A Pediatric Telecardiology Service 20 years on-An exploratory study

Background: Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform. Methods: This study aims at exploring the Pediatric Telecardiology Service's evolution, through a comprehensive assessment of the PCS's development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon's framework helped to understand the implementation and scale-up process and the role of policy-making. Results: With the total of 32,685 out-patient teleconsultations, growing steadily from 1998 to 2016, the Pediatric Telecardiology Service has reached national and international recognition, being a pioneer and an active promotor of telemedicine. This telemedicine service has saved significant resources, about 1.1 million euros for the health system (e.g. in administrative and logistic costs) and approximately 419 euros per patient (considering an average of 1777 patients per year). PCS presents a dominant "Clan" culture. The Momentum's critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals' engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service. Conclusion: The Pediatric Telecardiology Service enables real-time communication and the sharing of clinical information, overcoming many barriers (from geographical ones to shortage of healthcare professionals), improving access to specialized care both in Portugal and Africa. Motivation and teamwork, and perseverance, were key for the Pediatric Telecardiology Service to tackle the window of opportunity which created conditions for sustainability.publishersversionpublishe

estudo da opinião dos médicos e implicações para o futuro

INTRODUCTION: The COVID-19 pandemic led to the reorganization of healthcare services and teleconsultation emerged as a solution to facilitate patient appointments. The aim of this study was to characterize, from a physician perspective, the teleconsultations carried out in the Portuguese National Health Service (SNS) during the first phase of the pandemic and to identify factors that influence the experience of the teleconsultation. MATERIAL AND METHODS: A cross-sectional analytical study was conducted based on an online survey, between July-September 2020, aimed at SNS doctors. Data on demographics, practice, attitudes and perceptions associated with the teleconsultation was collected. The adjusted prevalence ratio (aPR) was calculated to identify demographic factors and determinants of teleconsultation associated with satisfaction, use of video calls and greater motivation to carry out teleconsultations in the future. RESULTS: 2225 valid responses were obtained. Teleconsultation was carried out by 93.8% of participants in this period, 99.0% used the telephone as a form of communication and only 8.0% used a video call. A high degree of satisfaction with the teleconsultation was significantly associated with perceiving the teleconsultation as providing care with equivalent quality to a face-to-face consultation (aPR = 1.472) and being motivated to do teleconsultation after the pandemic (aPR = 4.081). Reporting clinical (aPR = 0.763) or technical difficulties (aPR = 0.666) was negatively associated with satisfaction). 70.4% of doctors would like to continue doing follow-up teleconsultations and 53.3% consider that video call technologies should always or often be used during teleconsultations. CONCLUSION: Teleconsultation seems to have potential to to become a common practice in the future. However, it is important to address clinical, technical, organizational, and legal questions and, above all, to ensure that it is a safe and valuable practice for patients.publishersversionepub_ahead_of_prin

Obesidade: Paradigma da Disfunção Endotelial em Idade Pediátrica

Introdução: A obesidade é considerada pela Organização Mundial de Saúde como uma epidemia global sendo considerada um factor de risco cardiovascular independente. Material e Métodos: Estima-se que cerca de 10% da população pediátrica mundial apresente excesso de peso ou obesidade e que cerca de 40% sejam obesas na vida adulta. A obesidade caracteriza-se por um processo pró-inflamatório crónico que resulta na lesão do endotélio. O resultante desequilíbrio na produção de mediadores que normalmente regulam a homeostasia vascular, particularmente a biodisponibilidade do óxido nítrico, favorece um ambiente pró-aterosclerótico propício ao desenvolvimento da doença cardiovascular. Resultados: Estudos anátomo-patológicos em crianças com excesso de peso ou obesidade evidenciam lesões do endotélio que se traduzem nos precursores da lesão aterosclerótica. Discussão: A disfunção endotelial é a manifestação mais precoce da lesão aterosclerótica. Estas alterações evidenciam-se precocemente em crianças obesas, contribuindo para a doença cardiovascular no adulto. Conclusão: As repercussões clínicas destas alterações raramente se manifestam em idade pediátrica, sendo detectadas apenas através de biomarcadores, alterações morfológicas dos vasos ou modificações do tónus arterial periférico.Introduction: Obesity is considered a global epidemy with important public health issues as it is an independent risk factor in the development of cardiovascular disorders. Material and Methods: Approximately 10% of the world’s paediatric population has excess weight or obesity and 40% of these will be obese adults. Obesity is characterized by a chronic, low grade, pro-inflammatory process that ultimately results in endothelial dysfunction, the trigger lesion leading to adult cardiovascular disease. This leads to an imbalance in the synthesis of mediators that normally regulate vascular homeostasis, particularly nitric oxide bioavailability, favoring a pro-atherosclerotic status, the hallmark of cardiovascular disorders. Results: These changes begin early in childhood and anatomopathological studies in children with excess weight or obesity have shown endothelial changes that represent the precursors of the atherosclerotic lesion. Discussion: Endothelial dysfunction is the earliest manifestation of the atherosclerotic lesion. It is evident in obese children and, as such, it potentially contributes towards cardiovascular disease in the adult. Conclusion: Although the clinical impact of these changes rarely manifest themselves in infancy, the presence of related biomarkers as well as vascular morphological changes can, at this early stage, be found and assessed

Premature Atherosclerosis in HIV-Infected Pediatric Patients: Literature Review and Clinical Approach

Human immunodeficiency virus infected children and adolescents are a pediatric group with increased risk of premature cardiovascular disease. The virus itself, the antiretroviral therapy and the lifestyle establish a complex interplay of factors that promotes an accelerated atherosclerosis. This process is probably mediated by dyslipidaemia, dysregulation of glucose metabolism, lipodystrophy, inflammation, endothelial dysfunction and a prothrombotic state. The clinical approach to this population in terms of cardiovascular prevention is mainly based on efficient treatment of the infection, reduction of the modifiable risk factors and promotion of lifestyle changes

Endocardite Bacteriana — Caso Clínico

A endocardite infecciosa continua a ser uma causa importante de morbilidade na população infantil, nomeadamente, nas crianças com cardiopatia congénita.Os autores apresentam o caso clínico de um rapaz de 6 anos, previamente assintomático, que recorreu ao Serviço de urgência do Hospital Pediátrico de Coimbra por febre, dor no membro inferior direito e epistaxe. A existência, entre outros sinais, de febre, hipertensão nos membros superiores, sopro cardíaco e manifestações tromboembólicas do membro inferior direito, levou à suspeita de endocardite bacteriana e coartação da aorta, posteriormente confirmadas pela ecocardiografia e hemoculturas positivas.Chama-se a atenção para esta forma de apresentação, não-habitual, da endocardite na criança e para a doença de base (coartação da aorta), apenas diagnosticada na sequência duma complicação

Doença de Kawasaki. Casuística do Hospital Pediátrico de Coimbra

Os autores fizeram uma análise retrospectiva dos casos de doença de Kawasaki diagnosticados nos últimos 11 anos (1985-1995) no Hospital Pediátrico de Coimbra (HP). O número total foi de 35 casos, sendo 71% do sexo masculino. A idade das crianças variou entre os 3 meses e os 7 anos, tendo o pico de incidência ocorrido no 2.° ano de vida.As adenomegálias e a congestão conjuntival foram os critérios clássicos menos frequentes. A irritabilidade foi entre os outros sinais e sintomas clínicos não específicos, aquele que predominou. As complicações coronárias foram observadas em I I crianças (6 dilatações e 5 aneurismas).Dois casos ocorridos no 1." semestre de vida foram considerados formas atípicas, e noutro caso, houve uma recorrência 4 anos após o 1.° episódio. Em todas as 11 crianças houve resolução completa da patologia coronária e não houve mortalidade

Endocardite Infecciosa — Experiência de 10 Anos

Estudámos retrospectivamente, 17 casos de Endocardite Infecciosa internados no Hospital Pediátrico de Coimbra entre Janeiro de 1985 a Junhode 1995.A idade das crianças variou entre 10 dias e 11 anos sendo de realçar o facto de 35% terem idade inferior a 24 meses.Havia cardiopatia prévia em 65% dos doentes, sendo as mais frequentes a comunicação inter-ventricular (CIV) e a coartação da aorta.Em 88% das crianças encontrou-se um provável factor desencadeante.Todas as crianças realizaram ecocardiografia e foi possível visualizar vegetações em 65% das mesmas.Em duas o diagnóstico foi feito através daecocardiografia transesofágica.O Staphylococcus epidermidis foi o gérmen mais frequente.A percentagem de hemoculturas negativas foi elevada (41%).Nenhuma criança foi sujeita a tratamento cirúrgico na fase aguda, sendo o tratamento médico eficaz em 76% dos casos.As sequelas foram rarase a mortalidade global foi de 23,5%

