This study aimed to describe the clinical characteristics of the pediatric population with COVID-19 in an Emergency Department (ED) of a Brazilian general hospital.
Epidemiological and clinical data ...of patients younger than 20 years old were collected from patients' medical records from February 2020 to July 2021. Most of the epidemiological data described pertains to hospitalized patients. We also reviewed coinfections, treatment, and outcomes and compared the first and second waves of COVID-19.
We identified a total of 1303 episodes of SARS-CoV-2 infection. The median time from symptom onset to diagnosis was three days. Symptoms were present in 92.3% of the patients. The most common symptoms were fever (45.2%), nasal congestion/discharge (44.2%), and cough (39.4%). Chest radiography and tomography were performed in 7.7 and 3.3% of cases, with abnormal findings in 29.7 and 53.4%, respectively. Hospital admissions occurred in 3.5% of patients, mainly in the presence of comorbidities, in children under five years old and in those who presented to the ED during the first wave of COVID-19. Coinfection with a viral agent was identified in 20% of the 71 cases tested in this study, and a positive rapid test for Streptococcus pyogenes was found in 8% of the 174 cases tested, with no impact of these coinfections on hospitalization.
We found that COVID-19 was a mild disease in most children in our study population, with most hospitalizations and readmissions occurring during the first wave of COVID-19.
Chest pain is a frequent, potentially life-threatening condition in the emergency department and requires immediate investigation and treatment. This case report highlights a rare differential ...diagnosis of pleuritic chest pain: epipericardial fat necrosis. A 29-year-old man presented with normal clinical evaluation, electrocardiography, point-of-care ultrasound, and unremarkable laboratory tests. The initial hypothesis was acute pleuritis. Chest radiography revealed peri-cardiac nonspecific findings, and computed tomography revealed epicardial fat necrosis. Despite the rarity of this condition, accurate diagnosis allows for better practices. An algorithm for a diagnostic approach is proposed.
Cyanosis is typically a sign of a potentially life-threatening condition in the emergency department and requires immediate workup and treatment. This case report highlights the diagnostic reasoning ...and clinical approach to cocaine- and volatile nitrite–induced methemoglobinemia (MHG). MHG is a rare, life-threatening cause of cyanosis. The diagnosis must be suspected in the emergency department in the presence of hypoxia and cyanosis disproportionate to cardiopulmonary repercussions and refractory to oxygen supplementation. Acquired causes are more prevalent than genetics, and recreational drugs should be highly suspected. Despite the rarity of this situation, cyanosis precipitants and the specificities of each hemoglobinopathy are reviewed in this article.
Heyde's syndrome is the association of severe aortic stenosis with episodes of gastrointestinal bleeding due to angiodysplastic lesion. Little is known about the factors associated with new episodes ...of bleeding and long-term outcomes. Furthermore, most data are restricted to case reports and small case series.
To assess the clinical, laboratory and echocardiography profile of patients with Heyde's syndrome who underwent valve intervention or drug therapy.
Prospective cohort of 24 consecutive patients from 2005 to 2018. Clinical, laboratory and echocardiography data were assessed, as well as those related to valve intervention and outcomes after diagnosis. A P <0.05 was used to indicate statistical significance.
Half of the 24 patients presented with bleeding requiring blood transfusion on admission. Angiodysplasias were more frequently found in the ascending colon (62%). Valve intervention (surgical or transcatheter) was performed in 70.8% of the patients, and 29.2% remained on drug therapy. News episodes of bleeding occurred in 25% of the cases, and there was no difference between clinical and intervention groups (28.6 vs 23.5%, p = 1.00; respectively). Mortality at 2-year and 5-year was 16% and 25%, with no difference between the groups (log-rank p = 0.185 and 0.737, respectively).
Patients with Heyde's syndrome had a high rate of bleeding requiring blood transfusion on admission, suggesting that it is a severe disease with high mortality risk. No difference was found between clinical and intervention group regarding the rate of rebleeding and late mortality.
Resumo A doença valvar cardíaca é um problema de saúde crescente no mundo. Os pacientes com valvopatia podem apresentar diversas emergências cardiovasculares. O manejo desses pacientes é um desafio ...no departamento de emergência, principalmente quando a condição cardíaca prévia é desconhecida. Atualmente, recomendações específicas para o manejo inicial são limitadas. A presente revisão integrativa propõe uma abordagem baseada em evidência, de três etapas, desde a suspeita de valvopatia à beira do leito até o tratamento inicial das emergências. A primeira etapa é a suspeita de uma condição valvar subjacente com base nos sinais e sintomas. A segunda etapa consiste na tentativa de confirmação diagnóstica e avaliação da gravidade da valvopatia com exames complementares. Finalmente, a terceira etapa aborda as opções diagnósticas e terapêuticas para insuficiência cardíaca, fibrilação atrial, trombose valvar, febre reumática aguda, e endocardite infecciosa. Além disso, apresentamos imagens de exames complementares e tabelas para apoio aos médicos.
