The Self-Inflicted Burns - Typology and its Prognostic Relevance in a 14-Year Review of Self-Inflicted Burns in a Tertiary Referral Centre

Self-inflicted burns (SIB) are responsible for 2-6% of admissions to Burn Units in Europe and North America, and for as many as 25% of admissions in developing nations. Recently, a promising new tool was proposed to stratify SIB patients in the following subgroups: "typical", "delirious", and "reactive". However, as far as the authors know, the clinical usefulness of this instrument has not yet been validated by others. We retrospectively reviewed the clinical records of 56 patients admitted to our Burn Unit with the diagnosis of SIB injury in the past 14 years. The following parameters were evaluated: demographic features; psychiatric illness; substance abuse; mechanism of injury; burn depth, total body surface area (TBSA) involved, Abbreviated Burn Severity Index (ABSI); length of hospital stay, and mortality. All patients were followed up by a psychologist and a psychiatrist, and were classified according to the SIB-Typology Tool, into three classes: "typical", "delirious" and "reactive". There was a slight predominance of the "typical" type (44.6%), followed by the "delirious" type (30.4%), and, finally the "reactive" type (25.0%). Mortality was significantly higher in the "typical" subgroup. In conclusion, the SIB-Typology Tool appears to be a valuable instrument in the clinical management of SIB patients.

Octreótido - Uma Terapêutica Opcional para Quilotórax Pós-Cirúrgico em Crianças com Cardiopatia Congénita

INTRODUCTION: Chylothorax is a rare but serious postoperative condition in children with congenital heart disease. Conventional medical treatment consists of specific long-term dietary modification, and surgical reintervention, such as lymphatic duct ligation, may be indicated in refractory cases. In recent years, an additional conservative treatment, octreotide, a synthetic analog of somatostatin, has been used in management of congenital and postoperative chylothorax. METHODS: The objective of this work was to analyze the efficacy and safety of this treatment for chylothorax after congenital heart surgery. We reviewed the records of sixteen patients with chylothorax after surgery for congenital heart disease between January 1999 and December 2007, and collected the following data: demographic information; type of surgical procedure; onset, duration and management of chylothorax and treatment; and duration of hospital stay. To analyze efficacy we compared these parameters in children receiving conventional treatment only with those receiving octreotide. To analyze safety we compared the adverse effects of both treatments. Octreotide was administered at a dose of 4 to 10 microg/kg/hour, with monitoring of side effects. RESULTS: The incidence of chylothorax in our population was 1.6%. It occurred more often after Glenn and Fontan procedures (8 patients). Octreotide was begun three days after diagnosis of chylothorax and continued for a median of seventeen days (ranging from 4 to 26 days), until complete resolution. Side effects were frequent (in 3 of the 8 patients) but of no clinical relevance. All patients responded to the therapy and there was no indication for further surgical intervention. DISCUSSION AND CONCLUSIONS: Octreotide is safe and effective in the treatment of postoperative chylothorax in children with congenital heart disease. It is a useful adjunctive therapy to the conventional treatment of this complication.

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.

Avaliação da Analgesia Após Cesariana

OBJECTIVE: The aim of this study was to evaluate the efficacy of post-caesarean analgesia comparing three techniques most frequently used. PATIENTS AND METHODS: For three months all pregnant women submitted to elective or urgent caesarean section, under general or regional anaesthesia, were evaluate with a total of 129 parturient. These parturient were divided into three groups with different techniques of postoperative analgesia: Group 1 (n = 26) received intravenous pethidine and paracetamol per os, group 2 (n = 58) received epidural morphine and group 3 (n = 45) epidural morphine and intravenous propacetamol. Pain was assessed at rest and during mobilisation using a scale of 0-without pain, 1-mild pain, 2-moderate pain and 3-severe pain. Overall satisfaction was assessed with a verbal qualitative scale of very good, good, sufficient and bad. Side effects were analysed. RESULTS: The records of pain at rest and during mobilisation were significantly lower with epidural analgesia compared with intravenous pethidine. There were no significant differences between groups 2 and 3. Similar results were observed in the degree of satisfaction. For 50% of parturient of epidural analgesia (groups 2 and 3) and only 4% of intravenous pethidine (group 1) the analgesic technique was very good. Propacetamol and epidural morphine (group 3) had better pain scores (very good and good) when compared with morphine alone (group 2) but there were no significant differences. Epidural morphine was associated with more pruritus. CONCLUSION: From this study we are able to conclude that epidural morphine offers a good quality of analgesia with better satisfaction and minimal side effects.

