Browsing by Author "Silva, R."
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- Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?Publication . Fonseca, A.; Silva, R.; Rato, I.; Neves, A.; Peixoto, C.; Ferraz, Z.; Ramalho, I.; Carocha, A.; Félix, N.; Valdoleiros, S.; Galvão, A.; Gonçalves, D.; Curado, J.; Palma, M.; Lobo-Antunes, I.; Clode, N.; Graça, L.The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries.
- CONTROLE DA PRESSÃO INTRCUFF EM DOENTES TRAQUEOSTOMIZADOSPublication . Silva, A.; Taborda, A.; Vilarinho, H.; Rocha, I.; Vieira, O.; Silva, R.CONTROLE DA PRESSÃO INTRCUFF EM DOENTES TRAQUEOSTOMIZADOS Álvara Silva1, Ana Taborda1, Hélder Vilarinho1, Inês Rocha1, Olinda Vieira1, Rosa Silva1. 1Serviço de de Traumatologia Craneo Encefálica (TCE), HSA/CHP. Hospital de Santo António, Centro Hospitalar do Porto (HSA/CHP), Porto. Introdução A pressão de perfusão sanguínea da mucosa traqueal situa-se entre os 25-35mmHg/20-30cmH2O. Pressões superiores a 30 cmH2O podem gerar lesões na parede da traquéia como: estenose traqueal, perda do epitélio ciliado, hemorragia, ulceração e necrose. Por outro lado, pressões inferiores a 20 cmH2O, podem levar a broncoaspiração, tornando o doente susceptível a infecções respiratórias, um cuff pouco insuflado pode também provocar a fuga de ar em doentes ventilados artificialmente. Objectivos Identificar e analisar estudos empíricos que versem a temática da gestão da pressão intracuff em doentes traqueostomizados. Material e Métodos Revisão de literatura nas bases de dados: EBSCO, PUBMED, MEDSCAPE e Google Académico. As palavras-chave utilizadas foram: tracheostomy and cuff; tracheostomy tube cuff. Os critérios de inclusão foram: publicações em português e inglês, acesso livre, texto completo, no período de 2005-2011, num total de 71 artigos, foram incluídos apenas 14. Resultado A desinsuflação do cuff não é bem tolerada por muitos doentes, podendo resultar em aspiração. Quando insuflado protege a via aérea prevenindo a perda de ar, em doentes ventilados mecanicamente, e a broncoaspiração. No entanto, uma desinsuflação precoce do cuff na presença da peça em T reduz o esforço respiratório, é preferido em pacientes conscientes, beneficia a capacidade para falar e deglutir, acautelando-se que a capacidade para deglutir é cuidadosamente monitorizada e a acumulação de secreções supracuff é limitada para prevenir a aspiração. Quando a pressão do cuff é superior induz a isquemia/necrose. A lesão isquémica da traqueia depende da relação entre a pressão de perfusão da mucosa e a perfusão exercida pelo cuff. Relativamente aos estudos dos valores de monitorização da pressão intracuff verificam-se medidas irregulares, tanto acima quanto abaixo dos valores de segurança. Na rotina hospitalar, muitas vezes não há mensuração da pressão intracuff, ou esta é realizada de forma indirecta, através da palpação do balão externo, técnica extremamente inadequada. A utilização do cufómetro é a técnica recomendada pela literatura. Do mesmo modo, é aconselhada a sua verificação pelo menos uma vez por turno. Na maioria dos casos os procedimentos de manutenção do cuff são da exclusiva responsabilidade dos enfermeiros. Conclusões Valores de pressão abaixo ou acima dos recomendados são responsáveis por diversas complicações que convêm acautelar. A monitorização da pressão intracuff não é uma actividade de rotina e a sua gestão è realizada de forma variável, sendo o método mais utilizado o cufómetro. Apresentador: Álvara Silva, Enfermeira, Serviço de Traumatologia Craneo Encefálica (TCE), HSA/CHP.
- Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scenePublication . Silva, R.; Saraiva, M.; Cardoso, T.; Aragão, I.BACKGROUND: The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome. METHODS: Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years. RESULTS: There were 511 MET activations: 389 (76%) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8%), concern of medical staff in 121 (31.1%) and decrease in GCS > 2 in 98 (25.2%) patients; MET calls for cardiac arrest occurred in 68 patients (17.5%). The median (IQR) time the team stayed at the scene was 35 (20-50) minutes. At the scene, the most frequent actions were related to airway and ventilation, namely oxygen administration in 145 (37.3%); in circulation, fluid were administered in 158 (40.6%); overall medication was administered in 185 (47.5%) patients. End-of-life decisions were part of the MET actions in 94 (24.1%) patients. At the end of MET intervention, 73 (18.7%) patients died at the scene, 190 (60.7%) stayed on the ward and the remaining 123 patients were transferred to an increased level of care. Crude hospital mortality rate was 4.1% in the 3 years previously to MET implementation and 3.6% in the following 3 years (p < 0.001). DISCUSSION: During the study period, the rate of activation for medical inpatients was significantly higher than that for surgical inpatients. In our hospital, there is no 24/7 medical cover on the wards, with the exception of high-dependency and intensive care units; assuming that the number of unplanned admissions and chronic ill patients is greater in medical wards that could explain the difference found, which prompts the implementation of a 24/7 ward residence. The team stayed on site for half an hour and during that time most of the actions were simple and nurse-driven, but in one third of all activations medical actions were taken, and in a forth (24%) end-of-life decisions made, reinforcing the inclusion of a doctor in the MET. A significant decrease in overall hospital mortality rate was observed after the implementation of the MET. CONCLUSIONS: The composition of our MET with an ICU doctor and nurse was reinforced by the need of medical actions in more than half of the situations (either clinical actions or end-of-life decisions). After MET implementation there was a significant decrease in hospital mortality. This study reinforces the benefit of implementing an ICU-MET team.
- MODELO DE ACTUAÇÃO NA ABORDAGEM AO DOENTE SUBMETIDO A TRANSPLANTE DE ÓRGÃO HEPÁTICOPublication . Silva, E.; Silva, I.; Silva, R.; Oliveira, S.
- A Retrospective Analysis of the Real-Life Utilization of Ranibizumab in Patients with Wet Age-Related Macular Degeneration from PortugalPublication . Silva, R.; Goncalves, C.; Meireles, A.; Teixeira, C.; Rosa, P.; Monteiro-Grillo, M.; Canelas, J.; Carneiro, A.; Flores, R.INTRODUCTION: Anti-vascular endothelial growth factor therapy has revolutionized the treatment of wet age-related macular degeneration; however, it is important to monitor actual use of ranibizumab and related treatment outcomes in routine practice. MATERIAL AND METHODS: This was a retrospective, observational study to monitor the 2-year outcomes following ranibizumab treatment for wet age-related macular degeneration in Portugal. Patients treated between January 2009 and December 2009 were retrospectively evaluated. All decisions were made by the treating physician in accordance with their usual routine clinical practice. The primary assessment was mean change in visual acuity score using Early Treatment Diabetic Retinopathy Study or Snellen equivalent. RESULTS: A total of 128 patients with wet age-related macular degeneration were analyzed (mean age 79.4 years; mean visual acuity score 54.2 letters). Mean change in visual acuity score from baseline was -1.6 letters (n = 82) at year one and -5.1 letters (n = 72) at year two. The mean number of ranibizumab injections was 3.8 (year one) and 1.6 (year two). On average, patients attended 8.6 and 5.0 visits and optical coherence tomography was used in 75.0% of patients in year one and in 56.3% of patients in year two, respectively. DISCUSSION: Despite a relatively high number of visits, including monitoring visits and use of optical coherence tomography - guided therapy, few injections were administered and visual acuity was not improved. CONCLUSION: These findings indicate that as-needed treatment resulted in under-dosing in a real-life setting in Portugal. Such limitations may also be related to increasing numbers of patients, resulting in clinic saturation
- The Portuguese Severe Asthma Registry: Development, Features, and Data Sharing PoliciesPublication . Sá-Sousa, A.; Fonseca, J.; Pereira, A.; Ferreira, A.; Arrobas, A.; Mendes, A.; Drummond, M.; Videira, W.; Costa, T.; Farinha, P.; Soares, J.; Rocha, P.; Todo-Bom, A.; Sokolova, A.; Costa, A.; Fernandes, B.; Chaves Loureiro, C.; Longo, C.; Pardal, C.; Costa, C.; Cruz, C.; Loureiro, C.; Lopes, C.; Mesquita, D.; Faria, E.; Magalhães, E.; Menezes, F.; Todo-Bom, F.; Carvalho, F.; Regateiro, F.; Falcao, H.; Fernandes, I.; Gaspar-Marques, J.; Viana, J.; Ferreira, J.; Silva, J.; Simão, L.; Almeida, L.; Fernandes, L.; Ferreira, L.; van Zeller, M.; Quaresma, M.; Castanho, M.; André, N.; Cortesão, N.; Leiria-Pinto, P.; Pinto, P.; Rosa, P.; Carreiro-Martins, P.; Gerardo, R.; Silva, R.; Lucas, S.; Almeida, T.; Calvo, T.The Portuguese Severe Asthma Registry (Registo de Asma Grave Portugal, RAG) was developed by an open collaborative network of asthma specialists. RAG collects data from adults and pediatric severe asthma patients that despite treatment optimization and adequate management of comorbidities require step 4/5 treatment according to GINA recommendations. In this paper, we describe the development and implementation of RAG, its features, and data sharing policies. The contents and structure of RAG were defined in a multistep consensus process. A pilot version was pretested and iteratively improved. The selection of data elements for RAG considered other severe asthma registries, aiming at characterizing the patient's clinical status whilst avoiding overloading the standard workflow of the clinical appointment. Features of RAG include automatic assessment of eligibility, easy data input, and exportable data in natural language that can be pasted directly in patients' electronic health record and security features to enable data sharing (among researchers and with other international databases) without compromising patients' confidentiality. RAG is a national web-based disease registry of severe asthma patients, available at asmagrave.pt. It allows prospective clinical data collection, promotes standardized care and collaborative clinical research, and may contribute to inform evidence-based healthcare policies for severe asthma.
