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- Global and Regional Patterns of Longitudinal Strain in Screening for Chemotherapy-Induced CardiotoxicityPublication . Portugal, G; Branco, LM; Galrinho, A; Mota Carmo, M; Timóteo, AT; Feliciano, J; Abreu, J; Duarte Oliveira, S; Batarda, L; Cruz Ferreira, RINTRODUCTION: Serial echocardiographic assessment of left ventricular ejection fraction (LVEF) is the gold standard in screening for chemotherapy-induced cardiotoxicity (CIC). Measurement of myocardial deformation using speckle tracking enables more detailed assessment of myocardial contractility. The aim of this study was to determine the relationship between global and regional longitudinal strain and CIC. METHODS: This was a prospective study of 158 breast cancer patients undergoing chemotherapy with anthracyclines with or without adjuvant trastuzumab who underwent serial monitoring by transthoracic echocardiography with assessment of myocardial deformation. CIC was defined as a decrease in LVEF to <53%. Global longitudinal strain (GLS) was estimated using EchoPAC BT12 software on a GE Vivid E9 cardiac ultrasound system. Patients were classified according to the 2015 ASE/EACVI criteria as having impaired myocardial deformation when GLS was reduced (less negative), with a cutoff of -18%. RESULTS: During a mean follow-up of 5.4 months (1-48 months), the incidence of CIC was 18.9%. A decrease in GLS was observed during follow-up for the entire cohort (baseline GLS -20.1±3.5% vs. -18.7±3.4% at last follow-up assessment, p=0.001). A total of 97 patients (61.4%) were observed to have impaired myocardial deformation (GLS ≥18%) at some point during follow-up. This decrease was more significant in patients who eventually developed CIC (GLS -17.2±2.5%, p=0.02). On analysis of regional strain, impaired contractility was observed in the septal (6 out of 6) and anterior (2 out of 3) segments. Multivariate logistic regression showed that patients who developed impaired longitudinal strain had a 4.9-fold increased risk of developing CIC (odds ratio 4.88, confidence interval 1.32-18.0, p=0.017). CONCLUSIONS: Worsening of myocardial deformation as assessed by speckle tracking is common in breast cancer patients undergoing chemotherapy, with predominantly septal and anterior wall involvement. Impaired myocardial deformation was independently associated with increased incidence of CIC.
- Nasal Lobular Capillary Hemangioma as a Complication after an Endoscopic Transsphenoidal Gonadotrophin-Producing Pituitary Adenoma ResectionPublication . Forte, Da; Irañeta, A; Nabais, A; Figueiredo, A; Mafra, M; Gonçalves, VBackground Lobular capillary hemangioma is a rare benign tumor, most frequently located in the head or neck region, the nasal cavity being uncommonly affected. Its etiopathogenesis is not fully established, although traumatic and hormonal factors have been implied. Case Description A 50-year-old female patient underwent an uneventful endoscopic transsphenoidal removal of a pituitary cystic macroadenoma at our institution. Nasal packing was used in postoperative hemostasis. Histopathology was compatible with a gonadotrophin-producing adenoma. One month after the surgery, the patient presented with frequent episodes of epistaxis and a progressively growing nasal mass, which was removed endoscopically. Its pathological examination confirmed a lobular capillary hemangioma. Conclusions The authors present a clinical case combining two possible predisposing factors to the development of a nasal lobular capillary hemangioma: local traumatic injury through surgery and postoperative nasal packing and hormonal influence. This lesion is a rare complication of endoscopic transsphenoidal resections of pituitary adenomas.
- Usefulness of Right Ventricular and Right Atrial Two-Dimensional Speckle Tracking Strain to Predict Late Arrhythmic Events in Adult Patients with Repaired Tetralogy of FallotPublication . Timóteo, AT; Branco, LM; Rosa, S; Ramos, R; Agapito, A; Sousa, L; Galrinho, A; Oliveira, JA; Oliveira, MM; Cruz Ferreira, ROBJECTIVE: To determine whether right ventricular and/or atrial speckle tracking strain is associated with previous arrhythmic events in patients with repaired tetralogy of Fallot. METHODS AND RESULTS: We studied right ventricular and atrial strain in 100 consecutive patients with repaired tetralogy of Fallot referred for routine echocardiographic evaluation. Patients were divided into two groups, one with previous documentation of arrhythmias (n=26) and one without arrhythmias, in a median follow-up of 22 years. Patients with arrhythmias were older (p<0.001) and had surgical repair at an older age (p=0.001). They also had significantly reduced right ventricular strain (-14.7±5.5 vs. -16.9±4.0%, p=0.029) and right atrial strain (19.1±7.7% vs. 25.8±11.4%, p=0.001). Neither right ventricular nor right atrial strain were independent predictors of the presence of a history of documented arrhythmias, which was associated with age at correction and with the presence of residual defects. In a subanalysis after excluding 23 patients who had had more than one corrective surgery, right ventricular strain was an independent predictor of the presence of previous arrhythmic events (OR 1.19, 95% CI 1.02-1.38, p=0.025). Right atrial strain was also an independent predictor after adjustment (OR 0.93, 95% CI 0.87-0.99, p=0.029). The ideal cut-off for right ventricular strain was -15.3% and for right atrial strain 23.0%. CONCLUSIONS: Compared with conventional echocardiographic parameters, strain measures of the right heart are associated with the presence of arrhythmic events, and may be useful for risk stratification of patients with repaired tetralogy of Fallot, although a prospective study is required.
- Tuberculosis in Liver Transplant Recipients: A Report of Eight Cases During a Five Year PeriodPublication . Póvoas, D; Machado, J; Perdigoto, R; Morbey, A; Veloso, J; Glória, H; Mateus, E; Martins, A; Maltez, F; Barroso, EIntroduction: Tuberculosis incidence in Portugal ranged from 20 to 22 cases per 100 000 inhabitants between 2010 and 2014. Tuberculosis incidence in liver transplant recipients is not precisely known, but it is estimated to be higher than among the general population. Tuberculosis in liver transplant recipients is particularly challenging because of the atypical clinical presentation and side effects of the antibacillary drugs and their potential interactions with immunosuppressive therapies. Material and Methods: We retrospectively reviewed the clinical records of liver transplant recipients with post-transplant tuberculosis occurring from January 2010 to December 2014 at a liver transplantation unit in Lisbon, Portugal. Demographic data, baseline and clinical features, as well as treatment regimen, toxicities and outcomes, were analyzed. Results: Among 1005 recipients, active tuberculosis was diagnosed in eight patients between January 2010 and December 2014 (frequency = 0.8%). Late onset tuberculosis was more frequent than early tuberculosis. Mycobacterium tuberculosis complex was isolated from cultures in almost every case (7; 87.5%). Extra-pulmonary involvement and disseminated tuberculosis were frequent. Two patients developed rejection without allograft loss. Crude mortality was 37.5%, with 2 deaths being related to tuberculosis. Discussion: Despite the uncertainty regarding treatment duration in liver transplant recipients, disease severity, as well as number of active drugs against TB infection, should be taken into account. There was a need for a rifampin-free regimen and immunosuppression adjustment in patients who experienced acute graf rejection. Conclusion: Although the number of cases of tuberculosis is low, its post-transplant frequency is significant and the observed mortality rate is not to be neglected. The cases of hepatotoxicity and graft rejection seen in this case series demonstrate the challenges associated with tuberculosis diagnosis in liver transplant recipients and management of the interactions between immunosuppressors and rifampin. This study strengthens the recommendation of latent tuberculosis infection screening and treatment in liver transplant candidates or recipients.
- The Second Team Haemophilia Education Meeting, 2016, Frankfurt, GermanyPublication . Berntorp, E; Dargaud, Y; Hart, D; Lobet, S; Mancuso, ME; d'Oiron, R; Perry, D; Pollard, D; van den Berg, M; Blatný, J; Chambost, H; Doria, AS; Holme, PA; Kaczmarek, R; Mantovani, L; McLaughlin, P; Nanayakkara, L; Petrini, P; Sannié, T; Laane, E; Maia, R; Dettoraki, A; Farrell, A; Halimeh, S; Raza, S; Taylor, SThe first Team Haemophilia Education (THE) Meeting was held on 7-8 May 2015 in Amsterdam, The Netherlands. It aimed to promote the optimal care of patients with haemophilia through education of the multidisciplinary treatment team. This was achieved by reviewing the latest developments in haemophilia management, considering how these can be implemented in the clinic to improve patient care and providing a platform for networking and debate for all haemophilia treatment team members. The second THE Meeting was held on 19-20 May in Frankfurt, Germany, and participants included doctors, nurses, physiotherapists, patient representatives and data management staff from 20 different countries. Topics covered the role of the multidisciplinary team in delivering the best haemophilia care, challenges in the management of haemophilia across Europe, available clotting factor treatments, future treatments and the use of genetics in advising carriers of haemophilia. This report is a summary of the key developments in haemophilia care presented by various investigators and healthcare professionals at THE Meeting 2016.
