The role of clinical pharmacists in patients with suspected allergy to ß-lactams: A systematic review. / El farmacéutico clínico en el abordaje del paciente con sospecha de alergia a beta-lactámicos: una revisión sistemática.

OBJECTIVE: To analyze the role played by the clinical pharmacist and its impact in antibiotic stewardship facing suspected allergy to beta-lactam antibiotics. METHOD: We performed two different independent bibliographic searches. A total of 35 articles were found, and the final number included in the study was 12. We analysed the articles and collected variables of efficacy, safety and applicability of evaluation tools applied to patients with suspected allergy to beta-lactams. Also, the variation in the consumption and prescription profile of alternative antibiotics was analyzed. RESULTS: The selected studies analysed questionnaires, allergy delabeling, intradermal tests and oral challenge tests performed by pharmacists. Significant differences in the efficacy endpoint were found in 4 studies in favour of pharmaceutical intervention. In the study of Kwiatkowski et al, cefazolin use increased in surgical patients after pharmacist intervention (65 vs. 28%; p < 0.01). In a quasi-experimental study, the mean defined daily dose of aztreonam and the mean days of therapy per 1000 patients/day decreased (21.23 vs 9.05, p <0.01) and (8.79-4.24, p = 0.016), pre and post-intervention, respectively, increasing antibiotic de-escalations (p ≤ 0.01). In another quasi-experimental study, the prescription of restricted-use antibiotics decreased (42.5% vs. 17.9%, p < 0.01) and the use of pre-surgical prophylactic antibiotics alternative to cefazolin (81.9% vs 55.9%, p<0.01) in another study. Other study showed that the mean time per interview was 5.2 minutes per patient. No adverse events were reported in any study. CONCLUSION: The pharmacist intervention in the evaluation of the patient with suspected allergy to beta-lactams is effective, safe and feasible to implement on daily clinical practice. The standardization of protocols to clarify the history of allergies and development of evaluation tools represent simple screenings to perform delabelling or refer to the Immunoallergology service, improving penicilins use and reducing the need for second line antibiotics. More studies are needed to standardize the desensitization tests made by pharmacists. However, despite these results, the involvement and leadership of the pharmacist in this area is limited and constitutes a future challenge for the profession.

[Translated article] The role of clinical pharmacists in patients with suspected allergy to ß-lactams: A systematic review.

OBJECTIVE: To analyze the role played by the clinical pharmacist and its impact in antibiotic stewardship facing suspected allergy to beta-lactam antibiotics. METHOD: We performed 2 different independent bibliographic searches. A total of 35 articles were found, and the final number included in the study was 12. We analyzed the articles and collected variables of efficacy, safety, and applicability of evaluation tools applied to patients with suspected allergy to beta-lactams. Also, the variation in the consumption and prescription profile of alternative antibiotics was analyzed. RESULTS: The selected studies analyzed questionnaires, allergy delabeling, intradermal tests, and oral challenge tests performed by pharmacists. Significant differences in the efficacy endpoint were found in 4 studies in favor of pharmaceutical intervention. In the study of Kwiatkowski et al., cefazolin use increased in surgical patients after pharmacist intervention (65% vs 28%; P < .01). In a quasi-experimental study, the mean defined daily dose of aztreonam and the mean days of therapy per 1000 patients/day decreased (21.23 vs 9.05, P <.01) and (8.79-4.24, P = .016), pre- and post-intervention, respectively, increasing antibiotic de-escalations (P = < .01). In another quasi-experimental study, the prescription of restricted use antibiotics decreased (42.5% vs 17.9%, P < .01)and the use of pre-surgical prophylactic antibiotics alternative to cefazolin (81.9% vs 55.9%, P < .01)in another study. Other study showed that the mean time per interview was 5.2 min per patient. No adverse events were reported in any study. CONCLUSION: The pharmacist intervention in the evaluation of the patient with suspected allergy to beta-lactams is effective, safe, and feasible to implement on daily clinical practice. The standardization of protocols to clarify the history of allergies and development of evaluation tools represent simple screenings to perform delabeling or refer to the Immunoallergology service, improving penicilins use and reducing the need for second-line antibiotics. More studies are needed to standardize the desensitization tests made by pharmacists. However, despite these results, the involvement and leadership of the pharmacist in this area is limited and constitutes a future challenge for the profession.

