Non-toxigenic Corynebacterium diphtheriae infective endocarditis with embolic events: a case report.

BACKGROUND: Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis. CASE PRESENTATION: A 21-year-old male cocaine drug abuser presented to the emergency department with a 1-week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of antimicrobial treatment. CONCLUSION: Despite the effectiveness of toxoid-based vaccines, recent global outbreaks of invasive C. diphtheriae infectious related to non-toxigenic strains have been described. These infectious could be highly invasive as demonstrated in this case. Interdisciplinary work with an institutional "endocarditis team" is essential to achieve favorable clinical outcomes in such defiant scenarios.

Heart Transplant in Patients with Predominantly Rheumatic Valvular Heart Disease.

BACKGROUND AND AIM OF THE STUDY: International records indicate that only 2.6% of patients with heart transplants have valvular heart disease. The study aim was to evaluate the epidemiological and clinical profile of patients with valvular heart disease undergoing heart transplantation. METHODS: Between 1985 and 2013, a total of 569 heart transplants was performed at the authors' institution. Twenty patients (13 men, seven women; mean age 39.5 +/- 15.2 years) underwent heart transplant due to structural (primary) valvular disease. Analyses were made of the patients' clinical profile, laboratory data, echocardiographic and histopathological data, and mortality and rejection. RESULTS: Of the patients, 18 (90%) had a rheumatic etiology, with 85% having undergone previous valve surgery (45% had one or more operations), and 95% with a normal functioning valve prosthesis at the time of transplantation. Atrial fibrillation was present in seven patients (35%), while nine (45%) were in NYHA functional class IV and eight (40%) in class III. The indication for cardiac transplantation was refractory heart failure in seven patients (35%) and persistent NYHA class III/IV in ten (50%). The mean left ventricular ejection fraction (LVEF) was 26.6 +/- 7.9%. The one-year mortality was 20%. Histological examination of the recipients' hearts showed five (27.7%) to have reactivated rheumatic myocarditis without prior diagnosis at the time of transplantation. Univariate analysis showed that age, gender, LVEF, rheumatic activity and rejection were not associated with mortality at one year. CONCLUSION: Among the present patient cohort, rheumatic heart disease was the leading cause of heart transplantation, and a significant proportion of these patients had reactivated myocarditis diagnosed in the histological analyses. Thus, it appears valid to investigate the existence of rheumatic activity, especially in valvular cardiomyopathy with severe systolic dysfunction before transplantation.

Telemedicine medical evaluation of low-risk patients with dengue during an outbreak may be an option in reducing the need for on-site physicians.

OBJECTIVE: To analyze the effectiveness of telemedicine consultations during an outbreak in reducing the need for face-to-face consultations at a field hospital for patients with dengue. METHODS: We performed a retrospective unicentric study between April and May 2015 with 4626 patients (≥15 years old) who spontaneously sought care at an emergency field hospital (Sao Paulo/Brazil). A nurse initially assessed all patients with dengue through rapid diagnostic testing, automated complete blood count, and risk stratification. During overcrowded situations, a video-based telemedicine consultation was provided as an option to all low-to-moderate risk patients who tested positive. The management was carried out according to current dengue guidelines. The primary end point was a referral to immediate face-to-face medical evaluation. RESULTS: Of all patients suspected of dengue infection, 2003 presented positive testing, 1978 were classified as low-moderate risk, and 267 patients with dengue were evaluated by telemedicine. The mean age was 38.17 ± 13.7 years (54.6% female). Oral medications were recommended in 169 (63.3%), intravenous hydration or symptomatic drugs in 96 (36%), 252 (94.4%) were discharged after telemedicine assessment, and only 15 (5.6%) were referred to immediate face-to-face medical evaluation. No adverse events were recorded. CONCLUSION: Telemedicine medical assessment of low-to-moderate risk patients with dengue previously screened by nursing triage is effective in replacing the face-to-face evaluation in a field hospital. Telemedicine may be reinforced in epidemiological outbreak scenarios as a cost-effective strategy for the initial assessment of acute patients.

Cross-sectional study of the ambulance transport between healthcare facilities with medical support via telemedicine: Easy, effective, and safe tool.

