Estenose aórtica grave e choque cardiogénico: um desafio terapêutico

Acute heart failure in patients with severe aortic stenosis and left ventricular systolic dysfunction is well known for its dire prognosis and limited therapeutic options.The authors describe the case of a man admitted for non-ST-elevation myocardial infarction. Diagnostic exams revealed severe aortic stenosis, with good left ventricular systolic function, and two-vessel coronary artery disease. The development of cardiogenic shock with left ventricular systolic dysfunction on day four led to changes in the therapeutic strategy. Percutaneous aortic balloon valvuloplasty coupled with complete myocardial revascularization was performed with a view to future surgical intervention. After discharge, the patient was readmitted with acute pulmonary edema, cardiogenic shock and cardiopulmonary arrest. Ventilator weaning was not possible due to acute heart failure and so it was decided to administer levosimendan, which resulted in substantial clinical and echocardiographic improvement. The patient subsequently underwent successful aortic valve replacement.This case highlights the challenge that characterizes the management of patients with concomitant coronary artery disease, left ventricular systolic dysfunction and severe aortic stenosis. Percutaneous aortic balloon valvuloplasty and levosimendan were safe and effective in the treatment of acute heart failure, acting as a bridge to surgery.     

Pre-emptive skin toxicity treatment for anti-EGFR drugs: evaluation of efficacy of skin moisturizers and lymecycline. A phase II study

Background

Anti-epidermal growth factor receptor (EGFR) target therapies like erlotinib for metastatic lung cancer and cetuximab or panitumumab for metastatic colorectal cancer (mCRC) cause skin reaction that seems to be related to treatment efficacy. Skin toxicity evaluation protocol with panitumumab study has shown that preemptive treatment reduces the incidence of ≥Grade 2 (G2) skin toxicity in mCRC treated with panitumumab. Aim of this study is to evaluate if preemptive skin toxicity treatment with different drugs has good efficacy in patients receiving anti-EGFR therapies, such as cetuximab, panitumumab, and erlotinib, for mCRC and metastatic lung cancer.

Methods

Treatment included skin moisturizers with sunscreen and lymecycline 300 mg/daily. Primary objective is to reduce the incidence of ≥G2 skin toxicity during the first 3 months of therapy. Toxicities are reported with confidence interval at 95 %. Quality of life was assessed with Dermatology Life Quality Index every 2 weeks and evaluated with repeated measure ANOVA.

Results

Fifty-one patients with mCRC (60.8 %) and metastatic lung cancer (39.2 %) were enrolled. Anticancer drugs were erlotinib/cetuximab/panitumumab 20:30:1. At 3-month evaluation, 27.4 % patients had =G2 skin toxicity. Skin toxicity was not related with age (p?=?0.67), sex (p?=?0.65), previous chemotherapy regimens (p?=?0.41), and current anti-EGFR treatment (p?=?0.22). No gastrointestinal or hematological toxicities related to lymecycline were observed. Only six patients required further drugs. Quality of life analysis did not show a significant difference from the beginning and the end of treatment.

Conclusions

Data show efficacy of preemptive treatment with a well-tolerated profile. A reduction of severe skin toxicities is shown with an increase of grade 1 toxicities, not leading to anti-EGFR dose reduction and with better quality of life for patients.     

Extra-pulmonary manifestations of paracoccidioidomycosis associated with acquired immunodeficiency syndrome: a case report

We present a patient with Paracoccidioidomycosis/HIV coinfection which has been investigated because of chronic monoarthritis and mucocutaneous lesions. A biopsy of the synovial membrane and skin revealed structures consistent with Paracoccidioides brasiliensis. At diagnosis, the count of CD4 + T cells was 44 cells/mm³. We emphasize the importance of clinical suspicion of Paracoccidioidomycosis in patients with HIV/AIDS who live in or are from risk areas.     

Liver transplantation for autoimmune hepatitis: Pre-transplant does not predict the early post-transplant outcome

Background and Aims

Autoimmune hepatitis (AIH) is a rare indication (<5%) for liver transplantation (LT). The aim of this study was to describe the early outcome after LT for AIH.

Methods

A multicenter retrospective nationwide study including all patients aged ≥16 transplanted for AIH in France was conducted. Occurrences of biliary and vascular complications, rejection, sepsis, retransplantation and death were collected during the first year after LT.

Results

A total of 344 patients (78.8% of women, 17.0% of (sub)fulminant hepatitis and 19.2% of chronic liver diseases transplanted in the context of acute-on-chronic liver failure [ACLF]) were included, with a median age at LT of 43.6 years. Acute rejection, sepsis, biliary and vascular complications occurred in respectively 23.5%, 44.2%, 25.3% and 17.4% of patients during the first year after LT. One-year graft and patient survivals were 84.3% and 88.0% respectively. The main cause of early death was sepsis. Pre-LT immunosuppression was not associated with an increased risk for early infections or surgical complications. Significant risk factors for septic events were LT in the context of (sub)fulminant hepatitis or ACLF, acute kidney injury at the time of LT (AKI) and occurrence of biliary complications after LT. AKI was the only independent factor associated with graft (HR = 2.5; 95% CI: 1.1–5.4; p = .02) and patient survivals (HR = 2.6; 95% CI: 1.0–6.5; p = .04).

Conclusion

Early prognosis is good after LT for AIH and is not impacted by pre-LT immunosuppression but by the presence of AKI at the time of LT.     

A novel complex class 1 integron found in a Klebsiella pneumoniae isolate from Portugal

Klebsiella pneumoniae Kp1 carrying a novel complex class 1 integron was isolated from an inanimate surface of a female ward sanitary facility in the Hospital Infante D. Pedro, Aveiro, central Portugal. The integron consists of two variable regions (VRs); VR1 was previously described in Escherichia coli and Vibrio cholerae, and VR2 contains an ***ln37-like structure and is located downstream of an ISCR1 element. The integron was found on a plasmid of 225 kb. The qnrB10 gene, although present, is not associated with the complex class 1 integron.     

Child and adolescent psychiatry training in Brazil,Argentina, Uruguay and Chile: current panorama and future challenges

Mental disorders affect approximately 10–15% of children and adolescents worldwide. In South America these numbers are probably higher due to poverty and adverse life events that frequently affect this region. The availability of qualified services and well-trained professionals to care for those children are by far insufficient. The aim of this study was to assess and describe child and adolescent psychiatry (CAP) training in Brazil, Argentina, Uruguay, and Chile, to support the development and strengthen training standards. The coordinators of CAP residency programs in Brazil, Argentina, Uruguay, and Chile were invited to answer an online questionnaire about the characteristics of their training programs. Twelve programs from Brazil, three programs from Chile, two from Argentina, and one from Uruguay completed the questionnaires. In the last three countries, CAP is recognized as an independent specialty, while in Brazil it is considered a subspecialty of psychiatry. None of the countries have a national guideline for CAP residency training. Recently, there has been an increase in the number of professionals interested in pursuing a formal CAP training. This is the first study aiming to evaluate the current scenario of CAP training in South America. The results point to a great potential in the evaluated programs, but also to the need for homogeneous criteria for CAP training and evaluation of residents. A more efficient communication among programs would be an enriching strategy for their development, which may be facilitated by the results of this study.