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- Endocardite com Nódulos e Lesões JanewayPublication . Cruz, L; Pereira de Sousa, J
- Acute Stroke Presenting As Syncope: Wallenberg SyndromePublication . Mesquita, A; Ferreira, P; Carvalho, M; Martins, M
- The Accuracy of PiCCO® in Measuring Cardiac Output in Patients Under Therapeutic Hypothermia: Comparison With Transthoracic EchocardiographyPublication . Souto Moura, T; Aguiar Rosa, S; Germano, N; Cavaco, R; Sequeira, T; Alves, M; Papoila, AL; Bento, LBackground: Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes. Objective: To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO. Design and patients: Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values. Results: Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (-0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was -0.426 l/min, with limits of agreement (-1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (-0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%. Conclusions: The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients.
- Bedside Ultrasound to Detect Bone Flap Infections: a Case ImagePublication . Faustino, D; Reis de Almeida, L; Trigo, A; Soares, A; Prayce, RUltrasound showing an anechoic collection with interspersed echogenic foci (blue arrows - gas bubbles) proximal to the hyperechoic bone flap (red asterisk; post-decompressive craniectomy). Serratia marcescens was isolated from the collected fluid. Bedside ultrasound can be a reliable and effective tool to aid in the diagnosis of bone flap infections.
- Sociodemographic, Clinical, and Behavioral Factors Associated With Sexual Transmitted Infection Among HIV-1 Positive Migrants in Portugal: Are There Differences Between Sexes?Publication . Miranda, M; Pimentel, V; Graça, J; Seabra, S; Sebastião, C; Diniz, A; Faria, D; Teófilo, E; Roxo, F; Maltez, F; Germano, I; Oliveira, J; Ferreira, J; Poças, J; Mansinho, K; Mendão, L; Gonçalves, MJ; Mouro, M; Marques, N; Pacheco, P; Proença, P; Tavares, R; Correia de Abreu, R; Serrão, R; Faria, T; O. Martins, MR; Gomes, P; Abecasis, A; Pingarilho, MIntroduction: Sexually transmitted infections (STIs) continue to occur at high levels. According to the WHO, each year there are an estimated 374 million new infections with syphilis, gonorrhea, chlamydia, and trichomoniasis. STIs are associated with an increased risk of acquiring HIV infection. Migrants are reportedly highly affected by STIs. Objectives: This study aims to characterize factors associated with STIs in a population of HIV-positive migrants living in Portugal. Methodology: This is a cross-sectional observational study of 265 newly diagnosed HIV-1 positive migrants, who were defined as individuals born outside Portugal. This group of people were part of the BESTHOPE study that was developed in 17 Portuguese hospitals between September 2014 and December 2019, and included information collected through sociodemographic and behavioral questionnaires filled in by the migrant patients, clinical questionnaires filled in by the clinicians and HIV-1 genomic sequences generated through resistance testing (Sanger sequencing). A multivariable statistical analysis was used to analyze the association between sociodemographic characteristics, sexual behaviors, HIV testing and sexual infections. Results: Most HIV-1 positive individuals included in the study were men (66.8%) and aged between 25 and 44 years old (59.9%). Men had a higher proportion of STIs when compared to women (40.4% vs. 14.0%) and the majority of men reported homosexual contacts (52.0%). Most men reported having had two or more occasional sexual partners in the previous year (88.8%) and 50.9% reported always using condoms with occasional partners, while 13.2% never used it. For regular partners, only 29.5% of the women reported using condoms, compared to 47.3% of men. Other risk behaviors for acquiring HIV, such as tattooing and performing invasive medical procedures, were more prevalent in men (38.0% and 46.2%, respectively), when compared to women (30.4% and 45.1% respectively) and 4.7% of men reported having already shared injectable materials, with no data for comparison in the case for women. Additionally, 23.9% of women reported having had a blood transfusion while only 10.3% of men reported having had this medical procedure. Meanwhile, 30.9% of the individuals reported having been diagnosed with some type of STI in the last 12 months. In addition, 43.3% of individuals that answered a question about hepatitis reported to be infected with hepatitis B, while 13.0% reported having hepatitis C infection. According to the multivariable analysis, the only transmission route was significantly associated with reports of previous STI infection: men who have sex with men (MSM) were 70% more likely to have been diagnosed with an STI in the past 12 months compared to the heterosexual route. Conclusion: HIV-1 infected men were more likely to report previous STIs than women. On the other hand, most migrant women had a regular sexual partner and never or only sometimes used condoms. This somewhat discrepant findings suggest that gender inequalities may make women unable to negotiate safe sexual practices, resulting in increased susceptibility to infection. However, since migrant women report less STIs, we cannot exclude that these STIs may remain undiagnosed. The implementation of safer sex awareness campaigns for condom use and screening for STIs in women is crucial. On the other hand, health education campaigns for STI knowledge need to be implemented for both MSM and women and their partners.
