Tratamento da Co-Infecção do V��rus da Hepatite B e C. Resposta Excedida

Os vírus da hepatite B (VHB) e da hepatite C (VHC) constituem a causa mais frequente de doença hep��tica cr��nica. A partilha de vias de transmiss��o contribui para o risco de coinfec��ão VHB-VHC. Nos doentes co-infectados com o VHB e VHC verifica-se uma progressão mais r��pida para a cirrose hepática e existe um risco aumentado para o carcinoma hepatocelular. A terapêutica da co-infec��ão VHB/VHC é empírica, consistindo na indicada para a infecç��o exclusiva pelo VHC, o qual, na maioria dos casos, �� o v��rus dominante. A utilização do tratamento padrão para a hepatite C, nomeadamente interferão alfa peguilado e ribavirina, não mostra diferenças significativas na resposta virol��gica sustentada ao VHC comparativamente com a dos monoinfectados pelo VHC. �� incerto o benefício da associa��ão de análogos dos nucleós(t)idos. A acção terapêutica pode modificar a interac��ão entre os dois v��rus e, designadamente, exacerbar a doença por reactivação do VHB. Os autores apresentam o caso clínico de uma doente com co-infecção VHB-VHC, sem reconhecimento de vírus dominante, em que a resposta à terap��utica institu��da superou a expectativa da evidência científica dispon��vel.

Acidentes de Serviço em Profissionais de Sa��de: Identificaç��o, Representa��ões e Comportamentos Face à Exposição Microbiológica Acidental

Este estudo de investigaç��o teve subjacente a preocupa��ão com a exposi��ão microbiol��gica acidental nos profissionais de saúde, sabendo que os acidentes de trabalho por exposi��ão microbiol��gica acidental constituem um dos principais riscos de transmissão ocupacional de infecções por contacto com sangue e outros fluidos corporais. Os agentes infecciosos mais frequentemente envolvidos neste tipo de acidente são os v��rus da hepatite B, C e o vírus da imunodefici��ncia humana (VIH). Teve como objectivo identificar e caracterizar os acidentes de trabalho por exposiç��o microbiológica acidental ocorridos nos profissionais de sa��de de um Hospital Central da região de Lisboa durante os anos de 2002 a 2006 e conhecer as Representações e os Comportamentos dos profissionais de saúde aquando da ocorrência de uma exposi��ão microbiol��gica acidental. Tratou-se de um estudo descritivo e exploratório, inserido numa abordagem quantitativa e qualitativa. Os participantes deste estudo foram os profissionais de saúde (m��dicos, enfermeiros e t��cnicos de diagnóstico e terapêutica) que tenham sofrido um acidente de trabalho com exposiç��o microbiológica acidental do ano de 2002 até Julho do ano de 2007, tendo-se constituído uma amostra não probabilística de 20 participantes utilizando a técnica de amostragem por conveniência e que se disponibilizaram a participar no estudo após o Consentimento Informado. Para a realiza��ão do estudo optou-se por recorrer a um conjunto de métodos de colheita de dados, privilegiando a análise documental através do questionário epidemiológico de caracterizaç��o e análise dos acidentes de trabalho e do processo de sa��de individual e da realizaç��o de uma entrevista semi-directiva no âmbito da qual se aplicou um questionário de caracterizaç��o sócio-demográfica, apoio social e actividades de tempos livres, aspectos relacionados com a percepção sobre os riscos a que se encontram expostos no ambiente hospitalar e com o circuito de notifica��ão do acidente de serviço/trabalho. Elaborou ��� se um guião de entrevista semi-directiva de acordo com os objectivos da investigaç��o. Optou-se por uma metodologia quantitativa no que diz respeito �� análise dos acidentes de trabalho que envolveram exposição microbiológica durante o per��odo em estudo e dos dados sócio-demográficos do question��rio aplicado no ��mbito da entrevista, através do programa informático pakage estat��stico ��Statistica/Program for Social Sciences-SPSS��� para Windows (versão 12). Posteriormente optou-se por uma metodologia qualitativa no que concerne ao tratamento dos dados relativos às entrevistas efectuadas, que consistiu na análise de conteúdo tem��tico das entrevistas. A análise dos resultados obtidos revelaram que os acidentes de trabalho ocasionados por material perfuro-cortante entre os profissionais de saúde são frequentes devido ao n��mero elevado de manipulação destes instrumentos, principalmente de agulhas e apresentam prejuízos aos profissionais e �� Instituição. Verifica-se que dos 305 acidentes notificados, a categoria profissional que tem o maior n��mero de notifica��ões é a dos enfermeiros com 142 acidentes no total dos anos representando 46,6%. A picada acidental é o tipo de acidente mais frequente com 205 acidentes o que representa 67% do total. O instrumento que esteve associado directamente com a ocorr��ncia destes acidentes foram as agulhas (41,6%), nomeadamente as agulhas subcutâneas (18,8%), as agulhas intravenosas (9,4%), as agulhas intramusculares (5%), outras agulhas (8,4%). As lâminas de bisturi representam 13,1% dos acidentes ocorridos nos anos de 2002 a 2006. Estes acidentes podem oferecer riscos �� saúde física e mental dos profissionais de saúde, com repercuss��es psicossociais, levando a mudanças nas rela��ões sociais, familiares e de trabalho. Da forma como o indiv��duo viv��ncia e ultrapassa a situa��ão e dos meios encontrados para lidar com o stress provocado pelo acidente, depende o seu bem-estar futuro na profiss��o e na Organização evitando o turnover. Todos os entrevistados manifestam a percepç��o que o maior risco na sua actividade é a relacionada com a exposi��ão a agentes biológicos com ênfase na preocupação em adquirir uma doença infecto-contagiosa. A percep��ão do risco de contamina��ão através do sangue e fluidos corporais est�� relacionada com a ideia do VIH conduzir a uma doença fatal e incurável apesar de existir uma perspectiva de esperan��a e qualidade de vida devido aos avan��os das terapêuticas actualmente. Os sentimentos e as emo��ões ocasionadas ap��s a exposi��ão microbiol��gica e manifestadas pelos participantes são a ansiedade, o medo, a angústia e a preocupação, raramente referem a frustra��ão e a revolta por se sentirem traídos, daí a import��ncia do apoio social que tiveram por parte da saúde ocupacional, da família e amigos, bem como dos colegas de trabalho, fundamental para ultrapassar um episódio cr��tico da sua vida. No entanto a representa��ão que têm das doenças como o VIH/SIDA e das hepatites B e C, como podem ser prevenidas e o nível de controlo que sentem exercer sobre os factores de transmiss��o, reflectem a percepção de que as medidas preventivas podem reduzir o risco de contamina��ão. Uma das conclusões deste estudo prende-se com a necessidade de reformulação do circuito de notificaç��o dos acidentes de trabalho, com o objectivo de diminuir o tempo e os vários constrangimentos durante o percurso. A análise dos dados referentes aos acidentes de serviço por exposi��ão microbiol��gica, os relatórios de análise das causas, a selec��ão e avaliação dos instrumentos aplicados promovem a criação de uma cultura de seguran��a. Como medidas organizacionais, a preven��ão pressupõe o treino e a formação dos profissionais de saúde nos procedimentos de preven��ão da transmiss��o da infec��ão, o incentivo à notifica��ão das exposiç��es e o desenvolvimento de um sistema adequado de monitorizaç��o e gestão das exposi��ões ocupacionais. Sendo que a preven��ão destes acidentes passa essencialmente pela introdução de dispositivos médicos com sistemas de segurança, por práticas de trabalho seguras, e pela forma��ão dos profissionais de saúde.

Tratamento Cir��rgico dos Defeitos do Septo Auriculo-Ventricular. Experiência Uni-Institucional

OBJECTIVES: Atrio-ventricular septal (AVSD) defects include a variable spectrum of congenital malformations with different forms of clinical presentation. We report the surgical results, from a single institution, with this type of congenital cardiac malformation. Patients with hypoplasia of one of the ventricles were excluded from this analysis. POPULATION: Between November of 1998 and June of 2005, 49 patients with AVSD were operated on by the same team and in the same department. The average age was 37.3 months (medium 6 months) and 31 patients were female. In 38 patients (78%) an inter-ventricular communication was present (AVSD-complete) and of these, 26 were of the type A of Rastelli, being 13 of type B or C. The age for defect correction of the complete form was of 5.5 months, palliative surgery was not carried out on any of the patients. Associated lesions included: Down's syndrome in 22 patients (45%), patent arterial duct in 17 patients (35%), severe AV regurgitation in 4 patients (8%), tetralogy of Fallot in two (4%) and sub-aortic stenosis in one patient (2%). Pre-operatively 10 patients presented severe congestive heart failure and two were mechanically ventilated. RESULTS: Complete biventricular correction was carried out in all patients. The average time on bypass (ECC) was 74.1+/-17.5 min. and time of aortic clamping was 52.0+/-12.9 min. The complete defects were corrected by the double patch technique, and in all patients the mitral cleft was closed, except in two with single papillary muscle. There was no intra-operative mortality, but hospital mortality was 8%(4 patients), due to pulmonary hypertension crises, in the first 15 post-operative days. The mean ventilation time was of 36.5+/-93 hours (medium 7 h) and the average ICU stay was of 4.3+/-4.8 days (medium 3 days). The minimum follow-up period is 1 month and the maximum is 84 months (medium 29.5 months), during which time 4 re-operations (8%) took place: two for residual VSD's and two for mitral regurgitation. There was no mortality at re-do surgery. At follow up there was residual mitral regurgitation, mild in 17 patients and moderate in two. Four other patients presented with minor residual defects. CONCLUSIONS: The complete correction of AVSD can be carried out with acceptable results, in a varied spectrum of anatomic forms and of clinical severity. Despite the age of correction, for the complete forms, predominantly below 12 months, pulmonary hypertension was the constant cause for post operative mortality. Earlier timing of surgery and stricter peri-operative control might still improve results.

