Boerhaave's Syndrome: An Unusual Geriatric Presentation.

Boerhaave's syndrome (BS) is a non-iatrogenic spontaneous esophageal perforation that, if not appropriately recognized and managed, can cause localized infections such as mediastinitis, pneumonia, and empyema, as well as systemic infections with significant morbidity and mortality rates. An autonomous 83-year-old male presented to the emergency department with a three-day history of behavioral changes. Three days earlier, the patient had a self-limited episode of cough, nonspecific thoracalgia, palpitations, prostration, and pallor. On physical examination, he was alert but had temporal disorientation, hypoxemia, and pulmonary auscultation with abolished breath sounds in the middle third of the left chest. Laboratory tests showed hypoxemia, elevated C-reactive protein (28.2 mg/dL), and D-dimer (3.28 µg/mL). A chest X-ray revealed periaortic small bubbles, left atelectasis, and left pleural effusion. Computed tomographic angiography of the chest showed infra-carinal esophageal rupture, small bubbles of the anterior pneumomediastinum, and a loculated left pleural empyema. Mediastinitis and empyema due to BS were assumed. He underwent left thoracic drainage, broad-spectrum antibiotics, and the placement of a surgical esophageal prosthesis. He was discharged after 48 days. The condition known as BS is frequently misdiagnosed, mostly as a result of the lack of a preexisting pathological background and the wide array of potential symptoms that may manifest. The diagnosis in this particular case was rendered particularly complex due to the combination of an unusual presentation and a delayed seeking of medical attention. Against all expectations, our patient was successfully treated.

Predictors of Long-COVID-19 and its Impact on Quality of Life: Longitudinal Analysis at 3, 6 and 9 Months after Discharge from a Portuguese Centre.

INTRODUCTION: Long-COVID-19 impacts health-related quality of life (HR-QoL) but data is scarce. The aim of this study was to describe and prospectively assess the prevalence and risk factors for long-COVID-19 after hospital discharge, and to evaluate its impact on patient HR-QoL. MATERIAL AND METHODS: Single-centre longitudinal study including all COVID-19 patients discharged between December 2020 and February 2021. Patients were contacted remotely at three, six and nine months. Data were collected as follows: 1) Long-COVID-19 symptoms were self-reported; 2) HRQoL were assessed using the 3-level EuroQoL-5D (EQ-5D-3L) questionnaire. Pregnant women, demented, bedridden, and non-Portuguese-speaking patients were excluded. RESULTS: The three-, six- and nine-month assessments were completed by 152, 117 and 110 patients (median age: 61 years; male sex: 56.6%). Long-COVID-19 (≥ 1 symptom) was reported by 66.5%, 62.4% and 53.6% of patients and HR-QoL assessment showed impairment of at least some domain in 65.8%, 69.2% and 55.4% of patients at three, six and nine months, respectively. Fatigue was the most common long-COVID-19 symptom. Anxiety/depression domain was the most frequently affected in all three time-points, peaking at six months (39%), followed by pain/discomfort and mobility domains. Long-COVID-19 was associated with the impairment of all EQ-5D-3L domains except for self-care domain at each time-point. Neither intensive care unit admission nor disease severity were associated with long-COVID-19 nor with impairment of any EQ-5D-3L domain. After adjusting for sex, age, frailty status, and comorbid conditions, long-COVID-19 remained significantly associated with HR-QoL impairment at three (OR 4.27, 95% CI 1.92 - 9.52, p < 0.001), six (OR 3.46, 95% CI 1.40 - 8.57, p = 0.007) and nine months (OR 4.13, 95% CI 1.62 - 10.55, p = 0.003) after hospital discharge. In a longitudinal analysis, patients reporting long-COVID-19 at three months had an EQ-5D-3L index value decreased by 0.14 per visit (p < 0.001) compared to those without long-COVID-19 and both groups had a non-significant change in mean EQ-5D-3L index over the nine-month period (time-point assessment, Z = 0.91, p = 0.364). CONCLUSION: Clinical sequelae associated with long-COVID-19 can persist for at least nine months after hospital discharge in most patients and can impair long-term HR-QoL in more than half of patients regardless of disease severity, and clinicodemographic characteristics.

