Acute ischemic stroke in a patient with Cogan's syndrome.

Cogan's syndrome is a rare disorder characterized by inflammatory eye and inner ear/vestibular disease. In some cases patients may present medium and large vessel vasculitis which may produce neurological manifestations. We present the case of a patient who was admitted with clinical manifestations of stroke. After intense study, Cogan's syndrome was diagnosed and treated.

Design and development of an early warning score for covid-19 hospitalized patients.

Pandemics pose a major challenge for public health preparedness, requiring a coordinated international response and the development of solid containment plans. Early and accurate identification of high-risk patients in the course of the current COVID-19 pandemic is vital for planning and making proper use of available resources. The purpose of this study was to identify the key variables that account for worse outcomes to create a predictive model that could be used effectively for triage. Through literature review, 44 variables that could be linked to an unfavorable course of COVID-19 disease were obtained, including clinical, laboratory, and X-ray variables. These were used for a 2-round modified Delphi processing with 14 experts to select a final list of variables with the greatest predictive power for the construction of a scoring system, leading to the creation of a new scoring system: the COVID-19 Severity Index. The analysis of the area under the curve for the COVID-19 Severity Index was 0.94 to predict the need for ICU admission in the following 24 hours against 0.80 for NEWS-2. Additionally, the digital medical record of the Hospital Italiano de Buenos Aires was electronically set for an automatic calculation and constant update of the COVID-19 Severity Index. Specifically designed for the current COVID-19 pandemic, COVID-19 Severity Index could be used as a reliable tool for strategic planning, organization, and administration of resources by easily identifying hospitalized patients with a greater need of intensive care.

La pandemia por COVID-19 planteó un desafío para el sistema salud, debido a la gran demanda de pacientes hospitalizados. La identificación temprana de pacientes hospitalizados con riesgo de evolución desfavorable es vital para asistir en forma oportuna y planificar la demanda de recursos. El propósito de este estudio fue identificar las variables predictivas de mala evolución en pacientes hospitalizados por COVID-19 y crear un modelo predictivo que pueda usarse como herramienta de triage. A través de una revisión narrativa, se obtuvieron 44 variables vinculadas a una evolución desfavorable de la enfermedad COVID-19, incluyendo variables clínicas, de laboratorio y radiográficas. Luego se utilizó un procesamiento por método Delphi modificado de 2 rondas para seleccionar una lista final de variables incluidas en el score llamado COVID-19 Severity Index. Luego se calculó el Área Bajo la Curva (AUC) del score para predecir el pase a terapia intensiva en las próximas 24 horas. El score presentó un AUC de 0,94 frente a 0,80 para NEWS-2. Finalmente se agregó el COVID-19 Severity Index a la historia clínica electrónica de un hospital universitario de alta complejidad. Se programó para que el mismo se actualice de manera automática, facilitando la planificación estratégica, organización y administración de recursos a través de la identificación temprana de pacientes hospitalizados con mayor riesgo de transferencia a la Unidad de Cuidados Intensivos.

Management of COVID-19 Outbreak in Argentina: Stage 2.

OBJECTIVE: With the intention to try to contain the spread of the viral disease, several measures were taken in Argentina for long periods of time. METHODS: The lack of labor activity, social constraints, and a strong sense of helplessness, combined with a complex economic scenario with recession, inflation, and devaluation, led to the emergence of a dense climate of discontent. RESULTS: After a second wave hit the country, several measures were reinstalled. The Argentine society, polarized in many aspects, was further divided between those who supported the re-establishment of strict measures to help prevent further infections and those who desperately claimed for the urgent need to return to work to sustain their livings. CONCLUSIONS: The preexisting problems to which developing countries are usually exposed have been sharpened over the last year, determining a very complex scenario where every decision is important for the country's future. An updated report of the current situation and its management in different countries is of vital importance regarding global health issues and may serve for feedback and decision-making.

