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  • Prediction of short-term prognosis in elderly patients with spontaneous intracerebral hemorrhage
    Publication . Batista, António; Osório, Rui; Varela, Ana; Guilherme, Patrícia; Marreiros, Ana; Pais, Sandra; Nzwalo, Hipólito
    Aim 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.
  • Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal
    Publication . Fernandes, Adriana; Taveira, Isabel; Soares, Rita; Marreiros, Ana; Nzwalo, Hipólito
    Introduction: 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.
  • Contralateral carotid stenosis is a predictor of long-term adverse events in carotid endarterectomy
    Publication . Moreira, Rita; Duarte-Gamas, Luís; Pereira-Macedo, Juliana; Pereira-Neves, António; Domingues-Monteiro, Diogo; Jácome, Filipa; Andrade, José P.; Marreiros, Ana; Rocha-Neves, João
    Contralateral carotid stenosis (cICS) has been described as a perioperative predictor of mortality after carotid endarterectomy (CEA). However, its predictive value on long-term cardiovascular events remains controversial. The study aims to assess the potential role of cICS as a long-term predictor of major adverse cardiovascular events (MACE) in patients who underwent CEA. From January 2012 to July 2020, patients undergoing CEA under regional anesthesia for carotid stenosis in a tertiary care and referral center were eligible from a prospective database, and a post hoc analysis was performed. The primary outcome consisted in the occurrence of long-term MACE. Secondary outcomes included all-cause mortality, stroke, myocardial infarction, acute heart failure, and major adverse limb events. A total of 192 patients were enrolled. With a median 50 months follow-up, chronic kidney disease (CKD) (mean survival time (MST) 51.7 vs. 103.3, P < 0.010) and peripheral artery disease (PAD) (MST 75.1 vs. 90.3, P = 0.001) were associated with decreased survival time. After propensity score matching (PSM), CKD (MST 49.1 vs. 106.0, P = 0.001) and PAD (MST 75.7 vs. 94.0, P = 0.001) maintained this association. On multivariate Cox regression analysis, contralateral stenosis was associated with higher MACE (hazard ratio (HR) = 2.035; 95% CI: 1.113-3.722, P = 0.021 and all-cause mortality (HR = 2.564; 95% CI: 1.276-5,152 P = 0.008). After PSM, only all-cause mortality (HR 2.323; 95% CI: 0.993-5.431, P = 0.052) maintained a significant association with cICS. On multivariable analysis, cICS (aHR 2.367; 95% CI: 1.174-4.771, P = 0.016), age (aHR 1.039, 95% CI: 1.008-1.070), CKD (aHR 2.803; 95% CI: 1.409-5.575, P = 0.003) and PAD (aHR 3.225, 95% CI: 1.695-6.137, P < 0.001) were independently associated with increased all-cause mortality. Contrary to MACE, cICS is a strong predictor of long-term all-cause mortality after CEA. However, MACE risk may compromise CEA benefits by other competitive events. Therefore, further studies are needed to establish the role of cICS on postoperative events and on patients' specific assessments in order to determine the best medical treatment and easy access to surgical intervention.
  • Identification of colorectal cancer associated biomarkers: an integrated analysis of miRNA expression
    Publication . Fonseca, André; Ventura Ramalhete, Sara Maria; Mestre, André; Neves, Ricardo; Marreiros, Ana; Castelo-Branco, Pedro
    Colorectal cancer is one of the leading causes of cancer-related deaths worldwide. This complex disease still holds severe problems concerning diagnosis due to the high invasiveness nature of colonoscopy and the low accuracy of the alternative diagnostic methods. Additionally, patient heterogeneity even within the same stage is not properly reflected in the current stratification system. This scenario highlights the need for new biomarkers to improve non-invasive screenings and clinical management of patients. MicroRNAs (miRNAs) have emerged as good candidate biomarkers in cancer as they are stable molecules, easily measurable and detected in body fluids thus allowing for non-invasive diagnosis and/or prognosis. In this study, we performed an integrated analysis first using 4 different datasets (discovery cohorts) to identify miRNAs associated with colorectal cancer development, unveil their role in this disease by identifying putative targets and regulatory networks and investigate their ability to serve as biomarkers. We have identified 26 differentially expressed miRNAs which interact with frequently deregulated genes known to participate in commonly altered pathways in colorectal cancer. Most of these miRNAs have high diagnostic power, and their prognostic potential is evidenced by panels of 5 miRNAs able to predict the outcome of stage II and III colorectal cancer patients. Notably, 8 miRNAs were validated in three additional independent cohorts (validation cohorts) including a plasma cohort thus reinforcing the value of miRNAs as non-invasive biomarkers.