Can we predict if patients with SLE will require more than one cycle of rituximab?

OBJECTIVE: To identify clinical and serological features that distinguish patients with SLE who require single as opposed to repeated rituximab (RTX) cycles. METHODS: All 175 SLE patients followed up at University College Hospital from 2000 onwards were retrospectively reviewed. They were divided into a one-RTX-cycle group and a multiple-cycle group (2 or more cycles). Patients included had a follow-up of at least 3 years after their first RTX cycle, unless they needed a second infusion sooner. RESULTS: A total of 131 patients were included; 44 (33.6%) received one cycle of RTX and 87 (66.4%) received two or more. The former were older at diagnosis (31.4 vs 21 years, P < 0.001) and at first RTX infusion (39.9 vs 29 years, P < 0.001). This group of patients had more organs/systems involved (P = 0.044), more leukopenia, lymphopenia and thrombocytopenia (P = 0.001, P < 0.0001 and P = 0.003, respectively) and lower C3 levels (P = 0.035). They also had fewer immunosuppressive drugs before RTX therapy compared with those who required multiple RTX cycles (P = 0.003). There was no statistical difference in either the clinical or serological response after the first RTX cycle between both groups. Furthermore, patients who had received more immunosuppressive treatments were more likely to require more than one cycle of RTX infusions (P = 0.007). CONCLUSIONS: RTX is an effective option for SLE patients with severe flares. Patients who received more immunosuppressive drugs were more likely to receive more than one set of RTX infusions. This suggests that RTX is best used for SLE patients with no history of refractory disease.

Assessing outcomes in a lupus nephritis cohort over a 40-year period.

OBJECTIVES: To characterize a LN cohort over 40 years, assessing its evolution, analysing two major outcomes: the development of end-stage renal disease and mortality rates in the first 5 years after LN diagnosis. METHODS: An observational retrospective study of patients with LN, followed up from 1975 at University College Hospital. Patients were divided into four groups, depending on the decade of LN diagnosis: 1975-1985 (D1), 1986-1995 (D2), 1996-2005 (D3) and 2006-2015 (D4). Comparison between groups was performed with respect to demographic, clinical, serological and histological characteristics and outcome. RESULTS: Two hundred and nineteen patients with LN were studied. There was a change in ethnic distribution, with a decreasing proportion of Caucasians (58.6% in D1 to 31.3% in D4, P = 0.018) and increase in African-ancestry (17.2% in D1 to 39.6% in D4, P = 0.040). Serological and histological patterns changed throughout time, with a reduction in class IV nephritis (51.7% in D1 to 27.1% in D4, P = 0.035), and increase in class II nephritis (10% in D2 to 18.8% in D4, P = 0.01) and anti-extractable nuclear antigen antibody positivity (17.2% in D1 to 83.3% in D4, P = 0.0001). The 5-year mortality rates decreased from D1 (24.1%) to D2 (4%), stabilizing for the next 30 years. The 5-year progression to end-stage renal disease remained stable over the decades. CONCLUSION: Despite the changes in treatment of LN in the past 20 years, we have reached a plateau in 5-year mortality and progression to end-stage renal disease rates, suggesting that new therapeutic and management approaches, and strategies to enhance adherence, are needed to improve outcomes further in LN patients.

Análise da capacidade funcional de idosos atendidos pela estratégia de saúde da família. / Analysis of functional capacity of elderly assisted by the health strategy family