Design and development of an early warning score for COVID-19 hospitalized patients / Diseño y desarrollo de un sistema de alerta temprana para pacientes hospitalizados por COVID-19

Abstract Pandemics pose a major challenge for public health preparedness, requiring a coordinated international response and the development of solid containment plans. Early and accurate identifica tion of high-risk patients in the course of the current COVID-19 pandemic is vital for planning and making proper use of available resources. The purpose of this study was to identify the key variables that account for worse outcomes to create a predictive model that could be used effectively for triage. Through literature review, 44 variables that could be linked to an unfavorable course of COVID-19 disease were obtained, including clinical, laboratory, and X-ray variables. These were used for a 2-round modified Delphi processing with 14 experts to select a final list of variables with the greatest predictive power for the construction of a scoring system, leading to the creation of a new scoring system: the COVID-19 Severity Index. The analysis of the area under the curve for the COVID-19 Severity Index was 0.94 to predict the need for ICU admission in the following 24 hours against 0.80 for NEWS-2. Additionally, the digital medical record of the Hospital Italiano de Buenos Aires was electronically set for an automatic calculation and constant update of the COVID-19 Severity Index. Specifically designed for the current COVID-19 pandemic, COVID-19 Severity Index could be used as a reliable tool for strategic planning, organization, and administration of resources by easily identifying hospitalized patients with a greater need of intensive care.

Resumen La pandemia por COVID-19 planteó un desafío para el sistema salud, debido a la gran demanda de pacientes hospitalizados. La identificación temprana de pacientes hospitalizados con riesgo de evo lución desfavorable es vital para asistir en forma oportuna y planificar la demanda de recursos. El propósito de este estudio fue identificar las variables predictivas de mala evolución en pacientes hospitalizados por COVID-19 y crear un modelo predictivo que pueda usarse como herramienta de triage. A través de una revisión narrativa, se obtuvieron 44 variables vinculadas a una evolución desfavorable de la enfermedad COVID-19, incluyendo variables clínicas, de laboratorio y radiográficas. Luego se utilizó un procesamiento por método Delphi modificado de 2 rondas para seleccionar una lista final de variables incluidas en el score llamado COVID-19 Severity Index. Luego se calculó el Área Bajo la Curva (AUC) del score para predecir el pase a terapia intensiva en las próximas 24 horas. El score presentó un AUC de 0,94 frente a 0,80 para NEWS-2. Finalmente se agregó el COVID-19 Severity Index a la historia clínica electrónica de un hospital universitario de alta complejidad. Se programó para que el mismo se actualice de manera automática, facilitando la planificación estratégica, organización y administración de recursos a través de la identificación temprana de pacientes hospitalizados con mayor riesgo de transferencia a la Unidad de Cuidados Intensivos.

Pulmonary laceration.

INTRODUCTION: Pulmonary laceration is usually caused by penetrating trauma but it can also be found in non-penetrating trauma. It usually resolves quickly and with few problems if proper and timely treatment is given for which an adequate diagnosis is mandatory. In some cases it may require a surgical approach. CASE: A 21 year-old male was admitted after a car accident with multiple trauma lesions. He presented with tachycardia and tachypnea. Thorax CT revealed evident pulmonary lacerations. After placing two chest tubes he evolved favorably. CONCLUSION: Since we can usually find different kinds of injuries in multiple trauma, it is important to distinguish pulmonary lacerations from other types of lesions such as pneumothorax or concussions taking special consideration for mechanically ventilated patients and possible associated complications.

Changes in the management and clinical outcomes of critically ill patients without COVID-19 during the pandemic. / Modificações no manejo e desfechos clínicos de pacientes críticos sem COVID-19 durante a pandemia.

OBJECTIVE: To analyze whether changes in medical care due to the application of COVID-19 protocols affected clinical outcomes in patients without COVID-19 during the pandemic. METHODS: This was a retrospective, observational cohort study carried out in a thirty-eight-bed surgical and medical intensive care unit of a high complexity private hospital. Patients with respiratory failure admitted to the intensive care unit during March and April 2020 and the same months in 2019 were selected. We compared interventions and outcomes of patients without COVID-19 during the pandemic with patients admitted in 2019. The main variables analyzed were intensive care unit respiratory management, number of chest tomography scans and bronchoalveolar lavages, intensive care unit complications, and status at hospital discharge. RESULTS: In 2020, a significant reduction in the use of a high-flow nasal cannula was observed: 14 (42%) in 2019 compared to 1 (3%) in 2020. Additionally, in 2020, a significant increase was observed in the number of patients under mechanical ventilation admitted to the intensive care unit from the emergency department, 23 (69%) compared to 11 (31%) in 2019. Nevertheless, the number of patients with mechanical ventilation after 5 days of admission was similar in both years: 24 (69%) in 2019 and 26 (79%) in 2020. CONCLUSION: Intensive care unit protocols based on international recommendations for the COVID-19 pandemic have produced a change in non-COVID-19 patient management. We observed a reduction in the use of a high-flow nasal cannula and an increased number of tracheal intubations in the emergency department. However, no changes in the percentage of intubated patients in the intensive care unit, the number of mechanical ventilation days or the length of stay in intensive care unit.

