Browsing by Issue Date, starting with "2019-10"
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- Prognosis After Resection of Barcelona Clinic Liver Cancer (BCLC) Stage 0, A, and B Hepatocellular Carcinoma: A Comprehensive Assessment of the Current BCLC ClassificationPublication . Tsilimigras, D; Bagante, F; Sahara, K; Moris, D; Hyer, J; Wu, L; Ratti, F; Pinto Marques, H; Soubrane, O; Paredes, A; Lam, V; Poultsides, G; Popescu, I; Alexandrescu, S; Martel, G; Workneh, A; Guglielmi, A; Hugh, T; Aldrighetti, L; Endo, I; Pawlik, TBackground: Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have questioned the prognostic stratification of this classification schema, as well as the proposed treatment allocation of patients with a single large tumor. Methods: Patients who underwent curative-intent hepatectomy for histologically proven hepatocellular carcinoma (HCC) between 1998 and 2017 were identified using an international multi-institutional database. Overall survival (OS) among patients with BCLC stage 0, A, and B was examined. Patients with a single large tumor were classified as BCLC stage A1 and were independently assessed. Results: Among 814 patients, 68 (8.4%) were BCLC-0, 310 (38.1%) were BCLC-A, 279 (34.3%) were BCLC-A1, and 157 (19.3%) were BCLC-B. Five-year OS among patients with BCLC stage 0, A, A1, and B HCC was 86.2%, 69.0%, 56.9%, and 49.9%, respectively (p < 0.001). Among patients with very early- and early-stage HCC (BCLC 0, A, and A1), patients with BCLC stage A1 had the worst OS (p = 0.0016). No difference in survival was noted among patients undergoing surgery for BCLC stage A1 and B HCC (5-year OS: 56.9% vs. 49.9%; p = 0.259) even after adjusting for competing factors (hazard ratio 0.83, 95% confidence interval 0.54-1.28; p = 0.40). Conclusion: Prognosis following liver resection among patients with BCLC-A1 HCC was similar to patients presenting with BCLC-B tumors. Surgery provided acceptable long-term outcomes among select patients with BCLC-B HCC. Designation into BCLC stage B should not be considered an a priori contraindication to surgery.
- Rare Case of Sarcomatoid Squamous Cell Carcinoma Arising in an Ovarian Mature TeratomaPublication . Sousa Pedrosa, I; Alpendre, F; Sousa, R; Raposo Dinis, S; Gomes, DAlthough mature cystic teratoma (MCT) is benign, malignant transformation (MT) occurs in ∼ 1% to 2% of all cases, and usually consists of squamous cell carcinoma (SCC), which accounts for ∼ 80% of the cases. Spindle-cell (sarcomatoid) carcinoma (SCSC) is an uncommon type of SCC, comprising up to 3% of all cases. The lack of characteristic symptoms and specific imaging findings may lead to preoperative misdiagnosis. Moreover, the clinicopathologic characteristics, the treatment, the prognostic factors and the mechanism of MT have not yet been well understood due to the rarity of such tumors, especially in women of reproductive age. The authors present a case of a 34-year-old patient with 14 weeks of gestation who was diagnosed with an adnexal mass suggestive of ovarian teratoma. A laparoscopy salpingo-oophorectomy was performed after 6 months of delivery, and the histological exam revealed a sarcomatoid SCC in the MCT.
- Hepatic Abscess Due to Streptococcus Anginosus and Eikenella Corrodens, Secondary to Gastric Perforation by a Fish BonePublication . Gonçalves, RJ; Murinello, A; Gomes da Silva, S; Santos Coelho, J; Lopes Santos, A; Sá Damásio, HIntroduction: Foreign-body ingestion is a common event, but in only less than 1% of the cases complications occur. Hepatic abscesses induced by foreign-body penetration are rare. To date, there are only 62 reported cases of hepatic abscess secondary to fish bone perforation of the gastrointestinal tract. Case presentation: A 78-year-old male patient was admitted due to high fever and vomiting for 2 days, along with frequent eructations for the past 3 months. Abdominal ultrasound showed a liver abscess in the left lobe, and computed tomography revealed a hyperdense linear image that crossed the superior wall of the gastric antrum, contacting the liver lesion, suggestive of a foreign body, probably a fish bone. Blood cultures were positive with isolation of Streptococcus anginosus and Eikenella corrodens. Ultrasound-guided percutaneous drainage of the abscess was done, and S. anginosus was isolated in the pus. Surgical debridement and fish bone removal were performed; the patient completed 21 days of antibiotic therapy, with a favorable evolution. Conclusion: To the best of our knowledge, this is the first reported case of liver abscess caused by fish bone penetration with isolation of S. anginosus and E. corrodens. Bacterial coaggregation is one of the mechanisms that can explain their ability for causing invasive infections away from the oral cavity, by increasing their resistance to the innate immune system and survival of both species.
