Browsing by Issue Date, starting with "2018-05"
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- Conjunctival Melanoma: Association of Cyclooxygenase-2 Tumor Expression to PrognosisPublication . Proença, R; Santos, M; Fonseca, C; Fernandes, J; Gaspar, MF; Proença, RPURPOSE: Conjunctival melanoma is a rare but potentially lethal tumor. Its biologic profile is still largely unknown, with recent studies aiming at establishing histopathological and genetic tumor profiles. The aim of this study was to analyze the association between clinicopathological characteristics and tumor expression of cyclooxygenase-2 (COX-2) to prognosis, assessing its usefulness as a possible prognostic marker. METHODS: Case series of 50 patients from 1991 to 2008 with pathologically proven conjunctival melanoma. Demographic, clinical, and pathological characteristics were evaluated by reviewing clinical files and pathology. Expression of COX-2 was studied by immunohistochemistry of formalin-fixed paraffin-embedded tissue samples of 20 melanomas. Samples were classified in a score which included intensity of staining and percentage of cells with positive reactivity. RESULTS: Clinicopathological features significantly associated (p < .05) with a poor prognosis (death) included involvement of fornix and tarsal conjunctiva, tumor thickness exceeding 2 mm, local tumor recurrence, lymph node, and systemic metastasis. In the immunohistochemistry study (n = 20), 18 cases expressed COX-2 although with different scores. However, only cases with a high score were associated with a poor outcome. Multivariate association analysis revealed that recurrence rate, metastasis, corneal invasion, and tumor thickness were associated with high score cases and, therefore, with a clinical profile with a higher risk of death. CONCLUSIONS: Results suggest that higher COX-2 expression may be a negative prognostic factor in conjunctival melanoma. Further studies can address the potential use of anti-COX-2 drugs as adjuvant therapy of this disease.
- Infective Endocarditis: Surgical Management and Prognostic PredictorsPublication . Ilhão Moreira, R; Coutinho Cruz, M; Branco, LM; Galrinho, A; Coutinho Miranda, L; Fragata, J; Cruz Ferreira, RINTRODUCTION AND AIM: Infective endocarditis (IE) is associated with high morbidity and mortality. It is important to determine which factors increase the risk of poor outcome in order to enable early detection and aggressive treatment, including surgery. The aim of our study was to identify factors predicting complications and in-hospital mortality in patients with IE and to analyze conditions predisposing to surgery and its outcome. METHODS: We performed a retrospective study including patients with IE who underwent transesophageal echocardiography in a tertiary hospital center (2006-2014). RESULTS: A total of 233 patients were analyzed (69.1% male; mean age 63.4±15.2 years; mean follow-up 28.4±30.7 months). The complication rate was 56.6% and in-hospital mortality was 16.3%. Independent predictors of mortality were chronic obstructive pulmonary disease (OR 4.89; CI 1.36-17.63; p=0.015), clinical course complicated by cerebral embolism (OR 9.38; CI 3.26-26.96; p<0.001), and IE due to Staphylococcus spp. (OR 3.78; CI 1.32-10.85; p=0.014) and non-HACEK Gram-negative bacilli (OR 12.85; CI 2.61-63.23; p=0.002). Surgery was performed in 36.9%. This group had higher percentages of males, younger patients, aortic valve IE, large vegetations, perivalvular extension, severe valvular regurgitation and heart failure. In patients with surgical indication (n=133), those who underwent surgery had lower in-hospital mortality (15.5% vs. 32.6%, p=0.028) and better long-term survival (log-rank p=0.029). CONCLUSION: The results of this study may help to identify IE patients who are at increased risk of worse outcome, offering the opportunity to change the course of the disease and to improve prognosis with earlier and more aggressive intervention.
