Valor preditivo do national early warning SCORE 2 para admissão à unidade de terapia intensiva em pessoas com infecção por SARS-COV 2 / Predictive value of the national early warning SCORE 2 for admission to the intensive care unit in people with SARS-COV 2 infection

INTRODUÇÃO: Pacientes com infecção por SARS-CoV 2 podem apresentar rápida deterioração clínica, evoluindo para Síndrome do Desconforto Respiratório Agudo, sepse ou choque, bem como necessidade de ventilação mecânica ou de cuidados intensivos. É premente avaliar sinais de alerta de deterioração clínica, com vistas a intervir precocemente, aumentando as chances de sobrevida de pacientes com COVID-19. Tendo em vista que a alteração dos sinais vitais são frequentes na evolução da COVID-19, optou-se por utilizar a escala National Early Warning Score (NEWS2). O NEWS2 identifica o risco de deterioração clínica precoce e prediz os cuidados requeridos e sua frequência; sendo um indicador competente para intervenções precoces. No entanto, pouco se sabe sobre sua aplicação para pacientes com COVID-19. Este estudo visou analisar, de forma pioneira no Brasil, a performance prognóstica e o poder discriminatório do NEWS2 em unidades de internação adulto de um hospital universitário paulista quanto às admissões em unidades de terapia intensiva (UTI). MÉTODOS: Tratou-se de estudo de coorte retrospectivo que avaliou informações de 300 participantes hospitalizados por COVID-19 no período de março de 2020 a março de 2022. Foi utilizado o NEWS2 com vistas a obter um escore de risco de deterioração clínica precoce; e o Índice de Comorbidades de Charlson (ICC), para ajustar o risco estimado pelo NEWS2 de acordo com a prevalência de condições clínicas prévias. RESULTADOS: O escore médio do NEWS2 foi de 4,1 unidades, o que sugere moderada complexidade da atenção. O NEWS2 apresentou bom poder discriminatório, com sensibilidade de 71,1%, especificidade de 56,3%, Valor preditivo positivo de 22,4%, Valor preditivo negativo de 91,7%, Razão de verossimilhança positiva de 1,6 e Razão de verossimilhança negativa de 0,5. A análise da área sob a curva ROC (AUROC, 66%; IC95% = 0,57-0,54; p=0,0009) evidenciou que o índice foi modestamente capaz de predizer a deterioração clínica de pacientes com COVID-19 e a probabilidade de admissão na UTI. CONCLUSÕES: Conclui-se que o NEWS2 apresentou bom poder discriminatório para avaliar a gravidade de pacientes com COVID-19 e moderada capacidade de predição da admissão de pacientes com COVID-19 na UTI.

Avaliação do risco de deterioração clínica precoce em unidades de internação de um Hospital Universitário no Sudeste Paulista / Risk assessment of early clinical deterioration in inpatient units of a University Hospital in Southeast São Paulo

INTRODUÇÃO: A deterioração clínica precoce pode levar a um incremento do número de paradas cardiorrespiratórias, de admissões em Unidade de Terapia Intensiva e óbitos. A deterioração clínica pode ser identificada precocemente através da alteração dos sinais vitais. Por meio da monitorização constante dos sinais vitais, é possível realizar uma intervenção precoce, aumentando a sobrevida dos pacientes. A equipe de enfermagem é a primeira a identificar alterações clínicas dos pacientes e seu papel é premente na monitorização dos sinais vitais; favorecendo o resultado de sobrevida e aumentando a segurança do paciente. Instrumentos validados são capazes de detectar precocemente parâmetros fisiológicos e predizer o risco de deterioração clínica, por meio de avaliações rotineiras pelos enfermeiros; com vistas a gerenciar o risco de deterioração clínica. Este estudo teve como objetivo avaliar o risco de deterioração clínica precoce em unidades de internação (UI) de adultos de um hospital universitário público do sudeste do Brasil. MÉTODOS: Tratou-se de estudo transversal e exploratório em um hospital universitário do sudeste paulista. Fizeram parte desta pesquisa 251 leitos. Foi aplicada a escala National Early Warning Score (NEWS2) para cada paciente internado, por ocasião da admissão no setor, em até 24 horas de sua recepção. A meta era obter o diagnóstico situacional da instituição por meio de dados inéditos e preliminares sobre o risco de deterioração clínica precoce usual. O NEWS2 é baseado em um sistema de pontuação, no qual uma pontuação é alocada para medições fisiológicas, já registradas na prática de rotina hospitalar. RESULTADOS: A amostra foi caracterizada por maioria de mulheres (64,5%), com média de idade de 55 anos. O escore do NEWS2 evidenciou média de 2,9 unidades, o que sugere média ou moderada complexidade da atenção por parte da equipe de saúde; e foi maior entre os homens. Esse achado preconiza que a avaliação da enfermeira se repita no mínimo de 4 a 6 horas, monitorando o paciente, registrando eventual aumento dos parâmetros e oferecendo os cuidados necessários. CONCLUSÕES: O diagnóstico situacional evidenciou risco moderado de deterioração clínica precoce nas UI, com escores mais elevados entre os pacientes do sexo masculino. Espera-se, com o desenvolvimento dessa proposta, implementar de forma pioneira um sistema de alerta precoce junto ao referido serviço, com vistas a incrementar a qualidade do cuidado, melhorar os indicadores relacionados à segurança do paciente e diminuir a taxa de mortalidade hospitalar evitável.

