Contact tracing management of a measles case in a paediatric hospital: experience of the local public health unit, Portugal, January 2024.

In January 2024, a child was diagnosed with measles in a paediatric hospital in Lisbon. Of 123 contacts, 39 (32%) were not fully immunised, presenting a risk for a potential outbreak. The public health unit initiated control measures and identified challenges during the response, such as the lack of interoperability between information systems and accessing vaccination records. The lessons learned prompted changes to national contact tracing procedures for measles, further strengthening Portugal's preparedness.

Construção de um procedimento de preparação para o transporte inter-hospitalar da pessoa em situação crítica / Construction of a procedure to prepare for inter-hospital transportation of the person in critical condition

O presente relatório insere-se no âmbito do Estágio de Natureza Profissional do Mestrado em Enfermagem Médico-Cirúrgica da Escola Superior de Saúde do Instituto Politécnico de Viana do Castelo e procura evidenciar de uma perspetiva crítica e reflexiva o percurso e o processo de aquisição e desenvolvimento de competências especializadas em Enfermagem Médico-Cirúrgica, na área da Pessoa em Situação Crítica. Para a aquisição e desenvolvimento de competências procurou-se fundamentar a prática clínica na evidência científica mais recente englobando as dimensões da prestação de cuidados à pessoa e família em situação crítica, da formação, da gestão, da ética, da deontologia e da investigação. Nesse sentido, o estágio desenrolou-se num serviço de urgência básico, no qual emergiu a problemática de investigação, orientada para a necessidade de construir um Procedimento de Preparação para o Transporte Inter-hospitalar da Pessoa em Situação Crítica. A pertinência do estudo de investigação incorre numa perspetiva de segurança do doente na limitação e controlo de possíveis eventos adversos decorrentes do transporte inter-hospitalar e que implicam, quando surgem, aumento da mortalidade e morbilidade. Assim, a construção de um procedimento visa ser um instrumento de apoio a uma prática de cuidados especializada e segura. Tendo em conta o objetivo de investigação, optou-se por um estudo com recurso à técnica de Delphi. Assim, aplicou-se um questionário a um grupo de 10 enfermeiros peritos para avaliação da pertinência dos pressupostos sugeridos com vista à obtenção de um consenso. Os resultados evidenciaram um consenso robusto na maioria dos pressupostos colocados à consideração dos peritos. Desta forma, o estudo permitiu a construção de um procedimento com intervenções validadas e consensuais, para uma preparação do transporte inter-hospitalar, seguro e isento de eventos adversos. Na sequência deste estudo, sugere-se a validação e implementação do procedimento na prática clínica real, para aferir lacunas e alargar ao âmbito nacional. Da experiência de estágio, evidencia-se o papel fundamental do enfermeiro especialista em Enfermagem Médico-Cirúrgica, num contexto tão singular e ao mesmo tempo tão complexo como um serviço de urgência básico. Como aprendizagens pessoais, salienta-se a relevância e importância da prática profissional especializada em Enfermagem. Esta prática é orientada para todas as fases da vida, existindo o aprofundamento de competências, sustentadas na reflexão, na interação com o contexto e na evidência científica. Esta súmula de competências origina uma tomada de decisão consciente em ambientes altamente imprevisíveis, inconstantes e complexos.

This report is part of the Internship of a Professional Nature of the Master's Degree in Medical-Surgical Nursing at the Escola Superior de Saúde do Instituto Politécnico de Viana do Castelo, in a Basic Emergency Service and seeks to highlight from a perspective critical and reflective approach the path and process of acquiring and developing specialized skills in medical-surgical nursing, in the area of patients in critical situations. For the acquisition and development of skills, we sought to base clinical practice on the most recent scientific evidence, encompassing the dimensions of providing care to patients and families in critical situations, training, management, ethics, deontology, and research. The internship took place in a basic emergency service, in which the research problem emerged, form the need to build a preparation procedure for the inter-hospital transport of the patient in critical situation. The pertinence of the research study comes from a perspective of patient safety in limiting and controlling possible adverse events arising from inter-hospital transport and which, when they arise, imply increased mortality and morbidity. The construction of a procedure aims to be an instrument to support a specialized and safe care practice. Considering the research objective, we decided to use a Delphi technique in this study. For this, a questionnaire was applied to a group of 10 expert nurses to assess the pertinence of the suggested assumptions to obtain a consensus. The results showed a robust consensus on most of the assumptions put forward for the expert consideration. In this way, the study allowed the construction of a procedure with validated and consensual interventions, for the preparation of inter-hospital transport, safe and free of adverse events. Following this study, it is suggested the validation and implementation of the procedure in real clinical practice to assess gaps and be able to be extended nationwide. From the internship experience, the fundamental role of the specialist nurse in Medical-Surgical Nursing is evident, in a context as unique and at the same time as complex as a basic emergency service. As personal learning, the relevance and importance of professional practice specialized in Nursing is highlighted. This practice is aimed at all stages of life, with the development of skills, based on reflection, interaction with the context and scientific evidence. This summary of competences leads to conscious decision-making in highly unpredictable, changeable and complex environments.