OBJETIVO: Analisar se as modificações na atenção médica em razão da aplicação dos protocolos para COVID-19 afetaram os desfechos clínicos de pacientes sem a doença durante a pandemia. MÉTODOS: Este foi um estudo observacional de coorte retrospectiva conduzido em uma unidade de terapia intensiva clínica e cirúrgica com 38 leitos, localizada em hospital privado de alta complexidade na cidade de Buenos Aires, Argentina, e envolveu os pacientes com insuficiência respiratória admitidos à unidade de terapia intensiva no período compreendido entre março e abril de 2020 em comparação com o mesmo período no ano de 2019. Compararam-se as intervenções e os desfechos dos pacientes sem COVID-19 tratados durante a pandemia em 2020 e os pacientes admitidos em 2019. As principais variáveis avaliadas foram os cuidados respiratórios na unidade de terapia intensiva, o número de exames de tomografia computadorizada do tórax e lavados broncoalveolares, complicações na unidade de terapia intensiva e condições quando da alta hospitalar. RESULTADOS: Observou-se, em 2020, uma redução significante do uso de cânula nasal de alto fluxo: 14 (42%), em 2019, em comparação com 1 (3%), em 2020. Além disso, em 2020, observou-se aumento significante no número de pacientes sob ventilação mecânica admitidos à unidade de terapia intensiva a partir do pronto-socorro, de 23 (69%) em comparação com 11 (31%) em 2019. Contudo, o número de pacientes com ventilação mecânica 5 dias após a admissão foi semelhante em ambos os anos: 24 (69%), em 2019, e 26 (79%) em 2020. CONCLUSÃO: Os protocolos para unidades de terapia intensiva com base em recomendações internacionais para a pandemia de COVID-19 modificaram o manejo de pacientes sem COVID-19. Observamos redução do uso da cânula nasal de alto fluxo e aumento no número de intubações traqueais no pronto-socorro. Entretanto, não se identificaram alterações na percentagem de pacientes intubados na unidade de terapia intensiva, número de dias sob ventilação mecânica ou número de dias na unidade de terapia intensiva.

Modificações no manejo e desfechos clínicos de pacientes críticos sem COVID-19 durante a pandemia / Changes in the management and clinical outcomes of critically ill patients without COVID-19 during the pandemic

RESUMO Objetivo: Analisar se as modificações na atenção médica em razão da aplicação dos protocolos para COVID-19 afetaram os desfechos clínicos de pacientes sem a doença durante a pandemia. Métodos: Este foi um estudo observacional de coorte retrospectiva conduzido em uma unidade de terapia intensiva clínica e cirúrgica com 38 leitos, localizada em hospital privado de alta complexidade na cidade de Buenos Aires, Argentina, e envolveu os pacientes com insuficiência respiratória admitidos à unidade de terapia intensiva no período compreendido entre março e abril de 2020 em comparação com o mesmo período no ano de 2019. Compararam-se as intervenções e os desfechos dos pacientes sem COVID-19 tratados durante a pandemia em 2020 e os pacientes admitidos em 2019. As principais variáveis avaliadas foram os cuidados respiratórios na unidade de terapia intensiva, o número de exames de tomografia computadorizada do tórax e lavados broncoalveolares, complicações na unidade de terapia intensiva e condições quando da alta hospitalar. Resultados: Observou-se, em 2020, uma redução significante do uso de cânula nasal de alto fluxo: 14 (42%), em 2019, em comparação com 1 (3%), em 2020. Além disso, em 2020, observou-se aumento significante no número de pacientes sob ventilação mecânica admitidos à unidade de terapia intensiva a partir do pronto-socorro, de 23 (69%) em comparação com 11 (31%) em 2019. Contudo, o número de pacientes com ventilação mecânica 5 dias após a admissão foi semelhante em ambos os anos: 24 (69%), em 2019, e 26 (79%) em 2020. Conclusão: Os protocolos para unidades de terapia intensiva com base em recomendações internacionais para a pandemia de COVID-19 modificaram o manejo de pacientes sem COVID-19. Observamos redução do uso da cânula nasal de alto fluxo e aumento no número de intubações traqueais no pronto-socorro. Entretanto, não se identificaram alterações na percentagem de pacientes intubados na unidade de terapia intensiva, número de dias sob ventilação mecânica ou número de dias na unidade de terapia intensiva.

