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A Giant Arteriovenous Malformation of the Abdominal Wall
No full textINTRODUCTION: Arteriovenous Malformations (AVMs) are high-fow anomalous connections between the arterial and venous systems composed of dysplastic vessels resulting from aberrant angiogenesis. They are congenital and when symptomatic they rarely manifest before adolescence. Depending on the location, size, stage and severity of the symptoms, treatment options vary from conservative management to surgical resection. We report a case of a giant arteriovenous malformation of abdominal wall (tipe IIIb of Yakes Classifcation) treated with surgical resection after prior attempts of scleroembolization..
CLINICAL CASE: 54-year-old woman with known history of osteoarticular pathology and dyspepsia presented a mass on the left side of the abdominal wall with hard consistency, warm, slightly pulsating and tenderness to touch with several years of evolution. The mass showed infltration of the internal and external oblique muscles sparing the transverse muscle. Clinically she presented easy fatigue with efforts. Due to the risk of abdominal wall herniation after excision of the AVM, scleroembolization was considered frst-line treatment in this case. This strategy resulted in regression of the mass and symptoms improvement. Four years after the last intervention, the patient presented lesion growth, recurrence and worsening of symptoms with severe interference in the quality of life (QoL). After multidisciplinary discussion, she was proposed for complete resection of the AVM. She was frst submitted to scleroembolization with Onyx of identifed arterial afferents and sclerosis of the lesion
nidus with 2% polidocanol. One month after she underwent successfully total resection of the AVM with the collaboration of General Surgery.
CONCLUSION: No unifed agreement exists on the best treatment of these complex high fow lesions and it is diffcult to establish a comprehensive strategy given the pathology’s clinical variability, complex stratifcation and the risk of relapse. A case-by-case approach is needed in managing these types of lesions
Percutaneous Vertebral Biopsies – Case-Based Description of a Single Centre Experience
No full textIntrodução: A biópsia percutânea vertebral tem substituído a biópsia cirúrgica aberta nos últimos 50 anos. A biópsia não-invasiva é mais custo-efetiva e tem menos complicações quando comparada com procedimentos abertos. Realizou-se uma revisão das biópsias percutâneas vertebrais realizadas no nosso centro para avaliar o yield diagnóstico e a segurança.
Métodos: Analisou-se retrospetivamente 240 biópsias vertebrais percutâneas realizadas no nosso centro terciário durante 4 anos. As variáveis adquiridas incluíram técnica diagnóstica de imagem, segmento vertebral, localização da biópsia, resultados histopatológicos, tratamento adjuvante e complicações.
Resultados: 102 (42,5%) dos pacientes eram mulheres, com uma média de 68 anos. A técnica mais utilizada foi a fluoroscopia (99%, n=237). A maioria dos procedimentos foi realizado no segmento lombar, representando 47% (n=112), seguido do segmento torácico (42%, n=100). Obtivemos amostra suficiente para análise histológica em 93%. Das 240 biópsias, 18 (7,5%) tiveram de ser repetidas, tendo-se obtido um diagnóstico em 14 (78%). Histologicamente, em 28% (n=67) das amostras não se obteve alterações patológicas e em 27% (n=65) confirmou-se doença metastática. Realizou-se vertebroplastia em 19% (n=46) dos casos após a biópsia. Apenas um paciente teve uma complicação clinicamente significativa secundária ao procedimento.
Conclusão: A biópsia vertebral percutânea é uma importante ferramenta na avaliação de lesões vertebrais e dos tecidos paravertebrais adjacentes, e pode ser realizada com baixa morbilidade e alta taxa de deteção como um procedimento de ambulatório. Em conformidade com a literatura, a maior parte das nossas amostras eram adequadas para análise histopatológica e o achado mais comum foi lesão metastática.Introduction: Percutaneous spine biopsy has widely replaced open surgical biopsy for the last 50 years. Non-invasive biopsy is more cost effective and has fewer complications than open procedures. We reviewed our single center experience in percutaneous spinal biopsies to evaluate their diagnostic yield and safety.
Methods: We retrospectively analyzed 240 percutaneous vertebral biopsies performed at our tertiary center, in a 4-year period. Collected variables included diagnostic imaging techniques, vertebral segment, location of biopsy, histopathological results, adjunct treatment and complications.
Results: 102 (42.5%) of patients were female, with an average age of 68. Fluoroscopy was the most used technique (99%, n=237). The majority of our procedures were performed on the lumbar spine, representing 47% (n=112) of the total biopsies. In 93% of biopsies (n=223) we attained sufficient samples for histological analysis. Out of the 240 biopsies, 18 (7.5%) had to be repeated, of which 14 (78%) had diagnostic yield. Histologically, 28% (n=67) of samples had no pathological changes and 27% (n=65) yielded the diagnosis of metastatic disease. We performed adjunct treatment with vertebroplasty in 19% (n=46) of cases following biopsy. Only one patient had a clinically significant complication following the procedure.
