Predictive Variables Affecting Transfusion Requirements in Orthotopic Liver Transplantation

INTRODUCTION AND AIMS: Adult orthotopic liver transplantation (OLT) is associated with considerable blood product requirements. The aim of this study was to assess the ability of preoperative information to predict intraoperative red blood cell (RBC) transfusion requirements among adult liver recipients. METHODS: Preoperative variables with previously demonstrated relationships to intraoperative RBC transfusion were identified from the literature: sex, age, pathology, prothrombin time (PT), factor V, hemoglobin (Hb), and platelet count (plt). These variables were then retrospectively collected from 758 consecutive adult patients undergoing OLT from 1997 to 2007. Relationships between these variables and intraoperative blood transfusion requirements were examined by both univariate analysis and multiple linear regression analysis. RESULTS: Univariate analysis confirmed significant associations between RBC transfusion and PT, factor V, Hb, Plt, pathology, and age (P values all < .001). However, stepwise backward multivariate analysis excluded variables Plt and factor V from the multiple regression linear model. The variables included in the final predictive model were PT, Hb, age, and pathology. Patients suffering from liver carcinoma required more blood products than those suffering from other pathologies. Yet, the overall predictive power of the final model was limited (R(2) = .308; adjusted R(2) = .30). CONCLUSION: Preoperative variables have limited predictive power for intraoperative RBC transfusion requirements even when significant statistical associations exist, identifying only a small portion of the observed total transfusion variability. Preoperative PT, Hb, age, and liver pathology seem to be the most significant predictive factors but other factors like severity of liver disease, surgical technique, medical experience in liver transplantation, and other noncontrollable human variables may play important roles to determine the final transfusion requirements.

Fluido Torácico Total. Um Possível Determinante da Eficácia Ventilatória em Doentes com Insuficiência Cardíaca

A eficácia ventilatória, avaliada por prova de esforço cardiorrespiratória (PECR), tem um importante valor prognóstico em doentes (dts) com insuficiência cardíaca crónica (ICC) por disfunção sistólica ventricular esquerda (DSVE). Os seus determinantes mantêm-se, contudo, controversos. Objectivo: Investigar a eventual correlação entre parâmetros de eficácia ventilatória, obtidos por PECR, e o valor do fluido torácico total (FTT), avaliado por bioimpedância eléctrica torácica (BET), em dts com ICC por DSVE. Métodos: Estudámos 120 dts com ICC por DSVE, referenciados ao nosso laboratório para PECR — 76% do sexo masculino, idade 52,1 ± 12,1 anos, 37% de etiologia isquémica, fracção de ejecção ventricular esquerda 27,6 ± 7,9%, 83% em ritmo sinusal, 96% sob iECA e/ou ARAII, 79% sob beta-bloqueante e 20% tratados com dispositivo de ressincronização cardíaca. Os dts efectuaram PECR, em tapete rolante, protocolo de Bruce modificado,sendo considerados para análise, como parâmetro de capacidade funcional, o consumo de oxigénio de pico (VO2p) e, como parâmetros de eficácia ventilatória, o declive (d) da relação entre ventilação minuto(VE) e produção de CO2 (VCO2) e o valor do VE/VCO2 no limiar anaeróbico (LANA). Os estudos por BET, média de 20 minutos de aquisição, foram efectuados após 15 minutos de repouso, em posição supina, imediatamente antes das PECR, sendo analisado o valor do FTT. Resultados: O valor do FTT variou entre 20,6 e 45,8 kOhm−1, média = 32,2, DP = 5,7, mediana = 32,7, o de VO2p entre 8,9 e 40,6 ml/kg/min, média = 21,0, DP = 6,2, mediana = 20,2, o do dVE/VCO2 entre 19,8 e 60,7, média = 30,7, DP = 7,9, mediana = 29,1 e o do VE/VCO2 no LANA entre 21 e 62,média = 33,1, DP = 7,5, mediana = 31,5. Por regressão linear, o FTT não se correlacionou com o VO2p — r = 0,05, p = 0,58 — mas apresentou correlação com os parâmetros de eficácia ventilatória analisados: r = 0,20, p = 0,032, r² = 0,04 com dVE/VCO2 e r = 0,25, p = 0,009, r² = 0.06 com VE/VCO2 no LANA. Conclusão: O FTT correlaciona-se com os parâmetros de eficácia ventilatória, avaliados por PECR, em dts com ICC por DSVE, o que indica que poderá ser um dos seus determinantes.

