O que mudou entre os períodos de pico e de platô durante a primeira onda do SARS-CoV-2? Estudo multicêntrico português em unidades de cuidados intensivos / What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care

RESUMO Objetivo: Analisar e comparar as características de pacientes críticos com a COVID-19, a abordagem clínica e os resultados entre os períodos de pico e de platô na primeira onda pandêmica em Portugal. Métodos: Este foi um estudo de coorte multicêntrico ambispectivo, que incluiu pacientes consecutivos com a forma grave da COVID-19 entre março e agosto de 2020 de 16 unidades de terapia intensiva portuguesas. Definiram-se as semanas 10 - 16 e 17 - 34 como os períodos de pico e platô. Resultados: Incluíram-se 541 pacientes adultos com mediana de idade de 65 [57 - 74] anos, a maioria do sexo masculino (71,2%). Não houve diferenças significativas na mediana de idade (p = 0,3), no Simplified Acute Physiology Score II (40 versus 39; p = 0,8), na pressão parcial de oxigênio/fração inspirada de oxigênio (139 versus 136; p = 0,6), na terapia com antibióticos na admissão (57% versus 64%; p = 0,2) ou na mortalidade aos 28 dias (24,4% versus 22,8%; p = 0,7) entre o período de pico e platô. Durante o período de pico, os pacientes tiveram menos comorbidades (1 [0 - 3] versus 2 [0 - 5]; p = 0,002); fizeram mais uso de vasopressores (47% versus 36%; p < 0,001) e ventilação mecânica invasiva na admissão (58,1% versus 49,2%; p < 0,001), e tiveram mais prescrição de hidroxicloroquina (59% versus 10%; p < 0,001), lopinavir/ritonavir (41% versus 10%; p < 0,001) e posição prona (45% versus 36%; p = 0,04). Entretanto, durante o platô, observou-se maior uso de cânulas nasais de alto fluxo (5% versus 16%; p < 0,001) na admissão, remdesivir (0,3% versus 15%; p < 0,001) e corticosteroides (29% versus 52%; p < 0,001), além de menor tempo de internação na unidade de terapia intensiva (12 versus 8 dias; p < 0,001). Conclusão: Houve mudanças significativas nas comorbidades dos pacientes, nos tratamentos da unidade de terapia intensiva e no tempo de internação entre os períodos de pico e platô na primeira onda da COVID-19.

ABSTRACT Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care. / O que mudou entre os períodos de pico e de platô durante a primeira onda do SARS-CoV-2? Estudo multicêntrico português em unidades de cuidados intensivos.

OBJECTIVE: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. METHODS: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. RESULTS: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. CONCLUSION: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

OBJETIVO: Analisar e comparar as características de pacientes críticos com a COVID-19, a abordagem clínica e os resultados entre os períodos de pico e de platô na primeira onda pandêmica em Portugal. MÉTODOS: Este foi um estudo de coorte multicêntrico ambispectivo, que incluiu pacientes consecutivos com a forma grave da COVID-19 entre março e agosto de 2020 de 16 unidades de terapia intensiva portuguesas. Definiram-se as semanas 10 - 16 e 17 - 34 como os períodos de pico e platô. RESULTADOS: Incluíram-se 541 pacientes adultos com mediana de idade de 65 [57 - 74] anos, a maioria do sexo masculino (71,2%). Não houve diferenças significativas na mediana de idade (p = 0,3), no Simplified Acute Physiology Score II (40 versus 39; p = 0,8), na pressão parcial de oxigênio/fração inspirada de oxigênio (139 versus 136; p = 0,6), na terapia com antibióticos na admissão (57% versus 64%; p = 0,2) ou na mortalidade aos 28 dias (24,4% versus 22,8%; p = 0,7) entre o período de pico e platô. Durante o período de pico, os pacientes tiveram menos comorbidades (1 [0 - 3] versus 2 [0 - 5]; p = 0,002); fizeram mais uso de vasopressores (47% versus 36%; p < 0,001) e ventilação mecânica invasiva na admissão (58,1% versus 49,2%; p < 0,001), e tiveram mais prescrição de hidroxicloroquina (59% versus 10%; p < 0,001), lopinavir/ritonavir (41% versus 10%; p < 0,001) e posição prona (45% versus 36%; p = 0,04). Entretanto, durante o platô, observou-se maior uso de cânulas nasais de alto fluxo (5% versus 16%; p < 0,001) na admissão, remdesivir (0,3% versus 15%; p < 0,001) e corticosteroides (29% versus 52%; p < 0,001), além de menor tempo de internação na unidade de terapia intensiva (12 versus 8 dias; p < 0,001). CONCLUSÃO: Houve mudanças significativas nas comorbidades dos pacientes, nos tratamentos da unidade de terapia intensiva e no tempo de internação entre os períodos de pico e platô na primeira onda da COVID-19.

What do we know about carbon monoxide poisoning and cardiac compromise?

