Treatment Of Post-Operative Chylothorax: The Role Of Intranodal Lymphangiography And Thoracic Duct Disruption.

Thoracic duct embolization has been increasingly adopted as a first-line therapy of chylothorax and this procedure includes lipiodol lymphangiography, thoracic duct access and embolization. Lymphangiography itself has a therapeutic role, with volume-dependent success rates of 37%-97% and even a reported 100% success rate in outputs of < 500 mL/day. We present a clinical case of a 48-years-old man diagnosed with esophageal squamous cell carcinoma, who underwent esophagectomy and presented with post-operative high-output (> 1L/day) chylothorax; thoracic duct embolization was proposed. Even though thoracic duct access and embolization were not achieved due to technical and anatomical factors, lipiodol lymphangiography and possibly thoracic duct maceration (after several punctures/attempts) contributed to the clinical success of the procedure, and this chylothorax with output values superior to those reported in the literature resolved within three days. As such, the therapeutic role of intranodal lymphangiography and thoracic duct disruption should be taken into account.

Placenta Accreta: A Case Report on the Role of Interventional Radiology.

Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uterus-preserving approach.

Microwave ablation of solitary T1N0M0 papillary thyroid carcinoma: A case report.

BACKGROUND: The gold standard treatment for papillary thyroid carcinoma is total thyroidectomy and indications for microwave thermal ablation for primary thyroid cancers have not yet been clearly established However, some patients refuse surgery and others have no indication for it, for example patients under palliative care as in this case, or cannot undergo surgery, based on their comorbidities. These indications are described in the most recent Korean, North American and European guidelines. Laser ablation, radiofrequency ablation, and microwave ablation are similarly safe and effective, so the choice should be based on the specific competences and resources of the pertaining centers. These indications are Percutaneous minimally-invasive techniques; they can be useful to stop disease progression and as an alternative to surgery in patients with contraindication or who refuse surgery. We present a case of a thyroid papillary carcinoma with 17 mm effectively treated with microwave thermal ablation and without recurrence after one year of follow up. CASE SUMMARY: The authors present a case of a 71-years-old patient with a left lobe papillary thyroid carcinoma with 13 mm × 17 mm × 13 mm, with no indication for thyroid surgery given the context of another cancer in palliative treatment. Microwave thermoablation was performed on December 2021. Four months later he repeated computed tomography (CT) scan, which showed that the tumor had disappeared. Six months after ablation he underwent a positron emission tomography/CT-fluorodeoxyglucose scan, which didn't show any evidence of hypermetabolic tumor lesions. CONCLUSION: This case shows microwave thermoablation can be a safe and effective alternative to surgery in patients with no conditions to undergo surgery or when they refuse it. By treating the tumor, with this minimally invasive technique, we are stopping its growth and avoiding disease progression.

Secondary Hepatic Injury in Pediatric Intensive Care: Risk Factors and Prognostic Impact.

OBJECTIVES: The aim of this study was to assess the profile of secondary hepatic injury (SHI), to determine risk factors and to evaluate its impact on prognosis of pediatric intensive care patients. METHODS: An exploratory observational and retrospective study was conducted in a Pediatric Intensive Care Unit. Two groups were defined: with SHI [alanine aminotransferase (ALT) ≥100 IU/L or gamma glutamyl transpeptidase (GGT)≥100 IU/L or direct bilirubin ≥30 µmol/L] and without. SHI was divided into 3 patterns: cytolysis, cholestasis, and mixed. RESULTS: SHI occurred in 16.5%, cytolysis in 5%, cholestasis in 4%, and mixed pattern in 7%. Independent risk factors for SHI were: organ dysfunction score PELOD-2 in D1 in cytolysis (n = 28); total parenteral nutrition and Pediatric Index of Mortality 3 (PIM3) in cholestasis (n = 23); sepsis, oncologic comorbidities, PIM3, and respiratory dysfunction in mixed pattern (n = 37). The ALT was an independent risk factor and a good predictor of mortality (AUC = 0.865) with a cut-off of 137 IU/L. CONCLUSIONS: SHI was associated with worst prognostic. ALT may be useful for detecting patients at increased risk of death, probably being a surrogate marker of the illness severity, reflecting a secondary injury.

Teenage boy with high fever and rash: what could we be missing?

