The Intensive Care Global Study on Severe Acute Respiratory Infection (IC-GLOSSARI): a Multicenter, Multinational, 14-Day Inception Cohort Study

PURPOSE: In this prospective, multicenter, 14-day inception cohort study, we investigated the epidemiology, patterns of infections, and outcome in patients admitted to the intensive care unit (ICU) as a result of severe acute respiratory infections (SARIs). METHODS: All patients admitted to one of 206 participating ICUs during two study weeks, one in November 2013 and the other in January 2014, were screened. SARI was defined as possible, probable, or microbiologically confirmed respiratory tract infection with recent onset dyspnea and/or fever. The primary outcome parameter was in-hospital mortality within 60 days of admission to the ICU. RESULTS: Among the 5550 patients admitted during the study periods, 663 (11.9 %) had SARI. On admission to the ICU, Gram-positive and Gram-negative bacteria were found in 29.6 and 26.2 % of SARI patients but rarely atypical bacteria (1.0 %); viruses were present in 7.7 % of patients. Organ failure occurred in 74.7 % of patients in the ICU, mostly respiratory (53.8 %), cardiovascular (44.5 %), and renal (44.6 %). ICU and in-hospital mortality rates in patients with SARI were 20.2 and 27.2 %, respectively. In multivariable analysis, older age, greater severity scores at ICU admission, and hematologic malignancy or liver disease were independently associated with an increased risk of in-hospital death, whereas influenza vaccination prior to ICU admission and adequate antibiotic administration on ICU admission were associated with a lower risk. CONCLUSIONS: Admission to the ICU for SARI is common and associated with high morbidity and mortality rates. We identified several risk factors for in-hospital death that may be useful for risk stratification in these patients.

Acute Upper Limb Ischemia, a Rare Presentation of Giant Cell Arteritis

Giant cell arteritis (GCA) is a systemic large vessel vasculitis, with extracranial arterial involvement described in 10-15% of cases, usually affecting the aorta and its branches. Patients with GCA are more likely to develop aortic aneurysms, but these are rarely present at the time of the diagnosis. We report the case of an 80-year-old Caucasian woman, who reported proximal muscle pain in the arms with morning stiffness of the shoulders for eight months. In the previous two months, she had developed worsening bilateral arm claudication, severe pain, cold extremities and digital necrosis. She had no palpable radial pulses and no measurable blood pressure. The patient had normochromic anemia, erythrocyte sedimentation rate of 120 mm/h, and a negative infectious and autoimmune workup. Computed tomography angiography revealed concentric wall thickening of the aorta extending to the aortic arch branches, particularly the subclavian and axillary arteries, which were severely stenotic, with areas of bilateral occlusion and an aneurysm of the ascending aorta (47 mm). Despite corticosteroid therapy there was progression to acute critical ischemia. She accordingly underwent surgical revascularization using a bilateral carotid-humeral bypass. After surgery, corticosteroid therapy was maintained and at six-month follow-up she was clinically stable with reduced inflammatory markers. GCA, usually a chronic benign vasculitis, presented exceptionally in this case as acute critical upper limb ischemia, resulting from a massive inflammatory process of the subclavian and axillary arteries, treated with salvage surgical revascularization.

Effects of severe protein restriction in levels of parasitemia and in mortality of mice accutely infected with Trypanosoma cruzi

Adult mice were submitted to different degrees of protein restriction for five weeks (4.75, 9.5,14.25 and 19% of protein in isocaloric diets with normal content of mineral and vitamins), being subsequently infected with two strains of Trypanosoma cruzi: 10(5) trypomastigotes of Y strain or 14(5) trypomastigotes of CL strain. The same diet was maintained for all animals and the infection wasfollowed up by evaluation of blood parasites, mortality and intensity of lesions in the heart and skeleton muscle. Only severe protein restriction (4.75%) induced decrease in resistance to the infection with both the Y and CL strains of T. cruzi, which resulted in higher parasitemia and mortality. The inflammatory lesions in heart and skeleton muscle were less extensive in groups with severe protein restriction despite the increased number of parasite in muscle cells. Depression of immune mechanisms could be responsiblefor the reduced resistance and reduced inflammatory reaction after T. cruzi infection in severely protein restricted animals.

