Home management of INR in the public health system: feasibility of self-management of oral anticoagulation and long-term performance of individual POC devices in determining INR

The home prothrombin time/international normalized ratio (PT/INR) self-management could be convenient for patients, enhancing treatment compliance and improving the quality of the oral anticoagulation. However, patient self-management (PSM) of oral anticoagulation may not be feasible for up to half of the patients due to cognitive or educational issues. In the present study, we aimed to evaluate the feasibility of a PSM program in a public health medical center that provides care for low-income patients. We also aimed to determine the accuracy of individual point-of-care devices (CoaguChek XS^®) during long-term of home manipulation. Patients’ time-in-therapeutic range (TTR) and perception of quality of life, were evaluated at scheduled study-visits to the center. Additionally, the accuracy of individual CoaguChek XS^® was evaluated in comparison to the standard automated coagulometer at scheduled study-visits to the center. Twenty-five patients were included in the PSM program. The median TTR of patients was 75 % before inclusion, 72 % at 3 months, 75 % at 6 months and 100 % at 12 months after the beginning of self-management (P = 0.14).The median DASS scores were 64, 63, 61.5 and 71.5 before inclusion and at 3, 6 and 12 months, respectively (P = 0.09). One hundred paired INR values were obtained. Correlation between INR values delivered by individual CoaguChek XS^® and the automated coagulometer was 94 % and the mean result bias was 0.07 INR units. The coefficient of correlation and the mean bias between methods was stable during 24 months of follow-up. The present study suggests that PSM is feasible for patients treated in the public health system and that the results delivered by CoaguChek XS^® have long-term reliability.     

Serum proinflammatory cytokines and nutritional status in pediatric chronic liver disease

AIM: To evaluate the nutritional status and its association with proinflammatory cytokines in children with chronic liver disease.METHODS: We performed a cross-sectional study with 43 children and adolescents, aged 0 to 17 years, diagnosed with chronic liver disease. All patients regularly attended the Pediatric Hepatology Unit and were under nutritional follow up. The exclusion criteria were fever from any etiology at the time of enrollment, inborn errors of the metabolism and any chronic illness. The severity of liver disease was assessed by Child-Pugh, Model for End-stage Liver Disease(MELD) and Pediatric End Stage Liver Disease(PELD) scores. Anthropometric parameters were height/age, body mass index/age and triceps skinfold/age according to World Health Organization standards. The cutoff points for nutritional status were risk of malnutrition(Z-score -1.00) and malnutrition(Z-score -2.00). Interleukin-1β(IL-1β), IL-6 and tumor necrosis factor-α levels were assessed by commercial ELISA kits. For multivariate analysis, linear regression was applied to assess the association between cytokine levels, disease severity and nutritional status. RESULTS: The median(25th-75 th centile) age of the study population was 60(17-116)-mo-old, and 53.5% were female. Biliary atresia was the main cause of chronic liver disease(72%). With respect to Child-Pugh score, cirrhotic patients were distributed as follows: 57.1% Child-Pugh A, a mild presentation of the disease, 34.3% Child-Pugh B, a moderate stage of cirrhosis and 8.6% Child-Pugh C, were considered severe cases. PELD and MELD scores were only above the cutoff point in 5 cases. IL-6 values were increased in patients at nutritional risk(34.9%) compared with those who were well-nourished [7.12(0.58-34.23) pg/m L vs 1.63(0.53-3.43) pg/m L; P = 0.02], correlating inversely with triceps skinfold-for-age z-score(rs =-0.61; P 0.001). IL-6 levels were associated with liver disease severity assessed by Child-Pugh score(P = 0.001). This association remained significant after adjusting for nutritional status in a linear regression model. CONCLUSION: High IL-6 levels were found in children with chronic liver disease at nutritional risk. Inflammatory activity may be related to nutritional status deterioration in these patients.     

Longer Times of Receipt of Adjuvant Endocrine Therapy Correspond to Improved Functional Capacity and Lower Adiposity in Women Receiving Adjuvant Therapy

Purpose

To study the use of functional capacity (FC) level and duration of aromatase inhibitor (AI) therapy with adiposity parameters in women with breast cancer.

Challenges to the improvement of Colombian medical brigades aimed at the diagnosis of congenital heart disease: A qualitative approach

Qualitative research of brigades and the family experience of congenital heart disease is of current interest and has been previously neglected. This study aimed to explore the social factors conditioning outcomes of paediatric cardiology care in the setting of Colombian medical brigades and to identify feasible strategies to improve the experience of the beneficiary populations. Participants were selected using purposeful sampling. Semi-structured interviews were conducted with members of logistic and health care teams, caregivers and custodians of beneficiary children of the Programme. The data collected provided an understanding of the health culture, social background, household and intrafamily dynamics. The outcomes of the Programme are influenced by sociocultural dynamics such as communication gaps and the socioeconomic status of the beneficiary populations. Findings may be specific to brigades, but also cross-relevant to any family experience of a new diagnosis of Congenital Heart Disease (CHD) communicating with healthcare professionals. It is important to foresee the role and further development of the Programme. Recommendations are provided suggesting innovative work by means of telemedicine and other sociocultural measures to reduce healthcare inequity and strengthen comprehensive healthcare programmes.     

New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study

There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child–Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.     

Correlation between static balance and functional autonomy in elderly women

The purpose of the present study was to verify the correlation between static balance and functional autonomy in elderly women. The sample was a random selection of 32 sedentary elderly women (mean age = 67.47 ± 7.37 years, body mass index = BMI = 27.30 ± 5.07 kg/m²), who live in the city of Teresina in the state of Piauí, Brazil. Static balance was analyzed by stabilometric assessment using an electronic baropodometer which measured the average of the amplitude of postural oscillations in the right (RLD) and left (LLD) lateral displacements, anterior (AD) and posterior (PD) displacements, and in the elliptical area (EA) formed by the body's center of gravity. Functional autonomy was evaluated by a battery of tests from the LADEG protocol which is composed of: a 10 m walk (10 mW), getting up from a seated position (GSP), getting up from the prone position (GPP), getting up from a chair and movement around the house (GCMH), and putting on and taking off a shirt (PTS). The Spearman's correlation coefficient (r) indicated a positive and significant correlation between GPP and LLD (r = 0.382; p = 0.031), GPP and PD (r = 0.398; p = 0.024) and GPP and EA (r = 0.368; p = 0.038). These results show that sedentary elderly women who spent the greatest amount of time performing the GPP test achieved the largest mean amplitude of displacement leading to greater levels of instability.