Occurrence of NDM-1-producing Morganella morganii and Proteus mirabilis in a single patient in Portugal: probable in vivo transfer by conjugation.

OBJECTIVES: To decipher the genetics of acquisition of carbapenemase-encoding genes identified in two carbapenem-resistant Enterobacteriaceae recovered from a single patient in Portugal. METHODS: Carbapenemase genes were searched by PCR assays and mating-out assays were performed to further characterize the plasmid support of the carbapenemase genes. Genetic characterization of the plasmid supports was performed by whole-plasmid sequencing using the Illumina technology. RESULTS: We identified here two NDM-1-producing isolates, namely a Morganella morganii and a Proteus mirabilis, sharing the same blaNDM-1-positive plasmid. This 154 kb plasmid belonged to the IncA/C2 type, recently renamed IncC, and co-harboured two AmpC ß-lactamase genes, namely blaCMY-4 and blaDHA-1, in addition to the 16S rRNA methylase gene armA encoding high-level resistance to aminoglycosides. In addition, the M. morganii isolate produced the CTX-M-33 extended-spectrum ß-lactamase possessing weak carbapenemase activity, encoded by another plasmid. CONCLUSIONS: We showed here that, in addition to KPC-type and OXA-181 carbapenemases, which have been identified as widespread in this country, another concern is the emergence of NDM-1-producing enterobacterial isolates in Portugal. We demonstrated here the in vivo plasmid transfer of a blaNDM-1-positive plasmid leading to dissemination of this carbapenemase gene within different enterobacterial species in a single patient.

Intestinal carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae at admission in a Portuguese hospital.

To evaluate the prevalence of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae fecal carriers at admission in a Portuguese hospital and to determine the epidemiology and antimicrobial resistance patterns of ESBL-producing isolates. During a 2-month period, rectal swabs were collected at hospital admission from 151 at-risk patients. In addition, 48 rectal swabs were obtained from weekly screenings of 37 patients hospitalized for > 48 h. All ESBL/carbapenemase-producing isolates were tested for antimicrobial susceptibility and characterized by PFGE and MLST. The prevalence of ESBL producers at hospital admission was 17% and 24% among at-risk patients hospitalized for > 48 h, while the prevalence of carbapenemase producers was 3% in both cases. Most of the isolates were Escherichia coli (54%) and Klebsiella pneumoniae (41%). The most common ESBL identified was CTX-M-15 (n = 17/34; 50%), followed by CTX-M-27 (n = 10; 29%), CTX-M-33 (n = 4; 12%), SHV-12 (n = 2), and CTX-M-55 (n = 1). The 20 E. coli isolates were distributed into 16 PFGE types and nine sequence types (ST), with 60% of the isolates belonging to ST131. The 15 K. pneumoniae were grouped into 12 PFGE types and nine STs, with three STs (ST17, ST449, ST147) corresponding to 60% of the isolates. A high proportion of isolates showed resistance to ciprofloxacin (86%), trimethoprim-sulfamethoxazole (68%), tobramycin (57%), and gentamicin (43%). All isolates remained susceptible to fosfomycin. A high prevalence of ESBL-producing Enterobacteriaceae was found at hospital admission among at-risk patients and > 50% of the isolates showed resistance to first-line antibiotics for the treatment of lower urinary tract infections, leaving fosfomycin as an alternative.

Epidemiology of Carbapenemase-Producing Klebsiella pneumoniae in a Hospital, Portugal.

