Metastasis of small cell lung cancer to bilateral extraocular muscles: a case report.

BACKGROUND: Orbital metastasis is a possible complication of small cell lung cancer and a pattern of bilateral invasion of the extraocular muscles has rarely been reported in literature. CASE PRESENTATION: A 46-year-old white male with a past medical history of smoking and stage IV small cell lung carcinoma presented with loss of vision and pain in the left eye. Examination revealed bilateral proptosis and left afferent pupillary defect, and visual acuity was hand motion on the left eye and 4/10 on the right eye. An orbital computed tomography scan showed a compression of the left optic nerve between the extraocular muscles at the apex, and a lateral canthotomy was performed for a new-onset compressive optic neuropathy, with residual visual improvement. There was also significant enlargement of the extraocular muscles in the right orbit. The patient was maintained in palliative treatment with both chemotherapy and local medical and surgical (amniotic membrane cover for exposure keratopathy) ophthalmological treatments until he eventually died 5 months after. CONCLUSION: Bilateral metastasis to the extraocular muscles is a very rare manifestation of small cell lung cancer and the palliative treatment in these cases is challenging.

Resistance and virulence in Staphylococcus aureus by whole-genome sequencing: a comparative approach in blaZ-positive isolates.

Mastitis caused by Staphylococcus aureus is a worldwide problem in dairy farms, in part because of the pathogenicity of the bacteria, biofilm formation, and mechanisms of antimicrobial resistance that make the disease difficult to diagnose and treat, which is typically done with the use of beta-lactam antibiotics. The aim of the present study was to determine the virulence and resistance factors of S. aureus isolates from subclinical mastitis, blaZ + /mecA - /mecC - , resistant and sensitive to oxacillin. All isolates were classified as CC97 by MLST analysis, a clonal complex well adapted to the mammary gland and although STAU23 and STAU73 were resistant to oxacillin while STAU32 and STAU78 were sensitive, the genomic analysis identified only the blaZ operon corresponding to resistance to beta-lactams. However, the presence of the sdrC gene was revealed exclusively in resistant isolates, an important adhesin in the colonization process that potentiates pathogenicity in S. aureus. In addition, resistance islands (REIs) were identified in these isolates, suggesting more conserved REIs. In the analysis of SNPs throughout the genome, mutations were found in the trmB and smpB genes of the resistant isolates and in the murD and rimM genes of the sensitive isolates. This study highlights the potential benefit of genome-wide characterization tools to identify molecular mechanisms of S. aureus in bovine mastitis.

Effects of Upper-Body and Lower-Body Conditioning Activities on Postactivation Performance Enhancement During Sprinting and Jumping Tasks in Female Soccer Players.

ABSTRACT: Santos da Silva, V, Nakamura, FY, Gantois, P, Nogueira Gouveia, JN, Peña, J, Beato, M, and Abade, E. Effects of upper-body and lower-body conditioning activities on postactivation performance enhancement during sprinting and jumping tasks in female soccer players. J Strength Cond Res 38(2): 342-349, 2024-This study aimed to investigate the postactivation performance enhancement (PAPE) effects of "specific" (half-back squat) and "nonspecific" (bench press) conditioning activities on sprinting and jumping performances in female soccer players. Fourteen players (mean ± SD : age = 22.3 ± 4.0 years; body mass = 60.2 ± 7.8 kg; height = 164.1 ± 4.2 cm) competing at national level (first League) participated in this within-subject crossover study. The players performed a warm-up protocol including 3 sets of 3 repetitions of half-back-squat or bench press exercises at 90% 1RM or a warm-up protocol without lifting weights (i.e., control condition). Forty-meter shuttle sprints (20 + 20 m with change of direction [COD-180°]), countermovement jump (CMJ), and horizontal jump (HJ) performances were recorded 6 minutes after the conditioning activities protocols or the control condition. Nonsignificant large positive effects were found for the HJ after the half-back-squat (ES = 1.68; p > 0.05) and bench press (ES = 1.68; p > 0.05) protocols. Although nonsignificant, HJ changes ( Δ = 0.07 m) were greater than the smallest worthwhile change (0.02 m) and standard error of measurement (0.03 m) after both conditioning activities. Moreover, no significant changes were found for sprint and CMJ performance after neither half-back-squat nor bench press protocols ( p > 0.05). In conclusion, both specific and nonspecific conditioning activities using heavy loads (i.e., 90% 1RM) may be suitable to enhance individual HJ. Finally, both conditioning activities are potentially ineffective for increasing sprint and CMJ performance in the context of this study.

