Risco de Recidiva a 5 Anos Após Excisão Convencional de um Carcinoma Basocelular

Introduction: Basal cell carcinomas are mostly treated surgically, mostly by surgery with postoperative histopathologic margin evaluation (“conventional surgery”), but large long-term data regarding recurrence by completeness of excisions is limited. Methods: Retrospective cohort study of basal cell carcinomas treated by conventional surgery at different medical specialties in a large tertiary centre, between 2008 and 2014. Survival analysis with a Cox proportional-hazards was performed, stratified by completeness of excision (complete excision/incomplete excision) and adjusted to several potentially confounding covariates. Results: A total of 2876 basal cell carcinomas were identified, of which 2306 (2100 primary, 206 recurrent) were considered eligible for analysis. During the 5-years of follow-up, there were 80 (4%) recurrences among 1980 complete excisions (16/1000 cases-year) and 83 (23.9%) recurrences among 348 incomplete excisions (100/1000 cases-year). Survival analysis was performed with multivariable adjustment. In the final adjusted model, we identified an association between relapse and re-intervention on recurrent tumors [adjusted Hazard Ratio (HR) 2.20 (95% Confidence interval (IC), 1.26-3.84), p=0.006], a wrong preoperative clinical diagnosis/surgery devoid of preoperative biopsy [adjusted HR 2.75 (95% CI, 1.68-4.5), p<0.001], treatment prior to 2012 [adjusted HR 1.47 (95% IC, 1.06-2.05), p<0.021] and surgery on a high-risk location, accordingly to the NCCN stratification [adjusted HR 2.18 (95% CI, 1.08-4.40), p<0.030]. By specific anatomic location, the likelihood of recurrence was especially high in the nose [adjusted HR 3.18 (95% CI 1.71-5.87), p<0.001] and eyelids [adjusted HR 3.08 (95% CI, 1.32-7.17), p=0.009]. There was also a trend towards higher recurrence in aggressive histological subtypes [adjusted HR 1.43 (95% CI 0.99-2.07), p<0.058]. Conclusion: Recurrent basal cell carcinomas, regardless of location, and primary basal cell carcinomas on high-risk locations of the face, especially on the eyelids and nose, should be considered to have a higher and independent likelihood of recurrence, even on “complete excisions” evaluated by histopathology. On the other hand, wait-andsee approaches in incompletely excised BCCs should be considered against a significant 5-year risk of relapse (1 in 10 lesions).Introdução: O tratamento dos carcinomas basocelulares é maioritariamente cirúrgico, sobretudo por cirurgia com avaliação histopatológica pós-operatória da margem (cirurgia convencional), mas os dados a longo-prazo relativos a recidiva de acordo com o resultado histológico da margem (excisão completa versus excisão incompleta, mantida em follow-up) são limitados. Métodos: Estudo coorte retrospetivo dos carcinomas basocelulares tratados por cirurgia convencional e por diferentes especialidades médico-cirúrgicas num centro terciário, entre 2008 e 2014. Realizou-se uma análise multivariada com uma regressão de Cox, estratificada pelo resultado da avaliação histológica da margem (excisão completa/incompleta) e ajustada a várias variáveis recolhidas. Resultados: Um total de 2876 carcinomas basocelulares foram identificados, dos quais 2306 [2100 primários, 206 recidivantes (primeira recidiva)] foram considerados elegíveis para análise. Nos 5 anos de follow-up, verificaram-se 80 (4%) recidivas entre os 1959 tumores completamente excisados (16/1000 casos-ano), contrastando com 83 (23,9%) recidivas em 347 excisões incompletas (100/1000 casos-ano). Foi realizada uma análise de sobrevida ajustada. No modelo final, ajustado, multivariado, foi identificada associação entre recidiva e intervenção cirúrgica a tumores recorrentes [hazard ratio (HR) ajustado 2,20 (Intervalo confiança (IC) 95%, 1,26-3,84), p=0,006], cirurgia com diagnóstico pré-operatório errado/ausência de realização de biópsia prévia [HR ajustado 2,75 (IC 95%, 1,68-4,5), p<0,001], tratamento prévio a 2012 [HR ajustado 1,47 (CI 95%, 1,06- 2,05), p<0,021] e cirurgia em localização de alto-risco, de acordo com a classificação NCCN [HR ajustado 2,18 (IC 95%, 1,08- 4,40), p<0,030]. Por localização anatómica específica, a probabilidade de recidiva a longo-prazo é especialmente elevada se a cirurgia for na pirâmide nasal [HR ajustado 3,18 (IC 95%, 1,71-5,87), p<0,001] ou nas pálpebras [HR ajustado 3,08 (CI 95%, 1,32-7,17), p=0,009]. Verificou-se também uma tendência para maior recidiva nos subtipos histológicos agressivos [HR ajustado 1,43 (IC 95%, 0,99-2,07), p<0,058]. Conclusão: Os carcinomas basocelulares recorrentes, independentemente da localização, e os carcinomas basocelulares primários em localizações de alto-risco da face, particularmente na pirâmide nasal e nas pálpebras, determinam um risco de recidiva superior e independente a longo-prazo, mesmo nas excisões “completas”. Por outro lado, as estratégias wait-and-see nos carcinomas basocelulares incompletamente excisados devem ponderar o risco de recidiva aos 5 anos (1 in 10 lesões)

Multidrug-Resistant Bacteria in Diabetic Foot Infections: Experience from a Portuguese Tertiary Centre

In recent years, the emergence of antibiotic resistant pathogens made increasingly difficult to establish appropriate empiric antimicrobial therapy protocols for acute diabetic foot infection (DFI) treatment. Early recognition of the population at-risk for multidrug-resistant (MDR) bacterial infection is of paramount importance in order to decrease large-spectrum antibiotic overuse. This study used retrospective cohort study in a multidisciplinary tertiary diabetic foot unit. Patients with severe DFI were included and divided according to their infection resistance profile (susceptible vs MDR bacteria). Data regarding their comorbidities and length of hospital stay were collected. The primary endpoint was to determine the risk factors for MDR infections and to evaluate if these were associated with an increased length of stay (LOS). A total of 112 microbial isolates were included. Predominance of Gram-positive bacteria was observed and 22.3% of isolated bacteria were MDR. Previous hospitalisation was associated with a higher likelihood of MDR infection. MDR bacterial infection was also associated with an increased LOS (P = .0296). Our study showed a high incidence of MDR bacteria in patients with a DFI, especially in those who had a recent hospitalisation. MDR infections were associated with a prolonged LOS and represent a global public health issue for which emergent measures are needed.info:eu-repo/semantics/publishedVersio

Dermatology in Internal Medicine Wards: Retrospective Analysis of a Tertiary Center

Introdução: As doenças da pele são comuns nos doentes internados nas enfermarias de Medicina Interna e requerem frequentemente a observação por um dermatologista. Este estudo pretende caracterizar o padrão de patologia cutânea destes doentes, avaliando o impacto da Dermatologia na sua abordagem. Métodos: Foi realizado um estudo retrospectivo dos pedidos de observação por Dermatologia nos doentes internados nos Serviços de Medicina Interna do Hospital Santo António dos Capuchos, ao longo de 46 meses. Os diagnósticos associados a esses pedidos foram classificados de acordo com a 10ª revisão da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde. Resultados: Foram observados 231 homens e 217 mulheres, com uma idade média de 72,6 anos. As dermites de estase e as úlceras de perna venosa foram o diagnóstico mais comum. Discussão e Conclusão: A equipa de Dermatovenereologia diminuiu significativamente o número de doentes sem diagnóstico. O nosso estudo parece reforçar a importância dos dermatologistas em contexto hospitalar.Background: Skin diseases are common in Internal Medicine wards and often require observation by a dermatologist. This study intends to characterize the pattern of skin pathology in these patients and to evaluate the impact of dermatologists in their approach. Methods: A retrospective study was conducted. Dermatology observations over 46 months in Internal Medicine wards of Hospital Santo António dos Capuchos were analyzed. Patients’ conditions were classified according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. Results: 231 men and 217 women were observed, with an average age of 72.6 years. Stasis dermatitis and venous leg ulcers were the most common diagnosis. Discussion and Conclusion: The Dermatology team significantly reduced the number of undiagnosed patients. Our study reinforces the importance of dermatologists in the evaluation of inpatients with skin diseases

Relatório estágio profissional

Relatório final do estágio profissionalizante do 6.º an

Tratamento de Dermite Atópica com Dupilumab: Evidência de um Centro Português Terciário

Introduction: Dupilumab is a fully human monoclonal antibody that blocks interleukin-4 and interleukin-13, key drivers of type 2 helper T-cell (Th2)-mediated inflammatory response. It was the first biologic treatment approved for adult patients with inadequately-controlled moderate-to-severe atopic dermatitis (AD). Continuous collection of daily data practice is important in order to evaluate the real effectiveness and safety of dupilumab treatment. Methods: In this observational cohort study, we prospectively included all adult patients with moderate to severe AD treated with dupilumab in our portuguese dermatology center from July 2019 to April 2020. Baseline clinical data was initially collected and treatment effectiveness and safety were assessed after 16 weeks. Results: Twenty-five patients were included. All patients had been previously treated with systemic immunosuppressants. The estimated mean Eczema Area and Severity Index Score (EASI) decreased from 27.8 at baseline to 8.8 at week 16 (+/- 4 weeks). A ΔEASI 75 response was achieved by 58.3% of patients (ΔEASI 90 - 29.1%). Conjunctivitis was the main reported side-effect, affecting 20.8% of patients. Discussion: Our study showed a significant EASI reduction during the first 16-weeks of dupilumab treatment in adult patients with AD. Despite its overall safety, daily-practice data tend to report a higher risk of conjunctivitis than previously expected and we hence recommend that patients should be specifically informed about this possible side-effect.Introdução: O dupilumab é um anticorpo monoclonal totalmente humano que bloqueia a interleucina-4 e a interleucina-13, elementos chave da resposta inflamatória mediada por células T auxiliares tipo 2 (Th2). Foi o primeiro tratamento biológico aprovado para doentes adultos com dermatite atópica (DA) moderada a grave, inadequadamente controlada. A colheita contínua de dados de prática clínica diária é importante para avaliar a real eficácia e segurança do tratamento com dupilumab. Métodos: Neste estudo de coorte observacional, foram incluídos prospectivamente todos os doentes adultos com DA moderada a grave tratados com dupilumab no Centro Hospitalar Lisboa Central de julho de 2019 a abril de 2020. Os dados clínicos iniciais foram recolhidos e a eficácia e segurança do tratamento foram avaliadas após 16 semanas. Resultados: Vinte e cinco doentes foram incluídos e todos tinham sido previamente tratados com imunossupressores sistêmicos. O EASI médio inicial diminuiu de 27,8 no início do estudo para 8,8 à semana 16 (+/- 4 semanas). Uma resposta ΔEASI 75 foi alcançada em 58,3% dos doentes (ΔEASI 90 - 29,1%). A conjuntivite foi o principal efeito adver so registado, afetando 20,8% dos pacientes. Discussão: O nosso estudo mostrou uma redução significativa do EASI durante as primeiras 16 semanas de tratamento com dupilumab em pacientes adultos com DA. Apesar de sua segurança geral, os dados da prática diária tendem a relatar um risco maior de conjuntivite do que o esperado anteriormente e, por isso, recomendamos que os doentes sejam informados especificamente sobre esse possível efeito adverso

Do despotismo da gentalha à democracia da gravata lavada: história do conceito de democracia no Brasil (1770-1870)

The voting rate in Brazil only reached 40% (considered consistent with a modern democracy) in the 1980s. However, the bibliography always refers to the 1986, 1945, and 1933 elections as moments of "re-democratization", when explicitly or implicitly the original "democracy" could only have existed during the fraudulent and oligarchic First Republic (1889-1930). This article focuses on the process by which the 19th century Brazilian elites slowly forged this purely liberal-institutional concept of democracy, with extensive repercussions during the following century. The concept found its symbol in the "starched collar democracy" to which Teófilo Ottoni referred in his campaign in 1860, limited to the educated and moneyed stratum of the population, and reclaimed by the UDN party in the 1945 presidential campaign