Browsing by Author "Carvalho, M."
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- Avaliação da hiperalgesia em relação com a administração peri-operatória de opióidesPublication . Brás, A.; Carvalho, A.; Carvalho, C.; Carvalho, M.; Dias, J.; Duarte, A.; Mendes, D.; Mendes, T.; Mesquita, M.; Pinto, A.; Santos, A.; Alves, S.; Amorim, P.
- Chemical peritonitis in a patient treated with icodextrin and intraperitoneal vancomycinPublication . Freitas, C.; Rodrigues, A.; Carvalho, M.; Cabrita, A.
- Coarctação da aorta – detecção tardiaPublication . Álvares, S.; Mota, C.; Carvalho, M.; Loureiro, M.As causas mais frequentes de hipertensão arterial na população pediátrica variam com a idade. No lactente e criança mais pequena é habitualmente secundária a doença cardíaca ou renal. No adolescente e criança mais velha, obesos e com história familiar de hipertensão, a etiologia mais frequente é a hipertensão essencial ou idiopática. Apresenta-se o caso clínico de uma adolescente de 12 anos, referenciada à consulta de Cardiologia Pediátrica para avaliação das repercussões cardíacas de hipertensão arterial de difícil controlo. A hipertensão arterial tinha sido detectada há dois anos e a investigação anterior não revelara causa secundária. De relevante ao exame físico apresentava obesidade, sopro sistólico de ejecção, com irradiação para o dorso, ausência de sopro abdominal, pulsos femorais diminuídos relativamente aos radiais e um gradiente de pressão arterial com diferencial de 50 mmHg entre os membros superiores e inferiores. O ecocardiograma transtorácico mostrou hipertrofia concêntrica ventricular esquerda; o estudo ecocardiografico supraesternal não foi conclusivo; detectou-se fluxo de coarctação da aorta a nível da aorta abdominal. A angiorressonância confirmou a existência de coarctação da aorta após a emergência da artéria subclávia esquerda tendo efectuado tratamento cirúrgico. Este caso é exemplo da importância de um exame físico completo na abordagem da criança com hipertensão arterial, nomeadamente a palpação dos pulsos periféricos e a avaliação da pressão arterial nos 4 membros. Perante a suspeita clínica de coarctação da aorta e um estudo ecocardiográfico/Doppler inadequado, salienta-se que os registos de Doppler pulsado a nível da aorta abdominal revelam informações valiosas relativamente à presença de coarctação. ABSTRACT The causes of arterial hypertension in the pediatric population are related to the age of the child. In the infant and younger children it is usually secondary to cardiac or renal diseases. For the adolescent with mild elevation of blood pressure, overweight and a strong family history of hypertension, primary or essential hypertension is most likely. We present a case report of a 12 year-old girl referred for cardiac evaluation in the setting of hypertension difficult to control. Diagnosis of hypertension was established at the age of ten and former investigation was inconclusive. On physical examination she presented a precordial systolic ejection murmur with irradiation to the back, no abdominal murmur, diminished and delayed pulses in the right femoral artery compared with the right radial artery and an arm-leg pressure gradient of 50 mmHg. Two D/Doppler Echocardiogram showed concentric LV hypertrophy, with no other structural cardiac malformations; Doppler investigation of the aorta from the suprasternal view was not conclusive. Pulsed wave Doppler recordings from the abdominal descending aorta showed a continuous antegrade flow signal, with no evidence of flow reversal or cessation. MR angiography located the coarctation just distal to the left subclavian artery. Surgical repair consisted in the subclavian flap aortoplasty procedure. Aortic coarctation is still a missed and late diagnosis. This case report is an examples of the importance of a complete physical examination in the presence of arterial hypertension in children, namely the palpation of radial and femural pulses and the leg-arm pressure gradient. In the presence of clinical suspicion of coarctation of the aorta, and in those patients with inadequate supraesternal notch echocardiography or Doppler examinations, pulsed Doppler recording from the abdominal descending aorta can supply valuable indications of the presence of a thoracic coarctation.