Genomic Characterization of Aeromonas veronii Provides Insights into Taxonomic Assignment and Reveals Widespread Virulence and Resistance Genes throughout the World.

Aeromonas veronii is a Gram-negative bacterial species that causes disease in fish and is nowadays increasingly recurrent in enteric infections of humans. This study was performed to characterize newly sequenced isolates by comparing them with complete genomes deposited at the NCBI (National Center for Biotechnology Information). Nine isolates from fish, environments, and humans from the São Francisco Valley (Petrolina, Pernambuco, Brazil) were sequenced and compared with complete genomes available in public databases to gain insight into taxonomic assignment and to better understand virulence and resistance profiles of this species within the One Health context. One local genome and four NCBI genomes were misidentified as A. veronii. A total of 239 virulence genes were identified in the local genomes, with most encoding adhesion, motility, and secretion systems. In total, 60 genes involved with resistance to 22 classes of antibiotics were identified in the genomes, including mcr-7 and cphA. The results suggest that the use of methods such as ANI is essential to avoid misclassification of the genomes. The virulence content of A. veronii from local isolates is similar to those complete genomes deposited at the NCBI. Genes encoding colistin resistance are widespread in the species, requiring greater attention for surveillance systems.

Brugada Phenocopy Caused by Intracranial Hemorrhage.

Brugada syndrome (BrS) is a congenital channelopathy associated with an increased risk of malignant ventricular arrhythmias and sudden cardiac death in individuals without any structural cardiopathy. Brugada phenocopies (BrPs) are clinical entities that present electrocardiographic patterns similar to those of BrS that are elicited only under transitory pathophysiological conditions, with normalization of the ECG pattern after the resolution of those conditions. We present a rare case of BrP due to intracranial hemorrhage. We also present and discuss the diagnostic criteria for BrPs and their application to this case.

Blood parasite load by qPCR as therapeutic monitoring in visceral leishmaniasis patients in Brazil: a case series study.

BACKGROUND: This study aimed to describe the kinetics of Leishmania parasite load determined using kinetoplast DNA (kDNA)-based quantitative polymerase chain reaction (qPCR) in visceral leishmaniasis (VL) patients. METHODS: Parasite load in blood was assessed by qPCR at five time points, up to 12 months post-diagnosis. Sixteen patients were followed up. RESULTS: A significant reduction in the parasite load was observed after treatment (P < 0.0001). One patient had an increased parasite load 3 months post-treatment and relapsed clinically at month six. CONCLUSIONS: We have described the use of kDNA-based qPCR in the post-treatment follow-up of VL cases.

Looking back to look forward: Reflections from networked research on energy poverty.

Energy poverty is a far-reaching concept that intrinsically bridges numerous fields of study, ranging from engineering to anthropology and medical science to social psychology. The profound implications of energy poverty on the quality of life globally have also led to a wide range of metrics and policies aimed at measuring it and alleviating it, albeit with limited success. Using a mixed methods approach, our network has conducted research to advance knowledge and interpretations of energy poverty and boost scientific outputs' capacity to shape knowledge-based policies. In this article, we critically review this extensive research endeavor, as well as its results. We build on the conceptual, methodological, and policy dimensions of energy poverty research to set up pathways toward a new, interdisciplinary research and policy agenda on energy poverty mitigation better equipped to provide meaningful answers to the challenges posed by the current ongoing energy crisis.