- What Physical Education Teachers Know About Asthma: Impact of a Training CoursePublication . Couto, M; Marques, J; Silva, D; Paiva, M; Jacinto, T; Câmara, R
- Morphological Indexes: Can They Predict Lupus Nephritis Outcomes? A Retrospective StudyPublication . Navarro, D; Ferreira, AC; Viana, H; Carvalho, F; Nolasco, FINTRODUCTION: Lupus nephritis is a serious complication of systemic lupus erythematosus. Currently, therapy is guided by findings in the renal biopsy, following the International Society of Nephrology / Renal Pathology Society classification. Austin and Hill's histomorphological indexes are not routinely obtained. In this retrospective single-centre study, we aimed to analyze the importance and applicability of the different morphological indexes in predicting response to treatment and prognosis. MATERIAL AND METHODS: Patients with kidney biopsy demonstrating lupus nephritis from the 2010 - 2016 period were included. We analyzed their demographic data, comorbidities, clinical presentation and laboratorial evaluation at the time of renal biopsy. We evaluated the following outcomes: clinical remission, renal function and proteinuria at end of follow-up. Histologic analysis was performed using the International Society of Nephrology / Renal Pathology Society classification and the morphological indexes described by Austin (Activity and Chronicity) and Hill. Univariate and multivariate statistical analysis was performed using STATA software. RESULTS: We analyzed 46 biopsy-proven lupus nephritis cases, with a median follow-up of 31.9 (13.2 - 45.6) months. Based on biopsy findings, 35 patients were started on immunosuppressive therapy. We observed that Class IV patients had, at presentation, lower estimated glomerular filtration rate (67.3 vs 94.6 mL/min; p = 0.02), higher proteinuria (4.26 vs 2.37 g/24 hours; p = 0.02) and a non-significantly higher C3 consumption (58.9 vs 77.4 mg/dL; p = 0.06). We did not observe correlations between International Society of Nephrology / Renal Pathology Society classification and the outcomes at the end of follow-up. In contrast, both the Hill biopsy index and Austin's Chronicity index were correlated with renal function and proteinuria at the end of follow-up. Austin's Activity index correlated with the immunological findings (C3, C4 and anti-dsDNA) at presentation. DISCUSSION: Because clinical activity poorly correlates with histologic activity, histological findings are fundamental when assessing patients with suspected lupus nephritis. The most recent International Society of Nephrology / Renal Pathology Society report supports the European League Against Rheumatism guidelines, encouraging the adoption of histomorphological indexes when evaluating lupus nephritis. Our data, showing a correlation between the renal outcomes and the indexes described by Austin and Hill, supports this view. CONCLUSION: The histomorphological indexes in lupus nephritis are easily obtainable, can predict renal outcomes and may help in the management of such patients.
- Quality of Sleep Among Portuguese Anaesthesiologists: A Cross-Sectional StudyPublication . Valente, F; Batista, C; Simões, V; Tomé, I; Carrilho, AINTRODUCTION: Sleeping is essential to maintain proper relationships with others, keep alertness, and execute responsibilities, among many other functions. In the medical profession, there are several studies linking sleep deprivation with a decrease in responsiveness, cognition and attention. With this study we intended to characterize the sleep pattern of Portuguese anaesthesiologists and identify independent factors associated with sleep quality in this population. MATERIAL AND METHODS: An observational, cross-sectional study of senior and resident anesthesiologists working in Portugal was carried out through an online questionnaire. Individuals working exclusively in intensive care units, emergency departments or with previously diagnosed sleep disorders were excluded. Socio-demographic data, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Perceived Stress Scale were applied. Statistical significance was assessed using the Mann-Whitney test and the chi-square test. A multivariable analysis was performed to examine the association between the Pittsburgh Sleep Quality Index and certain variables. RESULTS: Among 256 respondents, 46.1% reported "poor" quality of sleep (Pittsburgh Sleep Quality Index > 5). Within these individuals, 77.1% slept less than 7 hours per night (p < 0.001). Excessive daytime sleepiness (Epworth Sleepiness Scale > 10) was present in 41.0% of the sample, and the median Perceived Stress Scale score was 17.0. The independent factors associated with worse quality ofsleep were the number of working hours/week (OR 1.03, 95% CI 1,01 to 1,06), perceived stress (OR 1.18, 95% CI 1.11 to 1.26), taking sleep medication (OR 14.72, 95% CI 5.55 to 39.08), and sleep hours/night (OR 0.25, 95% CI 0.15 to 0.42). DISCUSSION: This fraction of Portuguese anaesthesiologists presented a poorer quality of sleep, with excessive daytime somnolence, perceived stress and higher sedative use compared to previously studied populations. CONCLUSION: Our study characterizes sleep patterns and identifies potential risk factors linked to sleep disturbances in a sample of Portuguese anaesthesiologists. Government and institutional policies can endorse sleep hygiene practices and habits, promoting healthier working environments.
- Together We Stand, Divided We Fall: A Multidisciplinary Approach in Complicated Acute PancreatitisPublication . Paulino, J; Ramos, G; Veloso Gomes, FAcute pancreatitis (AP) is an inflammatory condition with a mild course in most patients, but 20-30% evolve to single or multiple organ dysfunction and pancreatic/peripancreatic necrosis, with potentially infected collections. In the first weeks of disease, a systemic inflammatory syndrome (SIRS) dominates the clinical setting, and early management decisions in this precocious phase can change the course of the disease. Imaging is crucial in the diagnosis, and since the adoption of the revised Atlanta classification, four different types of pancreatic/peripancreatic collections have been defined. The management of the complicated forms of AP has been defined by several treatment guidelines, and the main indication for intervention is local infection, preferably in walled-off necrosis. Open surgery necrosectomy is associated with a very high rate of morbimortality, giving a place to different multidisciplinary methodologies, emphasizing drainage and necrosectomy techniques in a "step-up" approach starting from mini-invasive endoscopic drainage and moving, if needed, to progressively more invasive techniques, including interventional radiology and mini-invasive surgery. With the advent of several new technologies in the specialties involved, the complicated AP cases which need drainage and necrosectomy benefit from a new era of multidisciplinary cooperation, permitting higher efficacy with lower levels of morbimortality and reducing hospital stay and costs.