Using Markov chains and temporal alignment to identify clinical patterns in Dementia.

In the healthcare sector, resorting to big data and advanced analytics is a great advantage when dealing with complex groups of patients in terms of comorbidities, representing a significant step towards personalized targeting. In this work, we focus on understanding key features and clinical pathways of patients with multimorbidity suffering from Dementia. This disease can result from many heterogeneous factors, potentially becoming more prevalent as the population ages. We present a set of methods that allow us to identify medical appointment patterns within a cohort of 1924 patients followed from January 2007 to August 2021 in Hospital da Luz (Lisbon), and to stratify patients into subgroups that exhibit similar patterns of interaction. With Markov Chains, we are able to identify the most prevailing medical appointments attended by Dementia patients, as well as recurring transitions between these. To perform patient stratification, we applied AliClu, a temporal sequence alignment algorithm for clustering longitudinal clinical data, which allowed us to successfully identify patient subgroups with similar medical appointment activity. A feature analysis per cluster obtained allows the identification of distinct patterns and characteristics. This pipeline provides a tool to identify prevailing clinical pathways of medical appointments within the dataset, as well as the most common transitions between medical specialities within Dementia patients. This methodology, alongside demographic and clinical data, has the potential to provide early signalling of the most likely clinical pathways and serve as a support tool for health providers in deciding the best course of treatment, considering a patient as a whole.

An isothermal lab-on-phone test for easy molecular diagnosis of SARS-CoV-2 near patients and in less than 1 hour.

OBJECTIVES: The performance of a new point-of-care CE-IVD-marked isothermal lab-on-phone COVID-19 assay was assessed in comparison to a gold standard real-time reverse transcriptase-PCR method. METHODS: The study was conducted following a nonprobability sampling of ≥16-year-old volunteers from three different laboratories, using direct mouthwash (N = 24) or nasopharyngeal (N = 191) clinical samples. RESULTS: The assay demonstrated 95.19% sensitivity and 100% specificity for detection of SARS-CoV-2 in direct nasopharyngeal crude samples and 78.95% sensitivity and 100% specificity in direct mouthwash crude samples. It also successfully detected currently predominant SARS-CoV-2 variants of concern (Beta B.1.351, Delta B.1.617.2, and Omicron B.1.1.529) and demonstrated to be inert against potential cross-reactions of other common respiratory pathogens that cause infections that present similar symptoms to COVID-19. CONCLUSION: This lab-on-phone pocket-sized assay relies on an isothermal amplification of SARS-CoV-2's N and E genes, taking just 50 minutes from sample to result, with only 2 minutes of hands-on time. It presents good performance when using direct nasopharyngeal crude samples, enabling a low-cost, real-time, rapid, and accurate identification of SARS-CoV-2 infections at the point of care, which is important for both clinical management and population screening, as a tool to break the chain of transmission of COVID-19 pandemic, especially in low-resources environments.

Therapeutic Plasmapheresis: Seven Year Experience of an Intensive Care Unit in Portugal.

INTRODUCTION: Therapeutic plasmapheresis is a therapeutic procedure in which the patient's blood is passed through a medical device which separates out plasma from other components of blood. The plasma is removed and replaced with a replacement solution. Studies on the use of plasmapheresis in critically ill patients are scarce. The aim of this study was to review all therapeutic plasmapheresis sessions carried out in the Hospital Beatriz Ângelo intensive care unit. MATERIAL AND METHODS: An observational retrospective study was conducted between April 2012 and March 2019. All patients who underwent therapeutic plasmapheresis in the intensive care unit were included, and plasmapheresis sessions held outside the intensive care unit were excluded. RESULTS: Of 46 patients, 63% were men (n = 29), with a median age of 53 years. The most frequent diagnoses were hypertriglyceridemia-induced pancreatitis, vasculitis, autoimmune haemolytic anaemia, and atypical haemolytic-uremic syndrome. A total of 198 plasmapheresis sessions were carried out in the intensive care unit. Most of the used replacement solutions were fresh frozen plasma (34.4%), albumin/crystalloid (24.2%), and albumin/fresh frozen plasma (19.2%). The most common complications were hydroelectrolytic changes (84; 42.4%) and coagulation disorders/thrombocytopenia (65; 32.8%). There was no need to interrupt any plasmapheresis session due to complications related to the patient. DISCUSSION: Therapeutic plasmapheresis is an urgent procedure that can reduce morbidity and mortality in critically ill patients. This justifies that 37% of patients started the technique before the diagnostic confirmation. The indications for plasmapheresis and the choice of replacement solution were in agreement with the guidelines. Despite the risk of bleeding, no haemorrhagic complications were recorded. CONCLUSION: Therapeutic plasmapheresis is a complex technique that requires specific training. The indications are diverse, and some are not consensual. Complications were frequent, but they did not increase morbidity.

Introdução: A plasmaferese terapêutica é um procedimento em que o sangue passa por um circuito extracorpóreo que separa o plasma dos outros componentes do sangue. O plasma removido é substituído por soluções de reposição. Os estudos sobre a utilização de plasmaferese terapêutica no doente crítico são escassos. O objetivo do estudo foi rever todas as sessões de plasmaferese realizadas no serviço de Medicina Intensiva do Hospital Beatriz Ângelo. Material e Métodos: Estudo observacional retrospetivo de todos os doentes admitidos no serviço de Medicina Intensiva entre abril de 2012 e março de 2019. Foram selecionados os doentes submetidos a plasmaferese e excluídas as sessões realizadas fora do serviço de Medicina Intensiva. Resultados: No período de estudo foram incluídos 46 doentes. A maioria eram homens (n = 29; 63%) com uma idade mediana de 53 anos. Os diagnósticos mais frequentes foram pancreatite secundária a hipertrigliceridemia, vasculite, anemia hemolítica autoimune e síndrome hemolítica urémica atípica. Foram realizadas 198 sessões de plasmaferese no serviço de Medicina Intensiva. As soluções de substituição mais utilizadas foram plasma fresco congelado (34,4%), albumina/cristalóide (24,2%) e albumina/plasma (19,2%). As complicações mais comuns foram alterações hidroeletrolíticas (84; 42,4%), e distúrbios da coagulação/plaquetas (65; 32,8%). Em nenhum dos casos a técnica teve que ser interrompida por complicações relacionadas com o doente. Discussão: A plasmaferese terapêutica é um procedimento urgente capaz de reduzir a morbilidade e mortalidade no doente crítico. Isto justifica que 37% dos doentes tenham iniciado a técnica antes da confirmação diagnóstica. As indicações e soluto de reposição escolhido foram de acordo com as recomendações. Apesar do risco hemorrágico, nenhuma complicação desta natureza foi reportada. Conclusão: A plasmafere terapêutica é uma técnica complexa que requer treino específico. As indicações são diversas e algumas não consensuais. As complicações foram frequentes, mas não condicionaram morbilidade associada.

Overactive Bladder Symptoms after Transobturator Sling Surgery for Pure Stress Urinary Incontinence: A Cross-Sectional Comparative Study.

INTRODUCTION: Transobturator tape (TOT) surgery has been associated with increased overactive bladder (OAB) although much controversy exists. METHODS: In a cross-sectional study, women who underwent TOT surgery for pure stress incontinence (MonarcTM) answered the 6 questions of the symptom bother (SB) subscale of the OAB questionnaire - short form (OABq-SF) and an additional question regarding whether symptoms began after surgery. Women with SB score over the 4th quartile (≥30/100) were reassessed after a longer follow-up. Patients from primary care were recruited as controls. RESULTS: We recruited 213 patients (135 in the TOT group and 78 age-adjusted controls). The mean age of operated patients was 58.7 ± 10.1 years with a mean follow-up of 25.9 ± 13.2 months. OABq-SF SB scores did not differ between the TOT group and controls (respectively, 18.5 ± 30 and 15.5 ± 6.7, p = 0.202). A total of 48% patients reported no relationship between symptoms and surgery. Highly symptomatic operated patients were reassessed after a longer follow-up (46.3 ± 10.6 months). The mean score in the second follow-up (n = 25) was not statistically different from the first assessment (46.4 ± 22.7 and 58.1 ± 19.8, p = 0.059). CONCLUSIONS: Women who underwent TOT surgery did not show increased OAB SB scores when compared to controls. Our study suggests that OAB symptoms may thus be present but overlooked during initial clinical assessment.

Spontaneous rupture of renal angiomyolipoma during pregnancy.

Renal angiomyolipoma is a benign tumor, composed of adipocytes, smooth muscle cells and blood vessels. The association with pregnancy is rare and related with an increased risk of complications, including rupture with massive retroperitoneal hemorrhage. The follow-up is controversial because of the lack of known cases, but the priorities are: timely diagnosis in urgent cases and a conservative treatment when possible. The mode of delivery is not consensual and should be individualized to each case. We report a case of a pregnant woman with 18 weeks of gestation admitted in the emergency room with an acute right low back pain with no other symptoms. The diagnosis of rupture of renal angiomyolipoma was established by ultrasound and, due to hemodynamically stability, conservative treatment with imaging and clinical monitoring was chosen. At 35 weeks of gestation, it was performed elective cesarean section without complications for both mother and fetus.

Spontaneous rupture of renal angiomyolipoma during pregnancy / Rotura espontânea de um angiomiolipoma durante a gravidez

Renal angiomyolipoma is a benign tumor, composed of adipocytes, smooth muscle cells and blood vessels. The association with pregnancy is rare and related with an increased risk of complications, including rupture with massive retroperitoneal hemorrhage. The follow-up is controversial because of the lack of known cases, but the priorities are: timely diagnosis in urgent cases and a conservative treatment when possible. The mode of delivery is not consensual and should be individualized to each case. We report a case of a pregnant woman with 18 weeks of gestation admitted in the emergency room with an acute right low back pain with no other symptoms. The diagnosis of rupture of renal angiomyolipoma was established by ultrasound and, due to hemodinamically stability, conservative treatment with imaging and clinical monitoring was chosen. At 35 weeks of gestation, it was performed elective cesarean section without complications for both mother and fetus.

O angiomiolipoma é um tumor benigno, constituído por adipócitos, células de músculo liso e vasos sanguíneos. Sua associação com a gravidez é rara e está relacionada com um aumento de complicações, nomeadamente rotura com hemorragia retroperitoneal maciça. O follow-up é controverso em razão do escasso número de casos descritos, no entanto as prioridades são: diagnóstico atempado nas situações urgentes e, sempre que possível, tratamento conservador. O tipo de parto não é consensual e deve ser individualizado caso a caso. Relatamos um caso de uma grávida com 18 semanas de gestação que recorreu ao serviço de urgência por lombalgia direita aguda, sem outros sintomas relevantes. Diagnosticou-se ecograficamente rotura de angiomiolipoma renal e, em decorrência da estabilidade hemodinâmica do quadro, procedeu-se ao tratamento conservador com monitorização imagiológica e clínica. Às 35 semanas de gestação, realizou-se uma cesariana eletiva que decorreu sem complicações maternas ou fetais.

Fulminant myocarditis caused by Legionella pneumophila: case report.

Myocarditis is defined as inflammation of the myocardium. The clinical manifestations of myocarditis vary from flu-like symptoms to fatal fulminant forms. We report the case of a 39-year-old woman with a diagnosis of cardiogenic shock caused by fulminant myocarditis. Extracorporeal membrane oxygenation was used as a bridge to recovery. Etiological study revealed Legionella pneumophila serogroup 1 infection. Recovery of biventricular function was seen after treatment with azithromycin.

[Hysteroscopic diagnostic accuracy in post-menopausal bleeding]. / Eficácia diagnóstica da histeroscopia nas metrorragias pós-menopausa.

