Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis.

OBJECTIVES: During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19. METHODS: We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS: A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION: APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.

Conjunctival melanoma following cornea transplant from a cancer donor: A case report.

Purpose: Conjunctival melanoma is a rare ocular tumor. We report a case of ocular conjunctival melanoma during topical immunosuppression, after a corneal transplant from a donor with metastatic melanoma. Observation: A 59-year-old white male presented with a progressive nonpigmented conjunctival lesion in his right eye. He had previously undergone two penetrating keratoplasties, and he was being treated with topical immunosuppression with 0.03% tacrolimus (Ophthalmos Pharma; Sao Paulo, SP/Brazil). The histopathology evaluation revealed the nodule to be a conjunctival epithelioid melanoma. The donor's death cause was disseminated melanoma. Conclusion and importance: The correlation between cancer and systemic immunosuppression after a solid organ transplant is widely known. The local influence, however, has not been reported. In this case, a causal relationship was not established. The correlation between conjunctival melanoma, exposure to topical tacrolimus immunosuppressive therapy, and the malignance characteristic of donor cornea should be better evaluated.

COVID-19-Associated Pulmonary Aspergillosis in a Series of Complete Autopsies from the Brazilian Amazon.

Between April and July 2020, and, therefore, prior to the broad recommendation of corticosteroids for severe COVID-19, a total of 50 full autopsies were performed in Manaus. We confirmed two invasive cases of aspergillosis through histopathology and gene sequencing (4%) in our autopsy series. The confirmed invasive aspergillosis incidence seems much lower than expected based on the "probable and possible" definitions, and an individualized approach should be considered for each country scenario. Interestingly, a prolonged length of stay in the intensive care unit was not observed in any of the cases. Timely diagnosis and treatment of fungal infection can reduce mortality rates.

Corneal Graft Rejection After Inactivated SARS-CoV-2 Vaccine: Case Report.

PURPOSE: Our aim was to report the case of endothelial corneal allograft rejection after inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine with an atypical presentation. METHODS: This was a case report. RESULTS: A 63-year-old woman with previous penetrating keratoplasty and laser in situ keratomileusis presented with clinical signs of endothelial corneal graft rejection 24 hours after CoronaVac (SinoVac Biotech, Beijing/China) vaccine. Slitlamp examination showed corneal edema and interface fluid accumulation. It was partially resolved after treatment with topical corticosteroids and polydimethylsiloxane. CONCLUSIONS: Corneal allograft rejection was already reported after another SARS-CoV-2 vaccine. This is the first report in the literature describing a possible association with inactivated SARS-CoV-2 vaccine and corneal allograft rejection, especially with laser in situ keratomileusis interface fluid accumulation presentation. Ophthalmologists should be aware of this potential complication.

Correção cirúrgica monocular em exotropias de grande ângulo: estudo de casos / Monocular surgical correction in wide-angle exotropias: case studies

Estrabismo consiste em uma enfermidade oftalmológica de alta prevalência na população mundial. A correção cirúrgica binocular, técnica que envolve a abordagem de três a quatro músculos extraoculares, é amplamente utilizada na terapêutica dos estrabismos de grande ângulo. Entretanto, a cirurgia monocular, realizada a partir de recuos e ressecções de maior amplitude, quando aplicada em pacientes amblíopes, possui importantes vantagens em relação à técnica binocular, tais como a preservação do olho dominante e a redução do tempo da cirurgia. Neste estudo, são descritos quatro casos de pacientes amblíopes portadores de exotropia de grande ângulo submetidos à correção cirúrgica monocular. Os pacientes apresentaram desvios oculares prévios equivalentes a 60, 65, 70 e 80 dioptrias prismáticas (Δ). Todos foram submetidos à cirurgia de recuo-ressecção através de recuo mínimo de 8 milímetros (mm) em músculo reto lateral e ressecção mínima de 9 mm em reto medial. Após três meses de acompanhamento, um paciente apresentou-se ortotrópico, enquanto os demais apresentaram desvios residuais de 10 a 12 (Δ). Observou-se limitação na abdução ocular no pós-operatório inicial de dois pacientes. Nenhum paciente apresentou restrição ao teste das versões e duções após três meses de acompanhamento. A cirurgia de recuo-ressecção monocular tem determinado importante relevância no tratamento dos estrabismos horizontais de grande ângulo, mostrando-se uma opção cirúrgica clinicamente factível. Contudo, deve-se estar atento às possíveis complicações que podem relacionar-se à maior amplitude das intervenções musculares (AU)