Adverse Cutaneous Drug Reactions in Children: A Retrospective Study in a Tertiary Hospital.

Adverse reactions to drugs are a major concern in health, and children seem to be particularly vulnerable to these reactions. Cutaneous reactions account for 35% of the drug-related adverse effects in children. We conducted a retrospective study to characterize the pediatric population having a diagnosis of cutaneous adverse drug reactions (CADRs) in children admitted in a tertiary hospital during 6 years. (SKINmed. 2022;20:126-129).

First Report of a Mastrevirus (Geminiviridae) Transmitted by the Corn Leafhopper.

Maize striate mosaic virus (MSMV; genus Mastrevirus) was recently reported in maize plants in Brazil and also detected by metagenomic analyses in the corn leafhopper, Dalbulus maidis (DeLong & Wolcott). Although these findings suggested that D. maidis is a potential vector, no transmission studies have been performed. Here, we tested the transmission of MSMV by D. maidis from field-collected infected plants and plants infected with MSMV via leafhopper-mediated transmission in the laboratory; all plants were confirmed positive for MSMV by PCR. In each one of three transmission replicates, aviruliferous D. maidis nymphs and adults were confined together on a source plant during a 4-day acquisition access period (AAP) and subsequently transferred to healthy maize seedlings (10 individuals per test plant) in a series of 4-day inoculation access periods (IAPs). We also tested transmission by the corn aphid, Rhopalosiphum maidis (Fitch) and by mechanical inoculation of healthy maize seedlings. Only D. maidis transmitted MSMV, with overall transmission rates of 29.4 and 39.5% on field-collected infected plants and 18.5% on infected plants in laboratory. D. maidis transmitted MSMV until the third (8 to 12 days after the AAP) or fourth successive IAP (12 to 16 days), with gradual loss in transmission efficiency and rate of viruliferous insects over time, suggesting a persistent but nonpropagative mode of transmission. Infected test plants showed mottling symptoms with mild chlorotic streaks and height reduction. This is the first report of transmission of a mastrevirus by D. maidis, facilitating the completion of Koch's postulate for MSMV.

Effectiveness of Oral Tofacitinib Dose Tapering in a Case of Alopecia Areata Universalis.

INTRODUCTION: Alopecia areata (AA) is a form of nonscarring alopecia and one of the most common autoimmune disorders. Persistent or severe variants lead to potential disfigurement and are associated with a significant negative impact on the patient's quality of life. CASE PRESENTATION: A 51-year-old female patient presenting with refractory alopecia universalis was successfully treated with oral tofacitinib. Recurrence was not observed following 17 months of therapy. DISCUSSION/CONCLUSION: None of the currently employed therapies for AA are reliably effective nor are they approved for the disease. In this setting, Janus kinase inhibitors emerge as a promising novel treatment, as increasing evidence supports their effectiveness in AA.

Diffuse Large B-Cell Lymphoma in the Setting of Chronic Lymphocytic Leukemia.

A 77-year-old man was referred to our department with a 6-month history of a painless, rapidly enlarging tumor on the left leg. Fourteen years ago, he was diagnosed with chronic lymphocytic leukemia (CLL), and he had presented with lymphocytosis and multiple lymphadenopathies (Rai stage II). Both bone marrow aspiration and peripheral blood immunophenotyping identified a monoclonal B-cell population expressing surface CD5, CD20, CD23, CD43, and IgG kappa. At that time, he underwent eight courses of treatment with oral fludarabine, followed by complete remission, and he had been clinically stable ever since (Rai stage 0).

