VASCULAR ACCESSES ON OCTOGENARIAN PATIENTS

Introduction: The vascular access used in hemodialysis patients with chronic renal disease include the arteriovenous fistulae (AVF) (proximal and distal), grafts and central venous catheters. It is a question of debate if there is an advantage or indication to obtain definitive vascular access in patients with advanced age, especially over 80 years. The aim of the article focuses on demonstrating the feasibility and advantages of autologous accesses on octogenarian patients.  Material and Methods: Retrospective analysis of electronic records of patients undergoing vascular access (AVF proximal, distal and grafts), aged> 79 years. The time period was evaluated from 01/01/2010 to 31/12/2015.  Results: The sample of six years includes 21 patients. Of the sample, 52% are male and 48% female. The age distribution shows 10 patients (82-84), 5 patients (79-81), 5 patients (85-88) and 1 patient (89-90) years. The analysis of the presence of the cardiovascular risk factors (RF) (diabetes mellitus, smoking and dyslipidemia), of which 35%: 2 RF; 24%: 3RF; 23%: 1RF; 12% none of the considered. Of the total sample, 67% had diabetes mellitus (57% non-insulin-treated and 43% insulin-treated). The evaluation of the functional status of the sample using the Katz scale, showed 3 patients with score 0, 9 patients with score 1, 5 patients with score 2, 2 patients with score 3 and 2 patients with score 4. For the location of the access, 40% distal AVF, 35% proximal AVF and 25% grafts. All patients were first tested with Doppler ultrasound for anatomic definition. From all surgeries, 19% of patients (4 in total) required a new more proximal access. It stands out as complications, one hematoma and two surgical infections.  Conclusion: This study proved that is possible to achieve permanent vascular access (fistula or graft) in octogenarian patients starting dialysis, and that the functional status is a more important determinant than the chronological age"  It is recommended an individualized approach, with more liberal use of proximal or prosthetic access, given the shorter life expectancy of patients.

Trabalho Livre nº 15 - Terapia de Pressão Negativa Tópica sobre Enxerto de Pele Parcial em Doentes Queimados

A introdução da terapia de pressão negativa tópica na integração e viabilidade dos enxertos de pele em doentes queimados mostra ser promissora e de grande eficácia, quando comparada com as terapias convencionais.N/

Trabalho Livre nº 04 - Complexidade do Tratamento da Úlcera de Perna Venosa em Doente Diabética

As Úlceras de Perna (UP) não constituem um diagnóstico mas sim um sinal da presença de uma ou várias doenças subjacentes. Estima-se que 80-90% das UP são causadas por doença vascular, sendo que as de etiologia venosa constituem o subtipo mais frequente (70% de todas as UP). Outras etiologias são a doença arterial, linfática, vasculites, hematológicas, infeciosas, metabólicas (principalmente diabetes Mellitus), tumorais, queimaduras e medicamentosas.N/

Trabalho Livre nº 01 - Doença Arterial Periférica: importância da revascularização

A doença arterial periférica (DAP) é causada, na maioria dos casos, por aterosclerose, que leva ao desenvolvimento de estenose e oclusões das artérias dos membros inferiores. Nestes doentes, após controlo dos fatores de risco, o tratamento com melhores resultados é a revascularização.N/

Trabalho Livre nº 17 - Sinus Pilonidalis - Utilidade da Terapia de Pressão Negativa Tópica

O Sinus Pilonidalis também conhecido por Quisto Sacro Coccígeo é um processo inflamatório crónico que ocorre habitualmente na região sacrococcígea, havendo casos descritos também no couro cabeludo, axilas e umbigo. Afeta principalmente jovens do sexo masculino entre os 15 e os 30 anos. O tratamento definitivo é cirúrgico, por excisão em bloco. O tempo de cicatrização tende a ser demorado, tendo a terapia de pressão negativa tópica demostrado vantagens na aceleração desse processo.N/

Trabalho Livre nº 18 - Síndrome de Fournier

O Síndrome de Fournier, também conhecido como fasceíte necrotizante do períneo, é uma infeção rara mas grave e que resulta muitas vezes da manipulação urológica ou proctológica, sendo mais frequente em doentes imunodeprimidos ou com Diabetes Mellitus. Caracteriza-se por uma infeção aguda dos tecidos moles e fáscias do períneo com celulite necrotizante secundária a bactérias gram-negativas e anaeróbias.N/

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research