- Acute Liver Failure Due to Trazodone and DiazepamPublication . Carvalhana, S; Oliveira, A; Ferreira, P; Resende, M; Perdigoto, R; Barroso, EMost antidepressant agents have the potential to cause liver injury, even at therapeutic doses. Nevertheless, drug-induced liver injury (DILI) from antidepressant agents is a rare event. There is no way to prevent idiopathic DILI, but the severity of the reaction may be minimized with prompt recognition and early withdrawal of the agent. We describe a rare case of a 63-year-old man presenting with acute liver failure after 3 months of trazodone and diazepam administration at normal therapeutic doses, requiring liver transplantation. This report should increase physicians' awareness of this complication and call attention to the regular monitoring of liver tests in patients taking trazodone, in order to prevent life-threatening complications.
- O Que Esconde a Pele?Publication . Campos, S; João, A
- Do Prices Reflect the Costs of Cardiac Surgery in the Elderly?Publication . Coelho, P; Rodrigues, V; Miranda, L; Fragata, J; Pita Barros, PINTRODUCTION: Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry. Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged ≥65 years undergoing cardiac surgery in one hospital department. METHODS: Data on 250 patients operated between September 2011 and September 2012 were prospectively collected. The procedures studied were coronary artery bypass graft surgery (CABG) (n=67), valve surgery (n=156) and combined CABG and valve surgery (n=27). Costs were calculated by two methods: micro-costing when feasible and mean length of stay otherwise. Price information was provided by the hospital administration and calculated using the hospital's mean case-mix. RESULTS: Thirty-day mortality was 3.2%. Mean EuroSCORE I was 5.97 (standard deviation [SD] 4.5%), significantly lower for CABG (p<0.01). Mean intensive care unit stay was 3.27 days (SD 4.7) and mean hospital stay was 9.92 days (SD 6.30), both significantly shorter for CABG. Calculated costs for CABG were €6539.17 (SD 3990.26), for valve surgery €8289.72 (SD 3319.93) and for combined CABG and valve surgery €11 498.24 (SD 10 470.57). The payment for each patient was €4732.38 in 2011 and €4678.66 in 2012 based on the case-mix index of the hospital group, which was 2.06 in 2011 and 2.21 in 2012; however, the case-mix in our sample was 6.48 in 2011 and 6.26 in 2012. CONCLUSION: The price paid for each patient was lower than the calculated costs. Prices would be higher than costs if the case-mix of the sample had been used. Costs were significantly lower for CABG.
- A Stab Wound to the Axilla Illustrating the Importance of Brachial Plexus Anatomy in an Emergency Context: a Case ReportPublication . Casal, D; Cunha, T; Pais, D; Iria, I; Almeida, MA; Millan, G; Videira e Castro, J; Goyri-O'Neill, JBACKGROUND:Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. CASE PRESENTATION: We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. CONCLUSIONS: We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.
- A Model of Free Tissue Transfer: The Rat Epigastric Free FlapPublication . Casal, D; Pais, D; Iria, I; Mota-Silva, E; Almeida, MA; Alves, S; Pen, C; Farinho, A; Mascarenhas-Lemos, L; Ferreira-Silva, J; Ferraz-Oliveira, M; Vassilenko, V; Videira, P; Gory O'Neill, JFree tissue transfer has been increasingly used in clinical practice since the 1970s, allowing reconstruction of complex and otherwise untreatable defects resulting from tumor extirpation, trauma, infections, malformations or burns. Free flaps are particularly useful for reconstructing highly complex anatomical regions, like those of the head and neck, the hand, the foot and the perineum. Moreover, basic and translational research in the area of free tissue transfer is of great clinical potential. Notwithstanding, surgical trainees and researchers are frequently deterred from using microsurgical models of tissue transfer, due to lack of information regarding the technical aspects involved in the operative procedures. The aim of this paper is to present the steps required to transfer a fasciocutaneous epigastric free flap to the neck in the rat. This flap is based on the superficial epigastric artery and vein, which originates from and drain into the femoral artery and vein, respectively. On average the caliber of the superficial epigastric vein is 0.6 to 0.8 mm, contrasting with the 0.3 to 0.5 mm of the superficial epigastric artery. Histologically, the flap is a composite block of tissues, containing skin (epidermis and dermis), a layer of fat tissue (panniculus adiposus), a layer of striated muscle (panniculus carnosus), and a layer of loose areolar tissue. Succinctly, the epigastric flap is raised on its pedicle vessels that are then anastomosed to the external jugular vein and to the carotid artery on the ventral surface of the rat's neck. According to our experience, this model guarantees the complete survival of approximately 70 to 80% of epigastric flaps transferred to the neck region. The flap can be evaluated whenever needed by visual inspection. Hence, the authors believe this is a good experimental model for microsurgical research and training.