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- Clinical implications of anti-HLA antibodies testing in kidney transplantationPublication . Malheiro, J.; Tafulo, S.Alloantibodies against donor human leukocyte antigens (HLA), termed as donor‑specific antibodies (DSA), are one of the most important factors for both early and late kidney allograft dysfunction. In the past, these antibodies were mainly detected through cell‑based crossmatch tests. Recently, new techniques such as solid phase immunoassays (SPI) have revealed these antibodies in patient sera with a high degree of detail, previously unimaginable. They have allowed us to accurately determine recipients’ allosensitization status, improve pre‑transplant risk assessment with a potential donor and post‑transplant alloimmune monitoring. However, the high sensitivity of these new assays has also created areas of uncertainty about their clinical impact. In the pre‑transplant setting, the presence of preformed DSA has been associated with an increased risk of antibody‑mediated rejection (AMR) and subsequent allograft loss. Nevertheless, several studies have shown that not all DSA are deleterious. Hence, understanding the clinical correlations of DSA characteristics, namely strength, HLA class, complement‑fixing ability or IgG subclasses, is paramount for an adequate stratification of the immunological risk at transplant. Furthermore, given that the number of allosensitized patients on waiting lists is increasing, the added information from these new SPI is essential to improve their chance of being transplanted with an admissible immunological risk. After transplantation, the appearance of de novo DSA (dnDSA) has also been associated with a deleterious effect on kidney allograft survival. Moreover, it has been acknowledged that a majority of late allograft failures are caused by alloantibody‑driven injury. The current challenges, in this setting, are determining cost‑effective DSA screening protocols and understanding which patients could benefit from specific interventions. Furthermore, although therapeutic strategies to control antibody‑induced damage remain limited, the longitudinal surveillance of dnDSA emergence and the clinical correlations of their characteristics will play a crucial role in the improvement of late kidney allograft survival.
- Long-term psychological outcome after discharge from intensive carePublication . Pereira, S.; Cavaco, S.; Fernandes, J.; Moreira, I.; Almeida, E.; Seabra-Pereira, F.; Castro, H.; Malheiro, M.; Cardoso, A.; Aragão, I.; Cardoso, T.Objective: To investigate the longterm psychological outcome in survivors of critical illness after intensive care unit discharge. Methods: A prospective cohort of survivors admitted to a mixed intensive care unit between January and September 2010 was evaluated six months and five years after hospital discharge. The Dementia Rating Scale-2, the Hospital Anxiety and Depression Scale, the Posttraumatic stress syndrome 14-questions inventory, the Euro Quality of Life 5 Dimensions (EQ-5-D), and the Visual Analogue Scale (EQ VAS) were assessed at both follow-up periods. Results: Of 267 patients, 25 patients were evaluated at 6 months after discharge (62 ± 16 years); 12 (48%) presented cognitive impairment, 6 (24%) anxiety, 4 (16%) depression, and 4 (16%) post-traumatic stress disorder. Among those re-evaluated five years after discharge (n = 17; 65 ± 15 years), the frequency of cognitive impairment dropped from 8 (47%) to 3 (18%) (p = 0.063), due to improvement in these patients over time, and other patients did not acquire any dysfunction after discharge. At five years after discharge, only two patients (12%) reported anxiety, and none had depression or post-traumatic stress disorder. No differences were found between the six-month and five-year follow-ups regarding EQ-5-D and EQ VAS. Conclusion: Survivors do not show a progressive decline in cognitive function or quality of life within five years after intensive care unit discharge. Psychopathological symptoms tend to decrease with time.