Conclusion: Percutaneous vertebral biopsy is an important tool in the evaluation of vertebral body lesions, and adjacent paravertebral tissues, and can be performed with minimal morbidity and high diagnostic yield as an outpatient procedure. In line with the literature, most of the biopsy samples in our study were adequate for histopathological analysis, and metastatic lesions were the most common finding
Primaquine-Induced Methemoglobinemia: A Case Report.
No full textMethemoglobinemia is a life-threatening side effect of several drugs, including primaquine. When endogenous counter-oxidative stress mechanisms are overwhelmed, hemoglobin is oxidized to methemoglobin. This "oxygen scavenger" leads to tissue hypoxia, despite adequate alveolar gas exchange. A 47-year-old male under immunosuppression after a reno-pancreatic transplant was admitted to the ICU for respiratory failure following suspected pneumonia (PJP), and empiric treatment was started. After ICU admission, treatment with cotrimoxazole was switched to primaquine due to hematological toxicity. Progressively, the oxygenated hemoglobin fraction declined despite normal PaO levels. Concurrently, methemoglobin levels rose, suggesting primaquine as the culprit. Treatment was switched to pentamidine, and ascorbic acid was administered. Methemoglobin levels subsequently lowered, and oxygen saturation normalized. G6PDH activity levels were within the normal range. Pentamidine was continued for a total of 21 days while the patient slowly recovered. Methemoglobinemia is a rare complication of primaquine treatment with severe consequences. A discrepancy between PaO and the oxygenated hemoglobin fraction should raise awareness of this diagnosis and prompt immediate action
A Composite Endpoint of Liver Surgery (CELS): Development and Validation of a Clinically Relevant Endpoint Requiring a Smaller Sample Size.
No full textBackground: The feasibility of trials in liver surgery using a single-component clinical endpoint is low because single endpoints require large samples due to their low incidence. The current study sought to develop and validate a novel composite endpoint of liver surgery (CELS) to facilitate the generation of more feasible and robust high-level evidence in the field of liver surgery.
Methods: Patients who underwent curative-intent hepatectomy for hepatocellular carcinoma, intrahepatic cholangiocarcinoma, or colorectal liver metastasis were identified using a multi-institutional database. Components of CELS were selected based on perioperative liver surgery-specific complications using univariable logistic regression models. The association of CELS with prolonged length of stay (LOS) and surgery-related death was evaluated and externally validated. Sample sizes were calculated for both individual outcomes and CELS.
Results: Among 1958 patients, 377 (19.3%) met CELS criteria based on postoperative bile leak (n = 221, 11.3%), post-hepatectomy liver failure (n = 71, 3.6%), post-hepatectomy hemorrhage (n = 38, 1.9%), or intraoperative blood loss of 2000 ml or greater (n = 101, 5.2%). CELS demonstrated favorable discriminative accuracy of surgery-related death (analytic cohort: area under the curve [AUC], 0.79 vs external validation cohort: AUC, 0.85). In addition LOS was longer among the patients with a positive CELS (analytic cohort: 14 vs. 9 days [p < 0.001] vs. the validation cohort: 10 vs. 6 days [p < 0.001]). Relative to individual endpoints, CELS allowed a 45.8-91.6% reduction in sample size.
Conclusion: CELS effectively predicted surgery-related death and can be used as a standardized, clinically relevant endpoint in prospective trials, facilitating smaller sample sizes and enhancing feasibility compared with single quality outcome metrics
Autosomal Dominant Polycystic Kidney Disease Inflammation Biomarkers in the Tolvaptan Era.
No full textWith the approval of tolvaptan as the first specific medicine for the treatment of rapidly progressive Autosomal Dominant Polycystic Kidney Disease (ADPKD), biomarker discovery has gained renewed interest as it is widely recognized that these will be crucial in clinical decision-making, serving as either prognostic or predictive tools. Since the marketing authorization was first issued in 2015 for ADPKD, tolvaptan has remained the sole pharmacological compound specifically targeting the disease. For ADPKD patients it is an invaluable medicine for retarding disease progression. Although the field of overall biomarker discovery and validation has been detailed in several publications, the role of inflammation remains largely overlooked in ADPKD. The current work aims to provide the reader with an updated review of inflammation biomarkers research in ADPKD, highlighting the role of urinary MCP-1 (monocyte chemoattractant protein-1) as the most promising tool
Predictive Factors for PCR and Relapse Following Neoadjuvant Dual HER2-Blockade in HER2+ Breast Cancer: an International Cohort Study.
No full textPurpose: Neoadjuvant systemic therapy with dual HER2-blockade, trastuzumab and pertuzumab, combined with chemotherapy has become a standard approach in patients with HER2-positive (HER2+) breast cancer (BC). However, the variability in treatment outcomes, such as pathological complete response (pCR) or relapse rates, underscores the need to identify predictive factors to optimize therapeutic strategies. This study aims to explore the relationship between clinicopathological factors and both pCR and disease-free survival (DFS) in an international cohort of patients with HER2+ BC, contributing to defining personalized treatment strategies.
Methods: An international, multicenter, retrospective cohort study was conducted, including 517 patients with HER2+ BC who received neoadjuvant therapy comprising trastuzumab, pertuzumab, and chemotherapy. Data were collected between January 2016 and December 2023. The relationship between clinicopathological factors and treatment outcomes was analyzed using univariate tests, logistic regression for pCR, and Cox proportional hazards regression for DFS. Kaplan-Meier survival curves with log-rank tests and hazard ratios were used to compare DFS across subgroups.
