Testosterone Therapy and Diaphragm Performance in a Male Patient with COVID-19: A Case Report.

Low levels of testosterone may lead to reduced diaphragm excursion and inspiratory time during COVID-19 infection. We report the case of a 38-year-old man with a positive result on a reverse transcriptase-polymerase chain reaction test for SARS-CoV-2, admitted to the intensive care unit with acute respiratory failure. After several days on mechanical ventilation and use of rescue therapies, during the weaning phase, the patient presented dyspnea associated with low diaphragm performance (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 37%, 1.7 cm, and 2.6 cm/s, respectively) by ultrasonography and reduced testosterone levels (total testosterone, bioavailable testosterone and sex hormone binding globulin (SHBG) levels were 9.3 ng/dL, 5.8 ng/dL, and 10.5 nmol/L, respectively). Testosterone was administered three times 2 weeks apart (testosterone undecanoate 1000 mg/4 mL intramuscularly). Diaphragm performance improved significantly (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 70%, 2.4 cm, and 3.0 cm/s, respectively) 45 and 75 days after the first dose of testosterone. No adverse events were observed, although monitoring was required after testosterone administration. Testosterone replacement therapy led to good diaphragm performance in a male patient with COVID-19. This should be interpreted with caution due to the exploratory nature of the study.

Recomendações para o manejo de pacientes com formas graves de dengue / Guidelines for the management of patients with severe forms of dengue

A dengue é a infecção viral transmitida por mosquito mais frequente no planeta. No Brasil a incidência vem aumentando em sucessivas epidemias, com uma proporção crescente de casos graves. A qualidade da assistência prestada influencia diretamente o prognóstico da doença. Estas recomendações apresentam o manejo das formas graves de dengue, incluindo o reconhecimento de sinais de alerta, o tratamento visando o pronto re-estabelecimento da euvolemia e a avaliação e cuidado das potenciais complicações, no intuito de reduzir a morbi-mortalidade de crianças e adultos infectados.

Dengue is the most common vector-borne viral infection worldwide. In Brazil, the incidence has increased with successive epidemics, and an increasing proportion of patients present with severe forms of the disease. The prognosis for these patients is directly influenced by the quality of medical care. These guidelines present the management of the severe forms of dengue, including the recognition of warning signs, the treatment for prompt re-establishment of euvolemia and the evaluation and appropriate care of potential complications, thus reducing morbidity and mortality of infected children and adults.

Guidelines for the management of patients with severe forms of dengue. / Recomendações para o manejo de pacientes com formas graves de dengue.

Dengue is the most common vector-borne viral infection worldwide. In Brazil, the incidence has increased with successive epidemics, and an increasing proportion of patients present with severe forms of the disease. The prognosis for these patients is directly influenced by the quality of medical care. These guidelines present the management of the severe forms of dengue, including the recognition of warning signs, the treatment for prompt re-establishment of euvolemia and the evaluation and appropriate care of potential complications, thus reducing morbidity and mortality of infected children and adults.

Terminalidade e cuidados paliativos na unidade de terapia intensiva: [revisão] / End of life and palliative care in intensive care unit: [review]

O objetivo da presente revisão foi avaliar o estado atual do conhecimento sobre doença terminal e cuidados paliativos em unidade de terapia intensiva. Identificar as questões-chave e sugerir uma agenda de pesquisa sobre essas questões. A Associação Brasileira de Medicina Intensiva organizou um fórum especifico para o debate de doenças terminais na unidade de terapia intensiva, onde participaram profissionais experientes em medicina intensiva. Esses profissionais foram subdivididos em 3 subgrupos, que discutiram: comunicação em unidade de terapia intensiva, decisões diante de um doente terminal e cuidados/ações paliativas na unidade de terapia intensiva. As informações e referências bibliográficas foram copiladas e trabalhadas através de um site de acesso restrito. Os trabalhos ocorreram em 12 horas quando foram realizadas discussões sistematizadas seguindo o método Delphi modificado. Foram elaboradas definições sobre a terminalidade. A adequada comunicação foi considerada de primordial importância para a condução do tratamento de um paciente terminal. Foram descritas barreiras de comunicação que devem ser evitadas sendo definidas técnicas para a boa comunicação. Foram também definidos os critérios para cuidados e ações paliativas nas unidades de terapia intensiva, sendo considerada fundamental a aceitação da morte, como um evento natural, e o respeito à autonomia e não maleficência do paciente. Considerou-se aconselhável a suspensão de medicamentos fúteis, que prolonguem o morrer e a adequação dos tratamentos não fúteis privilegiando o controle da dor e dos sintomas para o alívio do sofrimento dos pacientes com doença terminal. Para a prestação de cuidados paliativos a pacientes críticos e seus familiares, devem ser seguidos princípios e metas que visem o respeito às necessidades e anseios individuais. Os profissionais da unidade de terapia intensiva envolvidos com o tratamento desses pacientes são submetidos a grande estresse e tensão...

