Spontaneous pneumomediastinum, Hamman syndrome: case report

Pneumomediastinum is defined as free air or gas within the mediastinum, and in case of spontaneous pneumomediastinum there is no evidence of trauma, invasive procedures or previously diagnosed lung diseases. Spontaneous emphysema is a rare condition at urgent care centers. Hammam’s syndrome or spontaneous pneumomediastinum is more frequent in young adults. The more frequent symptoms are chest pain and dyspnea. Hammam’s sign, a pathognomonic sign of mediastinal emphysema, is a crunching, rasping sound, synchronous with heartbeat, heard over the precordium. Pneumomediastinum is diagnosed with the aid of chest X-rays and chest CT scans. It is usually a benign self-limited condition. Treatment is conservative and symptom alleviating. The purpose of this study was to describe a case of Hammam’s syndrome and the importance of clinical evaluation and early diagnosis of this diseaseO pneumomediastino caracteriza-se pela presença de ar no mediastino, sendo que no espontâneo não há evidências de traumatismo, iatrogenia ou pneumopatias prévias. O surgimento de enfisema espontâneo é uma situação rara nos serviços de urgência. A Síndrome de Hamman ou pneumomediastino espontâneo é mais frequente em adultos jovens. Os sintomas mais frequentes são dor torácica e dispneia. A presença de crepitação à ausculta cardíaca, denominado por sinal de Hamman é patognomônico. O diagnóstico é estabelecido por exames de imagem, como a radiografia torácica e a tomografia computadorizada do tórax. É uma enfermidade autolimitada e de evolução benigna na maioria dos casos. O tratamento é conservador e visa aliviar os sintomas. O objetivo do presente trabalho é descrever um caso de Síndrome de Hamman e demonstrar a importância da avaliação clínica e diagnóstico precoce dessa enfermidad

Lúpus eritematoso sistêmico diagnosticado durante a gestação: relato de caso

O lúpus eritematoso sistêmico (LES) é uma doença inflamatória crônica de etiologia autoimune, distribuição multissistêmica, cujas manifestações clínicas são bastante variáveis. Fatores genéticos, hormonais e ambientais estão correlacionados com o desenvolvimento da doença, a qual é caracterizada por períodos de remissão e exacerbação. No LES, os fenômenos imunológicos levam à produção de auto-anticorpos, os quais são dirigidos a antígenos nucleares do próprio organismo, resultando em diferentes manifestações clínicas, podendo acometer ossos, articulações, pulmões, fígado, rins e sistema nervoso central. Mulheres em período fértil têm alta prevalência, sendo que, na maior parte dos casos, não têm sua fertilidade comprometida. O início do quadro durante a gravidez é raro e indica pior prognóstico para mãe e feto. A gravidez está desaconselhada quando a doença está ativa durante a concepção, e quando se associa à nefrite lúpica. Mulheres portadoras de lúpus cursam com gestação de alto risco, haja vista, as gestantes lúpicas apresentarem maior taxa de abortamento espontâneo, restrição de crescimento intra-uterino e fetal, eclâmpsia, morte fetal, parto pré-termo. Há controvérsias sobre o efeito da gestação na atividade da doença, uma vez que, o LES pode afetar a gravidez, e o inverso também pode ocorrer; todavia, o LES não deve ser entendido como uma limitação à gestação, e o acompanhamento da mesma deve ser feito por equipe multiprofissional, assegurando uma gravidez segura para mãe e feto. Apresentamos o caso de uma paciente diagnosticada com LES no primeiro trimestre de gestação e que apresentou evolução clínica e laboratorial rápida e desfavorável, evoluindo com quadro de nefrite lúpica e abortamento.Systemic lupus erythematosus (SLE) is a chronic inflammatory disease of autoimmune etiology, multisystem distribution, whose clinical manifestations are quite variable. Genetic and environmental factors are correlated with the development of the disease, which is characterized by periods of remission and exacerbation. In SLE, immunological phenomena lead to the production of auto-antibodies, which are directed to nuclear antigens of the organism itself, resulting in different clinical manifestations and may involve the bones, joints, lungs, liver, kidneys and central nervous system. Women of childbearing age have high prevalence, and, in most cases, do not have a compromised fertility. The onset during pregnancy is rare and indicates poor prognosis for mother and fetus. Pregnancy is not recommended when the disease is active at conception. Women with lupus have high-risk pregnancy, because pregnant women lupus has high rates of abortion, intrauterine and fetal growth restriction, preeclampsia, fetal death, preterm delivery. There is controversy about the effect of pregnancy on disease activity, since SLE can affect pregnancy, and the reverse can also occur; however, the SLE should not be understood as a limitation to pregnancy, and the monitoring thereof should be done by multi-professional team, ensuring a safe pregnancy for mother and fetus. We present the case of a patient diagnosed with SLE in the first trimester of pregnancy and that presented clinical and laboratory evolution rapid and unfavourable, evolving with lupus nephritis and abortion