- Acidente Vascular Cerebral em Idade Ativa: Caracterização dos Utentes Enviados para a FisioterapiaPublication . Luzia Pimenta, CIntrodução – O acidente vascular cerebral (AVC) aumenta com a idade. No entanto, as incapacidades resultantes do AVC numa população jovem e ativa têm um grande impacto no indivíduo e na sociedade. Objetivo – Analisar as características pessoais, clínicas e funcionais dos indivíduos com AVC em idade ativa, verificando a associação entre variáveis e comparando os seus resultados com os indivíduos idosos com AVC. Método – Estudo observacional, descritivo e transversal. A população em estudo foram os indivíduos com AVC enviados para a fisioterapia num hospital terciário, em regime ambulatório, num período de três anos. Foram recolhidos dados de caracterização pessoal e clínica; aplicou-se a Motor Assessment Scale (MAS) e realizou-se o Timed Up and Go Test (TUG). Os dados foram analisados através de estatística descritiva, de análise de correlação e de inferência estatística (teste de Qui-quadrado e teste de Mann-Whitney), considerando-se um intervalo de confiança de 95%. Resultados – Dos 151 indivíduos avaliados, 64 tinham menos de 65 anos (42,4%), incluindo 10 com menos de 45 anos (6,6%). O género masculino foi o mais atingido e a maioria dos casos foram AVC isquémicos. Os mais jovens apresentaram um melhor desempenho funcional, maior percentagem de elementos com marcha autónoma e melhor mobilidade funcional. Estas diferenças são estatisticamente significativas ao comparar os resultados do TUG dos indivíduos em idade ativa com os idosos (p=0,004) e da MAS entre os menores de 45 anos com os maiores de 65 (p=0,048). A maioria dos utentes avaliados encontrava-se em risco de queda, constatando-se uma associação entre a idade e o risco de queda. Verificou-se uma correlação negativa entre as variáveis MAS e TUG. Conclusões – Com este estudo, pelas suas dimensões e limitações, não é possível elaborar considerações definitivas sobre o AVC em idade ativa e as suas repercussões funcionais; no entanto, pretende contribuir para uma reflexão sobre esta temática. Os fisioterapeutas deverão estar conscientes das necessidades específicas desta população e adaptar a sua intervenção de modo a minimizar o impacto desta condição na qualidade de vida dos indivíduos.
- Atypical Adult-Onset Methylmalonic Acidemia and Homocystinuria Presenting as Hemolytic Uremic SyndromePublication . Navarro, D; Azevedo, A; Sequeira, S; Ferreira, AC; Carvalho, F; Fidalgo, T; Vilarinho, L; Santos, MC; Calado, J; Nolasco, FThrombotic microangiopathy (TMA) syndromes can be secondary to a multitude of different diseases. Most can be identified with a systematic approach and, when excluded, TMA is generally attributed to a dysregulation in the activity of the complement alternative pathways-atypical hemolytic uremic syndrome (aHUS). We present a challenging case of a 19-year-old woman who presented with thrombotic microangiopathy, which was found to be caused by methylmalonic acidemia and homocystinuria, a rare vitamin B12 metabolism deficiency. To our knowledge, this is the first time that an adult-onset methylmalonic acidemia and homocystinuria presents as TMA preceding CNS involvement.
- Higher Programmatic Volume in Neonatal Heart Surgery Is Associated With Lower Early MortalityPublication . Kansy, A; Zu Eulenburg, C; Sarris, G; Jacobs, JP; Fragata, J; Tobota, Z; Ebels, T; Maruszewski, BBACKGROUND: The early results of congenital heart surgery in neonates remain a challenge. We sought to determine the nature of the association between annual center volume of neonatal cardiac surgery and operative mortality using a multicenter cohort. METHODS: The dataset consists of 27,556 neonatal procedures performed between 1999 and 2015 in 90 centers participating in the European Congenital Heart Surgeons Association database. Centers with mean annual volume load of six or more that submitted data for at least 3 consecutive years were included. World Bank annual gross national index per capita was utilized as an indicator of temporal national affluence. Multilevel logistic regression was used to create a model including the significant risk factors and to calculate odds ratios for operative mortality. Iterative modeling of the dataset incrementally excluding centers with lower annual caseload was used to identify the relationship between annual volume and mortality. RESULTS: In the model thus calculated including The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) mortality score, operative weight and age, noncardiac genetic anomalies, and annual volume of operations were independent risk factors for operative mortality in the analysis of the entire cohort. In the model containing these variables, annual gross national index and year of surgery were not significantly associated with mortality. In the iterative process, annual volume ceased to be a risk factor when units operating on fewer than 60 neonates annually were excluded. CONCLUSIONS: In neonatal congenital heart surgery, the risk of operative death decreased with the increase of volume load. The cutoff point in this cohort was a mean annual volume of 60 neonatal operations per year.
- Vascular Trauma in Children-Review from a Major Paediatric CenterPublication . Morão, S; Ferreira, RS; Camacho, N; Vital, VP; Pascoal, J; Ferreira, ME; Mota Capitão, L; Gonçalves, FBBACKGROUND: Traumatic noniatrogenic vascular injuries in children are rare and rarely discussed in literature. Pediatric vascular injuries pose a set of challenges mainly because of continued growth and development in a child or adolescent. The purpose of the study is to characterize management strategies and outcomes in these cases. METHODS: This is a single-center retrospective review of patients less than age 18 years (pediatric age) with acute, noniatrogenic traumatic vascular injuries between January 2009 and December 2015. Patient's demographics, injury characteristics, surgical management, complications, and follow-up were analyzed. RESULTS: From 2009 to 2015, 3277 children with traumatic injuries were treated, of which 21 (0.6%) had 23 significant vascular injuries: 17 arterial and 6 venous injuries. The majority were males (n = 16), and the median age was 14 years (range 1 to 16 years). Penetrating injuries were the predominant mechanism (n = 21), mainly by glass (n = 13). At presentation, 4 patients were hemodynamically unstable, 3 of them in hypovolemic shock. All patients were managed operatively. Operations for arterial injuries included 5 primary arterial repairs, 4 repairs using vein grafts and 8 ligations. The following adjunct procedures were necessary: one 4-compartment leg fasciotomy due to associated soft tissue trauma, 8 tendon repairs, and 11 nerve repairs. Operations for venous injuries included 4 ligations and 2 primary repairs. There were no intraoperative or postoperative deaths, major complications, or limb loss. The median length of stay in the hospital was 6 days (range: 2-23 days). The median time of follow-up was 52 months (range: 20-94 months). Ten patients did not have any sequelae, and 11 patients reported impaired mobility and/or decreased sensation, which was transitory in most cases and related to associated neurological or muscle tendon injuries. All reconstructions remained patent over the course of follow-up. No limb asymmetry was observed. CONCLUSIONS: Noniatrogenic pediatric vascular trauma is uncommon. Penetrating mechanism is more common than blunt and extremities are more frequently affected. Overall complications come from associated injuries to tendons and nerves.
- Reeducação Vestibular em Indivíduos Pós-Traumatismo Crânio-Encefálico: Série de CasosPublication . Domingos Correia, AIntrodução – Após sofrerem um traumatismo crânio-encefálico (TCE), muitos indivíduos apresentam vertigem e desequilíbrio. A reeducação vestibular (RV) procura aumentar a estabilidade postural (EP) e diminuir a sintomatologia, sendo considerado o tratamento mais importante para indivíduos com queixas vestibulares pós-TCE. Objetivos – Descrever os efeitos de um programa personalizado de RV na EP e na incapacidade percebida em indivíduos pós-TCE. Métodos – Estudo retrospetivo de uma série consecutiva de cinco indivíduos (entre os 48 e os 66 anos) com queixas de vertigem e desequilíbrio pós-TCE referenciados para RV. No início e no final do tratamento foi avaliada a EP através do teste clínico modificado de interação sensorial do equilíbrio (mCTSIB) na plataforma Basic Balance Master da Neurocom® e a incapacidade percebida através do Dizziness Handicap Inventory. Foram realizadas seis sessões de RV: exercícios de estabilização do olhar; exercícios de equilíbrio com estimulação multissensorial e em plataforma com biofeedback visual; estimulação optocinética. Resultados – Após RV verificou-se melhoria da estabilidade em três indivíduos e diminuição da perceção de incapacidade em quatro indivíduos. Discussão – Programas de exercícios de RV semelhantes ao realizado têm sido utilizados em indivíduos pós-TCE com resultados positivos, quer no aumento da estabilidade, quer na diminuição da sintomatologia e incapacidade. Considerando as melhorias verificadas nos indivíduos deste estudo, a aplicação de um programa de RV com maior durabilidade poderá apresentar melhores resultados. Conclusões – Na maioria destes indivíduos, a RV diminuiu a incapacidade percebida e aumentou a EP, o que pode contribuir para uma reinserção social e laboral mais precoce.
