Standardized approach for extubation during extracorporeal membrane oxygenation in severe acute respiratory distress syndrome: a prospective observational study.

BACKGROUND: Extubation during extracorporeal oxygenation (ECMO) in severe acute respiratory distress syndrome (ARDS) has not been well studied. Despite the potential benefits of this strategy, weaning from ECMO before liberation from invasive mechanical ventilation remains the most frequent approach. Our aim was to evaluate the safety and feasibility of a standardized approach for extubation during ECMO in patients with severe ARDS. RESULTS: We conducted a prospective observational study to assess the safety and feasibility of a standardized approach for extubation during ECMO in severe ARDS among 254 adult patients across 4 intensive care units (ICU) from 2 tertiary ECMO centers over 6 years. This consisted of a daily assessment of clinical and gas exchange criteria based on an Extracorporeal Life Support Organization guideline, with extubation during ECMO after validation by a dedicated intensive care medicine specialist. Fifty-four (21%) patients were extubated during ECMO, 167 (66%) did not reach the clinical criteria, and in 33 (13%) patients, gas exchange precluded extubation during ECMO. At ECMO initiation, there were fewer extrapulmonary organ dysfunctions (lower SOFA score [OR, 0.88; 95% CI, 0.79-0.98; P = .02] with similar PaO2/FiO2) when compared with patients not extubated during ECMO. Extubation during ECMO associated with shorter duration of invasive mechanical ventilation (7 (4-18) vs. 32 (18-54) days; P < .01) and of ECMO (12 (7-25) vs. 19 (10-41) days; P = .01). This was accompanied by a lower incidence of hemorrhagic shock (2 vs. 11%; P = .05), but more cannula-associated deep vein thrombosis (49 vs. 31%; P = .02) and failed extubation (20 vs. 6%; P < .01). There were no increased major adverse events. Extubation during ECMO is associated with a lower risk of all-cause death, independently of measured confounding (adjusted logistic regression OR 0.23; 95% confidence interval 0.08-0.69, P = .008). CONCLUSIONS: A standardized approach was safe and feasible allowing extubation during ECMO in 21% of patients with severe ARDS, selecting patients who will have a shorter duration of invasive mechanical ventilation, ECMO course, and ICU stay, as well as fewer infectious complications, and high hospital survival.

Linfoma de Burkitt como adenopatía axilar en un paciente inmunosuprimido / Burkitt lymphoma as an axillary adenopathy in an immunosuppressed patient

Burkitt lymphoma is derived from germinal or post-germinal center B cells and is a highly aggressive B cell non-Hodgkin lymphoma that represents <1 percent of adult non-Hodgkin lymphomas. The authors describe the case of a 63 years old Caucasian male, with history of human immunodeficiency virus infection, latent syphilis and varicella zoster infection on the left limb (L3 dermatome) who came to the emergency department with a palpable left axillary mass with three weeks evolution accompanied with vesicles 48 hours after. He reported a history of anorexia and weight loss on the past 3 months. Complete blood count was within normal range but was observed a fivefold elevation of lactate dehydrogenase and a CD4 count <200cells/microL. The histology of the adenopathic axillar conglomerate made the diagnosis of Burkitt lymphoma but, besides all efforts, the patient ended to die before starting a regimen of chemotherapy. (AU)

A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult.

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure. LEARNING POINTS: Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults.Misdiagnosis of BH as a tension pneumothorax (which has a similar clinical presentation) can delay treatment and put patients at risk.The outcome of BH depends on the presentation, early diagnosis and emergent intervention.

Acute Kidney Failure: When Multiple Myeloma Doesn´t Give Additional Clues.