- [Adverse postoperative cognitive disorders: a national survey of portuguese anesthesiologists]Publication . Susano, M.; Vasconcelos, L.; Lemos, T.; Amorim, P.; Abelha, F.Background and objectives: Postoperative delirium and postoperative cognitive dysfunction are some of the most common complications in older surgical patients and are associated with adverse outcomes. The aim of this study was to evaluate portuguese anesthesiologists' perspectives and knowledge about adverse postoperative cognitive disorders, and routine clinical practice when caring for older surgical patients. Methods: We used a prospective online survey with questions using a Likert scale from 1 to 5 (completely disagree to completely agree), or yes/no/don't know answer types. Potential participants were portuguese anesthesiologists working in hospitals affiliated with the portuguese national health system and private hospitals. Results: We analyzed 234 surveys (17.7% of total potential respondents). The majority believed that the risk of cognitive side effects should be considered when choosing the type of anesthesia (87.6%) and that preoperative cognitive function should be routinely assessed (78.6%). When caring for an agitated and confused patient postoperatively, 62.4% would first administer an analgesic and 11.1% an anxiolytic. Protocols to screen and manage postoperative cognitive disorders are rarely used. Nearly all respondents believe that postoperative delirium and postoperative cognitive dysfunction are neglected areas in anesthesiology. Conclusions: Overall, participants perceive postoperative cognitive disorders as important adverse outcomes following surgery and anesthesia are aware of the main risk factors for their development but may lack information on prevention and management of postoperative delirium. The majority of hospitals do not have protocols regarding preoperative cognitive assessment, diagnosis, management or follow-up of patients with delirium and postoperative cognitive dysfunction.
- [CR-POSSUM and Surgical Apgar Score as predictive factors for patients' allocation after colorectal surgery]Publication . Pinho, S.; Lagarto, F.; Gomes, B.; Costa, L.; Nunes, C.; Oliveira, C.Background and objectives: Surgical patients frequently require admission in high-dependency units or intensive care units. Resources are scarce and there are no universally accepted admission criteria, so patients' allocation must be optimized. The purpose of this study was to investigate the relationship between postoperative destination of patients submitted to colorectal surgery and the scores ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) and Surgical Apgar Score (SAS) and, secondarily find cut-offs to aid this allocation. Methods: A cross-sectional prospective observational study, including all adult patients undergoing colorectal surgery during a 2 years period. Data collected from the electronic clinical process and anesthesia records. Results: A total of 358 patients were included. Median score for SAS was 8 and CR-POSSUM had a median mortality probability of 4.5%. Immediate admission on high-dependency units/intensive care units occurred in 51 patients and late admission in 18. Scores from ward and high-dependency units/intensive care units patients were statistically different (SAS: 8 vs. 7, p<0.001; CR-POSSUM: 4.4% vs. 15.9%, p<0.001). Both scores were found to be predictors of immediate postoperative destination (p<0.001). Concerning immediate high-dependency units/intensive care units admission, CR-POSSUM showed a strong association (AUC 0.78, p=0.034) with a ≥9.16 cut-off point (sensitivity: 62.5%; specificity: 75.2%), outperforming SAS (AUC 0.67, p=0.048), with a ≤7 cut-off point (sensitivity: 67.3%; specificity: 56.1%). Conclusions: Both CR-POSSUM and SAS were associated with the clinical decision to admit a patient to the high-dependency units/intensive care units immediately after surgery. CR-POSSUM alone showed a better discriminative capacity.
- Epidemiologia das infeções fúngicas superficiais em Portugal - revisão de 3 anos (2014-2016)Publication . Rato, M.; Costin, A.; Furtado, C.; Sousa, C.; Toscano, C.; Veríssimo, C.; Trindade, F.; Almeida, F.; Velho, G.; Catorze, G.; Raposo, I.; Selada, J.; Ferreira, J.; Batista, J.; Santos, L.; Sereijo, M.; Silva, M.; Apetato, M.; Sanches, M.; Costa-Silva, M.; Filipe, P.; Santos, P.; Fonseca, P.; Mascarenhas, R.; Bajanca, R.; Lopes, V.; Lewis, V.; Duarte, M.; Galhardas, C.; Anes, M.Introdução: As infeções fúngicas superficiais são as dermatoses infeciosas mais frequentes e a sua incidência continua a aumentar. Os dermatófitos são os principais agentes causais apresentando, contudo, uma distribuição geográfica variável. Material e Métodos: O presente estudo teve como objetivo a caracterização epidemiológica das infeções fúngicas superficiais diagnosticadas nos Serviços/Unidades de Dermatologia pertencentes ao Serviço Nacional de Saúde Português entre janeiro de 2014 e dezembro 2016 através da análise retrospetiva dos resultados das culturas realizadas durante esse período. Resultados: Foram estudados 2375 isolamentos, pertencentes a 2319 doentes. O dermatófito mais frequentemente isolado foi o Trichophyton rubrum (53,6%), tendo sido o principal agente causal da tinha da pele glabra (52,4%) e das onicomicoses (51,1%). Relativamente às tinhas do couro cabeludo, globalmente o Microsporum audouinii foi o agente mais prevalente (42,6%), seguido do Trichophyton soudanense (22,1%). Enquanto na área metropolitana de Lisboa estes dermatófitos foram os principais agentes de tinha do couro cabeludo, nas regiões Norte e Centro o agente mais frequente foi o Microsporum canis (58,5%). Os fungos leveduriformes foram os principais responsáveis pelas onicomicoses das mãos (76,7%). Conclusão: Os resultados deste estudo estão globalmente concordantes com a literatura científica. O Trichophyton rubrum apresenta-se como o dermatófito mais frequentemente isolado em cultura. Na tinha do couro cabeludo, na área metropolitana de Lisboa, as espécies antropofílicas de importação assumem particular destaque.
- Acute tubulointersticial nephritis with uveitis: A report of two casesPublication . Silva, F.; Correia, S.; Castro, A.; Moreira, C.; Santos, S.; Malheiro, J.; Santos, J.; Martins, L.; Cabrita, A.Tubulointersticial nephritis and uveitis syndrome is an idiopathic and rare cause of acute kidney injury that should not overlooked, because it usually requires specific therapeutic interventions. We report two distinct cases: a young and an elder female. Both cases presented with unspecific constitutional symptoms but had different onset of renal and ocular involvement. Both were treated with topical and systemic corticoids and although there was a good initial response in both cases, an early relapse after steroids taper was observed in the younger patient and a persistent renal dysfunction in the older one. A high clinical suspicion and understanding of this disease is necessary for an adequate management and treatment of these patients. Recent data associates a worse renal prognosis when the disease appears in advanced age. In both of our cases the outcome was good but we had a short follow-up. The histological presentation of this disease in our older patient was similar to that reported in the literature, with a high percentage of fibrosis and chronicity of renal tissue that can contribute to the higher grade of renal dysfunction in this type of patients.
- Arterio-arterial graft – an option for hemodialysis patients with exhaustion of venous patrimonyPublication . Castro, A.; Almeida, P.; Silva, F.; Rego, D.; Tavares, J.; Santos, J.; Silva, F.; Queirós, J.; Cabrita, A.; Almeida, R.Introduction: Vascular access (VA) for hemodialysis (HD) is the lifeline for End Stage Renal Disease (ESRD) patients. Long-term HD patients often have exhaustion of their venous patrimony for an autologous VA construction and, sometimes, even for a central venous catheter (CVC) placement. Case report: We describe the case of a 43-year-old woman with ESRD due to lupus nephritis, on maintenance HD since 2009. She also had secondary antiphospholipid syndrome and was chronically anticoagulated. Nevertheless, the patient had multiorgan thrombotic events (without sequelae) and several episodes of irreversible thrombosis of arteriovenous fistulas. Her HD course was also marked by multiple severe CVC infections, at diferente locations; a hemoperitoneum during cholecystectomy, and an immediate thrombosis of the renal artery of a kidney transplant. She was admitted to our hospital after an irreversible dysfunction of a right jugular CVC, with documentation of thrombosis of the superior and inferior vena cava. Exhaustion of the venous patrimony for HD was assumed and it was decided to make an arterio-arterial graft (AAG) of early cannulation. The first cannulation of the AAG was performed two days after surgical intervention, with no complications. The patient performed a twelve hour per week HD treatment with good efficiency. Conclusion: AAG is an alternative for HD patients who have exhausted all their venous patrimony and it can be considered prior to the placement of a CVC as their sole remaining vascular access.