- Deciphering the Contribution of Biofilm to the Pathogenesis of Peritoneal Dialysis Infections: Characterization and Microbial Behaviour on Dialysis FluidsPublication . Sampaio, J.; Machado, D.; Gomes, A.; Machado, I.; Santos, C.; Lima, N.; Carvalho, M.; Cabrita, A.; Rodrigues, A.; Martins, M.Infections are major complications in peritoneal dialysis (PD) with a multifactorial etiology that comprises patient, microbial and dialytic factors. This study aimed at investigating the contribution of microbial biofilms on PD catheters to recalcitrant infections and their interplay with PD related-factors. A prospective observational study was performed on 47 patients attending Centro Hospitalar of Porto and Vila Nova de Gaia/Espinho to whom the catheter was removed due to infectious (n = 16) and non-infectious causes (n = 31). Microbial density on the catheter was assessed by culture methods and the isolated microorganisms identified by matrix-assisted laser desorption/ionization time-of-flight intact cell mass spectrometry. The effect of conventional and three biocompatible PD solutions on 16 Coagulase Negative Staphylococci (CNS) and 10 Pseudomonas aeruginosa strains planktonic growth and biofilm formation was evaluated. Cultures were positive in 87.5% of the catheters removed due infectious and 90.3% removed due to non-infectious causes. However, microbial yields were higher on the cuffs of catheters removed due to infection vs. non-infection. Staphylococci (CNS and Staphylococcus aureus) and P. aeruginosa were the predominant species: 32% and 20% in the infection and 43.3% and 22.7% in the non-infection group, respectively. In general, PD solutions had a detrimental effect on planktonic CNS and P. aeruginosa strains growth. All strains formed biofilms in the presence of PD solutions. The solutions had a more detrimental effect on P. aeruginosa than CNS strains. No major differences were observed between conventional and biocompatible solutions, although in icodextrin solution biofilm biomass was lower than in bicarbonate/lactate solution. Overall, we show that microbial biofilm is universal in PD catheters with the subclinical menace of Staphylococci and P. aeruginosa. Cuffs colonization may significantly contribute to infection. PD solutions differentially impact microbial species. This knowledge is important for the development of infection diagnosis, treatment and preventive strategies.
- Ecocardiografia por telemedicina em recém-nascidos num hospital de nível II - casuística de quatro anosPublication . Costa, A.M.; Carvalho, M.; Calviño, J.; Sousa, M.; Sousa, G.; Gaspar, E.; Castela, E.Introdução: A Ecocardiografia por Telemedicina (EcoTM) realiza-se desde Outubro de 2005 entre o serviço de pediatria do hospital nível dois e a cardiologia pediátrica do hospital de nível três. Objectivos: Caracterizar os recém-nascidos (RN) que realizaram EcoTM e avaliar a importância desta prática clínica na orientação dos doentes. Métodos: Estudo descritivo retrospectivo realizado através da revisão dos relatórios das EcoTM realizadas entre Outubro de 2005 e Setembro de 2009 e recolha das seguintes variáveis: idade, motivo da realização do exame, diagnóstico e orientação. Resultados: Foram realizadas 139 EcoTM a 122 RN (1,71% dos nados vivos). O sexo masculino predominou (57%); 30,9% realizaram EcoTM antes da alta da maternidade e 50% na primeira semana de vida. Em 11 casos foi realizada de urgência. Os principais motivos para a realização do exame foram: sopro cardíaco em RN assintomático (68,3%), alteração em EcoTM anterior (11,5%), presença malformações (5,8%) e hipoxia com cianose (3,6%). A comunicação inter-ventricular (CIV), a comunicação inter-auricular tipo ostium-secundum e a patência do canal arterial foram as cardiopatias mais frequentes. Foram transferidos para centro de referência em cardiologia pediátrica seis RN: transposição simples das grandes artérias (n=2), ventrículo único (n=1), ectasia da artéria subclávia esquerda (n=1), coarctação da aorta (n=1) e CIV sub-aórtica grande (n=1). Em 26,6% dos exames foi excluída cardiopatia congénita. Tiveram indicação para repetir exame 72% e 24% tiveram alta. Discussão: A programação da EcoTM antes da alta ou no primeiro mês, em RN com sopro assintomático, permite-nos fazer o diagnóstico precoce de cardiopatias. A EcoTM urgente possibilita o diagnóstico rápido e preciso, identificando RN com cardiopatia que necessita de intervenção imediata e transferência para centro de cardiologia pediátrica. A possibilidade de realização de Eco cardíaca utilizando a telemedicina trouxe benefícios nos cuidados de saúde prestados, evitando incómodos para os doentes e permitindo uma referenciação adequada a Cardiologia Pediátrica quando necessário. ABSTRACT Introduction: The Echocardiogram by Telemedicine (EcoTM) between the pediatric department of a level 2 hospital and the pediatric cardiology service of a level 3 hospital began in October 2005. Objective: To characterize the newborns (NB) who underwent EchoTM and emphasize the importance of this practice in the management of the patients. Methods: The authors reviewed the reports of EchoTM conducted between October 1, 2005 and September 30, 2009. The following variables were analyzed: age, sex, reason for the exam, diagnosis and orientation. Results: During this period, 139 EchoTM were done on 122 NB (1.71% of our live NB). Male patients predominated (57%). EchoTM was performed before discharge from the maternity in 30,9% and during the first week in 50%; it was urgent in 11 cases. The most frequent motives for EchoTM: asymptomatic heart murmur (68,3%), pervious abnormal EchoTM (11,5%), malformations (5,8%) and hypoxia (3,6%). The most frequent diagnosis were: ventricular septal defect (VSD) (31.3%), inter-auricular communication (25.8%) and patent ductus arteriosus (7%). Six infants were transferred (simple transposition of greater arteries (n=2), single ventricle (n=1), malformation of the aortic arch (n=1), aortic coarctation (n=1) and large sub-aortic VSD (n=1). In 26.6% it was excluded cardiopathy. EchoTM was repeated in 72 % of the infants and 24% were discharged. Discussion: The EchoTM scheduled before discharge or during the first month, in NB with asymptomatic murmur, allows us to make an early diagnosis of heart disease. The possibility of doing an emergency EchoTM allows a rapid and accurate diagnosis, identifying NB with critical heart disease requiring immediate intervention and transfer to a tertiary center. The EchoTM between these two hospitals of different level, brought benefits to the health care provided, avoiding discomfort to patients and allowing an adequate referral to pediatric cardiology when needed.
