Abstract Vaccine-induced immune thrombotic thrombocytopenia (VITT) is primarily a complication of adenoviral vector-based COVID-19 vaccination. Emerging data are consistent with the possibility that rare cases of VITT may be seen in the setting of an mRNA vaccine. We present a case of a 62-year-old man, admitted due to multiple arterial and venous thrombotic events with severe thrombocytopenia, coagulopathy and elevated D-dimer, some days after administration of mRNA COVID-19 vaccine. After the exclusion of other etiologies and in the presence of detectable antibodies against anti-PF4 (ELISA only), the diagnosis of VITT was made. The patient improved after starting treatment with intravenous immunoglobulin, methylprednisolone, and argatroban, followed by oral prednisolone and apixaban. Despite anticoagulation a progression of a deep vein thrombosis happened, and anticoagulation therapy was changed to unfractionated heparin and then to warfarin. Despite the guidelines, increasing knowledge of VITT pathogenesis suggests that heparin does not worsen the course of the disease.

Resumo A trombocitopenia trombótica imune induzida pela vacina (VITT) é uma complicação primariamente associada às vacinas COVID-19 de vetor adenovírus. Dados emergentes são consistentes com a possibilidade desta entidade ser observa-da no contexto de vacinas de mRNA. Apresentamos o caso de um homem de 62 anos, internado devido a múltiplos eventos trombóticos arteriais e venosos com trombocitopenia grave, coagulopatia e D-dímeros elevados, dias após a administração de uma vacina de mRNA contra a COVID-19. Após exclusão de outras etiologias e na presença de anticorpos anti-PF4, considerou-se o diagnóstico de VITT. O doente melhorou após o tratamento com imunoglobulina intravenosa, metilprednisolona e argatroban, seguido de prednisolona oral e apixabano. Apesar da anti-coagulação, houve progressão do processo trombótico e a terapêutica anticoagulante foi alterada para heparina não fracionada e posteriormente para varfarina. Apesar das guidelines, o conhecimento crescente da patogénese da VITT sugere que a heparina não agrava o curso da doença.

Abstract Epidural analgesia is frequently used for labour analgesia, and major complications are rare. This article illustrates a case of a healthy woman submitted to a caesarean section under epidural anaesthesia, which developed postpartum fever, worsening abdominal and lumbar pain and neurologic deficits. Lumbar magnetic resonance confirmed the epidural abscess with spinal compression, demanding urgent laminectomy and surgical drainage , along with prolonged antibiotic therapy. Epidural abscess, although a rare complication, can have an important impact on neurologic integrity. The clinical manifestations are unspecific, and timely diagnosis and treatment are crucial to prevent permanent neurologic damage and death.

Resumo Introdução: A investigação clínica (IC) é essencial para a formação médica, além de requisito obrigatório do currículo de Ginecologia e Obstetrícia (GO). Contudo, a literatura acerca da atitude dos internos portugueses relativamente à IC é escassa. O objetivo deste estudo foi avaliar obstáculos e incentivos à IC no internato de GO em Portugal. Materiais e Métodos: Estudo transversal, com realização de um questionário, anónimo, aos internos portugueses de GO, avaliando dados demográficos, experiência e perceções acerca dos obstáculos e incentivos à IC. Resultados: Dos 65 (25,5%) internos que responderam ao questionário, 90,8% eram mulheres. Destes, 58,5% provinham de hospital central e 41,5% de periférico. Todas as regiões do país e anos de internato estiveram representados. A maioria respondeu que: o seu hospital não disponibilizava centro de bioestatística de apoio (66,2%), mas que esta medida seria importante (96,9%), e não oferecia formação em bioestatística (93,8%). A maioria dos centros (81,5%) tem uma reunião científica semanal e 9,2% referiu ter mais que duas. Na análise da perspetiva relativamente à IC, 80% considerava uma experiência positiva, contudo que o ambiente do seu serviço não a promovia (60%). Os obstáculos à investigação mais apontados foram: tempo disponível insuficiente, falta de apoio em bioestatística e dificuldade no acesso aos registos clínicos. A formação num hospital central associou-se significativamente a disponibilização de apoio em bioestatística (p=0,03), maior número de artigos publicados (p=0,001) e de reuniões científicas (p=0,006). Discussão e Conclusão: O conhecimento dos fatores que influenciam a motivação dos internos relativamente à investigação é fulcral para a implementação de medidas de otimização da produção científica.

