Pleural empyema due to Rhodotorula mucilaginosa: A rare yet severe complication of a previously undiagnosed cancer patient.

Rhodotorula mucilaginosa (R. mucilaginosa) has been increasingly recognized as an emerging opportunistic pathogen causing invasive fungal infection, mainly in immunosuppressed patients. We report the case of a previously undiagnosed lung cancer patient with a pleural empyema due to R. mucilaginosa.

Ultra-rapid flow cytometry assay for colistin MIC determination in Enterobacterales, Pseudomonas aeruginosa and Acinetobacter baumannii.

OBJECTIVES: Both EUCAST and CLSI recommend broth microdilution for antimicrobial susceptibility testing of colistin, but this method is cumbersome and takes 16-24 h to give results. Our objective was to evaluate a rapid quantitative colistin MIC susceptibility assay based on flow cytometry analysis (FASTcolistin MIC) in comparison with standard broth microdilution assay. METHODS: One hundred and sixteen Gram-negative bacilli (78 Enterobacterales, 28 Pseudomonas aeruginosa and 10 Acinetobacter baumannii) were studied in parallel using standard broth microdilution following EUCAST recommendations and FASTcolistin MIC kit. In the last one, a bacteria suspension (0.5 MacFarland) was prepared, diluted in Muller-Hinton broth, incubated in the susceptibility panel containing different colistin concentrations (range 0.125-64 mg/L) with a fluorescent probe and incubated 1 h at 35ºC. After that, a flow cytometry analysis using CytoFLEX (Beckmam) was performed. Using a dedicated software (BioFAST) an automated MIC result was obtained after 1.5 h. Performance evaluation was performed according to the ISO standard 20776-2. Reproducibility and repeatability, categorical (CA) and essential agreement (EA), and lot-to-lot variation and operator-to-operator variability, as well as time to results were determined. RESULTS: Overall, 100% CA (CI 97-100%) and 95.7% EA (CI 90-98%) was obtained with high repeatability (100%; CI 80-100%)and reproducibility (97%; (CI 83-99%)). Absence of lot-to-lot variations or differences in the operators' performance was observed. CONCLUSIONS: FASTcolistin MIC is an accurate, reliable and ultra-rapid method (1 h incubation versus 24 h) for susceptibility testing of colistin of common Gram-negative bacilli recovered in clinical laboratories.

Cephalosporin-Resistant Neisseria gonorrhoeae Isolated in Portugal, 2019.

We report a multidrug-resistant Neisseria gonorrhoeae exhibiting resistance to ceftriaxone and cefixime, isolated in Portugal in 2019. Whole-genome sequencing was performed for typing and identification of genetic determinants of antimicrobial resistance. Because of its antimicrobial susceptibility profile, awareness should be raised for the circulation of this strain.

Infection and colonization by Corynebacterium pseudodiphtheriticum: a 9-year observational study in a university central hospital.

Despite constituting part of the human commensal flora, Corynebacterium pseudodiphtheriticum has been recognized as a potentially infectious agent, most frequently in immunocompromised patients or individuals with other morbidity factors, but significant association to comorbid states remains unproven. This study's purpose was to assess clinical significance, risk factors for infection and antimicrobial susceptibility of C. pseudodiphtheriticum isolates. A retrospective observational study was conducted. Relevance of isolation was determined by clinical, laboratory, and imaging criteria. Forty-nine isolates occurred in 47 episodes. Colonization was assumed in 12% and infection in 78%, of which 51% were nosocomial. Patients with infection were older, with male predominance; both age and gender were statistically significant (p < 0.05) between infection and colonization groups. Although dyslipidemia (58%), arterial hypertension (58%), invasive procedures (56%), and chronic lung disease (50%) were prevalent in the infection group, no comorbidity was a significant risk factor for infection compared with colonization. Charlson comorbidity index showed no statistically difference between groups. Mortality rate was 14% in infection. Respiratory samples were the main isolation product; all tested strains were susceptible to amoxicillin/clavulanate and vancomycin. Resistant strains were observed for clindamycin (77%) and erythromycin (48%). C. pseudodiphtheriticum isolation was associated with infection in most cases. Despite the high prevalence of comorbidities and invasive procedures, no factors other than age and gender were significantly associated with infection. Although C. pseudodiphtheriticum may constitute a contaminant or colonizer in clinical samples, positive cultures in patients with signs and symptoms consistent with infection should not be neglected.