Espondilite anquilosante no sexo feminino associado à hipermobilidade articular e HLA-B27 negativo: relato de caso

A espondilite anquilosante (EA) é uma espondiloartropatia inflamatória soronegativa crônica, sistêmica, que na maioria das vezes apresenta um marcador HLA-B27 positivo. A EA cursa com alterações inflamatória, traumáticas e degenerativas, podendo levar a redução da flexibilidade da coluna, perda completa de mobilidade da coluna vertebral, destruição e anquilose das articulações da coluna vertebral e sacro-ilíacas. A síndrome de hipermobilidade articular é um distúrbio no qual a dor musculoesquelética ocorre em um substrato de hipermobilidade articular generalizada. A associação entre espondilite anquilosante e síndrome da hipermobilidade articular é rara. Relatamos um caso em que uma paciente apresentou espondilite anquilosante e síndrome da hipermobilidade articular.Ankylosings pondylitis (AS) is an inflammatory spondy loarthropathy sero negative chronic, systemic, which most often has a positive HLA -B27 marker. EA presents with inflammatory, traumatic and degenerative changes, leading to reduced flexibility of the spine, complete loss of spinal mobility, destruction and ankylosis of the joints of the spine and sacroiliac column. The joint hypermobility syndrome is a disorder in which musculoskeletal pain occurs in a hypermobility substrategeneralized joint. The association between ankylosing spondylitis and joint hypermobility syndrome is rare. The association between ankylosing spondylitis and joint hypermobility syndrome rare. We report a case in which a patient has ankylosing spondylitis and joint hypermobility syndrome

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Variation in monocyte/HDL-cholesterol ratio is a predictor of major cardiovascular events after acute coronary syndrome