Results: Multivariable analysis revealed that hormonal receptor (HR) expression and nodal status significantly predicted the achievement of pCR in this cohort. Factors such as age, HR status, tumor grade, Ki-67 index, nodal status, and pathological response were associated with relapse risk.
Conclusion: Our real-world data demonstrates that a comprehensive approach considering pCR, age, HR status, and nodal involvement is essential for personalized treatment strategies. These factors should be taken into account when deciding whether to escalate or de-escalate treatment, contributing to improved HER2+ BC patient outcomes
Yellow Fever in South America - A Plea for Action and Call for Prevention Also in Travelers from SLAMVI, ESGITM, EVASG, ALEIMC, GEPI-SEIMC, SEMEVI, and CMTZMV-ACIN.
No full textAssociation of Noradrenaline Dose With Mortality in Critically Ill Patients: a Systematic Review and Dose-Response Meta-Analysis.
No full textBackground: Noradrenaline is currently the first-line vasopressor in treatment of circulatory failure. Its dose reflects illness severity, and together with dopamine, dobutamine and adrenaline, it is used in the Sequential Organ Failure Assessment (SOFA) score to grade cardiovascular dysfunction. Over the years, noradrenaline use has increased and it has largely replaced dopamine. As part of the SOFA-2 update, we conducted a systematic review and dose-response meta-analysis to assess the association between noradrenaline dose and mortality.
Methods: We searched MEDLINE, Embase, and Web of Science from 1 January 2013 to 30 October 2024 for studies reporting mortality by noradrenaline dose in critically ill adults. The primary outcome was mortality. We generated pooled relative risks (RR) and assessed linear and non-linear dose-response relationships. Mortality was also analysed by SOFA-2 noradrenaline categories. The study followed PRISMA guidelines and was registered with PROSPERO (CRD42024501533).
Results: Nineteen studies, including totally 29,935 patients, were included in the systematic review, and six in the meta-analysis. We observed a consistent increase in mortality: the relative risk escalated by a factor of 1.5 for every 0.1 µg/kg/min increase in peak noradrenaline dose. We did not find inflection points in the dose-mortality curve. In SOFA-2 categories, hospital mortality was 16.5% in the dose category ≤ 0.2 µg/kg/min, 31.9% in the category > 0.2 to 0.4 µg/kg/min, and 40.3% in the category > 0.4 µg/kg/min (p < 0.001).
Conclusions: In critically ill patients, escalating doses of noradrenaline correlate with an exponentially rising relative risk of mortality. This dose-dependent pattern reinforces the role of noradrenaline dose as a marker of cardiovascular failure severity
Mpox in People Living with HIV: Clinical Challenges, Preventive Strategies and Public Health Implications.
No full textMonkeypox virus (MPXV) re-emerged in 2022 with a global outbreak that affected more than 100,000 individuals worldwide. People living with HIV (PLWH) accounted for a substantial proportion of cases, raising concerns about disease presentation, management, and outcomes in this population. Evidence indicates that PLWH with advanced or uncontrolled HIV infection experienced more severe mpox, with higher hospitalization rates, more complications, and longer disease courses. In contrast, individuals with well-controlled HIV generally had outcomes similar to those without HIV. Access to timely diagnosis, consistent antiretroviral therapy, and availability of tecovirimat were key factors influencing prognosis. Reports also suggest bidirectional interactions between mpox and HIV pathogenesis. Immune activation and APOBEC3-related viral evolution have been proposed; however, these mechanisms remain incompletely characterized and warrant further investigation. Moreover, disparities in healthcare access and stigma compound the vulnerability of PLWH, emphasizing the need for integrated approaches
Preventing Laboratory-Acquired Infection: Literature Review and Case-Based Post-Exposure Prophylaxis Proposal.
No full textOccupationally acquired cases of the intracellular parasite have been reported, even though there is uncertainty on which infection prevention measures should be implemented in such event. We report a clinical case of laboratory-acquired toxoplasmosis and propose a protocol for post-exposure prophylaxis, given there are no formal guidelines. In this community case study, we describe the management and prevention protocol following an occupational laboratory exposure by a healthy 30-year-old -seronegative female researcher who suffered an accidental needle puncture with a sample containing a genetically modified hypervirulent strain. Post-exposure prophylaxis (PEP) with trimethoprim-sulfamethoxazole was implemented for 4 weeks, during which seroconversion occurred, without any accompanying symptoms. IgM and IgG positivity was observed 21 and 50 days after exposure, respectively, using a validated commercial electrochemiluminescence immunoassay (ECLIA, Roche). Follow-up was maintained for 1 year, during which the patient remained asymptomatic. This report highlights the importance of special care, surveillance and decision on the need for PEP upon occupational laboratory accidental exposure to . Since there are no guidelines on what the optimal PEP regimen should be, after a literature review, we propose a PEP occupational safety protocol to be implemented in laboratories that handle samples containing , either in clinical or research setting