Bacillus subtilis mejora el desarrollo de órganos digestivos, la morfología del intestino y el rendimiento productivo en pollos de engorde

La regulación en el uso de antibióticos promotores de crecimiento en la alimentación animal requiere de la búsqueda de alternativas nutricionales seguras, que mejoren la salud intestinal y el rendimiento productivo en los animales, mientras protegen la salud del consumidor. La investigación tuvo como objetivo evaluar el efecto de Bacillus subtilis sobre el desarrollo de órganos digestivos, la morfología del intestino y el rendimiento productivo, en pollos de engorde.192 pollos Cobb 500 de un día de edad fueron asignados aleatoriamente a una de tres dietas: basal libre de antibióticos (D1), basal adicionada con 10 ppm de avilamicina (D2) o basal adicionada con 50 ppm de esporas de B. subtilis (D3), durante 42 días. Los días 21 y 42 de edad, se determinó la conversión alimenticia (CA), la ganancia acumulada de peso (GAP) y se evaluó el desarrollo de los principales órganos digestivos y la histomorfología de cada segmento del intestino delgado, mediante el sacrificio de 48 aves (8 aves/dieta/día). El uso de B. subtilis incrementó significativamente la CA y la GAP. Por otra parte, B. subtilis aumentó la alométria del intestino en comparación con el uso de antibióticos, aunque no se evidenciaron diferencias significativas para el peso de órganos digestivos, entre ambos tratamientos; B. subtilis mejoró la altura de las vellosidades y disminuyó la profundidad de las criptas, significativamente. B. subtilis favorece el desempeño productivo en pollos de engorde, mejora el desarrollo de órganos digestivos y la histomorfología del intestino delgado.

Regulation in the use of growth promoters antibiotics in animal feed has led to the search for safe nutritional alternatives that improve intestinal health and growth performance in animal, while protecting consumer health. The aim was to assess the effect of Bacillus subtilis on the digestive organs development, intestinal morphology and growth performance in broilers. A total of 192 one-day old Cobb 500 chicks, were randomized and assigned to one of three diets: basal diet free of antibiotics (D1) or basal diet added with 10ppm of avilamicyn (D2) or basal diet added with 50ppm of B. subtilis's spores (D3) for 42 days. On days 21 and 42 the feed conversion ratio (FCR) and average body weight (ABW) were determined; also, eight birds per treatment were euthanized to assess the development of digestive organs and the histomorphology in the different sections of the small intestine. The use of B. subtilis significantly increased FCR and ABW. On the other hand, B. subtilis significantly small intestine length compared to antibiotic growth promoter, but there was no differences in the weight of the digestive organs between B. subtilis and antibiotic diet, in addition B. subtilis improve villus height and decreased crypt depth significantly. In conclusion, the use of B. subtilis improve growth performance, digestive organs development and small intestine histomorphology in broilers.

Eilhard Lubin, Academic Unorthodoxy, and the Dynamics of Confessional Intellectual Cultures.

The standard narrative of post-Reformation confessionalization suggests that confessional cultures clamped down on intellectual creativity in order to protect orthodox theology. Taking the case of Lutheranism, this article examines Eilhard Lubin's successful defense of his subversive ideas about God, creation, and evil. I put forward the concept of "academic unorthodoxy"-based on the plural, social character of orthodoxy and the potential for disciplinary boundary-work-as a complex but analytically rich approach to the relationship between confessional orthodoxy and intellectual diversity, specifically in early modern Lutheranism but applicable to early modern confessional cultures in general.

Overlapping synthetic peptides as a tool to map protein-protein interactions ̶ FSH as a model system of nonadditive interactions.

In earlier work, we used partially overlapped synthetic peptides as a tool to find regions of interaction between the human FSH hormone and its receptor, aiming to find possible antagonists or agonists. Years later, the FSH and FSH receptor 3D structures were reported by other laboratories. The 3D results were in close agreement with the interacting regions predicted by using synthetic peptides. These earlier studies are reviewed here, and the predicted regions of interaction compared to the FSH and FSH receptor 3D structures to illustrate the usefulness of the synthetic peptide strategy to find binding regions. Different contact regions contribute multiplicatively to the high affinity of the entire ligand; thus, peptides covering a fraction of the anchor sites and with low free energy density cannot reach the affinity of the entire molecule. The earlier use of multiple linear regression to find the relevant predictors for effective binding, and a new way to estimate ΔG° and nonadditive interactions for the synthetic peptides in solution, by using the buried surface area (BSA), will be discussed.