Results of Surgery for Ebstein Anomaly: a Multicenter Study from the European Congenital Heart Surgeons Association

OBJECTIVE: Since most centers' experience with Ebstein anomaly is limited, we sought to analyze the collective experience of participating institutions of the European Congenital Heart Surgeons Association with surgery for this rare malformation. METHODS: The records of all 150 patients (median age 6.4 years) who underwent surgery for Ebstein anomaly in the 13 participating Association centers between January 1992 and January 2005 were reviewed retrospectively. Patients with congenitally corrected transposition were excluded. RESULTS: Most patients (81%) had Ebstein disease type B or C and significant functional impairment (61% in New York Heart Association class III or IV) and 16% had prior operations. Surgical procedures (n = 179) included valve replacement (n = 60, 33.5%), valve repair (n = 49, 27.3%), 1(1/2) ventricle repair (n = 46, 25.6%), palliative shunt (n = 13, 7.26%), and other complex procedures (n = 11, 6.14%). There were 20 hospital deaths (operative mortality 13.3%) after valve replacement in 5 patients, valve repair in 3, 1(1/2) ventricle repair in 7, palliative procedures in 3, and miscellaneous procedures in 2. Younger age and palliative procedures were univariate risk factors for operative death, but only age was an independent predictor on multivariable analysis. CONCLUSIONS: Most patients coming to surgery presented in childhood and were significantly symptomatic. More than half underwent valve replacement or repair, but a considerable proportion had severe disease necessitating 1(1/2) ventricle repair or palliative procedures. Operative mortality did not differ significantly among repair, replacement, and 1(1/2) ventricle repair but was associated with palliative procedures for severe disease early in life, young age being the only independent predictor of operative death.

Inducibility of Atrial Fibrillation During Electrophysiologic Evaluation is Associated with Increased Dispersion of Atrial Refractoriness

The impact of atrial dispersion of refractoriness (Disp_A) in the inducibility and maintenance of atrial fibrillation (AF) has not been fully resolved. AIM: To study the Disp_A and the vulnerability (A_Vuln) for the induction of self-limited (<60 s) and sustained episodes of AF. METHODS AND RESULTS: Forty-seven patients with paroxysmal AF (PAF): 29 patients without structural heart disease and 18 with hypertensive heart disease. Atrial effective refractory period (ERP) was assessed at five sites--right atrial appendage and low lateral right atrium, high interatrial septum, proximal and distal coronary sinus. We compared three groups: group A - AF not inducible (n=13); group B - AF inducible, self-limited (n=18); group C - AF inducible, sustained (n=16). Age, lone AF, hypertension, left atrial and left ventricular (LV) dimensions, LV systolic function, duration of AF history, atrial flutter/tachycardia, previous antiarrhythmics, and Disp_A were analysed with logistic regression to determine association with A_Vuln for AF inducibility. The ERP at different sites showed no differences among the groups. Group A had a lower Disp_A compared to group B (47+/-20 ms vs 82+/-65 ms; p=0.002), and when compared to group C (47+/-20 ms vs 80+/-55 ms; p=0.008). There was no significant difference in Disp_A between groups B and C. By means of multivariate regression analysis, the only predictor of A_Vuln was Disp_A (p=0.04). Conclusion: In patients with PAF, increased Disp_A represents an electrophysiological marker of A_Vuln. Inducibility of both self-limited and sustained episodes of AF is associated with similar values of Disp_A. These findings suggest that the maintenance of AF is influenced by additional factors.