Objetivo: analisar o perfil sóciodemográfico, a capacidade funcional e as principais doenças relatadaspelos idosos na Estratégia de Saúde da Família no município de Ananindeua-Pa. Método: estudotransversal com 60 pacientes idosos, realizado por meio de questionário com informações:sóciodemográficas, questões referentes às Atividades de Vida Diária (AVDs), AtividadesInstrumentais de Vida Diária (AIVDs) e doenças auto-referidas. Para análise estatística utilizou-se osoftware Epiinfo 3.5.1. Resultados: dos idosos estudados, 65% eram do sexo feminino; 66,7%encontravam-se na faixa etária entre 60 a 70 anos; 43% eram casados; 41,7% residiam com filhos;75% recebiam aposentadoria e 71,7% possuíam o ensino fundamental incompleto. Quanto àcapacidade funcional, 70% dos entrevistados eram independentes na realização das AVDs, segundoíndice de Katz. Em relação às AIVDs, escala de Lawton, foi observada que 10% eram dependentestotais, 45% eram dependentes parciais e 45% independentes. Dentre as morbidades mais referidasdestacaram-se a hipertensão arterial sistêmica (51,7%), a doença osteoarticular (25%) e o diabetesmellitus (23,3%). Conclusão: a capacidade funcional é influenciada por diversos fatores, sendoimportante sua avaliação para subsidiar a elaboração de planejamento de ações na Atenção Primária aSaúde e melhorar os cuidados da população idosa

Objective: analyze the sociodemographic profile, functional capacity and the main diseases reportedby the elderly in the Family Health Strategy in the city of Ananindeua-Pa. Method: cross-sectionalstudy of 60 elderly patients, conducted through a questionnaire with information: sociodemographic,issues relating to activities of daily living (ADLs), Instrumental Activities of Daily Living (IADLs)and self-reported disease. Statisticalanalyse were performed using Epi Info 3.5.1. Results: among theelderly patients studied, 65% were female; 66,7% were aged 60 to 70 years; 43% were married; 41,7%lived with children; 75% and 71,7% had incomplete high school education. With regard to functionalcapacity, 70% of respondents were independent in the performance of ADL according to Katz Index.Regarding the IADL, Lawton scale, was observed that 10% were dependent total, 45% weredependent partial and 45% independents. Among the most common morbidities highlights werehypertension (51,7%), osteoarticular disease (25%) and diabetes mellitus (23,3%). Conclusion: thefunctional capacity is influenced by several factors, its evaluation is important to support thedevelopment of action planning in Primary Health Care and improve care of the elderly population.

Aspectos patológicos, imunológicos e propriedades moleculares do TT vírus / Pathological and immunological aspects and molecular properties of TT virus

O TT vírus (TTV) foi primeiramente descrito no Japão, em 1997, por T. Nishizawa, no soro de pacientes com hepatite, pós-transfusão, não-A-G. Tem sido intensivamente investigado, desde então, como uma possível adicão à lista dos vírus indutores de hepatite. O TTV é um vírus DNA não-envelopado, de fita simples. Uma considerável variabilidade genética tem sido demonstrada por parte do TTV, o que tem levado pesquisadores a agrupar isolados do vírus em inúmeros genótipos e subtipos. No entanto a significância clínica da infeccão por TTV permanece desconhecida. Ele é freqüentemente detectado em fluidos corporais e seu componente mais bem elucidado atualmente é o genoma. Conhecimentos relacionados ao TTV têm aumentado constantemente, porém vários aspectos fundamentais permanecem obscuros. Esta revisão apresenta algumas das propriedades moleculares do TT vírus.

Gestaçäo: orientaçöes básicas / Pregnancy: basic orientations

Com a constataçäo, por meio dos prontuários, da existência de alto índice de gravidez na regiäo da Unidade Básica de Saúde do Jardim Tókio, em Londrina, e por ser uma das questöes que preocupam a direçäo da unidade, o grupo de alunos do GIM5, de 1996, resolveu estudar e empreender uma açäo de acompanhamento e orientaçäo às mulheres grávidas da regiäo. Os acadêmicos também visitaram um colégio, onde conversaram sobre sexualidade e gravidez na adolescência com alunos do 2§ Grau. Os estudos dos membros do GIM5 compreenderam planejamento familiar, controle de doenças sexualmente transmissíveis, aleitamento materno e até preparo físico pré-parto. O ginecologista e a direçäo da UBS dera, cobertura a estes estudos e, ao final, foi organizada uma atividade com a participaçäo das mulheres grávidas , para o repasse das informaçöes de seu interesse