We aimed to provide updated epidemiologic data on carbapenem-resistant Klebsiella pneumoniae in Portugal by characterizing all isolates (N = 46) recovered during 2013-2018 in a 123-bed hospital in Lisbon. We identified blaKPC-3 (n = 36), blaOXA-181 (n = 9), and blaGES-5 (n = 8) carbapenemase genes and observed co-occurrence of blaKPC-3 and blaGES-5 in 7 isolates. A single GES-5-producing isolate co-produced the extended-spectrum ß-lactamase BEL-1; both corresponding genes were co-located on the same ColE1-like plasmid. The blaOXA-181 gene was always located on an IncX3 plasmid, whereas blaKPC-3 was carried on IncN, IncFII, IncFIB, and IncFIIA plasmid types. The 46 isolates were distributed into 13 pulsotypes and 9 sequence types. All isolates remained susceptible to ceftazidime/avibactam, but some exhibited reduced antimicrobial susceptibility (MIC = 3 mg/L).

Left ventricular thrombus routine screening with contrast echocardiography in patients with anterior ST-elevation myocardial infarction: is it worth it?

BACKGROUND: Left ventricular (LV) thrombus has a higher incidence among patients with anterior ST-elevation myocardial infarction (STEMI) when compared to other types of acute myocardial infarction and is associated with worse prognosis. The management of LV thrombus diagnosis remains challenging. Contrast echocardiography (transthoracic echocardiography, TTE) has shown potential in improving the accuracy for its diagnosis, thereby influencing treatment strategies concerning antithrombotic/anticoagulation therapy. The aim of this study was to assess the effectiveness of contrast TTE as a routine screening method for detecting LV thrombus in the acute phase of anterior STEMI. METHODS: A prospective, single center, randomized controlled trial was conducted among patients with anterior STEMI. The study group underwent contrast TTE, while the control group received a conventional approach. Demographical, clinical, and diagnostic data were collected. Thrombus detection rates were compared between groups. RESULTS: A total of 68 patients were included (32 in the study group and 36 in the control group). No substantial baseline differences were observed between groups. Thrombus detection rate was 25.0% in the study group and 13.9% in the control group, however these results did not reach statistical significance (P = 0.24). The prevalence of anterior/apical aneurysm was higher in the study group (46.9% vs. 22.2%, P = 0.03). CONCLUSIONS: Conventional TTE may be adequate for diagnosing LV thrombus in the acute phase of anterior STEMI; however, further larger-scale and multicenter studies are necessary to obtain more robust and conclusive results. Ultrasound contrast may play a significant role in the detection of anterior/apical aneurysms, which are known risk factors for the subsequent development of thrombus. TRIAL REGISTRATION: NCT06480929 (ClinicalTrials.gov, Retrospectively registered).

Predictive Model of the Psychological Well-Being of Nursing Students During the COVID-19 Lockdown.

Introduction: Lockdowns due to the COVID-19 pandemic radically changed nursing education. Along with social isolation, the transition to distance education affected the well-being of students in several countries, particularly Portugal and Spain. Objectives: To identify which variables are predictors of psychological well-being for Portuguese and Spanish nursing students during mandatory lockdowns. Methods: A multicenter, cross-sectional, descriptive, correlational study involving a sample of 1075 students (944 women, mean age 22.46 + /-4.95 years). Data were collected from an online questionnaire which applied the following scales: Perceived Stress Scale (α = .820); Brief COPE-14 Subscales (α = .430 < 0.930); Well-being Manifestations Measure Scale (α = .940); Herth Hope Index (α = .850). A multiple regression model was created to predict the psychological well-being of nursing students. Results: The following predictor variables were identified in the model of the psychological well-being of students during the COVID-19 pandemic: perceived stress (ß = .405; p ≤ .001); hope (ß = .404; p ≤ .001); and the mechanisms of active coping (ß = .405; p ≤ .001), planning (ß = .097; p ≤ .001), and positive reinterpretation (ß = .053; p = .12). These five variables predicted 62.0% of the nursing students' psychological well-being (R 2 = .620; F = 350.82; p ≤ .001). Conclusion: Promoting students' mental health is essential, especially in periods of great adversity, such as a pandemic. Our results lead the way for the design and validation of an intervention program that addresses the five variables identified as predictors of students' psychological well-being.

