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Predição da Resposta à Terapêutica de Ressincronização Cardíaca Utilizando Critérios Eletrocardiográficos: Revisão Sistemática
No full textBackground: Cardiac resynchronization therapy (CRT) is an established therapeutic option for heart failure, but despite careful selection around 30% of the patients still do not respond to this therapy. The standard electrocardiogram (ECG) is a practical and inexpensive tool to assess potential responders to CRT but with conflicting evidence regarding the value of different ECG parameters. As such, we conducted a systematic review of real-world studies to assess the value of pre-implantation standard ECG parameters in predicting response to CRT.
Methods: We searched on PubMed, Scopus, and Web of Knowledge online databases to identify analytic studies and synthesized results through evidence tables.
Results: Sixty-two eligible articles were included in this review. Traditional predictors of response were QRS duration ≥150 ms and the presence of left bundle branch block morphology. Contemporary ECG parameters, such as the presence of QRS notching or fragmentation, the S wave assessment, the time to intrinsicoid deflection (ID) in lateral leads, and a lead one ratio ≥12 also showed great potential in assessing response to CRT.
Conclusions: This review highlights the promising capability of the standard ECG in predicting response to CRT, particularly when using more contemporary predictors, while emphasizing the necessity for further research to validate the prognostic value of these predictors.Contexto: A terapêutica de ressincronizac¸ão cardíaca (TRC) é uma opc¸ão terapêutica consol idada para a insuficiência cardíaca; no entanto, apesar da selec¸ão criteriosa, cerca de 30%
dos doentes não respondem a esta terapêutica. O eletrocardiograma (ECG) padrão é uma
ferramenta prática e económica para avaliar potenciais respondedores à TRC, mas existem
evidências contraditórias sobre o valor de diferentes parâmetros do ECG. Assim, realizámos
uma revisão sistemática de estudos em contexto clínico real para avaliar o valor dos parâmetros
de ECG padrão antes da implantac¸ão na predic¸ão de resposta à TRC.
Métodos: Realizámos uma pesquisa nas bases de dados PubMed, Scopus e Web of Knowledge
para identificar estudos analíticos e sintetizámos os resultados em tabelas de evidências.
Resultados: Foram incluídos 62 artigos elegíveis nesta revisão. Os preditores tradicionais de
resposta foram a durac¸ão do QRS ≥ 150ms e a presenc¸a de bloqueio do ramo esquerdo (BRE)
com morfologia típica. Parâmetros de ECG contemporâneos, como a presenc¸a de entalhes ou
fragmentac¸ão do QRS, a análise da onda S, o tempo de deflexão intrinsicóide (ID) nas derivac¸ões
laterais e uma razão na derivac¸ão DI (LOR) ≥ 12, mostraram também grande potencial na
avaliac¸ão da resposta à TRC.
Conclusões: Esta revisão destaca a capacidade promissora do ECG padrão em prever a resposta
à TRC, particularmente ao utilizar preditores mais contemporâneos, sublinhando a necessidade
de mais investigac¸ão para validar o valor prognóstico destes preditores
O Impacto da Pandemia COVID-19 no Diagnóstico de Melanoma Cutâneo: um Estudo Multicêntrico em Portugal
No full textObjective: Malignant melanoma (MM) is among the most lethal skin cancers, with early diagnosis being essential for timely treatment and favorable prognosis. The coronavirus disease 19 (COVID-19) pandemic-related disruptions in global healthcare systems affected cancer screening and treatment. The aim of this study was to investigate the potential impact of the COVID-19 pandemic on the diagnosis and prognosis of MM.
Methods: A retrospective analysis of all histopathology-confirmed MMs diagnosed between 2019 and 2022 was conducted in three dermatology departments in Lisbon. Histopathology reports and medical records of included patients were reviewed and data of interest analyzed. Data from the pandemic period (2020 and 2021) were compared to the pre and post-pandemic ones (2019 and 2022, respectively).
Results: During the study period, a total of 644 MMs were diagnosed. When compared to the post-pandemic period, we observed a significant association between the pandemic group and a higher median Breslow thickness, ulcerated tumors, locoregional metastases, and more advanced stages (≥ T1B, final staging ≥ IIB) (p < 0.05). Conclusion: With the pandemic group being associated with unfavorable prognostic factors, we believe that restricted access to healthcare during the COVID-19 pandemic may have had a negative impact on the morbimortality of patients with MM.Objetivo: O melanoma maligno representa um dos cancros de pele mais letais, sendo o diagnóstico precoce essencial para um tratamento atempado e um prognóstico favorável. As alterações nos sistemas de saúde relacionadas com a pandemia COVID-19 afetaram negativamente o rastreio e o tratamento do cancro. O objetivo deste estudo foi investigar o potencial impacto da pandemia COVID-19 no diagnóstico e prognóstico do melanoma maligno.
