High-risk acute pulmonary embolism in a Portuguese centre: are we doing enough?

Introduction For high-risk acute Pulmonary Embolism patients (HR-PE pts), reperfusion treatment is imperative to improve mortality. Although systemic thrombolysis (ST) is generally an appropriate first-line therapy, several population-based studies report its underuse. Data on epidemiology, management and outcomes of HR-PE in Portugal is scarce. Purpose Estimate the reperfusion rate in HR-PE pts, the reasons for non-reperfusion (NR) and how it influences outcomes. Methods Retrospective single-centre registry of consecutive HR-PE pts between 2008–2018, defined by the 2019 ESC guidelines criteria. Independent predictors for NR were assessed by multivariate logistic regression. The cumulative incidence of PE-related mortality at 30 days was calculated according to the Kaplan-Meier method and differences stratified by reperfusion were assessed using the log-rank test. Results Of a total of 1955 pts admitted with acute PE, 74 (3.8%) had HD instability at admission (mean age 68±15 years). The majority of pts (68.5%) came from the emergency department while the remaining 31.5% were already hospitalized for other reasons. The total reperfusion rate was 50% - 35pts were submitted to systemic thrombolysis, 1pt to first-line percutaneous embolectomy and 1pt to rescue endovascular treatment. Age was an independent predictor of NR (63±17 vs 73±12, p=0.02) with >75 years representing 15 times the risk of non-treatment (OR 15.5, 95% CI 3.23–74.25, p<0.001). Absolute contraindication for thrombolysis was present in 29.7% (22pts), with recent major surgery (13pts) and recent cerebral event (8pts) as the most common reasons. The presence of an absolute contraindication for systemic thrombolysis was also an independent predictor of NR (66.7% vs 13.6%; OR 13.3, 95% CI 2.51–70.65, p=0.002). Being hospitalized was associated with the presence of absolute contraindications for thrombolysis (68.2% vs 14.0%, p<0.001) and was also an independent predictor of NR (38% vs 77.3%; OR 8.49, 95% CI 1.56–46.11, p=0.013). PE-related death at 30 days was 28.4% (21pts), which was significantly lower in the reperfusion group (17.1% vs 38.9%, p=0.042). At a mean follow-up of 2.5±3.3 years, survival rate was 33.8% (figure 1). Conclusions Low reperfusion rate due to contraindications for thrombolysis was associated with high PE-related mortality. This data suggests that it is necessary to implement interventional alternative strategies, at a national level, to improve outcomes. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Survival rate according to reperfusion.

Experiences of early air travel with pneumothorax after anterior spinal surgery

Anterior thoracic or thoracolumbar spinal surgery by retropleural approach always carries a risk of pneumothorax as its consequence. Conventionally, the Aerospace Medicine Association and the British Thoracic Society recommend 2 weeks delay of air travel for a patient with resolved postoperative pneumothorax. They also label active pneumothorax as an absolute contraindication for commercial air travel. Such a delay always causes psychological and financial stress to patients and family who are far from home. Here, we report three patients with postoperative pneumothorax, who insisted on early air travel despite being informed of the possible consequences.

Sometimes conventional removable partial denture is the only remedy!

Management of partially edentulous patients can still be a prosthodontic challenge especially for extensive maxillary Kennedy Class I. Replacing the missing teeth using conventional fixed and removable partial dentures (FPD/RPDs) associated with extracoronal attachments remains sometimes the only remedy for partial edentulism. The use of osseointegrated dental implants turn the possibilities of prosthetic reconstruction endless, but what about patients with absolute contraindication of surgery. It is therefore the objective of this article to describe the treatment sequence and technique for the use of attachments in therapy combining FPD/RPD.