Etiology and clinical characteristics of pediatric non-neoplastic posterior reversible encephalopathy: systematic review.

Although more commonly seen in adult population, posterior reversible encephalopathy syndrome (PRES) can also be observed in pediatric patients. The etiopathogenesis of pediatric PRES is poorly understood, and the available evidence comes mostly from childhood cancer. Analysis of the sociodemographic and clinical characteristics of the different noncancer-related types can improve the understanding of pediatric PRES. Methods: Systematic review of characteristics and outcome of noncancer pediatric PRES. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in relevant publications. Study protocol was registered (Prospero CRD42020165798). Results: We identified 449 cases of noncancer pediatric PRES from 272 studies, median age 10 (newborn to 17 years), 49.9% girls. The 4 most common groups of conditions were renal 165 (36.7%), hematologic 84 (18.7%), autoimmune 64 (14.3%), and cardiovascular 28 (6.2%) disorders. The 4 most prevalent precipitants identified were hypertensive crisis 119 (26.5%), corticosteroids 56 (12.5%), immunosuppression drugs 44 (9.8%), and biologic drugs 14 (3.1%). Clinical presentations included seizures 100 (22.3%), headaches 22 (4.9%), encephalopathy 17 (3.8%), visual disturbances 6 (1.3%), and focal deficit 3 (0.7%). The distribution of lesions was (n = 380): combined anterior/posterior circulation (40.8%), isolated posterior circulation (24.1%), anterior circulation (6.2%), and deep structures (1.6%). Residual neurological deficits occurred in about 1 out 10 cases. Conclusion: Pediatric PRES differs from the adult in etiology, precipitants, and clinical manifestations. Renal diseases predominate, acute raised blood pressure is less frequent, and cortical deficits are rarer. In addition, the proportion of patients with combined anterior/posterior circulation was higher. Permanent neurological sequels can occur.

Amoxicillin-Induced Aseptic Meningitis.

Amoxicillin is a semi-synthetic beta-lactam antibiotic that belongs to the penicillin family. It is the most prescribed antibiotic in the world. It has few side effects, even though hypersensitivity reactions may occur, with potential life-threatening effects. The authors present the case of a 63-year-old male admitted to the emergency department with a 2-week history of fever and occipital headache. The symptoms began after he started antibiotic prophylaxis with amoxicillin for a dental procedure. Cerebrospinal fluid analysis was suggestive of aseptic meningitis and the patient improved quickly after discontinuation of the drug. The patient's previous medical history highlighted a similar episode after he had started taking amoxicillin as part of a scheme for the treatment of a Helicobacter pylori infection. Aseptic meningitis is an extremely rare adverse reaction of amoxicillin, with only 16 cases reported in the literature. LEARNING POINTS: Aseptic meningitis is a rare side effect of amoxicillin.It is a diagnosis of exclusion and establishing a chronological relationship between the administration of amoxicillin and the onset of clinical symptoms is a key element for the diagnosis.The physiopathology is not well defined, but the consensus is that it is most probably the result of an immunologic hypersensitivity reaction.

Walled-off pancreatic necrosis: a staged multidisciplinary step-up approach.

Walled-off pancreatic necrosis (WOPN) is a rare complication of pancreatitis. We present the case of a woman in her eighties admitted for diffuse abdominal pain. She had a palpable abdominal mass and the CT scan showed necrosis throughout the tail of the pancreas, a peripancreatic and retrogastric hydroaerial collection (19 cm of diameter) and a calculus in the main biliary duct, thus establishing a diagnosis of emphysematous necrotising obstructive pancreatitis. A step-up approach was decided, first with removal of the biliary calculus, followed by a waiting period of 4 weeks in which the patient was under intravenous antibiotics. At re-evaluation, the CT scan showed a smaller and more organised collection, bounded by a wall, defining WOPN. At this stage, transgastric drainage via echoendoscopy was attempted, without success, followed by percutaneous CT-guided drainage, also with little effect. Surgical necrosectomy was then executed, as a final step, with a successful outcome.

Appropriateness of Radiology Test Requests by an Emergency Department: A Retrospective Study.