Overview and aims: Several risk factors for fetal growth restriction (FGR) have been described, however the impact of maternal working conditions is still poorly understood. To evaluate the impact of type of transport used, travel time, weekly hours of work, shift work, posture, environmental conditions, physical load and occupational stress on fetal weight. Study design and population: A case-control study was conducted. All professionally active pregnant woman that attended during 3rd trimester a pregnancy surveillance consultation at two Portuguese public hospitals during 4 months were included. The population was divided in two groups: FGR group - fetuses with estimated fetal weight (EFW) below the 10th percentile at 3rd trimester ultrasound; control group - fetuses with EFW equal to or higher than 10th percentile at 3rd trimester ultrasound. Methods: Data about working conditions, anthropometric and sociodemographic characteristics were collected using a questionnaire and the occupational stress questionnaire-general version (QSO-VG). Data on obstetric characteristics was acquired from clinical records. Data analysis was performed using SPSS ®, version 22.0. Results: There were 50 pregnant women in the FGR group and 295 in the control group. A predictive model of FGR was developed including 5 variables - sitting for at least 3 hours, high occupational stress levels, work by shifts, shifts with daytime and night rotation and load or lift weights greater than or equal to 25 Kg - with high specificity (98,5%), a positive predictive value of 85.7% and a negative predictive value of 74.2%, but with a low sensitivity (20.7%). Conclusions: This study showed that maternal working conditions can be important predictors of FGR.

Overview and Aims: The decision of the route of delivery in a breech presentation is one of the most controversial topics in contemporary obstetrics. The aim of this study is to develop a predictive model for vaginal breech delivery (VBD). Study Design, Population and Methods: It was performed an observational, retrospective, descriptive study based on the review of clinical records of pregnant woman with singleton gestations in breech presentation at term, with delivery between 2005 and 2015, in Hospital de Braga and Unidade Local de Saúde do Alto Minho. Potential predictors of VBD were analyzed by bivariate analysis and binary logistic regression. Results: There were included 92 VBD and 167 cesareans. The final model includes 6 variables: Maternal age, number of previous deliveries, percentile of estimated fetus weight, weight of the heaviest previous newborn, Bishop’s index and fetal gender. The area under the curve was 0,83, corresponding to a good discriminative ability. A probability equal to or greater than 50.3% may be an adjunct to the decision of the delivery route. Conclusions: A predictive model with good discriminative capacity was developed that can be useful helping the decision of the route of delivery in pregnant woman with singleton gestations in breech presentation at term.

Overview and Aims: Technology has allowed hysteroscopy to be increasingly performed in the office (HO). Yet, fear of patient pain associated with HO still prevents clinicians from choosing it instead of traditional hysteroscopy (HA). We aimed to compare pain perception and satisfaction in patients submitted to HO versus HA and to determine socio-demographic and clinical factors that influence patient experience. Methods: We performed a prospective, observational, descriptive and analytical study, comparing women submitted to HA (n=119) and HO (n=113), between September and December 2016 and January to July 2017, respectively. Three self-report questionnaires were answered by the patients before, immediately and one month after the hysteroscopy, and another questionnaire was answered by the clinician in charge of the technique. Results: Both HA and HO groups showed similar socio-demographic characteristics. Differences were found between felt and expected pain, both in HA (p<0,001) and HO (p= 0,001), with expected pain being higher in both groups. Despite HO group reported higher levels of pain (visual analog scale 4 versus 1,87 in the HA group), patients in this group presented significantly higher satisfaction regarding information given before (p=0,040) and after procedure (p<0,001) and with changes in their daily life (p<0,001). Generally, HO group showed higher levels of global satisfaction concerning the procedure (mean 20,45 versus mean 19,4 in the HA group, p= 0,001). Furthermore, the waiting time until hysteroscopy was lower in the HO group (p=0,007). We found no association between patients characteristics and the level of global satisfaction and experienced pain during hysteroscopy. Conclusion: HO presents higher levels of global satisfaction, which may be related to better communication, less waiting time until procedure and faster return to daily activities. Thus, given the safety and cost-effectiveness of HO, fear of patient pain should not prevent most diagnostic and simple surgical hysteroscopies from being performed in the HO context.