- When the Stomach Takes a Vacation: The Unseen Battles of GastroparesisPublication . Sousa, B; Rodrigues, T; Ribeiro, JGastroparesis is a syndrome characterised by delayed gastric emptying that is usually idiopathic, diabetic, or iatrogenic. This underdiagnosed disease has a substantial influence on the quality of life of its patients. We present the case of an 86-year-old man with dementia, benign prostatic hyperplasia, and gastroesophageal reflux disease who developed symptoms of gastroparesis during a lengthy hospital stay. Computed tomography (CT) and upper digestive endoscopy demonstrated gastric distention and pyloric stenosis. Despite cautious treatment and eventual pyloric dilation, the patient died from aspiration due to refractory respiratory failure. This example emphasises the need for early detection and thorough examination of gastroparesis to optimise patient outcomes and reduce morbidity and mortality.
- Case Report: Artifactual Hypoglycemia: A Condition That Should Not Be ForgottenPublication . Amaral, A; Palha, A; Bernardino, V; Silva-Nunes, JBackground: Hypoglycemia is uncommon in people who are not being treated for diabetes mellitus and, when present, the differential diagnosis is broad. Artifactual hypoglycemia describes discrepancy between low capillary and normal plasma glucose levels regardless of symptoms and should be considered in patients with Raynaud's phenomenon. Case presentation: A 46-year-old female patient with a history of a sleeve gastrectomy started complaining about episodes of lipothymias preceded by sweating, nausea, and dizziness. During one of these episodes, a capillary blood glucose was obtained with a value of 24 mg/dl. She had multiple emergency admissions with low-capillary glycemia. An exhaustive investigation for possible causes of hypoglycemia was made for 18 months. The 72h fasting test was negative for hypoglycemia. A Raynaud's phenomenon was identified during one appointment. Conclusion: Artifactual hypoglycemia has been described in various conditions including Raynaud's phenomenon, peripheral arterial disease, Eisenmenger syndrome, acrocyanosis, or hypothermia. With this case report, we want to reinforce the importance of being aware of this diagnosis to prevent anxiety, unnecessary treatment, and diagnostic tests.
