Thoracic Duct Decompression for Protein-Losing Enteropathy in Failing Fontan Circulation

An infrequent but devastating late complication of Fontan circulation is protein-losing enteropathy (PLE), which results from unbalanced lymphatic homeostasis. Surgical decompression of the thoracic duct by redirecting its drainage to the pulmonary venous atrium has been introduced recently as a possible treatment. This report describes a single-institution experience with this innovative procedure in 2 patients with failing Fontan circulation with PLE refractory to optimized medical therapy

Flow Diverters Devices for Treatment of Intra-Cranial Aneurysms - Six Months Follow-Up Results

A reconstrução endoluminal com sistemas de derivação de fluxo (flow diverter devices) constitui uma técnica inovadora no tratamento de aneurismas intra-cranianos. Estes novos stents, auto-expansíveis e de reduzida porosidade, são libertados através de microcateterização da artéria portadora do aneurisma, reconstruindo assim a sua parede e excluindo a formação aneurismática da circulação arterial. Neste trabalho mostramos os resultados preliminares obtidos no tratamento de 10 doentes no Hospital de São José, Lisboa. Estes doentes, com aneurismas de colo largo (> 4mm) ou ratio saco/colo não favorável (< 1,5), foram tratados com o sistema PIPELINE®, e estudos angiográficos de controlo foram efectuados aos três e seis meses. Novo controlo será feito aos 12 meses. A idade media dos doentes envolvidos é de 54,3 anos, oito doentes são do sexo feminino e dois doentes do sexo masculino. Os aneurismas foram incidentalmente descobertos em dois doentes e os restantes foram diagnosticados no contexto de investigação imagiológica por cefaleias (n = 3), defeito de campo visual (n = 1), vertigens (n = 1) e parésia de pelo menos um par craniano (n = 2). Em apenas dois doentes foi observada hemorragia subaracnoideia e outros dois doentes foram submetidos a terapêutica endovascular prévia, com espiras metálicas. As localizações dos aneurismas tratados são o segmento M1/M2 da artéria cerebral média (n = 1) e os segmentos da artéria carótida interna para-oftálmico (n = 6), oftálmico (n = 2) e cavernoso (n = 4). Treze aneurismas intra-cranianos foram tratados uma vez que três doentes apresentavam múltiplos aneurismas. Os estudos de controlo efectuados demonstram um grau de oclusão médio aos três meses de 74% e aos seis meses de 86%. Não se observou qualquer redução das dimensões do saco de um dos aneurismas para-oftálmico. A experiência deste serviço é muito favorável a utilização de sistemas de derivação de fluxo no tratamento de aneurismas seleccionados, tendo obtido taxas de oclusão elevadas dados os desafios existentes na terapêutica deste tipo de aneurismas

Delirium Pós-Operatório em Cirurgia Vascular

OBJECTIVES: The objectives of this study were to determine the incidence of Postoperative Delirium and to identify specific perioperative risk factors in patients undergoing Vascular Surgery. Other goals were to study its impact in hospital length of stay and to create an algorithm to deal with patients under suspicion of Postoperative Delirium. MATERIAL AND METHODS: A total of 56 consecutive vascular surgery patients were prospectively evaluated. Exclusion criteria were age less than 18, dementia, abnormal level of consciousness, psychiatric disorder and visual or hearing impairment. Mini Mental State Examination were applied during pre-anesthetic visit. In patients with clinical indicators of delirium the Confusion Assessment Method was applied. Patients were assessed during 5 days after surgery. RESULTS: The overall incidence of delirium was 12,5%, developped mostly by the second to fifth postoperative day. Patients with delirium presented moderate to severe pain. Patients who received combined general and regional anesthesia didn't develop delirium. The median hospital length of stay was 21 in patients with delirium and 7 days in patients without (p 0.001). CONCLUSIONS: The overall incidence of postoperative delirium was lower than previously reported. The incidence of delirium was higher in ICU patients and pain was associated with postoperative delirium suggesting the opportunity to control postoperative factores. The development of delirium in the second and fifth day indicated the need for early and more prolonged preventive and diagnosing measures. Clinical and costly considerations of prolonged hospital stay shown in this cohort warrant strong debate strategies to be applied.info:eu-repo/semantics/publishedVersio