Lipoprotein apheresis in the management of severe hypercholesterolemia and hyperlipoproteinemia(a)-The Portuguese experience.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) are established causal risk factors for cardiovascular disease (CVD). Lipoprotein apheresis is often required for treatment of patients with a high risk for CVD due to hypercholesterolemia and/or hyperlipoproteinemia(a). AIM: To describe our experience with lipoprotein apheresis in patients with severe hypercholesterolemia or with hyperlipoproteinemia(a). METHODS: We retrospectively investigated patients treated with Lipoprotein apheresis using direct adsorption of lipoproteins (DALI) technique, between December 2008 and March 2018, in our center. Adverse events, acute and long term reductions in lipid parameters were analyzed. RESULTS: Between December 2008 and March 2018, a total of 950 treatments were performed in five patients, four with heterozygous familial hypercholesterolemia (HeFH), all on maximally tolerated cholesterol-lowering drug therapy and in one patient with hyperlipoproteinemia(a) and progressive CVD. In the four patients with HeFH we obtained mean acute reductions in LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) of 62.0 ± 7.8% and 60.4 ± 6.8%, respectively. Regarding long-term efficacy we achieved a mean reduction of 43.1% in LDL-C and of 41.2% in non-HDL-C. In the patient with hyperlipoproteinemia(a) we attained mean acute reductions of 60.4 ± 6.4% in Lp(a) and of 75.4 ± 7.3% in LDL-C per session and long term reductions in Lp(a) and LDL-C of 67.4% and 40.5%, respectively. Adverse events were recorded in only 1.2% of treatments. CONCLUSION: Lipoprotein apheresis is an efficient and safe treatment in severely hypercholesterolemic patients who are refractory to conservative lipid-lowering therapy or with hyperlipoproteinemia(a) and progressive CVD.

Preoperative Staphylococcus aureus Screening/Decolonization Protocol Before Total Joint Arthroplasty-Results of a Small Prospective Randomized Trial.

To study the prevalence of Staphylococcus aureus carriage and the impact of preoperatively treating carriers in prosthetic joint infection (PJI), a prospective randomized trial was organized. From January 2010 to December 2012, 1028 of 1305 total joint arthroplasties performed were screened, and selected carriers underwent preoperative decolonization. We observed a 22.2% (228/1028) S aureus colonization rate and only 0.8% methicillin-resistant S aureus. Prosthetic joint infection rate was higher, albeit not significantly, in S aureus carriers than among noncarriers-3.9% (9/228) vs 2.0% (16/800). Treated and untreated carriers showed no significant differences-3.4% (3/89) vs 4.3% (6/139). Most of the 14 S aureus PJI occurred in noncarriers suggesting a lack of causal relation between nasal and PJI S aureus. No clear benefit in screening/decolonizing carriers before total joint arthroplasty could be demonstrated.

LDL apheresis in the treatment of familial hypercholesterolemia: experience of Hospital Santo António, Porto.

INTRODUCTION: High plasma levels of low-density lipoprotein (LDL) cholesterol are a risk factor for the development of premature atherosclerosis. Direct adsorption of lipoproteins (DALI) is an apheresis technique by which LDL cholesterol is selectively removed from whole blood. OBJECTIVE: The present study describes our experience with DALI LDL apheresis in severely hypercholesterolemic patients. METHODS: Three hypercholesterolemic patients suffering from atherosclerotic complications were treated fortnightly by DALI apheresis, in a total of 308 sessions between December 2008 and January 2013. All patients were on the highest tolerated dose of statins and other lipid-lowering drugs. RESULTS: The sessions were essentially uneventful, adverse events being recorded in only 3.6% of them. A mean 63.3% acute reduction in LDL cholesterol was obtained. CONCLUSION: DALI apheresis proved to be a simple, safe and efficient method of lipid apheresis in hypercholesterolemic patients refractory to conservative lipid-lowering therapy.