Impact of Emergency Medical System Transportation in ST-segment Elevation Myocardial Infarction: A Nationwide Retrospective Study.

INTRODUCTION: Emergency medical system transportation has been shown to reduce treatment times in ST-segment elevation myocardial infarction. The authors studied the Portuguese National Registry of Acute Coronary Syndromes to determine the nationwide impact of the emergency medical system transportation in the treatment of ST-segment elevation myocardial infarction. MATERIAL AND METHODS: A multicentric, nationwide, retrospective study of ST-segment elevation myocardial infarction patients inserted in the National Registry from 2010 to 2017 was performed. The patients were divided into: Group I, composed of patients transported by emergency medical system, and Group II, patients arriving to the Emergency department by other means. RESULTS: Of the 5702 patients studied, 25.9% were transported via emergency medical system. Rates of emergency medical system activation increased by 17% in the last 7 years. The emergency medical system provided a higher rate of transport to a percutaneous coronary intervention capable centre, of Emergency department bypass, of on-site fibrinolysis, and ensured a 59-minute reduction of the median reperfusion time (p < 0.001). There was no difference in in-hospital mortality. DISCUSSION: In this nationwide cohort, emergency medical system transportation is associated with a reduction in reperfusion times. It provides a higher amount of salvaged myocardium and reduces the incidence of acute heart failure. However, emergency medical system use did not result in lower in-hospital mortality, probably due to confounding factors of higher disease severity and comorbidity. CONCLUSION: The benefits associated with emergency medical system based transportation of patients with ST-segment elevation myocardial infarction do not translate into lower in-hospital mortality.

Introdução: O transporte através de sistemas de emergência médica reduz os tempos de tratamento no enfarte agudo do miocárdio com elevação do segmento ST. Os autores estudaram o Registo Nacional de Síndromes Coronários Agudos para avaliar o impacto nacional do transporte através de sistema de emergência médica no tratamento do enfarte agudo do miocárdio com elevação do segmento ST. Material e Métodos: Foi realizado um estudo retrospetivo, multicêntrico de doentes com enfarte agudo do miocárdio com elevação do segmento ST inseridos no Registo Nacional desde 2010 até 2017. Os doentes foram divididos em Grupo I, representando doentes transportados por viaturas de emergência médica e Grupo II, doentes que chegaram ao Serviço de Urgência por outros meios. Resultados: Do total de 5702 doentes, 25,6% foram transportados por viaturas de emergência médica. Registou-se um aumento no uso de viaturas de emergência médica de 17% nos últimos sete anos. Os sistemas de emergência médica garantiram uma maior taxa de transporte para centros capazes de realizar intervenção coronária percutânea, de bypass do Serviço de Urgência e de fibrinólise no local. O transporte através de viaturas de emergência médica conseguiu uma redução da mediana do atraso para a reperfusão de 59 minutos (p < 0,001). Não houve diferença na mortalidade intra-hospitalar. Discussão: Nesta amostra nacional, é evidente que os sistemas de emergência médica reduziram significativamente os tempos de reperfusão, associando-se a uma menor incidência de insuficiência cardíaca aguda pós-enfarte. No entanto, esse benefício não resultou numa menor mortalidade intra-hospitalar, provavelmente devido ao facto dessa população representar um subgrupo de doentes com doença mais grave e mais comorbilidades. Conclusão: Os benefícios associados ao uso de sistemas de emergência médica no transporte de doentes com enfarte agudo do miocárdio com elevação do segmento ST não se traduziram numa menor mortalidade intra-hospitalar.

Double coronary thrombosis in a patient with Behçet's disease.

