Giant Aneurysm of the Interatrial Septum: A Multidisciplinary Approach.

A 46-year-old woman presented for a routine echocardiogram, which revealed a giant atrial septal aneurysm (ASA) with an atrial septal defect (ASD). We surgically excised the ASA and closed the ASD with a pericardial patch. ASA, although rare, poses embolic risks, thus necessitating closure when associated with shunts. Optimal stroke prevention remains uncertain.

Danon Disease Presenting as Eosinophilic Myocarditis: Key Role of Endomyocardial Biopsy.

A 21-year-old woman with a history of atopy, peripheral eosinophilia, Wolf-Parkinson-White syndrome, and 5 episodes of myocarditis was diagnosed with eosinophilic myocarditis. Despite adequate immunosuppressive treatment and resolution of the myocarditis episode, the patient developed dilated cardiomyopathy and presented with worsening of her functional class. Finally, genetic testing unveiled an additional diagnosis: Danon disease. (Level of Difficulty: Advanced.).

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort.

OBJECTIVES: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). METHODS: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. RESULTS: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. CONCLUSION: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective.

Prognostic Factors at Admission for In-Hospital Mortality from COVID-19 Infection in an Older Rural Population in Central Spain.

BACKGROUND: Risk factors for in-hospital mortality from severe coronavirus disease 2019 (COVID-19) infection have been identified in studies mainly carried out in urban-based teaching hospitals. However, there is little data for rural populations attending community hospitals during the first wave of the pandemic. METHODS: A retrospective, single-center cohort study was undertaken among inpatients at a rural community hospital in Spain. Electronic medical records of the 444 patients (56.5% males) admitted due to severe SARS-CoV-2 infection during 26 February 2020-31 May 2020 were reviewed. RESULTS: Mean age was 71.2 ± 14.6 years (rank 22-98), with 69.8% over 65. At least one comorbidity was present in 410 patients (92.3%), with chronic obstructive pulmonary disease (COPD) present in 21.7%. Overall in-hospital mortality was 32%. Multivariate analysis of factors associated with death identified patients' age (with a cumulative effect per decade), COPD as a comorbidity, and respiratory insufficiency at the point of admission. No additional comorbid conditions proved significant. Among analytical values, increased serum creatinine, LDH > 500 mg/dL, thrombocytopenia (<150 × 109/per L), and lymphopenia (<1000 cells/µL) were all independently associated with mortality during admission. CONCLUSIONS: Age remained the major determinant for COVID-19-caused mortality; COPD was the only comorbidity independently associated with in-hospital death, together with respiratory insufficiency and analytical markers at admission.

Recommendations for airway management in a suspected or confirmed case with COVID-19. A protocol of the Department of Cardiovascular Anesthesia of the National Institute of Cardiology Ignacio Chávez / Recomendaciones para el manejo de la vía aérea en caso sospechoso y/o confirmado con COVID-19. Protocolo del Departamento de Anestesiología Cardiovascular del Instituto Nacional de Cardiología Ignacio Chávez

The new coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), detected in Wuhan, China, causes coronavirus disease 2019 (COVID-19), which was declared pandemic, and has caused more than 19 million confirmed cases and more than 700 thousand deaths worldwide. When our institution was converted to COVID's hospital since early April 2020, specific care protocols were developed, with the aim of improving the quality of care and safety of patients and the staff involved in their management. Airway management represents one of the highest risks of direct contact infection with aerosol generation (orotracheal intubation, secretion aspiration, extubation, cardiopulmonary resuscitation, high flow oxygen therapy, noninvasive ventilation, and invasive ventilation). We present the current recommendations for airway management as well as a step-by-step airway management protocol to carry out a more secure procedure based on the literature reported so far.

