se, increase the risk of short-term death. Message Age per se should not justify any decision of withholding best treatment in elderly SICH patients. Offering the best acute treatment can potentially improve the clinical outcome.
- Predictors of pneumonia in patients with acute spontaneous intracerebral hemorrhage in Algarve, Southern PortugalPublication . Soares, Rita; Fernandes, Adriana; Taveira, Isabel; Marreiros, Ana; Nzwalo, HipólitoIntroduction: Following the hyperacute phase of spontaneous intracerebral hemorrhage (SICH), the severest form of stroke, pneumonia emerges as the leading cause of morbidity and mortality. Prevention of stroke associated pneumonia (SAP) is fundamental to improve the prognosis of SICH patients. Aim: Identify clinical, sociodemographic and process of care factors associated with occurrence of SAP after SICH in Algarve, southern Portugal. Methods: Observational, retrospective study of community representative consecutive case series of patients with SICH admitted to the sole public hospital in the region. Logistic regression was used to identify predictors of SAP after SICH. Results: A total of 525 patients were included. The mean age was 71 ( +/- 13) years and 64% were men. SAP occurred in 165 (31.5%). Lower Glasgow Coma Scale score (GCS score): <= 8 (OR= 2.087; 95% CI= [1.027;4.424]; p = 0.042) and GCS 9-12 (OR= 1.775; 95% CI= [1.030;3.059]; p = 0.039); prolonged emergency room stay (OR= 8.066; 95%CI=[3.082;21.113]; p < 0.001) and hyperactive delirium (OR=2.860; 95% CI= [1.661;4.925]; p < 0.001) increased the likelihood of SAP. Being younger, = 59 years (OR= 0.391; 95% CI= [0.168; 0.911]; p = 0.029) and 60-71 years (OR= 0.389; 95% CI= [0.185; 0.818]; p = 0.013); and having less severe SICH/intracerebral hemorrhage score (ICH score) <= 2 (OR=0.601; 95% CI= [0.370; 0.975]; p = 0.039), decreased the risk of SAP. Conclusion: After SICH, SAP occurs in approximately a third of patients. Non preventable (admission severity, ageing) and potentially preventable (prolonged emergency room stay, hyperactive delirium) determine the occurrence of SAP. Intensification of preventive intervention in high-risk patients, delirium prevention and improvement of the process of care can potentially reduce the occurrence of SAP after SICH.
- Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern PortugalPublication . Fernandes, Adriana; Taveira, Isabel; Soares, Rita; Marreiros, Ana; Nzwalo, HipólitoIntroduction: Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. Patients and methods: Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. Results: Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival > 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and > 24 h in the Emergency Department (OR =19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). Conclusion: The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.
- Systematic review of the prevalence, predictors, and treatment of insomnia in palliative carePublication . Nzwalo, Isa; Aboim, Maria Ana; Joaquim, Natércia; Marreiros, Ana; Nzwalo, HipólitoIntroduction: The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce. Methodology: Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. Results: A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer). Conclusions: The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia's risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.
- Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysisPublication . Abreu, Pedro; Nogueira, Jerina; Rodrigues, Filipe Brogueira; Nascimento, Ana; Carvalho, Mariana; Marreiros, Ana; Nzwalo, HipólitoIntracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization. We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol. Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis. ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.
- Reprogramming iPSCs to study age-related diseases: models, therapeutics, and clinical trialsPublication . Esteves, Filipa; Brito, David; Rajado, Ana Teresa; Silva, Nádia; Apolónio, Joana; Roberto, Vania Palma; Araújo, Inês Maria; Nóbrega, Clévio; Castelo-Branco, Pedro; Bragança, José; P. Andrade, Raquel; M. Calado, Sofia; Faleiro, L; Matos, Carlos A; Marques, Nuno; Marreiros, Ana; Nzwalo, Hipólito; Pais, Sandra; Palmeirim, Isabel; S, Simão; Joaquim, Natércia; Miranda, Rui; Pêgas, António; Raposo, Daniela Marques; Sardo, AnaThe unprecedented rise in life expectancy observed in the last decades is leading to a global increase in the ageing population, and age-associated diseases became an increasing societal, economic, and medical burden. This has boosted major efforts in the scientific and medical research communities to develop and improve therapies to delay ageing and age-associated functional decline and diseases, and to expand health span. The establishment of induced pluripotent stem cells (iPSCs) by reprogramming human somatic cells has revolutionised the modelling and understanding of human diseases. iPSCs have a major advantage relative to other human pluripotent stem cells as their obtention does not require the destruction of embryos like embryonic stem cells do, and do not have a limited proliferation or differentiation potential as adult stem cells. Besides, iPSCs can be generated from somatic cells from healthy individuals or patients, which makes iPSC technology a promising approach to model and decipher the mechanisms underlying the ageing process and age-associated diseases, study drug effects, and develop new therapeutic approaches. This review discusses the advances made in the last decade using iPSC technology to study the most common age-associated diseases, including age-related macular degeneration (AMD), neurodegenerative and cardiovascular diseases, brain stroke, cancer, diabetes, and osteoarthritis.
- Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of PortugalPublication . Nzwalo, Hipólito; Nogueira, Jerina; Félix, Catarina; Guilherme, Patrícia; Baptista, Alexandre; Figueiredo, Teresa; Ferreira, Fatima; Marreiros, Ana; Thomassen, Lars; Logallo, NicolaBackground: There is scarce information on incidence and case fatality of spontaneous intracerebral hemorrhage (SICH) in certain regions of the world, including in Europe. There is no community-based data on SICH in Southern Portugal. Aim: To determine the incidence and early case-fatality from SICH in Algarve, the southernmost region of Portugal. Methods: The recommended criteria for stroke incidence studies was used to identify cases of incident first-ever SICH from January 1st to December 31st 2015 in a subregion with 280,081 inhabitants. Crude incidence rates per age group and gender; standardized rates to the European population; and age adjusted case fatality rates were calculated. Results: Eighty-two first-ever cases of SICH (64.6% men) occurred. The mean age was 72.3 years (SD +/- 12.1); women were 3 years older than men on average and had more frequently lobar SICH. The crude annual incidence rate was 29.2/100,000 (95% CI 23.4- 38.6; p < 0.001); higher in men (39.7/100,000) than women (19.8/100,000). The standardized to the European population incidence was 15.1/100,000 (95% CI 3.6-18.9; p < 0.05); 26.9 and 10.9/100,000 for men and women respectively. The 30-day case-fatality was 40 % (95% CI 29-51) and increased steeply with age Conclusion: The incidence of SICH in Southern Portugal was high, but within the figures found in some parts of Europe. However, a marked predominance of males was found and the case-fatality rate was amongst the highest reported in western countries. (C) 2017 Elsevier B.V. All rights reserved.
- Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhagePublication . Martinez, Joana; Mouzinho, Maria; Teles, Joana; Guilherme, Patricia; Nogueira, Jerina; Felix, Catarina; Ferreira, Fatima; Marreiros, Ana; Nzwalo, HipólitoObjectives: The case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage-Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal. Patients and Methods: analysis of prospective collected data of 157 consecutive SICH patients (2014-2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics). Results: forty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]). Conclusion: the early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.
- Establishment of an induced pluripotent cell line (ABCRIi001-A) from an elderly female for ageing researchPublication . Esteves, Filipa; Vilhena Catarino Brito, David; Rajado, Ana Teresa; Silva, Nádia; Apolónio, Joana; Roberto, Vânia; Andrade, Raquel; Calado, Sofia; Faleiro, Maria Leonor; Albuquerque Andrade de Matos, Carlos Adriano; Marques, Nuno; Marreiros, Ana; Nzwalo, Hipólito; Pais, Sandra; Palmeirim, Isabel; Simãoa, Sónia; Joaquim, Natércia; Miranda, Rui; Pêgas, António; Raposo, Daniela Marques; Sardo, Ana; Araújo, Inês; Nóbrega, Clévio; Castelo-Branco, Pedro; Bragança, JoséHuman induced pluripotent stem cells (hiPSCs) hold promises to model and understand human diseases, including those associated with ageing. Here, we describe ABCRIi001-A, a hiPSC line generated from peripheral blood mononuclear cells (PBMCs) of a 79-year-old female enrolled in a study for development of an ageing score (ALFA Score). PBMCs were reprogrammed using three Sendai virus-based reprogramming vectors (hKOS, hc-Myc, and hKlf4). ABCRIi001-A showed normal morphology and karyotype, viral clearance, absence of genomic aberrations, and their pluripotency was confirmed by expression of pluripotency-related markers and their ability to differentiate into the three germ layers. ABCRIi001-A is valuable for ageing-related studies.
- Clinical and epidemiological characteristics of patients with functional stroke mimics: a case–control study from Southern PortugalPublication . Figueira Domingos, Miguel; Silva, Vítor Hugo; Schuh, Sara; Correia, Helena; Palma, Pedro; Pedro, João Pedroso; Nova, Bruno Vila; Marreiros, Ana; Félix, Ana Catarina; Nzwalo, HipólitoBackground: Patients with functional neurological disorder presenting as stroke mimics or functional stroke mimics (FSMs) pose significant diagnostic challenges. In the acute phase, especially when patients are present within the therapeutic window for acute reperfusion treatments, a misdiagnosis of FSM can lead to unnecessary and costly interventions. Despite its clinical importance, the literature on the risk factors for FSM is limited. This study aims to compare the clinical and epidemiological characteristics of patients with FSM to those with confirmed acute ischemic stroke (AIS). Methods: This case-control study involved temporal matching between consecutive series of patients with FSM and controls with AIS from a single tertiary university hospital in southern Portugal. Results: A total of 188 patients were included: 64 cases (FSM) and 188 controls (AIS). The rate of stroke code activation and use of ambulance between was comparable between the two groups. The group of patients with FSM was younger (53.2 years vs. 69.5 years, p < 0.001) and had a higher proportion of females (52.4% vs. 47.6%, p = 0.001). There was no difference in terms of clinical severity at presentation. The proportion of specific signs, such as transcortical aphasia (3.1% vs. 20.9%, p = 0.014), gait abnormalities (15.6% vs. 33.9%, p = 0.004), and cranial nerve abnormalities (31.2% vs. 43.5%, p = 0.042), was lower in the FSM group compared to the AIS group. The proportion of patients on antithrombotic therapy (90.9% vs. 9.1%, p = 0.007) and antihypertensive drugs (78.5%, vs. 21.5%, p < 0.001) prior to the event was significantly higher in the AIS group. Likewise, the prevalence of cerebrovascular risk factors such as diabetes mellitus (14.3% vs. 85.7%, p = 0.005), arterial hypertension (23.8% vs. 76.2%, p = 0.001), and smoking (43.7% vs. 56.3%, p = 0.005) was lower in the FSM group compared to the AIS group. No statistically significant differences were observed in cholesterol levels or the prevalence of dyslipidemia between the two groups. Psychiatric comorbidities, including generalized anxiety disorder (71.4% vs. 28.6%, p = 0.05) and major depressive disorder (61.9% vs. 28.1%, p = 0.01), were more prevalent in the FSM group. Conclusions: Patients with FSM display different clinical and epidemiological profiles, with a higher likelihood of being younger, female, having prior psychiatric conditions, and lacking traditional cerebrovascular risk factors.