Mitral Valve Surgery for Rheumatic Lesions in Young Patients

BACKGROUND: The appropriateness of rheumatic mitral valve repair remains controversial due to the risks of recurrent mitral dysfunction and need for reoperation. The aims of this study were to determine the overall short- and long-term outcomes of pediatric rheumatic mitral valve surgery in our center. METHODS: Single-center, observational, retrospective study that analyzed the results of rheumatic mitral valve surgery in young patients, consecutively operated by the same team, between 1999 and 2014. RESULTS: We included 116 patients (mean age = 12.6 ± 3.5 years), of which 66 (57%) were females. A total of 116 primary surgical interventions and 22 reoperations were performed. Primary valve repair was possible in 86 (74%) patients and valve replacement occurred in 30 (26%). Sixty percent of the patients were followed up beyond three months after surgery (median follow-up time = 9.2 months [minimum = 10 days; maximum = 15 years]). Long-term clinical outcomes were favorable, with most patients in New York Heart Association functional class I (89.6%) and in sinus rhythm (85%). Freedom from reoperation for primary valve repair at six months, five years, and ten years was 96.4% ± 0.25%, 72% ± 0.72%, and 44.7% ± 1.34%, respectively. Freedom from reoperation for primary valve replacement at six months, five years, and ten years was 100%, 91.7% ± 0.86%, and 91.7% ± 0.86%, respectively. Mitral stenosis as the primary lesion dictated early reintervention. CONCLUSIONS: Despite the greater rate of reoperation, especially when the primary lesion was mitral stenosis, rheumatic mitral valve repair provides similar clinical outcomes as compared with replacement, with the advantage of avoiding anticoagulation

Arteriovenous Hemangioma of the Mitral Valve: Successful Surgical Removal in an Infant

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Fall risk assessment in elderly with and without history of falls: strength analysis of lower limb: a comparative study

Objectives: The objective of this research was to analyse muscle performance criteria of the knee joints and ankle flexor and extensor muscles among elderly with and without history of falls. Material and methods: The sample was non-probabilistic, of convenience, comprising a total of 30 elderly (15 with history of falls and 15 without history of falls) who met the inclusion and exclusion criteria. Data were collected through a characterization questionnaire and through the Biodex System Isokinetic Dynamometer. The isokinetic assessment consisted in collecting the Peak Torque per unit of mass (N.m/BW) and ratio FlexorsCon/ExtensorsCon (%) of the knee joints and ankle flexor and extensor muscles, with 5 repetitions and the 60º/s angular speed. This collection has been made in both lower limbs. Results: The sample consisted of 30 individuals, 15 from the group without history of falls and 15 from the group with history of falls with average age of (69,17±4,77) years old. The muscle performance parameters were not significantly different between the groups (p>0,05). Conclusion: The group of elderly with history of falls showed lower Peak Torque numbers per unit of mass (N.m/BW) for the knee and ankle joint comparing with the group without history of falls. In present research also the values of the ratio flexorsCon/ExtensorsCon was analyzed weren't differences found in the knee and ankle joint. Although there are no statistically significant differences between results obtained, approach we believe it will be beneficial to include strengthening exercises for the flexors and extensors muscles of these joints, thereby contributing to the prevention of falls

Fall risk assessment in elderly with and without history of falls: kinematic gait analysis: a comparative study

Objectives: The objective of this research was to verify if there was a variation in the MFC (Minimum Foot Clearance) value among elderly with and without history of falls and, if there were any, verify which joint of the lower limb was responsible for that variation. It was also a main objective to verify if there was a correlation between the risk of falling, achieved through the Timed Up and Go Test (TUG), and the MFC variation. Material and Methods: The sample consisted of a total of 30 elderly who met the inclusion and exclusion criteria. These were divided into the group without history of falls (n=15) and into the group with history of falls (n=15). The MFC and the joint movement amplitudes of the hip, knee and ankle, of the dominant lower limb, were assessed using the Kinovea programme and for the risk of fall assessment it was used the TUG. Results: There were no statistically significant differences in the MFC and TUG values between the groups with and without history of falls. However, there is a decrease of the MFC value for the group with history of falls, being the ankle the joint that most contributed to the MFC variation in the group without history of falls, and the knee in the group with history of falls. About the relation between MFC and TUG, it was obtained a negative correlation (r=-0,269) but it was not significant (p=0,150). Conclusion: In our sample no significant differences in the MFC value were obtained between the group with history of falls and the group without history of falls. Besides the lack of significant differences in the MFC value it was determined the articulation of the lower limb responsible for its variation, and it has been found, although with a p>0,05, that for the group with no history of falls it was the ankle that more contributed to this variation and the knee to the group with history of falls. Concerning to the TUG and MFC value correlation it wasn’t significant. Thus, it was concluded that the TUG use is more effective and sensitive in predicting the risk of falling when compared with the kinematic analysis to obtain the MFC value and the joints amplitude

Fall risk assessment in elderly with and without history of falls: gait electromyographic analysis: a comparative study

Objectives: To determinate if there were differences in electromyography parameters of rectus anterior, biceps femoris, gluteus medius, soleus, gastrocnemius medialis and tibialis anterior muscles between group with and without history of falls during. Was analized the relationship between the levels of muscle activation and score in POMA (Performance-Oriented Mobility Assessment). Materials and Methods: This is a transversal, not experimental and comparative study. The sample was composed by 30 older adults, 15 with and 15 without history of falls. To collect the data of electromyography was used BIOPAC systems and followed the SENIAM guidelines. For the collection of kinematic data was used Kinovea program and for assess the risk of falling was applied POMA. Results: Individuals with history of falls present levels of muscle activity relatively to maximum voluntary contraction (MVC) higher in the dominant lower limb (right) compared to subjects without a history of falls, however these differences aren´t statistically significant (p>0,05). There is enormous variation between the sample in relation to phases of gait in which the muscles are more actives. The group with history of falls shows values lower than group without history of falls in POMA score, the difference is significant (p=0.001). The relationship between percentage of muscle activation and the values obtained in POMA not proved statistically significant (p>0,05). Conclusion: Although results obtained weren´t statistically significants, we can conclude that individuals with falls have higher levels of muscle activation relative to MVC that individuals without history of falls, it is believed that the changes are related to the development of strategies for increased stability during gait. There is considerable variability in phases in which the subjects engaged higher levels of muscle activation, which might occur due to task compensatory strategies or by the task have been made at speed of comfort for the individual. It follows that POMA is an instrument more sensitive and effective to identify the risk of falling in these individuals that the electromyographic analysis

Octreotide - Additional Conservative Therapy for Postoperative Chylothorax in Congenital Heart Disease

INTRODUCTION: Chylothorax is a rare but serious postoperative condition in children with congenital heart disease. Conventional medical treatment consists of specific long-term dietary modification, and surgical reintervention, such as lymphatic duct ligation, may be indicated in refractory cases. In recent years, an additional conservative treatment, octreotide, a synthetic analog of somatostatin, has been used in management of congenital and postoperative chylothorax. METHODS: The objective of this work was to analyze the efficacy and safety of this treatment for chylothorax after congenital heart surgery. We reviewed the records of sixteen patients with chylothorax after surgery for congenital heart disease between January 1999 and December 2007, and collected the following data: demographic information; type of surgical procedure; onset, duration and management of chylothorax and treatment; and duration of hospital stay. To analyze efficacy we compared these parameters in children receiving conventional treatment only with those receiving octreotide. To analyze safety we compared the adverse effects of both treatments. Octreotide was administered at a dose of 4 to 10 microg/kg/hour, with monitoring of side effects. RESULTS: The incidence of chylothorax in our population was 1.6%. It occurred more often after Glenn and Fontan procedures (8 patients). Octreotide was begun three days after diagnosis of chylothorax and continued for a median of seventeen days (ranging from 4 to 26 days), until complete resolution. Side effects were frequent (in 3 of the 8 patients) but of no clinical relevance. All patients responded to the therapy and there was no indication for further surgical intervention. DISCUSSION AND CONCLUSIONS: Octreotide is safe and effective in the treatment of postoperative chylothorax in children with congenital heart disease. It is a useful adjunctive therapy to the conventional treatment of this complication

Fall risk assessment in elderly with and without history of falls: relationship between disorders of balance, fear of falling and gait changes: a comparative study

Objectives: The aim of this study was to assess the changes that occur in the balance, fear of falling and kinematic parameters such as stride length, velocity and time support in elderly with and without a history of falling. Main objective was also to verify whether a relationship exists between changes in gait parameters evaluated, balance and fear of falling. Methods: The sample comprised 30 patients (15 with history of falls and 15 without a history of falls), which met the criteria for inclusion and exclusion. The kinematic evaluation was performed in the dominant leg, which was right in this sample. The stride length, speed and duration of support were assessed using the program Kinovea and for assessment of balance and fear of falling were assessed using the Berg Balance Scale and the Falls Efficacy Scale. Statistical analysis was performed with SPSS version 20. Results: There were no significant differences in the parameters analyzed, except for scores on the Berg Balance Scale (p=0.000) between groups with and without history of falls. However, there is a decrease in the length of the stride and duration of left leg support and the increased length of right leg support, the speed and the fear of falling. The relationship between the parameters obtained, there is only statistically significant result between speed and stride length (r=0.507, p=0.004) and between the score of the Berg Balance Scale and the stride length (r=0.393, p=0,032). Conclusion: Although not having obtained statistically significant results we can conclude that in elderly with a history of falls have changes in speed and stride length that can be related to balance disorders and the aging process itself. However, it is concluded that the use of the Berg Balance Scale is more responsive and effective in the detection of changes occurring in the individual after a fall, and subsequent evaluation of the risk of falling that performing a kinematic analysis