The Impact of Resistant Bacterial Pathogens including Pseudomonas aeruginosa and Burkholderia on Lung Transplant Outcomes

Pseudomonas and Burkholderia are gram-negative organisms that achieve colonization within the lungs of patients with cystic fibrosis, and are associated with accelerated pulmonary function decline. Multidrug resistance is a hallmark of these organisms, which makes eradication efforts difficult. Furthermore, the literature has outlined increased morbidity and mortality for lung transplant (LTx) recipients infected with these bacterial genera. Indeed, many treatment centers have considered Burkholderia cepacia infection an absolute contraindication to LTx. Ongoing research has delineated different species within the B. cepacia complex (BCC), with significantly varied morbidity and survival profiles. This review considers the current evidence for LTx outcomes between the different subspecies encompassed within these genera as well as prophylactic and management options. The availability of meta-genomic tools will make differentiation between species within these groups easier in the future, and will allow more evidence-based decisions to be made regarding suitability of candidates colonized with these resistant bacteria for LTx. This review suggests that based on the current evidence, not all species of BCC should be considered contraindications to LTx, going forward.

Risks of anaesthesia in laparoscopic interventions in the abdominal cavity

Laparoscopic surgical technologies in abdominal surgeries strengthen their position every year, especially du­ring planned surgeries, reduce the patient’s trauma and length of stay in the hospital. However, the technique of laparoscopic interventions involves non-physiological position of the patient on the operating table (especially during long operations), the use of pneumoperitoneum with carbon dioxide. Pneumoperitoneum creates increased pressure on the diaphragm, disrupts venous return and can create other unpleasant situations. There is no absolute contraindication to laparoscopic surgery, although we should anticipate possible problems in conditions such as obesity, pregnancy and previous abdominal surgeries. In order to reduce the trauma of surgery, laparoscopic techniques are used, and incorrect assessment of their capabilities in high-risk patients can lead to serious complications. Anaesthesiologists should carefully consider all the risks associated with laparoscopic technique, interact with surgeons to reduce the risk of complications, constantly monitor the patient’s state and use modern approaches to the choice of anaesthesia. The purpose of this work is to summarize the best available evidence and established practice for perioperative management of patients with laparoscopic interventions in the abdominal cavity.

Transtorno dismórfico corporal - a importância do diagnóstico prévio à consulta inicial em procedimentos estéticos

Aesthetic procedures do not have an absolute contraindication in patients with psychiatric disorders, however, anamnesis must take into account the body dysmorphic disorder that is the most common among individuals who seek body and facial changes through aesthetic procedures. Individuals with body dysmorphic disorder are distressed by perceived flaws in their physical appearance, commonly in their face. Although these “defects” are generally not noticeable to others, individuals with BDD misinterpret a certain part of their body as unattractive and repulsive. They spend several hours a day worrying about appearance, engaging in repetitive, time-consuming behaviors, like comparing, checking the mirror. They camouflage with the hair, handkerchiefs or the clothes the part and the body that the disturbed person sees with a problem. They tidy up their appearance excessively and seek guarantees from third parties that the problem exists. The purpose of this article is to alert the aesthetic professional about the obstacles that they may face when they are careless about the body dysmorphic disorder.

Management of an angulated maxillary central incisor impacted: A case report

The inclusion of the maxillary incisors, although rare, poses even more difficulty to the practitioner who diagnoses it. This difficulty is increased in front of an angulated incisor in a labial position with the “policeman's sign”, the prognosis of orthodontic therapy being reserved.This article aims to describe a clinical case of retention of two maxillary central incisors with radicular angulation and in a vestibular position in an 11-year-old adolescent, referred in the Rabat dental consultation and treatment center. clinically, we can note the absence of the two maxillary central incisors on the dental arch, confirmed by the X-ray with the presence of obstacles on the path of the incisors which are in a very high position with angulated roots. The challenge was to put on the arch of the teeth and especially the aesthetic challenge. The satisfactory result obtained is only the result of the motivation of the patient as well as the dexterity of the practitioner. Despite the current treatment, we are comforted in our choice to treat. it is obvious for us that the only absolute contraindication to traction in the case of an impacted incisor remains dilaceration