Cirurgia Obliterativa do Prolapso dos Órgãos Pélvicos - uma Opção ainda Válida?

Objective: To investigate the results of vaginal obliterate surgery in elderly women with pelvic organ prolapse. Design: observational retrospective study. Material and Methods: a total of 69 women with the diagnosis of pelvic prolapse were submitted to obliterative surgery in the urogynecology unit of a tertiary care hospital centre over the course of 8 years (2001 to 2008). The following data were collected from their clinical records: age, number of vaginal births, body mass index (BMI), hormone therapy, other existing diseases, type of prolapse and stage, anaesthetic risk score, duration of surgery, length of hospital stay, and short-term complications. Results: Of the 69 women studied, 31 were submitted to colpocleisis and the remaining 38 were managed by the LeFort technique. Mean age was 74.8 years with a standard deviation (sd) of 7.14 years. Average BMI was 26.2 (sd =3.76). Vaginal births were recorded in all patients. Only three patients were taking hormone therapy at the time of surgery. Sixty-three women were classified as having and anesthetic risk of II or III and 55 underwent local-regional anesthesia. Complications were reported in five cases, four of which in the first days after surgery. Nearly all were mild and resolved within the first 6 weeks. Conclusion: Complication rates appear to be low after obliterative surgery for pelvic organ prolapse in elderly women.

Long-Term Evaluation of Recurrence after Photodynamic Therapy with Topical Methyl Aminolevulinate for Non-Melanoma Skin Cancer: a Hospital-Based Study

Introduction & Objectives: Several factors may influence the decision to pursue nonsurgical modalities for the treatment of non-melanoma skin cancer. Topical photodynamic therapy (PDT) is a non-invasive alternative treatment reported to have a high efficacy when using standardized protocols in Bowen’s disease (BD), superficial basal cell carcinoma (BCC) and in thin nodular BCC. However, long-term recurrence studies are lacking. The aim of this study was to evaluate the long-term efficacy of PDT with topical methylaminolevulinate (MAL) for the treatment of BD and BCC in a dermato-oncology department. Materials & Methods: All patients with the diagnosis of BD or BCC, treated with MAL-PDT from the years 2004 to 2008, were enrolled. Treatment protocol included two MAL-PDT sessions one week apart repeated at three months when incomplete response, using a red light dose of 37-40 J/cm2 and an exposure time of 8’20’’. Clinical records were retrospectively reviewed, and data regarding age, sex, tumour location, size, treatment outcomes and recurrence were registered. Descriptive analysis was performed using chi square tests, followed by survival analysis with the Kaplan-Meier and Cox regression models. Results: Sixty-eight patients (median age 71.0 years, P25;P75=30;92) with a total of 78 tumours (31 BD, 45 superficial BCC, 2 nodular BCC) and a median tumour size of 5 cm2 were treated. Overall, the median follow-up period was 43.5 months (P25;P75=0;100), and a total recurrence rate of 33.8% was observed (24.4 % for BCC vs. 45.2% for BD). Estimated recurrence rates for BCC and BD were 5.0% vs. 7.4% at 6 months, 23.4% vs. 27.9% at 12 months, and 30.0% vs. 72.4% at 60 months. Both age and diagnosis were independent prognostic factors for recurrence, with significantly higher estimated recurrence rates in patients with BD (p=0.0036) or younger than 58 years old (p=0.039). The risk of recurrence (hazard ratio) was 2.4 times higher in patients with BD compared to superficial BCC (95% CI:1.1-5.3; p=0.033), and 2.8 times higher in patients younger than 58 years old (95% CI:1.2-6.5; p=0.02). Conclusions: In the studied population, estimated recurrence rates are higher than those expected from available literature, possibly due to a longer follow-up period. To the authors’ knowledge there is only one other study with a similar follow-up period, regarding BCC solely. BD, as an in situ squamous cell carcinoma, has a higher tendency to recur than superficial BCC. Despite greater cosmesis, PDT might no be the best treatment option for young patients considering their higher risk of recurrence.

Playing With Fire: Decrease in Safe-Sex Attitudes Among Men Who Have Sex With Men in a Portuguese STI Clinic

Background: Sexually transmitted infections (STIs) present a major public health concern and a global cause of illness in both industrialized and developing countries. Portugal is no exception, with an increasing incidence of STIs, and one of the highest prevalences of HIV in Europe. Reduced risk perceptions among men who have sex with men (MSM) and a consequent high-risk sexual behaviour have been increasingly reported throughout the world. Objectives: To characterize the population of MSM attending a STI clinic in Lisbon, and to assess practice of condom use among these patients. Methods: Records of all MSM patients who attended the STI clinic from 2008 to 2011 were reviewed to study demographic characteristics, sexual behaviours, and leading diagnoses in this population. Results: Of a total of 389 patients, 108 MSM were identified (27.8%), mostly Portuguese men with high school or above education, aged 17 to 61 years (medium age of 32.4 years). More than half of the patients (52.8%) reported more than one sexual partner in the past 6 months (19.4% more than 5 partners), and only a third consistently used condom. A history of sex with sex workers was mentioned in 9.2%. The most prevalent diagnoses were syphilis (45.6%) and condylomata acuminata (38.9%). The prevalence of HIV infection in this subgroup of patients was significantly higher than in the rest of the population (47.2% vs. 14.9%). Inconsistent condom use increased over the years (36.4% in 2008, 66.7% in 2011), and these patients revealed a greater number of sexual partners than condom users (60.4% vs. 50%). However, 38.9% of condom users presented with early syphilis, suggesting inadequate use of this barrier method. Among HIV patients, almost half of them (49%) had sex with more than one partner in the previous six months, and 47.1% did not use the condom during all sexual practices. Of these, 45.8% were not on antiretroviral therapy. Conclusions: High-risk sexual behaviours (inconsistent use of condom and multiple partners) are increasingly prevalent in this MSM subpopulation, despite previous educational programmes. The high incidence of risk behaviours among HIV infected patients is particularly worrisome, and must be addressed with innovative interventions and population-based prevention strategies.

Multiple Sclerosis and Motherhood Choice: an Observational Study in Portuguese Women Patients

INTRODUCTION. Multiple sclerosis (MS) is a disabling disease occurring mainly in women of childbearing age. MS may interfere with family planning and motherhood decision. AIM. To study the influence of MS diagnosis and course of the disease on motherhood decision. PATIENTS AND METHODS. The cohort of 35 to 45-year-old female patients diagnosed with MS for at least ten years was selected from six Portuguese MS centers. A structured questionnaire was applied to all patients in consecutive consultation days. Clinical records were reviewed to characterize and collect information about the disease and pregnancies. RESULTS. One hundred women were included; mean age at MS diagnosis was 26.3 ± 5.0 years; 90% of the participants presented with a relapsing-remitting MS; 57% had no pregnancies after the diagnosis. MS type and number of relapses were not significantly different between women with or without pregnancies after the diagnosis (p = 0.39 and p = 0.50, respectively). Seventy-seven percent of the patients did not have the intended number of pregnancies. Main reasons given were fear of future disability and the possibility of having relapses. Forty-three women considered that pregnancy might worsen MS. CONCLUSION. In our population, motherhood choice was unrelated to the MS type and the number of relapses. However, a relevant number of women had fewer pregnancies than those intended before MS diagnosis and believed that pregnancy could worsen the disease. An effort to better inform the patients should be made to minimize the impact of MS diagnosis on motherhood decision.