Análise Descritiva de Parturientes e Recém-Nascidos na Maternidade: Hospital Dona Estefânia entre 2005 e 2008

Entre 2005 e 2008, registaram-se 8413 nascimentos na maternidade do Hospital Dona Estefânia (HDE), aproximadamente 8% do total nacional no mesmo período. A mortalidade fetal (0,20%) atingiu os objectivos do Plano Nacional de Saúde (PNS) para 2010 e está aos melhores niveis da União Europeia. Contudo, a percentagem média de nascimentos prétermo (8,1%) e de cesarianas (31,9%) situam-se ainda acima das metas estabelecidas pelo PNS de, respectivamente, 4,9% e 24,8%. O odds ratio de ocorrência de um índice Apgar baixo aos 5 minutos por cada 100 g de peso a menos à nascença foi de 1,35 e por cada semana a menos de gestação foi de 1,33. As parturientes tiveram em média 30,4 anos de idade, sendo 3,8% adolescentes. Cerca de 22% eram estrangeiras, valor superior à média nacional de 9%. Registou-se variabilidade entre as principais nacionalidades quanto a percentagem de partos pré-termo e de cesarianas, sendo menor nas mães chinesas. Encontrou-se significado estatístico na relação do peso à nascença com a idade de gestação,tipo de gravidez (simples/gemelar), sexo, paridade e idade da mãe. Fixando as covariáveis,uma semana de gestação a mais correspondeu, em média, a mais 176 g; um recém-nascido(RN) gémeo teve, em média, menos 381 g que um não-gémeo e um RN do sexo feminino pesou, em média, menos 48 g que um masculino. Apresentam-se tabelas de percentis de peso por sexo e idade gestacional (36-41 semanas) para os RN do HDE.

Risco Cardiovascular em Doentes com Infecção por Vírus da Imunodeficiência Humana

O aumento do risco cardiovascular é considerada uma importante complicação da infecção Infecção por Vírus da Imunodeficiência Humana (VIH) e da terapêutica anti-retroviral (TARV). À disfunção endotelial característica do processo inflamatório crónico desencadeado pela infecção retroviral, associa-se a disfunção metabólica induzida pela terapêutica, predispondo, em conjunto, para a aterogénese precoce. O reconhecimento deste aumento de risco cardiovascular permite-nos elaborar estratégias de prevenção e optimização terapêutica que passam pelo uso criterioso de hipolipemiantes e modificação da TARV, consoante a avaliação do risco cardiovascular global de cada doente.

Electroencefalograma Interictal. Sensibilidade e Especificidade no Diagnóstico de Epilepsia

O electroencefalograma (EEG) é um método não invasivo, económico e acessível, universalmente utilizado na investigação da epilepsia. Realizámos uma revisão dos principais trabalhos sobre a prevalência de actividade epileptiforme em EEGs de doentes epilépticos e não epilépticos, com o objectivo de tirar conclusões sobre a sensibilidade e especificidade deste exame no diagnóstico de epilepsia. Concluímos que o primeiro EEG tem uma sensibilidade global de 50-55% podendo atingir os 92% com a repetição do exame e recurso a registos de sono e técnicas de activação. A especificidade atinge os 96%, sendo afectada por múltiplos factores.

Actividade Científica e de Investigação num Hospital Central: Análise Retrospectiva de Dez Anos

Introdução: A actividade científica faz parte do desempenho de um clínico da carreira médica hospitalar e os hospitais centrais devem ser a sede privilegiada da investigação clínica hospitalar. O objectivo do presente trabalho é o de avaliar retrospectivamente a actividade científica e de investigação de um hospital central, o Hospital de Dona Estefânia. Métodos: Foram avaliados, de 1993 a 2002 (dez anos), os resumos do Anuário do Hospital de Dona Estefânia, publicação anual que colige os trabalhos realizados pelo seu corpo clínico. O estudo incluiu a análise do tipo de trabalhos, a sua forma de divulgação e a produção científica, por intermédio da taxa de trabalhos por médico e por área de assistência. Resultados: Nos dez anos em análise foram incluídos 1821 trabalhos científicos, sendo 49.7% de investigação; a produção média anual do Hospital foi de 182 trabalhos, 165 comunicações e 24.5 publicações. Em 2002 foram considerados 312 médicos em 24 áreas de assistência, calculando-se uma razão por médico de 0.73 trabalhos científicos, dos quais 0.29 trabalhos de investigação. Discussão: O Anuário constituiu um excelente instrumento para medição directa da actividade científica e de investigação, abrangendo não só trabalhos publicados, mas também os não publicados. Embora não haja dados nacionais similares para comparação, seria de esperar uma maior produção científica do que a que consta no Anuário, tratando-se de um hospital central. Para tal facto podem ter contribuído a sobrecarga assistencial e o valor exíguo atribuído à actividade científica e, particularmente à investigação, na legislação que regula a contratação do corpo clínico nos hospitais portugueses.

