Influenza vaccination in older adults and patients with chronic disorders: A position paper from the Portuguese Society of Pulmonology, the Portuguese Society of Diabetology, the Portuguese Society of Cardiology, the Portuguese Society of Geriatrics and Gerontology, the Study Group of Geriatrics of the Portuguese Society of Internal Medicine, and the Portuguese Society of Infectious Diseases and Clinical Microbiology.

Influenza affects millions of people worldwide each year and can lead to severe complications, hospitalizations, and even death, especially among vulnerable populations such as older adults and those with chronic medical conditions. Annual vaccination is considered the most effective measure for preventing influenza and its complications. Despite the widespread availability of influenza vaccines, however, vaccination coverage rates remain suboptimal in several countries. Based on the latest scientific evidence and expert opinions on influenza vaccination in older people and patients with chronic disease, the Portuguese Society of Pulmonology (SPP), the Portuguese Society of Diabetology (SPD), the Portuguese Society of Cardiology (SPC), the Portuguese Society of Geriatrics and Gerontology (SPGG), the Study Group of Geriatrics of the Portuguese Society of Internal Medicine (NEGERMI-SPMI), and the Portuguese Society of Infectious Diseases and Clinical Microbiology (SPDIMC) discussed best practices for promoting vaccination uptake and coverage and drew up several recommendations to mitigate the impact of influenza. These recommendations focus on the efficacy and safety of available vaccines; the impact of influenza vaccination on older adults; patients with chronic medical conditions, namely cardiac and respiratory conditions, diabetes, and immunosuppressive diseases; and health care professionals, optimal vaccination timing, and strategies to increase vaccination uptake and coverage. The resulting position paper highlights the critical role that vaccinations play in promoting public health, raising awareness, and encouraging more people to get vaccinated.

3D-planned corrective osteotomy of metacarpal arch disruption after Motec® wrist prosthesis.

We report two cases of metacarpal arch disruption after Motec® total wrist arthroplasty, with hyperextension of the third metacarpal and dorsal protrusion of the head. Correction osteotomies of the adjacent metacarpals using preoperative 3D surgical planning were successful. This report seeks to shed light on the origin of this deformation and to recommend some operative precautions. It is important that surgeons should be aware of the existence of this complication, as disruption of the transverse metacarpal arch affects both grasp and hand esthetics. LEVEL OF EVIDENCE: IV.

Anakinra treatment of acute calcium deposits in hand and wrist.

Acute calcium deposit (ACD) in the hand and wrist is a cause of acute pain due to crystal-induced soft-tissue inflammation. There are no standard management guidelines for this condition, which is frequently treated with non-steroidal anti-inflammatory drugs (NSAIDs), with variable efficacy, some patients presenting symptoms for several months. We retrospectively analyzed the results of all patients treated with anakinra for hand or wrist ACD in our department in 2020. We extracted data on treatment duration, pain, range of motion, skin erythema, hypervascularization, edema, and X-ray findings. Ten patients were treated for hand or wrist ACD with anakinra 100 mg per day for a mean 2.7 days. We observed rapid and significant improvement in pain, range of motion, local erythema and edema from day 2 and a decrease in skin temperature from day 3. Calcifications significantly decreased in size or disappeared in the majority of the patients. There were no adverse events or recurrences at 1 year's follow-up. Anakinra was associated with significant clinical improvement after only two days' treatment and may be considered to treat patients with hand or wrist ACD, especially in case of contraindications to NSAIDs or glucocorticoids. Further controlled studies are needed to confirm the present observations.

Medullary Paracoccidioidomycosis Treated Successfully with Oral Itraconazole

Paracoccidioidomycosis is the most prevalent endemic mycosis in Latin America, with a great incidence in Brazil. Although a common disease, its medullary form is rare. We present a case report of medullary paracoccidioidomycosis presenting with subacute, progressive, spinal cord symptoms, and with multiple expansive lesions into the cervical and thoracic spinal cord. The patient was treated with itraconazole and showed good clinical and radiologic recovery upon six months of follow-up.

Paracoccidioidomicose é a micose endêmica de maior prevalência na America Latina, com grande incidência no Brasil. Apesar de comum, sua forma medular é rara. Apresentamos um relato de caso de paracoccidioidomicose medular apresentando sintomas subagudos e progressivos na medula, com múltiplas lesões expansivas na medula, cervical e torácica. O paciente foi tratado com itraconazole e apresentou melhora clínica e recuperação radiológica após seis meses.

Multiple Extracranial Metastases from a Rhabdoid Meningioma: A Case Report / Metástases Extracraniais Multiplas de um Meningioma Rabdóide: Relato de Caso

Meningiomas are among the most common intracranial primary tumors, and generally have a benign behavior. The incidence of extracranial metastasis of this pathology is low. There are different variants of them, with a wide variety of aggressiveness and potential tometastatic spread. Among themalignant meningiomas (1­3% of total), the rhabdoid variant is known for its aggressive biological and clinical behavior. It is also known that some histological subtypes are inherently prone to recur or spread, as the latter. In the latest World Health Organization classification, extracranial metastases are not currently considered a pathological criterion for malignancy, and, when present, they are most commonly found in the lung, liver, lymph nodes, and bone. Treatment is usually surgical resection of the metastases, but there is still no consensus about it. Owing to its poor prognosis, the rhabdoid subtype is commonly treated aggressively. Patients are submitted to local radiotherapy to prevent recurrence. Extracranial metastases of meningiomas are rare, but should always be remembered, especially in cases of local recurrence and malignant histology, as the rhabdoid variant. We report one case of extracranial metastases in a patient diagnosed with rhabdoid subtype of meningioma, and discuss the literature on this pathology.

Meningiomas estão entre os tumores intracranianos primários mais comuns, e geralmente possuem comportamento benigno. A incidência de metástases extracranianas desta patologia é baixa. Existem diversas variantes, com uma ampla variedade de agressividade e potencial para disseminação metastática. Entre os meningiomas malignos (1­3% do total), a variante rabdoide é conhecida por seu comportamento agressivo clínico e biológico. Também é sabido que alguns subtipos histológicos são propensos à recidiva e disseminação, como o supracitado. Na última classificação da Organização Mundial de Saúde, metástases extracranianas não são consideradas como critério patológico para malignidade, e, quando presentes, são geralmente encontradas nos pulmões, fígado, linfonodos e ossos. O tratamento é geralmente a ressecção cirúrgica das metástases, embora não há consenso. Devido ao seu prognóstico pobre, o subtipo rabdoide é comumente tratado de forma agressiva. Os pacientes são submetidos à radioterapia local para prevenção de recidivas. As metástases extracranianas de meningiomas são raras, mas sempre devem ser consideradas, especialmente em casos com recidiva local e histologia maligna, como a variante rabdoide. Relatamos um caso de metástases extracranianas em um paciente com o subtipo rabdoide de meningioma, e discutimos a literatura a seu respeito.

Mortalidad en las primeras 48 horas del ingreso en un servicio de cirugía general y digestiva / Mortality in the first 4s hours of income in a general service and difestive surgery

Objetivo: Identificar las características clínicas y epidemiológicas de los pacientes quirúrgicos fallecidos dentro de las primeras 48 horas, parámetro considerado como "centinela" de la calidad asistencial en cirugía. Materiales y Método: Estudio observacional descriptivo y retrospectivo de los pacientes fallecidos antes de las 48 horas siguientes al ingreso en una planta de cirugía general y digestiva, durante el periodo comprendido entre enero del 2002 y diciembre del 2011. Se recogen variables demográficas, forma y diagnostico de ingreso, morbilidad asociada, riesgo quirúrgico y la actitud terapéutica. Excluimos a los pacientes fallecidos por traumatismos. Resultados: Desde enero del 2002 hasta diciembre del 2011 se realizaron 48716 ingresos, de los cuales fallecieron 417 pacientes (0,85%), de éstos, 28 pacientes fallecieron en las primeras 48 horas del ingreso (0,05%). La media de edad de éstos pacientes fue de 81 años (55-94), sin predominio de sexo. El 96% de los fallecidos provenían de ingresos de urgencias. La causa principal de muerte fue isquemia mesentérica aguda. El 89% de los pacientes presentaba alguna comorbilidad severa. El 75% de los fallecimientos se produjeron en los primeros 5 años del periodo estudiado. Conclusión: La mortalidad quirúrgica temprana se encuentra ligada a pacientes de edad avanzada, frágiles y a cirugía urgente. La excepcionalidad de la mortalidad postoperatoria temprana y la tipología de pacientes que la presentan, hace que este dato tenga escaso valor como criterio de calidad asistencial. En los últimos años ha disminuido el número de estas muertes lo que puede tener varias explicaciones

Aim: Early surgical mortality within the first 48 hours is a parameter used as "sentinel" of quality in surgery, so it is important to identify its clinical and epidemiological characteristics. Materials and Methods: We performed a descriptive, retrospective, observational study including patients who died within 48 hours of admission at a plant in general and digestive surgery, during the period between January 2002 and December 2011. Demographic variables were collected, mode of admission and diagnosis, comorbidity, surgical risk and therapeutic approach. We excluded patients who died of trauma. Results: From January 2002 to December 2011 were carried out 48,716 income, of which 417 patients died (0.85%) and 28 patients died within 48 hours of admission (0.057%). The average age of these patients was 81 years (55-94), there was no predominance of sex. 96% of those died within the first 48 hours had an emergency admission. The cause of death in half of the cases was acute mesenteric ischemia. 89,% of patients had a severe comorbidity (ASA III - IV). 75% of deaths occurred in the first 5 years of the study period. Conclusion: Early surgical mortality is linked to elderly patients with poor baseline health and emergency surgery. This uniqueness of early postoperative mortality and the type of patients who present it, makes this data of little value as a criterion of quality of care. The reduced early mortality in the most recent years may have several explanations

Parálisis bilateral del III par craneal con afectación pupilar como primera manifestación de esclerosis múltiple / Bilateral third nerve palsy with pupil involvement as the first manifestation of multiple sclerosis

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Implantable cardioverter-defibrillator: beyond efficacy.

OBJECTIVES: The introduction of the implantable cardioverter-defibrillator was a very important advance in the treatment of malignant ventricular arrhythmias. However, its use is associated with some possible adverse events, which should be taken into consideration when a patient is proposed for implantation. These complications may occur early after implantation and be associated with the procedure itself, or they may be late complications, usually associated with the device or the arrhythmia. It was our objective to assess the incidence of these complications in our population of patients. POPULATION AND METHODS: We describe the complications found in 98 patients (55.9 +/- 13.9 years, 89% male) with an implantable cardioverter-defibrillator and compare our results with the incidence of complications described by other authors. RESULTS: We found complications associated with the presence of the implantable cardioverter-defibrillator in 32% of patients. The most frequent complication was inappropriate shocks in 13%. The presence of infection was detected in 4%, lead insulation faults in 5%, need for lead extraction in 2%, repositioning in 1% and re-establishment of the connection with the generator in 2%. In 5% of patients, there was inefficacy of the device, 3% due to non-detected ventricular tachycardias (slow tachycardias) and 2% due to electrical storms. There was syncope in 2% of patients. The total mortality in a 2.9 +/- 1.9 year follow-up was 13% (sudden death in 3%). CONCLUSIONS: Major complications associated with implantable cardioverter-defibrillators were in our experience relatively rare, our results agreeing with those of other centers.

[Constrictive pericarditis: an early diagnosis?]. / Pericardite constritiva: um diagnóstico precoce?

The authors report a case study of a 73-year-old male, with signs of right-sided heart failure with 6 months of evolution. It was constrictive pericarditis, without radiologic, echocardiographic and magnetic resonance imaging manifestations, diagnosed on the basis of the clinical situation and hemodynamic evaluation during cardiac catheterization. The authors suggest that the lack of imagiologic manifestations might have been the result of an early diagnosis, before the development of the classic picture. Pericardiectomy, performed with success, was followed by resolution of the heart failure. It was not possible, histologically, to draw conclusions about the etiology. The development of mitral regurgitation after pericardiectomy has enriched this case with an unusual, but previously described, complication of this type of surgery.

Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device.

OBJECTIVE: Atrial fibrillation has been a difficult problem to solve in many surgical patients, especially in those with mitral valve pathology. This study evaluates the results of endocardial and epicardial radiofrequency ablation with a new intra-operative device in the treatment of atrial fibrillation. METHODS: We operated on 65 patients with atrial fibrillation, 58 of which had concomitant mitral surgery. Atrial fibrillation was chronic (over 1 year) in 46 patients (group A) and paroxysmal or recent onset in 12 (group B). Group C had lone atrial fibrillation (two), concomitant coronary artery disease (four) or a sarcoma (one). Bilateral pulmonary vein isolation with a new intra-operative device was performed through multiple dry lesions in all patients. Groups A and B had endocardial applications at 70 degrees C during 60 s and group C had epicardial applications at 75 degrees C. Three group C patients had epicardial applications off pump. Atrial wall biopsies were performed in nine patients from groups A and B. RESULTS: There were no serious post-operative complications. At 1 month follow-up 54% of all patients were out of atrial fibrillation and 34% were in normal sinus rhythm with bilateral atrial contraction (Santa Crus Score 4). At 6 months follow-up, in spite of some crossover of patients among groups, similar results were obtained. The success of the procedure was 69% (Santa Crus scores 3 and 4) in mitral patients with a left atrial volume smaller than 200 cm(3). Preliminary data on the transmurality of the lesions is presented. The patients submitted to epicardial radiofrequency ablation (group C) have satisfactory results at 1 month (six out of seven were out of AF). CONCLUSIONS: Both endocardial and epicardial RF applications are simple and quick to perform and do not pose an additional risk for most patients. Furthermore we believe that it is possible to perform bilateral epicardial radiofrequency ablation of the pulmonary veins without cardiopulmonary bypass. Further refinements of the technique are needed to assure transmurality of all lesions and better results.

Prognostic value of cardiac troponin I release kinetics in unstable angina.

BACKGROUND: Cardiac Troponins (cTn) are useful in unstable angina (UA). Moreover the different elevation patterns that can be observed in this condition seem to have different prognostic implications. AIM: To study cTn kinetics and cTn nadir in patients with UA, defined as angina at rest within the last 24 hours before admission accompanied by ischemic ECG changes and no myocardial infarction (MI) enzymatic criteria. POPULATION AND METHODS: Samples were collected from 156 patients for cardiac enzymes and cTnI at admission and at 6, 12, 18 and 24 hours. The chemilluminescence method (Access/Sanofi Pasteur) was used for cTnI. The primary end-point at 30 days was the combined occurrence of death, MI and recurrent ischemia. RESULTS: All determinations were below 0.10 ng/ml (group N) in 114 patients and the other 42 pts (group P) had at least one value equal to or above 0.10 ng/ml. The primary endpoint was observed in 24.6% of group N pts compared with 45.2% of group P pts (p = 0.02). Three different patterns of cTnI kinetics were observed. This enabled the identification of a subgroup--group N pts with increasing cTnI values within the first 12 hours and a total differential value > or = 0.03 ng/ml--with an increased risk (50.0% versus 21.4%--p = 0.02--Kaplan-Meier test). CONCLUSION: Besides the prognostic value conferred by cTnI elevation, cTnI kinetics analysis established another sub-group of patients with an adverse prognosis at 30 days follow-up, despite having a negative cTnI.

[Acute megaloblastic anemia caused by inhalation of nitrous oxide in a patient with multiple autoimmune pathology]. / Anemia megaloblástica aguda por inalação de óxido nitroso em doente com patologia autoimune múltipla.

Although megaloblastic anemias are generally regarded as chronic conditions of insidious appearance, a megaloblastic state can arise over the course of only a few days due to acute folate or vitamin B12 deficiency. One of the most common causes, though seldom reported, is the nitrous oxide (N02) action in tissue. In fact N02, a volatile substance commonly used in anaesthesia, destroys methylcobalamin, leading to the rapid development of a megaloblastic haematopoiesis. This phenomenon may occur in patients without previous vitamin B12 deficit, but is more frequent and severe when there is a pre-existent deficiency state. A case report is described of a patient with femoral fracture who developed acute anemia after surgery and a latent pernicious anemia was revealed upon investigation.