- The Role of Multidimensional Prognostic Index to Identify Hospitalized Older Adults with COVID-19 Who Can Benefit from Remdesivir Treatment: An Observational, Prospective, Multicenter StudyPublication . Custodero, C; Veronese, N; Topinkova, E; Michalkova, H; Polidori, MC; Cella, A; Cruz-Jentoft, AJ; von Arnim, CAF; Azzini, M; Gruner, H; Castagna, A; Cenderello, G; Custureri, R; Zieschang, T; Padovani, A; Sanchez-Garcia, E; Pilotto, A; Barbagallo, M; Dini, S; Diesner, NM; Fernandes, M; Gandolfo, F; Garaboldi, S; Musacchio, C; Pilotto, A; Pickert, L; Podestà, S; Ruotolo, G; Sciolè, K; Schlotmann, JBackground: Data regarding the importance of multidimensional frailty to guide clinical decision making for remdesivir use in older patients with coronavirus disease 2019 (COVID-19) are largely unexplored. Objective: The aim of this research was to evaluate if the Multidimensional Prognostic Index (MPI), a multidimensional frailty tool based on the Comprehensive Geriatric Assessment (CGA), may help physicians in identifying older hospitalized patients affected by COVID-19 who might benefit from the use of remdesivir. Methods: This was a multicenter, prospective study of older adults hospitalized for COVID-19 in 10 European hospitals, followed-up for 90 days after hospital discharge. A standardized CGA was performed at hospital admission and the MPI was calculated, with a final score ranging between 0 (lowest mortality risk) and 1 (highest mortality risk). We assessed survival with Cox regression, and the impact of remdesivir on mortality (overall and in hospital) with propensity score analysis, stratified by MPI = 0.50. Results: Among 496 older adults hospitalized for COVID-19 (mean age 80 years, female 59.9%), 140 (28.2% of patients) were treated with remdesivir. During the 90 days of follow-up, 175 deaths were reported, 115 in hospital. Remdesivir treatment significantly reduced the risk of overall mortality (hazard ratio [HR] 0.54, 95% confidence interval CI 0.35-0.83 in the propensity score analysis) in the sample as whole. Stratifying the population, based on MPI score, the effect was observed only in less frail participants (HR 0.47, 95% CI 0.22-0.96 in propensity score analysis), but not in frailer subjects. In-hospital mortality was not influenced by remdesivir use. Conclusions: MPI could help to identify less frail older adults hospitalized for COVID-19 who could benefit more from remdesivir treatment in terms of long-term survival.
- The UriCath Study: Characterization of the Use of Indwelling Urinary Catheters Among Hospitalized Older Patients in the Internal Medicine Departments of PortugalPublication . Almeida, P; Duque, S; Araújo, A; Vilas-Boas, A; Novais, A; Gruner, H; Gorjão Clara, JPurpose: Approximately 25% of older inpatients have an indwelling urinary catheter (IUC), 45-54% unnecessarily. This study aims to describe the prevalence, indications, and complications of IUC use in Portuguese older inpatients. Methods: Multicentric, cross-sectional, observational study conducted in Portuguese internal medicine wards (UriCath). Results: Of a total of 3135 inpatients from 39 hospitals, we included 628 patients with 65 years old or more using an IUC, mean age 82.0 ± 7.5. Prevalence of IUC use was 20.0%. The average Barthel Index was 44.0 ± 37.3 and Charlson comorbidity Index was 7.0 ± 2.8. The main reasons for IUC use were: urinary output monitoring (47.5%), urinary retention (22.5%), and pressure ulcers (11.0%). The IUC removal was attempted in 9.1% and 24.7% developed a complication. Conclusion: IUC use among older inpatients is prevalent and often inappropriate. Clinical awareness and development guidelines for restricted use of IUC are essential to reduce morbimortality and healthcare costs.
- Kawasaki-Like Syndrome as an Emerging Complication of SARS-CoV-2 Infection in Young AdultsPublication . Germano, N; Pelicano Paulos, J; Botelho Cardoso, F; Ferreira, AT; Burgi Vieira, CBackground: Kawasaki-like syndrome occurring in children during the COVID-19 pandemic has been labelled multisystem inflammatory syndrome in children (MIS-C) by the CDC and paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection (PIMS-TS) by the ECDC. Case report: We report the case of an 18-year-old male patient presenting with a 72-hour history of abdominal pain, fever, erythematous skin rash, vomiting and diarrhoea. Examination showed he also had shock and he was first thought to have oedematous cholecystitis. SARS-CoV-2 infection was also diagnosed. He was admitted to the ICU, and echocardiography showed cardiac dysfunction, with a low ejection fraction and low cardiac index. High-sensitivity troponin serum levels were elevated. The patient received inotropic and vasopressor support. As he fulfilled several criteria for MIS-C/PIMS-TS, he was administered acetylsalicylic acid, corticosteroids and immunoglobulin, with a good clinical response. Conclusion: This case emphasizes how this severe presentation of COVID-19 can easily be misdiagnosed if the clinician is less aware of this syndrome in younger patients. Learning points: SARS-CoV-2 infection is a diagnostic challenge in some patients with atypical clinical presentations, who may have MIS-C/PIMS-TS.Physicians should be aware of this condition when evaluating teenagers and young adults with COVID-19.