Púrpura. Manifestação de Amiloidose Sistémica Primária

Primary Systemic Amyloidosis (AL) is the most frequent form of systemic amyloidosis and its morbilility is associated with immunoglobulin light chains deposition in vital organs. The mucocutaneous manifestations occur in about 30-40% of the cases and are important in diagnostic suspicion, once they appear in early stages of disease. We report a 71-years-old female patient, with disseminated purpura and cutaneous fragility with 6 months of evolution, accompanied by recent complaints of dysphagy. The first laboratory evaluation didn't show any alterations. The histological and immunohistochemical study of subcutaneous abdominal fat and skin biopsy showed lambda type amyloid protein. In the systemic work-up, we highlight a proteinúria > 1g/24h with Bence Jones proteins and the presence of monoclonal immunoglobulin light chain (lambda type) in serum immunoelectrophoresis. With the diagnosis of primary systemic amyloidosis, treatment with prednisolone and melphalan was started.

Cirurgia do Timo num Serviço de Cirurgia Geral

AIMS: Evaluation of thymectomy cases between 1990-2003, in a General Surgery Department. Evaluation of the therapeutic efficacy in Miastenia Gravis patients. PATIENTS AND METHODS: Retrospective study based on evaluation of data from Serviço de Cirurgia, Neurologia and Consult de Neurology processes, between 1990-2003, of 15 patients submitted to total thymectomy. RESULTS: 15 patients, aged 17 to 72, 11 female and 4 male. Miastenia Gravis was the main indication for surgery, for uncontrollable symptoms or suspicion of thymoma. In patients with myasthenia, surgery was accomplish after compensation of symptoms. There weren't post-surgery complications. Pathology were divided in thymic hyperplasia and thymoma. Miastenia patients have there symptoms diminished or stable with reduction or cessation of medical therapy. CONCLUSIONS: Miastenia was the most frequent indication for thymectomy. Surgery was good results, with low morbimortality, as long as the protocols are respected.

Disfagia e Disartria. Forma Invulgar de Apresentação da Miastenia Gravis

Myasthenia Gravis is an autoimmune disorder that generally presents with ocular symptoms, specially diplopia and ptosis. Dysphagia may be a manifestation of the generalised type of the disease, but rarely is its presenting feature. The authors describe a case of Myasthenia Gravis in an old patient complaining of dysphagia and dysarthria. Because Myasthenia Gravis is a potentially serious but treatable disease, we emphasize the need to consider it in the differential diagnosis of dysphagia, namely in the elderly. In fact, the disorder is probably underdiagnosed in this population group, because clinicians tend to accept other more frequent diagnosis to explain these symptoms.

Prevalência de Doença Carotídea na Patologia Cérebro-Vascular Isquémica. O Papel do Eco-Doppler

BACKGROUND: Atherosclerotic carotid disease represents approximately 20% of the causes of ischemic stroke. Effective treatment options, such as endovascular or surgical revascularization procedures, are available. Doppler Ultrasound (DUS) is a non-invasive, inexpensive, routine exam used to evaluate the presence of internal carotid artery (ICA) stenosis. We retrospectively analysed the prevalence of severe atherosclerotic carotid disease in a population of patients with acute ischemic stroke/transitory ischemic attacks (TIAs), and the role of DUS in the detection of ICA stenosis and treatment decisions in these patients. METHODS: A total of 318 patients with ischemic stroke or TIAs was admitted to our stroke unit, and 260 patients were studied by DUS. ICA stenosis was evaluated by DUS according to peak systolic velocity. All DUS exams were performed by the same operator. ICA stenosis was further assessed in 43 patients by digital subtraction angiography (DSA) using NASCET criteria. RESULTS: Of the total 318 patients, 260 (82%) had DUS evaluation. Of the total 520 ICAs studied by DUS, degrees of ICA stenosis were: 0-29% n= 438 (84%); 30-49% n= 8 (2%); 50-69% n= 27 (5%); 70-89% n= 15 (3%); 90-99% n= 20 (4%); oclusão n= 14 (2%). Of the total 260 patients studied, 43 (16.5%) underwent DSA. Sensibility and specificity of DUS in the diagnosis of carotid stenosis over 70% were, respectively, 91% e 84%. Of the total 31 patients with significant carotid stenosis (70-99%), 23 (74%) underwent subsequent carotid revascularization procedures. DISCUSSION: DUS is an important screening test in our stroke unit, justifying its use as a routine exam for all patients with ischemic stroke/TIAs. Moreover, our results show the relevance of severe carotid disease in a population with acute ischemic stroke/TIAs (16.5%), with a total of 9% of patients being submitted to carotid revascularization procedures.