Is asymptomatic bacteriuria a risk factor for prosthetic joint infection?

BACKGROUND: Infection is a major complication after total joint arthroplasty. The urinary tract is a possible source of surgical site contamination, but the role of asymptomatic bacteriuria (ASB) before elective surgery and the subsequent risk of infection is poorly understood. METHODS: Candidates for total hip or total knee arthroplasty were reviewed in a multicenter cohort study. A urine sample was cultured in all patients, and those with ASB were identified. Preoperative antibiotic treatment was decided on an individual basis, and it was not mandatory or randomized. The primary outcome was prosthetic joint infection (PJI) in the first postoperative year. RESULTS: A total of 2497 patients were enrolled. The prevalence of ASB was 12.1% (303 of 2497), 16.3% in women and 5.0% in men (odds ratio, 3.67; 95% confidence interval, 2.65-5.09; P < .001). The overall PJI rate was 1.7%. The infection rate was significantly higher in the ASB group than in the non-ASB group (4.3% vs 1.4%; odds ratio, 3.23; 95% confidence interval, 1.67-6.27; P = .001). In the ASB group, there was no significant difference in PJI rate between treated (3.9%) and untreated (4.7%) patients. The ASB group had a significantly higher proportion of PJI due to gram-negative microorganisms than the non-ASB group, but these did not correlate to isolates from urine cultures. CONCLUSIONS: ASB was an independent risk factor for PJI, particularly that due to gram-negative microorganisms. Preoperative antibiotic treatment did not show any benefit and cannot be recommended.

Retinal angiography and colour Doppler of retrobulbar vessels in Takayasu arteritis.

OBJECTIVE: Takayasu arteritis (TA) is a chronic, granulomatous, idiopathic, inflammatory disease that primarily affects large vessels. The objective of this study was to evaluate and describe the ocular manifestations of TA, correlating the resistivity and pressure in retrobulbar vessels by colour Doppler and retinal angiography. DESIGN: Cross-sectional study. PARTICIPANTS: Twenty-one patients with TA, 42 eyes, and 21 patients without TA (42 eyes) as control subjects. METHODS: This study was performed in clinical practice. Patients with TA received complete ophthalmologic examination, fluorescein and indocyanine green angiography, and colour Doppler ultrasound to evaluate blood flow in the retrobulbar vessels. RESULTS: A statistical correlation was found between peak systolic velocity (PSV) in the ophthalmic artery (OA) and Heidelberg retinal angiography (HRA) examination results (p = 0.006), and resistivity index (RI) in the OA was abnormal in patients with long (average, 14 years) versus short (average, 5.5 years) onset time of the disease (p = 0.035). RI in the central retinal artery (CRA) was abnormal in patients with a long time of disease onset (mean 14.4 years) versus those with a short time (mean 4.6 years) of onset (p = 0.006). CONCLUSIONS: The longer the onset of the disease, the more commonly the RI showed changes in the OA and CRA, and, to a lesser extent, in the short posterior ciliary artery. When abnormalities are observed in the HRA examination, abnormal PSV in the OA may be present. Doppler blood flow evaluation and HRA may have predictive value in all patients with TA as part of serial monitoring.

[Discriminant analysis of patients with primary open-angle glaucoma by color Doppler exam and visual field]. / Análise discriminante dos pacientes portadores de glaucoma primário de ângulo aberto através do exame de Doppler colorido e do campo visual.

