Economic Evaluation of Ticagrelor for Secondary Prevention Following Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES: To estimate the cost-effectiveness and cost-utility of ticagrelor in the treatment of patients with acute coronary syndromes (unstable angina or myocardial infarction with or without ST-segment elevation), including patients treated medically and those undergoing percutaneous coronary intervention or coronary artery bypass grafting. METHODS: A short-term decision tree and a long-term Markov model were used to simulate the evolution of patients' life-cycles. Clinical effectiveness data were collected from the PLATO trial and resource use data were obtained from the Hospital de Santa Marta database, disease-related group legislation and the literature. RESULTS: Ticagrelor provides increases of 0.1276 life years and 0.1106 quality-adjusted life years (QALYs) per patient. From a societal perspective these clinical gains entail an increase in expenditure of €610. Thus the incremental cost per life year saved is €4780 and the incremental cost per QALY is €5517. CONCLUSIONS: The simulation results show that ticagrelor reduces events compared to clopidogrel. The costs of ticagrelor are partially offset by lower costs arising from events prevented. The use of ticagrelor in clinical practice is therefore cost-effective compared to generic clopidogrel.

Tecnologia na Saúde. Problemas Éticos

A evolução da tecnologia médica tem sido bastante importante no que diz respeito ao tratamento e diagnóstico de doenças. No entanto, colocam-se algumas questões relativamente à utilização desta tecnologia. Será que se deve salvar todos aqueles em busca de tratamento? Com que custos para os restantes, tendo em conta a limitação de recursos financeiros e humanos? No extremo, considerando a possibilidade de terapia genética, não existirá um aumento exagerado da população e um gasto incomportável dos recursos do planeta? Deve-se então reflectir profundamente nestas questões e analisar se, com esta evolução tecnológica, não caminhamos para uma população envelhecida em que a salvação de alguns surgirá à custa de muitos.

A Case of Post-Radiotherapy Gastritis: Radiation Does Not Explain Everything

Hemorrhagic gastritis is a possible late toxicity outcome after radical radiotherapy but it is nowadays a very rare condition and most likely depends on other clinical factors. We report the case of a 77-year-old woman with a symptomatic solitary extramedullary intra-abdominal plasmacytoma and multiple gastric comorbidities, treated with external beam radiotherapy. Despite the good response to radiotherapy, the patient experienced multiple gastric bleeding a few months later, with the need of multiple treatments for its control. In this paper we will discuss in detail all aspects related to the different causes of hemorrhagic gastritis.

Metastização Gástrica e Entérica de Carcinoma Lobular Invasivo da Mama

O carcinoma lobular invasivo (CLI) representa 5-15% dos casos de cancro invasivo da mama, diferindo do carcinoma ductal invasivo(CDI), o tumor invasivo mais frequente da mama, quer na forma de apresentação clínica, quer nos aspectos imagiológicos e histológicos, assim como no padrão de metastização. O objectivo deste artigo passa pelo relato clínico de um padrão atípico de metastização de cancro da mama. Mulher de 80 anos, que apresentava queixas de dor abdominal, com 6 meses de evolução, de carácter generalizado, com maior intensidade nos quadrantes direitos, associada a episódios de sub-oclusão. O exame objectivo revelou volumosa hérnia incisional paramediana direita sem sinais de sofrimento e uma lesão ulcerada da mama esquerda nunca antes revelada pela doente. Realizou uma mamografia que mostrou uma lesão T4 e a biópsia da mesma revelou Carcinoma Ductal Invasivo. Por apresentar anemia microcítica hipocrómica de 7 g/dL realizou também uma Endoscopia Digestiva Alta que demonstrou uma úlcera da pequena curvatura gástrica cuja biópsia revelou um carcinoma difuso. Optou-se pela intervenção cirúrgica com ideação paliativa. Foi efectuada mastectomia simples esquerda e correcção de hérnia incisional com enterectomia segmentar. Os resultados histológicos das peças operatórias foram surpreendentes: Carcinoma lobular invasivo da mama e metástase do mesmo no segmento de intestino ressecado. Foram revistas as lâminas referentes à biópsia gástrica previamente realizada, tendo sido feito estudo imunohistoquímico que mostrou positividade para os receptores hormonais o que favorecia tratar-se de metástase de carcinoma lobular da mama no estômago. Como conclusão temos a referir que o CLI apresenta um padrão distinto de metastização em relação ao CDI, com diferentes órgãos-alvo, realçando o papel fundamental da suspeição clínica e de uma histologia exigente para o seu diagnóstico.