Maize Bushy Stunt Phytoplasma Favors Its Spread by Changing Host Preference of the Insect Vector.

Plant pathogenic bacteria may influence vector behavior by inducing physiological changes in host plants, with implications for their spread. Here, we studied the effects of maize bushy stunt phytoplasma (MBSP) on the host selection behavior of the leafhopper vector, Dalbulus maidis (DeLong and Wolcott). Choice assays contrasting leaves of healthy (mock-inoculated) vs. infected maize (Zea mays L.) were conducted during the asymptomatic and symptomatic phases of plant infection, with leafhopper males or females previously exposed to infected plants (bacteriliferous insects) or not. In each assay, 40 adults were released in choice arenas where only the leaves of two plants from each treatment were offered and visible, and the insects landed on the leaves were counted 1, 2, 3, 5, 7, 9, 11 and 23 h after release. During the asymptomatic phase of plant infection, an effect was observed only on bacteriliferous females, who preferred leaves of healthy plants 5 h after release or later. The symptomatic phase triggered a pull-push effect on non-bacteriliferous females, who were first attracted to symptomatic leaves but hours later moved to healthy leaves. Non-bacteriliferous males initially preferred symptomatic leaves (up to 5 h after release) and later became equally distributed between treatments. Bacteriliferous males and females initially did not discriminate between healthy and symptomatic leaves, but only the females tended to move to healthy leaves 9 h after release. Oviposition was drastically reduced on symptomatic leaves. The changes in vector behavior induced by MBSP favor its primary spread, since bacteriliferous females prefer healthy leaves at early (asymptomatic) stages of the crop. At later stages, secondary spread may be favored because non-bacteriliferous females are initially attracted to infected (symptomatic) leaves, allowing pathogen acquisition and subsequent transmission as they move to healthy plants.

XadA2 Adhesin Decreases Biofilm Formation and Transmission of Xylella fastidiosa subsp. pauca.

Xylella fastidiosa is a vector-borne bacterium that causes diseases in many plants of economic interest. The bacterium-vector initial interactions involve bacterial membrane-bound adhesins that mediate cell attachment to the foregut of insect vectors. We investigated the role of the afimbrial adhesin XadA2 in the binding and biofilm formation of X. fastidiosa subsp. pauca to vector surfaces in vitro, as well as its potential to disrupt pathogen transmission. We showed that XadA2 has binding affinity for polysaccharides on sharpshooter hindwings, used as a proxy for the interactions between X. fastidiosa and vectors. When in a medium without carbon sources, the bacterium used wing components, likely chitin, as a source of nutrients and formed a biofilm on the wing surface. There was a significant reduction in X. fastidiosa biofilm formation and cell aggregation on vector wings in competition assays with XadA2 or its specific antibody (anti-XadA2). Finally, pathogen acquisition and transmission to plant were significantly reduced when the vectors acquired X. fastidiosa from an artificial diet supplemented with anti-XadA2. These results show that XadA2 is important in mediating bacterial colonization in the insect and that it could be used as a target for blocking X. fastidiosa transmission.

Solitary nodule on the shoulder of an 11-year-old child.

Plexiform fibrohistiocytic tumor is an uncommon soft tissue neoplasm of intermediate malignancy, most frequently occurring as a painless, slow-growing nodule that shows a distinct predilection for children and young adults. We report a healthy 11-year-old boy presenting with a 1-year history of an asymptomatic cutaneous nodule on his left shoulder. Histopathological and immunohistochemical analysis confirmed a diagnosis of plexiform fibrohistiocytic tumor. Despite following a usually benign clinical course, this neoplasm is prone to frequent local recurrence and occasional metastatic ability. It should be considered in the differential diagnosis of an enlarging nodule in pediatric patients.

Ulcerated Nodule in a Young Girl's Thigh.

A 9-year-old girl with no relevant past medical history presented to our department due to a painless solitary nodule on the anterior aspect of the left thigh. The lesion had appeared 18 months before and showed a gradual significant growth, along with recent ulceration. Examination revealed a 20-mm firm, well-circumscribed pink-violaceous nodule but a yellow hue and an ulcerated erythematous center.

Vasculitic Leg Ulcer Revealing an Essential Thrombocythemia.