Métodos: Foi realizada uma análise retrospetiva dos melanomas malignos confirmados histologicamente, diagnosticados entre 2019 e 2022 em três departamentos de dermatologia em Lisboa. Foram revistos os relatórios de histopatologia e os registos clínicos dos doentes incluídos e analisados os dados de interesse. Os dados do período pandémico (2020 e 2021) foram comparados com os pré e pós-pandemia(2019 e 2022 respetivamente).
Resultados: No período estudado foram diagnosticados 644 melanomas malignos. Quando comparado ao período pós-pandemia, observamos uma associação significativa entre o grupo pandémico e maior espessura de Breslow média, tumores ulcerados, metástases locorregionais e estadios mais avançados (≥ T1B, estadio final ≥ IIB) (p <0.05).
Conclusão: Estando o grupo pandémico associado a fatores prognósticos desfavoráveis, acreditamos que o acesso restrito aos cuidados de saúde durante a pandemia COVID-19 pode ter tido um impacto negativo na morbimortalidade dos doentes com melanoma maligno
Spectrum of Cutaneous Lesions in a Cohort of Patients With Neurofibromatosis Type 2.
No full textBackground: Neurofibromatosis type 2 (NF2) is a rare autosomal dominant syndrome with a predisposition to the development of central nervous system tumors, ophthalmic manifestations, and dermatological lesions. The latter are present in 70-95% of patients and can precede the evolution of other tumors. However, they are not included in the diagnostic criteria and are frequently undervalued during follow-up.
Methods: An observational cross-sectional study characterizing cutaneous lesions in a cohort of NF2 patients was carried out. Dermatological examinations were performed, and lesions were classified into neural cutaneous tumors (superficial, SNCT, and deep, DNCT), hyperpigmented patches (HyperP), and hypopigmented patches (HypoP). The Dermatology Life Quality Index (DLQI) and EQ-5D questionnaires were applied to evaluate the impact on quality of life.
Results: Nineteen patients with a mean age of 36 years were included. Sixteen (84%) patients had cutaneous lesions, mostly developed 10 or more years before the diagnosis. SNCT, DNCT, and HyperP showed similar frequencies (58%). HypoP were observed in only one patient. HyperP developed, on average, earlier than NCT (9.6 vs. 16.5 SNCT, 17.0 DNCT; years). The excised lesions had different histological patterns, including neurofibromas, schwannomas, and a hybrid tumor. Most patients reported a low impact of cutaneous manifestations on the quality of life (DLQI 0 or 1).
Conclusions: Cutaneous lesions are frequent in NF2 and may precede the diagnosis by several years. Their identification is important to establish the diagnosis earlier and potentially reduce morbidity and mortality
Under-Five Mortality and Social Determinants in Africa: a Systematic Review
No full textPurpose: Under-five mortality is a key public health indicator, highly responsive to preventive interventions. While global efforts have made strides in reducing mortality rates in this age group, significant disparities persist, particularly in Sub-Saharan Africa. This study aimed to systematically review the factors influencing under-five mortality in Africa, focusing on sociodemographic factors and health-related determinants.
Methods: A systematic review was conducted adhering to PRISMA guidelines. Studies were identified from a range of well-established indexed academic databases. Keywords and Boolean operators facilitated relevant study retrieval. Only articles published in English, Portuguese, or Spanish between January 2013 and November 2024, in peer-reviewed journals, were included. Methodological quality assessment utilised the Joanna Briggs Institute tool.
Results: Of the 602 studies identified, 39 met the inclusion criteria. Key determinants of under-five mortality included socioeconomic factors such as poverty and maternal education, along with maternal age extremes, multiparity, inadequate prenatal care, and low birth weight.
Conclusion: Addressing social disparities, particularly through enhanced maternal education and improved access to primary healthcare, is critical in reducing under-five mortality in Africa. The findings underscore the importance of targeted interventions that address both social and healthcare-related factors to mitigate child mortality in the region.
