RESUMO
BACKGROUND: Randomized clinical trials in non-critically ill COVID-19 patients showed that therapeutic-dose heparin increased survival with reduced organ support as compared with usual-care thromboprophylaxis, albeit with increased bleeding risk. The purpose of the study is to assess the safety of intermediate dose enoxaparin in hospitalized patients with moderate to severe COVID-19. METHODS: A phase II single-arm interventional prospective study including patients receiving intermediate dose enoxaparin once daily according to body weight: 60 mg for 45-60 kg, 80 mg for 61-100 kg or 100 mg for > 100 kg for 14 days, with dose adjustment according to anti-factor Xa activity (target range: 0.4-0.6 UI/ml); an observational cohort (OC) included patients receiving enoxaparin 40 mg day for comparison. Follow-up was 90 days. Primary outcome was major bleeding within 30 and 90 days after treatment onset. Secondary outcome was the composite of all-cause 30 and 90-day mortality rates, disease severity at the end of treatment, intensive care unit (ICU) admission and length of ICU stay, length of hospitalization. All outcomes were adjudicated by an independent committee and analyzed before and after propensity score matching (PSm). RESULTS: Major bleeding was similar in IC (1/98 1.02%) and in the OC (none), with only one event observed in a patient receiving concomitantly anti-platelet therapy. The composite outcome was observed in 53/98 patients (54%) in the IC and 132/203 (65%) patients in the OC (p = 0.07) before PSm, while it was observed in 50/90 patients (55.6%) in the IC and in 56/90 patients (62.2%) in the OC after PSm (p = 0.45). Length of hospitalization was lower in the IC than in OC [median 13 (IQR 8-16) vs 14 (11-21) days, p = 0.001], however it lost statistical significance after PSm (p = 0.08). At 30 days, two patients had venous thrombosis and two pulmonary embolism in the OC. Time to first negative RT-PCR were similar in the two groups. CONCLUSIONS: Weight adjusted intermediate dose heparin with anti-FXa monitoring is safe with potential positive impact on clinical course in COVID-19 non-critically ill patients. TRIAL REGISTRATION: The study INHIXACOVID19 was registred on ClinicalTrials.gov with the trial registration number (TRN) NCT04427098 on 11/06/2020.
Assuntos
COVID-19 , Tromboembolia Venosa , Humanos , Anticoagulantes/efeitos adversos , COVID-19/complicações , Enoxaparina/efeitos adversos , Hemorragia/tratamento farmacológico , Heparina/efeitos adversos , Estudos Prospectivos , Resultado do Tratamento , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controleRESUMO
There is increasing evidence that psycho-social factors can influence antimicrobial prescribing practice in hospitals and the community, and represent potential barriers to antimicrobial stewardship interventions. Clinicians are conditioned both by emotional and cognitive factors based on fear, uncertainty, a set of beliefs, risk perception and cognitive bias, and by interpersonal factors established through social norms and peer and doctor-patient communication. However, a gap is emerging between research and practice, and no stewardship recommendation addresses the most appropriate human resource allocation or modalities to account for psycho-social determinants of prescribing. There is a need for translation of the evidence available from human behaviour studies to the design and implementation of stewardship interventions and policies at hospital and community levels. The integration of behaviour experts into multidisciplinary stewardship teams seems essential to positively impact on prescribers' communication and decision-making competencies, and reduce inappropriate antibiotic prescribing.
Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/métodos , Terapia Comportamental/organização & administração , Prescrições de Medicamentos/normas , Uso de Medicamentos/normas , Médicos/psicologia , Padrões de Prática Médica , HumanosRESUMO
SCOPE: The aim of these guidelines is to provide recommendations for decolonizing regimens targeting multidrug-resistant Gram-negative bacteria (MDR-GNB) carriers in all settings. METHODS: These evidence-based guidelines were produced after a systematic review of published studies on decolonization interventions targeting the following MDR-GNB: third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE), carbapenem-resistant Enterobacteriaceae (CRE), aminoglycoside-resistant Enterobacteriaceae (AGRE), fluoroquinolone-resistant Enterobacteriaceae (FQRE), extremely drug-resistant Pseudomonas aeruginosa (XDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), cotrimoxazole-resistant Stenotrophomonas maltophilia (CRSM), colistin-resistant Gram-negative organisms (CoRGNB), and pan-drug-resistant Gram-negative organisms (PDRGNB). The recommendations are grouped by MDR-GNB species. Faecal microbiota transplantation has been discussed separately. Four types of outcomes were evaluated for each target MDR-GNB:(a) microbiological outcomes (carriage and eradication rates) at treatment end and at specific post-treatment time-points; (b) clinical outcomes (attributable and all-cause mortality and infection incidence) at the same time-points and length of hospital stay; (c) epidemiological outcomes (acquisition incidence, transmission and outbreaks); and (d) adverse events of decolonization (including resistance development). The level of evidence for and strength of each recommendation were defined according to the GRADE approach. Consensus of a multidisciplinary expert panel was reached through a nominal-group technique for the final list of recommendations. RECOMMENDATIONS: The panel does not recommend routine decolonization of 3GCephRE and CRE carriers. Evidence is currently insufficient to provide recommendations for or against any intervention in patients colonized with AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB and XDRPA. On the basis of the limited evidence of increased risk of CRE infections in immunocompromised carriers, the panel suggests designing high-quality prospective clinical studies to assess the risk of CRE infections in immunocompromised patients. These trials should include monitoring of development of resistance to decolonizing agents during treatment using stool cultures and antimicrobial susceptibility results according to the EUCAST clinical breakpoints.
Assuntos
Antibacterianos/farmacologia , Farmacorresistência Bacteriana Múltipla , Bactérias Gram-Negativas/efeitos dos fármacos , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Acinetobacter baumannii/efeitos dos fármacos , Infecção Hospitalar/tratamento farmacológico , Europa (Continente) , Humanos , Hospedeiro Imunocomprometido , Pseudomonas aeruginosa/efeitos dos fármacos , Stenotrophomonas maltophilia/efeitos dos fármacosAssuntos
Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Embolia Pulmonar/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , COVID-19 , Angiografia por Tomografia Computadorizada , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico por imagem , Infecções por Coronavirus/patologia , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hospitalização , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/patologia , Prevalência , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/patologia , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/patologia , SARS-CoV-2RESUMO
OBJECTIVES: To describe 5 cases of ureteral bladder augmentation. METHODS: From may 1995 to september 1997, ureterocystoplasty was performed on 5 patients (3 males and 2 females), aged 2 to 18 years (mean 9.8). The mean follow-up was 16.6 months (range 4-28). RESULTS/CONCLUSION: Augmentation ureterocystoplasty has the beneficial effects of enterocystoplasty without the complications that may arise from the use of bowel segments. It is a simple surgical technique whose outcome depends entirely on careful patient selection.
Assuntos
Ureter/transplante , Bexiga Urinária/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , MasculinoRESUMO
OBJECTIVE: To report a case of transitional cell carcinoma of the urethra associated with human papilloma virus (HPV) infection in areas of squamous differentiation of the neoplasm. METHODS/RESULTS: A 32-year-old male with a previously treated condylomata acuminatum of the prepuce presented with a verrucous lesion in the penile meatus, corresponding to well differentiated, low grade papillary transitional cell carcinoma with squamous differentiation. Histological viral expression of HPV was confirmed by in situ hybridization. CONCLUSION: We emphasize the rare presentation of transitional carcinoma in the distal urethra associated with HPV infection.
Assuntos
Carcinoma de Células de Transição/patologia , Transformação Celular Neoplásica/patologia , Transformação Celular Viral , Papillomaviridae , Infecções por Papillomavirus/patologia , Infecções Tumorais por Vírus/patologia , Neoplasias Uretrais/patologia , Adulto , Carcinoma de Células de Transição/virologia , Humanos , Hibridização In Situ , Masculino , Infecções por Papillomavirus/virologia , Infecções Tumorais por Vírus/virologia , Uretra/patologia , Uretra/virologia , Neoplasias Uretrais/virologiaRESUMO
OBJECTIVE: To report a case of renal cell carcinoma associated with renal angiomyolipoma and renal cortical adenoma and discuss the possibility of a hereditary etiology. METHODS: A 64-year-old patient with a tumor in the right kidney underwent right renal nephrectomy. The pathological findings revealed a clear cell renal carcinoma, two cortical angiomyolipoma and a renal cortical adenoma. The literature on these three coincident renal tumors is reviewed. RESULTS: The association of these three renal tumors is rare and is usually seen in patients with tuberous sclerosis. CONCLUSIONS: Renal angiomyolipoma is a benign tumor frequently associated with Bourneville's disease or tuberous sclerosis, a disorder of autosomal dominant transmission. Familial evidence of renal cell carcinoma has been previously reported, as in von Hippel-Lindau disease. It has been suggested that heredity may play an important role in the association of renal cell carcinoma and other renal tumors.