Severe digestive pathology associated with chronic Chaga's disease in Ecuador: report of two cases

DNA extracted from peripheral blood of two Ecuadorian patients showing severe digestive pathology was amplified by the polymerase chain reaction using a Trypanosoma cruzi specific oligonucleotide primers derived from the primary sequence of a cDNA encoding for a 24 kDa excretory/secretory protein. The positive PCR results together with the clinical findings confirmed that both patients had a digestive pathology due to Chagas' disease. This pathology could be more frequent than previously described in the chagasic endemic regions of Andean countries.

Human parvovirus B19 infection in HIV-positive patients

Parvovirus B19 infects predominantly erythroid cells, leading to transient inhibition of erythropoiesis. Immunocompromised patients may be unable to produce neutralizing antibodies and may develop severe chronic anemia. Epidemiological studies done on Niterói population showed that B19 infection occurs periodically in late spring and summer. We report a study from 55 HIV infected patients attending an infectious diseases outpatient clinic in this city during a 5-month period in which B19 circulation was well documented. All patients were under anti-retroviral therapy. No anti-B19 IgM was found, but a high prevalence of IgG anti-B19 (91%) was observed. In six patients, B19 DNA was found by dot-blot hybridization techniques, but this was not confirmed by PCR. None of these 6 patients manifested anemia and only one had CD4 cell count below 200 x 10(7)/L. We conclude that persistent infection causing anemia is an infrequent finding in our HIV positive patients under drug therapy.

Clinicopathological and immunohistochemical featuresof the severe pulmonary form of leptospirosis

Four cases of severe pulmonary form of leptospirosis (SPFL) are described. In all four of these blood culture proven cases, there was severe pulmonary injury characterized by alveolar hemorrhage and acute respiratory failure. Three patients died in less than 48 hours after onset of the first respiratory signs. Leptospiral antigen detection in lung tissues was positive by immunoperoxidase in all three of these cases, suggesting that the microorganism exerts a local direct destructive action. Patients with SPFL should be carefully monitored, as the abrupt onset of severe alveolar hemorrhage can lead to respiratory insufficiency and death. The authors emphasize the importance of radiological findings and blood gas analysis for prompt clinical diagnosis, and suggest that corticosteroids, associated with antibiotics, early respiratory support, and platelet transfusions are useful as an attempt to prevent further development of SPFL.

Clinical presentation of parvovirus B19 infection in HIV-infected patients with and without AIDS

Human parvovirus B19 replicates in erythrocyte precursors. Usually, there are no apparent hematological manifestations. However, in individuals with high erythrocyte turnover, as in patients with sickle-cell disease and in the fetus, the infection may lead to severe transient aplasia and hydrops fetalis, respectively. In AIDS patients, persistent infection may result in chronic anemia. By contrast, in HIV-positive patients without AIDS the infection evolves as a mild exanthematous disease. Two clinical descriptions exemplify these forms of presentation. In the first, an AIDS patient presented with bone marrow failure that responded to immunoglobulin. In the second, an HIV-positive patient without AIDS had a morbilliform rash, and needed no treatment. Knowing that an AIDS patient has chronic B19 anemia lessens concern about drug anemia; protects the patient from invasive diagnostic maneuvers; and prevents the patient from disseminating the infection. In AIDS patients with pure red cell aplasia, a search for parvovirus B19 DNA in the serum or in the bone marrow is warranted.

Multivariate analysis applied to clinical analysis data

Dissertação para obtenção do Grau de Mestre em Engenharia e Gestão Industrial

Schistosomiasis mansoni and severe gastrointestinal cytomegalovirus disease in a patient with acquired immunodeficiency syndrome

The behavior of the Schistosoma mansoni infection in patients with AIDS has not been explored. The case of a young woman with schistosomiasis mansoni, AIDS, and cytomegalovirus disease is reported. The authors suggest that the helminth was not a bystander in this case, or rather, by interfering with the host's immune response, it set the stage for the development and/or aggravation of the viral infection.