Characterization of Static Strength, Vertical Jumping, and Isokinetic Strength in Soccer Players According to Age, Competitive Level, and Field Position.

Muscular strength is strongly related to speed and agility tasks, which have been described as the most decisive actions preceding goals in the soccer game. This study aimed to characterize the players' strength indicators and to analyze the variation associated with age, competition level, and positional role. Eighty-three male soccer players from A team (n = 22), B team (n = 17), U-23 (n = 19), and U-19 (n = 25) participated in this study. Handgrip strength was assessed using a hand dynamometer (Jamar Plus+), countermovement jump (CMJ) and the squat jump (SJ) were evaluated using Optojump Next, and a Biodex System 4 Pro Dynamometer was used to assess the isokinetic strength of knee extension/flexion. Team A players showed increased lower-body strength compared to their peers, mainly through their increased vertical jumping capacity (i.e., CMJ and SJ; ps < 0.019), and superior performance in isokinetic assessments (i.e., peak torque, total work, and average power). Overall, older players outperformed their younger peers regarding vertical jumping, static strength, and average power in isokinetic strength (ps < 0.005). This study emphasizes the superior strength levels of professional soccer players compared with their lower-division peers, even after controlling by age. This information is of great value to sports agents and coaches, underlining the need to design and include strength-specific content during soccer training.

Action of crude ethanol extract of Hymenaea martiana leaf, gallic acid, and polypyrrole (PPy) against Aeromonas hydrophila.

Pisciculture represents one of the industries with the fastest growth rates worldwide. However, it presents obstacles to its development, such as bacteriosis, which is conventionally treated with antibiotics. The indiscriminate and inappropriate use of antibiotics can lead to bacterial resistance, thus alternatives to the use of antibiotics have been researched. The study aimed to analyze the potential of crude ethanol extract (CEE) from Hymenaea martiana leaf, gallic acid (GA), and polypyrrole (PPy) against Aeromonas hydrophila. Tests were performed to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of the compounds individually and in synergy (checkerboard) against A. hydrophila and in silico tests between the compounds evaluated. The CEE of H. martiana leaf and PPy were effective against A. hydrophila with MBC results of 3125 µg/mL for the CEE of H. martiana and 125 µg/mL for PPy. Evaluating the GA, a MIC and MBC of 125 µg/mL was obtained. In the interaction tests (checkerboard, using PPy/CEE and PPy/GA), there was a significant reduction in individual introductions. Thus, for the PPy/CEE tests, we had a reduction of MIC/MBC to 1.95 and 781.25 µg/mL, and for the synergy tests between PPy/GA to 7.8125 and 31.125 µg/mL, respectively. The synergy tests are encouraging, and it is possible to verify a decrease of up to 98% in the introduction of PPy, 75% in CEE for H. martiana and 75.1% for GA, when compared to their individual tests. The tests with GA are encouraging due to GA's effectiveness as an antimicrobial agent and high synergy with polypyrrole, both in vitro results and molecular docking experiments showed the actions at the same activation site in A. hydrophila. In vivo tests evaluating isolated components of CEE from H. martiana in synergy with PPy should be performed, to verify the quality of the interactions and the improvement of the immune responses of the animals. It was evidenced that gallic acid, a substance isolated from the extract, tends to have more promising results. This is relevant since the industry has been developing these compounds for different uses, thus providing easier access to the product. Thus, the present study indicates an efficient alternative in the use of bioactive compounds as substitutes for conventional antimicrobials.

Blood parasite load by qPCR as therapeutic monitoring in visceral leishmaniasis patients in Brazil: a case series study

ABSTRACT Background: This study aimed to describe the kinetics of Leishmania parasite load determined using kinetoplast DNA (kDNA)-based quantitative polymerase chain reaction (qPCR) in visceral leishmaniasis (VL) patients. Methods: Parasite load in blood was assessed by qPCR at five time points, up to 12 months post-diagnosis. Sixteen patients were followed up. Results: A significant reduction in the parasite load was observed after treatment (P < 0.0001). One patient had an increased parasite load 3 months post-treatment and relapsed clinically at month six. Conclusions: We have described the use of kDNA-based qPCR in the post-treatment follow-up of VL cases.

