Mutilations Due to Medical Disorders in Children

Soft-tissue and bone necrosis, although rare in childhood, occasionally occur in the course of infectious diseases, either viral or bacterial, and seem to be the result of hypoperfusion on a background of disseminated intravascular coagulation. Treatment consists in correction of septic shock and control of necrosis. Necrosis, once started, shows extraordinarily rapid evolution, leading to soft-tissue and bone destruction and resulting in anatomic, functional, psychological, and social handicaps. Ten mutilated children were treated from January 1986 to January 1999 in Hospital de Dona Estefaˆ nia, Lisbon, Portugal. One was recovering from hemolytic-uremic syndrome with a severe combined immunodeficiency, another malnourished, anemic child had malaria, and three had chicken pox (in one case complicated by meningococcal septicemia). There were three cases of meningococcal and two of pyocyanic septicemia (one in a burned child and one in a patient with infectious mononucleosis). The lower limbs (knee,leg, foot) were involved in five cases, the face (ear, nose, lip) in four, the perineum in three, the pelvis (inguinal region, iliac crest) in two, the axilla in one, and the upper limb (radius, hand) in two. Primary prevention is based on early recognition of risk factors and timely correction. Secondary prevention consists of immediate etiologic and thrombolytic treatment to restrict the area of necrosis. Tertiary prevention relies on adequate rehabilitation with physiotherapy and secondary operations to obtain the best possible functional and esthetic result.

Coarctação Isolada da Aorta: Experiência em 100 Doentes Consecutivos

INTRODUCTION: Coarctation of the aorta (CoA) is a stenosis usually located in the descending aorta. Treatment consists of surgical or percutaneous removal of the obstruction and presents excellent immediate results but significant residual problems often persist. OBJECTIVES: To describe the presentation, treatment and long-term evolution of a population of 100 unselected consecutive patients with isolated CoA in a single pediatric cardiology center. METHODS: This was a retrospective study of all patients with isolated CoA treated during4 the last 21 years (1987-2008). RESULTS: The patients (n=100, 68.3% male) were diagnosed at a median age of 94 days (1 day to 16 years). The clinical presentation differed between patients aged less or more than one year, the former presenting with heart failure and the latter being asymptomatic with evidence of hypertension (88 and 63%, respectively; p < 0.01). Treatment, a median of 8 days after diagnosis, was surgical in 79 cases (20 end-to-end anastomosis, 31 subclavian flap, 28 patch) and percutaneous in the remaining 21 (15 balloon angioplasty, 6 with stenting). The mean age of surgical patients was younger than in those treated percutaneously (3.4 vs. 7.5 years; p < 0.01). Immediate mortality was 2% and occurred in the surgical group. There was no late mortality, in a mean follow-up of 7.2 +/- 5.4 years. Recoarctation occurred in 8 patients (6 surgical, 2 percutaneous). There are 46 patients who currently have hypertension (19 at rest, 27 with effort), their median age at diagnosis being older than the others (23 vs. 995 days; p < 0.01). CONCLUSIONS: Isolated CoA has an excellent short-term prognosis but a significant incidence of long-term complications, and should thus no longer be seen as a simple obstruction in the descending aorta, but rather as a complex pathology that requires careful follow-up after treatment. Its potentially insidious presentation requires a high level of clinical suspicion, femoral pulse palpation during physical examination of newborns and older children being particularly important. Delay in treatment has an impact on late morbidity and mortality. Taking into account the data currently available on late and immediate results, the final choice of therapeutic technique depends on the patient's age, associated lesions and the experience of the medical-surgical team. Hypertension should be closely monitored in the follow-up of these patients, as well as its risk factors and complications.

Diabetic Foot Infections: Current Diagnosis and Treatment

Diabetes mellitus (DM) is a global epidemic, and diabetic foot ulcer (DFU) is one of its most serious and costly complications. DFUs result from a complex interaction of a number of risk factors. Once the protective layer of skin is broken, deep tissues are exposed to bacterial infection that progresses rapidly. Patients with DFUs frequently require amputations of the lower limbs and, in more than half the cases, infection is the preponderant factor. Given the challenges of treating these complex infections, this paper aims to provide a hospital-based framework for the diagnosis and treatment of diabetic foot infections (DFIs). We propose a treatment-oriented assessment of DFIs based on a cross-examination of the medical, foot, and wound history; a systemized and detailed physical examination; and the results of complementary diagnostic procedures. We stress the need for a clinical diagnosis of DFIs and the importance of microbiological evaluation for antibiotic therapy guidance. Regarding treatment, we propose a multidisciplinary approach prioritizing invasive infection drainage, necrosis debridement, and the prompt start of empirical antibiotic therapy, followed by complete and appropriate vascular reconstruction. For severe DFIs, we suggest that negative pressure wound therapy (NPWT) be included in the treatment pathway. We also provide rules for managing particular situations, such as osteomyelitis. It is our hope that this protocol will improve the hospital management of DFIs and, ultimately, the prognosis of DFI patients.