The objective of this review was to evaluate current knowledge regarding terminal illness and palliative care in the intensive care unit, to identify the major challenges involved and propose a research agenda on these issues The Brazilian Critical Care Association organized a specific forum on terminally ill patients, to which were invited experienced and skilled professionals on critical care. These professionals were divided in three groups: communication in the intensive care unit, the decision making process when faced with a terminally ill patient and palliative actions and care in the intensive care unit. Data and bibliographic references were stored in a restricted website. During a twelve hour meeting and following a modified Delphi methodology, the groups prepared the final document. Consensual definition regarding terminality was reached. Good communication was considered the cornerstone to define the best treatment for a terminally ill patient. Accordingly some communication barriers were described that should be avoided as well as some approaches that should be pursued. Criteria for palliative care and palliative action in the intensive care unit were defined. Acceptance of death as a natural event as well as respect for the patient's autonomy and the nonmaleficence principles were stressed. A recommendation was made to withdraw the futile treatment that prolongs the dying process and to elected analgesia and measures that alleviate suffering in terminally ill patients. To deliver palliative care to terminally ill patients and their relatives some principles and guides should be followed, respecting individual necessities and beliefs. The intensive care unit staff involved with the treatment of terminally ill patients is subject to stress and tension. Availability of a continuous education program on palliative care is desirable.

End of life and palliative care in intensive care unit. / Terminalidade e cuidados paliativos na unidade de terapia intensiva.

The objective of this review was to evaluate current knowledge regarding terminal illness and palliative care in the intensive care unit, to identify the major challenges involved and propose a research agenda on these issues The Brazilian Critical Care Association organized a specific forum on terminally ill patients, to which were invited experienced and skilled professionals on critical care. These professionals were divided in three groups: communication in the intensive care unit, the decision making process when faced with a terminally ill patient and palliative actions and care in the intensive care unit. Data and bibliographic references were stored in a restricted website. During a twelve hour meeting and following a modified Delphi methodology, the groups prepared the final document. Consensual definition regarding terminality was reached. Good communication was considered the cornerstone to define the best treatment for a terminally ill patient. Accordingly some communication barriers were described that should be avoided as well as some approaches that should be pursued. Criteria for palliative care and palliative action in the intensive care unit were defined. Acceptance of death as a natural event as well as respect for the patient's autonomy and the nonmaleficence principles were stressed. A recommendation was made to withdraw the futile treatment that prolongs the dying process and to elected analgesia and measures that alleviate suffering in terminally ill patients. To deliver palliative care to terminally ill patients and their relatives some principles and guides should be followed, respecting individual necessities and beliefs. The intensive care unit staff involved with the treatment of terminally ill patients is subject to stress and tension. Availability of a continuous education program on palliative care is desirable.

Adrenal function testing in patients with septic shock.

INTRODUCTION: Adrenal failure (AF) is associated with increased mortality in septic patients. Nonetheless, there is no agreement regarding the best diagnostic criteria for AF. We compared the diagnosis of AF considering different baseline total cortisol cutoff values and Deltamax values after low (1 microg) and high (249 microg) doses of corticotropin, we analyzed the impact of serum albumin on AF identification and we correlated laboratorial AF with norepinephrine removal. METHODS: A prospective noninterventional study was performed in an intensive care unit from May 2002 to May 2005, including septic shock patients over 18 years old without previous steroid usage. After measurement of serum albumin and baseline total cortisol, the patients were sequentially submitted to 1 microg and 249 microg corticotropin tests with a 60-minute interval between doses. Post-stimuli cortisol levels were drawn 60 minutes after each test (cortisol 60 and cortisol 120). The cortisol 60 and cortisol 120 values minus baseline were called Deltamax1 and Deltamax249, respectively. Adrenal failure was defined as Deltamax249 < or = 9 microg/dl or baseline cortisol < or = 10 microg/dl. Other baseline cortisol cutoff values referred to as AF in other studies (< or =15, < or =20, < or =25 and < or =34 mug/dl) were compared with Deltamax249 < or = 9 microg/dl and serum albumin influence. Norepinephrine removal was compared with the baseline cortisol values and Deltamax249 values. RESULTS: We enrolled 102 patients (43 male). AF was diagnosed in 22.5% (23/102). Patients with albumin < or =2.5 g/dl presented a lower baseline total cortisol level (15.5 microg/dl vs 22.4 microg/dl, P = 0.04) and a higher frequency of baseline cortisol < or =25 microg/dl (84% vs 58.3%, P = 0.05) than those with albumin > 2.5 g/dl. The Deltamax249 levels and Deltamax249 < or = 9, however, were not affected by serum albumin (14.5 microg/dl vs 18.8 microg/dl, P = 0.48 and 24% vs 25%, P = 1.0). Baseline cortisol < or = 23.6 microg/dl was the most accurate diagnostic threshold to determine norepinephrine removal according to the receiver operating characteristic curve. CONCLUSION: AF was identified in 22.5% of the studied population. Since Deltamax249 < or = 9 microg/dl results were not affected by serum albumin and since the baseline serum total cortisol varied directly with albumin levels, we propose that Deltamax249 < or = 9 microg/dl, which means Deltamax after high corticotropin dose may be a better option for AF diagnosis whenever measurement of free cortisol is not available. Baseline cortisol < or =23.6 microg/dl was the best value for predicting norepinephrine removal in patients without corticosteroid treatment.

Osteonecrosis in patients with acquired immunodeficiency syndrome (AIDS): report of two cases and review of the literature

Um aumento na incidência de anormalidades no metabolismo ósseo-mineral (osteopenia/osteoporose) tem sido observado em pacientes com síndrome de imunodeficiência humana adquirida (SIDA). Relatamos dois casos de osteonecrose em pacientes com SIDA. Ambos os pacientes estavam recebendo terapia anti-retroviral de alta potência (HAART) e apresentavam um ou mais fatores de risco conhecidos para osteonecrose. Nós revisamos a literatura e discutimos a patogênese, diagnóstico, prevenção e tratamento desta patologia em pacientes com SIDA.

Osteonecrosis in patients with acquired immunodeficiency syndrome (AIDS): report of two cases and review of the literature.

An increase in the incidence of abnormalities on bone and mineral metabolism (osteopenia/osteoporosis) and the development of osteonecrosis has been observed in patients with acquired immunodeficiency syndrome (AIDS). Two cases of osteonecrosis in patients with AIDS are reported. Both patients were receiving highly active antiretroviral therapy (HAART) and presented with one or more known risk factors for osteonecrosis. We review the literature and discuss the pathogenesis, diagnosis, prevention and treatment of this entity in patients with AIDS.

Tuberculoma cerebral como manifestaçäo neurológica no curso de uma infecçäo pelo HIV: relato de caso e revisäo da literatura / Tuberculomas of the CNS in HIV-infection: case report and review of literature

À medida que a sobrevida dos doentes com infecção pelo HIV aumenta, as complicações neurológicas tornam-se mais prevalentes. O reconhecimento imediato de algumas destas é muito importante visto que a demora do diagnóstico e do início do tratamento são fatores que pioram sua evolução. Descrevemos um caso de tuberculoma cerebral em paciente HIV positivo que vinha em profilaxia com isoniazida. A evolução desfavorável em vigência do tratamento para toxoplasmose e os achados liquóricos foram os indícios mais importantes de que as lesões cerebrais eram tuberculomas. Comparamos as lesões antes e após o tratamento para tuberculoses através da ressonância magnética nuclear, documentando sua melhora. Os autores revisam ainda as manifestações neurológicas focais da síndrome da imunodeficiência adquirida, enfocando principlamente a tuberculose cerebral. Concluímos que os tuberculomas cerebrais devem sempre ser lembrados naqueles pacientes com lesões encefálicas focais que não respondem adequadamente ao tratamento para toxoplasmose cerebral, tanto pela forte prevalência da tuberculose em nosso meio quanto pelas implicações prognósticas desfavoráveis se o diagnóstico e a terapêutica forem retardados.

Tuberculoma cerebral como manifestacao neurologica no curso de uma infeccao pelo HIV: relato de caso e revisao da literatura

A medida que a sobrevida dos doentes com infeccao pelo HIV aumentoa, as complicacoes neurologicas tornam-se mais prevalentes. O reconhecimento imediato de algumas destas e muito importante visto que a demora do diagnostico e do inicio do tratamento sao fatores que pioram sua evolucao. Descrevemos um caso de tuberculoma cerebral em paciente HIV positivo que vinha em profilaxia com isoniazida. A evolucao desfavoravel em vigencia do tratamento para toxoplamose e os achados liquoricos foram os indicios mais importantes de que as lesoes cerebrais eram tuberculomas. Comparamos as lesoes antes e apos o tratamento para tuberculose atraves da ressonancia magnetica nuclear, documentando sua melhora. Os autores revisam ainda as manifestacoes neurologicas focais da sindrome da imunodeficiencia adquirida, enfocando principalmente a tuberculose cerebral. Concluimos que os tuberculomas cerebrais devem sempre ser lembrados naqueles pacientes com lesoes encefalicas focais que nao respondem adequadamente ao tratamento para toxoplasmose cerebral, tanto pela forte prevalencia da tuberculose em nosso meio quanto pela implicacoes prognosticas desfavoraveis se o diagnostico e a terapeutica forem retardados.