O que mudou entre os períodos de pico e de platô durante a primeira onda do SARS-CoV-2? Estudo multicêntrico português em unidades de cuidados intensivos / What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care

RESUMO Objetivo: Analisar e comparar as características de pacientes críticos com a COVID-19, a abordagem clínica e os resultados entre os períodos de pico e de platô na primeira onda pandêmica em Portugal. Métodos: Este foi um estudo de coorte multicêntrico ambispectivo, que incluiu pacientes consecutivos com a forma grave da COVID-19 entre março e agosto de 2020 de 16 unidades de terapia intensiva portuguesas. Definiram-se as semanas 10 - 16 e 17 - 34 como os períodos de pico e platô. Resultados: Incluíram-se 541 pacientes adultos com mediana de idade de 65 [57 - 74] anos, a maioria do sexo masculino (71,2%). Não houve diferenças significativas na mediana de idade (p = 0,3), no Simplified Acute Physiology Score II (40 versus 39; p = 0,8), na pressão parcial de oxigênio/fração inspirada de oxigênio (139 versus 136; p = 0,6), na terapia com antibióticos na admissão (57% versus 64%; p = 0,2) ou na mortalidade aos 28 dias (24,4% versus 22,8%; p = 0,7) entre o período de pico e platô. Durante o período de pico, os pacientes tiveram menos comorbidades (1 [0 - 3] versus 2 [0 - 5]; p = 0,002); fizeram mais uso de vasopressores (47% versus 36%; p < 0,001) e ventilação mecânica invasiva na admissão (58,1% versus 49,2%; p < 0,001), e tiveram mais prescrição de hidroxicloroquina (59% versus 10%; p < 0,001), lopinavir/ritonavir (41% versus 10%; p < 0,001) e posição prona (45% versus 36%; p = 0,04). Entretanto, durante o platô, observou-se maior uso de cânulas nasais de alto fluxo (5% versus 16%; p < 0,001) na admissão, remdesivir (0,3% versus 15%; p < 0,001) e corticosteroides (29% versus 52%; p < 0,001), além de menor tempo de internação na unidade de terapia intensiva (12 versus 8 dias; p < 0,001). Conclusão: Houve mudanças significativas nas comorbidades dos pacientes, nos tratamentos da unidade de terapia intensiva e no tempo de internação entre os períodos de pico e platô na primeira onda da COVID-19.

ABSTRACT Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

Feasibility and performance of a combined extracorporeal assisted cardiac resuscitation and an organ donation program after uncontrolled cardiocirculatory death (Maastricht II).

INTRODUCTION: Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking. METHODS: We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon. RESULTS: Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities. DISCUSSION: The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results.

A Suicide Attempt: Deltamethrin Intoxication.

Poisoning is a frequent cause of emergency department visits, with attempted suicide accounting for up to two-thirds of all fatalities from pesticide poisoning. Despite extensive pyrethroid use worldwide, relatively few cases of human poisoning have been reported in the literature. Although most pesticide use occurs in the developed world, 99% of all acute pesticide poisoning occurs in developing countries. Deltamethrin poisoning is uncommon, with fewer than 10 deaths reported following ingestion or occupational exposure. The present case report describes deltamethrin intoxication due to intentional oral ingestion in a suicide attempt, resulting in a life-threatening combination of seizures and coma due to non-convulsive status epilepticus. LEARNING POINTS: Up to two-thirds of all fatalities from pesticide poisoning are due to suicide.Organophosphate or organochloride poisoning can mimic pyrethroid poisoning.Poisoning with deltamethrin, which belongs to the pyrethroid family, is uncommon; there is no antidote, with supportive and symptom-directed treatment being the gold standard.

Downregulation of growth plate genes involved with the onset of femoral head separation in young broilers.