Abstract Introduction: Pre-transfusion tests, essential for the release of blood components, may be affected by drugs. Monoclonal antibodies represent a class of medications increasingly used in the clinical practice, with anti-CD38 monoclonal antibodies (daratumumab) being a promising resource in the treatment of refractory myeloma. This monoclonal antibody recognizes CD38 in myeloma cells and interferes with pre-transfusion tests by causing panreactivity in indirect antiglobulin tests thereby clinically masking alloantibodies. Dithiothreitol is a reagent that breaks disulfide bonds and effectively destroys antigenic sites for CD38 on red blood cells. This study reports the immunohematological findings of pre-transfusion tests of patients with multiple myeloma receiving daratumumab and on solutions to prevent the interference of this monoclonal antibody. Methods: Serum samples from five patients on anti-CD38 monoclonal antibody treatment were evaluated. Tests performed included ABO/RhD typing, indirect antiglobulin test, direct antiglobulin test and eluate test. A daily evaluation was performed to determine the shelf life of dithiothreitol-treated red blood cells when stored in Alsever's solution. Results: No interference in the ABO/RhD typing results was noted but in all samples, a panreactivity was observed in indirect antiglobulin tests. Regarding the direct antiglobulin test, two samples presented positive results but negative eluates. In all samples, treatment of reagent red blood cells with 0.2 M dithiothreitol offset interference by anti-CD38 monoclonal antibodies. Dithiothreitol-treated red blood cells stored in Alsever's solution were stable for up to 15 days. Conclusion: Treatment of reagent red blood cells with dithiothreitol can be efficient and accessible to offset the interference of the anti-CD38 drug in pre-transfusion tests. The number of costly serological workups can be reduced by having stored dithiothreitol red blood cells with this proving to be a useful reagent for investigating anti-CD38.

Overview: The first trimester screening for fetal aneuploidy includes a combined evaluation of maternal age, obstetric history, ultrasound and biochemical markers. Variations in maternal serum levels of biochemical markers (free b-hCG and PAPP-A) have been associated with adverse obstetric outcomes, even in the absence of aneuploidy. This study aimed to evaluate the association of PAPP-A and free b-hCG with the occurrence of adverse obstetric outcomes, in an obstetric population with negative first trimester screening for chromosomal abnormalities. Study design: Observational, descriptive, analytic and retrospective study that included 1128 pregnancies with a negative first trimester screening, in 2013. Delivery occurred in our Hospital. Methods: The levels of both biochemical markers (free b-hCG and PAPP-A) were compared between groups with a given adverse obstetric outcome and women without any adverse event. Binary logistic regression and multiple linear regression analysis were performed to determine if free b-hCG and PAPP-A were important predictors for adverse outcomes. Results: Maternal serum levels of PAPP-A were significantly lower in women who developed pre-eclampsia compared to women without any adverse obstetric outcome (0.98±0.2 vs. 1.18±0.63 MoM; p=0.027). Maternal serum free b-hCG was significantly lower in pregnant women who had birth before 37 weeks of gestation, compared to pregnant women with a term birth (median; interquartile range: 0.78; 0.39 vs.0.94; 0.75 MoM; p=0.037). Linear regression analysis showed that PAPP-A is an independent predictor of fetal birth weight and that free b- hCG is a predictor of fetal gestational age at birth. Conclusion: Serum PAPP-A and free â-hCG in the first trimester are significantly reduced in pregnancies, with a negative first trimester combined screening for fetal aneuploidy, who developed pre-eclampsia and had a preterm delivery, respectively. In these populations, for a better risk assessment, we suggest to perform pre-eclampsia and preterm labour screening.

Overview: Integrity of the uterine cavity is critical to embryonic implantation and it is mandatory to evaluation it in the routine investigation of infertility. Hysteroscopy is considered the gold standard, allowing concomitant treatment , which optimizes the conditions for future embryo transfers. Nevertheless, controversies still exist in its routine performance prior to the first assisted reproductive technique. Aims: To assess the concordance between the findings of transvaginal ultrasonography and hysteroscopy and to investigate risk factors for intracavitary pathology. Study Design: Retrospective observational study. Population: 104 women submitted to transvaginal ultrasonographic evaluation (with normal uterine cavity evaluation) and hysteroscopy before the first assisted reproductive technique. Methods: A database was constructed through the analysis of each patient's file. Descriptive and inferential statistical analysis was performed with Statistical Package for Social Sciences, version 20.0. P ≤0,05 was considered statistically significant. Results: The study group had a mean age of 33,3 years and a mean duration of infertility of 45,6 months. About 87% patients had primary infertility. Hysteroscopy revealed intracavitary alterations in 20 women. In 6 patients a simultaneous surgical procedure was performed and 4 had an alteration of the therapeutic plan. No complications were documented. Descriptive analysis revealed that uterine abnormalities observed in hysteroscopy were significantly more frequent in women aged ≥ 35years (35,1 vs 32,8%, p=0,008). In the logistic regression it was observed that hysteroscopic alterations were significantly and positively associated with female age ≥35years (OR=2,85; IC95%: 1,1-7,7). Conclusions: Ultrasound findings were not consistent with hysteroscopic findings in 19,23% patients, and this was more frequent in women aged ≥35years. Hysteroscopy has a special role in the investigation of infertility, mainly in populations with risk factors for intracavitary anomaly and its impact should be reassessed.