Exploring the experience of stigma in severe mental illness : a Portuguese contribution to the validation of a psychometric instrument

RESUMO: Fizemos uma análise da evolução do conceito de estigma, das suas correlações e das suas consequências e analisámos os instrumentos psicométricos utilizados para estudar experiências pessoais de estigma. Revimos os principais estudos de investigação sobre estigma em Portugal. Revimos, igualmente, os estudos relevantes utilizando o “Consumer Experiences of Stigma Questionnaire” (CESQ) e as propriedades psicométricas já documentadas. O nosso estudo teve como objetivos: explorar as experiências de estigma numa amostra portuguesa de pessoas com perturbação mental grave e contribuir para a documentação das propriedades psicométricas do “Consumer Experiences of Stigma Questionnaire” e para a validação da sua versão portuguesa. Fizemos um estudo transversal, descritivo e analítico, recolhemos dados sociodemográficos e clínicos e medimos as experiências de estigma e o funcionamento global. A frequência das respostas da secção de estigma foi semelhante à dos restantes estudos utilizando a CESQ. A frequência das respostas na secção de discriminação foi ligeiramente inferior à reportada noutros estudos. Verificámos a existência de uma associação entre a pontuação da subescala de discriminação, o sexo masculino e o facto de se viver na comunidade. A pontuação da subescala de discriminação está também correlacionada de forma positiva com o funcionamento global. Os alfas de Cronbach para a CESQ e para as suas subescalas foram considerados bons. Os coeficientes de correlação intraclasse foram igualmente considerados igualmente bons. Utilizando técnicas de análise fatorial, verificámos que a maior parte dos itens da CESQ se enquadrava em dois fatores, correspondendo sensivelmente às subescalas definidas previamente. Concluímos que o presente estudo explorou com sucesso a questão do estigma em Portugal, contribuindo em simultâneo para a validação do “Consumer Experiences of Stigma Questionnaire.--------------ABSTRACT: We reviewed the evolution of concept of stigma, its correlates and consequences, and analysed psychometric instruments that were used to study personal experiences of stigma. We provided an insight over research of stigma in Portugal. We reviewed relevant studies that use Consumer Experiences of Stigma Questionnaire and documented psychometric properties of this instrument. Our study aimed both to explore experiences of stigma in a Portuguese sample of people with severe mental illness and to contribute to the assessment of the psychometric properties of Consumer Experiences of Stigma Questionnaire and to the validation of its Portuguese translation. We performed a cross sectional descriptive and analytic study, collected socio-demographic data and measured experiences of stigma and global functioning. Frequency of responses regarding stigma section of CESQ matched previous studies using that scale. Frequency of responses in discrimination section was slightly lower than previously reported studies. We found an association between the discrimination score of CESQ and both male gender and living in the community. The discrimination score also positively correlated with global functioning. Cronbach alphas for CESQ and its subscales were good. Intraclass correlation coefficients for CESQ and stigma subscale were also good. Using factor analysis we found most of the items in CESQ would fit 2 factors, grossly corresponding to the previously defined subscales. We conclude that this study successfully explored stigma in Portugal, contributing in simultaneous to the validation of Consumer Experiences Questionnaire.

Detection of Cryptosporidium spp and other intestinal parasites in children with acute diarrhea and severe dehydration in Rio de Janeiro

The objective of the present study was to estimate the frequency of infection by Cryptosporidium spp and other intestinal parasites in dehydrated children with gastroenteritis who were admitted to a pediatric hospital. Stool examinations from 218 children were performed. Cryptosporidium spp was identified in eighteen out of 193 stool samples (9.3%) subjected to safranin-methylene blue staining. Giardia lamblia was detected in ten out of 213 (4.7%) samples examined via the direct or Ritchie methods. Other parasites identified were Ascaris lumbricoides (4.2%), Blastocystis hominis (1.4%), Entamoeba coli (0.9%), Entamoeba histolytica/Entamoeba dispar (0.5%), Endolimax nana (0.5%), Trichuris trichiura (0.5%) and Enterobius vermicularis (0.5%).

Needs assessment of people with severe mental illnesses and their families in Azerbaijan

RESUMO: Os indivíduos com doença mental grave, assim como os seus familiares, podem ser caracterizados como uma população em que ocorre uma combinação complexa de necessidades médicas e psicossociais, nomeadamente a nível do diagnóstico e do acesso aos serviços de saúde mental. A avaliação de necessidades pode fornecer informações importantes para o desenvolvimento de intervenções eficazes, tanto a nível da população como a nível individual. Este estudo teve como objetivo determinar as diferentes necessidades reportadas pelos pacientes com doença mental grave e seus familiares , assim como investigar as possíveis relações entre o estado de necessidades e as variáveis sócio-demográficas e clínicas. Simultaneamente, o estudo teve como objetivo avaliar a sobrecarga familiar e a satisfação dos utentes com os serviços de saúde mental. Foi elaborado um estudo transversal, realizado numa amostra de conveniência de cinquenta díades de paciente/membro da família, seguidos em regime de ambulatório no Centro Nacional de Saúde Mental. Foram utilizados como instrumentos de avaliação um questionário sociodemográfico, a Escala Breve de Avaliação Psiquiátrica (BPRS), o questionário de Avaliação de Necessidades de Camberwell (CAN), o Questionário de Avaliação do Envolvimento (IEQ) e a Escala de Verona de Satisfação com os Serviços (VSSS). As mais frequentes necessidades não-satisfeitas foram o ‘sofrimento psicológico’, as ‘atividades sociais’ e os ‘benefícios sociais’. O estudo mostrou uma sobrecarga significativa nas famílias que cuidam de pessoas com doença mental grave, que se correlacionou com as suas opiniões sobre as necessidades dos pacientes e teve um impacto negativo sobre o bem-estar psicológico. Os três mais importantes predictores de sofrimento psíquico em familiares foram o sexo, a situação laboral e a relação com o paciente. A avaliação da satisfação com os serviços revelou a existência de um hiato significativo entre os serviços prestados e os serviços desejados, reportados pelos pacientes e seus familiares. A maioria dos participantes do estudo desejavam ter um trabalho protegido, ou receber ajuda para encontrar emprego. Os resultados deste estudo poderão ser usados para fins de planeamento desenvolvimento e avaliação de serviços de saúde mental no Azerbeijão. Algumas recomendações sobre a melhoria dos serviços de saúde mental para pacientes com doença mental grave e suas famílias são feitas na secção final do trabalho.----------ABSTRACT: Patients suffering from severe mental illness, in addition to their family members, may be characterized as a population with a complex combination of medical and psychosocial needs, which are under-recognized and under-addressed by mental health services. At the same time, needs assessment provides important information necessary for developing effective interventions at both population and individual level. The study was aimed to determine various needs perceived by patients with SMI and their family members, as well as to find out possible relations between the needs and socio-demographic and clinical variables. Similarly the study was intended to evaluate family burden and users’ satisfaction with services. This was a cross-sectional study conducted on a convenience sample. Fifty dyads of a patient and family member applying for out-patient services to the National Mental Health Centre participated in the study. Sociodemographic questionnaire, Brief Psychiatric Rating Scale, Camberwell Assessment of Need, Involvement Evaluation Questionnaire, and Verona Service Satisfaction Scale were used as assessment tools. The most prominent unmet needs reported by people with SMI and their relatives were psychological distress, social activities and welfare benefits. The study showed significant burden in families caring for people with SMI, which correlated with their views about patients’ needs and had a negative impact on the psychological well-being. The three most important predictors of psychological distress in family members were gender, employment status and relationship to patient. Evaluation of satisfaction with services pointed out the gap between provided and desired services reported by patients and their relatives. Most of study participants wished to have sheltered work, or receive help in finding employment. The results of this study may be used for the purposes of mental health service planning, development and evaluation in our country. Some recommendations on improvement of mental health services for patients with SMI and their families have been made in the conclusion.