A 15-year-old boy was admitted to a local hospital with high fever, generalised rash and a mild sore throat. He was started on intravenous flucloxacillin and 12 hours later develops a sustained low diastolic blood pressure (DBP), unresponsive to fluid volume expansion and cardiovascular support with dopamine. Intravenous clindamycin was added and transportation to paediatric intensive care unit arranged. Dopamine dosing was increased and norepinephrine infusion was added subsequently with immediate stabilisation of DBP. A sacrococcygeal pilonidal abscess was identified, requiring prompt surgical drainage. The microbiological culture of abscess material was positive for an enterotoxin-producing Staphylococcus aureus and Peptostreptococcus magnus He was free of symptoms after 4 days. This case report summarises a potential severe complication of the pilonidal disease.

Invasive Meningococcal Disease: Application of Base Excess and Platelets Score in a Portuguese Paediatric Intensive Care Unit.

INTRODUCTION: Meningococcal infection has a high mortality and morbidity. Recently a new prognostic scoring system was developed for paediatric invasive meningococcal disease, based on platelet count and base excess â base excess and platelets score. The main objective of this study was to evaluate the accuracy of base excess and platelets score to predict mortality in children admitted to intensive care due to invasive meningococcal disease. MATERIAL AND METHODS: Observational study, with retrospective data collection, during a 13.5 years period (01/2000 to 06/2013). Mortality by invasive meningococcal disease and related factors (organ dysfunction and multi-organ failure) were analysed. The base excess and platelets score was calculated retrospectively, to evaluate its accuracy in predicting mortality and compared with Paediatric Risk of Mortality and Paediatric Index of Mortality2. RESULTS: Were admitted 76 children with invasive meningococcal disease. The most frequent type of dysfunction was cardiovascular (92%), followed by hematologic (55%). Of the total, 47 patients (62%) had criteria for multi-organ failure. The global mortality was 16%. Neurologic and renal dysfunction showed the strongest association with mortality, adjusted odds ratio 315 (26 - 3 804) and 155 (20 - 1 299). After application of receiver operating characteristic curves, Base Excess and Platelets score had an area under curve of 0.81, Paediatric Index of Mortality2 of 0.91 and Paediatric Risk of Mortality of 0.96. DISCUSSION: The Base Excess and Platelets score showed good accuracy, although not as high as Paediatric Risk of Mortality or Paediatric Index of Mortality2. CONCLUSIONS: The Base Excess and Platelets score may be useful tool in invasive meningococcal disease because is highly sensitive and specific and is objectively measurable and readily available at presentation.

Introdução: A infeção meningocócica tem uma elevada mortalidade e morbilidade. Recentemente foi desenvolvido um score de prognóstico para a doença meningocócica invasiva em idade pediátrica, baseado na contagem plaquetar e no excesso de base - o Base Excess and Platelets Score. O objetivo principal desde estudo foi avaliar a precisão prognóstica do Base Excess and Platelets Score em doentes admitidos em cuidados intensivos pediátricos por doença meningocócica invasiva.Material e Métodos: Estudo observacional, com colheita de dados retrospetiva, que incluiu um período de 13,5 anos (01/2000 a 06/2013). Foram analisados: mortalidade por doença meningocócica invasiva e fatores associados (disfunção de órgão e falência multi-órgão). Foi calculado o Base Excess and Platelets Score de forma retrospetiva, para avaliar a sua precisão na predição da mortalidade e foi comparado com o Paediatric Risk of Mortality e Paediatric Index of Mortality2.Resultados: Foram admitidas 76 crianças com doença meningocócica invasiva. O tipo de disfunção mais frequente foi a cardiovascular (92%), seguida da hematológica (55%). Cumpriram critérios de falência multi-órgão 47 doentes (62%). A mortalidade global foi de 16%. A disfunção neurológica e a renal foram as que apresentaram uma maior associação com a mortalidade, odds ratio ajustado 315 (26 - 3 804) e 155 (20 - 1 299). Após aplicação das curvas receiver operating characteristic, o Base Excess and Platelets Score tinha umaarea under curve de 0,81, o Paediatric Index of Mortality2 de 0,91 e o Paediatric Risk of Mortality de 0,96.Discussão: O Base Excess and Platelets Score apresentou uma boa precisão apesar de não tão elevada como o Paediatric Index of Mortality2 ou o Paediatric Risk of Mortality.Conclusões: O Base Excess and Platelets Score pode ser útil como indicador prognóstico na doença meningocócica invasiva, por apresentar uma elevada sensibilidade e especificidade e ser objetivo e rapidamente disponível na admissão.

Renovascular hypertension: a case with atypical neurological signs.

Secondary hypertension is the most frequent form of hypertension in children. Renovascular disease accounts for 5-10% of all childhood hypertension and should be suspected in the presence of severe hypertension found difficult to manage with medical therapy. Uncontrolled hypertension can lead to severe target organ damage. We describe the case of a 13-month-old baby boy with failure to thrive, recent muscular weakness of the lower extremities and irritability. Hypertension was detected and he was admitted to the paediatric intensive care unit with a refractory hypertensive emergency, despite multiple antihypertensive therapies. Bilateral renal artery stenosis was diagnosed through renal angiography and balloon dilation was performed, leading to lower blood pressure. He is currently withdrawing from antihypertensive medication, and slowly gaining weight and recovering from target organ damage. However, weakness of the lower extremities persists and he has been diagnosed with a neurogenic bladder.

[Meningococcal disease admissions in a paediatric intensive care unit]. / Doença invasiva meningocócica em cuidados intensivos pediátricos.

INTRODUCTION: Meningococcal infection has a high mortality and morbidity in children. Aggressive initial shock approach, early referral, secondary transport and vaccination are potential factors with impact in reducing its mortality. Objectives were to characterize children admitted to intensive care due to invasive meningococcal disease, to evaluate their prognostic scores and mortality. MATERIAL AND METHODS: Observational study, with retrospective data collection. Two periods were created according to the year of admission (A: 2000-2005 and B: 2006-2011). Prognostic parameters, organ failure and mortality rates were compared in these groups. RESULTS: 70 children were admitted with invasive meningococcal disease. When compared with other causes of admission, a decrease in the number of admissions due to invasive meningococcal disease was observed (period A: 3.4%; period B: 1.5%; p = 0.001). The presence of meningitis was 41% in period A and 29% in period B (p = 0.461). Rapidly progressive purpura occurred in 78% in period A and 50% in period B (p = 0.032). Children from period A had multi-organ failure (80%), disseminated intravascular coagulation (76%) and coma (22%) more frequently than children from period B (29%, 29%, 0%; p < 0.05). Mortality was 26% in period A and 0% in period B (p = 0.006) and standardized mortality by PRISM was 1.3 and 0 in period A and B respectively. DISCUSSION: The decrease in the number of admissions due to invasive meningococcal disease can be explained by the introduction of anti-meningococcal C vaccine in 2006. Mortality decline can be possibly explained by an improvement in the initial patient stabilization and to secondary transport. CONCLUSION: A decrease in the number of admissions due to invasive meningococcal disease and in mortality was observed.

Introdução: A infecção meningocócica tem uma elevada mortalidade e morbilidade em crianças. O tratamento agressivo do choque, a referenciação precoce, o transporte secundário especializado e a vacinação são factores com impacto potencial na redução da mortalidade. Foram objectivos caracterizar as crianças com doença invasiva meningocócica admitidas em cuidados intensivos, avaliar parâmetros de gravidade e mortalidade. Material e Métodos: Estudo observacional, cujo método de colheita de dados foi retrospectivo. Foram constituídos dois períodos, de seis anos cada, de acordo com o ano de admissão (A: 2000-2005 e B: 2006-2011) e nestes compararam-se índices de gravidade, disfunção orgânica e mortalidade. Resultados: Foram admitidas 70 crianças com doença invasiva meningocócica. Quando comparadas com as outras causas verificouse uma redução nas admissões por doença invasiva meningocócica (período A: 3,4%; período B: 1,5%; p = 0,001). A ocorrência de meningite foi de 41% no período A e de 29% no período B (p = 0,461). Tiveram púrpura rapidamente progressiva 78% no período A e 50% no período B (p = 0,0032). As crianças do período A tiveram disfunção multi-órgão (80%), coagulação intravascular disseminada (76%) e coma (22%) mais frequentemente que as crianças do período B (29%, 29%, 0%; p < 0,05). A mortalidade foi 26% no período A e 0% no período B (p = 0,006) e a mortalidade estandardizada pelo PRISM foi 1,3 e 0 no período A e B respectivamente. Discussão: A redução do número de admissões por doença menigocócica invasiva pode ser explicada pela introdução da vacina anti-meningocócica C em 2006. Pensa-se que a redução da mortalidade observada, possa ser atribuível à melhoria da estabilização inicial e ao transporte secundário. Conclusão: Nos últimos anos houve uma redução significativa no número de admissões e na mortalidade por doença invasiva meningocócica.

[Asymptomatic cardiac tumor in a child: an incidental diagnosis]. / Tumor cardíaco em criança assintomática: um diagnóstico acidental.

Cardiac tumors in the pediatric population are rare, their incidence range between 0.001% and 0.003%. They are mostly benign, rhabdomyomas the most common type, followed by fibromas. The clinical features are being usually nonspecific and depend on the size and location of the tumor within the heart. We report the case of a previously healthy four-year-old boy referred for flu-like symptoms. A respiratory infection was suspected and a chest X-ray showed an increased cardiothoracic index. An echocardiogram revealed a single large heterogeneous mass in the left ventricle emerging from the lateral wall. Despite its size, the mass did not obstruct the left ventricular outflow tract or affect mitral valve function. Cardiac magnetic resonance imaging showed a large mass whose imaging features were suggestive of a fibroma. He became symptomatic during follow-up and was referred for surgical excision of the mass. Histological study confirmed a fibroma. At present the patient remains asymptomatic.

Left ventricular noncompaction: analysis of a pediatric population.

INTRODUCTION: Left ventricular noncompaction (LVNC) is a rare and potentially progressive cardiomyopathy, characterized by the persistence of multiple trabeculations and deep intratrabecular recesses in the ventricular myocardium. Although two-dimensional and color Doppler echocardiography are the most useful diagnostic modalities, cardiac magnetic resonance imaging has proved to have high sensitivity and specificity in the diagnosis of this anomaly. OBJECTIVE: To characterize the clinical and imaging features of LVNC in a pediatric population and to assess their evolution. METHODS AND RESULTS: We performed a retrospective chart review of five pediatric patients with LVNC, followed at Coimbra Pediatric Hospital between January 1999 and December 2007. Median age at presentation was five months (ranging from one day to 13 years), and they were mainly male (1.5:1). Two of the children had a family history of sudden death. In one case the clinical presentation was cardiac arrest due to ventricular fibrillation and in three others, congestive cardiac failure. None of the five cases had associated congenital cardiac anomalies. Involvement of the ventricular apical region was found in all cases. Four children additionally had ventricular dysfunction which improved with diuretic and vasodilator therapy. Mean follow-up was 34 months, ranging from six months to seven years. In one case a change in the morphological phenotype was noted, from a dilated to a hypertrophic form. In this case and in the child's father a mutation in the MYBPC3 gene was identified, which is associated with hypertrophic cardiomyopathy. No thromboembolic phenomena or deaths occurred during the study period. CONCLUSION: In the pediatric population, congestive cardiac failure is the most common clinical presentation of LVNC, which can coexist with other cardiomyopathies, particularly dilated and hypertrophic forms. The sample presented in this analysis is statistically non-significant due to its limited size and the authors highlight the need for larger prospective studies in the pediatric population in order to clarify this disease and its diagnostic criteria.

[Circumferential pulmonary vein isolation with the cryoballoon technique]. / Isolamento circunferencial das veias pulmonares com a técnica do criobalão.

We present a clinical case on cryoballoon ablation of paroxysmal atrial fibrillation. This is a report of the first case performed at our center using this new technology.

Atrial fibrillation ablation using simultaneous multielectrode application of radiofrequeney energy.

Despite technological advances in equipment for ablation of atrial fibrillation (AF), conventional pulmonary vein (PV) isolation with point-by-point radiofrequency application encircling the PV ostia remains a complex procedure requiring a high degree of operator skill and experience. Novel multielectrode catheters have been developed that deliver duty-cycled bipolar and unipolar radiofrequency energy, designed for PV electrical isolation and for ablation of complex fractionated electrograms in the left atrium. Initial studies suggest good results, reducing procedure time and with safety and efficacy equivalent to the conventional method. We describe the first four cases of AF ablation in our center using this method, with acute success in two patients: one with paroxysmal AF and the other with chronic AF.