Abstract Objective: To analyze whether changes in medical care due to the application of COVID-19 protocols affected clinical outcomes in patients without COVID-19 during the pandemic. Methods: This was a retrospective, observational cohort study carried out in a thirty-eight-bed surgical and medical intensive care unit of a high complexity private hospital. Patients with respiratory failure admitted to the intensive care unit during March and April 2020 and the same months in 2019 were selected. We compared interventions and outcomes of patients without COVID-19 during the pandemic with patients admitted in 2019. The main variables analyzed were intensive care unit respiratory management, number of chest tomography scans and bronchoalveolar lavages, intensive care unit complications, and status at hospital discharge. Results: In 2020, a significant reduction in the use of a high-flow nasal cannula was observed: 14 (42%) in 2019 compared to 1 (3%) in 2020. Additionally, in 2020, a significant increase was observed in the number of patients under mechanical ventilation admitted to the intensive care unit from the emergency department, 23 (69%) compared to 11 (31%) in 2019. Nevertheless, the number of patients with mechanical ventilation after 5 days of admission was similar in both years: 24 (69%) in 2019 and 26 (79%) in 2020. Conclusion: Intensive care unit protocols based on international recommendations for the COVID-19 pandemic have produced a change in non-COVID-19 patient management. We observed a reduction in the use of a high-flow nasal cannula and an increased number of tracheal intubations in the emergency department. However, no changes in the percentage of intubated patients in the intensive care unit, the number of mechanical ventilation days or the length of stay in intensive care unit.

Síndrome de asma crítico con soporte de oxigenación por membrana extracorpórea / Critical asthma syndrome with extracorporeal membrane oxygenation support

Resumen El síndrome de asma crítico es una emergencia médica que amenaza la vida y de no instaurar un tratamiento urgente, progresa a un estado de hipoxia irreversible o paro cardiorrespiratorio. La ventilación mecánica invasiva constituye uno de los pilares terapéuticos, sin embargo, también puede desarrollar injuria pulmonar por barotrauma. En ese contexto, el uso de oxigenación por membrana extracorpórea (ECMO) supone una estrategia adicional para mejorar el intercambio gaseoso y reducir el daño inducido por la ventilación mecánica. Se presenta el caso de una paciente con síndrome de asma crítico que requirió ECMO por barotrauma grave.

Abstract Critical asthma syndrome is a life-threatening medical condition that can lead to irreversible hypoxia or cardiorespiratory arrest. Invasive mechanical ventilation is one of the therapeutic pillars, however, it can also develop ventilator-induced lung injury. For this reason, the use of extracorporeal membrane oxygenation (ECMO) could be an additional strategy to improve gas exchange and reduce damage induced by mechanical ventilation. We present the case of a patient with critical asthma syndrome who required ECMO due to severe barotrauma.

[Critical asthma syndrome with extracorporeal membrane oxygenation support]. / Síndrome de asma crítico con soporte de oxigenación por membrana extracorpórea.

Critical asthma syndrome is a life-threatening medical condition that can lead to irreversible hypoxia or cardiorespiratory arrest. Invasive mechanical ventilation is one of the therapeutic pillars, however, it can also develop ventilator-induced lung injury. For this reason, the use of extracorporeal membrane oxygenation (ECMO) could be an additional strategy to improve gas exchange and reduce damage induced by mechanical ventilation. We present the case of a patient with critical asthma syndrome who required ECMO due to severe barotrauma.

El síndrome de asma crítico es una emergencia médica que amenaza la vida y de no instaurar un tratamiento urgente, progresa a un estado de hipoxia irreversible o paro cardiorrespiratorio. La ventilación mecánica invasiva constituye uno de los pilares terapéuticos, sin embargo, también puede desarrollar injuria pulmonar por barotrauma. En ese contexto, el uso de oxigenación por membrana extracorpórea (ECMO) supone una estrategia adicional para mejorar el intercambio gaseoso y reducir el daño inducido por la ventilación mecánica. Se presenta el caso de una paciente con síndrome de asma crítico que requirió ECMO por barotrauma grave.

[Lung injury due to electric burn]. / Lesión pulmonar por trauma eléctrico.