Multiple myeloma (MM) is characterized by a proliferation of malignant plasma cells and a subsequent overabundance of monoclonal paraprotein. This disease commonly presents with hypercalcemia, kidney failure, anemia, and bone lesions. Acute kidney failure (AKF) as an initial presentation of MM has rarely been reported. Herein, we present a case of a 49-year-old female who was admitted to our intensive care unit (ICU) for AKF in June 2017. The patient was admitted to our emergency room (ER) with abdominal pain and biliary vomiting within six days. From the laboratory tests, we highlight a serum creatinine of 19 mg/dl and urea of 377 mg/dl. The physical examination was globally unremarkable. Once clinically stable, she was admitted to our infirmary with a creatinine of 8.00 mg/dl. The patient underwent an extensive study: markers for hepatitis B and C, human immunodeficiency syndrome (HIV), and autoimmune markers were all negative; renal ultrasound, abdominal and pelvic CT had no relevant alteration; and the skeletal survey had no significant change. Peripheral blood smear showed no abnormalities. Serum immunoglobulin analysis revealed an elevated immunoglobulin A (IgA). Serum protein electrophoresis showed a monoclonal spike and urine protein electrophoresis showed an increased amount of protein consistent with Kappa light chains. The Kappa:Lambda chain ratio was increased. In order to understand the etiology of this AKF, we ended up performing a kidney biopsy, which was compatible with a myeloma kidney. The patient was transferred to the Portuguese Oncology Institute in Porto and initiated chemotherapy. Two months after the hospital discharge, creatinine levels were stable around 1.5 g/dL. This case illustrates AKF as the initial and sole presentation of MM. This presentation, even though previously reported, is very uncommon, especially considering that it occurred in a young woman and it was associated with light chain precipitation of IgA. MM is an important differential diagnosis in AKF, particularly when excluded pre and post-renal etiologies. Although being an invasive procedure with inherent possible complications, a kidney biopsy is still a very important procedure that was essential in this case to achieve a final diagnosis and, therefore, the patients' treatment.

Isoniazid-induced Lupus: When the Cure Can Be Lethal.

A 50-year-old female with a past medical history of bone tuberculosis diagnosed nine months ago was admitted in our infirmary for persistent fever with no evident cause. The patient was treated with isoniazid, rifampicin, pyrazinamide, and ethambutol for seven months and for the past two months, she was taking isoniazid and rifampicin. She went to our emergency room (ER) for back pain and fever that she had been experiencing for the last month. She was admitted with suspicion of disseminated tuberculosis that was never confirmed. Physical examination was unremarkable. Blood tests showed an elevation of inflammation parameters. A computed tomography (CT) scan of the chest showed a mild pleural effusion. She remained with fever during the three weeks in the infirmary while undergoing many other studies that were all negative. The back pain would change sides, and three consecutive thoracic radiographies showed a small-sized pleural effusion that was either predominantly right-sided or left-sided. Several differential diagnoses were considered in the process, namely an active infection, neoplasia, or autoimmune disease. The search for circulating lupus anticoagulant was positive. Antinuclear antibodies (ANA) were positive and the anti-histone antibody was strongly positive. At this point, we suspected a drug-induced lupus diagnosis, and isoniazid was discontinued. Following discontinuation of isoniazid, back pain and fever subsided and patient was discharged after one week. This case is a diagnostic challenge because of the rarity and symptom severity of isoniazid-induced lupus. Isoniazid rarely induced this lupus-like syndrome, with an incidence of considerably less than 1%.

Knowledge, Attitudes and Practices of Mozambican Public Employees in relation to the Prevention of COVID-19 / Conhecimentos, Atitudes e Práticas dos Funcionários Públicos de Moçambique em relação à Prevenção da COVID-19

In the middle of December 2019, COVID-19 appeared in the Chinese City of Wuhan. It is a pathology that quickly spread around the world, counting, until the completion of the present study, with more than 2 million infected and about 140 thousand dead. The aim of the present study was to analyze knowledge, attitudes and practices of public workers from Mozambique on the prevention of COVID-19. To this end, 126 public workers in Mozambique (79 men, 43 women and 4 who chose not to disclose their gender) answered a closed questionnaire applied to the Google Form online platform. The questionnaire was open for 5 days (two weekend days and three business days). The results revealed that most employees have basic knowledge and appropriate measures for the prevention of COVID-19, more than half adopt behaviors conducive to disease prevention and less than half effectively comply with preventive actions guided by governmental and the health sector. The results suggest that public officials are knowledgeable, however efforts should be made to carry out educational actions to improve attitudes and change practices related to the prevention of COVID-19.