BACKGROUND: Feasibility and safety of ambulance transport between healthcare facilities with medical support exclusively via telemedicine are unknown. METHODS: This was a retrospective study with a single telemedicine center reference for satellite emergency departments of the same hospital. The study population was all critically ill patients admitted to one of the peripheral units from November 2016 to May 2020 and who needed to be transferred to the main building. Telemedicine-assisted transportation was performed by an emergency specialist. The inclusion criteria included patients above the age of 15 and initial stabilization performed at the emergency department. Unstable, intubated, ST-elevation myocardial infarction and acute stroke patients were excluded. There was a double-check of safety conditions by the nurse and the remote doctor before the ambulance departure. The primary endpoint was the number of telemedicine-guided interventions during transport. RESULTS: 2840 patients were enrolled. The population was predominantly male (53.2%) with a median age of 60 years. Sepsis was the most prevalent diagnosis in 28% of patients, followed by acute coronary syndromes (8.5%), arrhythmia (6.7%), venous thromboembolism (6.1%), stroke (6.1%), acute abdomen (3.6%), respiratory distress (3.3%), and heart failure (2.5%). Only 22 (0.8%) patients required telemedicine-assisted support during transport. Administration of oxygen therapy and analgesics were the most common recommendations made by telemedicine emergency physicians. There were no communication problems in the telemedicine-assisted group. CONCLUSIONS: Telemedicine-assisted ambulance transportation between healthcare facilities of stabilized critically ill patients may be an option instead of an onboard physician. The frequency of clinical support requests by telemedicine is minimal, and most evaluations are of low complexity and easily and safely performed by trained nurses.

Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate.

OBJECTIVE: To analyze the antibiotic prescription rate in low-risk patients evaluated at a telemedicine program that adopts antibiotic stewardship protocols. METHODS: Adult patients who accessed a single direct-to-consumer telemedicine center (Jan/2019-Feb/2020) were retrospectively enrolled. Diseases amenable to antimicrobial treatment were classified under five diagnostic groups: upper respiratory tract infection (URI), acute pharyngotonsillitis (PT), acute sinusitis (AS), urinary tract infection (UTI), and acute diarrhea (AD). Physicians were trained on and advised to strictly follow the current guideline recommendations supported by institutional antibiotic stewardship protocols, readily available online during consultations. We analyzed the antibiotic prescription rate among patients, referral rate, and antibiotic class through descriptive statistics. RESULTS: A total of 2328 patients were included in the study. A total of 2085 (89·6%) patients were discharged with usual recommendations, medication (if needed), and instructions about red flags, while 243 (10·4%) were referred to a face-to-face consultation. Among the discharged patients, the antibiotic prescription rates by the diagnostic group were URI - 2·5%, PT - 35·0%, AS - 51·8%, UTI - 91.6%, and AD - 1·6%. In most cases, prescribed antibiotics were in line with institutional stewardship protocols. CONCLUSIONS: Low prescription rate of antibiotics can be achieved using antibiotic stewardship protocols at direct-to-consumer telemedicine consultations, showing high adherence to international guidelines. These results reinforce telemedicine as a cost-effective and safe strategy for the initial assessment of acute non-urgent symptoms.

Myocardial Fibrosis in Classical Low-Flow, Low-Gradient Aortic Stenosis.

Background Few data exist on the degree of interstitial myocardial fibrosis in patients with classical low-flow, low-gradient aortic stenosis (LFLG-AS) and its association with left ventricular flow reserve (FR) on dobutamine stress echocardiography. This study sought to evaluate the diffuse interstitial fibrosis measured by T1 mapping cardiac magnetic resonance technique in LFLG-AS patients with and without FR. Methods Prospective study including 65 consecutive patients (41 LFLG-AS [mean age, 67.1±8.4 years; 83% men] and 24 high-gradient aortic stenosis used as controls) undergoing dobutamine stress echocardiography to assess FR and cardiac magnetic resonance to determine the extracellular volume (ECV) fraction of the myocardium, indexed ECV (iECV) to body surface area and late gadolinium enhancement. Results Interstitial myocardial fibrosis measured by iECV was higher in patients with LFLG-AS with and without FR as compared with high-gradient aortic stenosis (35.25±9.75 versus 32.93±11.00 versus 21.19±6.47 mL/m2, respectively; P<0.001). However, both ECV and iECV levels were similar between LFLG-AS patients with and without FR ( P=0.950 and P=0.701, respectively). Also, FR did not correlate significantly with ECV (r=-0.16, P=0.31) or iECV (r=0.11, P=0.51). Late gadolinium enhancement mass was also similar in patients with versus without FR but lower in high-gradient aortic stenosis (13.3±10.2 versus 10.5±7.5 versus 4.8±5.9 g, respectively; P=0.018). Conclusions Patients with LFLG-AS have higher ECV, iECV, and late gadolinium enhancement mass compared with high-gradient aortic stenosis. Moreover, among patients with LFLG-AS, the degree of myocardial fibrosis was similar in patients with versus those without FR. These findings suggest that diffuse myocardial fibrosis may not be the main factor responsible for the absence of FR in LFLG-AS patients.