- New Calcipotriol/Betamethasone Dipropionate Foam Formulation for the Treatment of Psoriasis: An OverviewPublication . Torres, T.; Filipe, P.ABSTRACT – Psoriasis is a chronic, inflammatory, immune-mediated, potentially disfiguring and disabling skin disorder, affecting over 100 million individuals worldwide. Calcipotriol plus betamethasone fixed-combination (0.005% Cal/0.064% BD) is the recommended topical treatment for psoriasis. However, topical treatments are associated to lack of efficacy and low adhesion rates due to poor cosmetic characteristics’ formulations, and vehicle issues. To answer the need for improving patients’ acceptability and adherence, an innovative Cal/BD aerosol foam formulation was developed for the topical treatment of adults with plaque psoriasis. Phase II and III clinical trials have consistently shown that the two-compound formulation is more effective and safer than its individual ingredients in the same vehicle. Cal/BD aerosol foam formulation has proved higher efficacy in clinical studies, and a pooled analysis of the main clinical studies has demonstrated that this does not occur at the safety profile expense. Furthermore Cal/BD aerosol foam has shown a significantly improved efficacy compared with more traditional formulations, such as ointments, gels, and lotions. The improved efficacy and safety profile of this new formulation, together with the once-daily treatment, a moreacceptable tolerability profile, and an early and rapid response, offers improved convenience and better acceptance over the twice--daily applications required for the respective monotherapies, which may improve adherence to treatment, leading to faster and greater improvements in HR-QoL, representing a useful therapeutic option to the management of patients with plaque psoriasis. Further clinical investigations to explore the possibility of Cal/BD aerosol foam treatment ability to provide long-term psoriasis’ management are required.
- LEIGH SYNDROME: A CASE REPORT WITH A MITOCHONDRIAL DNA MUTATIONPublication . Lopes, T.; Coelho, M.; Bordalo, D.; Bandeira, A.; Bandeira, A.; Vilarinho, L.; Fonseca, P.; Carvalho, S.; Martins, C.; Oliveira, J.Objective: Leigh syndrome is a neurodegenerative disorder with an incidence of 1:40,000 live births. It presents wide clinical, biochemical, and genetic heterogeneity, but with homogenous neuropatoradiological alterations. There is no specific treatment, and the prognosis is reserved. This case report aimed familiarize health professionals with the disease. Case Description: A 16-month-hold girl who was followed in outpatient clinic due to axial hypotonia and delayed psychomotor development. Karyotype, auditory evoked potentials and ophthalmologic evaluation were normal. Evidence of hyperlactacidemia and hypocitrullinemia was detected in the patient. After performing brain magnetic resonance under anesthesia, hypotonia got worse, and the patient was hospitalized after an episode of cyanosis and apnea. The electroencephalogram showed no epileptiform activity. Neuroimaging revealed bilateral lenticular hyperintensity, especially in the putamen and in the left globus pallidus regions. Molecular analysis revealed an 8993T>G (MT-ATP6) mutation in the mitochondrial DNA. Comments: Between 10 and 30% of individuals with Leigh syndrome have mitochondrial DNA mutations. The decompensation after anesthetic intercurrences is typically associated with neurological deterioration and, in this case, increased the diagnosis suspicion. It is important to alert for similar cases and to reduce invasive diagnostic tests if the diagnosis is suspected.
- Pulmonary hypertension: Real-world data from a Portuguese expert referral centrePublication . Gomes, A.; Cruz, C.; Rocha, J.; Ricardo, M.; Vicente, M.; Melo, A.; Santos, M.; Carvalho, L.; Gonçalves, F.; Reis, A.Pulmonary hypertension (PH) is a heterogeneous, debilitating condition with highly relevant impact on functional capacity, quality of life, and life-expectancy.