Gravidez após Colocação de Banda Gástrica para Tratamento da Obesidade Mórbida

Obesity is known to have a negative impact on pregnancy outcome, as it is associated with an increase in the incidence of gestational diabetes, hypertension, preeclampsia, neural tube defects, macrosomia, and late fetal death. Gastric banding is considered an appropriate intervention for morbid obesity when other weight-loss measures are unsuccessful, and this treatment has been shown to be effective in causing a sustainable weight loss. Some women will become pregnant after bariatric surgery, and the nutritional and metabolic challenges brought by gastric banding may have a profound impact on maternal health and pregnancy outcome. The authors report the case of a 27 year old pregnant woman, with a past medical history of gastric banding surgery for morbid obesity. At 18 weeks of gestation, the patient started complaining of severe nausea and vomiting, The situation deteriorated three weeks later when she rapidly developed severe desnutrition, dehydration and early signs of liver and renal failure. Migration of the gastric band was diagnosed, and laparoscopy conducted to remove it. In the day following surgery the patient complained of absent fetal movements, and an intrauterine demise was diagnosed on ultrasound. Pathological examination of the fetus and placenta failed to reveal the cause of death, but no growth restriction was documented, suggesting the occurrence of an acute event.

Inferior Vena Cava Filter Placement During Pregnancy: an Adjuvant Option When Medical Therapy Fails

The authors present a case of a 27-year-old multiparous woman, with multiple thrombophilia, whose pregnancy was complicated with deep venous thrombosis requiring placement of a vena cava filter. At 15th week of gestation, following an acute deep venous thrombosis of the right inferior limb, anticoagulant therapy with low-molecular-weight heparin (LMWH) was instituted without improvement in her clinical status. Subsequently, at 18 weeks of pregnancy, LMWH was switched to warfarin. At 30th week of gestation, the maintenance of high thrombotic risk was the premise for placement of an inferior vena cava filter for prophylaxis of pulmonary embolism during childbirth and postpartum. There were no complications and a vaginal delivery was accomplished at 37 weeks of gestation. Venal placement of inferior vena cava filters is an attractive option as prophylaxis for pulmonary embolism during pregnancy.

Psychiatric and Psychosocial Predictors of Medical Outcome After Liver Transplantation: a Prospective, Single-Center Study

OBJECTIVE: Recognizing the potential impact of psychiatric and psychosocial factors on liver transplant patient outcomes is essential to apply special follow-up for more vulnerable patients. The aim of this article was to investigate the psychiatric and psychosocial factors predicted medical outcomes of liver transplanted patients. METHODS: We studied 150 consecutive transplant candidates, attending our outpatient transplantation clinic, including 84 who had been grafted 11 of whom died and 3 retransplanted. RESULTS: We observed that active coping was an important predictor of length of stay after liver transplantation. Neuroticism and social support were important predictors of mortality after liver transplantation. CONCLUSION: It may be useful to identify patients with low scores for active coping and for social support and high scores for neuroticism to design special modes of follow-up to improve their medical outcomes.

Dor à Palpação da Tiróide

A 37-years-old woman, complaining of fever, malaise, myalgia, sore throat and dysphagia lasting for 15 days, had been taking antibiotics and paracetamol for 7 days, without symptoms' improvement. The clinical examination revealed hyperaemic oropharynx and enlarged, painful thyroid. Further exams showed increased analytic inflammatory serum parameters as well as thyrotoxicosis. The thyroid gland had heterogeneous echostructure, with markedly hypoechoic areas and significant capsular oedema as well as decreased radionuclide uptake in the scintigraphy. Both symptoms and imaging improved with paracetamol and ibuprofen. Thyroid gland function normalized in two months. The patient remains in follow-up. This case reports the clinical features of subacute or De Quervain's thyroiditis. The differential medical approach to the patient with painful thyroid palpation is discussed. The diagnosis is essentially clinic, highlighting the importance of a rigorous physical exam. These patients' follow-up is required, considering the clinical and analytic progression.