- Urticária crónica numa população pediátricaPublication . Rios, M.; Silva, R.; Cunha, L.; Gomes, E.; Falcão, H.Introdução: A urticária crónica (UC) é uma patologia rara na criança e no adolescente. Objetivo: Caracterizar um grupo de crianças e adolescentes com UC, analisando os subtipos de UC identificados, patologias associadas, tratamento e evolução. Material e métodos: Estudo retrospetivo baseado na consulta dos processos clínicos de uma amostra consecutiva de 59 crianças e adolescentes seguidos numa consulta de Imunoalergologia pediátrica. Resultados: Os 59 doentes tinham idades compreendidas entre 16 meses e 17 anos. Destes, 37 (62,7%) eram do sexo masculino. Trinta e cinco (59,3%) casos corresponderam a urticária espontânea crónica, 20 (33,9%) a urticária física (15 factícia, cinco ao frio), e quatro (6,8%) a outro tipo de urticária (dois induzida pelo exercício, um colinérgica, um aquagénica). Foram detetados autoanticorpos em quatro doentes com urticária espontânea e em cinco com urticária física/outro tipo. Diagnosticou-se infecção aguda por CMV num doente com urticária espontânea e infeção por Giardia num doente com urticária induzida pelo exercício. Em 31 (88,6%) dos 35 casos cuja evolução é conhecida durante os primeiros cinco anos de doença, houve remissão da sintomatologia, em média 24 meses depois (mediana 12 meses). Conclusões: Para além da UC espontânea, identificada na maioria, a urticária factícia e desencadeada pelo frio são subtipos frequentes neste grupo etário. O rastreio de doenças autoimunes parece ter interesse não só nos casos de urticária espontânea, como nos restantes subtipos. Na maioria dos doentes ocorre resolução espontânea dos sintomas durante os primeiros cinco anos de doença, sobretudo durante o primeiro ano. ABSTRACT Introduction: Chronic urticaria (CU) is a rare disease in children and adolescents. Aim: To characterize a group of children and adolescents with CU, analyzing the subtypes of CU, associated diseases, treatment and evolution. Material and methods: Retrospective study based on medical records consultation of a consecutive sample of 59 children and adolescents followed in a pediatric Immunoallergology department. Results: There were 59 patients aged between 16 months and 17 years, 37 of them (62,7%) were male. Thirty five (59,3%) cases corresponded to spontaneous chronic urticaria, 20 (33,9%) to physical urticaria (15 factitious and five cold urticaria), and four (6,8%) to another type of urticaria (two induced by exercise, one cholinergic, one aquagenic). Autoantibodies were detected in four patients with spontaneous urticaria and in five with physical urticaria or other. Acute CMV infection was diagnosed in a patient with spontaneous urticaria, and Giardia infection was found in a patient with exercise-induced urticaria. In 31 (88,6%) of the 35 cases in which evolution during the first five years is known, there was remission of symptoms, after 24 months on average (median 12 months). Conclusions: In addition to spontaneous CU, identified in most cases, cold and factitious urticaria subtypes are common in this age group. The screening of autoimmune diseases seems to have a role not only in patients with spontaneous urticaria, but also in those with the other types. In the large majority of patients the spontaneous resolution of symptons occurs during the first five years of disease, especially during the first year.