[Intrahospital Protocol for the Management of COVID-19 Disease in Adults]. / Protocolo Intra-Hospitalar para Abordagem da Doença COVID-19 no Adulto.

The COVID-19 pandemic is currently responsible for over 526 million infections and over 6.3 million deaths. As a new disease, the number of papers on the subject is extensive, motivating considerable heterogeneity in its approach. Despite some medicines having sound evidence of benefit, new interventions and strategies continue to be proposed, and some still lack scientific evidence, which hinders a uniform and consensual approach. This article aims to standardize healthcare to adult patients with moderate-to-critical COVID-19, from the emergency department to hospitalization, either in a general ward or in level 2 or level 3 intensive care units, based on the best and most updated scientific evidence available. This protocol presents recommendations for the stratification of adult patients with COVID-19 disease, adequate workup at admission and during hospitalization, inpatient treatment criteria, general treatment measures, pharmacological treatment, management of complications such as organizing pneumonia and bacterial superinfection, thromboprophylaxis, special considerations on pregnancy and breastfeeding and possible future therapies.

A pandemia de COVID-19 é, atualmente, responsável por mais de 526 milhões de infeções e mais de 6,3 milhões de mortes. Como nova doença, é extenso o número de publicações sobre o tema, motivando uma considerável heterogeneidade na sua abordagem. Apesar de existirem terapêuticas com benefício comprovado, continuam a ser propostas novas intervenções e estratégias, algumas das quais carecendo ainda de suporte científico, dificultando assim uma abordagem uniforme e consensual. Este documento tem como objetivo uniformizar, baseando-se na melhor e mais atualizada evidência científica disponível, a prestação de cuidados aos doentes adultos com COVID-19 moderada a crítica, desde o serviço de urgência até à hospitalização, quer em enfermarias gerais, quer em enfermarias de cuidados intensivos de nível 2 e 3. Este protocolo apresenta recomendações para a estratificação da doença COVID-19, critérios de hospitalização, meios complementares de diagnóstico adequados à admissão e durante a hospitalização, medidas terapêuticas gerais e terapêutica farmacológica dirigida, gestão de complicações como pneumonia organizativa e sobreinfeção bacteriana, tromboprofilaxia, considerações especiais na gravidez e amamentação, e possíveis opções terapêuticas futuras.

An Atypical Presentation of Non-Hodgkin's Lymphoma.

Lymphomas result from the proliferation of malignant lymphocytes, which can affect lymph nodes, blood, and other organs. Primary involvement of the spine by haematological diseases is rare. Non-Hodgkin's lymphoma with an extranodal location most frequently involves the gastrointestinal tract and airways, affecting the bone, muscle, and nervous system. We present a clinical case of an atypical form of non-Hodgkin's lymphoma. A 78-year-old woman was admitted to the hospital with complaints of pain in the lumbar region, hip, and left leg for the last month. Computed tomography of the lumbar spine revealed a mass of left paravertebral tissue with involvement from L3 to L5. Thoraco-abdominal CT-guided biopsy revealed diffuse large-cell non-Hodgkin B lymphoma. The remainder of the study did not show lymphatic involvement, so a diagnosis of primary extranodal large cell non-Hodgkin B lymphoma was made.

Celiac Patient With New Episodes of Diarrhea: A Case Report.

Celiac disease is a relatively common autoimmune disease that affects the gut's ability to process gluten. It is frequently associated with other autoimmune diseases. In this article, the authors present a clinical case of a 65-year-old female patient with a history of celiac disease and autoimmune hypothyroidism. This patient was admitted to the emergency room with generalized edema and chronic diarrhea with mucus as well as reports of unusual weight loss. A requested fecal analysis tested positive for fecal calprotectin. An endoscopic study further displayed flattening of the intestinal villi. A subsequent biopsy expressed overlapping evidence for both celiac disease and lymphocytic colitis. This case illustrates how a diagnosis of microscopic colitis should be explored when celiac patients with a history of a stable gluten-free diet display a sudden onset of chronic diarrhea. As the symptoms associated with this disease can often become debilitating, an early diagnosis and treatment are crucial.

Mycobacterium chelonae Cutaneous Infection: A Challenge for an Internist.

Cutaneous infections caused by the Mycobacterium chelonae complex show a heterogeneous clinical presentation, which varies according to the patient's immune status. Most standard antimycobacterials have no effect against these species. Clarithromycin alone was shown to provide adequate treatment, although resistance has been reported. Consequently, the literature supports multi-drug therapy to combat resistant strains. Here, we describe the case of a 59-year-old man under systemic immunosuppressive therapy who developed cutaneous lesions whose evolution was highly suggestive of atypical infection. LEARNING POINTS: Mycobacterium chelonae is a ubiquitous species of mycobacteria found in the environment; cutaneous infections by the M. chelonae complex show a heterogeneous clinical presentation.The combination of linezolid and clarithromycin has been used in some cases, with rapid clinical resolution and less or no relapse observed after long-term follow-up.Internal Medicine is the appropriate speciality to treat particularly complex or multisystem diseases, such as infections in immunocompromised patients.

Novel anticoagulants in an older and frail population with atrial fibrillation: the effect of inappropriate dosing on clinical outcomes.

PURPOSE: An individualized approach should be taken regarding the use of novel oral anticoagulants (NOAC) in frail and older patients with atrial fibrillation (AF). We hypothesized that there would be a high proportion of underdosed patients among an older and frail population, where bleeding risk is higher. METHODS: We retrospectively analyzed patients admitted to an Internal Medicine ward with a previous diagnosis of AF and discharged with a NOAC (n = 327). We compared survival and incidence of dosing-related events (stroke, systemic embolism, and major bleeding) at 1-year between inappropriately underdosed patients (dose reduction without a formal indication) and the rest of the population. RESULTS: A total of 167 patients (51%) received a reduced dose despite lacking formal criteria for dose reduction. Before adjustment, underdosed patients, in comparison with non-underdosed patients, had a higher mortality at 1 year (HR = 1.6, 95% CI 1.2-2.1, p = 0.003) and a higher combined stroke, systemic embolism, and major bleeding event rate at 1-year (HR = 3.2, 95% CI 1.3-8.0, p = 0.015). After adjustment, combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients (HR 3.7, 95% CI 1.1-12.3, p = 0.030), but survival was not different in the adjusted model (HR 1.4, 95% CI 0.9-2.1, p = 0.110). CONCLUSIONS: Underdosed patients have a significant survival disadvantage and this may be due to clinician prescription bias, since this difference does not remain after adjusting for confounders. Combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients.