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- Acute Heart Failure Comorbidome: The Impact of Everything ElsePublication . Meireles, Mariana; Gonçalves, João; Neves, JoãoIntroduction: Heart failure frequently coexists with several comorbidities. Our aim is to evaluate the prognostic role of various comorbidities in the risk of acute heart failure development. Material and methods: Comorbidities of patients with acute heart failure were, retrospectively, compared to a control group of patients with chronic heart failure admitted to an Internal Medicine unit in a 2-year period. Logistic regression models were constructed to determine their association with acute heart failure and to develop a comorbidome. Results: We identified 229 patients with acute heart failure and 201 patients with chronic heart failure. Age and female gender were higher in acute heart failure group (p < 0.001) as was the number of comorbidities (4.0 ± 3.0 vs 4.0 ± 2.0, p = 0.044). Hyperuricemia (odds ratio 2.46, confidence interval 95% 1.41 - 4.31, p = 0.002), obesity (odds ratio 2.22, confidence interval 95% 1.31 - 3.76, p = 0.003), atrial fibrillation (odds ratio 1.93, confidence interval 95% 1.31 - 2.87, p = 0.001), peripheral artery disease (odds ratio 2.12, confidence interval 95% 1.01 - 4.42, p = 0.046) and chronic kidney disease (odds ratio 2.47, confidence interval 95% 1.65 - 3.71, p < 0.001) were associated with acute heart failure. Obesity, atrial fibrillation, peripheral artery disease and chronic kidney disease were identified as independent risk factors. Patients with multiple comorbidities had a superior risk of hospitalization due to heart failure: zero comorbidities - odds ratio 0.43, 95% confidence interval 0.28 - 0.67, p < 0.001; one comorbidity - odds ratio 0.69, 95% confidence interval 0.47 - 1.01, p = 0.057; two comorbidities - odds ratio 1.85, 95% confidence interval 1.11 - 3.08, p = 0.019; ≥ three comorbidities - odds ratio 5.81, 95% confidence interval 2.77 - 12.16, p < 0.001. Discussion: This study shows an association between several comorbidities and hospital admission due to acute heart failure. The association seems to strengthen in the presence of multiple comorbidities. Conclusion: A comorbidome is a useful tool to identify comorbidities associated with higher risk of acute heart failure. The identification of vulnerable patients may allow multidimensional interventions to minimize future hospital admissions.
- Adult Native Joint Septic Arthritis: A Nine-Year Retrospective Analysis in a Portuguese University HospitalPublication . Cipriano, Ana; Videira Santos, Fábio; Dias, Rita; Carvalho, André; Reis, Ernestina; Pereira, Claudia; Santos, Ana Cláudia; Sousa, Ricardo; Abreu, Miguelntroduction: Septic arthritis of a native joint represents a medical emergency. Drainage and effective antibiotic treatment are critical to avoid joint destruction and long-term impairment. The aim of this study was to evaluate epidemiological and clinical characteristics of patients with the diagnosis of septic arthritis to help establish local guidelines for empirical antibiotic treatment. Material and methods: Retrospective analysis of adult patients admitted at Centro Hospitalar Universitário do Porto from 2009 to 2017 with suspected native joint septic arthritis. Relevant demographics, microbiology findings and respective antibiotic susceptibilities were analysed. Results: Ninety-seven patients, predominantly males (59.8%) with a median age of 61 years old were included. The most commonly reported comorbidity associated with septic arthritis was diabetes mellitus (20.6%). The knee was the most commonly affected joint (71.1%). Arthrocentesis was performed in all patients, but only 50.5% had positive microbial growth in the synovial fluid. Staphylococcus aureus was the most frequently identified microorganism, 86% of which were methicillin susceptible. Gram-negative bacteria were the causative agent in 15% of cases. A wide range of empirical antibiotic regimens were prescribed with a combination of vancomycin/carbapenem being the most common (30.9%). Analysis of antibiotic susceptibility profiles revealed that amoxicillin/clavulanate would have been appropriate as the initial regimen in 89% of cases. Discussion: The main causative pathogen was Staphylococcus aureus, with methicillin resistant Staphylococcus aureus remaining rare. The proportion of Gram-negative bacteria implies that these agents should be covered by empirical treatment, although no case of Pseudomonas infection has been identified. Therefore, antipseudomonal coverage is not necessary in empirical regimens. Conclusion: Routine coverage of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa is not warranted but must be considered when specific risk factors are found. Amoxicillin/clavulanate can provide adequate antibiotic coverage as an empirical treatment for adult native joint septic arthritis. Its use may allow a reduction in use of broader spectrum antibiotics.
- Alteplase for Massive Pulmonary Embolism after Complicated PericardiocentesisPublication . Marinho, Ricardo Cleto; Martins, J.; Costa, S.; Baptista, R.; Gonçalves, L.; Franco, F.Background: The occurrence of a high-risk pulmonary embolism (PE) within 48 hours of a complicated pericardiocentesis to remove a haemorrhagic pericardial effusion, is an uncommon clinical challenge. Case summary: The authors report the case of a 75-year-old woman who presented with signs of imminent cardiac tamponade due to recurring idiopathic pericardial effusion. The patient underwent pericardiocentesis that was complicated by the loss of 1.5 litres of blood. Within 48 hours, the patient had collapsed with clear signs of obstructive shock. This was a life-threating situation so alteplase was administered after cardiac tamponade and hypertensive pneumothorax had been excluded. CT chest angiography later confirmed bilateral PE. The patient achieved haemodynamic stability less than an hour after receiving the alteplase. However, due to the high risk of bleeding, the medical team suspended the thrombolysis protocol and switched to unfractionated heparin within the hour. The cause of the PE was not identified despite extensive study, but after 1 year of follow-up the patient remained asymptomatic. Discussion: Despite the presence of a contraindication, the use of thrombolytic therapy in obstructive shock after exclusion of hypertensive pneumothorax can be life-saving, and low-dose thrombolytic therapy may be a valid option in such cases. Learning points: A quick and systematic approach to a collapsed patient with signs of shock is mandatory; understanding the type of shock may help narrow the differential diagnosis and help in therapeutic decisions.After exclusion of cardiac tamponade and hypertensive pneumothorax, life-saving thrombolytic therapy can be administered in obstructive shock due to probable massive pulmonary embolism.Contraindications for thrombolytic therapy originated as exclusion criteria for clinical trials but should not prevent the use of this therapy in life-threatening situations.
- An Immunological Non-responder Human Immunodeficiency Virus/Hepatitis C Virus Coinfected Patient: Considerations About a Clinical CasePublication . Correia, Rui; França, MargaridaHuman immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections are two chronic viral infections that share the same mode of transmission, making HIV/HCV coinfection frequent. Highly active antiretroviral therapy (HAART) was a turning point in HIV treatment and has been shown to successfully restore immune function and reduce the frequency of opportunistic infections. Despite a virological response to HAART, a proportion of patients fail to achieve substantial immune recovery, as measured by peripheral CD4 cell counts. Herein, we present the case of a patient with HIV/HCV coinfection who did not achieve successful immune function restoration despite HIV suppression and HCV treatment. Our goal is to promote discussion. Despite considerable advances in the understanding of the impact of HCV on HIV disease progression, there are many individual variables that influence a patient's immune function. In addition, we consider hypogammaglobulinemia as a possible contributor. Further understanding and improvement of immune reconstitution in patients infected with HIV remain an important field of scientific research.
- ANCA-positive vasculitis: Clinical implications of ANCA types and titersPublication . Domingues, V.; Machado, B.; Santos, J.INTRODUCTION: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune disease that can affect multiple organs, the kidney being one of the most affected. Apart from the diagnostics value of ANCA, they have also been advocated as biomarkers of the disease activity. Recently, the genetic changes found in polyangiitis associated with serine-protease proteinase 3 (PR3)-ANCA or myeloperoxidase (MPO)-ANCA raised the possibility of immune-pathogenic and therapeutic differences. OBJECTIVE: To identify differences in the number of relapses, inflammatory markers, outcomes and renal histology related to the types of ANCA. To analyze the implications of ANCA titers in prognosis. METHOD: A retrospective observational study in a Portuguese tertiary hospital. RESULTS: There were no differences in the progression of renal function, histological pattern and initial treatment with regard to ANCA subtypes. As for the evaluated parameters, there were no significant differences according to the types of ANCA, except for mean CRP values within the normal range, which was 6.3±1.3 mg/L for MPO-ANCA and 12.4±10.14 mg/L for PR3-ANCA (p=0.04). We found that 66.7% of the MPO-ANCA-positive showed no relapses versus 40% in the case of PR3-ANCA-positive. There was no correlation between the ANCA titers at presentation, during remission, and in the last evaluation, and the number of relapses. CONCLUSION: PR3-ANCA patients have a mean CRP value within the normal range significantly higher than that of MPO-ANCA patients (p=0.04), which seems to reveal greater inflammatory activity in the first.
- Antineutrophil cytoplasmatic antibody positive systemic vasculitis in a patient treated with propylthiouracilPublication . Silva, S.; Ferreira, J.; Carvalho, S.; Seabra, F.; Marinho, A.
- Aortic Dissection With Cardiac Tamponade in Pregnancy: A Challenging Clinical ScenarioPublication . Barroso, Daniela; Santos, Sérgio; Tomás, Ana Sofia; Castro, Heloísa; Pinheiro Vieira, AntónioAortic dissection is the acute aortic syndrome with the highest mortality, and pregnancy and arterial hypertension are known risk factors. Its association with the perinatal period is a particularly unique and potentially devastating clinical catastrophe which is why the approach to a pregnant woman in cardiorespiratory arrest (CRA) should be multidisciplinary and early, with extraction of the fetus ideally within five minutes after the arrest. We present the case of a 39-year-old pregnant woman, who presented with a cardiorespiratory arrest in the context of an aortic dissection with cardiac tamponade and the need for an urgent perimortem cesarean section. Increasing knowledge and understanding among healthcare professionals has the potential to aid in the early detection and effective treatment of this challenging medical issue.
- Atypical pathogens in hospitalized patients with community-acquired pneumonia: a worldwide perspectivePublication . Gramegna, A.; Sotgiu, G.; Di Pasquale, M.; Radovanovic, D.; Terraneo, S.; Reyes, L.; Vendrell, E.; Neves, J.; Menzella, F.; Blasi, F.; Aliberti, S.; Restrepo, M.BACKGROUND: Empirical antibiotic coverage for atypical pathogens in community-acquired pneumonia (CAP) has long been debated, mainly because of a lack of epidemiological data. We aimed to assess both testing for atypical pathogens and their prevalence in hospitalized patients with CAP worldwide, especially in relation with disease severity. METHODS: A secondary analysis of the GLIMP database, an international, multicentre, point-prevalence study of adult patients admitted for CAP in 222 hospitals across 6 continents in 2015, was performed. The study evaluated frequency of testing for atypical pathogens, including L. pneumophila, M. pneumoniae, C. pneumoniae, and their prevalence. Risk factors for testing and prevalence for atypical pathogens were assessed through univariate analysis. RESULTS: Among 3702 CAP patients 1250 (33.8%) underwent at least one test for atypical pathogens. Testing varies greatly among countries and its frequency was higher in Europe than elsewhere (46.0% vs. 12.7%, respectively, p < 0.0001). Detection of L. pneumophila urinary antigen was the most common test performed worldwide (32.0%). Patients with severe CAP were less likely to be tested for both atypical pathogens considered together (30.5% vs. 35.0%, p = 0.009) and specifically for legionellosis (28.3% vs. 33.5%, p = 0.003) than the rest of the population. Similarly, L. pneumophila testing was lower in ICU patients. At least one atypical pathogen was isolated in 62 patients (4.7%), including M. pneumoniae (26/251 patients, 10.3%), L. pneumophila (30/1186 patients, 2.5%), and C. pneumoniae (8/228 patients, 3.5%). Patients with CAP due to atypical pathogens were significantly younger, showed less cardiovascular, renal, and metabolic comorbidities in comparison to adult patients hospitalized due to non-atypical pathogen CAP. CONCLUSIONS: Testing for atypical pathogens in patients admitted for CAP in poorly standardized in real life and does not mirror atypical prevalence in different settings. Further evidence on the impact of atypical pathogens, expecially in the low-income countries, is needed to guidelines implementation.