HYBRID AORTIC ARCH SURGERY TO CREATE A LANDING ZONE IN THE ASCENDING AORTA.

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.

High-resolution time-dependent probabilistic assessment of the hydraulic performance for historic coastal structures: application to Luarca Breakwater.

Historic coastal structures have played a key role in small- to medium-size ports, being the driving force for the local development of coastal communities. Because coastal managers require reliable risk-based analysis of the whole life cycle of these coastal structures, previous lifetimes should be studied. This is a differentiating factor with respect to the newly built breakwaters. For this reason, in this work, a methodology for assessing how the hydraulic performance of an expired lifetime has evolved over the years is presented. It is performed following a probabilistic approach due to the uncertainty related to both the involved variables (wave climate, geometrical and structural breakwater variables) and the hydraulic response of the structure. The first ones are characterized by reliable probability distribution functions. The second ones are characterized by reliable formulae for the analysis of the hydraulic response. However, their non-conventional designs located in shallow-water locations require site-dependent formulae. To overcome this problem, a novel methodology to apply CFD numerical models is presented. Finally, it is integrated in a high-resolution time-dependent probabilistic methodology which takes into account the stochastic behaviour of all the involved variables, coastal and structural processes with a good uncertainty level. This article is part of the theme issue 'Environmental loading of heritage structures'.

Efecto del aceite esencial de orégano (Lippia origanoides) sobre metabolitos sanguíneos en pollos de engorde / Effect of oregano essential oil (Lippia origanoides) on blood metabolites in broiler chickens / Efeito do óleo essencial de orégano (Lippia origanoides) sobre metabolitos sanguíneos em frangos de corte

Resumen Objetivo: evaluar parámetros sanguíneos en pollos de engorde de la línea genética Cobb500, luego de la administración de aceite esencial de orégano (Lippia origanoides) (AEO). Materiales y métodos: se utilizaron 200 pollos de línea genética Cobb 500 y se realizaron mediciones los días 14, 28 y 42. Los animales fueron aleatorizados a una de dos dietas: dieta comercial con antibiótico y sin este. A esta última se adicionaron diferentes concentraciones de AEO (75 ppm, 100 ppm o 200 ppm AEO). Se realizó un diseño estadístico de bloques al azar en un arreglo de parcelas dividas. Resultados: los pollos del grupo D5 (200 ppm) presentaron mayores valores en glucosa, fosfatasa y fósforo que los pollos alimentados con antibiótico (D2) a lo largo del experimento. Conclusión: la adición de 200 ppm de AEO en el alimento de pollos de engorde de la línea genética Cobb 500 induce una mejora en metabolitos sanguíneos. Este trabajo permitió evaluar las variables metabólicas de pollos que consumieron AEO.

Abstract Objective: To evaluate blood parameters in broiler chickens of the Cobb 500 genetic line, after the administration of oregano essential oil (Lippia origanoides) (OEO). Materials and methods: 200 chickens of the Cobb 500 genetic line were used, and measurements were taken on days 14, 28, and 42. The animals were randomly assigned to one of two diets: commercial diet with and without antibiotic supplementation. To the antibiotic-free diet different concentrations of OEO were added (75 ppm, 100 ppm, or 200 ppm). A statistical randomized block design was used in an array of divided plots. Results: Chickens from group D5 (200 ppm of OEO) had higher values in glucose, phosphatase, and phosphorus than chickens fed with antibiotic supplementation (D2) throughout the experiment. Conclusion: The addition of 200 ppm of OEO in the food of broiler chickens of the Cobb 500 genetic line induces an improvement in blood metabolites. This work allowed evaluating metabolic variables of chickens that consumed OEO.

Resumo Objetivo: avaliar parâmetros sanguíneos em frangos de corte da linha genética Cobb500, após administração de azeite essencial de orégano (Lippia origanoides) (AEO). Materiais e métodos: Foram utilizados 200 frangos de linha genética Cobb 500 e foram realizadas medições nos dias 14, 28 e 42. Os animais foram submetidos aleatoriamente a uma de duas dietas: dieta comercial com antibiótico e sem este. A esta última foram adicionadas diferentes concentrações de AEO (75 ppm, 100 ppm ou 200 ppm AEO). Se realizou um desenho estatístico de blocos aleatórios em uma matriz de parcelas dividas. Resultados: os frangos do grupo D5 (200 ppm) apresentaram maiores valores em glicose, fosfatase e fósforo que os frangos alimentados com antibiótico (D2) ao longo do experimento. Conclusão: a adição de 200 ppm de AEO no alimento de frangos de corte da linha genética Cobb 500 induz a uma melhora em metabolitos sanguíneos. Este trabalho permitiu avaliar as variáveis metabólicas de frangos que consumiram AEO.