PURPOSE: To determine if variables from color Doppler and visual field exam could discriminate normal from glaucomatous eyes. METHODS: Prospectively, 36 patients with primary open-angle glaucoma (glaucoma group) and 20 normal volunteers (control group) were studied. Gender, age, central corneal thickness, intraocular pressure, Octopus automated perimetry global indices (mean defect and loss variance) and several parameters of the color Doppler (peak systolic velocity and resistivity index) were compared between groups. RESULTS: There was no statistically significant difference in age, central corneal thickness and intraocular pressure. Discriminant analysis showed that the variables: resistivity index (RI) in the short posterior ciliary artery (SPCA), mean defect (MD) and loss variance (LV) had presented significant influence for the positive diagnosis of glaucoma. The gotten discriminant function was: -3.637 + 0.109 x MD + 0.028 x LV + 4.325 x RI SPCA. Considering score -1.61, the probability of positive diagnosis of glaucoma was 90%. CONCLUSION: Through discriminant analysis it was possible to identify which of the color Doppler variables that associated to the visual field variables allowed differentiate normal from glaucomatous patients. These variables were: resistivity index in the short posterior ciliary artery, and the visual field variables, mean defect and loss variance.

Análise discriminante dos pacientes portadores de glaucoma primário de ângulo aberto através do exame de Doppler colorido e do campo visual / Discriminant analysis of patients with primary open-angle glaucoma by color Doppler exam and visual field

OBJETIVO: Determinar se as variáveis obtidas com exame Doppler colorido associadas às de campo visual são capazes de discriminar olhos normais de olhos glaucomatosos. MÉTODOS: Foram avaliados prospectivamente 36 pacientes portadores de glaucoma primário de ângulo aberto em uso de medicação antiglaucomatosa (grupo glaucoma) e 20 voluntários normais (grupo controle). Analisou-se a distribuição dos grupos quanto ao sexo, idade, espessura corneana central, pressão intraocular, índices globais da perimetria computadorizada Octopus ("mean defect" e "loss variance") e os parâmetros do Doppler colorido (velocidade sistólica máxima e índice de resistência). RESULTADOS: Não houve diferença estatística significativa entre os grupos em relação à idade, espessura corneana e pressão intraocular. A análise discriminante mostrou que as variáveis: índice de resistência (IR) da artéria ciliar curta posterior (ACCP), "mean defect" (MD) e "loss variance" (LV) apresentaram influência estatisticamente significativa para o diagnóstico positivo de glaucoma. A função discriminante obtida foi: -3,637 + 0,109 MD + 0,028 LV + 4,325 IR ACCP. A probabilidade do diagnóstico positivo do glaucoma a partir do "score" -1,61 foi de 90 por cento. CONCLUSÃO: Foi possível identificar através da análise discriminante, quais das variáveis do Doppler colorido que, associados às do campo visual, permitiram diferenciar pacientes glaucomatosos de normais. Essas variáveis foram: índice de resistência da artéria ciliar curta posterior e índices da perimetria computadorizada "mean defect" e "loss variance".

PURPOSE: To determine if variables from color Doppler and visual field exam could discriminate normal from glaucomatous eyes. METHODS: Prospectively, 36 patients with primary open-angle glaucoma (glaucoma group) and 20 normal volunteers (control group) were studied. Gender, age, central corneal thickness, intraocular pressure, Octopus automated perimetry global indices (mean defect and loss variance) and several parameters of the color Doppler (peak systolic velocity and resistivity index) were compared between groups. RESULTS: There was no statistically significant difference in age, central corneal thickness and intraocular pressure. Discriminant analysis showed that the variables: resistivity index (RI) in the short posterior ciliary artery (SPCA), mean defect (MD) and loss variance (LV) had presented significant influence for the positive diagnosis of glaucoma. The gotten discriminant function was: -3.637 + 0.109 x MD + 0.028 x LV + 4.325 x RI SPCA. Considering score -1.61, the probability of positive diagnosis of glaucoma was 90 percent. CONCLUSION: Through discriminant analysis it was possible to identify which of the color Doppler variables that associated to the visual field variables allowed differentiate normal from glaucomatous patients. These variables were: resistivity index in the short posterior ciliary artery, and the visual field variables, mean defect and loss variance.