Distrofia Miotónica

Os autores apresentam dois casos de distrofia miotónica em adultos jovens com compromisso cardíaco. Sublinham a raridade desta afecção, o seu envolvimento multissistémico e a dificuldade em estabelecer um diagnóstico definitivo na ausência do quadro clássico da doença.

Pustulose Generalizada Exantemática Aguda Associada ao Diltiazem

Acute generalized exanthematous pustulosis (AGEP) usually presents with the acute appearance of oedematous and erythematous lesions, on which multiple sterile pustules appear, associated with fever. Almost 90% of cases are associated with drugs, with antibiotics (penicillins and macrolides) being the most frequent causative agents. We describe a 36-year-old female patient, which started diltiazem 120mg/day for hypertension. After 6 days of therapy, multiple erythematous and oedematous lesions appeared, with associated multiple small non-follicular pustules. Oral corticosteroids were started, with progressive and complete improvement. Patch-tests were performed, which revealed positivity for diltiazem. Although a rare entity, AGEP must be considered in cases of acute eruptions with disseminated pustules and fever. The use of patch tests in this disease may be useful as positive reactions are frequent.

Leishmaniose Cutânea Causada por Leishmania Infantum Zimodeme Mon-1 em Portugal

Leishmania infantum zimodeme MON-1 foi isolado a partir de uma lesão cutânea da face de uma criança, residente em Lisboa e que nunca saíu do país. Após biópsia excisional não houve recorrência da lesão. Este é o primeiro caso em que este agente é identificado como responsável pela leishmaniose cutãnea em Portugal.

Paralisia Facial: Técnicas de Reconstrução Neuro-Muscular

Several surgical procedures have been proposed through the years for the treatment of facial paralysis. The multiplicity and diversity of techniques portray the complexity and challenge represented by this pathology. Two basic dynamic options are available: -Reconstruction of nerve continuity through direct micro suture, with interposition grafts or nerve transpositions. -Regional muscular transposition, most often using the temporalis. Facial reanimation with the temporalis transfer has withstood the test of time and still is a reference technique. In a few weeks, good results can be obtained with a single and rather simple surgical procedure. Functional free flaps have been used with increasing frequency in the last two decades, most often combining a cross-facial nerve graft followed by a gracilis free flap nine months later. With this method there is a potential for restoration of spontaneous facial mimetic function. Apparently there is a limit in microsurgical technique and expertise beyond which there is no clear improvement in nerve regeneration. Current research is now actively studying and identifying nerve growth factors and pharmacological agents that might have an important and complementary role in the near future.

Expansão Tissular Seriada e Múltipla nas Sequelas de Queimaduras

The authors present the case of a 16 year old female with 3rd degree burn sequelae. They describe the surgical steps during the three years of treatment with serial and multiple tissue expansion. From the 9 tissue expanders used with reference capacities of 3350cc, 10350 were achieved. The conclusions point out the utility of this technique, using re-expansion and supraexpansion as one, should be associated with careful surgical planning and constant rapport with the patient.

Lesões Inalatórias no Doente Queimado

Inhalation injuries are currently the factor most responsible for mortality in thermally injured patients. Inhalation injuries may occur independently, but generally occur together with skin burn. Smoke inhalation affects all levels of the respiratory system and the extent of the inhalation injury depends on the duration, exposure, amount and toxicity of the fume temperature, concentration and solubility of toxic gases, the occurrence of the accident in a closed space and pre-existing diseases. Smoke inhalation also induces changes in the systemic organs with the need for more fluid for resuscitation. Systemic vasoconstriction, with an elevation in systemic vascular resistance, a fall in myocardial contractility and a great increase in lymphatic flow in soft tissue are the most important changes in systemic organs. On admission of a burn patient there is a high suspicion of inhalation injury when there are signs and symptoms such as hoarseness, strides, dyspnea, carbonaceous sputum, anxiety or disorientation, with or without face burns. The patient with these findings has partial airway obstruction and there is substantial risk complete airway obstruction occurring of secondary to the edema. Patients with suspected inhalation injury should be intubated so as to maintain airway patency and avoid a total obstruction. This group of patients frequently develop respiratory failure with the need for mechanical ventilatory support. Nosocomial infections, sepsis and multiple organ system failure may occur. Late complications of inhalation injury are tracheitis, tracheal stenosis or tracheomalacia and chronic airway disease, which is relatively rare. Early diagnosis of inhalation injury and treatment in a Burn Unit by a group of highly motivated clinicians and a good team of nurses is essential in order to decrease the morbidity and mortality related to inhalation injury.