Type B Aortic Dissection with Retrograde Intramural Hematoma and Pulmonary Embolism.

We report the case of 67-year old male patient who was admitted with a 2-week history of progressively worsening chest pain and dyspnea. Diagnostic investigation showed a type B aortic dissection with a retrograde intramural hematoma and bilateral pulmonary embolism. These simultaneous findings highly complicated patient management. Patient was started on anticoagulation therapy with partial resolution of pulmonary embolism after which surgical correction was performed. The patient was successfully submitted to a modified Frozen Elephant Trunk technique with a 3-branched customized Dacron tube and aortic arch replacement with E-Vita Open Plus. Patient post-operative period was uneventful, and he was discharged at the tenth postoperative day. The authors consider this case to be highly unusual regarding the clinical aspects, the challenging decision-making process and the complex surgical approach performed with a favorable outcome.

Os autores descrevem o caso de um homem de 67 anos, admitido por dor torácica e dispneia, de agravamento progressivo, com 2 semanas de evolução. A investigação diagnóstica revelou disseção aórtica tipo B com hematoma intramural retrógrado complicado com embolia pulmonar bilateral, o que constituiu um desafio na abordagem terapêutica deste doente. O doente iniciou terapêutica anticoagulante com resolução parcial da embolia pulmonar e foi submetido, posteriormente, a correção cirúrgica com a técnica Frozen Elephant Trunk modificada com implantação de um tubo Dacron com 3 ramos e substituição do arco aórtico com E-Vita Open Plus. O pós-operatório decorreu sem intercorrências e teve alta ao décimo dia de internamento. Os autores consideram este caso invulgar no que diz respeito à combinação dos aspetos clínicos com difícil manejo terapêutico e à complexa abordagem cirúrgica realizada, com desfecho favorável.

Extracellular pH and lung infections in cystic fibrosis.

Cystic fibrosis (CF) is an autosomal recessive disease caused by CFTR mutations. It is characterized by high NaCl concentration in sweat and the production of a thick and sticky mucus, occluding secretory ducts, intestine and airways, accompanied by chronic inflammation and infections of the lungs. This causes a progressive and lethal decline in lung function. Therefore, finding the mechanisms driving the high susceptibility to lung infections has been a key issue. For decades the prevalent hypothesis was that a reduced airway surface liquid (ASL) volume and composition, and the consequent increased mucus concentration (dehydration), create an environment favoring infections. However, a few years ago, in a pig model of CF, the Na+/K+ concentrations and the ASL volume were found intact. Immediately a different hypothesis arose, postulating a reduced ASL pH as the cause for the increased susceptibility to infections, due to a diminished bicarbonate secretion through CFTR. Noteworthy, a recent report found normal ASL pH values in CF children and in cultured primary airway cells, challenging the ASL pH hypothesis. On the other hand, recent evidences revitalized the hypothesis of a reduced ASL secretion. Thus, the role of the ASL pH in the CF is still a controversial matter. In this review we discuss the basis that sustain the role of CFTR in modulating the extracellular pH, and the recent results sustaining the different points of view. Finding the mechanisms of CFTR signaling that determine the susceptibility to infections is crucial to understand the pathophysiology of CF and related lung diseases.

Efecto de la inclusión de aceite esencial de orégano (Lippia origanoides) sobre perfil lipídico en carne de pollos de engorde / Effect of inclusion of essential oil of oregano (Lippia origanoides) on lipid profile in broiler meat