Intraocular Pressure in Eyes Receiving Intravitreal Antivascular Endothelial Growth Factor Injections

PURPOSE: The aim of the this study was to determine the effect of intravitreal antivascular endothelial growth factor injections on intraocular pressure (IOP) and identify possible risk factors for the development of increased IOP. MATERIALS AND METHODS: This prospective study included a total of 106 eyes receiving intravitreal injection of bevacizumab as treatment for macular edema or active choroidal neovascularization. IOP was measured by Goldmann applanation tonometry immediately before the intravitreal injection and 5 min, 1 h and 15 days after the procedure. The records of the study patients were reviewed for age, gender, history of glaucoma, diabetes mellitus, phakic status, systemic and topical medication and number of previous injections. Subconjunctival reflux was registered. IOP elevation was defined as IOP ≥21 mm Hg and/or a change from baseline of ≥5 mm Hg recorded at least on two or more measurements on the same visit. RESULTS: Mean preoperative IOP was 15.31 ± 3.90 mm Hg and postoperative IOP values were 27.27 ± 11.87 mm Hg (after 5 min), 17.59 ± 6.24 mm Hg (after 1 h) and 16.86 ± 3.62 mm Hg (after 15 days). The IOP variation was statistically significant between pre- and postoperative measurements (p < 0.05). Subconjunctival reflux was recorded in 11.3%, and in this subgroup the IOP at 5 min and at 1 h was lower than preoperative IOP (p < 0.05). CONCLUSIONS: More than one third of the eyes achieved IOPs >30 mm Hg 5 min after injection. Subconjunctival reflux contributed to a lower mean postoperative IOP (p < 0.05). Considerations for the management include prophylactic IOP lowering with medical therapy and/or preinjection ocular decompression for patients with a history of glaucoma or ocular hypertension and switching to an as-needed injection protocol in patients suffering a marked IOP rise in previous injections. © 2015 S. Karger AG, Basel.

Análise Estrutural do Segmento Anterior por Tomografia de Coerência Ótica no Glaucoma Congénito Primário

Objectivo: Analisar a morfologia do segmento anterior por tomografia de coerência ótica de segmento anterior (OCT-SA) em crianças com glaucoma congénito primário (GCP). Material e métodos: Realizou-se um estudo caso-controlo, prospetivo, em crianças com GCP e em crianças sem glaucoma (grupo controlo), seguidas em Consulta de Oftalmologia Pediátrica do Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central. Efectuou-se avaliação oftalmológica completa e OCT-SA utilizando o protocolo A C biometry. Resultados: O estudo incluiu 27 olhos (17 crianças com OCP) e 22 olhos (11 crianças sem glaucoma). Detetaram-se valores significativamente superiores de profundidade central e largura da câmara anterior (CA) (p<0,001) e maiores distâncias de abertura do ângulo a 500 CP<0,001) e 750µm (p=0,00 l), áreas de espaço irido-trabecular a 500 e 750µm (p<0,001) e áreas do recesso do ângulo a 500 (p<0,00l) e 750µm (p=0,001), no grupo GCP. A espessura da íris foi significativamente mais fina a 500µm do ângulo (p=0,011), no centro da íris (p<0,001) e na região mais espessa da mesma (p=0,001) no grupo GCP, assim como o comprimento da íris foi superior (p<0,001). A largura de CA e a acuidade visual (logMAR) apresentam correlação positiva (r=0,688; p<0,001). Outros achados morfológicos: anteriorização e hipoplasia da íris, alteração da morfologia do ângulo no local de intervenção cirúrgica (goniotomia, trabeculotornia, trabeculectomia, válvula de Ahmed). Conclusão: Este primeiro estudo em crianças com GCP sugere que a OCT-SA é de aquisição relativamente fácil, poderá ajudar no seguimento clínico e cirúrgico e ser útil como fator prognóstico destes doentes.

Contribuição da Microscopia Confocal In Vivo para o Diagnóstico e Follow-Up de Neoplasias Conjuntivais Intraepiteliais

Objectivo: Analisar o contributo da microscopia confocal in vivo para o diagnóstico efollow-up de neoplasias conjuntivais intraepiteliais. Métodos: Avaliámos 5 doentes com neoplasia conjuntival intraepitelial unilateral com o Heidelberg Retina Tomograph II, Rostock Cornea Module. Três doentes foram submetidos a excisão com crioterapia adjuvante, um doente a excisão com crioterapia adjuvante e ciclos de IFN-a2b e um doente a excisão simples e ciclos de IFN-a2b. As imagens de microscopia confocal foram comparadas com a histologia das mesmas lesões. 0 follow-up clínico, através de fotografias do segmento anterior, foi comparado com os achados da microscopia confocal. Resultados: Três dos doentes foram identificados histologicamente como neoplasia intraepitelial de alto grau e dois como carcinoma in situ. As características histológicas descritas correlacionam- se bem com as visíveis à microscopia confocal: alteração da estrutura do epitélio com acantose, disqueratose, pleomorfismo celular, aumento da refletibilidade celular e nuclear, com relação núcleo/citoplasma aumentada e por vezes binucleação. A lesão é bem delimitada e os plexos nervosos sob a lesão não são visíveis. A microscopia confocal identificou uma recidiva e demonstrou-se útil na monitorização da resposta ao tratamento. Conclusão: A microscopia confocal ill vivo pode ter um papel importante não só no diagnóstico inicial como também na deteção de recidivas e na avaliação da resposta ao tratamento, de uma forma minimamente invasiva.