A 64-year-old man was referred to our department due to painful ulcers on the right leg that had evolved over the previous 6 months. There was also progressive weight loss. He had no relevant medical history. Clinically, we observed multiple ulcers, some of them with a necrotic base, located over the medial malleolus and calcaneus (Figures 1 and 2), with an associated livedoid appearance of the dorsum of the feet. A skin biopsy revealed epidermis with ulceration. The superficial and deep dermis showed perivascular and interstitial neutrophilic inflammatory infiltrate, with fibrinoid necrosis of the vessels as well as leukocytoclasia (Figure 3). Blood analysis showed significant thrombocytosis (1128×106 per µL) and leukocytosis (21.38×106 per µL). The autoimmune study showed no abnormalities. Abdominal ultrasound showed hepatosplenomegaly. The patient was seen in the hematology department, and a bone marrow biopsy was obtained that was compatible with essential thrombocythemia (ET). The patient had a karyotype that showed no metaphases, and was BCR-ABL-negative and JAK2-positive. He started treatment with α-interferon 1.8 million units, three times per week. Daily polyacrylate wound dressing was carried out to debride the skin lesions, and there was gradual improvement of the ulcers (Figure 4).

A case of cutaneous nodules in a sporotrichoid pattern.

A sporotrichoid pattern describes a clinical presentation in which inflammatory nodules spread along the path of lymphatic drainage, being reported in association with several infectious, neoplastic, and inflammatory skin conditions. Herein, we report a 65-year-old man presenting with a three-month history of erythematous nodules in a linear distribution along the left hand and forearm. He reported recent rose gardening and regular contact with an aquarium. The diagnosis was made through culture of skin biopsy tissue and isolation of Mycobacterium marinum. The patient was treated with a combination of clarithromycin and rifampicin and clinical resolution was evident within two months. We present a patient with a sporotrichoid cutaneous infection by Mycobacterium marinum, highlighting that even with the availability of novel microbiological detection techniques, tissue culture remains an essential tool for diagnostic confirmation.

Transmission Efficiency of Xylella fastidiosa subsp. pauca Sequence Types by Sharpshooter Vectors after In Vitro Acquisition.

Xylella fastidiosa subsp. pauca is genetically diverse and has many vector species. However, there is limited information on vector specificity and efficiency for different sequence types (STs) within the pathogen subspecies. Both STs of X. fastidiosa and vectors differ in their associations with plants; therefore, assessment of vector competence should include the standardized vector acquisition ability of bacteria from artificial diets. This work aimed to adapt and validate an in vitro acquisition system for strains of X. fastidiosa that cause citrus variegated chlorosis, and to compare the transmission efficiency of STs of subsp. pauca by different species of sharpshooter vector. First, acquisition and transmission of ST13 by Bucephalogonia xanthophis and Macugonalia leucomelas was tested using an artificial diet with bacteria grown on minimum defined medium (X. fastidiosa medium) with or without 1% galacturonic acid (GA). Subsequently, four sharpshooter species (B. xanthophis, M. leucomelas, M. cavifrons, and Sibovia sagata) were compared as vectors of ST13 acquired from artificial diets, and four STs of subsp. pauca (11, 13, 65, and 70) were tested for acquisition and transmission by M. leucomelas. The artificial system allowed efficient acquisition and transmission of ST13 to plants, with no differences between the media tested. ST13 was transmitted more efficiently by B. xanthophis and M. leucomelas when compared with M. cavifrons and S. sagata. Different STs influenced acquisition and transmission rates by M. leucomelas. The differences in vector competence, despite the standardized acquisition system, suggest that ST-vector foregut or vector-plant interactions may influence bacterial acquisition, retention and inoculation by the insect.

Dermatoscopy of flat pigmented facial lesions-evolution of lentigo maligna diagnostic criteria.

Recognition of facial lentigo maligna (LM) is often difficult, particularly at early stages. Algorithms and multivariate diagnostic models have recently been elaborated on the attempt to improve the diagnostic accuracy. We conducted a cross-sectional and retrospective study to evaluate dermatoscopic criteria aiding in diagnosis of flat pigmented facial lesions (FPFL). We examined 46 FPFL in 42 Caucasian patients and found that 4 of 20 dermatoscopic criteria reached the significance level required for features indicating malignancy namely, hyperpigmented follicular openings, obliterated follicular opening, annular-granular structures, and pigment rhomboids. Concomitant presence of at least 2 or 3 of the 4 mentioned criteria was significantly more frequent in LM than in pigmented actinic keratosis (PAK). However, despite more frequently seen in LM, these features were also displayed in some of the PAK and other FPFL, so we found them not specific for LM. Although dermatoscopy enhances the diagnostic accuracy in evaluating FPFL, histopathology remains the gold standard for correct diagnosis, making evident the need for improvements in early noninvasive diagnosis of LM.