- Bacterial etiology of community-acquired pneumonia in immunocompetent hospitalized patients and appropriateness of empirical treatment recommendations: an international point-prevalence studyPublication . Carugati, Manuela; Aliberti, S.; Sotgiu, G.; Blasi, F.; Gori, A.; Menendez, R.; Encheva, M.; Gallego, M.; Leuschner, P.; Ruiz-Buitrago, S.; Battaglia, S.; Fantini, R.; Pascual-Guardia, S.; Marin-Corral, J.; Restrepo, M. I.; Aruj, Patricia Karina; Attorri, Silvia; Barimboim, Enrique; Caeiro, Juan Pablo; Garzón, María I; Cambursano, Victor Hugo; Ceccato, Adrian; Chertcoff, Julio; Lascar, Florencia; Tulio, Fernando Di; Díaz, Ariel Cordon; de Vedia, Lautaro; Ganaha, Maria Cristina; Lambert, Sandra; Lopardo, Gustavo; Luna, Carlos M; Malberti, Alessio Gerardo; Morcillo, Nora; Tartara, Silvina; Pensotti, Claudia; Pereyra, Betiana; Scapellato, Pablo Gustavo; Stagnaro, Juan Pablo; Shah, Sonali; Lötsch, Felix; Thalhammer, Florian; Vincent, Jean Louis; Anseeuw, Kurt; Francois, Camille A; Van Braeckel, Eva; Djimon, Marcel Zannou; Bashi, Jules; Roger, Dodo; Nouér, Simone Aranha; Chipev, Peter; Encheva, Milena; Miteva, Darina; Petkova, Diana; Dodo, Balkissou Adamou; Ngahane, Mbatchou; Hugo, Bertrand; Shen, Ning; Xu, Jin-fu; Rico, Carlos Andres Bustamante; Buitrago, Ricardo; Paternina, Fernando Jose Pereira; Jean-Marie, Kayembe Ntumba; Carevic, Vesna Vladic; Jakopovic, Marko; Jankovic, Mateja; Matkovic, Zinka; Mitrecic, Ivan; Jacobsson, Marie-Laure Bouchy; Christensen, Anette Bro; HeitmannBødtger, Uff e Christian; Meyer, Christian Niels; Jensen, Andreas Vestergaard; Baunbæk-knudsen, Gertrud; Petersen, Pelle Trier; Andersen, Stine; El-Wahhab, Ibrahim El-Said Abd; Morsy, Nesreen Elsayed; Shafiek, Hanaa; Sobh, Eman; Bertrand, Fabrice; Brun-Buisson, Christian; de Montmollin, Etienne; Fartoukh, Muriel; Messika, Jonathan; Tattevin, Pierre; Dreher, Michael; Kolditz, Martin; Meisinger, Matthias; Pletz, Mathias W; Hagel, Stefan; Rupp, Jan; Schaberg, Tom; Spielmanns, Marc; Siaw-Lartey, Beatrice; Dimakou, Katerina; Papapetrou, Dimosthenis; Tsigou, Evdoxia; Ampazis, Dimitrios; Bhatia, Mohit; Dhar, Raja; D’Souza, George; Garg, Rajiv; Koul, Parvaiz A; Mahesh, P A; Jayaraj, B S; Narayan, Kiran Vishnu; Udnur, Hirennappa B; Krishnamurthy, Shashi Bhaskara; Golshani, Keihan; Keatings, Vera M; Martin-Loeches, Ignacio; Maor, Yasmin; Strahilevitz, Jacob; Battaglia, Salvatore; Carrabba, Maria; Ceriana, Piero; Confalonieri, Marco; d’Arminio Monforte, Antonella; Del Prato, Bruno; De Rosa, Marino; Fantini, Riccardo; Fiorentino, Giuseppe; Gammino, Maria Antonia; Menzella, Francesco; Milani, Giuseppe; Nava, Stefano; Palmiero, Gerardo; Petrino, Roberta; Gabrielli, Barbra; Rossi, Paolo; Sorino, Claudio; Steinhilber, Gundi; Zanforlin, Alessandro; Kurahashi, Kiyoyasu; Bacha, Zeina Aoun; Ugalde, Daniel Barajas; Zuñiga, Omar Ceballos; Villegas, José F; Medenica, Milic; van de Garde, E M W; Mihsra, Deebya Raj; Shrestha, Poojan; Ridgeon, Elliott; Awokola, Babatunde Ishola; Nwankwo, Ogonna N O; Olufunlola, Adefuye Bolanle; Olumide, Segaolu; Ukwaja, Kingsley N; Irfan, Muhammad; Minarowski, Lukasz; Szymon, Skoczyński; Froes, Felipe; Leuschner, Pedro; Meireles, Mariana; Ferrão, Cláudia; Leuschner, Pedro; Neves, João; Ravara, Sofia B; da Beira, Cova; Brocovschii, Victoria; Ion, Chesov; Rusu, Doina; Toma, Cristina; Chirita, Daniela; Birkun, Alexei; Kaluzhenina, Anna; Almotairi, Abdullah; Abdulbaqi, Zakeya; Bukhary, Ali; Edathodu, Jameela; Fathy, Amal; Enani, Abdullah Mushira Abdulaziz; Mohamed, Nazik Eltayeb; Memon, Jawed Ulhadi; Bogdanović, Nada; Milenkovic, Branislava; Pesut, Dragica; Borderìas, Luis; Garcia, Noel Manuel Bordon; Alarcón, Hugo Cabello; Cilloniz, Catia; Torres, Antoni; Diaz-Brito, Vicens; Casas, Xavier; González, Alicia Encabo; Fernández-Almira, Maria Luisa; Gallego, Miguel; Gaspar-GarcÍa, Inmaculada; del