El nuevo coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), detectado en Wuhan (China), causante de la enfermedad por coronavirus 2019 (COVID-19), que se declaró como pandemia, ha causado más de 19 millones de casos confirmados y más de 700 mil muertes en el mundo. Nuestra institución se reconvirtió a hospital COVID desde principios de abril del 2020, con lo que se desarrollaron protocolos de atención específicos, con el objetivo de mejorar la calidad de atención y seguridad de los pacientes y el personal involucrado en su manejo. El manejo de la vía aérea representa uno de los riesgos más altos de contagio por contacto directo en la generación de aerosoles (intubación orotraqueal, aspiración de secreciones, extubación, resucitación cardiopulmonar, terapia de oxígeno de alto flujo, ventilación no invasiva y ventilación invasiva). Presentamos las recomendaciones actuales para el manejo de la vía aérea, así como un protocolo de manejo paso a paso para llevar a cabo un procedimiento con mayor seguridad basados en la literatura reportada hasta el momento.

Use of bedside ultrasound in the evaluation of acute dyspnea: a comprehensive review of evidence on diagnostic usefulness / Uso de ecografía a pie de cama en la evaluación de la disnea aguda: una revisión exhaustiva de la evidencia sobre su utilidad diagnóstica / Uso de ultrassom à beira do leito na avaliação da dispneia aguda: uma revisão abran-gente das evidencias sobre sua utilidade diagnostica

Introduction: Acute dyspnea is one of the most frequently observed symptoms in emergency departments, which can be caused mainly by pulmonary or cardiac system involvement. Bedside ultrasound is postulated as an inno-vative tool for basic use by the physician, which can complement the physical examination and quickly explore the integrity of thoracic structures. Objectives: To synthesize recent evidence on the use of bedside ultrasound in the evaluation of acute dyspnea. Materials and methods: A bibliographic search was carried out using search terms such as "Bedside Ultrasound" and "Acute Dyspnea," as well as synonyms, which were combined with Boolean operators, in the databases PubMed, ScienceDirect, Embase, EBSCO, and MEDLINE. Results: During the literature review, 10 observational studies, 2 clinical trials and 2 systematic reviews met the inclusion criteria and were ana-lyzed. The use of bedside ultrasound changes the main diagnosis associated with acute dyspnea in more than 60% of cases, the most frequent being acute decompensated heart failure and pneumonia. Protocols such as SEARCH 8Es for the evaluation of dyspnea in the emergency department, has a performance with sensitivity, specificity, positive and negative predictive value parameters above 95%. Conclusions: The current evidence on the use of bedside ultrasound in the management of patients with acute dyspnea in the emergency department is limited, Although the level of evidence is not the best, it suggests that this tool may promote the diagnostic perfomance of acute dyspnea of pulmonary or cardiac causes, improve the time to diagnosis, and enhance physician diagno-stic confidence.

Introducción: La disnea aguda es uno de los síntomas más observados en los servicios de urgencias, que puede estar causada por la afectación del sistema pulmonar o cardiaco. La ecografía a pie de cama se postula como una herramienta innovadora, al complementar la exploración física con la eva-luación rápida de las estructuras intratorácicas. Objetivo: Sintetizar la evidencia reciente sobre el uso de la ecografía a pie de cama en la evaluación de la disnea aguda. Materiales y métodos: Búsqueda bibliográfica utilizando términos de búsqueda como Bedside Ultra-sound y Acute Dyspnea, así como sinónimos, que se combinaron con operadores booleanos, en cinco bases de datos. Resultados: Se evidenció que el uso de la ecografía a pie de cama cambia el diagnóstico principal asociado con la disnea aguda en más del 60 % de los casos, entre los cuales los más frecuentes fueron la insuficiencia cardiaca aguda descompensada y la neumonía. Protocolos como el SEARCH 8Es para la evaluación de la disnea en el servicio de urgencias tiene un rendimiento con parámetros de sensibi-lidad, especificidad, valor predictivo positivo y negativo superiores al 95 %. Conclusión: La evidencia actual sobre el uso de la ecografía a pie de cama en el tratamiento de los pacientes con disnea aguda en el servicio de urgencias es limitada. No obstante, sugiere que esta herramienta puede favorecer el rendimiento diagnóstico de la disnea aguda de causa pulmonar o cardiaca, mejorar el tiempo de diagnóstico y aumentar la confianza del médico en el diagnóstico