What is known: •Under-five mortality in Sub-Saharan Africa is primarily driven by preventable infectious diseases, such as diarrhoea, pneumonia, malaria, and HIV/AIDS, compounded by malnutrition and inadequate healthcare infrastructure. •Socio-economic factors, including poverty, maternal education, and limited access to quality healthcare, are consistently identified as key determinants of high child mortality rates in the region.
What is new: •This review applies the Mosley and Chen framework to categorise the determinants of under-five mortality into distal, intermediate, and proximal factors, providing a structured understanding of their interconnections. •The findings underscore how socio-economic conditions, maternal education, and healthcare access interact to influence child survival outcomes in Sub-Saharan Africa, offering valuable insights for region-specific public health interventions
Unveiling the Dark Side of Negative Behaviors Among Nurses and Their Implications in Workforce Well-Being and Patient Care: A Scoping Review.
No full textIntroduction: Negative behaviors in nursing undermine well-being, erode team cohesion, and jeopardize patient safety. Rooted in systemic stressors-workload, emotional strain, and power imbalances-they have far-reaching effects on job satisfaction and care quality.
Objective: To systematically map the scientific evidence on negative behaviors among nurses in healthcare organizations.
Methods: A scoping review was conducted using five databases: CINAHL, MEDLINE, Scopus, Psychology & Behavioral Sciences Collection, and RCAAP (for grey literature). The review followed the Joanna Briggs Institute methodology and PRISMA-ScR reporting guidelines. Two independent reviewers conducted data extraction and synthesis. Results: Eighteen studies published between 2017 and 2024 met inclusion criteria from an initial pool of 88 references. Eleven thematic domains emerged: (1) the cycle of violence; (2) victims profile; (3) perpetrator profile; (4) negative behaviors spectrum; (5) negative behaviors prevalence; (6) risk predictors; (7) protective predictors; (8) impact of negative behaviors on nurses; (9) impact of negative behaviors on patients; (10) impact of negative behaviors on healthcare organizations; (11) organizational strategies and the role of the nurse managers.
Conclusions: The findings highlight the multidimensional nature of negative behaviors and the variability in how they are defined and assessed. This review highlights the need for conceptual clarity and standardized tools to address negative behaviors in nursing. Nurse managers, as key organizational agents, play a critical role in fostering psychological safety, promoting ethical leadership, and ensuring accountability. System-level strategies that align leadership with organizational values are essential to protect workforce well-being and safeguard patient care
Decision-Making for Endovascular Thrombectomy in Patients With Large Vessel Occlusions and Mild Neurological Deficit: A Consensus Statement.
No full textAcute ischemic stroke patients with mild deficits (National Institutes of Health Stroke Scale [NIHSS] of 0-5) but confirmed large vessel occlusions (LVO) present a clinical challenge for endovascular thrombectomy (EVT) decisions due to limited evidence and the absence of clear guidelines. A Delphi consensus was conducted at the 2024 5T (Teamwork, Training, Technology, Technique, Transport) Think Tank conference with 40 international stroke experts. Following a systematic literature review, three iterative Delphi rounds were employed to explore EVT decision-making in strokes due to LVO with low NIHSS. Data were collected through surveys and in-person discussions, focusing on disability evaluation, imaging markers, procedural risk, and outcome scales. Consensus was achieved on key factors influencing EVT decisions. Experts emphasized the importance of symptom-specific disability (e.g., aphasia, vision loss) over NIHSS scores alone. Early neurological deterioration (END) was perceived as main concern in this patient population. Imaging markers such as proximal occlusion, poor collaterals, and large penumbra were expected to be predictors of END. The anticipated technical difficulty and patient-specific factors, such as independence and quality of life, also guided decisions. The Potential of rtPA for Ischemic Strokes With Mild Symptoms (PRISMS) trial definition of disabling deficits and the 9-level modified Rankin Scale were favored as outcome measures for future studies. EVT decisions for acute ischemic strokes with mild deficit but proven LVO require nuanced, individualized approaches beyond NIHSS thresholds. Disability assessment, imaging-based risk evaluation, and patient-centered discussions are critical for optimizing outcomes, emphasizing the need for further research and standardized guidelines
Evaluation of the Efficacy of the SARS-CoV-2 Vaccine Additional and Booster Doses in Immunocompromised Patients With Multiple Sclerosis: the COVACiMS Study.