INTRODUCTION: Imaging tests are essential for diagnosis in the emergency context and convey clinical information that is essential to assess the appropriateness of the tests and improve their interpretation. Therefore, we aimed to analyze the imaging tests requested by the Emergency Department in a district hospital. MATERIAL AND METHODS: We retrospectively analyzed computed tomography and ultrasound scans requested by the Emergency Department at the Centro Hospitalar Universitário do Algarve and considered the following variables: requested test, clinical information provided (complete/incomplete), appropriateness of the test (appropriate/inappropriate), outcome (presence/absence of relevant findings) and findings related to the clinical information (yes/no). Pearson's chi-squared and odds ratio association tests were used to evaluate the statistical association between the variables. RESULTS: Out of 1427 requests, only 219 (15.3%) were considered to have complete clinical information. Nonetheless, 1075 (75.3%) requests were considered appropriate. Relevant findings were present in about one-third (n = 453; 31.7%) and most of these findings were related to the clinical context (n = 410; 90.5%). There was a significant association between test appropriateness and the presence of relevant findings in the test (p < 0.001). The odds ratio of having a relevant finding was 5.0 times higher in the tests considered appropriate when compared with those classified as inappropriate (CI = 3.4 - 7.3; p < 0.001). DISCUSSION: The fact that appropriate tests potentiate the probability of having a relevant finding emphasizes the importance of defining guidelines so that only the adequate tests are performed. CONCLUSION: Creating guidelines should improve the appropriateness of imaging tests requested in the Emergency Department, yielding their result, with the consequent rationalization of the available resources.

Introdução: Os exames de imagem são essenciais para o diagnóstico em contexto de emergência, sendo a informação clínica determinante para verificar a sua adequação e melhorar a sua interpretação. O nosso objetivo compreendeu a análise dos exames de imagem requisitados pelo Departamento de Emergência num hospital distrital. Material e Métodos: Realizámos uma análise retrospetiva das tomografias computorizadas e ecografias requeridas pelo Departamento de Emergência no Centro Hospitalar Universitário do Algarve considerando as seguintes variáveis: exame requisitado, informação clínica fornecida (completa/incompleta), adequação do exame (adequado/não adequado), resultado (presença/ausência de achados relevantes) e relação dos achados com contexto clínico (relacionados/não relacionados). A associação entre variáveis foi avaliada utilizando as análises qui-quadrado de Pearson e razão de possibilidades. Resultados: Das 1427 requisições, apenas 219 (15,3%) foram consideradas como contendo informação clínica completa. No entanto, 1075 (75,3%) requisições foram consideradas adequadas. Cerca de um terço dos exames continha achados relevantes (n = 453; 31,7%) e a maioria destes achados estavam relacionados com o contexto clínico (n = 410; 90,5%). Encontrámos associações significativas entre a adequação do pedido e presença de achados clínicos relevantes (p < 0,001). A razão de possibilidades de ter um achado relevante é 5,0 vezes maior nos pedidos adequados relativamente aos não adequados (IC = 3,4 - 7,3; p < 0,001). Discussão: O facto de os exames adequados potenciarem a probabilidade de existir um achado relevante enfatiza a importância da definição de diretrizes para que só os exames adequados sejam realizados. Conclusão: A criação destas diretrizes deverá aumentar a adequação dos exames de imagem solicitados no Departamento de Emergência, otimizando o seu resultado, com a consequente racionalização dos recursos disponíveis.

Mediastinum Teratoma Rupture: A Rare Manifestation.

We present the case of a 22-year-old man who presented with cough, haemoptysis and fever of 3 days' duration. A teratoma had been diagnosed 2 years previously. Physical examination was unremarkable but laboratory tests showed anaemia, neutrophilic leucocytosis and an increase in C-reactive protein. Chest CT revealed a teratoma of the anterior mediastinum with post-obstructive pneumonitis suggestive of tumour rupture. Antibiotic treatment resulted in a good clinical outcome. The patient was submitted to a left upper lobectomy and pathological examination revealed a mature teratoma. Teratomas are germ cell tumours that are usually asymptomatic and their rupture is a rare event. LEARNING POINTS: Mature teratomas are usually asymptomatic.Teratoma bronchial rupture is rare.The most frequent location for mature teratomas is the anterior mediastinum.

Giant granadilla's seeds phytobezoar rectal impactation: a very unusual case of intestinal obstruction.

A 78-year-old Caucasian man presented to the emergency department with bloody diarrhoea, diffuse abdominal pain and fever with 1-week duration. He had just returned from Angola where he had been treated for a presumed Clostridium difficile infection without improvement. He had no relevant medical or familiar history except for hypertension and prostate benign hyperplasia. He was drowsy, feverish and eupnoeic. His oxygen saturation on pulse oximetry was 92%, blood pressure was 173/99 mm Hg and pulse rate 100 beats per minute. Except for a distended, silent and painful abdomen, particularly on lower quadrants, the rest of the examination was unremarkable. A CT showed a mesh-like mass inside the rectum conditioning colonic obstruction and distention. This turned to be a giant granadilla's seeds phytobezoar and was removed endoscopically. Five days later, the patient had a colonic perforation requiring total colectomy. He made a full recovery after rehabilitation for 3 months.

Fever and generalised lymphadenopathy in an HIV-positive patient: a diagnostic challenge.

Fever and generalised lymphadenopathy is a common presentation of a variety of diseases and a thorough investigation is often necessary for appropriate diagnosis.We present a 53-year-old male patient admitted with fever, weight loss of 15 kg in 3 months and abdominal discomfort. Examination was only remarkable for axillary and inguinal lymphadenopathy. Blood tests showed normocytic normochromic anaemia, cholestasis and a previously unknown HIV-1 infection with lymphocyte CD4 +count of 239 cells/mm3 and viral load 3.172.370 copies/mL. A body CT scan showed multiple axillary, mediastinal, lumbar, aortic, iliac and pelvic lymphadenopathy as well as hepatosplenomegaly. An excisional biopsy of the left axillary lymphadenopathy was performed and histology ultimately revealed multicentric Castleman's disease associated with Human Herpes Virus-8. After initiation of antiretroviral therapy, rituximab was given and progressive clinical improvement occurred.

Sweet's Syndrome and relapsing polychondritis signal myelodysplastic syndrome.

The emergence of certain skin conditions belonging to the group of mucocutaneous paraneoplastic syndromes may indicate the future appearance of a previously unknown malignancy. Sweet's Syndrome and relapsing polychondritis are included in this group. Sweet's Syndrome and relapsing polychondritis are very rarely found together in the same patient. This dual occurrence is more commonly found in cancer patients with associated hematological malignancies. We report the case of a 79 year-old male with Sweet's Syndrome and relapsing polychondritis, who was subsequently diagnosed with a myelodysplastic syndrome.

Arterite de Takayasu: diagnóstico, evolução e tratamento de paciente com ulceração em couro cabeludo. Relato de caso / Takayasu's arteritis: diagnosis, evolution and treatment of patient with scalp ulceration. Case report

A arterite de Takayasu é uma vasculite autoimune rara, que afeta predominantemente a aorta e seus ramos principais, produzindo variados sinais e sintomas, como febre, mialgia, hipertensão, úlceras e isquemia. É mais comum na Ásia e menos frequente nos países ocidentais, acometendo mulheres em idade reprodutiva. As manifestações cutâneas podem estar presentes. Os critérios diagnósticos do American College of Rheumatology incluem idade <40 anos, diminuição dos pulsos braquiais, claudicação de extremidades, diferença de 10mmHg na pressão arterial sistólica de membros superiores, sopros em suclávia e aorta, e alterações angiográficas de aorta e seus arcos principais. Os melhores resultados terapêuticos baseiam-se na corticoterapia associada à imunossupressores como metotrexato. O uso de imunobiológicos é incipiente e carece de estudos para comprovar sua eficácia. A paciente em questão apresentava-se com quadro atípico, manifestando ulceração em couro cabeludo, decorrente de estenose em ramos superficiais da carótida externa. Evoluiu com trombose venosa cerebral e osteomielite, sendo submetida à oxigenoterapia hiperbárica e imunossupressão com 160mg de prednisona.Velocidade de hemossedimentação e proteína C-reativa estavam elevados, mas seu valor isolado carece de especificidade, embora sejam critérios de atividade da doença. A terapêutica com prednisona, metotrexato e anticoagulação com varfarina foi eficiente, pois reduziu a área da lesão em couro cabeludo e minimizou o quadro sistêmico, propiciando melhor qualidade de vida para a paciente.

Takayasu's arteritis is a rare autoimmune vasculitis, which primarily affects the aorta and its main branches, producing varied symptoms and signs, such as fever, myalgia, hypertension, ulcers, and ischemia. It is more common in Asia and less frequente in western countries, affecting women of childbearing age.Cutaneous manifestations may be present. The diagnostic criteria of the American College of Rheumatology include age <40 years,reduction of brachial pulses, extremity claudication, difference of 10 mmHg in systolic blood pressure of upper limbs, murmurs in subclavian artery and aorta, and angiographic changes of the aorta and its main arches. The best therapeutic results are based on corticosteroid therapy associated with immunosuppressants such as methotrexate. The use of immunobiologicals is incipiente and requires studies to prove its effectiveness. The patient presented with an atypical clinical picture, showing ulceration on the scalp as a result of stenosis in superficial branches of the external carotid. She progressed with cerebral venous thrombosis and osteomyelitis, undergoing hyperbaric oxygen therapy and immunosuppression with 160mg of prednisone. Erythrocyte sedimentationrate and C-Reactive Protein were high, but their individual value lacks specificity, although they are criteria for disease activity. Therapy with prednisone, methotrexate, and anticoagulation with warfarin were efficient, because they reduced the area of the lesion on the scalp, and minimized the systemic picture, providing better quality of life for the patient.

[Cardiovascular risk in HIV infected patients]. / Risco cardiovascular em doentes com infecção por vírus da imunodeficiência humana.

The increased cardiovascular risk has been implicated in both HIV infection and antirretroviral therapy. The endothelial dysfunction triggered by the infection and the metabolic abnormalities associated with therapy predispose to premature atherosclerosis. The recognition of the increased cardiovascular risk in these patients will allow more appropriate prevention strategies, as well as therapy optimization with lipid-lowering agents and antirretroviral therapy modification.

Warm antibody autoimmune haemolytic anaemia associated with ovarian teratoma.

The ovarian cystic teratoma is a rare cause of autoimmune haemolytic anaemia by warm antibodies, resistant to corticotherapy, with few case reports published in the medical literature. We present a case of a 45-year-old woman admitted to hospital due to general weakness. Laboratory studies revealed macrocytic anaemia, biochemical parameters of haemolysis and peripheral spherocytosis. The direct Coombs test was positive. Viral serologies, anti-nuclear antibodies, anti-double-stranded DNA antibodies and ß2-microglobulin were negative. CT scan of the thorax, abdomen and pelvis showed a heterogeneous right anexial lesion. The patient was treated with corticotherapy without improvement of anaemia. Regression of extra-vascular haemolysis and normalisation of haemoglobin was obtained only after laparoscopic splenectomy and right ooforectomy, and the histopathology of the right anexial mass revealed a cystic teratoma. Previously published cases controlled the haemolysis by surgically removing the lesion associated with splenectomy.

Síndrome de Sweet e policondrite recidivante reveladores de síndrome mielodisplásica / Sweet's Syndrome and relapsing polychondritis signal myelodysplastic syndrome

Certas dermatoses, pertencentes ao grupo das síndromes paraneoplásicas mucocutâneas, podem ser o prenúncio de uma neoplasia previamente não conhecida. Tanto a síndrome de Sweet como a policondrite recidivante incluem-se neste grupo. A síndrome de Sweet e a PR são raramente encontradas em um mesmo paciente. A presença de policondrite recidivante e síndrome de Sweet em um mesmo paciente tem se revelado mais frequente em pacientes com neoplasias associadas, sobretudo hematológicas. Relata-se o caso de paciente do sexo masculino, 79 anos, com síndrome de Sweet e policondrite recidivante, em quem, subsequentemente, foi diagnosticada uma síndrome mielodisplásica.

The emergence of certain skin conditions belonging to the group of mucocutaneous paraneoplastic syndromes may indicate the future appearance of a previously unknown malignancy. Sweet's Syndrome and relapsing polychondritis are included in this group. Sweet's Syndrome and relapsing polychondritis are very rarely found together in the same patient. This dual occurrence is more commonly found in cancer patients with associated hematological malignancies. We report the case of a 79year-old male with Sweet's Syndrome and relapsing polychondritis, who was subsequently diagnosed with a myelodysplastic syndrome.