Behçet's disease is a chronic relapsing multisystem autoinflammatory condition, in which cardiac involvement is rare, but among the most life-threatening complications. Treatment is largely empirical, and is aimed at suppressing vasculitis. In this role glucocorticoids and colchicine are frequently used. We present the case of a 42-year-old male with previously diagnosed Behçet's disease presenting to our emergency department with an anterior-inferior STEMI. He presented combined thrombosis of the distal anterior descending coronary artery and proximal right coronary artery, and was treated with sequential primary percutaneous coronary interventions and implantation of drug-eluting stents, but required two interventions due to high thrombotic load. His clinical course during hospitalization was good, with no systolic dysfunction at discharge. During follow-up, he has so far had no new cardiovascular events.

Application of Risks Scores in Acute Coronary Syndromes. How Does ProACS Hold Up Against Other Risks Scores?

BACKGROUND: Multiple risk scores (RS) are approved in the prediction of worse prognosis in acute coronary syndromes (ACS). Recently, the Portuguese Journal of Cardiology has proposed the ProACS RS. OBJECTIVE: Application of several validated RS, as well as ProACS in patients, admitted for ACS. Evaluation of each RS's performance in predicting in-hospital mortality and the occurrence of all-cause mortality or non-fatal ACS at one-year follow-up and compare them to the ProACS RS. METHODS: A retrospective study of ACS was performed. The following RS were applied: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS and ProACS. ROC Curves were created to determine the predictive power for each RS and then were directly compared to ProACS. RESULTS: The ProACS, ACTION Registry-GWTG and GRACE showed a c-statistics of 0.908, 0.904 and 0.890 for predicting in-hospital mortality, respectively, performing better in ST-segment elevation myocardial infarction patients. The other RS performed satisfactorily, with c-statistics over 0.750, apart from the CHA2DS2-VASc-HS and C-ACS which underperformed. All RS underperformed in predicting worse long-term prognosis revealing c-statistics under 0.700. CONCLUSION: ProACS is an easily obtained risk score for early stratification of in-hospital mortality. When evaluating all RS, the ProACS, ACTION Registry-GWTG and GRACE RS showed the best performance, demonstrating high capability of predicting a worse prognosis. ProACS was able to demonstrate statistically significant superiority when compared to almost all RS. Thus, the ProACS has showed that it is able to combine simplicity in the calculation of the score with good performance in predicting a worse prognosis.

Septic Shock of Unknown Origin: A Case Report of a Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare complication of infective endocarditis and trauma, particularly of aortic valve surgery. Clinical symptoms are usually unspecific and generally due to complications. Transesophageal echocardiography (TEE) is the most commonly used exam to diagnose P-MAIVF. The main echocardiographic feature is the presence of a cavity communicating with the left ventricular outflow tract that expands during systole and collapses during diastole. Most frequent complications are formation of a fistulous tract and compression of adjacent structures. Surgical correction is usually the treatment of choice. The authors describe a case of a female patient with a septic shock of unclear origin. After antibiotic therapy and organ-supporting measures without apparent improvements, a TEE revealed infective endocarditis, complicated with P-MAIVF. Despite adequate treatment, the patient did not survive for long enough to be submitted to surgical repair.

Bem-estar psicológico e coping em estudantes de enfermagem durante a quarentena pela COVID-19 / Nursing students' psychological well-being and coping during the COVID-19 quarantine / Bienestar psicológico y afrontamiento (coping) en estudiantes de enfermería durante la cuarentena por la COVID-19

Resumo Enquadramento: A crise pandémica da COVID-19 acarretou mudanças na vida académica dos estudantes do ensino superior, o que poderá afetar o seu bem-estar psicológico. Objetivo: Analisar a relação entre estratégias de coping utilizadas e o bem-estar psicológico em estudantes de enfermagem durante a quarentena pela COVID-19. Metodologia: Estudo transversal, descritivo-correlacional, utilizando uma amostra de 136 estudantes. Colheita de dados online, com recurso à Escala de Medida de Manifestação de Bem-estar Psicológico e à Brief COPE. Resultados: Os estudantes dos últimos anos de curso utilizam mais frequentemente a estratégia de coping suporte instrumental (p = 0,015) e emocional (p = 0,009), apresentam ainda, maiores níveis de bem-estar psicológico (p = 0,012). As alterações no rendimento familiar estão associadas ao bem-estar psicológico (p = 0,024), assim como as estratégias de coping religião (r = 0,36; p ≤ 0,01), reinterpretação positiva (r = 0,47; p ≤ 0,01) e humor (r = 0,37; p ≤ 0,01). Conclusão: As estratégias de coping adotadas pelos estudantes parecem estar relacionadas com o bem-estar psicológico durante a quarentena.