Assuntos
Neoplasias do Córtex Suprarrenal/patologia , Adenoma Adrenocortical/patologia , Angiomiolipoma/patologia , Carcinoma de Células Renais/patologia , Neoplasias Renais/patologia , Neoplasias Primárias Múltiplas/patologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To report our experience over the last 10 years with Fournier's gangrene, an extensive fulminant infection of the perineoscrotal region, and to review the literature. METHODS: The medical records of 9 patients with Fournier's gangrene that had been diagnosed from January 1988 to December 1997 were reviewed. Patient age, etiology and predisposing factors, microbiological findings, duration of hospital stay, treatment and outcome were analyzed. RESULTS: The mean age of the patients was 53.8 years (range 43-71). The source of the gangrene was perirectal (22.22%), urinary (66.66%) and cutaneous (11.11%). Predisposing factors included diabetes mellitus, alcoholism, malnutrition and low socio-economic status. All patients were treated with surgical debridement and broad-spectrum antimicrobial therapy. Two patients underwent delayed reconstructive surgery. Cystostomy was performed in 100% of the cases. Two patients died from severe sepsis. CONCLUSIONS: Necrotizing fasciitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. Good management is based on aggressive debridement, broad-spectrum antibiotics and intensive supportive care.
Assuntos
Gangrena de Fournier/diagnóstico , Adulto , Idoso , Terapia Combinada , Suscetibilidade a Doenças , Gangrena de Fournier/tratamento farmacológico , Gangrena de Fournier/etiologia , Gangrena de Fournier/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Existe amplia evidencia de que el cáncer está asociado con anormalidades en la regulación génetica expresada en la superficie de la membrana celular. El 80 por ciento de los individuos son capaces de secretar los antígenos ABH en saliva y otras secreciones. La presencia de estas sustancias está controlada por un gen que puede adoptar dos formas alélicas: SE dominante y SE recesiva. El objetivo de este trabajo fue investigar la relación entre la expresión antigénica ABH en célkulas de descamación urotelial y el carácter secretor en pacientes con cáncer de vejiga. Se examinaron 33 pacientes con tumores de vejiga clasificados en superficiales y profundos y una población de 40 individuos normales. Se investigó el carácter secretor en saliva y la expresión de los antígenos ABH uroteliales en sedimentos urinario. Se empleó para estos estudios la técnica de inhibición de la aglutinación. En la población normal todos expresaron los antígenos ABH en células de sedimento urinario y sólo el 80 por ciento presentó dichos antígenos en sus secreciones. En los pacientes con cáncer de vejiga el 30,31 por ciento resultó no secretor y de ellos el 70 por ciento presentó deleción antigénica ABH en sedimento urinario con mayor incidencia de tumores profundos. Nuestros resultados indicarían que los pacientes con cáncer de vejiga no secretores desarrollarían tumores con mayor grado de infiltración respecto de los pacientes secretores
Assuntos
Humanos , Isoantígenos/isolamento & purificação , Saliva/metabolismo , Neoplasias da Bexiga Urinária/sangue , Neoplasias da Bexiga Urinária/urina , Antígenos de Grupos Sanguíneos/análiseRESUMO
Los quistes del rafe medio representan defectos del desarrollo embriológico de la zona genitc cuentran tapizados por diferentes epitelios según su ubicación. Estas lesiones, que son más comúnmente hall ca del meato uretral, pueden localizarse en cualquier lugar del rafe medio genitoperineal, desde el glandi ano. El tratamiento de elección es la escisión quirúrgica. Presentamos tres nuevos casos y revisamos la literatura.
Assuntos
Humanos , Masculino , Adolescente , Adulto , Criança , Cistos , Genitália Masculina , Diagnóstico DiferencialRESUMO
Los pólipos fibroepiteliales son tumores benignos que se pueden manifestar a lo largo de todo el tracto urinario. Se presenta un caso de pólipo fibroepitelial en uréter. Revisamos la literatura y discutimos las características clínicas, diagnósticas y terapéuticas de esta rara entidad