Adenosine is an antiarrhythmic drug that slows conduction through the atrioventricular node and acts as a coronary blood vessel dilator. This case report highlights two unusual life-threatening ...events following the use of adenosine to revert supraventricular tachycardia in a structurally normal heart: non-sustained polymorphic ventricular tachycardia and myocardial infarction. A 46-year-old woman presented to the emergency department with a two-hour history of palpitations and was diagnosed with supraventricular tachycardia. Vagal maneuvers were ineffective, and after intravenous adenosine administration, the patient presented with chest pain and hypotension. The rhythm degenerated into non-sustained polymorphic ventricular tachycardia and spontaneously reverted to sinus rhythm with ST elevation in lead aVR and ST depression in the inferior and anterolateral leads. The patient spontaneously recovered within a few minutes. Despite successful arrhythmia reversal, the patient was admitted to the intensive care unit because of an infarction without obstructive atherosclerosis. This report aims to alert emergency physicians about the potential complications associated with supraventricular tachycardia and its reversal with adenosine.
Background: As infective endocarditis has particular characteristics compared to other infectious diseases, it is not clear if sepsis scores are reported with good accuracy in these patients. The aim ...of this study is to evaluate the accuracy of the qSOFA and SOFA scores to predict mortality in patients with infective endocarditis. Methods: Between January 2010 and June 2019, 867 patients with suspected left-sided endocarditis were evaluated; 517 were included with left-sided infective endocarditis defined as "possible" or "definite" endocarditis, according to the Modified Duke Criteria. ROC curves were constructed to assess the accuracy of qSOFA and SOFA sepsis scores for the prediction of in-hospital mortality. Results: The median age was 57 years, 65% were male, 435 (84%) had pre-existing heart valve disease, and the overall mortality was 28%. The most frequent etiologies were Streptococcus spp. (36%), Enterococcus spp. (10%), and Staphylococcus aureus (9%). The sepsis scores from the ROC curves used to predict in-hospital mortality were qSOFA 0.601 (CI95% 0.522-0.681) and SOFA score 0.679 (CI95% 0.602-0.756). A sub-group analysis in patients with and without pre-existing valve disease for SOFA >= 2 showed ROC curves of 0.627 (CI95% 0.563-0.690) and 0.775 (CI95% 0.594-0.956), respectively. Conclusions: qSOFA and SOFA scores were associated with increased in-hospital mortality in patients with infective endocarditis. However, as accuracy was relatively lower compared to other sites of bacterial infections, we believe that this score May have lower accuracy when predicting the prognosis of patients with IE, because, in this disease, the patient's death May be more frequently linked to valvular and cardiac dysfunction, as well as embolic events, and less frequently directly associated with sepsis.
•We explore cardiac/inflammatory biomarkers to predict in-hospital mortality in endocarditis.•Troponin concentration measured at admission showed the highest accuracy for mortality ...prediction.•Inflammatory biomarkers had better accuracy at the 7th day than at admission.
Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE.
Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality.
Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8–6.4; P<0.001), BNP (OR 2.7; 95%CI 1.4–5.1; P=0.002), IL-6 (OR 2.06; 95%CI 1.3–3.7; P=0.019), procalcitonin (OR 1.9; 95%CI 1.1–3.2; P=0.018), TNF-α (OR 1.8; 95%CI 1.1–2.9; P=0.019), and CRP (OR 1.8; 95%CI 1.0–3.3; P=0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759).
S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE.
Resumo Fundamentos A síndrome de Heyde é a associação de estenose aórtica importante com episódio de sangramento gastrointestinal por lesões angiodisplásicas. Pouco é conhecido sobre os fatores ...associados a novos sangramentos e desfechos em longo prazo. Além disso, a maioria dos dados é restrita a relatos de casos e pequenas séries. Objetivo Avaliar o perfil clínico, laboratorial e ecocardiográfico de pacientes com síndrome de Heyde submetidos a intervenção valvar ou tratamento medicamentoso. Métodos Coorte prospectiva de 24 pacientes consecutivos entre 2005 e 2018. Foram avaliados dados clínicos, laboratoriais, ecocardiográficos e relacionados à intervenção valvar e a desfechos após o diagnóstico. Valor de p<0,05 foi considerado estatisticamente significante. Resultados Metade dos 24 pacientes apresentou sangramento com necessidade de transfusão sanguínea na admissão. Angiodisplasias foram encontradas mais frequentemente no cólon ascendente (62%). Intervenção valvar (cirúrgica ou transcateter) foi realizada em 70,8% dos pacientes, e 29,2% foram mantidos em tratamento clínico. Novos episódios de sangramento ocorreram em 25% dos casos, e não houve diferença entre os grupos clínico e intervenção (28,6 vs. 23,5%, p=1,00; respectivamente). A mortalidade no seguimento de 2 e 5 anos foi de 16% e 25%, sem diferença entre os grupos (log-rank p = 0,185 e 0,737, respectivamente). Conclusões Pacientes com síndrome de Heyde tiveram alta taxa de sangramento com necessidade de transfusão sanguínea na admissão, sugerindo ser uma doença grave e com risco elevado de mortalidade. Não encontramos diferenças entre os grupos submetidos ao tratamento clínico e à intervenção valvar em relação a taxas de ressangramento e mortalidade tardia.
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