White-coat hypertension and normotension in the League of Hypertension of the Hospital das Clínicas, FMUSP: prevalence, clinical and demographic characteristics.

OBJECTIVE: To assess the prevalence of white-coat normortension, white-coat hypertension, and white-coat effect. METHODS: We assessed 670 medical records of patients from the League of Hypertension of the Hospital das Clínicas of the Medical School of the University of S o Paulo. White-coat hypertension (blood pressure at the medical office: mean of 3 measurements with the oscillometric device > or = 140 or > or = 90 mmHg, or both, and ambulatory blood pressure monitoring mean during wakefulness < 135/85) and white-coat normotension (office blood pressure < 140/90 and blood pressure during wakefulness on ambulatory blood pressure monitoring > or = 135/85) were analyzed in 183 patients taking no medication. The white-coat effect (difference between office and ambulatory blood pressure > 20 mmHg for systolic and 10 mmHg for diastolic) was analyzed in 487 patients on treatment, 374 of whom underwent multivariate analysis to identify the variables that better explain the white-coat effect. RESULTS: Prevalence of white-coat normotension was 12%, prevalence of white-coat hypertension was 20%, and prevalence of the white-coat effect was 27%. A significant correlation (p<0.05) was observed between white-coat hypertension and familial history of hypertension, and between the white-coat effect and sex, severity of the office diastolic blood pressure, and thickness of left ventricular posterior wall. CONCLUSION: White-coat hypertension, white-coat normotension, and white-coat effect should be considered in the diagnosis of hypertension.

Efeito hipertensäo e normotensäo do avental branco na liga de hipertensäo do Hospital das Clínicas, FMUSP. Prevalência, características clínicas e demográficas / White-coat hypertension and normotension in the league of hypertension of the Hospital das Clínicas, FMUSP. Prevalence, clinical and demographic characteristics

OBJECTIVE: To assess the prevalence of white-coat normortension, white-coat hypertension, and white-coat effect. METHODS: We assessed 670 medical records of patients from the League of Hypertension of the Hospital das Clínicas of the Medical School of the University of Säo Paulo. White-coat hypertension (blood pressure at the medical office: mean of 3 measurements with the oscillometric device ³140 or ³90 mmHg, or both, and ambulatory blood pressure monitoring mean during wakefulness < 135/85) and white-coat normotension (office blood pressure < 140/90 and blood pressure during wakefulness on ambulatory blood pressure monitoring ³ 135/85) were analyzed in 183 patients taking no medication. The white-coat effect (difference between office and ambulatory blood pressure > 20 mmHg for systolic and 10 mmHg for diastolic) was analyzed in 487 patients on treatment, 374 of whom underwent multivariate analysis to identify the variables that better explain the white-coat effect. RESULTS: Prevalence of white-coat normotension was 12 percent, prevalence of white-coat hypertension was 20 percent, and prevalence of the white-coat effect was 27 percent. A significant correlation (p<0.05) was observed between white-coat hypertension and familial history of hypertension, and between the white-coat effect and sex, severity of the office diastolic blood pressure, and thickness of left ventricular posterior wall. CONCLUSION: White-coat hypertension, white-coat normotension, and white-coat effect should be considered in the diagnosis of hypertension

Valvopatias: atividades físicas e esportes / Valvopathy: physical activity and sports

Ao se recomendar atividade física e esporte, o médico deve considerar as característica da atividade proposta, associada ao tipo de valvopatia e sua gravidade. Uma das formas de se classificar esporte,atividade física é pelo tipo de exercício e pela intensidade empregados em sua prática. Assim, os exercícios podem ser classificados em dinâmicos e estáticos leves, moderados e intensos. A avaliação da doença valvar, por outro lado, inicia-se pelo diagnóstico, com anamnese, exame físico e exames complementares, acrescentada pela estratificação de gravidade que leva em conta parâmetros anatômicos e funcionais das valvas, alterações anatômicas do coração e presença de síntomas, principalemnte dispnéia aos esforços. Dessa forma, baseado no diagnóstico tanto anatômico como funcional da valvopatia, e com a caracterização da gravidade, o médico pode recomendar atividade física e/ou esporte de forma individualizada para o paciente.