OBJECTIVE: To evaluate the diagnostic accuracy of hysteroscopy at our unit for postmenopausal bleeding, specially concerning proliferative lesions. METHODS: We analyzed the results of 335 hysteroscopies that were done during the last 8 years in our hysteroscopic unit and we compared the hysteroscopic diagnosis with the biopsy result done during the procedure. Data were group according to pathologic findings in three groups normal, proliferative lesions and benign lesions. Data were analyzed by direct comparison. Sensitivity and specificity were calculated, Kappa index was used to access the inter-rater reliability, and likelihood ratio and the post test probability were used to analyze the true value of hysteroscopy. RESULTS: Women were aged between 36 and 88 years, with an average of 61,5. Histological diagnosis was atrophy in 42,1% patients, polyps in 43,3%, sub-mucous fibromioma in 5%, hyperplasic lesions in 9,6%, half of them being carcinomas. Overall Kappa index for the 3 groups was 0,831 which is in line with excellent agreement. Concerning proliferative lesions (hyperplasia + carcinoma vs carcinoma alone) and comparing to histology, sensitivity was 78,1% vs 81,3%; specificity 95,7% vs 98,7%. The positive likelihood ratio was 18,2 vs 64,8 and the negative likelihood ratio was 0,23 vs 0,19. The probability post positive test was 66% vs 76% and the probability post negative test was 2,4% vs 0,95%. No cases of carcinoma were identified among the 129 women diagnosed as having atrophy. However 3,9% of all the lesions regarded as being polyps at the hysteroscopy proved to be proliferative lesions at hysteroscopy. CONCLUSION: Hysteroscopy at our unit is a highly accurate procedure concerning post menopausal endometrial bleeding, with its results being in line with the literature. Diagnosing atrophy or excluding a proliferative lesion by the observer was highly predictive of a negative carcinoma in the histology. Using this argument whenever a proliferative lesion was excluded, only 1 in 302 hysteroscopies hid a carcinoma. Polyps should be regarded as possible proliferative lesions. Despite this result we believe a biopsy should always be undertaken no matter the observer's diagnosis.

[Peripartum cardiomyopathy]. / Miocardiopatia periparto.

The Peripartum Cardiomyopathy is a rare form of heart disease, of uncertain etiology, more common in black and multiparous women, older than thirty years old. Is defined as development of maternal congestive heart failure, in the last month of pregnancy or within five months after delivery, with documented left ventricular systolic dysfunction, in the absence of a demonstrable cause for heart failure in a previously healthy woman. The diagnosis is commonly established with chest radiography, electrocardiogram and echocardiography. Treatment consist in medical therapy with inotropic support, afterload and preload redution, and anticoagulation. Surgical care with cardiac transplantation is indicated in severe cases with progressive left ventricular dysfunction, despite medical therapy. Prognosis seems dependent on recovery of left ventricular function and maternal mortality rates could reach 50%. Future pregnancy is not recommended in woman with persistent ventricular dysfunction. The authors present a case report in a black nuliparous woman at term, with 33 years old, without previous heart disease that presents a sudden heart failure, with ventricular dysfunction on echocardiography, after the caesarean, with recovery of normal ventricular function at 11th day of puerperium.

Cystocele - vaginal approach to repairing paravaginal fascial defects.

The objective of this study is to determine the efficacy and safety of vaginal approach to repair paravaginal defects in patients with symptomatic cystocele. This was a retrospective study of 66 women with a diagnosis of symptomatic cystocele grade 2 to 4, referred to our unit between January 2002 and March 2005. A clinical evaluation was carried out using the Baden-Walker classification before and after the surgery. The same surgical team performed every surgery. The repair of paravaginal fascial defects was carried out through a vaginal approach, exposing the arcus tendineus. The paravaginal fascial defects were corrected through suspension of vesicovaginal fascia to the arcus tendineus with nonreabsorbable Ethibond 0 sutures. Women were seen for follow-up at 3, 6, and 12 months. The presence of well-demarcated vaginal lateral sulci at grade 0, firmly apposed to the lateral pelvic sidewalls and no anterior relaxation with Valsalva maneuver, were used as criteria for cure. Grade 2 cystocele was diagnosed preoperatively in most women. The mean duration of complaints due to prolapse was 64.6 months. There were no major intraoperative complications. Mean time of inpatient stay was of 4.9 days. The cure rate at 12 months was 91.6%. There were five cases of recurrence of cystocele 6 months after surgery. Surgical repair of symptomatic cystocele through a paravaginal approach is a safe and efficacious technique. Vaginal approach to repair paravaginal fascia defects had a low postoperative morbidity and high cure rate at 12 months (91.6%).