Hospital de Santa Maria
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Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations
Get PDFDespite the increasingly high rate of implantation of cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We comprehensively reviewed the state-of-the-art data regarding the applicability, safety, clinical- and cost-effectiveness of the ICD in elderly patients, and analysed which patients in this age stratum are more likely to get a survival benefit from this therapy. Although peri-procedural risk may be slightly higher in the elderly, this procedure is still relatively safe in this age group. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be largely attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in highly selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD intervention among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. Biological age rather than chronological age per se should be the decisive factor in making a decision on ICD selection for survival benefit
Heart Transplantation in Patients Older than 65 Years: Worthwhile or Wastage of Organs?
Get PDFBACKGROUND:
Patients older than 65 years have traditionally not been considered candidates for heart transplantation. However, recent studies have shown similar survival. We evaluated immediate and medium-term results in patients older than 65 years compared with younger patients.
METHODS:
From November 2003 to December 2013, 258 patients underwent transplantation. Children and patients with other organ transplantations were excluded from this study. Recipients were divided into two groups: 45 patients (18%) aged 65 years and older (Group A) and 203 patients (81%) younger than 65 years (Group B).
RESULTS:
Patients differed in age (67.0 ± 2.2 vs. 51.5 ± 9.7 years), but gender (male 77.8 vs. 77.3%; p = 0.949) was similar. Patients in Group A had more cardiovascular risk factors and ischemic cardiomyopathy (60 vs. 33.5%; p < 0.001). Donors to Group A were older (38.5 ± 11.3 vs. 34.0 ± 11.0 years; p = 0.014). Hospital mortality was 0 vs. 5.9% (p = 0.095) and 1- and 5-year survival were 88.8 ± 4.7 versus 86.8 ± 2.4% and 81.5 ± 5.9 versus 77.2 ± 3.2%, respectively. Mean follow-up was 3.8 ± 2.7 versus 4.5 ± 3.1 years. Incidence of cellular/humoral rejection was similar, but incidence of cardiac allograft vasculopathy was higher (15.6 vs. 7.4%; p = 0.081). Incidence of diabetes de novo was similar (p = 0.632), but older patients had more serious infections in the 1st year (p = 0.018).
CONCLUSION:
Heart transplantation in selected older patients can be performed with survival similar to younger patients, hence should not be restricted arbitrarily. Incidence of infections, graft vascular disease, and malignancies can be reduced with a more personalized approach to immunosuppression. Allocation of donors to these patients does not appear to reduce the possibility of transplanting younger patients
A technique to remove a stable all-polyethylene cemented acetabular liner in revision hip arthroplasty: A case report
No full textINTRODUCTION: The removal of a well-fixed acetabular component in a total hip arthroplasty can cause
bone fractures, excessive bleeding, as well as extended bone loss. The reimplantation of a new acetabular
component may be compromised.
PRESENTATION OF CASE:We report a technique using 2 cork-screws for removal a stable cemented acetabular
component for the treatment of a recurrent dislocation of a cemented total hip arthroplasty, due to
acetabular malposition.
DISCUSSION: A diversity of approaches and tools has been used for extraction ofthe acetabular prosthesis.
Using 2 cork-screws it is possible to create fissures and fractures into the cement mantle, and greater
manual control is obtained facilitating the manipulation of the acetabular component in different directions.
The cup-cemented bond can be disrupted, the host bone is preserved and the risks of complications
are minimized.
CONCLUSION: This technique is simple, available in any environment, reproducible, non-costly, nontiming
consuming and safe
Uso de cúpula acetabular tripolar constritiva no tratamento de fratura do colo do fémur em doente com elevado risco de luxação protética.
Get PDFIntrodução
A artroplastia da anca é o procedimento mais usado para o tratamento das fraturas traumáticas do colo do fémur com desvio. Todavia, nos idosos, nos doentes com alterações cognitivas/demência, com patologia neuromuscular, com atrofia muscular, entre outros, o risco de luxação protética é uma séria complicação, que importa prevenir. Para além de outros fatores, a via de abordagem e o tipo de artroplastia podem contribuir para minimizar o risco de luxação protética. Neste sentido, as cúpulas acetabulares tripolares constritivas, bem como outros tipos de reconstruções acetabulares, podem encontrar indicação. O objetivo deste poster é mostrar o tipo de endoprótese implantada para o tratamento de uma fratura do colo do fémur, num doente com elevado risco de luxação protética pós-operatória.