Strabismus is an ophthalmologic disease of high prevalence in the world population. Binocular surgical correction, a technique that involves approaching three to four extraocular muscles, is widely used in the treatment of wide-angle strabismus. However, monocular surgery, performed from wider recoils and resections, when applied to amblyopic patients, has important advantages over the binocular technique, such as preservation of the dominant eye and reduction of surgery time. In this study, four cases of amblyopia patients with large angle exotropia submitted to monocular surgical correction are described. The patients had previous ocular deviations equivalent to 60, 65, 70 and 80 prismatic diopters. All patients underwent recoil-resection surgery with minimal recoil of 8 mm in the lateral rectus muscle and minimal resection of 9 mm in the medial rectus. After three months of follow-up, one patient was orthoptic, while the others had residual deviations of 10 to 12 diopters. Limitation of ocular abduction in the initial postoperative period was observed in two patients. No patient had a restriction on the test of the versions and ductions after three months of follow-up. The monocular recoil-resection surgery has acquired an important relevance in the treatment of horizontal wide-angle strabismus, proving to be a clinically feasible surgical option. However, one should be aware of the possible complications that may be related to the greater amplitude of the muscular interventions (AU)

Electrophysiological Studies and Radiofrequency Ablations in Children and Adolescents with Arrhythmia / Estudos Eletrofisiológicos e Ablações com Radiofrequência em Crianças e Adolescentes com Arritmia

Background: Radiofrequency ablation is the standard non-pharmacological treatment for arrhythmias in pediatric patients. However, arrhythmias and their associated causes have particular features in this population. Objective: To analyze the epidemiological characteristics and findings of electrophysiological diagnostic studies and radiofrequency ablations in pediatric patients referred to the Electrophysiology Unit at Instituto de Cardiologia do Rio Grande do Sul, in order to characterize the particularities of this population. Methods: Cross-sectional study with 330 electrophysiological procedures performed in patients aged less than 20 years between June 1997 and August 2013. Results: In total, 330 procedures (9.6% of the overall procedures) were performed in patients aged less than 20 years (14.33 ± 3.25 years, age range 3 months to 19 years), 201 of which were males (60.9%). A total of 108 (32.7%) electrophysiological diagnostic studies were performed and of these, 48.1% showed abnormal findings. Overall, 219 radiofrequency ablations were performed (66.3%) with a success rate of 84.8%. The presence of an accessory pathway was the most prevalent finding, occurring in 158 cases (72.1%), followed by atrioventricular nodal reentrant tachycardia (16.8%), typical atrial flutter (3.1%) and extrasystoles originating from the right ventricular outflow tract (2.7%). Three patients developed complications during ablation (1.4%). Among congenital heart diseases, which occurred in 51 (15.4%) patients, atrial sept defect was the most frequent (27.4%), followed by ventricular sept defect (25.4%) and Ebstein's anomaly (17.6%). Conclusion: Electrophysiological study and radiofrequency ablation are effective tools for diagnosis and treatment of arrhythmias in the pediatric population. .

Fundamento: A ablação com radiofrequência é o tratamento não farmacológico de eleição para arritmias na população pediátrica. Porém, as arritmias e suas causas apresentam características particulares nesta população. Objetivos: Analisar as características epidemiológicas e os achados de estudo eletrofisiológico diagnóstico e ablação com radiofrequência na população pediátrica encaminhada à Eletrofisiologia do Instituto de Cardiologia do Rio Grande do Sul, a fim de caracterizar as suas particularidades. Resultados: Foram realizados 330 procedimentos (9,6% do total de procedimentos) em pacientes com idade inferior a 20 anos (14,33 ± 3,25 anos, variação entre 3 meses e 19 anos), dos quais 201 eram do sexo masculino (60,9%). Foram realizados 108 (32,7%) exames eletrofisiológicos diagnósticos e destes, 48,1% apresentaram anormalidades em seus achados. Ao todo, 219 ablações com radiofrequência foram realizadas (66,3%), obtendo-se sucesso em 84,8%. A presença de feixe acessório foi o achado mais prevalente, responsável por 158 casos (72,1%), seguida de taquicardia por reentrada nodal atrioventricular (16,8%), flutter atrial típico (3,1%) e extrassístole de via de saída de ventrículo direito (2,7%). Três pacientes apresentaram complicações durante a ablação (1,4%). Cardiopatia congênita esteve presente em 51 (15,4%) casos, sendo a comunicação interatrial a mais encontrada (27,4%), seguida de comunicação interventricular (25,4%) e anomalia de Ebstein (17,6%). Conclusão: Estudo eletrofisiológico e ablação com radiofrequência constituem ferramentas eficazes no diagnóstico e tratamento das arritmias na população pediátrica. .