Clinical and Bacteriological Survey of Diabetic Foot Infections in Lisbon

AIMS: An epidemiological survey of diabetic foot infections (DFIs) in Lisbon, stratifying the bacterial profile based on patient demographical data, diabetic foot characteristics (PEDIS classification), ulcer duration and antibiotic therapy. METHODS: A transversal observational multicenter study, with clinical data collection using a structured questionnaire and microbiological products (aspirates, biopsies or swabs collected using the Levine method) of clinically infected foot ulcers of patients with diabetes mellitus (DM). RESULTS: Forty-nine hospitalized and ambulatory patients were enrolled in this study, and 147 microbial isolates were cultured. Staphylococcus was the main genus identified, and methicillin-resistant Staphylococcus aureus (MRSA) was present in 24.5% of total cases. In the clinical samples collected from patients undergoing antibiotic therapy, 93% of the antibiotic regimens were considered inadequate based on the antibiotic susceptibility test results. The average duration of an ulcer with any isolated multi-drug resistant (MDR) organism was 29 days, and previous treatment with fluoroquinolones was statistically associated with multi-drug resistance. CONCLUSIONS: Staphylococcus aureus was the most common cause of DFIs in our area. Prevalence and precocity of MDR organisms, namely MRSA, were high and were probably related to previous indiscriminate antibiotic use. Clinicians should avoid fluoroquinolones and more frequently consider the use of empirical anti-MRSA therapy.

Perinatal Bacterial Infection: Screenning of Vertical Transmitted Infections

Perinatal bacterial infection may be caused by any microorganism colonizing the vaginal tract. Neonatologists and paediatricians are especially concerned about group B Stretpococcus (GBS). However, Enterobactereacea, mainly E.coli and Proteus, are also responsible for infection. GBS screening may be accomplished in over 90% of pregnant women. In our maternity in 2007-2008, 85% of the mothers had been screened. Screening and prophylaxis were responsible for a decreasing incidence of neonatal infection - from 0.6/1000 to 0.15/1000 live births in Portugal, from 2002 to 2007. However there are some difficulties related to screening. In the second Portuguese study 16/57 NB with early-onset infection (28%) were born to “negative” mothers. Several factors illustrate how difficult is to draw national screening policies: a wide range of carrier’s state rate throughout a country - in Portugal from 12% to 30%. The success of any screening policy may also be affected by additional technical and organizational problems. In countries where home delivery is a tradition or a trend intrapartum GBS prophylaxis requires a very well organized assistance.. Moreover factors usually accepted as protective are not so effective. In the Portuguese study 24/57 infected newborns (42%) were delivery by caesarean section. Another subject deals with the workload in the postnatal ward generated by deficient compliance to the guidelines a problem not confirm by a study of our group. Decreasing the importance of GBS, highlight the importance of E. coli in perinatal infection. From the 16 340 registrations of the National Registry 1676 were newborns with mother-related infection. Applying the same reasoning to E.coli as to GBS and Listeria monocytogenes – that is considering all of them are of maternal origin - 6.7% of these infections were due to E. coli, 4.6% to SGB and 0.5% to Listeria monocytogenes. In conclusion screening and prophylaxis may be not the best way to prevent all GBS neonatal infections but by now it is the only available procedure. The other bacteria continue to demand a high suspicion level and immediate intervention.

