Hospital de Santa Maria
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Safety of low- to medium-dose glucocorticoid treatment in rheumatoid arthritis: myths and reality over the years
Get PDFLow- to medium-dose glucocorticoids have been shown to have not only anti-inflammatory but also disease-modifying properties in rheumatoid arthritis. The evidence for the benefit of its early use in combination with disease-modifying antirheumatic drugs underlines the need for a close evaluation of their risk-benefit ratio. Over time, numerous myths and fears about glucocorticoid toxicity in rheumatoid arthritis have arisen from observational studies, and many concerns have been unduly extrapolated from observations with higher-dose treatment. Furthermore, we cannot exclude the possibility of a powerful effect of bias by indication in these studies. Low- to medium-dose glucocorticoid regimens continued to be evaluated in randomized clinical trials, particularly in early disease, but these studies also have relevant methodological limitations in assessing safety, particularly due to small size and/or short duration. At present, the evidence on which to support clear recommendations about glucocorticoid toxicity remains remarkably weak. A large prospective pragmatic trial dedicated to the toxicity of low-dose glucocorticoids is dearly needed. Meanwhile, adherence to recommendations on standardized methodologies for registration and report of glucocorticoid adverse events is essential for improving our knowledge and competence in the best management of these important medications
Cavilha cefalomedular antirrotativa versus placa e parafuso dinâmico no tratamento de fraturas trocantéricas instáveis da anca.
No full textAs fraturas da extremidade superior do fémur, nomeadamente as fraturas trocantéricas, continuam a representar um sério problema de saúde pública em idosos com osteoporose, presentando um elevado índice de morbilidade e mortalidade, apesar dos avanços registados tanto na sua
prevenção como no seu tratamento. Apenas o tratamento cirúrgico pode permitir uma marcha e uma recuperação funcional precoces, por forma que o doente consiga uma autonomia próxima da anterior à lesão. Para isso, o
ortopedista dispõe atualmente de um leque alargado de implantes cirúrgicos que não tem, todavia, o mesmo valor e indicações, estando na dependência da “personalidade da fratura”.
O objetivo central deste trabalho foi determinar, através de um estudo
comparativo, os resultados radiológicos, clínicos e ortopédicos de uma série de 116 fraturas trocantéricas instáveis do fémur (AO 31 A2), em que se
utilizaram dois tipos diferentes de implantes, a cavilha cefaloendomedular antirrotativa (PFNA®) e placa e parafuso dinâmico (DHS®).
Foram analisados os registos clínicos de 116 doentes com fraturas trocantéricas instáveis, com um tempo de recuo igual ou superior a 12 meses. 66 casos foram tratados com DHS® e os restantes 50 com PFNA®.
Procedeu-se ao registo do tempo operatório, do tempo de internamento, do tipo e qualidade da redução da fratura, do tempo de consolidação da fratura, da necessidade de transfusão sanguínea e das complicações clínicas
e ortopédicas. Os dados obtidos foram sujeitos a um estudo estatístico usando o programa SPSS - Statistical Package for Social Sciences, versão 22.0 para Windows. Considerando a totalidade das fraturas 31 A2, o DHS® apresentou taxas
superiores de reduções das fraturas consideradas insatisfatórias (23,4% e 18,0% para DHS® e PFNA®, respetivamente) e de complicações clínicas (34,8% e 32,0% para DHS® e PFNA®, respetivamente) e ortopédicas
(15,2% e 14,0% para DHS® e PFNA®, respetivamente). O tempo de cirurgia, a necessidade de transfusão sanguínea (53,0% e 68,0% para DHS® e PFNA®, respectivamente) e a proporção de reduções das fraturas
consideradas anatómicas (21,9% e 36,0% para DHS® e PFNA®, respectivamente) foi superior no grupo do PFNA®. O tempo de internamento e as taxas de consolidação foram semelhantes nos dois tipos
de implante. Restringindo a análise apenas para o tipo específico de fraturas 31 A2.2., alguns resultados estatísticos sofreram alterações. As taxas de complicações clínicas (20,7% e 14,3% para DHS® e PFNA®,
respectivamente) e ortopédicas (37,9% e 31,0% para DHS® e PFNA®, respetivamente) acentuaram-se no grupo do DHS®, com taxas de
transfusão (69,0% e 64,3% para DHS® e PFNA®,respetivamente) semelhantes em ambos os grupos.
No tratamento das fraturas trocantéricas instáveis da anca (31 A2.2) o PFNA® mostrou ser superior ao DHS®, em termos da qualidade de redução da fratura e nas taxas de complicações clínicas e ortopédicas. Nas estantes variáveis, o PFNA® não mostrou resultados inferiores
Expressão fenotípica da miocardiopatia hipertrófica e realce tardio na ressonância magnética cardíaca
No full textINTRODUCTION AND AIM:
The prognostic value of late gadolinium enhancement (LGE) for risk stratification of hypertrophic cardiomyopathy (HCM) patients is the subject of disagreement. We set out to examine the association between clinical and morphological variables, risk factors for sudden cardiac death and LGE in HCM patients.
