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Association of Chronic Heart Failure with Mortality in Old Intensive Care Patients Suffering from Covid‐19
No full textAims: Chronic heart failure (CHF) is a major risk factor for mortality in coronavirus disease 2019 (COVID-19). This prospective international multicentre study investigates the role of pre-existing CHF on clinical outcomes of critically ill old (≥70 years) intensive care patients with COVID-19.
Methods and results: Patients with pre-existing CHF were subclassified as having ischaemic or non-ischaemic cardiac disease; patients with a documented ejection fraction (EF) were subclassified according to heart failure EF: reduced (HFrEF, n = 132), mild (HFmrEF, n = 91), or preserved (HFpEF, n = 103). Associations of heart failure characteristics with the 30 day mortality were analysed in univariate and multivariate logistic regression analyses. Pre-existing CHF was reported in 566 of 3917 patients (14%). Patients with CHF were older, frailer, and had significantly higher SOFA scores on admission. CHF patients showed significantly higher crude 30 day mortality [60% vs. 48%, P < 0.001; odds ratio 1.87, 95% confidence interval (CI) 1.5-2.3] and 3 month mortality (69% vs. 56%, P < 0.001). After multivariate adjustment for confounders (SOFA, age, sex, and frailty), no independent association of CHF with mortality remained [adjusted odds ratio (aOR) 1.2, 95% CI 0.5-1.5; P = 0.137]. More patients suffered from pre-existing ischaemic than from non-ischaemic disease [233 vs. 328 patients (n = 5 unknown aetiology)]. There were no differences in baseline characteristics between ischaemic and non-ischaemic disease or between HFrEF, HFmrEF, and HFpEF. Crude 30 day mortality was significantly higher in HFrEF compared with HFpEF (64% vs. 48%, P = 0.042). EF as a continuous variable was not independently associated with 30 day mortality (aOR 0.98, 95% CI 0.9-1.0; P = 0.128).
Conclusions: In critically ill older COVID-19 patients, pre-existing CHF was not independently associated with 30 day mortality.info:eu-repo/semantics/publishedVersio
A Phylogenomic Approach for the Analysis of Colistin Resistance-Associated Genes in Klebsiella Pneumoniae, its Mutational Diversity and Implications for Phenotypic Resistance
No full textThe emergence of carbapenemase-producing Klebsiella pneumoniae strains has triggered the use of old antibiotics such as colistin. This is driving the emergence of colistin resistance in multidrug-resistant strains that underlie life-threatening infections. This study analyses the mutational diversity of 22 genes associated with colistin resistance in 140 K. pneumoniae clinical isolates integrated in a high-resolution phylogenetic scenario. Colistin susceptibility was accessed by broth microdilution. A total of 98 isolates were susceptible and 16 were resistant, 10 of which were carbapenemase producers. Across the 22 genes examined, 171 non-synonymous mutations and 9 mutations associated with promoter regions were found. Eighty-five isolates had a truncation and/or deletion in at least one of the 22 genes. However, only seven mutations, the complete deletion of mgrB or insertion sequence (IS)-mediated disruption, were exclusively observed in resistant isolates. Four of these (mgrBIle13fs, pmrBGly207Asp, phoQHis339Asp and ramAIle28Met) comprised novel mutations that are potentially involved in colistin resistance. One strain bore a ISEcp1-blaCTX-M-15::mgrB disruption, underlying co-resistance to third-generation cephalosporins and colistin. Moreover, the high-resolution phylogenetic context shows that most of the mutational diversity spans multiple phylogenetic clades, and most of the mutations previously associated with colistin resistance are clade-associated and present in susceptible isolates, showing no correlation with colistin resistance. In conclusion, the present study provides relevant data on the genetic background of genes involved with colistin resistance deeply rooted across monophyletic groups and provides a better understanding of the genes and mutations involved in colistin resistance.info:eu-repo/semantics/publishedVersio
Long‐Term Survival After Choriocarcinoma Transmitted by Liver Graft: A Successful Report in Pediatric Transplantation
No full textBackground: LT is the standard of care for many pediatric liver disorders. Although long-term outcomes have improved, some rare complications such as transmission of occult donor tumors have been reported.