Femoral head separation (FHS) is characterized by the detachment of growth plate (GP) and articular cartilage, occurring in tibia and femur. However, the molecular mechanisms involved with this condition are not completely understood. Therefore, genes and biological processes (BP) involved with FHS were identified in 21-day-old broilers through RNA sequencing of the femoral GP. 13,487 genes were expressed in the chicken femoral head transcriptome of normal and FHS-affected broilers. From those, 34 were differentially expressed (DE; FDR ≤0.05) between groups, where all of them were downregulated in FHS-affected broilers. The main BP were enriched in receptor signaling pathways, ossification, bone mineralization and formation, skeletal morphogenesis, and vascularization. RNA-Seq datasets comparison of normal and FHS-affected broilers with 21, 35 and 42 days of age has shown three shared DE genes (FBN2, C1QTNF8, and XYLT1) in GP among ages. Twelve genes were exclusively DE at 21 days, where 10 have already been characterized (SHISA3, FNDC1, ANGPTL7, LEPR, ENSGALG00000049529, OXTR, ENSGALG00000045154, COL16A1, RASD2, BOC, GDF10, and THSD7B). Twelve SNPs were associated with FHS (p < 0.0001). Out of those, 5 were novel and 7 were existing variants located in 7 genes (RARS, TFPI2, TTI1, MAP4K3, LINK54, and AREL1). We have shown that genes related to chondrogenesis and bone differentiation were downregulated in the GP of FHS-affected young broilers. Therefore, these findings evince that candidate genes pointed out in our study are probably related to the onset of FHS in broilers.

Comprehensive Analyses of Bone and Cartilage Transcriptomes Evince Ion Transport, Inflammation and Cartilage Development-Related Genes Involved in Chickens' Femoral Head Separation.

Femoral head separation (FHS) is usually a subclinical condition characterized by the detachment of articular cartilage from the bone. In this study, a comprehensive analysis identifying shared and exclusive expression profiles, biological processes (BP) and variants related to FHS in the femoral articular cartilage and growth plate in chickens was performed through RNA sequencing analysis. Thirty-six differentially expressed (DE) genes were shared between femoral articular cartilage (AC) and growth plate (GP) tissues. Out of those, 23 genes were enriched in BP related to ion transport, translation factors and immune response. Seventy genes were DE exclusively in the AC and 288 in the GP. Among the BP of AC, the response against bacteria can be highlighted, and for the GP tissue, the processes related to chondrocyte differentiation and cartilage development stand out. When the chicken DE genes were compared to other datasets, eight genes (SLC4A1, RHAG, ANK1, MKNK2, SPTB, ADA, C7 and EPB420) were shared between chickens and humans. Furthermore, 89 variants, including missense in the SPATS2L, PRKAB1 and TRIM25 genes, were identified between groups. Therefore, those genes should be more explored to validate them as candidates to FHS/FHN in chickens and humans.

Impact of polymorphisms in blaZ, blaR1 and blaI genes and their relationship with ß-lactam resistance in S. aureus strains isolated from bovine mastitis.

There is not a consensus between the presence of the genotypic resistance marker gene and the phenotypic resistance to ß-lactams in Staphylococcus aureus, which means, positive S. aureus blaZ isolates demonstrating sensitivity to ß-lactams. The present study aimed to characterize the blaZ, blaR1 and blaI genes, identify and evaluate single nucleotide polymorphisms (SNPs) and their relationship with ß-lactam resistance in samples of Staphylococcus aureus obtained from cases of bovine mastitis. Five isolates (two resistant and three sensitive to oxacillin) of Staphylococcus aureus with detected production of beta-lactamase, previously evaluated as containing the blaZ gene and negative for the mecA and mecC genes, had the bla operon completely sequenced. Impacts on the protein sequence due to the detected polymorphisms were evaluated by modeling the proteins encoded by the blaZ, blaR1 and blaI genes using a three-dimensional model structure obtained from the Protein Data Bank (PDB) database. Fifteen SNPs were detected in the blaZ gene, 30 in the blaR1 gene and three in the blaI gene. These SNPs caused alterations in amino acid sites. Deleterious mutations were detected in the blaZ gene (E146G, P218S, Y221C) and the blaR1 gene (K481E). Molecular docking analysis revealed that polymorphisms in the blaZ gene may explain the phenotypic sensitivity in isolates that contain the resistance marker gene. Although sensitive and resistant isolates encode beta-lactamase, these proteins are functionally altered due to a change in the binding site with the antibiotic.