Introduction: Electrical burns account for 3 to 4% of all burns. The most common sites of impact are the cardiovascular system, muscle tissue, neurological and skin. The commitment of the respiratory system is uncommon, with few cases reported in the literature. Case: 26-year-old male patient who enters after high-voltage electrical injury. He presented skin and respiratory distress engagement with requirement of mechanical respiratory assistance, deep sedation and neuromuscular blockade. Conclusion: There are few reported cases in the literature of lung injury associated with electrical trauma. Recognizing the respiratory system as a possible site of impact by highlighting the importance of advanced life support is critical.

Introducción: Las quemaduras eléctricas representan entre el 3 y el 4% de todas las quemaduras. Los sitios de impacto más frecuentes son el sistema cardiovascular, el tejido muscular, el neurológico y el cutáneo. El compromiso del sistema respiratorio es infrecuente, con escaso número de casos reportados en la literatura. Caso clinico: Paciente varón de 26 años que ingresa luego de lesión eléctrica de alto voltaje. Presentó compromiso cutáneo y distress respiratorio con requerimiento de asistencia respiratoria mecánica, sedación profunda y bloqueo neuromuscular. Conclusión: Hay pocos casos reportados en la literatura de lesión pulmonar asociado a trauma eléctrico. Es fundamental reconocer el sistema respiratorio como posible sitio de impacto resaltando la importancia de un soporte vital avanzado.

Whole bowel irrigation in dapsone intoxication with persistent methemoglobinemia.

Dapsone intoxication can be a life-threatening condition due its enterohepatic recirculation pharmacokinetics, and therefore, persistent methemoglobinemia development. We describe a case of a 17-year-old girl who was admitted 4 h after ingesting 5 g of dapsone. She presented methemoglobinemia (39%) and showed clinical signs of toxicity (cyanosis and altered mental status) despite mechanical ventilation. Multiple activated charcoal dosis and methylene blue infusions were performed. Notwithstanding initial improvement, a pattern of peaks and valleys was observed in serial methemoglobinemia measurements, with cyclic states of hypoxemia. On account of enterohepatic recirculation pharmacokinetics, clearance was enhanced by whole bowel irrigation. After 7 days of hospitalization, she was discharged in good general condition.

Management of COVID-19 Outbreak in Argentina: The Beginning.

The aim of this study was to analyze the impact coronavirus disease 2019 (COVID-19) had in Argentina during its initial stage, identify the measures taken to try to mitigate its impact, and briefly compare it with the influenza A H1N1 pandemic in 2009. This is a descriptive study. Pandemics constitute a serious problem to global health with a major impact on the affected countries' populations. The recent COVID-19 outbreak represents one of the most important viral pandemics lately. It reached Argentina 64 days after the first case was identified in China. Since then, several measures were taken by the Argentinian government to try to mitigate its impact in this initial stage. An updated report of the current situation and its management in different countries is of vital importance regarding global health issues and may serve for feedback and decision-making.

Zigomicosis y síndrome hemofagocítico en un paciente inmunocompetente: informe de caso / Zygomycosis and hemophagocytic lymphohistiocytosis in an immunocompetent patient: a case report

Introducción: la zigomicosis es una infección fúngica poco frecuente, con alta tasa de mortalidad y de mal pronóstico. Afecta principalmente a pacientes inmunocomprometidos. La asociación con el síndrome hemofagocítico es extremadamente inusual, más aún en pacientes inmunocompetentes, con pocos ejemplos registrados en la literatura. Caso clínico: se presenta el caso de un paciente masculino inmunocompetente de 40 años con diagnóstico de mucormicosis y síndrome hemofagocítico que evoluciona desfavorablemente, con fallo multiorgánico, a pesar de los esfuerzos médicos. Conclusión: la asociación de mucormicosis con síndrome hemofagocítico en un paciente inmunocompetente es extremadamente rara; existen pocos casos informados en Latinoamérica. Debemos tener presente esta asociación, ya que requiere un tratamiento agresivo y soporte vital avanzado. (AU)

Introduction: zygomycosis is a rare fungal infection that carries with high mortality rates. This poor prognosis, rapidly progressive infection mainly affects immunocompromised patients. The association with hemophagocytic lymphohistiocytosis is extremely unusual, even more in immunocompetent patients, with few cases reported. Case: we present the case of an immunocompetent male patient who was diagnosed with zygomycosis and hemophagocytic lymphohistiocytosis. Despite medical efforts he developed multiorganic failure. Conclusion: the association of mucormycosis with hemophagocytic lymphohistiocytosis in an immunocompetent patient is exceptional with few cases reported in Latin America. We must always suspect this association considering they require aggressive treatment and advanced life support. (AU)