Nos meados do mês de Dezembro do ano 2019, surgiu a COVID-19, na Cidade Chinesa de Wuhan. Trata-se de uma patologia que rapidamente se espalhou pelo mundo, contando, até a realização do presente estudo, com mais de 2 milhões de infectados e cerca de 140 mil mortos. O objectivo do presente estudo foi de analisar o grau de conhecimentos, atitudes e práticas dos funcionários públicos de Moçambique sobre a prevenção da COVID-19. Para tal, 126 funcionários públicos de Moçambique (79 homens, 43 mulheres e 4 que preferiram não revelar o sexo) responderam a um questionário fechado aplicado na plataforma online Google Form. Refira-se que o questionário esteve aberto durante 5 dias (dois de final de semana e três dias úteis). Os resultados revelaram que a maior parte dos funcionários tem conhecimentos básicos e de medidas apropriadas para a prevenção da COVID-19, mais que a metade assume comportamentos conducentes à prevenção da doença e menos que a metade cumpre eficazmente com acções preventivas orientadas pelas entidades governamentais e de saúde. Os resultados sugerem que os funcionários públicos têm conhecimentos, contudo devem ser envidados esforços no sentido de serem realizadas acções educativas para o melhoramento das atitudes e mudança das práticas relativas à prevenção da COVID-19.

An Overlapping Case of Miller Fisher Syndrome and the Pharyngeal-Cervical-Brachial Variant of Guillain-Barré Syndrome.

A 55-year-old Caucasian male presented initially to the emergency room (ER) reporting myalgia, chills and fever. Physical examination and laboratory tests were unremarkable and he was discharged with symptomatic care. He returned to our ER 2 weeks later reporting dizziness, loss of balance, blurred vision, mild dysarthria and bilateral hand paraesthesia. On examination, he presented complete bilateral ophthalmoplegia, mild dysarthria, left finger-to-nose dysmetria, ataxia, areflexia and bilateral hand hypoaesthesia without fever. Blood tests and head computed tomography were normal. The patient was admitted to the Internal Medicine department. On the second day on the ward, the patient presented dysphagia. A head magnetic resonance angiogram showed no signs of ischaemia or vascular disease and a lumbar puncture was performed but no pleocytosis, albumin-cytological dissociation or hypoglycorrhachia was present. Despite the normal results we suspected a Guillain-Barré syndrome variant, and started treatment with intravenous immunoglobulin (IVIG) at a dose of 400 mg per kilogram which continued for 5 days with immediate neurological improvement. We present a rare overlapping case of Miller Fisher syndrome and the pharyngeal-cervical-brachial variant of Guillain-Barré syndrome. LEARNING POINTS: The overlap of Miller Fisher syndrome and pharyngeal-cervical-brachial variants of Guillain-Barré syndrome are rarely described in the literature but should be considered when multiple cranial nerves are involved with normal neuroimaging results, even with normal cerebrospinal fluid analysis.Due to similar clinical presentation, a misdiagnosis of cerebral ischaemia, botulism or ocular myasthenia gravis can delay treatment and put patients at risk.In its natural history, this syndrome evolves to respiratory arrest and death, but with accurate diagnosis and prompt treatment, the prognosis improves considerably.

Investigações microbiológicas sobre manteigas / Microbiological investigations on butters

Foram examinadas 366 amostras de manteigas de proveniência diversa. A percentagem total de germes do grupo coliforme foi de 45,6% no total das manteigas examinadas. A Escherichia coli foi encontrada em 92 amostras examinadas, ou seja, em 25,1%; a Escherichia freundii foi encontrada em12 amostras ou seja em 3,2%; o A. aerogenes foi verificado em 57 amostras ou em 15,5%; o A. cloacae foi identificado em 15 amostras, ou seja, em 4%. Em 250 amostras a contagem da flora global foi inferior a 30 milhões de germes por grama e em 116 amostras superior a 30 milhões de germes por grama (AU).

Investigações microbiológicas sobre queijos / Microbiological investigations on cheese

Empregando métodos adequados de controle microbiológico foram examinadas 147 amostras de queijos de diferentes espécies, (tipo Minas, tipo Prato, tipo Provolone, tipo Parmesão). Em 88 das amostras examinadas (59,8%) foram encontrados microrganismos do grupo coliforme nas seguintes percentagens em relação ao total do grupo: E. coli 75,2%, A. aerogenes, 14,6%, A. cloacae, 6,8% e E. freundii, 3,4%. Em 71 amostras em que foi realizada a contagem da flora global, 20 apresentaram contagens de 0 até 30 milhões de germes por grama (28,2%) enquanto que nas 51 restantes (71,8%) a contagem obtida era superior a 30 milhões de germes por grama. Foram isolados cogumelos em 120 amostras e estafilococos em 32 queijos examinados (AU).