Case report: An adolescent diagnosed with tyrosinemia was submitted to LT from a previous healthy donor due to HCC. Almost 8 months after LT, the patient presented a nodular hepatic lesion. Clinically, he had mild weight loss, lower limb edema, and gynecomastia. Thorax CT found lesions in the left lung parenchyma, which showed no increased uptake in PET SCAN. Liver biopsy revealed a carcinoma with desmoplastic stroma. ISS was withdrawn, and palliative chemotherapy was started for presumptive HCC relapse. AFP remained normal, but HCG had reached unexpected values of 1984 IU/L. As we requested detailed information about the other organ recipients from the same donor, we found that one of them passed away due to disseminated tumor. Five months after the beginning of chemotherapy, the patient underwent resection of liver segments V and VI. Histological examination confirmed liver metastatic choriocarcinoma. At the time of writing, with 11 years of follow-up, the patient had sustained remission with no signs of relapse.
Discussion: This case reports a diagnostic challenge in an adolescent with a particular unique background and a very rare pattern of tumor transmission. The authors aim to highlight the risk of cancer-bearing organs reveled post-LT and to testimony the experience of the successful outcome after a choriocarcinoma transmitted by liver graft.info:eu-repo/semantics/publishedVersio
Localização Pré-Operatória de Adenomas da Paratiroide no Hiperparatiroidismo Primário: o Papel da Ecografia Cervical com Doppler
No full textIntroduction: Parathyroid adenoma is the most frequent cause of primary hyperparathyroidism. In recent years, the preoperative location of parathyroid adenomas allowed minimally invasive surgical techniques that have become preferred over the traditional bilateral neck exploration. The more recent guidelines on this subject highlight the role of nuclear medicine imaging tests. The aim of this study was to review the current role of Doppler ultrasound (US) in assessing the preoperative location of parathyroid adenomas in patients with primary hyperparathyroidism.
Material and methods: Retrospective study based on data from patients with primary hyperparathyroidism that underwent parathyroidectomy between January 2013 and January 2022 at the Centro Hospitalar Universitário Lisboa Central. Statistical analysis was performed with IBM SPSS Statistics, version 26.0.0.0®.
Results: Parathyroidectomy was performed in 171 patients (77.8% females) with primary hyperparathyroidism. Cervical Doppler ultrasound was the most performed test (64.3%, n = 110) for preoperative location and detected a suspicious lesion in 98 patients (89.1%). The preoperative location of the parathyroid adenomas was assessed through the Doppler ultrasound and was compared with the surgical reports and histological findings; a correct identification was made in 76 patients (77.6%). Doppler ultrasound slightly underestimated the mean adenoma size (18.1 ± 7.7 mm preoperative versus 22 ± 8.4 mm postoperative). Calcium, parathyroid hormone levels, adenoma size and concomitant presence of thyroid nodules did not affect the accuracy of Doppler ultrasound.
Conclusion: Doppler ultrasound showed high diagnostic accuracy even in patients with nodular thyroid disease regardless of calcium and parathyroid hormone levels and adenoma size. Furthermore, its safety, affordability and availability should favor its use as first line test in primary hyperparathyroidism to assess the preoperative location of parathyroid adenomas.Introdução: O adenoma da paratiroide é a causa mais frequente de hiperparatiroidismo primário. Nos últimos anos, a localização pré-operatória de adenomas da paratiroide tem permitido técnicas cirúrgicas minimamente invasivas que se tornaram preferíveis à exploração cervical bilateral tradicio-nal. As recomendações internacionais mais recentes relativamente a este tópico têm dado ênfase aos exames de imagem de medicina nuclear. Neste estudo, os autores revêem o papel atual da ecografia cervical com Doppler na localização pré-operatória de adenomas da paratiroide em doentes com hiperparatiroidismo primário. Material e Métodos: Estudo retrospetivo de doentes com hiperparatiroidismo primário submetidos a paratiroidectomia entre janeiro de 2013 e 2022 no Centro Hospitalar Universitário Lisboa Central. Análise estatística realizada com IBM SPSS Statistics, versão 26.0.0.0®.Resultados: Foram identificados 171 doentes com hiperparatiroidismo primário submetidos a paratiroidectomia (77,8% sexo feminino). A ecografia cervical com Doppler foi o exame mais solicitado para localização pré-operatória de adenomas da paratiroide (64,3%, n = 110) e detetou a lesão em 98 doentes (89,1%). A análise comparativa da localização pré-operatória do adenoma da paratiroide baseada na ecografia cervical com Doppler com os achados cirúrgicos e histológicos demonstrou identificação correta do adenoma em 76 doentes (77,6%). A ecografia cervical com Doppler subestimou ligeiramente a dimensão dos adenomas (18,1 ± 7,7 mm pré-operatório versus 22 ± 8,4 mm pós-operatório). Os níveis de cálcio, paratormona, a dimen-são do adenoma e a presença concomitante de nódulos tiroideus não afetou a eficácia diagnóstica da ecografia cervical com Doppler.Conclusão: A ecografia cervical com Doppler demonstrou elevada precisão diagnóstica independentemente da presença concomitante de nódulos tiroideus, dos níveis de cálcio e paratormona e da dimensão dos adenomas da paratiroide. A sua disponibilidade, segurança e custo aliado à capacidade diagnóstica demonstrada devem favorecer o seu uso como primeira linha na localização pré-operatória de adenomas da paratiroide no hiperparatiroi-dismo primárioinfo:eu-repo/semantics/publishedVersio
Cellulitis at GLP-1 Agonist Injection Site: Rare But Relevant
No full textWe present a case of cellulitis complicating with abscess formation as a possible complication of treatment with injectable GLP-1 agonists on a sixty-one-year-old woman. Pus cultures showed isolation of Streptococcus anginosus and clindamycin was started as targeted therapy but absence of improvement prompted a consultation with the surgery department and a manual surgical debridement was performed. A second isolate of Eikenella corrodens, which is frequently resistant to clindamycin, was identified. We opted for a switch to ceftriaxone and after nineteen days, having achieved clinical improvement, plans were made for her to continue to change her wound dressing at her local health center and for a short-term revaluation at a surgery outpatient consultation. Caring for social needs and assuring continuity across multiple care levels can be fundamental in
preventing adverse effects from self-injectable drugs.info:eu-repo/semantics/publishedVersio
Increased 30-Day Mortality in Very Old ICU Patients with COVID-19 Compared to Patients with Respiratory Failure without COVID-19
No full textPurpose: The number of patients ≥ 80 years admitted into critical care is increasing. Coronavirus disease 2019 (COVID-19) added another challenge for clinical decisions for both admission and limitation of life-sustaining treatments (LLST). We aimed to compare the characteristics and mortality of very old critically ill patients with or without COVID-19 with a focus on LLST.
Methods: Patients 80 years or older with acute respiratory failure were recruited from the VIP2 and COVIP studies. Baseline patient characteristics, interventions in intensive care unit (ICU) and outcomes (30-day survival) were recorded. COVID patients were matched to non-COVID patients based on the following factors: age (± 2 years), Sequential Organ Failure Assessment (SOFA) score (± 2 points), clinical frailty scale (± 1 point), gender and region on a 1:2 ratio. Specific ICU procedures and LLST were compared between the cohorts by means of cumulative incidence curves taking into account the competing risk of discharge and death.
Results: 693 COVID patients were compared to 1393 non-COVID patients. COVID patients were younger, less frail, less severely ill with lower SOFA score, but were treated more often with invasive mechanical ventilation (MV) and had a lower 30-day survival. 404 COVID patients could be matched to 666 non-COVID patients. For COVID patients, withholding and withdrawing of LST were more frequent than for non-COVID and the 30-day survival was almost half compared to non-COVID patients.