Pr��-Ecl��mpsia Grave. Compromisso Materno e Fetal

Introdução: A pré-eclâmpsia (PE) é uma síndrome espec��fica da gravidez, associado a morbimortalidade materna e perinatal. Métodos: Estudo retrospectivo descritivo das 134 gestações com PE grave, seguidas na nossa instituiç��o de 2003 a 2005, com o objectivo de avaliar as repercussões maternas e fetais desta patologia. Resultados: Na maioria dos casos houve repercuss��o sistémica, manifestada por sintomatogia (79%) e valores laboratoriais indicativos de gravidade cl��nica. Os dados ecográficos revelaram 22,7% de restriç��o de crescimento intra-uterino e 21,3% de fluxometria doppler patol��gica. Decidiu-se interromper electivamente a gravidez em 95,3% dos casos, 60,5% nas primeiras 48h, sendo a síndrome materno a principal indicaç��o. Verificaram-se 4 abortos e 5 mortes fetais. O parto ocorreu antes das 34 semanas em 63,1% dos casos. Em 82,8% a via de parto foi cesariana. Salientam-se 4 casos de insufici��ncia renal aguda e 2 casos de acidente vascular cerebral hemorrágico com morte materna. 20% dos rec��m-nascidos eram leves para a idade gestacional e verificou-se asfixia neonatal em 7,7%. Conclusão: A pré-eclâmpsia grave continua a ser uma patologia com implicaç��es importantes no desfecho obst��trico.

Pr��-Ecl��mpsia Grave. Gravidade Relacionada com Idade Gestacional

A pré-eclâmpsia (PE) complica 3% das gesta��ões. Nas suas formas mais graves �� responsável por importante morbilidade e mortalidade materna e fetal. Neste estudo de 126 gravidezes com PE grave após as 24 semanas, pretendeu-se avaliar se a precocidade da instala��ão do quadro cl��nico esteve associada a maior morbilidade materna e perinatal. Formaram-se dois grupos de acordo com a idade gestacional no parto - antes e ap��s as 32 semanas (Grupo 1 e 2, respectivamente). Foram avaliadas 49 gravidezes no grupo 1 e 77 gravidezes no grupo 2. Verificou-se maior incidência de sintomatologia clínica, alteraç��es laboratoriais indicadoras de gravidade cl��nica, dados ecográficos sugestivos de compromisso fetal e risco relativo para rec��m-nascido leve para idade gestacional, asfixia neonatal e síndrome de dificuldade respirat��ria no grupo 1. Não se encontraram diferen��as na mortalidade materna. A PE grave com parto antes das 32 semanas de gestaç��o associou-se a maior deteriora��ão da condição clínica materna, restrição de crescimento intra-uterino, fluxometria doppler fetal patol��gica e asfixia neonatal.

Impact of Renal Dysfunction on Liver Transplantation: a Retrospective Study in 708 Orthotopic Liver Transplant Recipients

Renal dysfunction often complicates the course of orthotopic liver transplant recipients and is associated with increased morbid -mortality. The aims of this study were to determine the incidence of chronic renal disease and its impact on patient survival. Clinical data included age, gender and weight,aetiology of hepatic failure, presence of diabetes,hypertension, hepatitis B and C infection, renal dysfunction pretransplant and immunosuppression. Laboratory data included serum creatinine at days 1, 7, 21, month 6, 12 and yearly. The glomerular filtration rate was determined by Cockcroft-Gault equation. We studied retrospectively from September 1992 to March 2007 708 orthotopic liver transplant recipients. Mean age 44��12.6 years, 64% males, 17% diabetic, 18.8% hypertensive, 19.9% with hepatitis C and 3.8% hepatitis B. Renal dysfunction pretransplant was known in 21.6%. Mean follow-up was 3.6 years. Mean transplant survival 75% at 12 months. 154 patients died. Univariate and multivariate analyses were performed and a p<0.05 was considered significant. Acute kidney injury occurred in 33.2%. Chronic kidney disease stage 3 was observed in 34.3%,stage 4 in 6.2% and stage 5 in 5.1%. At the time of this study, 46.4% were on Cyclosporine A, 44.7% on tacrolimus and 8.9% on sirolimus. Using multivariate analysis, renal dysfunction was correlated with renal dysfunction pre -orthotopic liver transplant (p<0.001), acute kidney injury (p<0.001), haemodialysis development (p<0.001), and inversely correlated with the use of mycophenolate mophetil (p<0.001); mortality was positively correlated with renal dysfunction pretransplant (p=0.03),chronic kidney disease stage 4 (p=0.001), chronic kidney disease stage 5 (p<0.001) and inversely correlated with the use of tacrolimus (p=0.006). In conclusion orthotopic liver transplant recipients are disposed to renal complications that have a negative impact on survival of these patients.