Electrophysiological studies and radiofrequency ablations in children and adolescents with arrhythmia.

BACKGROUND: Radiofrequency ablation is the standard non-pharmacological treatment for arrhythmias in pediatric patients. However, arrhythmias and their associated causes have particular features in this population. OBJECTIVE: To analyze the epidemiological characteristics and findings of electrophysiological diagnostic studies and radiofrequency ablations in pediatric patients referred to the Electrophysiology Unit at Instituto de Cardiologia do Rio Grande do Sul, in order to characterize the particularities of this population. METHODS: Cross-sectional study with 330 electrophysiological procedures performed in patients aged less than 20 years between June 1997 and August 2013. RESULTS: In total, 330 procedures (9.6% of the overall procedures) were performed in patients aged less than 20 years (14.33 ± 3.25 years, age range 3 months to 19 years), 201 of which were males (60.9%). A total of 108 (32.7%) electrophysiological diagnostic studies were performed and of these, 48.1% showed abnormal findings. Overall, 219 radiofrequency ablations were performed (66.3%) with a success rate of 84.8%. The presence of an accessory pathway was the most prevalent finding, occurring in 158 cases (72.1%), followed by atrioventricular nodal reentrant tachycardia (16.8%), typical atrial flutter (3.1%) and extrasystoles originating from the right ventricular outflow tract (2.7%). Three patients developed complications during ablation (1.4%). Among congenital heart diseases, which occurred in 51 (15.4%) patients, atrial sept defect was the most frequent (27.4%), followed by ventricular sept defect (25.4%) and Ebstein's anomaly (17.6%). CONCLUSION: Electrophysiological study and radiofrequency ablation are effective tools for diagnosis and treatment of arrhythmias in the pediatric population.

Risco da radiação ionizante em mulheres férteis submetidas à ablação por radiofrequência / Risk of ionizing radiation in women of childbearing age undergoing radiofrequency ablation

FUNDAMENTO: A Comissão Internacional de Radiologia indica rastreamento com teste de gravidez a todas pacientes do gênero feminino em período fértil que serão submetidas a exame radiológico. Sabe-se que a radiação é teratogênica e que seu efeito é cumulativo. O potencial teratogênico inicia-se com doses próximas às das utilizadas durante esses procedimentos. Não se sabe a prevalência de teste de gravidez positivo em pacientes submetidos a estudo eletrofisiológico e/ou à ablação por cateter em nosso meio. OBJETIVO: Avaliar a prevalência de teste de gravidez positivo em pacientes do gênero feminino encaminhadas para estudo eletrofisiológico e/ou ablação por radiofrequência. MÉTODOS: Estudo transversal com análise de 2.966 pacientes submetidos a estudo eletrofisiológico e/ou ablação por cateter, de junho 1997 a fevereiro 2013, no Instituto de Cardiologia do Rio Grande do Sul. Foram realizados 1.490 exames em mulheres sendo que, destas, 769 encontravam-se em idade fértil. Todas as pacientes foram rastreadas com teste de gravidez no dia anterior ao procedimento. RESULTADOS: Detectou-se positividade do teste em três pacientes, impossibilitando a realização do exame. Observou-se prevalência de 3,9 casos por 1.000 mulheres em idade fértil. CONCLUSÃO: Devido ao baixo custo e à segurança, indica-se a realização de teste de rastreamento para gravidez a todas pacientes em idade fértil, uma vez que o grau de radiação ionizante necessária nesse procedimento é muito próximo ao limiar de teratogenicidade, principalmente no primeiro trimestre, quando os sinais de gestação não são exuberantes.

BACKGROUND: The International Commission of Radiology recommends a pregnancy screening test to all female patients of childbearing age who will undergo a radiological study. Radiation is known to be teratogenic and its effect is cumulative. The teratogenic potential starts at doses close to those used during these procedures. The prevalence of positive pregnancy tests in patients undergoing electrophysiological studies and/or catheter ablation in our midst is unknown. OBJECTIVE: To evaluate the prevalence of positive pregnancy tests in female patients referred for electrophysiological study and/or radiofrequency ablation. METHODS: Cross-sectional study analyzing 2966 patients undergoing electrophysiological study and/or catheter ablation, from June 1997 to February 2013, in the Institute of Cardiology of Rio Grande do Sul. A total of 1490 procedures were performed in women, of whom 769 were of childbearing age. All patients were screened with a pregnancy test on the day before the procedure. RESULTS: Three patients tested positive, and were therefore unable to undergo the procedure. The prevalence observed was 3.9 cases per 1000 women of childbearing age. CONCLUSION: Because of their safety and low cost, pregnancy screening tests are indicated for all women of childbearing age undergoing radiological studies, since the degree of ionizing radiation needed for these procedures is very close to the threshold for teratogenicity, especially in the first trimester, when the signs of pregnancy are not evident.

