PHENYTOIN – BOUNDARIES OF THE TREATMENT

Introdução: As crises convulsivas são manifestações clínicas frequentes no período neonatal. Continua pouco claro qual a melhor abordagem terapêutica, nao existindo ainda consenso entre os diversos protocolos. A terapêutica antiepiletica usada tradicionalmente e, muitas vezes, pouco eficaz e pode originar efeitos secundários importantes. Caso Clínico: Apresenta-se o caso clínico de um recém-nascido que iniciou convulsões no primeiro dia de vida. Por persistência das crises após terapêutica com fenobarbital, foi iniciada fenitoina, tendo desenvolvido um quadro de encefalopatia devida a intoxicação por este fármaco, apesar do seu uso em doses habituais. Dado que a investigacao complementar foi normal, concluiu-se que esta se deveu provavelmente a susceptibilidade individual. Conclusão: Atendendo aos potenciais efeitos secundários da fenitoina, mais frequentes e graves em recém-nascidos, este fármaco tende a ser menos usado como segunda linha no tratamento das convulsões neste grupo etário, considerando-se atualmente as benzodiazepinas e a lidocaina alternativas mais eficazes e seguras.Introduction: Seizures are rather common in the neonatal period. It still remains unclear what is the best therapeutic approach, and there is no consensus protocol. Currently used antiepileptic drugs are sometimes ineffective and may cause significant adverse effects. Case report: We present the case of a newborn with seizures during the first day of life. After unsuccessful treatment with phenobarbital, phenytoin was added. He developed a picture of encephalopathy due to intoxication with this drug, despite the use of standard dosages. Given unchanged further investigations, individual’s susceptibility was considered to be the cause. Conclusion: Because of potential side effects, more frequent and severe in newborns, phenytoin tends to be less used in the treatment of neonatal seizures. Benzodiazepines and lidocaine seems to be safer and more effective options

The identification of multiple thrombophilic risk factors in an infant with cerebrovascular accident

We found 1 article: Rev Neurol. 2005 Apr 16-30;40(8):479-81. [The identification of multiple thrombophilic risk factors in an infant with cerebrovascular accident] [Article in Spanish] Neves J, Costa E, Branca R, Carrilho I, Barbot J, Barbot C. Servicio de Hematología, Hospital de Crianças Maria Pia, 4050-111 Porto, Portugal. Abstract INTRODUCTION: Neonatal stroke (NNS) incidence appears to be increasing over the last years. This is believed to be a consequence of diagnostic accuracy rather than a real amplification of this entity. Nowadays, NNS incidence is estimated to be 1:4000 full newborns. CASE REPORT: Child with left middle cerebral artery territory infarction in which several thromboembolic risk factors were documented both in the child (neonatal sepsis and factor V Leiden) and his mother (lupus anticoagulant, pre-eclampsy and factor V Leiden). CONCLUSIONS: This case supports the increasing evidence in recent reports that association of multiple prothrombotic risk factors (maternal and foetal) is present in NNS genesis. This way the authors agree that wide prothrombotic study may be of crucial interest in identifying subjacent thrombophilic disease, even when an exogenous risk factor is present. PMID: 15861329 [PubMed - indexed for MEDLINE

First Trimester Prediction of Pre-Eclampsia in Low Risk Pregnancies: Determining the Cut-Off in a Portuguese Group

Objective:We aimed to identify the cut-off for risk of pre-eclampsia (PE) in Portuguese population by applying the first trimester prediction model from Fetal Medicine Foundation (FMF) in a prospective enrolled cohort of low risk pregnant women. Population and methods: A prospective cohort of low risk singleton pregnancies underwent routine first-trimester scree - ning from 2011 through 2013. Maternal characteristics, blood pressure, uterine artery Doppler, levels of pregnancy-associated plasma protein-A (PAPP-A) and free b-human chorionic gonadotropin were evaluated. The prediction of PE in first trimester was calculated through software Astraia, the outcome obtained from medical records and the cutoff value was subse quently calculated. Results:Of the 273 enrolled patients, 7 (2.6%) developed PE. In first trimester women who developed PE presented higher uterine arteries resistance, represented by higher values of lowest and mean uterine pulsatility index, p <0.005. There was no statistical significance among the remaining maternal characteristics, body mass index, blood pressure and PAPP-A. Using the FMF first trimester PE algorithm, an ideal cut-off of 0.045 (1/22) would correctly detect 71% women who developed PE for a 12% false positive rate and a likelihood ratio of 12.98 (area under the curve: 0.69; confidence interval 95%: 0.39-0.99). By applying the reported cutoff to our cohort, we would obtain 71.4% true positives, 88.3% true negatives, 11.4% false positives and 28.6% false negatives. Conclusion: By applying a first trimester PE prediction model to low risk pregnancies derived from a Portuguese population, a significant proportion of patients would have been predicted as high risk. New larger studies are required to confirm the present findings

Melhorar a Resposta aos Estimuladores da Eritropoiese em Hemodiálise com Menos Ferro: Estudo Observacional

Introdução: A suplementação de ferro a doentes em hemodiálise (HD) com défice funcional de ferro aumenta a resposta aos estimuladores da eritropoiese (EE), mas existem preocupações com a possibilidade de sobrecarga. O índice de resposta aos estimuladores de eritropoiese (ERI) permite quantificar a resistência aos EE. A administração frequente de uma pequena dose de ferro endovenoso pode melhorar a eritropoiese, mas não existe evidência para a recomendação desta estratégia. Métodos: Avaliou-se o impacto no ERI da mudança de uma dose variável, intermitente, de óxido ferroso sacarosado endovenoso, para uma dose fixa, frequente (3 vezes por semana) de 10mg. Realizou-se um estudo observacional, comparativo de 2 períodos de 4 meses antes (período 1) e 6 meses depois (período 2), em 51 doentes estáveis, em HD sob terapêutica de manutenção com ferro endovenoso (óxido ferroso sacarosado) e EE (darbepoetina alfa endovenosa). Resultados: idade 66,2 ± 14 anos, vintage de diálise 55 ± 58 meses, 21% melanodérmicos, 43% sexo masculino. A média da hemoglobina Hb (g/dL) no período 1 (10,9 ± 0,7) não diferiu do período 2 (11,05 ± 0,6), p = 0,061. A dose de ferro por doente/mês foi 203mg (IQR 117-217) durante o período 1 e 130mg no período 2 (p < 0,001). A dose mensal de EE diminuiu de 90 μg para 70 μg (p < 0,001), melhorando o ERI de 6,17 para 4,47 (p < 0,001). Enquanto os níveis de ferritina não diferiram, a média da TSAT no final foi superior à inicial (29,38 ± 10,8 vs. 23,76 ± 8,48), respectivamente, p < 0,001), sugerindo melhoria da disponibilidade do ferro para a eritropoiese. A média dos custos mensais (incluindo o ferro e o EE) diminuiu 25%. Conclusão: A administração de menos ferro de forma mais frequente permitiu atingir o valor alvo de Hb, melhorando a resposta ao EE e reduzindo os custos globaisinfo:eu-repo/semantics/publishedVersio

Biomonitoring and predictive modelling of genomic instability in childhood obesity

Epidemiological evidence indicates obesity in childhood and adolescence to be an independent risk factor for cancer and premature mortality in adulthood. Pathological implications from excess adiposity may begin early in life. Obesity in childhood and adolescence is concurrent with a state of chronic, low-grade inflammation, a well-known aetiological factor for DNA damage. In addition, obesity in childhood and adolescence has been associated with micro-nutritional deficiencies. Vitamin D has attracted attention for its anti-inflammatory properties and role in genomic integrity and stability. We have conducted research aimed at devising a novel approach for predicting genomic instability in childhood obesity via the combined, non-invasive assessment of adiposity, DNA damage, systemic inflammation, and vitamin D status. We carried out a cross-sectional study with participants, aged 10–18, recruited from schools and paediatric obesity clinics in London. Our results support the hypothesis that childhood obesity is associated with increased genomic instability. Importantly, we have found that obesity, vitamin D and oxidative DNA damage can together predict genomic instability. Non-invasive biomonitoring and predictive modelling of genomic instability in young patients with obesity may contribute to the prioritisation and severity of clinical intervention measures

Qualidade de Sono dos Anestesiologistas Portugueses: um Estudo Transversal

INTRODUCTION: 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 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.info:eu-repo/semantics/publishedVersio

Healthcare providers’ views and perceptions on post-mortem procedures for cause of death determination in Southern Mozambique

Background: The minimally invasive autopsy (MIA) is being investigated as an alternative to the complete diagnostic autopsy (CDA), gold standard for CoD determination, in settings where CDA is unfeasible and/or unacceptable. We aimed to explore healthcare providers’ views and perceptions on theoretical and factual acceptability of the CDA and the MIA. Methods: A qualitative study, combining ethnographic and grounded-theory approaches, was conducted within a project aiming to validate the MIA tool against the CDA for CoD investigation. We present data on in-depth and semi-structured interviews of 33 healthcare providers operating within the formal and informal health services in Southern Mozambique. MIA perception was analysed through the theory of diffusion of innovations. Results: All participants considered CDA useful for CoD determination. CDA was perceived reliable, but the unpleasant nature of the procedure and its associated infection risk were the main perceived disadvantages. Participants considered the MIA simple, easy and quick to perform; likely to meet families’ expectations to know the CoD, and able to provide evidence-based knowledge for disease management. Concerns were raised on its reliability compared to the CDA. Family's emotional status and accessibility to decision-makers were mentioned as principal barriers for MIA performance. The main jeopardizing factors for MIA implementation were the shortage of required resources and the significant proportion of people dying at home. Key facilitators for MIA acceptance included the need for the support from community and religious leaders, provision of clear information to the community, and accompaniment to bereaved families. Conclusions: Healthcare providers consider the MIAs potentially more acceptable and feasible than CDAs in places where the latter have shown significant implementation challenges. A clear understanding of healthcare provider’s perceived barriers and facilitators for conducting post-mortem procedures in general, and MIAs in particular, will shed light on their future field implementation for more robust mortality surveillance

Prognostic value of NT-proBNP, adrenomedullin, copeptin and proenkephalin in patients with pulmonary hypertension

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017.Introduction: Pulmonary hypertension (PH) comprises a group of progressive diseases characterized by an increase in pulmonary vascular resistance, leading to right ventricular dysfunction. Risk stratification is essential for prognostic evaluation and therapeutic decision, making the determination of new biomarkers important. Purpose: To assess the prognostic value of new biomarkers in the prognostic evaluation of patients with PH. Methods: Prospective cohort study of patients (pts) with PH confirmed by hemodynamic evaluation. Pts underwent clinical and laboratory evaluations at baseline and every 3 months. Follow-up lasted for 18 months. NTproBNP and the new biomarkers (adrenomedullin, copeptin and proenkephalin) were measured. The Mann-Whitney test, Kaplan-Meier survival analysis and Cox regression were used for statistical analysis. Results: Fifty one pts (75% males, mean age: 54±15 years) belonging to all groups of the WHO PH classification were included. At inclusion, all pts were in WHO functional class II or III. During the study period, 17 pts (33%) died. Baseline NTproBNP values were significantly higher in the non-survivors group (1327; 1061–2703pg/ml vs. 353.5; 190–1661pg/ml; p=0.022). The same did not occur for adrenomedullin, copeptin and proenkephalin baseline levels. The maximum NTproBNP, adrenomedullin and copeptin levels recorded during the follow-up period were significantly higher in the non-survivors group [2347.5 (1667–5073.25) pg/ml vs. 642.5 (208.25–4109.5) pg/ml, p=0.007; 53.6 (38.8- 94.2) pg/ml vs. 33.4 (27–48.8) pg/ml, p=0.0075; 20.69 (13.18–35.69) pmol/L vs. 9.97 (6.18–14.74) pmol/L, p=0.022, respectively]. This did not occur for the maximum proenkephalin level. The NT-proBNP level at admission and adremedullin level at 3 months were independent predictors of mortality (HR 2.78, CI95 1.23–6.30, p=0.01; HR 4.36, CI95 1.17–16.2, p=0.03).Conclusion: The maximum level of NTproBNP, adrenomedullin and copeptin during the follow up were associated with higher mortality in pts with PH. NTproBNP level proved to be an independent predictor of mortality in those patients. These results suggest the prognostic importance of these biomarkers in the approach of pts with PH.info:eu-repo/semantics/publishedVersio

Weak surveillance and policy attention to cancer in global health: the example of Mozambique

Cancer is an emerging public health problem in sub-Saharan Africa due to population growth, ageing and westernisation of lifestyles. The increasing burden of cancer calls for urgent policy attention to develop cancer prevention and control programmes. Cancer surveillance is an essential prerequisite. Only one in five low-income and middle-income countries have the necessary data to drive policy and reduce the cancer burden. In this piece, we use data from Mozambique over a 50-year period to illustrate cancer epidemiological trends in low-income and middle-income countries to hypothesise potential circumstances and factors that could explain changes in cancer burden and to discuss surveillance weaknesses and potential improvements. Like many low-income and middle-income countries, Mozambique faces the dual challenge of a still high morbidity and mortality due to infectious diseases in rural areas and increased incidence of cancers associated with westernisation of lifestyles in urban areas, as well as a rise of cancers related to the HIV epidemic. An increase in cancer burden and changes in the cancer profile should be expected in coming years. The Mozambican healthcare and health-information systems, like in many other low-income and middle-income countries, are not prepared to face this epidemiological transition, which deserves increasing policy attention