Introdução: Recentemente emergido como um marcador de um estado pró-aterogênico e pró-inflamatório, a relação do número de monócitos pelo valor do HDL-colesterol (RMH) tem sido relatada como um preditor prognóstico nas doenças cardiovasculares. Objetivo: Avaliar se a variação do RMH obtido durante a hospitalização por um evento de síndrome coronariana aguda (SCA) e repetido ambulatorialmente após dois meses é um melhor preditor de eventos cardiovasculares maiores do que a RMH isolada obtida durante o evento agudo. Material e métodos: Coorte prospectiva que incluiu pacientes admitidos por SCA no período de janeiro de 2019 a março de 2020. O RMH foi quantificado em dois momentos: durante a admissão por SCA (RMH1) e no primeiro retorno ambulatorial (RMH2). A partir destes dois valores, foi quantificada a variação desta relação (&Delta;RMH). Todos os pacientes foram seguidos prospectivamente por meio de contato telefônico avaliando a ocorrência de eventos cardiovasculares maiores (MACE) conforme padronizado internacionalmente durante 180 dias de seguimento. Resultados: Foram incluídos 191 pacientes nesta investigação. Com base na RMH1 e na RMH2, obtida após 66 dias [intervalo interquartil (IQ) 39 - 93], os indivíduos foram divididos em dois grupos, um com diminuição do &Delta;RMH < 0 (N=113) e, outro, com aumento do &Delta;RMH &ge; 0 (N=78). Não foram observadas diferenças estatisticamente significativas entre estes dois grupos. A prevalência de MACE foi maior no grupo &Delta;RMH &ge; 0 em comparação com grupo &Delta;RMH <0 (22% vs. 07%); p = 0,003. As curvas de Kaplan-Meier mostram uma maior ocorrência de MACE no grupo &Delta;RMH &ge; 0 vs. grupo &Delta;RMH < 0 [Hazard ratio (HR): 3,96; (intervalo de confiança (IC) de 95% 1,74 - 8,99); p = 0,0004. A análise da curva de Característica de Operação do Receptor (ROC) mostrou que o &Delta;RMH foi um melhor preditor da ocorrência de MACE do que as outras duas relações isoladas, &Delta;RMH área sob a curva (ASC) ROC de 0,73 (IC95% 0,63 - 0,83) vs. RMH1 ASC de 0,49 (IC95% 0,38 - 0,60) vs. RMH2 ASC de 0,65 (IC95% 0,53 - 0,77), respectivamente, p=0,0009. Conclusão: A &Delta;RMH é um importante marcador prognóstico após SCA. Esta relação é calculada a partir de exames bioquímicos que já fazem parte da rotina destes pacientes, não trazendo custos adicionais. Este é um marcador que poderá ser utilizado para identificação do risco cardiovascular residual após evento de SCA ajudando a identificar pacientes que, potencialmente, se beneficiariam de intervenções adicionais com medicamentos anti-inflamatórios.Introduction: Recently emerged as a marker of a pro-atherogenic and pro-inflammatory state, the relationship between the number of monocytes and the value of HDL-cholesterol (MHR) has been reported as a prognostic predictor in cardiovascular diseases. Objective: To assess whether the variation of MHR obtained during hospitalization due to an acute coronary syndrome (ACS) event and repeated on an outpatient basis after 2 months is a better predictor of major cardiovascular events than the isolated MHR obtained during the acute event. Material and methods: Prospective cohort, which included patients admitted for ACS from January 2019 through March 2020. MHR was quantified in two times: during admission by ACS (MHR1) and on the first outpatient evaluation (MHR2). From these two values, the variation of this relation (&Delta;MHR) was quantified. All patients were followed prospectively through telephone contact assessing the occurrence of major cardiovascular events (MACE) as internationally standardized during 180 days of follow-up. Results: One hundred ninety one patients were included in this investigation. Based on MHR1 and MHR2, obtained after 66 days [interquartile range (IQR) 39-93], individuals were divided into two groups, one with a decrease in &Delta;MHR <0 (N = 113), and another with an increase in &Delta;MHR < 0 (N = 78). There were no statistically significant differences between these two groups. The prevalence of MACE was higher in the &Delta;MHR &ge; 0 group compared to the &Delta;MHR < 0 group (22% vs. 07%); p = 0.003. The Kaplan-Meier curves show a higher occurrence of MACE in the group &Delta;MHR &ge; 0 vs. group &Delta;MHR <0 [Hazard ratio (HR): 3.96; (95% confidence interval (CI) 1.74 - 8.99)]; p = 0.0004. Analysis of the Receiver Operating Characteristic Curve (ROC) showed that &Delta;MHR was a better predictor of the occurrence of MACE than the other two isolated relation, &Delta;MHR with area under curve (AUC) ROC of 0.73 (95%CI 0.63 - 0.83) vs. MHR1 AUC of 0.49 (95%CI 0.38 - 0.60) vs. MHR2 AUC of 0.65 (95%CI 0.53 0.77) respectively, p = 0.0009. Conclusion: &Delta;MHR is an important prognostic marker after ACS. This relation is calculated based on biochemical tests that are already part of the routine of these patients, without additional financial costs. This is a marker that can be used to identify residual cardiovascular risk after an ACS event helping to identify patients who potentially could have a benefit from additional interventions with anti-inflammatory drugs