Antecedentes: la trasmisión de trazas de antibióticos en la carne, ha llevado a la prohibición de la utilización de alimentos con antibióticos promotores de crecimiento en las diferentes especies productivas para consumo humano. Por lo anterior, se hace necesario buscar nuevas alternativas que puedan remplazar la función que éstos desempeñan durante el proceso productivo. Objetivo: evaluar el perfil lipídico de pechugas en pollos de engorde de la línea genética Cobb500, luego de la administración Aceite Esencial de Orégano (Lippia origanoides) (AEO). Métodos: se utilizaron 200 pollos de línea genética Cobb500 y se realizó el muestreo de pechuga para el perfil lipídico, sólo el día 42. Los animales fueron aleatorizados a una de cinco dietas: dieta comercial con y sin antibiótico, dieta comercial sin antibiótico adicionada con diferentes niveles de AEO (75ppm, 100ppm o 200ppm AEO). Los animales fueron sacrificados a los 42 días de edad, y se realizó la toma de muestras de pechuga y contramuslo para determinar el perfil de ácidos grasos por cromatografía de gases. Se realizó un diseño estadístico de bloques al azar cada tratamiento tuvo un total de cuatro repeticiones; el análisis estadístico se realizó según el procedimiento GLM (Modelos Lineales Generales) del SAS. Resultados: el perfil lipídico en pechugas mostró resultados más sobresalientes en la dieta con mayor adición de AEO (0.72, C14:0; 29.1, C16:0; 6.01, C18:0). Conclusión: La adición de 200ppm de AEO (Lippia origanoides) en el alimento de pollos de engorde de la línea genética Cobb500 induce una mejora en la composición de ácidos grasos de su carne.

Background: the transmission of traces of antibiotics in meat, has led to the prohibition of the use of food with antibiotics growth promoters in the different productive species for human consumption. Therefore, it is necessary to look for new alternatives that can replace the function they perform during the production process. Objectives: to evaluate the lipid profile of breasts in broilers of the Cobb500 genetic line, after the administration of Essential Oil of Oregano (Lippia origanoides) (AEO). Methods: 200 chickens of Cobb500 genetic line were used. The animals were randomized to one of five diets: commercial diet with and without the addition of antibiotic, commercial diet without antibiotic added with three different levels of AEO (75ppm, 100ppm or 200ppm AEO). The animals were sacrificed at 42 days of age, and breast and thigh samples were taken to determine the fatty acid profile by gas chromatography. A statistical block design was performed randomly, each treatment had a total of four repetitions; the statistical analysis was performed according to the GLM (General Linear Models) procedure of the SAS. Results: the lipid profile in breasts showed more outstanding results in the diet with greater addition of AEO (0.72, C14: 0, 29.1, C16: 0, 6.01, C18: 0). Conclusions: the addition of 200ppm of AEO in the broiler feed of the Cobb500 genetic line induces an improvement in meat quality in the fatty acid composition of the broiler carcass.

A global classification of coastal flood hazard climates associated with large-scale oceanographic forcing.

Coastal communities throughout the world are exposed to numerous and increasing threats, such as coastal flooding and erosion, saltwater intrusion and wetland degradation. Here, we present the first global-scale analysis of the main drivers of coastal flooding due to large-scale oceanographic factors. Given the large dimensionality of the problem (e.g. spatiotemporal variability in flood magnitude and the relative influence of waves, tides and surge levels), we have performed a computer-based classification to identify geographical areas with homogeneous climates. Results show that 75% of coastal regions around the globe have the potential for very large flooding events with low probabilities (unbounded tails), 82% are tide-dominated, and almost 49% are highly susceptible to increases in flooding frequency due to sea-level rise.

CFTR impairment upregulates c-Src activity through IL-1ß autocrine signaling.

Cystic Fibrosis (CF) is a disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Previously, we found several genes showing a differential expression in CFDE cells (epithelial cells derived from a CF patient). One corresponded to c-Src; its expression and activity was found increased in CFDE cells, acting as a signaling molecule between the CFTR activity and MUC1 overexpression. Here we report that bronchial IB3-1 cells (CF cells) also showed increased c-Src activity compared to 'CFTR-corrected' S9 cells. In addition, three different Caco-2 cell lines, each stably transfected with a different CFTR-specific shRNAs, displayed increased c-Src activity. The IL-1ß receptor antagonist IL1RN reduced the c-Src activity of Caco-2/pRS26 cells (expressing a CFTR-specific shRNA). In addition, increased mitochondrial and cellular ROS levels were detected in Caco-2/pRS26 cells. ROS levels were partially reduced by incubation with PP2 (c-Src inhibitor) or IL1RN, and further reduced by using the NOX1/4 inhibitor GKT137831. Thus, IL-1ß→c-Src and IL-1ß→NOX signaling pathways appear to be responsible for the production of cellular and mitochondrial ROS in CFTR-KD cells. In conclusion, IL-1ß constitutes a new step in the CFTR signaling pathway, located upstream of c-Src, which is stimulated in cells with impaired CFTR activity.

Frozen Elephant Trunk with E-Vita Open Hybrid Prosthesis for Surgical Correction of Multisegmental Thoracic Aortic Pathology: Review of Results.