[Renin-angiotensin-aldosterone system (RAAS) and its pharmacologic modulation]. / Sistema renina-angiotensina-aldosterona e sua modulação farmacológica.

The renin-angiotensin-aldosterone system (RAAS) is a neuroendocrine complex system that regulates the modulation of salt and water homeostasis, and regulation of blood pressure. Through its multiple interactions it protects the endothelium, heart, brain and kidney. In addition, the RAAS regulates the vascular response to injury and inflammation. Chronic activation/dysregulation of the RAAS leads to hypertension and perpetuates a cascade of proinflammatory, prothrombotic and atherogenic effects associated with endorgan damage (heart, brain, kidney, endothelium). Consequently, the RAAS is an important therapeutic target in these situations. This article presents an overview of physiology, pathophysiology and pharmacologic modulation of the RAAS.

Análise discriminante dos pacientes portadores de glaucoma primário de ângulo aberto através do exame doppler colorido e do campo visual / Discriminant analysis of patients with primary open-angle glaucoma by color doppler exam and visual field

Objetivo: Identificar quais das variáveis obtidas com exame doppler colorido que, associadas às de campo visual, podem permitir discriminar olhos normais de glaucomatosos. Métodos: Realizou-se um estudo prospectivo de 36 pacientes portadores de glaucoma primário de ângulo aberto em uso de medicação antiglaucomatosa (grupo glaucoma) e 20 voluntários normais (grupo controle). Em ambos os grupos, apenas um olho de cada paciente foi escolhido de forma aleatória. Todos os pacientes foram submetidos a exame de acuidade visual, tonometria, oftalmoscopia, paquimetria ultra-sônica, perimetria computadorizada e análise do fluxo sangüíneo dos vasos retrobulbares através do aparelho doppler colorido. Analisou-se a distribuição dos grupos quanto ao sexo, idade, espessura corneana central, pressão intra-ocular (Po), índices globais da perimetria computadorizada ("mean defect" e "loss variance") e os diversos parâmetros do doppler colorido (velocidade sistólica máxima da artéria central da retina, índice de resistência da artéria central da retina e artéria ciliar curta posterior). Foram aplicados os testes t de Student e o teste exato de Fisher para as variáveis independentes. Para as variáveis que tinham informações que diferenciavam os grupos controle e glaucoma, empregou-se a análise discriminante. Resultados: Não houve diferença estatística entre os grupos em relação à idade (p=0,155) e a espessura corneana central (p=0,147). As médias da Po foram 17,2 ± 5,1 mmHg nos olhos dos pacientes do grupo glaucoma e 15,5 ± 2,6 mmHg no grupo controle (p=0,112). O "mean defect" (MD) médio do grupo controle foi de -0,6 ± 1,1 dB e 14,2 ± 8,1 dB no grupo glaucoma (p=0,001). O "loss variance" (LV) médio do grupo controle foi de 2 ± 1,1 dB e 23,8 ± 24,4 dB no grupo glaucoma (p=0,001). A média da velocidade sistólica máxima (VSM) da artéria central da retina (ACR) analisada através do doppler colorido foi 12,8 ± 2,8 cm/s no grupo glaucoma e 10,6 ± 3,3 cm/s no grupo controle (p=0,014). A média do índice de resistência (IR) da ACR do grupo glaucoma foi de 0,75 ± 0,1 e do grupo controle foi de 0,63 ± 0,03 (p=0,01). As médias do IR da artéria ciliar curta posterior (ACCP) no grupo glaucoma e no grupo controle foram, respectivamente, 0,67 ± 0,1 e 0,54 ± 0,03 (p=0,001)...