Abstract Background: The COVID-19 pandemic crisis has brought about changes in the lives of higher education students that may influence their psychological well-being. Objective: To analyze the association between nursing students' coping strategies and their psychological well-being during the COVID-19 quarantine. Methodology: Cross-sectional, descriptive-correlational study using a convenience sample of 136 students. Data were collected online using the Portuguese version of the Échelle de Mesure des Manifestations du Bien-être Psychologique and the Brief COPE. Results: Students in the last years of their undergraduate studies used the instrumental support (p = 0.015) and emotional support (p = 0.009) coping strategies more often and had higher levels of psychological well-being (p = 0.012). Psychological well-being is associated with household income changes (p = 0.024), as well as with religion (r = 0.36; p ≤ 0.01), positive reframing (r = 0.47; p ≤ 0.01), and humor (r = 0.37; p ≤ 0.01) coping strategies. Conclusion: Students' coping strategies seem to be associated with their psychological well-being during the COVID-19 quarantine.

Resumen Marco contextual: La crisis provocada por la pandemia de la COVID-19 produjo cambios en la vida académica de los estudiantes de educación superior, que pueden afectar su bienestar psicológico. Objetivo: Analizar la relación entre las estrategias de afrontamiento utilizadas y el bienestar psicológico en estudiantes de enfermería durante la cuarentena por la COVID-19. Metodología: Estudio transversal, descriptivo-correlacional, con una muestra de 136 estudiantes. La recopilación de datos se realizó en línea mediante la Escala de Medición de la Manifestación del Bienestar Psicológico y el Brief COPE. Resultados: Los estudiantes de los últimos cursos utilizan con más frecuencia la estrategia de afrontamiento apoyo instrumental (p = 0,015) y emocional (p = 0,009), y también tienen mayores niveles de bienestar psicológico (p = 0,012). Los cambios en los ingresos familiares se asocian con el bienestar psicológico (p = 0,024), así como con las estrategias de afrontamiento religión (r = 0,36; p ≤ 0,01), reinterpretación positiva (r = 0,47; p ≤ 0,01) y estado de ánimo (r = 0,37; p ≤ 0,01). Conclusión: Las estrategias de afrontamiento adoptadas por los estudiantes parecen estar relacionadas con el bienestar psicológico durante la cuarentena.

Iatrogenic Complications During the Diagnostic Work-Up of an Inflammatory Cardiomyopathy

Abstract A 72-year-old woman was admitted for acute heart failure. The echocardiography revealed moderate depression of the left ventricular ejection fraction. Coronary disease was excluded by coronarography. Cardiac magnetic resonance showed predominantly left ventricular septal hypertrophy and severe depression of the left ventricular systolic function. There was also a bright, multifocal and patchy late gadolinium enhancement with subendocardial, mesocardial and subepicardial involvement, suggestive of sarcoidosis. Biochemical study, thoracic computed tomography and positron emission tomography were inconclusive for extra-cardiac sarcoidosis. Therefore, an endomyocardial biopsy was performed. The procedure was complicated by the development of complete atrioventricular block, requiring implantation of a cardiac resynchronization pacing device. A few days after device implantation, the patient developed fever. The echocardiography revealed extensive vegetations, and thus the diagnosis of a device-associated infective endocarditis was made. Even though antibiotic therapy was promptly started, the patient ended up dying. Biopsy results revealed lymphocytic myocarditis. This case is paradigmatic because it shows how the etiologic diagnosis of dilated cardiomyopathy can be challenging. Non-invasive diagnostic exams may not provide a definite diagnosis, requiring an endomyocardial biopsy. However, the benefits versus risks of such procedure must always be carefully weighted.

Application of Risks Scores in Acute Coronary Syndromes. How Does ProACS Hold Up Against Other Risks Scores? / Aplicação de Escores de Risco em Síndromes Coronárias Agudas: Como o ProACS se Comporta Diante de Outros Escores de Risco?

Abstract Background: Multiple risk scores (RS) are approved in the prediction of worse prognosis in acute coronary syndromes (ACS). Recently, the Portuguese Journal of Cardiology has proposed the ProACS RS. Objective: Application of several validated RS, as well as ProACS in patients, admitted for ACS. Evaluation of each RS's performance in predicting in-hospital mortality and the occurrence of all-cause mortality or non-fatal ACS at one-year follow-up and compare them to the ProACS RS. Methods: A retrospective study of ACS was performed. The following RS were applied: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS and ProACS. ROC Curves were created to determine the predictive power for each RS and then were directly compared to ProACS. Results: The ProACS, ACTION Registry-GWTG and GRACE showed a c-statistics of 0.908, 0.904 and 0.890 for predicting in-hospital mortality, respectively, performing better in ST-segment elevation myocardial infarction patients. The other RS performed satisfactorily, with c-statistics over 0.750, apart from the CHA2DS2-VASc-HS and C-ACS which underperformed. All RS underperformed in predicting worse long-term prognosis revealing c-statistics under 0.700. Conclusion: ProACS is an easily obtained risk score for early stratification of in-hospital mortality. When evaluating all RS, the ProACS, ACTION Registry-GWTG and GRACE RS showed the best performance, demonstrating high capability of predicting a worse prognosis. ProACS was able to demonstrate statistically significant superiority when compared to almost all RS. Thus, the ProACS has showed that it is able to combine simplicity in the calculation of the score with good performance in predicting a worse prognosis.

Resumo Fundamento: Existem muitos escores de risco (ERs) aprovados na predição de um pior prognóstico em síndromes coronárias agudas (SCAs). Recentemente, a Revista Portuguesa de Cardiologia propôs o ER ProACS. Objetivo: Aplicar vários ERs validados, bem como o ProACS em pacientes internados por SCA. Avaliar o desempenho de cada ER em predizer mortalidade hospitalar e a ocorrência de mortalidade por todas as causas ou SCA não fatal em um ano de acompanhamento e compará-los com o ProACS. Métodos: Estudo retrospectivo de SCA. Os seguintes ERs foram aplicados: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS e ProACS. Curvas ROC foram criadas para determinar o poder preditivo de cada ER e diretamente comparadas com a do ProACS. Resultados: Os escores ProACS, ACTION Registry-GWTG e GRACE mostraram estatística-C de 0,908, 0,904 e 0,890, respectivamente, em predizer mortalidade hospitalar, mostrando melhor desempenho em pacientes com infarto do miocárdio com elevação do segmento ST. Os demais ERs mostraram desempenho satisfatório, com estatística-C acima de 0,750, com exceção de CHA2DS2-VASc-HS e C-ACS, que mostraram baixa performance. Todos os ERs apresentaram baixo desempenho em predizer um pior prognóstico em longo prazo, com estatística-C abaixo de 0,700. Conclusão: O ProACS é um escore de risco facilmente obtido para estratificação precoce de mortalidade intra-hospitalar. Ao avaliar todos os ERs, ProACS, ACTION Registry-GWTG e GRACE mostraram o melhor desempenho, com alta capacidade de predizer um pior prognóstico. O ProACS mostrou superioridade estatisticamente significativa em comparação aos outros ERs. Portanto, o ProACS mostrou-se capaz de combinar simplicidade no cálculo do escore com bom desempenho em predizer um pior prognóstico.