Paciente idosa portadora de doença aterosclerótica submetida à cineangiocoronariografia com achado incidental de origem e curso anômalos de artéria coronária esquerda: relato de caso

As anomalias das artérias coronárias são formas relativamente raras de malformação congênita acometendo aproximadamente 1% da população. O paciente portador de anomalia de artéria coronária pode apresentar-se assintomático por um longo período, ou, apresentar de forma súbita um infarto agudo do miocárdio, arritmias graves e até morte súbita. O diagnóstico baseado em história clínica e exame físico muitas vezes não é possível, pois não há alterações clínicas significativas; portanto o uso de exames de imagem é de suma importância, tais como cineangiocoronariografia, angiotomografia e ressonância de artérias coronárias. Relatamos um caso em que uma paciente idosa, hipertensa e tabagista, portadora de doença aterosclerótica apresentou angina instável e foi submetida à cineangiocoronariografia, a qual revelou de maneira incidental, origem e curso anômalos de artéria coronária esquerda.Anomalies of the coronary arteries are relatively rare forms of congenital malformation affecting approximately 1% of the population. Patients affected by these anomalies may present themselves asymptomatic, or suffer of a sudden form of acute myocardial infarction, severe arrhythmia and even sudden death. The diagnosis based on clinical history and physical examination often can not be done, for there are no clinically significant changes; therefore the use of imaging is of utmost importance, as in coronary cineangiography, angiotomography and coronary arteries NMR. We report a case in which an elderly, hypertense and smoker patient, associated to atherosclerotic disease presented unstable angina and submitted to coronary cineangiography which revealed incidentally an anomalous origin and course of the left coronary artery

Ambulatory and hospitalized patients with suspected and confirmed mpox: an observational cohort study from BrazilResearch in context

Summary: Background: By October 30, 2022, 76,871 cases of mpox were reported worldwide, with 20,614 cases in Latin America. This study reports characteristics of a case series of suspected and confirmed mpox cases at a referral infectious diseases center in Rio de Janeiro, Brazil. Methods: This was a single-center, prospective, observational cohort study that enrolled all patients with suspected mpox between June 12 and August 19, 2022. Mpox was confirmed by a PCR test. We compared characteristics of confirmed and non-confirmed cases, and among confirmed cases according to HIV status using distribution tests. Kernel estimation was used for exploratory spatial analysis. Findings: Of 342 individuals with suspected mpox, 208 (60.8%) were confirmed cases. Compared to non-confirmed cases, confirmed cases were more frequent among individuals aged 30–39 years, cisgender men (96.2% vs. 66.4%; p < 0.0001), reporting recent sexual intercourse (95.0% vs. 69.4%; p < 0.0001) and using PrEP (31.6% vs. 10.1%; p < 0.0001). HIV (53.2% vs. 20.2%; p < 0.0001), HCV (9.8% vs. 1.1%; p = 0.0046), syphilis (21.2% vs. 16.3%; p = 0.43) and other STIs (33.0% vs. 21.6%; p = 0.042) were more frequent among confirmed mpox cases. Confirmed cases presented more genital (77.3% vs. 39.8%; p < 0.0001) and anal lesions (33.1% vs. 11.5%; p < 0.0001), proctitis (37.1% vs. 13.3%; p < 0.0001) and systemic signs and symptoms (83.2% vs. 64.5%; p = 0.0003) than non-confirmed cases. Compared to confirmed mpox HIV-negative, HIV-positive individuals were older, had more HCV coinfection (15.2% vs. 3.7%; p = 0.011), anal lesions (45.7% vs. 20.5%; p < 0.001) and clinical features of proctitis (45.2% vs. 29.3%; p = 0.058). Interpretation: Mpox transmission in Rio de Janeiro, Brazil, rapidly evolved into a local epidemic, with sexual contact playing a crucial role in its dynamics and high rates of coinfections with other STI. Preventive measures must address stigma and social vulnerabilities. Funding: Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz)

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat