Monitoring food consumption and its determinants over time is essential for defining and implementing health promotion strategies, but surveillance is scarce in Africa. The present study aimed to ...describe fruit and vegetable consumption in Mozambique according to socio-demographic characteristics and place of residence (urban/rural). A national representative sample (n 3323) of subjects aged 25-64 years was evaluated in 2005 following the WHO Stepwise Approach to Chronic Disease Risk Factor Surveillance, which included an assessment of usual fruit and vegetable consumption (frequency and quantity). Crude prevalence and age-, education- and family income-adjusted prevalence ratios (PR) with 95 % CI were computed. Less than 5 % of the subjects reported an intake of five or more daily servings of fruits/vegetables. Both fruits and vegetables were more often consumed by women and in rural settings. In urban areas, the prevalence of fruit intake ( ≥ 2 servings/d) increased with education ( ≥ 6 years v. < 1 year: women, adjusted PR = 3·11, 95 % CI 1·27, 7·58; men, adjusted PR = 3·63, 95 % CI 1·22, 10·81), but not with income. Conversely, vegetable consumption ( ≥ 2 servings/d) was less frequent in more educated urban men ( ≥ 6 years v. < 1 year: adjusted PR = 0·30, 95 % CI 0·10, 0·94) and more affluent rural women ( ≥ $801 US dollars (USD) v. $0-64: adjusted PR = 0·32, 95 % CI 0·13, 0·81). The very low intake of these foods in this setting supports the need for fruit and vegetable promotion programmes that target the whole population, despite the different socio-demographic determinants of fruit and vegetable intake.
Early reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is indicated by the European Society of Cardiology, while a timely invasive strategy is recommended for patients ...with high-risk and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE-ACS). This study aims to assess patient and system delays according to diagnosis and risk profile, and to identify predictors of prolonged delay.
We assembled a cohort of patients (n=939) consecutively admitted to the cardiology department of two hospitals, one in the metropolitan area of Porto and one in the north-east region of Portugal, between August 2013 and December 2014.
The proportion of patients with time from symptom onset to first medical contact (FMC) ≥120 min was highest among high-risk NSTE-ACS (57.7%), followed by intermediate-risk NSTE-ACS (52.1%) and STEMI (43.3%). Regardless of diagnosis and risk stratification, use of own transportation and inability to interpret cardiac symptoms correctly were associated with prolonged delays. Regarding system delays, we found that 78.0% of patients with STEMI and 65.8% of patients with high-risk NSTE-ACS were treated in a timeframe exceeding the recommended limits. Admission to a non-percutaneous coronary intervention-capable hospital, admission on weekends and complications at admission were associated with prolonged delays to treatment.
Due to both patient and system delays, a large proportion of STEMI and high-risk NSTE-ACS patients still fail to have access to timely reperfusion.
Atualmente, as normas de orientação clínica da Sociedade Europeia de Cardiologia (SEC) recomendam uma estratégia de reperfusão precoce tanto nos doentes com enfarte agudo do miocárdio com elevação do segmento ST (EAMcST) como nos doentes com síndrome coronária aguda sem elevação do segmento ST (SCAsST) de alto-risco ou risco-intermédio. O objetivo deste estudo foi, considerando o diagnóstico e o perfil de risco dos doentes, avaliar a demora atribuível aos doentes e ao sistema de saúde e identificar preditores de uma demora superior ao recomendado.
Recrutamos uma coorte de doentes com SCA (n=939) admitidos consecutivamente nos serviços de cardiologia de dois hospitais, um na área metropolitana do Porto e um na região de Trás-os-Montes e Alto Douro, entre agosto de 2013 e dezembro de 2014.
A proporção de doentes com tempo ≥120 minutos entre os sintomas e o primeiro contacto com o médico foi de 43,3% nos doentes com EAMcST, 57,7% nos doentes com SCAsST de alto risco e 52,1% nos doentes com SCAsST de risco intermédio. Os doentes que utilizaram transporte próprio e que não reconheceram os sintomas como cardíacos demoraram mais tempo até ao primeiro contacto com o médico. Relativamente aos atrasos atribuíveis ao sistema, 78,0% dos doentes com EAMcST e 65,8% dos doentes com SCAsST de alto-risco demoraram mais tempo do que o recomendado. Ser admitido num hospital sem capacidade de tratamento, ser admitido durante o fim de semana e ter complicações na admissão foram os fatores que contribuíram para os atrasos no tratamento.
Os resultados mostram que uma grande proporção de doentes com SCA é tratada depois do tempo recomendado, limitando o benefício da terapêutica de reperfusão.
To identify a single/panel of biomarkers and to provide a point score that, after 48 h of treatment, could early predict treatment failure at fifth day of Intensive Care Unit (ICU) stay in severe ...community-acquired pneumonia (SCAP) patients.
Single-center, prospective cohort study of 107 ICU patients with SCAP. Primary outcome included death or absence of improvement in Sequential Organ Failure Assessment score by ≥2 points within 5 days of treatment. Biomarkers were evaluated within 12 h of first antibiotic dose (D1) and 48 h after the first assessment (D3).
A model based on Charlson's score and a panel of biomarkers (procalcitonin on D1 and D3, B-natriuretic peptide on D1, D-dimer and lactate on D3) had good discrimination for primary outcome in both derivation (AUC 0.82) and validation (AUC 0.76) samples and was well calibrated (X2 = 0.98; df = 1; p = .32). A point score system (PRoFeSs score) built on the estimates of regression coefficients presented good discrimination (AUC 0.81; 95% Confidence Interval 0.72–0.89) for primary outcome.
In SCAP, a combination of biomarkers measured at admission and 48 h later may early predict treatment failure. PRoFeSs score may recognize patients with poor short-term prognosis.
•Combination of biomarkers may play a central role in the management of SCAP patients.•If measured within the 1st 48 h, they may identify early treatment failure in SCAP.•PRoFeSs score may help to recognize SCAP patients with poor short-term prognosis.
Aim
With the use of a joint model (JM) we investigated how different definitions of baseline serum creatinine (SCr) would affect the association between an acute increase in inpatients' SCr and ...30‐day mortality and whether this effect depends on premorbid SCr trajectory.
Methods
This was a retrospective study including adult patients admitted to a tertiary acute‐care hospital in Porto, Portugal, between January 1, 2013, and December 31, 2015, who had at least two preadmission ambulatory and two inpatients SCr measurements. The baseline SCr was defined as the lowest (‐min), the most recent (‐last) or the median (‐medi) value over the preadmission period. The JM combined a linear mixed model for repeated inpatient SCr relative to baseline value and a Cox proportional survival model. Preadmission SCr courses were identified using linear regression and subsequently clustered based upon a patient‐specific slope. Preadmission SCr trajectories were described as median SCr courses within clusters.
Results
SCr trajectories were: “Stable” (78.0% of patients), “Decreasing” (11.3%) and “Increasing” (10.7%). Overall, an increase in inpatient SCr by 50% relative to baseline SCr‐min raised the risk of 30‐day mortality by 74%; the estimate was not different from hazard ratio (HR) obtained for SCr‐last (1.78) and SCr‐medi (1.71). We found no differences in HR across preadmission trajectories.
Conclusion
The increased risk of death associated with an abrupt rise in inpatient SCr depends neither on the definition of baseline SCr nor patients' SCr trajectory before hospitalisation. Preadmission SCr‐medi value may be the least biased estimate of the baseline renal function.
SUMMARY AT A GLANCE
A novel approach to identify the best way of defining baseline serum creatinine in patients with AKI. This is the first time that mathematical modelling is used to show that the median serum creatinine value over the pre‐admission period may be the least biased estimate of baseline renal function.
ObjectivesPrompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study ...aimed to identify sex differences in presenting symptoms of ACS.DesignData were collected within a prospective cohort study (EPIHeart).SettingPatients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014.ParticipantsPresenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview. Outcome measures: Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex.ResultsChest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P<0.001).ConclusionsWhile there are no significant differences in the frequency or location of pain between sexes, women are more likely to feel pain of higher intensity and to present with referred pain and symptoms other than pain. Knowledge of these ACS presentation profiles is important for health policy decisions and clinical practice.
Abstract Background Information is scarce about the geographic variation in time trends of mortality from coronary heart disease (CHD). We aimed to describe trends in death rates, absolute number of ...deaths and years of life lost (YLL) due to CHD among men and women in Portugal, by region, from 1981–2012. Methods The age-standardized mortality rates from CHD were estimated by sex and region. We used joinpoint regression analysis to calculate the annual percent change (APC) in mortality and to identify points of significant change in the trend. The YLL due to premature mortality for CHD were computed using the Global Burden of Disease method. Results The age-adjusted mortality from CHD decreased between 1981 and 2012, both in men and women, but with significantly different APC by region. Smaller declines in rates were observed in Alentejo (men: APC 1993-2012:-2.4%; women: APC 1991-2012:-2.4%). The greatest decline was observed in Madeira between 2003 and 2012, in men (APC: -7.6%) and women (APC: -9.7%). The decline in rates in Algarve started only after 2003, whereas it was consistent from 1981 in the North and started in the 1990s in most other regions. A decrease in the number of deaths was only observed after 2000. The YLL from CHD decreased from 1981 to 2012, mainly after 2000. Conclusions In Portugal, between 1981 and 2012, relative declines of CHD mortality indicators were different by geographic region. Consistent decreases in mortality rates were only observed in the Centre, Lisbon and North, the most populated and urbanized regions.
•Individual diuretic dose adjustments were frequent over the course of the disease.•At individually optimized doses, chronic diuretic therapy did not impair survival.•Diuretic dose was associated ...with the severity of the patient's clinical condition.
High diuretic doses in chronic heart failure (HF) are potentially deleterious. We assessed the effect of dynamic furosemide dose on all-cause mortality among HF ambulatory patients.
A cohort of 560 ambulatory patients from an outpatient clinic specialized in HF, with median age 70 years, 67% male, and 89% with moderate-severely reduced ejection fraction, was retrospectively followed for up to 5 years. Dynamic furosamide exposure was categorized as low (0–59 mg/d), medium (60–119 mg/d), high (120–159 mg/d), and very high (≥160 mg/d). Extended Cox models were used to estimate the association between time-varying diuretic dose and mortality. A dose-dependent crude association between higher doses of furosemide and death (hazard ratio HR = 1.34, 95% confidence interval (CI): 1.06–2.16; HR = 2.09, 95% CI: 1.54–2.84, for high and very high dose, respectively) was totally explained by patients' characteristics and disease severity indicators (adjusted HR = 0.94, 95% CI: 0.63–1.38; HR = 1.10, 95% CI: 0.79–1.55, for high and very high dose, respectively).
In this context, higher doses of diuretic did not impair survival, but rather indicated greater severity of the patient's condition.
Summary
Background
Real‐world data from different levels of hospital specialisation would help to understand if differences in management between women and men with acute coronary syndrome (ACS) are ...still a priority target. We aimed to identify sex inequalities in management of patients with different types of ACS.
Methods
We analysed 1757 patients with a non‐ST‐elevation ACS (NSTEACS) and 1184 with ST elevation myocardial infarction (STEMI) or left bundle branch block (non‐classifiable (NC) ACS (STEMI/NC ACS group), consecutively discharged from ten Portuguese hospitals with different specialisation levels, between 2008 and 2010. We estimated odds ratios (OR) and 95% confidence intervals (95% CI) for the association between sex and the performance of coronary angiography, reperfusion and revascularisation.
Results
Among STEMI/NC ACS, men had higher probability of performing coronary angiography than women (adjusted OR = 1.64, 95% CI: 1.11‐2.44), while among NSTEACS patients there was no significant difference by sex (adjusted OR = 1.26, 95% CI: 0.99‐1.62). In patients who underwent coronary angiography, there was no difference in proportion of women and men submitted to revascularisation, regardless of the ACS type. Although men with STEMI/NC ACS were more likely to undergo reperfusion (crude OR = 2.17, 95% CI: 1.68‐2.81), the effect became not significant after multivariable adjustment (adjusted OR = 1.33, 95% CI: 0.96‐1.84).
Conclusion
Women diagnosed with STEMI/NC, but not NSTEACS, had lower probability when compared with men to be submitted to coronary angiography. There was no difference in performance of reperfusion and revascularisation by sex.
Abstract Introduction and objectives Renal function impairment predicts poor survival in heart failure. Attention has recently shifted to worsening renal function, based mostly on serum creatinine ...and estimated glomerular filtration rate. We assessed the prognostic effect of worsening renal function in ambulatory heart failure patients. Methods Data from 306 ambulatory patients were abstracted from medical files. Worsening renal function was based on the change in estimated glomerular filtration rate, serum creatinine and urea within 6 months of referral. Prognosis was assessed by the composite endpoint all-cause death or heart failure hospitalization, censored at 2 years. Hazard ratios were estimated for worsening renal function, adjusted for sex, age, diabetes, New York Heart Association class, left ventricular systolic dysfunction, medications and baseline renal function. Results The agreement among definitions was fair, with kappa coefficients generally not surpassing 0.5. Worsening renal function was associated with poor outcome with adjusted hazard ratios (95% confidence interval) of 3.2 (1.8–5.9) for an increase of serum creatinine > 0.3 mg/dl; 2.2 (1.3–3.7) for an increase in serum urea > 20 mg/dl and 1.9 (1.1–3.3) for a decrease in estimated glomerular filtration rate > 20%, independent of baseline renal function. The 2-year risk of death/heart failure hospitalization was approximately 50% in patients with an increase in serum creatinine or in serum urea; this positive predictive value was higher than for decreasing estimated glomerular filtration rate. Conclusions In conclusion, worsening renal function was significantly associated with a worse outcome. Different definitions identified different patients at risk and increasing creatinine/urea performed better than decreasing estimated glomerular filtration rate.
AbstractIntroduction and objectivesDespite increased awareness of sex disparities in care and outcomes of acute myocardial infarction (AMI), there appears to have been no consistent attenuation of ...these differences over the last decade. We investigated differences by sex in management and 30-day mortality using the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QIs) for AMI.MethodsProportions and standard errors of the 20 Acute Cardiovascular Care Association QIs were calculated for 771 patients with AMI who were admitted to the cardiology departments of 2 tertiary hospitals in Portugal between August 2013 and December 2014. The association between the composite QI and 30-day mortality was derived from logistic regression.ResultsSignificantly fewer eligible women than men received timely reperfusion, were discharged on dual antiplatelet therapy and high-intensity statins, and were referred to cardiac rehabilitation. Women were less likely to receive recommended interventions (59.6% vs 65.2%; P < .001) and also had higher mean GRACE 2.0 risk score-adjusted 30-day mortality (3.0% vs 1.7%; P < .001). An inverse association between the composite QI and crude 30-day mortality was observed for both sexes (OR, 0.08; 95%CI, 0.01-0.64 for the highest performance tertile vs the lowest). ConclusionsPerformance in AMI management is worse for women than men and is associated with higher 30-day mortality, which is also worse for women. Evidence-based QIs have the potential to improve health care delivery and patient prognosis in the overall AMI population and may also bridge the disparity gap between women and men.
PDF