Castillo, Juan González; Victoria, Patricia Javaloyes; Martínez, Elena Laserna; de Molina, Rosa Malo; Marcos, Pedro J; Menéndez, Rosario; PandoSandova, Ana; Aymerich, Cristina Prat; del la Torre, Alicia Lacoma; García-Olivé, Ignasi; Rello, Jordi; Moyano, Silvia; Sanz, Francisco; Sibila, Oriol; Rodrigo-Troyano, Ana; Solé-Violán, Jordi; Uranga, Ane; van Boven, Job FM; Torra, Ester Vendrell; Pujol, Jordi Almirall; Feldman, Charles; Yum, Ho Kee; Fiogbe, Arnauld Attannon; Yangui, Ferdaous; Bilaceroglu, Semra; Dalar, Levent; Yilmaz, Ufuk; Bogomolov, Artemii; Elahi, Naheed; Dhasmana, Devesh J; Ions, Rhiannon; Skeemer, Julie; Woltmann, Gerrit; Hancock, Carole; Hill, Adam T; Rudran, Banu; Ruiz-Buitrago, Silvia; Campbell, Marion; Whitaker, Paul; Allen, Karen S; Brito, Veronica; Dietz, Jessica; Dysart, Claire E; Kellie, Susan M; Franco-Sadud, Ricardo A; Meier, Garnet; Gaga, Mina; Holland, Thomas L; Bergin, Stephen P; Kheir, Fayez; Landmeier, Mark; Lois, Manuel; Nair, Girish B; Patel, Hemali; Reyes, Katherine; Rodriguez-Cintron, William; Saito, Shigeki; Soni, Nilam J; Noda, Julio; Hinojosa, Cecilia I; Levine, Stephanie M; Angel, Luis F; Anzueto, Antonio; Whitlow, K Scott; Hipskind, John; Sukhija, Kunal; Wunderink, Richard G.; Shah, Ray D; Mateyo, Kondwelani JohnAn accurate knowledge of the epidemiology of community-acquired pneumonia (CAP) is key for selecting appropriate antimicrobial treatments. Very few etiological studies assessed the appropriateness of empiric guideline recommendations at a multinational level. This study aims at the following: (i) describing the bacterial etiologic distribution of CAP and (ii) assessing the appropriateness of the empirical treatment recommendations by clinical practice guidelines (CPGs) for CAP in light of the bacterial pathogens diagnosed as causative agents of CAP. Secondary analysis of the GLIMP, a point-prevalence international study which enrolled adults hospitalized with CAP in 2015. The analysis was limited to immunocompetent patients tested for bacterial CAP agents within 24 h of admission. The CAP CPGs evaluated included the following: the 2007 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA), the European Respiratory Society (ERS), and selected country-specific CPGs. Among 2564 patients enrolled, 35.3% had an identifiable pathogen. Streptococcus pneumoniae (8.2%) was the most frequently identified pathogen, followed by Pseudomonas aeruginosa (4.1%) and Klebsiella pneumoniae (3.4%). CPGs appropriately recommend covering more than 90% of all the potential pathogens causing CAP, with the exception of patients enrolled from Germany, Pakistan, and Croatia. The 2019 ATS/IDSA CPGs appropriately recommend covering 93.6% of the cases compared with 90.3% of the ERS CPGs (p < 0.01). S. pneumoniae remains the most common pathogen in patients hospitalized with CAP. Multinational CPG recommendations for patients with CAP seem to appropriately cover the most common pathogens and should be strongly encouraged for the management of CAP patients.
- Brugada Pattern: Unraveling Possible Cardiac Manifestation of SARS-CoV-2 InfectionPublication . Boncoraglio, Maria Teresa; Esteves, Joana; Pereira, Francisca; Braga, Joana; Veiga, Carolina; Oliveira, Daniel G; Barbeito, PilarWe report the case of a 41-year-old patient with no family history of sudden cardiac death. The patient presented with high fever and vomiting and was diagnosed with acute pyelonephritis. Screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was positive. An electrocardiogram (ECG) performed during a fever episode revealed a Brugada pattern. Fever can be a trigger for induction of the electrocardiographic Brugada pattern but it is still unknown if the cardiac involvement by coronavirus disease 2019 (COVID-19) can interfere with myocardial ion channels.