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

Intoxicação do Sistema Nervoso Central Durante a Implantação de um Cardioversor Desfibrilhador Implantável -- Um Caso Clínico e Revisão da Literatura

Lidocaine, a local anesthetic, is commonly used in various medical procedures. Despite its widespread use, most physicians are not familiar with the life threatening presentation of lidocaine toxicity and its treatment. Our case demonstrates successful management of local lidocaine-induced systemic toxicity in a 53-year-old female during insertion of an implantable cardioverter defibrillator. Our goal was to raise awareness of the risks and symptoms of local anesthetic toxicity, educate regarding the site of administration and dose of anesthetic delivery as independent risk factors for systemic toxicity and highlight the use of intravenous lipid emulsion as an antidote.A lidocaína é um anestético local vulgarmente usado em vários procedimentos médicos. Apesar do seu uso abrangente, a maioria dos clínicos não está familiarizada com os sinais e sintomas de toxicidade e o seu tratamento. O nosso caso demonstra o tratamento bem-sucedido de uma intoxicação sistémica de lidocaína numa mulher de 53 anos durante a implantação de um cardioversor desfibrilhador implantável (CDI). O nosso objetivo é consciencializar para os riscos, sinais e sintomas da intoxicação de anestésicos locais, informar sobre o local e dose de administração como fatores de risco independentes para a toxicidade sistémica e enfatizar ouso de emulsão lipídica como antídoto.info:eu-repo/semantics/publishedVersio

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: 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

Thromboembolic Complications During Endovascular Treatment of Ruptured Intracranial Aneurysms - Prevention and Therapy

As complicações tromboembólicas são as mais frequentemente reportadas durante a terapêutica endovascular de aneurismas intracranianos com espiras metálicas. A frequência deste tipo de complicação varia na literatura, contudo autores referem uma incidência entre 2,5 e 28%. Diversos mecanismos poderão estar envolvidos na formação e migração do trombo: pode ser já preexistente no interior do aneurisma a tratar e deslocar-se para o vaso portador; pode formar-se de novo na superfície das espiras ou dos cateteres utilizados; ou ainda no eventual colo residual se o grau de oclusão não for completo. Estudos demonstraram maior incidência de complicações tromboembólicas em aneurismas de colo largo. Neste trabalho discutimos a importância e justificação de medidas utilizadas na prevenção de complicações tromboembólicas durante e após a terapêutica endovascular de aneurismas rotos intra-cranianos. Referem-se ainda as opções e estratégias a adoptar na eventualidade de uma oclusão vascular ser detectada durante o procedimento, como a administração de inibidores da glicoproteina IIb/IIIa ou mesmo a libertação de stents intra-cranianos. Diversos casos exemplificativos são exibidos. A prevenção de complicações tromboembólicas e a rápida actuação perante a oclusão vascular são essenciais para a melhoria do prognóstico dos doentes submetidos a terapêutica endovascular de aneurismas rotos. O conhecimento profundo das opções disponíveis é essencial para a persecução desse objectivo

Prevalência de Doença Carotídea na Patologia Cérebro-Vascular Isquémica. O Papel do Eco-Doppler

BACKGROUND: Atherosclerotic carotid disease represents approximately 20% of the causes of ischemic stroke. Effective treatment options, such as endovascular or surgical revascularization procedures, are available. Doppler Ultrasound (DUS) is a non-invasive, inexpensive, routine exam used to evaluate the presence of internal carotid artery (ICA) stenosis. We retrospectively analysed the prevalence of severe atherosclerotic carotid disease in a population of patients with acute ischemic stroke/transitory ischemic attacks (TIAs), and the role of DUS in the detection of ICA stenosis and treatment decisions in these patients. METHODS: A total of 318 patients with ischemic stroke or TIAs was admitted to our stroke unit, and 260 patients were studied by DUS. ICA stenosis was evaluated by DUS according to peak systolic velocity. All DUS exams were performed by the same operator. ICA stenosis was further assessed in 43 patients by digital subtraction angiography (DSA) using NASCET criteria. RESULTS: Of the total 318 patients, 260 (82%) had DUS evaluation. Of the total 520 ICAs studied by DUS, degrees of ICA stenosis were: 0-29% n= 438 (84%); 30-49% n= 8 (2%); 50-69% n= 27 (5%); 70-89% n= 15 (3%); 90-99% n= 20 (4%); oclusão n= 14 (2%). Of the total 260 patients studied, 43 (16.5%) underwent DSA. Sensibility and specificity of DUS in the diagnosis of carotid stenosis over 70% were, respectively, 91% e 84%. Of the total 31 patients with significant carotid stenosis (70-99%), 23 (74%) underwent subsequent carotid revascularization procedures. DISCUSSION: DUS is an important screening test in our stroke unit, justifying its use as a routine exam for all patients with ischemic stroke/TIAs. Moreover, our results show the relevance of severe carotid disease in a population with acute ischemic stroke/TIAs (16.5%), with a total of 9% of patients being submitted to carotid revascularization procedures

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: 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

Low Prevalence of Fetal-Type Posterior Cerebral Artery in Patients with Basilar Tip Aneurysms

BACKGROUND: Basilar tip aneurysms (BTA) are multifactorial in origin, with luminal forces playing a major role in their formation. Considering the reduced hemodynamic stress on the basilar apex in the fetal-type posterior cerebral artery (fPCA), we hypothesize that BTA should be less common in patients with this variant. OBJECTIVE: To investigate, in a retrospective case-control study, the frequency of fPCA in patients with and without BTA. MATERIALS AND METHODS: We collected clinical and imaging data from consecutive patients with BTA undergoing catheter angiography between July 2010 and July 2015, and from a randomly selected, age- and sex-matched non-BTA control population from our prospective database. Anatomical variants of the distal basilar artery region were assessed in the two groups and compared using parametric and non-parametric tests. RESULTS: Fifty-nine BTA cases and 337 controls were included. fPCA was present in 3% of patients with BTA and 23% in the control group (p<0.001; OR=0.11, 95% CI 0.03 to 0.48). Basilar tip disposition was cranial in 49% of BTA and 63% of non-BTA cases (p=0.04; OR=0.57, 95% CI 0.33 to 0.99); a caudal disposition was found in 24% and 6% of cases, respectively (p<0.001; OR=4.65, 95% CI 2.21 to 9.80). CONCLUSIONS: We found a statistically significant association between the absence of fPCA and BTA. Our findings underline the importance of hemodynamic stress in the formation of intracranial aneurysms, and suggest that fPCA is a protective variant for formation of BTA.info:eu-repo/semantics/publishedVersio

Reprodutibilidade e Validade da Versão Portuguesa da Escala de Fragilidade de Edmonton em Doentes de Cirurgia Cardíaca

Introduction: Frailty is a multidimensional syndrome characterized by the loss of functional reserve, associated with higher mortality and less functional survival in cardiac surgery patients. The Edmonton Frail Scale (EFS) is a comprehensive tool devised for brief frailty detection. To the best of our knowledge, there are no culturally adapted and validated frailty screening tools that enable the identification of vulnerability domains suited for use in the preoperative setting in Portugal. This was the motivation for this study. Objectives: To assess the validity and reproducibility of the Portuguese version of the EFS. Methods: Prospective observational study, in a sample of elective cardiac surgery patients. The Edmonton Frail Scale (EFS) translation and backtranslation were performed. Demographic and clinical data were collected, and the translated EFS translated, Geriatric Depression Scale, and Mini Mental State Examination Portuguese versions, Katz and Clinical Frailty Scales were administered. To assess validity Mann-Whitney test, Spearman's correlation coefficient, marginal homogeneity test and Kappa coefficient were employed. Reproducibility was assessed estimating kappa coefficient for the frailty diagnosis and the 11 EFS items. Intra-class correlation coefficients and the corresponding 95% confidence interval were estimated using linear mixed effects model. Results: The EFS Portuguese version revealed construct validity for frailty identification, as well as criterion validity for cognition and mood domains. Reproducibility was demonstrated, with k=0.62 (95% confidence interval (CI) 0.42-0.82) and intraclass correlation (ICC)=0.94 (95% CI 0.89-0.97) in inter-observer test and k=0.48 (95% CI 0.26-0.70) and ICC=0.85 (95% CI 0.72-0.92) in intra-observer test. Conclusions: The EFS Portuguese version is valid and reproducible for use, suiting pre-operative frailty screening in a cardiac surgery setting.Introdução: A fragilidade é uma síndrome multidimensional caracterizada pela perda de reserva funcional, associada a maior mortalidade e menor sobrevivência funcional após cirurgia cardíaca. A Escala de Fragilidade de Edmonton (EFS) é uma ferramenta abrangente de deteção de fragilidade. Não existe ainda em Portugal uma ferramenta de rastreio culturalmente adaptada e validada que permita a identificação de domínios específicos de vulnerabilidade para utilização no pré-operatório. Objetivos: Avaliar a validade e reprodutibilidade da versão portuguesa da EFS. Métodos: Estudo prospetivo observacional, realizado numa amostra de doentes propostos para cirurgia cardíaca. A EFS foi traduzida e retrotraduzida. Colheram-se dados demográficos e clínicos, aplicaram-se as versões traduzidas da EFS, Escala de Depressão Geriátrica e MMSE, as escalas de Katz e Clinical Frailty Scale. Validade avaliada utilizando o teste de Mann-Whitney, o coeficiente de correlação de Spearman, o teste de homogeneidade marginal e o coeficiente Kappa. Reprodutibilidade avaliada pelo cálculo do coeficiente kappa para o diagnóstico de fragilidade e para os 11 itens da escala. Coeficientes de correlação intraclasse e correspondentes intervalos de confiança a 95% estimados usando um modelo linear de efeitos mistos. Resultados: A versão portuguesa da EFS demonstrou validade de constructo, assim como validade de critério nos domínios de cognição e humor. É reprodutível, com k=0,62 (95% IC 0,42-0,82) e CCI=0,94 (95% IC 0,89-0,97) no teste interobservador e k=0,48 (95% IC 0,26-0,70) e CCI=0,85 (95% IC 0,72-0,92) no teste intraobservador. Conclusões: A versão portuguesa da EFS é adequada para rastreio pré-operatório de fragilidade em cirurgia cardíaca.info:eu-repo/semantics/publishedVersio