- Síndrome de Gorlin-Goltz: Anestesia para Cirurgia Oral em AmbulatórioPublication . Carioca, F; Lijnzaat, L; Prates, M; Poeira, R
- Mandatory Criteria for Cardiac Rehabilitation Programs: 2018 Guidelines from the Portuguese Society of CardiologyPublication . Abreu, A; Mendes, M; Dores, H; Silveira, C; Fontes, P; Teixeira, M; Santa Clara, H; Morais, JCardiac rehabilitation (CR) is a multidisciplinary process for patients recovering after an acute cardiac event or with chronic cardiovascular disease that reduces mortality and morbidity and improves quality of life. It is considered a cost-effective intervention and is expressly indicated in the guidelines of the major medical societies. In Portugal, only 8% of patients discharged from hospital after myocardial infarction are included in CR programs. In Europe overall, the percentage admitted to CR programs is 30%, while in the USA it is 20-30%. In view of the underuse of CR in Portugal, we call the attention of the health authorities to the need to increase the number and national coverage of CR programs, while maintaining high quality standards. The aim is for all patients resident in Portugal who are eligible for CR programs to have the same opportunities for access and attendance. In order to preserve the benefits and safety of this intervention, CR needs to be performed according to international guidelines. The fact that various initiatives in this field have been developed by different professional groups, some of them non-medical, that do not follow the European guidelines, has prompted us to prepare a series of norms defining mandatory criteria for CR, based on current knowledge and evidence. In this way we aim to ensure that the required increase in the number of CR programs, linked in a national network of CR centers, does not detract from the need to maintain their efficacy and quality. These criteria should serve as the basis for the future accreditation of CR centers in Portugal.
- Congenital Heart Disease in Adults: Assessment of Functional Capacity Using Cardiopulmonary Exercise TestinPublication . Aguiar Rosa, S; Agapito, A; Soares, RM; Sousa, L; Oliveira, JA; Abreu, A; Silva, AS; Alves, S; Aidos, H; Pinto, MF; Cruz Ferreira, RAIM: The aim of the study was to compare functional capacity in different types of congenital heart disease (CHD), as assessed by cardiopulmonary exercise testing (CPET). METHODS: A retrospective analysis was performed of adult patients with CHD who had undergone CPET in a single tertiary center. Diagnoses were divided into repaired tetralogy of Fallot, transposition of the great arteries (TGA) after Senning or Mustard procedures or congenitally corrected TGA, complex defects, shunts, left heart valve disease and right ventricular outflow tract obstruction. RESULTS: We analyzed 154 CPET cases. There were significant differences between groups, with the lowest peak oxygen consumption (VO2) values seen in patients with cardiac shunts (39% with Eisenmenger physiology) (17.2±7.1ml/kg/min, compared to 26.2±7.0ml/kg/min in tetralogy of Fallot patients; p<0.001), the lowest percentage of predicted peak VO2 in complex heart defects (50.1±13.0%) and the highest minute ventilation/carbon dioxide production slope in cardiac shunts (38.4±13.4). Chronotropism was impaired in patients with complex defects. Eisenmenger syndrome (n=17) was associated with the lowest peak VO2 (16.9±4.8 vs. 23.6±7.8ml/kg/min; p=0.001) and the highest minute ventilation/carbon dioxide production slope (44.8±14.7 vs. 31.0± 8.5; p=0.002). Age, cyanosis, CPET duration, peak systolic blood pressure, time to anaerobic threshold and heart rate at anaerobic threshold were predictors of the combined outcome of all-cause mortality and hospitalization for cardiac cause. CONCLUSION: Across the spectrum of CHD, cardiac shunts (particularly in those with Eisenmenger syndrome) and complex defects were associated with lower functional capacity and attenuated chronotropic response to exercise.