Phacoemulsification Versus Peripheral Iridotomy in the Management of Chronic Primary Angle Closure: Long-Term Follow-Up

Primary angle closure occurs as a result of crowded anterior segment anatomy, causing appositional contact between the peripheral iris and trabecular meshwork, thereby obstructing aqueous outflow. Several studies highlight the role of the crystalline lens in its pathogenesis. The objective of this work is to compare the long-term efficacy of phacoemulsification versus laser peripheral iridotomy (LPI) in the management of chronic primary angle closure (CPAC). Prospective case-control study with 30 eyes of 30 patients randomly divided in two groups: 15 eyes in the LPI group and 15 eyes in the IOL group. Patients in the LPI group underwent LPI using argon and Nd:YAG laser. Patients in the IOL group underwent phacoemulsification with posterior chamber intraocular lens (IOL) implantation. Examinations before and after the procedure included gonioscopy, Goldmann applanation tonometry, and anterior chamber evaluation using the Pentacam rotating Scheimpflug camera. The mean follow-up time was 31.13 ± 4.97 months. There was a statistically significant reduction in the intraocular pressure (IOP) and number of anti-glaucoma medications (p < 0.01) only in the IOL group. Anterior chamber depth, angle, and volume were all higher in the IOL group (p < 0.01) at the end of the follow-up period. Phacoemulsification with posterior chamber IOL implantation results in a higher anterior chamber depth, angle, and volume, when compared to LPI. Consequently, phacoemulsification has greater efficacy in lowering IOP and preventing its long-term increase in patients with CPAC and cataract.

Effect of C282Y Genotype on Self-Reported Musculoskeletal Complications in Hereditary Hemochromatosis

OBJECTIVE: Arthropathy that mimics osteoarthritis (OA) and osteoporosis (OP) is considered a complication of hereditary hemochromatosis (HH). We have limited data comparing OA and OP prevalence among HH patients with different hemochromatosis type 1 (HFE) genotypes. We investigated the prevalence of OA and OP in patients with HH by C282Y homozygosity and compound heterozygosity (C282Y/H63D) genotype. METHODS: A total of 306 patients with HH completed a questionnaire. Clinical and demographic characteristics and presence of OA, OP and related complications were compared by genotype, adjusting for age, sex, body mass index (BMI), current smoking and menopausal status. RESULTS: In total, 266 of the 306 patients (87%) were homozygous for C282Y, and 40 (13%) were compound heterozygous. The 2 groups did not differ by median age [60 (interquartile range [IQR] 53 to 68) vs. 61 (55 to 67) years, P=0.8], sex (female: 48.8% vs. 37.5%, P=0.18) or current smoking habits (12.4% vs. 10%, P=0.3). As compared with compound heterozygous patients, C282Y homozygous patients had higher median serum ferritin concentration at diagnosis [1090 (IQR 610 to 2210) vs. 603 (362 to 950) µg/L, P<0.001], higher median transferrin saturation [80% (IQR 66 to 91%) vs. 63% (55 to 72%), P<0.001]) and lower median BMI [24.8 (22.1 to 26.9) vs. 26.2 (23.5 to 30.3) kg/m2, P<0.003]. The overall prevalence of self-reported OA was significantly higher with C282Y homozygosity than compound heterozygosity (53.4% vs. 32.5%; adjusted odds ratio [aOR] 2.4 [95% confidence interval 1.2-5.0]), as was self-reported OP (25.6% vs. 7.5%; aOR 3.5 [1.1-12.1]). CONCLUSION: Patients with C282Y homozygosity may be at increased risk of musculoskeletal complications of HH.