METHODS:
From a population of 78 patients with HCM, we studied 53 who underwent cardiac magnetic resonance. They were divided into two groups according to the presence or absence of LGE. Ventricular arrhythmias and morbidity and mortality during follow-up were analyzed.
RESULTS:
Patients with LGE were younger at the time of diagnosis (p=0.046) and more often had a family history of sudden death (p=0.008) and known coronary artery disease (p=0.086). On echocardiography they had greater maximum wall thickness (p=0.007) and left atrial area (p=0.037) and volume (p=0.035), and more often presented a restrictive pattern of diastolic dysfunction (p=0.011) with a higher E/É ratio (p=0.003) and left ventricular systolic dysfunction (p=0.038). Cardiac magnetic resonance supported the association between LGE and previous echocardiographic findings: greater left atrial area (p=0.029) and maximum wall thickness (p<0.001) and lower left ventricular ejection fraction (p=0.056). Patients with LGE more often had an implantable cardioverter-defibrillator (ICD) (p=0.015). At follow-up, no differences were found in the frequency of ventricular arrhythmias, appropriate ICD therapies or mortality.
CONCLUSIONS:
The presence of LGE emerges as a risk marker, associated with the classical predictors of sudden cardiac death in this population. However, larger studies are required to confirm its independent association with clinical events
IRIS: A new tool for suicide risk assessment
No full textNa introdução os autores procedem a uma revisão histórica e conceptual dos
instrumentos psicométricos que têm como objectivo a avaliação do risco de suicídio em
indivíduos que apenas verbalizam ideação suicida. Nas secções seguintes é apresentado
todo o processo de desenvolvimento do IRIS (Índice de Risco de Suicídio) - um novo
índice com o mesmo objectivo de avaliação mas construído utilizando metodologias
que proporcionam avanços qualitativos em relação aos índices existentes, bem como
uma melhor adequação a contingências e características da realidade portuguesa.
The introduction contains a historical and conceptual review of psychometric
tools that aim at assessing the risk of suicide in individuals presenting suicidal ideation.
In the following sections the whole process of development of IRIS (“Índice de Risco
de Suicídio” – Suicide Risk Index) is presented - a new tool with the same objective
but built using methods that provide qualitative advances over existing indexes, while
better accounting for the contingencies and characteristics of the Portuguese reality
First report of chronic hepatitis E in renal transplant recipients in Portugal
Get PDFHepatitis E virus (HEV) infection can be responsible for chronic hepatitis in immunocompromised patients, and can rapidly evolve into fibrosis and/or hepatic cirrhosis. We present two cases of chronic hepatitis E, emphasizing the need to be aware of this entity as a growing etiology of hepatitis in transplant and immunocompromised patients
Aging is Associated with Impaired Renal Function, INF-gamma Induced Inflammation and with Alterations in Iron Regulatory Proteins Gene Expression
No full textOur aim was to contribute to a better understanding of the pathophysiology of anemia in elderly, by studying how aging affects renal function, iron metabolism, erythropoiesis and the inflammatory response, using an experimental animal model. The study was performed in male Wistar, a group of young rats with 2 months age and an old one with 18 months age. Old rats presented a significant higher urea, creatinine, interferon (INF)-gamma, ferritin and soluble transferrin receptor serum levels, as well as increased counts of reticulocytes and RDW. In addition, these rats showed significant lower erythropoietin (EPO) and iron serum levels. Concerning gene expression of iron regulatory proteins, old rats presented significantly higher mRNA levels of hepcidin (Hamp), transferrin (TF), transferrin receptor 2 (TfR2) and hemojuvelin (HJV); divalent metal transporter 1 (DMT1) mRNA levels were significantly higher in duodenal tissue; EPO gene expression was significantly higher in liver and lower in kidney, and the expression of the EPOR was significantly higher in both liver and kidney. Our results showed that aging is associated with impaired renal function, which could be in turn related with the inflammatory process and with a decline in EPO renal production. Moreover, we also propose that aging may be associated with INF-gamma-induced inflammation and with alterations upon iron regulatory proteins gene expression
Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram
Get PDFINTRODUCTION:
Achievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR).
METHODS:
This single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m(2).
RESULTS:
The incidence of ARC was 36% (n = 29/79) and 40% (10/25) in group 1 (n = 79) and 2 (n = 25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r(2) = 0.66; P < 0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n = 21/25) versus 51% (n = 40/79) - P < 0.005.
CONCLUSIONS:
This new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment
Postanesthetic Severe Oral Angioedema in Patient's Taking Angiotensin-Converting Enzyme Inhibitor
No full textAngiotensin-converting enzyme (ACE) inhibitors are the leading cause of a drug-induced angioedema. This occurrence is frequently underdiagnosed, but its relapse can be life-threatening. The authors' intention in reporting this clinical case is to sound a warning about reviewing attitudes and surveillance to try to improve patient perioperative safety