INTRODUCTION: The Frozen Elephant Trunk (FET) surgery allows correction of ascending, arch and proximal descending aortic pathology, using a hybrid prosthesis at the same time. It is a complex intervention and requires a multidisciplinary team that, besides scheduling and performing the surgery, accompanies the patient (pt) throughout the postoperative period. OBJECTIVES: To review short and medium term clinical results with this technique. METHODS: Between January 2010 and September 2017, we operated 34 patients (pts) using FET. The surgery was performed under cardiopulmonary bypass (CPB) with cardio-circulatory arrest in deep hypothermia, always with bilateral antegrade selective cerebral protection and under noninvasive neuromonitorization. Antegrade and retrograde, hematic, cold, intermittent cardioplegia was used. All patients were followed in our outpatient clinic with imaging techniques. RESULTS: The mean age of the pts was 62.8 ± 11.5 years, 16 males. The mean follow-up period was 18.7 ± 16.1 months. Diagnoses were: chronic type A dissection 9 pts, ascending aortic aneurysm and distal arch 9 pts, pseudoaneurysm 1 pt, mega-aorta syndrome 11 pts. No pt was operated in acute situation. Seven pts (20.6%) were reoperations and in 4 pts (11.8%) associated cardiac procedures were required. The left subclavian was conserved in 24 pts (70.6%). CPB, aortic clamping and distal ischemia mean times were, respectively; 260, 149 and 54 minutes. Hospital mortality occurred in five pts (14.7%), 3 of which at the beginning of the series, due to mesenteric ischemia. The hospital morbidity consisted of: ventilator-associated pneumonia 3 pts (8.8%), stroke 2 pts (5.9%), perioperative infarction 1 pt (2.9%) and paraplegia 1 pt (2.9%). Seven pts (20.6%) required 9 endovascular re-interventions (TEVAR) in the distal descending aorta and in two of these an abdominal fenestrated endoprosthesis was implanted by the vascular team. Three pts presented early type IIB endoleaks, which resolved spontaneously in follow-up CT. Among the others there were no endoleaks and the expected involution of the aneurysmal sac and positive remodeling of the aorta was observed. All survivors are clinically stable, asymptomatic, in class NYHA I. CONCLUSION: The overall results are in line with the literature. Mesenteric ischaemia is the leading cause of in-hospital death. FET is a safe and effective intervention. The expandable segment of the hybrid prosthesis is an excellent landing zone to complete the procedure, when necessary, with the second stage TEVAR. Survivors acquire an excellent quality of life in the medium term. Clinical follow-up and lifelong imaging techniques are mandatory.

TEVAR - A Primary or Adjunct Procedure Helpful in the Surgical Correction of Complex Pathology of the Thoracic Aorta?

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) made possible the treatment of aortic disease that previously could only be approached openly, associated with a considerable morbidity and mortality. However, it also brings new challenges influencing patient selection - favourable landing zone, good peripheral access, propensity for endoleak (EL) - that requires rigorous clinical and imaging follow- -up. OBJECTIVE: Review all patients that underwent TEVAR in our Department and assess morbidity and mortality. METHODS: From November 2007 to September 2017, 57 TEVAR were performed in our Department to 52 patients. All patients performed postoperative CT angiography within 30 days after surgery. Follow-up was carried in our Outpatient Clinic with annual imaging. Statistical analysis was performed with SPSSTM 22 (© IBM). RESULTS: Patients' mean age was 65.6 ± 10.3 years and 69.2% were male (n = 36). Mean follow-up was 48.1 ± 34.1 months. The most frequent surgical indication was thoracic aortic aneurysm (42.1%), followed by chronic type B aortic dissection (35.1%), pseudoaneurysm (10.5%), reintervention by EL (7.0%), penetrating aortic ulcer (3.5%) and traumatic dissection of the aorta (1.8%). Surgery was elective in 87.7% of cases and part of a dual stage strategy in 17.3%. In-hospital mortality was 3.9%. Survival at 1, 2 and 5 years was 87.9%, 85.6% and 71.5%, respectively. Reported complications were: need for endovascular reintervention 7.7%; complication of femoral access 7.7%; and cerebellar infarction 1.9%. Throughout follow-up, no EL was detected in 56.1% of patients. There was an incidence of early EL in 38.4%, of which 45.0% had spontaneous resolution, documented in subsequent CT scans. The most frequent was type IA (42.9%) that was also the one with the highest spontaneous resolution rate (62.5%). Mean time to diagnosis of late EL was 36.9 ± 21.4 months and occurred in 11.5% of patients, the most frequent being type IA (50.0%); there was no spontaneous resolution observed. In all cases of reintervention due to EL a good surgical result was obtained. CONCLUSION: TEVAR is a procedure with low morbidity and mortality, good long-term outcome and a relatively low incidence of EL. Most patients do not have EL during their follow-up and have an excellent survival. The most frequent early EL is type IA and about half resolve in the following months. Although rare, late EL did not present spontaneous resolution. The treatment of EL can easily be achieved with new intervention and excellent result.

Simplified Technique for Aortic Arch Replacement in Patients at High Risk for Frozen Elephant Trunk.

INTRODUCTION: Surgical approach of multisegmental pathology of the thoracic aorta, namely aortic arch / descending aorta is challenging. The Frozen Elephant Trunk (FET) has good results, with acceptable risk. However, in the subgroup of patients (pts) older than 75 years and with important comorbidities, the surgical risk is very high. OBJECTIVES: Review short-term results of this original, simplified and potentially hybrid technique developed in our Department for this subgroup of patients. METHODS: From January 2016 to September 2017, 10 pts were operated with this technique - mean age 70.2 ± 15.3 years, 7 males. The diagnoses were: 6 pts with aneurysmal disease and 4 pts with aortic dissection. Four pts had previous cardiac surgery. The surgical concept consists of 3 key points: 1) Use of a patient-tailored graft, built in a back-table, to replace the ascending aorta and arch, with side-branches proximally anastomosed to reroute the supra-aortic vessels, allowing a proximal, long Landing Zone for eventual TEVAR. 2) Debranching of the supra-aortic vessels. 3) Maintain bilateral anterograde selective cerebral perfusion. All pts were operated on cardiopulmonary bypass (CPB) with a period of hypothermic (24oC) cardiocirculatory arrest for the open distal anastomosis. Preservation of the left subclavian artery depended on paraplegia risk and was individually assessed preoperatively. In a second stage, a TEVAR was electively deployed in 2 patients. All patients were followed in our clinic and imaging clinic at 6 months and annually after surgery. RESULTS: Mean CPB, aortic cross clamping and visceral ischemia were, respectively, 196, 120 and 44 minutes. One pt died in- hospital due to bowel ischemia. Four pts had respiratory complications requiring prolonged ventilation. The mean ICU and hospital stay was, respectively, 7,8 and 23,6 days. The mean follow-up was 15.2 months and three pts died during this follow-up. One pt was re-hospitalized with deep sternal wound infection. Of the survivors, one had a stroke at 6 months postoperatively and the remainder are asymptomatic. The postoperative period of the 2 pts submitted to TEVAR was uneventful; to date, they remain surgically stable, without needing re-intervention. CONCLUSION: The technique is effective and avoids the burden of FET. The short-term results are encouraging but, in the long-term, they should be evaluated to determine their role among arch interventions, specially their value in relation to recent pure endovascular techniques with fenestrated or branched endoprosthesis. Long ICU and hospital stay points towards the implementation of measures and protocols to improve them.

Ascending Aorta Aneurysms in Octogenarians.

INTRODUCTION: Older age is often regarded as a relative contraindication for open surgery for aortic aneurysms. These individuals often have a greater comorbidity burden that predispose them for development of postoperative complications. The aim of our study is to evaluate the surgical outcomes of selected octogenarians after open aortic surgery. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 67.7% of the patients were male. The mean age was 81.5 ± 1.8 years. The preoperative comorbidities were hypertension (83.9%), aortic valve disease (54.8%), dyslipidaemia (48.4%), renal impairment (9.7%), type 2 diabetes mellitus (9.7%) and COPD (3.2%). As for the procedures performed the majority was aortic valve replacement and graft interposition (48.4%) followed by graft interposition (35.5%), ascending aorta and arch replacement (9.7%) and graft interposition and combined CABG (6.5%). 16.1% of the procedures were reoperations and 6.5% were performed as urgent. In-hospital mortality was 9.4% and 1-year survival was 77.4%. The mean survival time after surgery was 736.4 ± 530.3 days. As for complications, 22.6% developed respiratory complications, 6.5% had infectious complications and 3.2 developed renal and central nervous system complications. Older age was not related to early (p = 0.266) or late mortality (p = 0.779). There was no association between older age and longer ICU stay (p = 0.781) or total hospital stay (p = 0.985). CONCLUSIONS: Highly selected octogenarians benefit from surgery, having a similar rate of postoperative complications and survival, as described in the literature.

Cardiac Fibroelastoma: 10-Year Experience.