Carbon monoxide (CO) poisoning is one of the most common types of poisoning and the leading cause of death by poisoning worldwide. Cardiac injury caused by CO poisoning has been little described despite being a predictor of poor prognosis. We present the case of a healthy 24-year-old woman, admitted to our emergency room due to an episode of lipothymia without loss of consciousness. She reported holocranial headache for the previous two weeks associated with nausea and vomiting. Laboratory tests revealed blood gas analysis: pH 7.392, pCO2 32 mmHg, pO2 101 mmHg, lactate 3.5 mmol/l, HCO3 20.8 mmol/l; COHb 29.2%; serial troponin I 1.21 → 5.25 → 6.13 → 3.65 µg/l; myoglobin 1378 → 964 → 352 µg/l; and NT-proBNP 1330 pg/l. The electrocardiogram showed sinus rhythm, heart rate 110 bpm, and ST-segment depression of 2 mm in V4 and 1 mm in V5. Transthoracic echocardiography revealed a left ventricle with normal wall motion and preserved ejection fraction. Given the clinical and epidemiological context, myocardial and central nervous system ischemia due to prolonged CO exposure was assumed and normobaric oxygen therapy was immediately started. In view of evidence of injury to two major organ systems the indication for hyperbaric oxygen therapy was discussed with a specialist colleague, who suggested maintaining conservative treatment with oxygen therapy and in-hospital monitoring for 72 h. The patient was discharged on the third day and was still asymptomatic at 400 days of follow-up. Besides symptoms and signs of central nervous system dysfunction, myocardial damage should also always be considered in the context of CO poisoning. Hyperbaric therapy is still controversial and the lack of objective data highlights the need for new randomized studies.

Severe hypercalcaemia and colon ischaemia: dehydration as an unusual cause?

Hypercalcaemia is an emergency with severe consequences. Dehydration can be an uncommon cause of hypercalcaemia, as seen in this case. A 63-year-old woman with type 2 diabetes mellitus, hypothyroidism and osteoporosis, was admitted to the emergency room with abdominal distension and vomiting for 24 h. Initial evaluation was Hg 18.5 g/dL, Htc 56.2%, creatinine 2 mg/dL, metabolic acidaemia, lactate 8.3 mmol/L, anion gap 19, total Ca(2+) 17.7 mg/dL and PO4+ 6.6 mg/dL. CT revealed colonic distension without obstruction or ischaemia. Renal replacement therapy and pamidronate were initiated. The patient's clinical condition deteriorated with septic shock in the context of toxic megacolon and she underwent an emergency subtotal colectomy (10 kg). Hypercalcaemia was corrected in 24 h with aggressive fluid replacement (8 L NaCl 0.9% first 12 h), with a reduction of total Ca(2+) to 8.2 mg/dL. Other causes of hypercalcaemia were excluded. 'Hypercalcaemic crisis' secondary to severe acute dehydration is not mentioned in the literature.

Atrial fibrillation and thromboembolic risk: what is the extent of adherence to guidelines in clinical practice?

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac rhythm disorder in clinical practice, with a growing prevalence in recent decades. Through the use of thromboembolic risk scores it is possible to adjust thromboprophylaxis to individual risk. The aim of this study was to evaluate the conformity of antithrombotic therapy prescribed at hospital discharge with the guidelines in patients with AF and its influence on long-term morbidity and mortality. METHODS: We performed a retrospective analysis, based on medical records and phone interview, of consecutive patients admitted to an internal medicine department over a one-year period with a diagnosis of AF or atrial flutter--ICD-9-CM 427.31/32. We determined individual thromboembolic risk in accordance with the ACC/AHA/ESC risk categories, and assessed conformity of antithrombotic therapy with the guidelines. Independent predictors of long-term (378 +/- 241 days) mortality and mortality or readmission were identified by multivariate analysis. RESULTS: The study population consisted of 174 patients with a diagnosis of AF, 59.8% (104) female, mean age 77 +/- 10 years. Hypertension (65.7%) and heart failure (61.3%) were the most prevalent comorbidities. Most patients (82.7%) were stratified as high thromboembolic risk and the remainder as moderate risk. The antithrombotic therapy prescribed at hospital discharge was documented in 155 patients, 126 (81.3%) with high thromboembolic risk. Of the latter group of patients, oral anticoagulation (OAC) was prescribed in 65 (51.6%) and proposed but contraindicated in 24 (19.0%). In patients with moderate thromboembolic risk, therapeutic options were divided between OAC (69.0%), antiplatelet therapy (17.2%) and no thromboprophylaxis (13.8%). Overall there was discordance between the therapy instituted and the guidelines in 25.8% of patients. Age 85 years or over was the only independent predictor of death (HR 1.92; 95% CI 0.94-3.91), while OAC (HR 0.43; 95% CI 0.27-0.70) and male gender (HR 0.58; 95% CI 0.36-0.94) were independent protective factors against death or hospital readmission. CONCLUSIONS: In this study, patients admitted with AF were mainly elderly, women and with high thromboembolic risk. The prescription rate of OAC in patients at high risk was lower than recommended in the guidelines, which were not followed in a quarter of patients. The main therapeutic option in cases of moderate risk was OAC. OAC use was the only modifiable factor able to improve prognosis of patients with AF, and it is thus crucial to ensure adherence to the guidelines in daily clinical practice.

[Histiocytic necrotizing lymphadenitis: (Kukuchi-Fujimoto disease): a diagnostic challenge]. / Dilemas de diagnóstico de linfadenite necrotizante (doença de Kikuchi-Fujimoto).

Kikuchi-Fujimoto disease, also called Histiocytic necrotizing lymphadentis, is a rare, benign and self-limited disease, with unknown etiology, that affects mainly young women, and is characterized by adenopathy (usually localized in the cervical region) and fever. Diagnosis is based on histopathological findings in ganglionar tissue obtained in excisional biopsy, which allows, in most cases, the differential diagnosis with other similar clinical conditions, but which have a completely different clinical evolution and therapeutic needs. We report a case of a twenty four year old woman with persistent cervical lymphadenopathy, in which histopathological examination followed by immunohistochemical analysis of ganglionar tissue revealed to be Kikuchi-Fujimoto disease.