Effects of a Shortage of Imiglucerase on Three Patients with Type I Gaucher Disease

Background: Children with Gaucher disease type I (GD1) are usually treated with enzyme replacement therapy (ERT) at a dose of 30-60U/Kg/2W. Recently, due to an acute shortage supply of imiglucerase, a reduced dose or a reduced infusion frequency was recommended. Objective: To evaluate the effects of a reduced infusion frequency of imiglucerase over 15 months of follow-up. Patients and Methods: Three patients (1M:2F) were treated with ERT since a median age of 7 years (range 5-12). Only one had bone crisis and Erlenmeyer deformations. Median duration of treatment before dose reduction was 3 years (range 1-8). ERT resulted in total regression of symptoms, normalization of hematological parameters and progressive improvement of chitotriosidase in all patients. In August 2009 infusion schedule was changed from a media 45U/Kg every two weeks to every four weeks. Results: All patients remained asymptomatic and with no major change on hematological parameters except for the patient with bone crisis who presented subnormal platelet count. All patients showed an upward trend in chitotriosidase values. Comments: Although a longer follow-up is needed, is probable that even children completely stabilized can probably not be kept on lower doses even though the reduction of frequency of the infusions represent a lower social burden.

Artroplastia Total do Joelho Dolorosa

A Artroplastia Total do Joelho (ATJ) tem vindo a assumir-se como a opção cirúrgica mais frequente no tratamento de doentes com alterações degenerativas da articulação do joelho devido aos ótimos resultados funcionais e melhoria da dor. No entanto, a percentagem de doentes com sintomas dolorosos após a realização deste procedimento atinge em algumas estatísticas publicadas valores significativos que oscilam entre os 10 e os 20%. Em alguns casos a dor não é facilmente explicável, representando um desafio para o cirurgião. Os autores relatam o caso de uma doente de 71 anos submetida a ATJ primária, no contexto de patologia degenerativa idiopática associado a desvio axial em varum. A dor localizava-se na face anteroexterna do joelho ao nível da interlinha articular e tiveram início no pós-operatório de forma gradual, associadas ao aumento da mobilidade. Devido à presença de um sintoma associado a atividade mecânica, foram colocadas várias hipóteses, entre as quais a possibilidade de conflito com resquício intra-articulares do compartimento externo do joelho. A doente foi submetida a artroscopia da articulação do joelho que revelou a existência de um fragmento meniscal que provocava conflito entre o côndilo externo do componente artroplástico femoral e o polietileno no movimento de extensão máxima do joelho. Procedeu-se a remoção artroscópica do fragmento com melhoria sintomática completa. Os autores pretendem com este caso evidenciar a importância da investigação diagnóstica para o tratamento da dor inexplicável na ATJ, e o valor terapêutico da artroscopia nos casos de provável conflito.

Endocardite por Cândida Parapsilosis Após Correcção Total de Tetralogia de Fallot. Tratamento Médico-Cirúrgico

São apresentados três casos de endocardite por Cândida Parapsilosis que surgiram em crianças com idade entre os sete e os nove anos, após terem sido submetidas a correcção total de Tetralogia de Fallot. As três crianças foram reoperadas, tendo recebido previamente uma delas terapêutica médica com anfotericina B e duas exclusivamente com Ketoconazol oral. Após negativação das hemoculturas foi efectuada remoção cirúrgica das vegetações com substituição do patch septal de dacron. A terapêutica com Ketoconazol prosseguiu durante 24 meses, com follow-up de 30 a 42 meses, não se tendo verificado nem reinfecção nem efeitos secundários da terapêutica. A ecocardiografia bidimensional revelou-se um método eficaz no diagnóstico e seguimento a longo prazo. A terapêutica médico-cirúrgica combinada, com timing cirúrgico baseado em dados clínicos e laboratoriais foi fundamental para os bons resultados, estando as crianças actualmente curadas.