Material e Métodos
Trata-se de um doente do sexo masculino, com 67 anos de idade, que sofreu uma fratura do colo do fémur esquerdo, tipo III segundo a classificação de Gardner. O exame radiográfico mostrou, também, a existência de obliquidade pélvica, associada a displasia acetabular e coxartrose ipsilateral grau II/III segundo a classificação de Tönnis. Clinicamente, o doente apresentava rigidez do joelho esquerdo com deficit de extensão de 35º e pé esquerdo em equino fixo, sequelas de provável paralisia infantil; o seu perfil cognitivo era baixo, compatível com deficiência mental desde a infância, limitando a sua interacção sociofamiliar. Devido ao status osteoarticular e à atrofia muscular da anca e coxa, implantou-se uma prótese total da anca constritiva, por via posterior. A reconstrução acetabular consistiu na aplicação de um anel metálico de suporte acetabular aparafusado e cimentação de uma cúpula tripolar constritiva. No fémur, cimentou-se uma haste autobloqueante com um colo médio.
Resultados
Não foram registadas complicações no período pós-operatório. O doente mantém seguimento regular em consulta, apresentando-se assintomático, não tendo ocorrido luxação da prótese total da anca.
Discussão
Embora reconhecendo as complicações ligadas a este tipo de implantes, incluindo conflitos, dissociações e luxações intraprotéticas, as cúpulas tripolares constritivas e não constritivas (dupla mobilidade) têm sido usadas na cirurgia de revisão de instabilidades recorrentes de artroplastias da anca, em casos selecionados. Tanto quanto sabemos, não existem trabalhos publicados que suportem o uso de anéis de reconstrução acetabular e de cúpulas tripolares constritivas no tratamento de fraturas do colo do fémur com desvio, no contexto de uma artroplastia primária em anca displásica. Temos vindo a indicar este tipo de cúpulas em traumatologia, em doentes com grave demência, debilitados, com insuficiência muscular e, também, em casos extremos ASA III-IV, como alternativa à ressecção artroplástica, com incontornáveis benefícios para o doente.
Conclusão
A cúpula tripolar constritiva pode ser uma das soluções para o tratamento de fraturas do colo do fémur em doentes com elevado risco de luxação protética, relegando para segundo plano a questão da via de abordagem
Anti-Signal Recognition Particle Myopathy in a Geriatric Patient
Get PDFAnti-signal recognition particle (SRP) myopathy is a rare idiopathic inflammatory myositis that usually affects middle-age women, and is characterized by rapidly progressive proximal and symmetrical muscle weakness, elevated creatine kinase levels, severe necrotizing immune-mediated myopathy, presence of anti-SRP autoantibodies and poor response to steroid therapy. We report a geriatric case of a previously independent patient, presenting with slow onset of proximal paraparesis, myalgia and severe gait impairment. The patient was treated with steroid and azathioprine, with laboratory and pain response but modest muscle strength improvement. The clinical presentation of this unusual patient was atypical, which hampered the correct diagnosis
Efficacy and safety of percutaneous radiofrequency thermal ablation in the treatment of lung cancer lesions.
No full textINTRODUCTION:
In this study, we reviewed a clinical series composed by all malignant lung lesions submitted to computed tomography-guided percutaneous thermal radiofrequency ablation, in our hospital, a rather recent technique that has been gaining scientific recognition.
MATERIAL AND METHODS:
For data purposes, all radiofrequency ablation and corresponding clinical records were retrospectively analysed. A computed tomography scan was performed before and after each procedure to evaluate the tumour's features, and at a second step to assess results and complications. The frequency of local recurrence and disease progression were determined based on imaging follow-up. Kaplan-Meier analysis was used to estimate survival. Univariate analysis recognized clinical and pathological factors affecting survival. These were also tested by multivariate analysis.