Sling da Artéria Pulmonar: Caso Clínico e Breve Revisão Teórica

ResumoO Sling da Artéria Pulmonar é uma anomalia congénita na qual a artéria pulmonar esquerda emerge da face posterior da artéria pulmonar direita, passando anterior ao esófago e posterior à traqueia, formando um anel que pode causar compressão traqueal. A incidência não é tão rara como inicialmente se julgava e deve ser pensado como uma causa de dificuldade respiratória no recém-nascido e pequeno lactente. A mortalidade pode ser de 90% na ausência de correcção cirúrgica.Os autores apresentam um caso clínico de um pequeno lactente com Sling da Artéria Pulmonar. Faz-se uma pequena revisão teórica.Palavras-Chave: Sling da Artéria Pulmonar — Estenose Traqueal — Anel Vascula

Circulating endothelial progenitor cells in obese children and adolescents

Objective: This study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity. Methods: Observational and transversal study, including 120 children and adolescents with primary obesity of both sexes, aged 6–17 years, who were recruited at this Cardiovascular Risk Clinic. The control group was made up of 41 children and adolescents with normal body mass index. The variables analyzed were: age, gender, body mass index, systolic and diastolic blood pressure, high‐sensitivity C‐reactive protein, lipid profile, leptin, adiponectin, homeostasis model assessment‐insulin resistance, monocyte chemoattractant protein‐1, E‐selectin, asymmetric dimethylarginine and circulating progenitor endothelial cell count. Results: Insulin resistance was correlated to asymmetric dimethylarginine (ρ = 0.340; p = 0.003), which was directly, but weakly correlated to E‐selectin (ρ = 0.252; p = 0.046). High sensitivity C‐reactive protein was not found to be correlated to markers of endothelial activation. Systolic blood pressure was directly correlated to body mass index (ρ = 0.471; p < 0.001) and the homeostasis model assessment‐insulin resistance (ρ = 0.230; p = 0.012), and inversely correlated to adiponectin (ρ = −0.331; p < 0.001) and high‐density lipoprotein cholesterol (ρ = −0.319; p < 0.001). Circulating endothelial progenitor cell count was directly, but weakly correlated, to body mass index (r = 0.211; p = 0.016), leptin (ρ = 0.245; p = 0.006), triglyceride levels (r = 0.241; p = 0.031), and E‐selectin (ρ = 0.297; p = 0.004). Conclusion: Circulating endothelial progenitor cell count is elevated in obese children and adolescents with evidence of endothelial activation, suggesting that, during infancy, endothelial repairing mechanisms are present in the context of endothelial activation

Traumatismo cardíaco por arma branca num adolescente

Os ferimentos penetrantes do tórax representam 10 a20% de todas as admissões hospitalares de crianças vítimasde trauma e as feridas por armas brancas são responsáveispor cerca de dois terços dos traumatismoscardíacos abertos.Descreve-se o caso clínico de um adolescente de 17anos, vítima de agressão por arma branca. Manteve-sesempre hemodinamicamente estável, sem alteraçõessignificativas no exame físico, com exceção de três feridasincisas no couro cabeludo e regiões inframamilar eperi-umbilical esquerdas. A avaliação diagnóstica revelouuma solução de continuidade na região apical doventrículo direito, associada a moderado derrame pericárdico,com função biventricular conservada. Foi referenciadopara um centro cirúrgico cardiotorácico, ondefoi submetido a sutura direta da ferida, com remoção docoágulo que tamponava parcialmente a hemorragia. Opós-operatório imediato decorreu sem complicações,mas nos três meses seguintes, o adolescente teve trêsepisódios compatíveis com pericardite, que responderama terapêutica anti-inflamatória