Introdução: A dispneia aguda é um dos sintomas mais observados no departamento de emergência, que pode ser causado pela afetação do sistema pulmonar o cardíaco. O ultrassom à beira do leito é proposto como uma ferramenta inovadora, complementando o exame físico com uma rápida ava-liação das estruturas intratorácicas. Objetivo: sintetizar evidências recentes sobre o uso do ultrassom à beira do leito na avaliação da dispneia aguda. Materiais e métodos: Pesquisa de literatura usando termos de busca tais como Bedside Ultrasound e Acute Dyspnea, bem como sinônimos, que foram combinados com operadores booleanos, em cinco bancos de dados. Resultados: O uso do ultrassom á beira do leito mostrou a mudança do principal diagnóstico associa-do com a dispneia aguda em mais de 60% dos casos, sendo o mais frequente a insuficiência cardíaca descompensada aguda e a pneumonia. Protocolos como o SEARCH 8Es para a avaliação da dispneia no serviço de emergência tem um desempenho com parâmetros de sensibilidade, especificidade, valor preditivo positivo e negativo superiores ao 95%. Conclusão: As evidencias atuais sobre o uso do ultrassom á beira do leito no gerenciamento de pa-cientes com dispneia aguda no serviço de emergências são limitadas. No entanto, sugere que esta ferramenta pode favorecer o rendimento diagnóstico da dispneia aguda de causa pulmonar ou car-díaca, melhorar o tempo de diagnóstico e aumentar a confiança do médico no diagnóstico.

Navigating mysterious lands regarding the predictive value of the SOFA score: the race dilemma / Navegando por un territorio misterioso en cuanto al valor predictivo de la puntuación del SOFA: el dilema de la raza

Critical syndromes are conditions that carry a high global burden of disease. Scoring systems are practical and reproducible aids that allow patients with more severe disease to be quickly identified and admitted to intensive care and to initiate structured and aggressive therapy. The Sequential Organ Failure Assessment (SOFA) score is one of the most widely used in the world, as there are several versions and it is simple. However, with the appearance of the COVID-19, several studies showed that there was a disparity in the estimation of mortality and associated outcomes, with respect to race, which culminated in an excess of preventable mortality in certain racial groups. Constant evaluation of the performance of these scoring systems must be performed due to definitional updates, which may vary the accuracy of the predictive value. There is a very large evidence gap in this regard, as the existing studies are from high-income countries where the predominant racial group is Caucasian, which should draw attention to the magnitude of the problem. Based on the above, the objective of this review is to discuss evidence on the performance of critical care scoring systems, particularly SOFA, and the impact that race has had on its predictive value.

Los síndromes críticos son condiciones que acarrean una elevada carga de enfermedad a nivel global. Los sistemas de puntaje, son ayudas prácticas y reproducibles que permiten identificar de manera rápida pacientes con enfermedad más grave e ingresarlos a cuidado intensivo e iniciar terapia estructurada y agresiva. El score Sequential Organ Failure Assessment (SOFA), es uno de los más utilizados en el mundo, al existir varias versiones y ser sencillo. No obstante, con la aparición de la COVID-19, diversos estudios demostraron que existía una disparidad en cuanto a la estimación de mortalidad y desenlaces asociados, respecto a la raza, lo que culminó en un exceso de mortalidad prevenible en ciertos grupos raciales. La evaluación constante del rendimiento de estos sistemas de puntaje, debe realizarse debido a actualizaciones de definiciones, las cuales pueden variar la precisión del valor predictivo. Existe una brecha muy grande en cuanto la evidencia al respecto, puesto que los estudios existentes provienen de países de altos ingresos, donde el grupo racial predominante son los caucásicos, lo que debe llamar la atención de la magnitud del problema. Sobre la base de lo anterior, el objetivo de esta revisión consiste en discutir evidencia al respecto sobre el rendimiento de sistemas de puntuación en cuidado crítico, particularmente del SOFA y el impacto que ha tenido la raza sobre su valor predictivo.