- Hematoma subdural em Pediatria - Diagnosticar e tratar precocementePublication . Carvalho, M.; Leal, E.; Santos, M.; Ramos, J.; Távora, L.; Barata, D.Introdução: O hematoma subdural agudo não traumático é uma entidade rara em Pediatria. A presença de sintomas neurológicos de instalação aguda associada a anticoagulação obriga à exclusão desta entidade. Caso clínico: Apresentamos o caso de uma criança, do sexo masculino, de sete anos de idade, com prótese mitral mecânica, medicada com varfarina, que recorreu ao serviço de urgência por cefaleias intensas e progressivas, associadas a alteração no estado de consciência e convulsões. A nível laboratorial o INR (International Normalized Ratio) era de 4,2. Foi admitida na Unidade de Cuidados Intensivos Pediátricos (UCIP) em coma com anisocoria. Iniciou ventilação mecânica, medidas anti-edema cerebral e antiepilépticos. O exame de imagem mostrou hematoma subdural agudo à esquerda, com desvio da linha média. Foi submetida a craniotomia descompressiva, 56 horas após o início da sintomatologia, com recuperação clínica e actualmente sem sequelas. Conclusão: Este caso clínico ilustra a importância da suspeição clínica de hematoma subdural em doentes anticoagulados, bem como a necessidade de optimização das condições cirúrgicas e da utilização das técnicas não invasivas na monitorização do nível de consciência. ABSTRACT Introduction: Non-traumatic acute subdural hematoma is a rare entity in children. In the presence of acute neurological symptoms associated with long term anticoagulation, it is mandatory to rule out this entity. Case report: We report the case of a seven-year-old boy, with mechanical mitral valve prosthesis under warfarin treatment, presenting severe and progressive headache associated with altered level of consciousness and seizures. Laboratory studies revealed a high value of International Normalized Ratio (INR: 4,2). He was admitted to the Pediatric Intensive Care Unit in a coma with anisocoria. He was mechanically ventilated and started on specific measures to reduce cerebral edema in addition to anticonvulsants. Cranial computerized tomography (CT scan) revealed acute left subdural hematoma, with midline shift. Fifty-six hours after the onset of symptoms, he was submitted to decompressive craniectomy. There was progressive clinical recovery with neurological and imaging improvement and an excellent outcome. Discussion: This case illustrates the importance of the clinical suspicion of a subdural hematoma in patients treated with anticoagulants, as well as the need of optimizing surgical conditions and the use of noninvasive techniques for monitoring the level of consciousness.
- Hepatocyte growth factor signalizes peritoneal membrane failure in peritoneal dialysisPublication . Bernardo, A.; Oliveira, J.; Santos, O.; Carvalho, M.; Cabrita, A.; Rodrigues, A.BACKGROUND: Hepatocyte growth factor (HGF) counteracts peritoneal fibrosis in animal models and in-vitro studies, but no study explored effluent HGF in peritoneal dialysis (PD) patients with ultrafiltration failure (UFF). Our aim was to assess the relationship between effluent HGF with UF profile, free water transport (FWT) and small-solute transport. METHODS: We performed 4-hour, 3.86% PET with additional UF measurement at 60 minutes in 68 PD patients. MTACcreatinine, FWT, small-pore ultrafiltration, and effluent HGF were quantified. RESULTS: Effluent HGF negatively correlated with UF (r=-0.80, p=0.009) and FWT (r=-0.69, p=0.04). Patients with UFF had higher dialysate HGF (103 pg/mL vs 77 pg/mL, p=0.018) and, although not statistically significant, those with FWT compromise had also higher dialysate HGF compared with subgroup of UFF without FWT compromise (104 pg/mL vs 88 pg/mL, p=0.08). FWT≤45% without clinical UFF was documented in some patients who also had increased effluent HGF. CONCLUSIONS: Dialysate HGF concentration is significantly higher among patients with UFF, specially, if FWT is impaired, being a sign of peritoneal membrane deterioration.
- Leucemia aleucémicaPublication . Carvalho, M.; Oliva, T.; Silva, I.; Almeida, M.; Estevinho, N.; Costa, V.; Norton, L.Introdução: O termo leucemia aleucémica é usado quando ocorre infiltração cutânea por células leucémicas na ausência de blastos no sangue periférico e medula óssea, podendo ser a primeira manifestação da doença. Em cerca de 25-30% das leucemias congénitas é documentada infiltração cutânea no decorrer da doença ou como manifestação inicial. A maioria está associada ao tipo mieloide e a detecção do gene MLL (mixed-lineage leukemia gene) confere mau prognóstico, exigindo tratamento com quimioterapia intensiva. Caso Clínico: Apresenta-se o caso de uma lactente do sexo feminino e de raça negra, com diagnóstico de Leucemia Aguda Linfoblástica linhagem B, efectuado aos seis meses de vida, no Hospital de Joanesburgo, através de biópsia de nódulo subcutâneo com três meses de evolução. Admitida no Instituto de Oncologia do Porto, a pedido da mãe, para realização de quimioterapia. Discussão: O caso apresentado documenta uma entidade rara e de mau prognóstico mas que, neste caso, teve uma boa resposta à terapêutica instituída. ABSTRACT Introduction: The term aleukemic leukemia is used when there is skin infiltration by malignant leukocytes in the absence of blasts in peripheral blood and bone marrow, and it can be the first signal of the disease. Infiltration of the skin has been documented in 25-30% of patients with congenital leukemia. Leukemia cutis may be the first manifestation of congenital leukaemia, and may even precede blood or bone marrow leukaemia by several weeks or months. Most are associated with the myeloid lineage. The presence of mixed-lineage leukemia (MLL) gene has been associated with poor prognosis, requiring treatment with intensive chemotherapy. Case report: The authors report the case of a six-year-old black female, with skin lesions for three months, consistent with Acute Lymphoblastic Leukemia. Admitted in our Pediatric Department – Instituto de Oncologia do Porto – Portugal, by mother’s request, for chemotherapy. Discussion: Although a poor prognosis is usually associated with this situation, our patient had a good response to treatment.
- Modelling competing risks in nephrology research: an example in peritoneal dialysisPublication . Teixeira, L.; Rodrigues, A.; Carvalho, M.; Cabrita, A.; Mendonça, D.BACKGROUND: Modelling competing risks is an essential issue in Nephrology Research. In peritoneal dialysis studies, sometimes inappropriate methods (i.e. Kaplan-Meier method) have been used to estimate probabilities for an event of interest in the presence of competing risks. In this situation a competing risk analysis should be preferable. The objectives of this study are to describe the bias resulting from the application of standard survival analysis to estimate peritonitis-free patient survival and to provide alternative statistical approaches taking competing risks into account. METHODS: The sample comprises patients included in a university hospital peritoneal dialysis program between October 1985 and June 2011 (n = 449). Cumulative incidence function and competing risk regression models based on cause-specific and subdistribution hazards were discussed. RESULTS: The probability of occurrence of the first peritonitis is wrongly overestimated using Kaplan-Meier method. The cause-specific hazard model showed that factors associated with shorter time to first peritonitis were age (>=55 years) and previous treatment (haemodialysis). Taking competing risks into account in the subdistribution hazard model, age remained significant while gender (female) but not previous treatment was identified as a factor associated with a higher probability of first peritonitis event. CONCLUSIONS: In the presence of competing risks outcomes, Kaplan-Meier estimates are biased as they overestimated the probability of the occurrence of an event of interest. Methods which take competing risks into account provide unbiased estimates of cumulative incidence for each specific outcome experienced by patients. Multivariable regression models such as those based on cause-specific hazard and on subdistribution hazard should be used in this competing risk setting.
- Overhydration prevalence in peritoneal dialysis - A 2 year longitudinal analysisPublication . Aguiar, P.; Santos, O.; Teixeira, L.; Silva, F.; Azevedo, P.; Vidinha, J.; Ferrer, F.; Carvalho, M.; Cabrita, A.; Rodrigues, A.Hypervolemia is a major concern in dialysis patients, and is associated with increased cardiovascular risk and death. Cross sectional analysis have previously demonstrated that peritoneal dialysis (PD) patients are not more overhydrated when compared to haemodialysiś ones. This study was designed to evaluate longitudinal trends in hydration status and corporal composition in a PD population.