From Gut to Heart: A Case Report of Infectious Endocarditis Stemming From Cholecystitis-Induced Enterococcus faecium Bacteremia.

Systemic infections are not always going to present as we expect. The study of bacteremia and febrile syndrome represents one of the most important diagnostic challenges nowadays. This case demonstrates the importance of a multidisciplinary approach and finding a common point that explains all the patient's symptoms, no matter how disconnected they may seem. Here, we present the case of a patient where multiple treatments were performed to manage recurrent infective endocarditis due to Enterococcus faecium but the cause of this persistence was never found despite surgical management. With only a few cases reported in literature involving this pathogen, it is of great importance to emphasize how searching for a natural reservoir, such as the gallbladder, for this pathogen helped solve the diagnostic mystery that this patient represented. Here, we present how the culture of biological materials, such as the aortic valve replacement, as well as blood cultures, made it possible to identify the etiological agent associated with the pathology and, in turn, find the cause of recurrent bacteremia.

Clinical Risk Factors for Mortality Among Critically Ill Mexican Patients With COVID-19.

Little literature exists about critically ill patients with coronavirus disease 2019 (COVID-19) from Latin America. Here, we aimed to describe the clinical characteristics and mortality risk factors in mechanically ventilated COVID-19 patients from Mexico. For this purpose, we recruited 67 consecutive mechanically ventilated COVID-19 patients which were grouped according to their clinical outcome (survival vs. death). Clinical risk factors for mortality were identified by machine-learning and logistic regression models. The median age of participants was 42 years and 65% were men. The most common comorbidity observed was obesity (49.2%). Fever was the most frequent symptom of illness (88%), followed by dyspnea (84%). Multilobe ground-glass opacities were observed in 76% of patients by thoracic computed tomography (CT) scan. Fifty-two percent of study participants were ventilated in prone position, and 59% required cardiovascular support with norepinephrine. Furthermore, 49% of participants were coinfected with a second pathogen. Two-thirds of COVID-19 patients developed acute kidney injury (AKIN). The mortality of our cohort was 44.7%. AKIN, uric acid, lactate dehydrogenase (LDH), and a longitudinal increase in the ventilatory ratio were associated with mortality. Baseline PaO2/FiO2 values and a longitudinal recovery of lymphocytes were protective factors against mortality. Our study provides reference data about the clinical phenotype and risk factors for mortality in mechanically ventilated Mexican patients with COVID-19.

Prolonged Intermittent Renal Replacement Therapy for Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome.

INTRODUCTION: Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI. METHODS: We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose. RESULTS: We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36-73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7-14) days. The median of PIRRT procedures for each patient was 5 (IQR 4-9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4-28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3-12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented. CONCLUSIONS: PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.

[Purpura due to Strongyloides stercoralis in an immunocompetent patient]. / Púrpura por Strongyloides stercoralis en un paciente inmunocompetente.

Infection with Strongyloides stercoralis is a common parasitic infection in tropical and subtropical regions, including the Peruvian Amazon. The clinical manifestations are varied in patients with immunocompromised disease, and the systemic spread of the disease is frequent, compromising different organs and systems. Cutaneous manifestations are infrequent, being described in patients with some degree of immunosuppression. We present the case of an immunocompetent patient who developed a reactive purpura due to chronic Strongyloides stercoralis infection. Thus, skin involvement is possible in immunocompetent patients with systemic exacerbation due to this parasite.

Púrpura por Strongyloides stercoralis en un paciente inmunocompetente / Purpura due to Strongyloides stercoralis in an immunocompetent patient

Resumen La infección por Strongyloides stercoralis es una parasitosis frecuente en las regiones tropicales y subtropicales, incluyendo la Amazonía peruana. En pacientes con inmunocompromiso, las manifestaciones clínicas son variadas y es frecuente la diseminación sistémica de la enfermedad, con compromiso de diversos órganos. Las manifestaciones cutáneas son infrecuentes y se describen en pacientes con algún grado de inmunosupresión. Se presenta el caso de un paciente inmunocompetente que desarrolló una púrpura reactiva por una infección por Strongyloides stercoralis crónica. Ante ello, es posible el compromiso cutáneo en pacientes inmunocompetentes con reagudización sistémica por este parásito.

Infection with Strongyloides stercoralis is a common parasitic infection in tropical and subtropical regions, including the Peruvian Amazon. The clinical manifestations are varied in patients with immunocompromised disease, and the systemic spread of the disease is frequent, compromising different organs and systems. Cutaneous manifestations are infrequent, being described in patients with some degree of immunosuppression. We present the case of an immunocompetent patient who developed a reactive purpura due to chronic Strongyloides stercoralis infection. Thus, skin involvement is possible in immunocompetent patients with systemic exacerbation due to this parasite.

Design and implementation of a control structure for quality products in a crude oil atmospheric distillation column.

In recent years, interest for petrochemical processes has been increasing, especially in refinement area. However, the high variability in the dynamic characteristics present in the atmospheric distillation column poses a challenge to obtain quality products. To improve distillates quality in spite of the changes in the input crude oil composition, this paper details a new design of a control strategy in a conventional crude oil distillation plant defined using formal interaction analysis tools. The process dynamic and its control are simulated on Aspen HYSYS® dynamic environment under real operating conditions. The simulation results are compared against a typical control strategy commonly used in crude oil atmospheric distillation columns.

Sleep architecture in children and adolescents with cystic fibrosis and the association with severity of lung disease.

Previous studies have shown that sleep complaints are common in adult patients with cystic fibrosis (CF). However, there is very little data on sleep in children and adolescents with CF and the association with severity of lung disease. A prospective study was conducted in CF children and age-matched controls. All patients completed sleep questionnaire and underwent an overnight polysomnographic study. Thirty-eight children and adolescents met the criteria for entry into the analysis, 24 children and adolescents with CF (S) and 14 controls (C). Sleep complaints were common in children and adolescents with CF; 43.5% reported sleep onset problem, 39.1% reported sleep maintenance problem, 30.4% were noted to snore at night, and 73.9% reported daytime sleepiness. Children and adolescents with CF had a significant decrease in sleep efficiency [SE; 75.2 +/- 2.5% (S) vs 85.6 +/- 1.7%(C); P < 0.01], prolonged rapid eye movement (REM) latency [150.5 +/- 16.6 min (S) vs 85.6 +/- 11.0 min (C); P < 0.05], and reduction in percentage of REM sleep [12.7 +/- 1.5% (S) vs 18.3 +/- 1.3% (C); P < 0.05]. The degree of sleep disruption as indicated by SE was correlated with forced expiratory volume in one second (FEV(1); r = 0.52, P < 0.05). However, there was no significant correlation between SE and minimum oxygen saturation [r = 0.30, P=not significant (NS)] or SE and maximal end-tidal pCO(2) (r = 0.11, P=NS). It is concluded that children and adolescents with CF have frequent sleep complaints and significant alteration in the sleep architecture. The magnitude of sleep disruption is associated with severity of lung disease, but is not directly correlated with the degree of nocturnal hypoxemia or hypoventilation. It is speculated that sleep disruption in children and adolescents with CF may have an impact on quality of life and clinical outcomes in this population.