Tannin as a modulator of rumen microbial profile, apparent digestibility and ingestive behavior of lactating goats: A preliminary metagenomic view of goats adaptability to tannin.

The aim with this study was to use interdisciplinary techniques and visions in order to identify the modulating effect of tannins on adaptive factors in lactating goats with different genetic patterns, through the assessment of digestibility and nutrient intake, ingestive behavior and rumen metagenome. We used in this study 8 of the Repartida ecotype and 6 of the Canindé breed goats, on average five years old, distributed in a completely randomized design, in a 2 × 2 factorial design, with two genetic groups and two diets. The applied diets were: basal diet and inclusion of 5% commercial tannin extract in basal diet. Intake and apparent digestibility of nutrients were evaluated, based on the quantification of the offered feed and refusals, and bromatological evaluation of samples of the offered feed, refusals and feces. Behavioral data were collected in 24-h continuous visual observations. The ruminal fluid was collected and DNA extraction, sequencing, and evaluation of relative abundance of the rumen microbiome were performed. The data obtained were analyzed statistically, through analysis of variance with 5% significance and, when necessary, a comparison of means test was applied. In this preliminary findings was observed that the genetic group factor caused changes in the number of chews and the relative abundance of microorganisms (P = 0.0290 and P = 0.0051). The diet factor influenced digestibility, which better values were observed for the tannin diet (P = 0.0049), in addition, it promoted changes in the rumen microbiota, with a beneficial modulatory characteristic. The inclusion of 5% tannin extract from Acacia mearnsii modulates the rumen microbiome, improving the apparent digestibility of nutrients without affecting the feed intake of goats from the Repartida and Canindé genetic groups.

Update of the recommendations of the Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group for the approach to COVID-19 in Intensive Care Medicine. / Atualização das recomendações da Sociedade Portuguesa de Cuidados Intensivos e do Grupo de Infeção e Sépsis para a abordagem da COVID-19 em Medicina Intensiva.

INTRODUCTION: The Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group have previously issued health service and management recommendations for critically ill patients with COVID-19. Due to the evolution of knowledge, the panel of experts was again convened to review the current evidence and issue updated recommendations. METHODS: A national panel of experts who declared that they had no conflicts of interest regarding the development of the recommendations was assembled. Operational questions were developed based on the PICO methodology, and a rapid systematic review was conducted by consulting different bibliographic sources. The panel determined the direction and strength of the recommendations using two Delphi rounds, conducted in accordance with the principles of the GRADE system. A strong recommendation received the wording "is recommended", and a weak recommendation was written as "is suggested." RESULTS: A total of 48 recommendations and 30 suggestions were issued, covering the following topics: diagnosis of SARS-CoV-2 infection, coinfection and superinfection; criteria for admission, cure and suspension of isolation; organization of services; personal protective equipment; and respiratory support and other specific therapies (antivirals, immunomodulators and anticoagulation). CONCLUSION: These recommendations, specifically oriented to the Portuguese reality but that may also apply to Portuguese-speaking African countries and East Timor, aim to support health professionals in the management of critically ill patients with COVID-19. They will be continuously reviewed to reflect the progress of our understanding and the treatment of this pathology.

INTRODUÇÃO: A Sociedade Portuguesa de Cuidados Intensivos e o Grupo de Infeção e Sépsis emitiram previamente recomendações visando à organização dos serviços de saúde e ao manejo dos doentes críticos com COVID-19. Em virtude da evolução do conhecimento, o painel de peritos voltou a se organizar para rever a atual evidência e emitir recomendações atualizadas. MÉTODOS: Foi reunido um painel nacional de peritos que declararam não ter conflitos de interesse para o desenvolvimento das recomendações. Foram desenvolvidas perguntas operacionais conforme a metodologia PICO, e foi conduzida uma revisão sistemática rápida por meio da consulta de diferentes fontes bibliográficas. O painel determinou a direção e a força das recomendações com a utilização de duas rodadas de um método Delphi, conduzido seguindo princípios do sistema GRADE. Uma recomendação forte recebeu a redação "recomenda-se", e uma recomendação fraca foi redigida como "sugere-se". RESULTADOS: Foram emitidas 48 recomendações e 30 sugestões abrangendo os seguintes tópicos: diagnóstico de infecção por SARS-CoV-2, coinfecção e superinfecção; critérios de admissão, cura e suspensão de isolamento; organização dos serviços; Equipamentos de Proteção Individual; terapêuticas de suporte respiratório e outras e terapêuticas específicas (antivirais, imunomodeladores e anticoagulação). CONCLUSÃO: Essas recomendações, especificamente orientadas para a realidade portuguesa, mas que podem se aplicar também aos Países Africanos de Língua Oficial Portuguesa e ao Timor-Leste, visam apoiar os profissionais de saúde no manejo de doentes críticos com COVID-19. Pretende-se que sejam constantemente revistas, de modo a refletir o avanço de nossa compreensão e o da terapêutica dessa patologia.

What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care. / O que mudou entre os períodos de pico e de platô durante a primeira onda do SARS-CoV-2? Estudo multicêntrico português em unidades de cuidados intensivos.

OBJECTIVE: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. METHODS: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. RESULTS: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. CONCLUSION: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

OBJETIVO: Analisar e comparar as características de pacientes críticos com a COVID-19, a abordagem clínica e os resultados entre os períodos de pico e de platô na primeira onda pandêmica em Portugal. MÉTODOS: Este foi um estudo de coorte multicêntrico ambispectivo, que incluiu pacientes consecutivos com a forma grave da COVID-19 entre março e agosto de 2020 de 16 unidades de terapia intensiva portuguesas. Definiram-se as semanas 10 - 16 e 17 - 34 como os períodos de pico e platô. RESULTADOS: Incluíram-se 541 pacientes adultos com mediana de idade de 65 [57 - 74] anos, a maioria do sexo masculino (71,2%). Não houve diferenças significativas na mediana de idade (p = 0,3), no Simplified Acute Physiology Score II (40 versus 39; p = 0,8), na pressão parcial de oxigênio/fração inspirada de oxigênio (139 versus 136; p = 0,6), na terapia com antibióticos na admissão (57% versus 64%; p = 0,2) ou na mortalidade aos 28 dias (24,4% versus 22,8%; p = 0,7) entre o período de pico e platô. Durante o período de pico, os pacientes tiveram menos comorbidades (1 [0 - 3] versus 2 [0 - 5]; p = 0,002); fizeram mais uso de vasopressores (47% versus 36%; p < 0,001) e ventilação mecânica invasiva na admissão (58,1% versus 49,2%; p < 0,001), e tiveram mais prescrição de hidroxicloroquina (59% versus 10%; p < 0,001), lopinavir/ritonavir (41% versus 10%; p < 0,001) e posição prona (45% versus 36%; p = 0,04). Entretanto, durante o platô, observou-se maior uso de cânulas nasais de alto fluxo (5% versus 16%; p < 0,001) na admissão, remdesivir (0,3% versus 15%; p < 0,001) e corticosteroides (29% versus 52%; p < 0,001), além de menor tempo de internação na unidade de terapia intensiva (12 versus 8 dias; p < 0,001). CONCLUSÃO: Houve mudanças significativas nas comorbidades dos pacientes, nos tratamentos da unidade de terapia intensiva e no tempo de internação entre os períodos de pico e platô na primeira onda da COVID-19.