Two Novel CMY-2-Type β-Lactamases Encountered in Clinical Escherichia Coli Isolates

BACKGROUND: Chromosomally encoded AmpC β-lactamases may be acquired by transmissible plasmids which consequently can disseminate into bacteria lacking or poorly expressing a chromosomal bla AmpC gene. Nowadays, these plasmid-mediated AmpC β-lactamases are found in different bacterial species, namely Enterobacteriaceae, which typically do not express these types of β-lactamase such as Klebsiella spp. or Escherichia coli. This study was performed to characterize two E. coli isolates collected in two different Portuguese hospitals, both carrying a novel CMY-2-type β-lactamase-encoding gene. FINDINGS: Both isolates, INSRA1169 and INSRA3413, and their respective transformants, were non-susceptible to amoxicillin, amoxicillin plus clavulanic acid, cephalothin, cefoxitin, ceftazidime and cefotaxime, but susceptible to cefepime and imipenem, and presented evidence of synergy between cloxacilin and cefoxitin and/or ceftazidime. The genetic characterization of both isolates revealed the presence of bla CMY-46 and bla CMY-50 genes, respectively, and the following three resistance-encoding regions: a Citrobacter freundii chromosome-type structure encompassing a blc-sugE-bla CMY-2-type -ampR platform; a sul1-type class 1 integron with two antibiotic resistance gene cassettes (dfrA1 and aadA1); and a truncated mercury resistance operon. CONCLUSIONS: This study describes two new bla CMY-2-type genes in E. coli isolates, located within a C. freundii-derived fragment, which may suggest their mobilization through mobile genetic elements. The presence of the three different resistance regions in these isolates, with diverse genetic determinants of resistance and mobile elements, may further contribute to the emergence and spread of these genes, both at a chromosomal or/and plasmid level.

First Diabetic Retinopathy Prevalence Study in Portugal: RETINODIAB Study-Evaluation of the Screening Programme for Lisbon and Tagus Valley Region

BACKGROUND/AIMS: In Portugal, so far, there is no study or even accurate data on the prevalence of diabetic retinopathy (DR), based on a large representative sample and on a long-term follow-up. The objective of our study was to determine the prevalence of DR based on a national screening community-based programme. METHODS: A 5-year retrospective analysis of the RETINODIAB screening programme results was implemented in Lisbon and Tagus Valley area between July 2009 and October 2014. We estimated the prevalence of retinopathy for all patients with type 2 diabetes and studied the association between known risk factors and retinopathy emergence at their first screening. RESULTS: Throughout this period, from a total of 103 102 DR readable screening examinations, 52 739 corresponded to patients who attended RETINODIAB screening at entry. Globally, DR was detected in 8584 patients (16.3%). Of these, 5484 patients (10.4%) had mild non-proliferative (NP) DR, 1457 patients (2.8%) had moderate NPDR and 672 (1.3%) had severe NPDR. Finally, 971 patients (1.8%) had proliferative DR requiring urgent referral to an ophthalmologist. The presence of any DR, non-referable DR or referable DR was strongly associated with increasing duration of diabetes and earlier age at diagnosis. CONCLUSIONS: The prevalence rate of DR in our study (16.3%) was slightly lower than other published international data. The RETINODIAB network proved to be an effective screening programme as it improved DR screening in Lisbon and Tagus Valley surrounding area

Tumors of the Brachial Plexus in a Tertiary Referral Center: a Case Series and Literature Review

Introduction: Brachial plexus (BP) tumors are very rare tumors, with less than 800 cases been described in the literature worldwide since 1970. These tumors often present as local or radicular pain, with scant or no neurological deficits. These symptoms are shared by many other more common rheumatologic diseases, thus making their diagnosis difficult in most cases. Additionally, these tumors often present as lumps and are therefore biopsied, which carries a significant risk of iatrogenic nerve injury. Material and Methods: In this paper the authors describe their experience with the management of 5 patients with BP tumors followed up for at least 2 years. There were 4 males and 1 female. Median follow-up time was 41 ± 21 months. Average age at diagnosis was 40,0 ± 19,9 years. The most common complaints at presentation were pain and sensibility changes. All patients had a positive Tinel sign when the lesion was percussed. In all patients surgery was undertaken and the tumors removed. In 4 patients nerve integrity was maintained. In one patient with excruciating pain a segment of the nerve had to be excised and the nerve defect was bridged with sural nerve grafts. Results: Pathology examination of the resected specimens revealed a Schwannoma in 4 cases and a neurofibroma in the patient submitted to segmental nerve resection. Two years postoperatively, no recurrences were observed. All patients revealed clinical improvement. The patient submitted to nerve resection had improvement in pain, but presented diminished strength and sensibility in the involved nerve territory. Conclusion: Surgical excision of BP tumors is not a risk free procedure. Most authors suggest surgery if the lesion is symptomatic or progressing in size. If the tumor is stationary and not associated with neurological dysfunction a conservative approach should be taken.