Resumo Objetivo: O objetivo deste estudo é descrever a experiência de uma instituição no tratamento com intenção curativa de doentes diagnosticados com carcinoma espinocelular da hipofaringe localmente avançado. Materiais e Métodos: Os dados relativos aos doentes portadores de carcinoma espinocelular da hipofaringe localmente avançado tratados entre janeiro de 2006 e junho de 2012 foram revistos. Resultados: Foram incluídos 144 doentes. O tempo mediano de seguimento foi 36,6 meses. A sobrevivência mediana, aos 2 anos e aos 5 anos foi 26 meses, 51% e 30,5%, respectivamente. A sobrevivência livre de recorrência mediana, aos 2 anos e aos 5 anos foi 18 meses, 42,8% e 28,5%, respectivamente. Conclusão: Os resultados encontrados na nossa série estão em acordo com a literatura.

Abstract Objective: The present study was aimed at describing a single-institution experience in the curative treatment of patients diagnosed with locally advanced hypopharyngeal squamous cell carcinoma. Materials and Methods: Data concerning all patients treated for locally advanced hypopharyngeal squamous cell carcinoma between January 2006 and June 2012 were reviewed. Results: A total of 144 patients were included in the present study. The median follow-up period was 36.6 months. Median survival was 26 months, and 2-year and 5-year overall survival rates were, 51% and 30.5%, respectively. Median recurrence-free survival was 18 months and 2-year and 5-year recurrence-free survival rates were 42.8% and 28.5%, respectively. Conclusion: The outcomes in the present series are in line with the literature.

The objective of this study was to describe the Brazilian scientific reports published over the past twenty years on Fournier's gangrene. It is an integrative review conducted through incursions in the LILACS, MEDLINE, BDENF and Coleciona SUS databases with the descriptor ‘Fournier's Gangrene’. Texts published between January 1994 and July 2014, in Portuguese, and freely available online were selected. According to the 14 articles found, the main symptoms of Fournier's gangrene include discomfort with painful sensations, high fever, edema, malaise, and sweating. In most cases erythema and blistering are observed, evolving into a wound. The clinical profile assists in the selection of empirical antimicrobial therapy even before the culture results. It was concluded that early diagnosis and appropriate and aggressive treatment are crucial in patient prognosis. There is still a shortage of Brazilian scientific production with a high power of evidence on the subject.

El objetivo fue describir producciones brasileñas publicadas en los últimos veinte años acerca de la gangrena de Fournier. Revisión integradora realizada en las bases de datos LILACS, MEDLINE, BDENF y Colecciona SUS, con el descriptor "Gangrena de Fournier". Se seleccionaron textos publicados entre enero de 1994 y julio de 2014, en portugués y disponibles gratuitamente en Internet. Según los 14 artículos encontrados, los principales síntomas de la gangrena de Fournier incluyen malestar, con sensaciones dolorosas, fiebre alta, edema, malestar general, sudoración. En la mayor parte de los casos, son observados eritema y formación de bollas, surgiéndose una herida. El cuadro clínico ayuda en la selección de la terapia antimicrobiana empírica antes del resultado de la cultura. En conclusión, el diagnóstico precoz y el tratamiento apropiado y agresivo son cruciales en el pronóstico del paciente. Aún, hay escasez de producciones científicas brasileñas con gran poder de evidencia sobre el tema.

Objetivou-se descrever os registros científicos brasileiros publicados nos últimos vinte anos acerca da gangrena de Fournier. Trata-se de uma revisão integrativa realizada por intermédio de incursões nas bases LILACS, MEDLINE, BDENF e Coleciona SUS com o descritor "Gangrena de Fournier". Foram selecionados os textos publicados entre janeiro de 1994 e julho de 2014, em português e disponíveis gratuitamente online. De acordo com os 14 artigos encontrados, os principais sintomas da gangrena de Fournier incluem desconforto com sensações dolorosas, febre elevada, edema, mal estar e sudorese. Na maior parte dos casos são observados eritema e formação de bolhas, evoluindo para uma ferida. O quadro clínico auxilia na seleção da terapêutica antimicrobiana empírica antes mesmo do resultado da cultura. Conclui-se que o diagnóstico precoce e o tratamento adequado e agressivo são determinantes no prognóstico do paciente. Ainda há escassez de produções científicas brasileiras com alto poder de evidência sobre o tema.