No full textStudies evaluating COVID-19 primary vaccination with two vaccines reported a blunt response in Multiple Sclerosis (MS) patients under anti-CD20 and sphingosine-1-phosphate (S1P) modulators. An extended primary vaccination (EPV) was recommended in immunosuppressed MS patients. Data on the effectiveness of the EPV and subsequent booster dose are limited. A prospective cohort study (n = 270) was conducted to evaluate the humoral and cellular immunogenicity of the EPV scheme in immunocompromised MS patients (i.e., treated with anti-CD20, S1P modulators, natalizumab, teriflunomide, or dimethyl fumarate) vs. regular primary vaccination in non-treated patients - primary course (PC) cohort. The effect of a subsequent booster dose was also assessed - first booster (FB) cohort . The seroconversion rates were 55% and 56% in anti-CD20 and 75% and 67% in S1P modulators group in PC and FB cohort, respectively, and 100% in the remaining groups. A positive SARS-CoV-2 Spike T-spot was observed in 22% of patients under S1P modulators in PC cohort and 67% in FB cohort; the remaining groups had 75% or more. Similar rates of breakthrough infection were observed in both groups vs. controls. Compared to non-treated MS patients, immunosuppressed patients under anti-CD20 and S1P modulators drugs receiving EPV scheme or booster dose still present lower protection rates to SARS-CoV-2
Home Mechanical Ventilation in Adults: Clinical Practice Recommendations from the Portuguese Respiratory Society Home Mechanical Ventilation Assembly.
No full textThe use of home mechanical ventilation (HMV) has been increasing worldwide, driven by widening of clinical applications and improved patient survival rates. In Portugal, recent data indicate an even faster growth, although national HMV recommendations have remained unchanged for 25 years. We aimed to provide an update in clinical practice guidelines for HMV in adults, applicable to the Portuguese context, grounded on the latest available evidence and experts' opinion. A multidisciplinary panel with experience in HMV in the adult population was assembled. A comprehensive literature search was conducted during March 2023 regarding specific topics: equipment, ventilatory modes and interfaces, HMV initiation, follow-up and monitoring, disease specificities (neuromuscular diseases, obesity-hypoventilation syndrome, restrictive chest wall diseases; chronic obstructive pulmonary disease, and other diseases), home mechanical invasive ventilation, and palliative and end of life care. A 2-round Delphi process was conducted to establish consensus among panel members. A minimum agreement threshold of 80% was required. Out of 88 recommendations initially included in the Delphi process, 61 were selected by consensus. Final recommendations grounded in the current level of evidence are outlined, and the key limitations and proposals for future research are discussed
Terapêutica Específica Para Doentes com Amiloidose por Transtirretina Hereditária com Envolvimento Cardíaco Após Transplante Hepático Ortotópico. Consenso do Grupo de Estudo de Doenças do Miocárdio e Pericárdio da Sociedade Portuguesa de Cardiologia e dos Centros de Referência Nacionais Para a Amiloidose Familiar
No full textMycotic Aneurysm in an Immunocompromised Patient with Pneumonia and Spondylodiscitis: Who’s Guilty?
No full textBACKGROUND: Mycotic aneurysm is a rare entity with rapid progression, which can be fatal without adequate treatment. The incidence of rupture is greater than that of degenerative aneurysms and is associated with a high mortality rate.
CASE REPORT: We report the case of a 58-year-old man with a known history of HIV infection with good immunovirological staging, treated squamous cell carcinoma of the anal canal and chronic gastritis, who presented with a six-day history of intense back pain, malaise, fever, and chills. After examination, he was hospitalized with a clinical suspicion of acute pyelonephritis. During hospitalization, he was diagnosed with pneumonia of the right pulmonary base, infectious spondylodiscitis, and mycotic aneurysm of the abdominal aorta, which involved the visceral plaque. The microbiological workup revealed only positive blood cultures for Klebsiella pneumoniae. After a multidisciplinary discussion of the case and six weeks of antibiogram-oriented antibiotic therapy, the patient underwent an aorto-aortic interposition via left thoracophrenolaparotomy without the need to reimplant visceral vessels due to the patch confguration of the proximal anastomosis. The procedure was performed under left heart bypass. The postoperative course was uneventful, and the patient was discharged four weeks later. At 18 months follow-up, she remained asymptomatic and free of recurrence.
CONCLUSION: In this case, it remains to be defned whether the cause of the mycotic aneurysm was hematogenous dissemination from the identifed pneumonia or contiguity from the diagnosed spondylodiscitis. Given the morbidity and mortality associated with this entity, early diagnosis and adequate treatment with surgical correction and antibiotic therapy with suffcient duration and dose are important aspects for improving survival in these cases