RESULTS:
A total of 28 malignant lung lesions, 20 primary and 8 metastatic, from 28 patients (78.6% male; mean age 62 ± 17 years old), were submitted to computed tomography-guided radiofrequency ablation between January 2004 and July 2010. Total necrosis was achieved in 74.1% of the lesions. Immediate radiofrequency ablation-related complications were observed in half of the procedures. Among major complications, death occurred in one patient only. Median overall survival was 43.0 months for a mean 2-years follow-up.Median progression-free survival was 31.6 months. Lesion's size smaller than 35 mm, stage III disease by the TNM classification and previous treatment attempts were significantly associated with better outcomes. Disease-related mortality was 46.4%.
DISCUSSION:
This procedure proved to be efficient to treat lung cancerous lesions, with a low-rate of major complications.
CONCLUSIONS:
Computed tomography-guided percutaneous radiofrequency ablation is a minimally invasive procedure that appears to be valuable in the treatment of lung cancer lesions
Transarterial embolisation of a large focal nodular hyperplasia, using microspheres, in a paediatric patient
No full textBenign liver tumours are uncommon in children, haemangiomas being the most frequent. Focal nodular hyperplasia (FNH) represents about 2% of paediatric liver tumours. In children, as in adults, a conservative approach is generally recommended. However, large lesions (greater than 5 cm) are more frequent in the paediatric age group, and in these cases, as well as in growing lesions, surgical removal may be advised. Transarterial embolisation (TAE) has been a successful alternative option described in older patients, especially in cases where surgical removal is not possible. This minimally invasive procedure may also become an option in the paediatric group. The authors report the case of a boy with a large FNH treated with TAE using microspheres
Early magnetic resonance imaging control after temporomandibular joint arthrocentesis
Get PDFTemporomandibular joint (TMJ) lysis and lavage arthrocentesis with viscosupplementation are an effective treatment for acute disc displacement (DD) without reduction. Clinical success seems to be related to multiple factors despite the lack of understanding of its mechanisms. The authors present a case report of 17-year-old women with acute open mouth limitation (12 mm), right TMJ pain-8/10 visual analog scale, right deviation when opening her mouth. The clinical and magnetic resonance imaging (MRI) diagnosis was acute DD without reduction of right TMJ. Right TMJ arthrocentesis was purposed to the patient with lysis, lavage, and viscosupplementation of the upper joint space. After 5 days, a new MRI was performed to confirm upper joint space distension and disc position. Clinical improvement was obtained 5 days and 1 month after arthrocentesis. Upper joint space increased 6 mm and the disc remained displaced. We report the first early TMJ MRI image postoperative, with measurable upper joint space.info:eu-repo/semantics/publishedVersio
Circumferential vascular strain rate to estimate vascular load in aortic stenosis: a speckle tracking echocardiography study
Get PDFEvaluation of vascular mechanics through two-dimensional speckle-tracking (2D-ST) echocardiography is a feasible and accurate approach for assessing vascular stiffening. Degenerative aortic stenosis (AS) is currently considered a systemic vascular disease where rigidity of arterial walls increases. To assess the circumferential ascending aorta strain rate (CAASR) in thoracic aortas of patients with AS, applying 2D-ST technology. 45 patients with indexed aortic valve areas (iAVA) ≤0.85 cm(2)/m(2) were studied. Global CAASR served to assess vascular deformation. Clinical, echocardiographic, and non-invasive hemodynamic data were collected. A follow up (955 days) was also performed. Average age of the cohort was 76. ± 10.3 years, with gender balance. Mean iAVA was 0.43 ± 0.15 cm(2)/m(2). Waveforms adequate for determining CAASR were found in 246 (91 %) of the 270 aortic segments evaluated, for a mean global CAASR of 0.74 ± 0.26 s(-1). Both intra- and inter-observer variability of global CAASR were deemed appropriate. CAASR correlated significantly with age (r = -0.49, p < 0.01), the stiffness index (r = -0.59, p < 0.01), systemic arterial compliance and total vascular resistance. There was a significant positive correlation between CAASR, body surface area (BSA), iAVA, and a negative relationship with valvulo-arterial impedance and E/e' ratio (r = -0.37, p = 0.01). The stiffness index was (β = -0.41, p < 0.01) independently associated with CAASR, in a model adjusted for age, BSA, iAVA and E/e'. Patients with a baseline CAASR ≤0.66 s(-1) had a worse long-term outcome (survival 52.4 vs. 83.3 %, Log Rank p = 0.04). CAASR is a promising echocardiographic tool for studying the vascular loading component of patients with AS.info:eu-repo/semantics/publishedVersio