INTRODUCTION: Papillary fibroelastoma is one of the most common types of primary cardiac tumour. Though a rare pathology, its importance relates to its form of presentation, with stroke and sudden death, and the questions regarding its management. OBJECTIVES: To review the casuistic of cardiac tumours in our service, in special the papillary fibroelastomas. METHODS: clinical case series overviewing the period from 1st January 2008 to 30th September 2017. We analysed all patients submitted to cardiac surgery due to cardiac masses or tumours and verified all the pathology results to confirm the diagnosis. RESULTS: In the period selected, around 6500 surgeries were performed. Of those, 59 patients were operated on due to cardiac tumours. 81.4% were myxomas, 13.6% were papillary fibroelastomas, 3.4% were cardiac sarcomas and 1.7% were metastasis. Of the patients that had papillary fibroelastomas (n=8), 5 were male, and the mean age was 51.5 ± 16.2 years. 62.5% (n=5) had origin in the aortic valve and 37.5% (n=3) in the mitral valve. Regarding presentation, 3 patients presented with stroke, 2 patients had episodes of syncope and 3 patients were asymptomatic. After surgery, all patients remained asymptomatic and there was no evidence of recurrence. At the end of follow-up all patients were alive. CONCLUSION: Although a rare pathology, papillary fibroelastomas remain important due to their potential for embolization and cardiac chamber obstruction, therefore should be primarily treated with surgery.

Elective 2nd Stage TEVAR to Complete Frozen Elephant Trunk in the Surgical Correction of Complex Multisegmental Pathology of the Thoracic Aorta.

INTRODUCTION: Classical conventional surgery to treat multi-segmental thoracic aortic disease in two operative stages, sternotomy and left thoracotomy, is associated with significant mortality and complications. The Frozen Elephant Trunk (FET) associated with an endovascular procedure (TEVAR) allows an extensible and simplified surgical approach of the descending and thoracoabdominal aorta without increasing the risk. METHODS: Retrospective study of 8 patients (pts), 5 males, mean age 67.5 ± 4.2 years, with ascending and arch disease associated with descending aortic disease (chronic dissection 2 pts, aneurysmal disease 6 pts), treated between January 2014 and September 2017. All survivors are periodically followed up in our outpatient clinic with CT or MRI angiography. RESULTS: The average follow-up period is 18,7 ± 12,2 months. In the first stage (FET) - the left subclavian was conserved in all cases. In six of these pts, after an average period of 37 days, a TEVAR was performed, to complete the exclusion of the aneurysmal sac or the false lumen in the descending aorta. In 2 pts, the interval was longer and in the same intervention, a fenestrated endoprosthesis was implanted in the abdominal aorta by the vascular team. After TEVAR, mean ICU time was 16 hours and hospitalization was 5,2 days. One pt died in the 1st month post-intervention TEVAR + EVAR fenestrated. The remaining pts are stable and asymptomatic, in Class I NYHA, without endoleaks and with the expected involution of the aneurysmal sac and positive remodeling of the aorta. There were no cases of paraplegia or other neurological complications documented. CONCLUSION: This strategy is safe and effective. Clinical follow- -up associated with close postoperative imaging surveillance is required not only to determine the optimal interval between the two stages, which is dependent on the anatomy and underlying pathology of each patient, but also to identify possible complications. The quality of life of these pts in the medium-term is excellent.

Ascending Aorta Aneyrysms Over 70mm.

INTRODUCTION: Current guidelines suggest that patients with aortic diameter over 55-60 mm should undergo ascending aorta replacement, depending on associated valve pathology and other comorbidities. Studies show that the risk of aortic rupture over 60 mm is over 30%. Even though, we still receive in our practice patients that present with aneurysms of greater dimensions. The aim of our study is to evaluate the surgical outcomes of patients presenting with ascending aorta with diameter larger than 70 mm. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 64.5% of the patients were male. The mean age was 67.9 ± 12.9 years. The preoperative comorbidities were hypertension (64.5%), dyslipidaemia (45.2%), aortic valve disease (35.4%), renal impairment (9.7%) and COPD (3.2%). The average diameter was 82.3 ± 18.6 mm, with values ranging from 70 to 160 millimeters. As for the procedures performed the majority was interposition of prosthetic graft (45.2%), followed by aortic valve replacement and graft interposition (35.5%), Frozen Elephant Trunk (12.9%), tube interposition and combined CABG (3.2%) and aortic root replacement with graft interposition (3.2%). 9.7% of the procedures were reoperations and 9.7% were performed as urgent. In-hospital mortality was 3.2% and 1-year survival was 83.9%. The mean survival time after surgery was 1135.9 ± 777.1 days. As for complications, 29% developed respiratory complications, 9.7% had cardiac complications, 6.5% had central nervous system complications and 3.2% developed renal and vascular complications. Greater diameter was not associated with early (p = 0.929) or late mortality (p = 0.987). CONCLUSIONS: These results show that patients with aneurysms greater than 70 mm can be safely operated on, with no increase in complications in the postoperative period or greater mortality.