Demographic and Clinical Characteristics of Human Immunodeficiency Virus-Infected Patients Receiving Dialysis in Portugal: a Nationwide Multicentre Survey

Background: Data on human immunodeficiency virus (HIV) infected patients receiving dialysis in Portugal is scarce. Methods: This nationwide epidemiological survey retrospectively evaluates HIV-infected patients on chronic dialysis in Portugal between 1997 and 2002. Results: Sixty-six patients were evaluated (mean age: 39.1±1.6 years, 47 men, 35 black African). Sixty-two patients started dialysis and 4 patients who were receiving dialysis had HIV seroconversion. Eighty-five percent of patients were treated in Lisbon. The annual incidence of HIV-infected patients on chronic dialysis was 0.5% in 1997 and 0.9% in 2002. Seventy-eight percent of patients were HIV-1 infected , 13% had hepatitis B and 31% hepatitis C. Sexual contact was the mode of transmission of HIV in 53% of cases. Four patients had biopsy-proved HIV-associated nephropathy. Ninety-five percent of patients were on chronic hemodialysis. Fifty percent of patients had acquired immunodeficiency syndrome. At follow-up, 12 patients died. HIV-infected CKD patient survival after starting dialysis was 80% at 3 years. Conclusion: The incidence of HIV-infected patients on chronic dialysis in Portugal has almost doubled. Widespread use of highly active antiretroviral therapy and the increasing number of black Africans from former overseas Portuguese colonies now living in Portugal are possible reasons for this large increase.

Time to Left Ventricular Reverse Remodeling after Cardiac Resynchronization Therapy: Better Late than Never

INTRODUCTION: Left ventricular reverse remodeling (LVRR), defined as reduction of end-diastolic and end-systolic dimensions and improvement of ejection fraction, is associated with the prognostic implications of cardiac resynchronization therapy (CRT). The time course of LVRR remains poorly characterized. Nevertheless, it has been suggested that it occurs ��6 months after CRT. OBJECTIVE: To characterize the long-term echocardiographic and clinical evolution of patients with LVRR occurring >6 months after CRT and to identify predictors of a delayed LVRR response. METHODS: A total of 127 consecutive patients after successful CRT implantation were divided into three groups according to LVRR response: Group A, 19 patients (15%) with LVRR after >6 months (late LVRR); Group B, 58 patients (46%) with LVRR before 6 months (early LVRR); and Group C, 50 patients (39%) without LVRR during follow-up (no LVRR). RESULTS: The late LVRR group was older, more often had ischemic etiology and fewer patients were in NYHA class ≤II. Overall, group A presented LVRR between group B and C. This was also the case with the percentage of clinical response (68.4% vs. 94.8% vs. 38.3%, respectively, p<0.001), and hospital readmissions due to decompensated heart failure (31.6% vs. 12.1% vs. 57.1%, respectively, p<0.001). Ischemic etiology (OR 0.044; p=0.013) and NYHA functional class I (OR 0.056; p=0.063) were the variables with the highest predictive value for late LVRR. CONCLUSIONS: Late LVRR has better clinical and echocardiographic outcomes than no LVRR, although with a suboptimal response compared to the early LVRR population. Ischemic etiology and NYHA functional class II are predictors of late LVRR.

Urinary Tract Effects of HPSE2 Mutations

Urofacial syndrome (UFS) is an autosomal recessive congenital disease featuring grimacing and incomplete bladder emptying. Mutations of HPSE2, encoding heparanase 2, a heparanase 1 inhibitor, occur in UFS, but knowledge about the HPSE2 mutation spectrum is limited. Here, seven UFS kindreds with HPSE2 mutations are presented, including one with deleted asparagine 254, suggesting a role for this amino acid, which is conserved in vertebrate orthologs. HPSE2 mutations were absent in 23 non-neurogenic neurogenic bladder probands and, of 439 families with nonsyndromic vesicoureteric reflux, only one carried a putative pathogenic HPSE2 variant. Homozygous Hpse2 mutant mouse bladders contained urine more often than did wild-type organs, phenocopying human UFS. Pelvic ganglia neural cell bodies contained heparanase 1, heparanase 2, and leucine-rich repeats and immunoglobulin-like domains-2 (LRIG2), which is mutated in certain UFS families. In conclusion, heparanase 2 is an autonomic neural protein implicated in bladder emptying, but HPSE2 variants are uncommon in urinary diseases resembling UFS.