Cirurgia de Reparação Mitral em Crianças com Valvulopatia Adquirida

BACKGROUND: Valve surgery in children is aimed at restoring correct hemodynamics with few reoperations and limited resort to prostheses, which would imply early deterioration or definitive hypocoagulation. OBJECTIVES: Report a series of paediatric pts with acquired mitral valve disease, mostly due to rheumatic disease, in whom it was possible, for the great majority, to repair the damaged valve. DEMOGRAPHICS: Fifty children with predominant mitral valve disease, 47 rheumatic (94%) and 3 after endocarditis were consequently operated by the same surgical team over the last five years. Ages were 12.5+/-3.1 yrs and weights 33.2+/-8.4 Kg, 30 pts presented with predominant mitral regurgitation and 20 pts had significant stenosis. In 8 pts there also moderate to severe aortic regurgitation and in 2 pts severe tricuspid regurgitation was present. Patients were not operated during the acute phase of the disease. Five pts were reoperations and from those, all but one received mechanical prosthesis. RESULTS: In all operations the intention was to repair the mitral valve. In 46 pts complex mitral valvuloplasties were performed extended comissurotomies, shortening of chordae, chordal replacement with PTFE, and reconstruction of valve leaflefts by direct patching or pericardial extension of the retracted posterior leaflet (78.2% cases), plus reshaping of the annulus by using a fixed prosthetic CE ring (sizes 26 to 32) in every case. Ring sizes correlated poorly with body weights, but correlation was close and positive for the use of pericardial advancement of the posterior leaflet (p<0.01). There was no operative mortality, but one pt died early from sepsis and there was no late mortality. Maximum follow up extends now to 50 months (median 28 months) and functional evaluation, at latest follow up, as assessed by Doppler Echocardiography, showed residual mitral regurgitation, mild-moderate in 4 pts and LA-LV gradients mild in 5 and moderate in 2 pts. NYHA functional class, at present follow-up is class I for 43 pts (88%) and class II in the remaining 6 pts. Along the follow-up period 2 pts had to be reoperated for early repair failures and other three for late failures, presently freedom for reoperation is 91.8% at 5 years. CONCLUSIONS: Mitral valve repair in children with rheumatic lesions can be achieved for the great majority of cases by using different techniques. Pericardial extension of the retracted posterior leaflet allowed the use of a bigger size prosthetic ring. Intermediate functional results are good with fair functional classes and few reoperations but follow-up is short and does not allow us to draw conclusions about the long-term results of the repair in these rheumatic patients.

The Turbocharged Becker Flap: a Simple Variation that Allows Coverage of Most of the Dorsum of the Hand

Cover of medium and large defects of the dorsum of the hand remains a substantial surgical challenge that often requires free tissue transfer. We report the case of a 28-year-old male who presented with necrosis of most of the dorsum of his dominant hand after an iatrogenic injury. A large Becker flap was raised to cover the entire defect. However, venous insufficiency was noted intraoperatively. The flap was turbocharged by performing a venous anastomosis between the flap and the recipient site, resulting in complete survival of the flap. The authors conclude that the turbocharged Becker flap can be a good alternative for expeditiously covering large defects of the dorsum of the hand without having to resort to free tissue transfer.

Mutilação Genital Feminina: o que Sabem os Profissionais de Saúde?

Portugal is considered by the World Health Organization (WHO) a risk country for the practice of Female Genital Mutilation (FGM). Objectives: To evaluate the knowledge that health professionals from Maternity Dr. Alfredo da Costa (MAC) have regarding FGM. Population and Methods: Analysis of surveys delivered to health professionals from MAC (a hospital dedicated to reproductive health), between April and June 2008, addressing issues related to the knowledge about FGM. Results: Authors collected 112 valid surveys involving 38 doctors, 48 nurses and 26 medical auxiliaries/administrative personnel. From the respondents, 106 (95%) had heard about FMG practice before, the media being the most reported source of information; 59 (53%) replied they could be able to recognize FGM cases in their clinical practice; however, only 31 (28%) claimed to know the FGM type classiication and 32 (29%) admitted to be prepared to recognize and manage these situations in their own clinical practice; 9 had been consulted explicitly by a FGM practice complication and 1 doctor had admitted having been asked to perform/execute FGM; 13 (12%) recognized that the Portuguese legislation its this practice. Regarding the practice of FGM, 100 (89%) of respondentes stated that it should not be maintained and 97 (87%) stated that it should not be tolerated. However, 42 (38%) considered that if these practices were a reality, then they should be medical assisted. Discussion: Health professionals can play an important role in eliminating the practice of FGM, not only by the proper clinical management of this situation, but also by preventing those communities at risk to resort to FGM. Most health professionals are not prepared to deal with FGM in their clinical practice. It is important to promote a better knowledge on the subject and to create protocols for proper clinical management.

A Review of National Guidelines for Management of COPD in Europe

The quality of care can be improved by the development and implementation of evidence-based treatment guidelines. Different national guidelines for chronic obstructive pulmonary disease (COPD) exist in Europe and relevant differences may exist among them.This was an evaluation of COPD treatment guidelines published in Europe and Russia in the past 7 years. Each guideline was reviewed in detail and information about the most important aspects of patient diagnosis, risk stratification and pharmacotherapy was extracted following a standardised process. Guidelines were available from the Czech Republic, England and Wales, Finland, France, Germany, Italy, Poland, Portugal, Russia, Spain and Sweden. The treatment goals, criteria for COPD diagnosis, consideration of comorbidities in treatment selection and support for use of long-acting bronchodilators, were similar across treatment guidelines. There were differences in measures used for stratification of disease severity, consideration of patient phenotypes, criteria for the use of inhaled corticosteroids and recommendations for other medications (e.g. theophylline and mucolytics) in addition to bronchodilators.There is generally good agreement on treatment goals, criteria for diagnosis of COPD and use of long-acting bronchodilators as the cornerstone of treatment among guidelines for COPD management in Europe and Russia. However, there are differences in the definitions of patient subgroups and other recommended treatments.