Conclusion: Very old COVID patients have a different trajectory than non-COVID patients. Whether this finding is due to a decision policy with more active treatment limitation or to an inherent higher risk of death due to COVID-19 is unclear.info:eu-repo/semantics/publishedVersio
Diagnostic Challenge in a Sickle Cell Disease Patient with COVID-19
No full textAcute chest syndrome is a life-threatening complication in sickle cell disease. Infections are frequently implied,
and like other viruses, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be a trigger.
In addition, due to their inflammatory status, they may present a higher risk for severe coronavirus disease 2019 (COVID-19). Pneumonia and acute chest syndrome share clinical, laboratory, and radiological
features and may overlap, which makes their differential diagnosis especially challenging. We describe a case
of an adolescent with homozygous sickle cell disease that developed acute chest syndrome in the context of
COVID-19. With it, we intend to bring awareness to the potential role of imaging in the differential diagnosis
and in establishing the best approach for the patient. Chest computed tomography findings were suggestive
of an alternative diagnosis to COVID-19 pneumonia and red cell transfusion, fluid management, analgesics, and antibiotics were administered with favorable outcome.info:eu-repo/semantics/publishedVersio
Non-COVID-19 Respiratory Viral Infection
No full textImplemented control measures brought about by the coronavirus disease 2019 (COVID-19) pandemic have changed the prevalence of other respiratory viruses, often relegating them to a secondary plan. However, it must not be forgotten that a diverse group of viruses, including other human coronaviruses, rhinoviruses, respiratory syncytial virus, human metapneumoviruses, parainfluenza and influenza, continue to be responsible for a large burden of disease. In fact, they are among the most common causes of acute upper and lower respiratory tract infections globally. Viral respiratory infections can be categorised in several ways, including by clinical syndrome or aetiological agent. We describe their clinical spectrum. Distinctive imaging features, advances in microbiological diagnosis and treatment of severe forms are also discussed.info:eu-repo/semantics/publishedVersio
Seguimento a Longo Prazo da Ablação de Arritmias Ventriculares com Origem na Câmara de Saída Ventricular Baseada em Mapeamento Não Contacto por Balão Multi-Elétrodos
No full textIntroduction: The outflow tract (OT) regions of the ventricles are a common location of origin for idiopathic ventricular arrhythmias (VA). Non-contact mapping (NCM) with a multi-electrode balloon catheter Ensite-Array enables three-dimensional reconstruction of the geometry of the cardiac chambers and accurate mapping of the propagation map, based on a single beat analysis, facilitating the ablation and contributing procedure success.
Objective: Assessment of the feasibility and long-term outcomes following NCM-guided OT VA ablation.
Methods: Single center retrospective analysis of patients admitted for symptomatic OT VA ablation. Demographic and clinical characteristics of patients, procedure data and long-term outcomes were assessed.
Results: Fifty-eight patients (79.3% female, age 43.9±17.6 years) were considered, 89.7% without structural heart disease. In 85.7% of the cases left ventricle ejection fraction (LVEF) was preserved (LVEF≥50%), 8.6% had mild systolic dysfunction (LVEF 40%-49%) and 5.7% had moderate systolic dysfunction (LVEF 30%-39%). Twenty-four-hour Holter recording documented sustained VA episodes in 12.1% of the patients, non-sustained VA in 31.0%, and >10 000 premature ventricular complex (PVC)/24 h in 56.9%, with an ECG suggesting right ventricular OT origin in 84.5%. There was total elimination of PVC in 87.9% cases and a significant reduction in 3.4%. During a mean follow-up of 5.5 years, 87.9% patients remained asymptomatic without medication, 12.1% underwent re-ablation due to symptomatic PVC recurrence, and two cases underwent a third successful intervention.
Conclusion: Non-contact mapping-guided multi-electrode balloon catheter VA ablation is a highly effective and safe procedure, with a low rate of long-term recurrence.info:eu-repo/semantics/publishedVersio