Risk of ionizing radiation in women of childbearing age undergoing radiofrequency ablation.

BACKGROUND: The International Commission of Radiology recommends a pregnancy screening test to all female patients of childbearing age who will undergo a radiological study. Radiation is known to be teratogenic and its effect is cumulative. The teratogenic potential starts at doses close to those used during these procedures. The prevalence of positive pregnancy tests in patients undergoing electrophysiological studies and/or catheter ablation in our midst is unknown. OBJECTIVE: To evaluate the prevalence of positive pregnancy tests in female patients referred for electrophysiological study and/or radiofrequency ablation. METHODS: Cross-sectional study analyzing 2966 patients undergoing electrophysiological study and/or catheter ablation, from June 1997 to February 2013, in the Institute of Cardiology of Rio Grande do Sul. A total of 1490 procedures were performed in women, of whom 769 were of childbearing age. All patients were screened with a pregnancy test on the day before the procedure. RESULTS: Three patients tested positive, and were therefore unable to undergo the procedure. The prevalence observed was 3.9 cases per 1000 women of childbearing age. CONCLUSION: Because of their safety and low cost, pregnancy screening tests are indicated for all women of childbearing age undergoing radiological studies, since the degree of ionizing radiation needed for these procedures is very close to the threshold for teratogenicity, especially in the first trimester, when the signs of pregnancy are not evident.

Glioblastoma multicêntrico originado em dois locais incomuns: cerebelo e tálamo / Multicentric glioblastoma arising in two unusual sites: cerebellum and thalamus

Multicentric glioblastomas (MGBM) arising in infra/supratentorial regions are uncommon lesions. The authors report a case of MGBM in a 61 year-old female patient, who presented a sudden onset of left hemiplegia. The magnetic resonance imaging (MRI) showed two expansive large lesions affecting cerebellum and thalamus, with strong contrast enhancement. The patient underwent resection of the cerebellar lesion. Microscopy revealed a high grade glial neoplasm exhibiting high mitotic index, areas of necrosis and microvascular proliferation. The neoplastic cells showed positive immunoexpression for glial fibrillary acidic protein (GFAP). The morphological findings were consistent with glioblastoma (GBM). The patient was referred to radiotherapy, with discrete signs of tumor regression after a 60-day clinical follow-up.

Glioblastomas multicêntricos (GBMM) originados em regiões infra/supratentoriais são lesões incomuns. Os autores relatam um caso de GBMM em paciente do sexo feminino, 61 anos de idade, que apresenta quadro súbito de hemiplegia esquerda. O exame de ressonância magnética (RM) mostrou duas lesões expansivas volumosas, com forte impregnação pelo contraste no cerebelo e no tálamo. A paciente foi submetida à ressecção da lesão cerebelar. À microscopia, foi identificada uma neoplasia glial de alto grau exibindo alto índice mitótico, áreas de necrose e proliferação microvascular. As células neoplásicas revelaram imunoexpressão positiva para proteína glial acídica (GFAP). O conjunto das alterações morfológicas foi consistente com glioblastoma. A paciente foi encaminhada para radioterapia, com sinais discretos de regressão tumoral após acompanhamento clínico de 60 dias.

Incidence of tracheal aspiration in tracheotomized patients in use of mechanical ventilation / Incidência de aspiração traqueal em pacientes traqueostomizados em uso de ventilação mecânica

Context: Many patients in use of mechanical ventilation show clinical complications due to tracheal aspiration. Assessment and early methods are necessary, so that preventive and safety measures apply to this patients Objective: To study the incidence of tracheal aspiration of saliva in tracheotomized patients treated in intensive care unit using two modes of mechanical ventilation and with different sedation levels. Method: Prospective study with 14 tracheotomized non-neurological patients using mechanical ventilation. The sample was divided into two groups based on ventilation mode: pressure support ventilation and pressure controlled ventilation. Those two groups were subdivided into two others according to sedation level. The speech pathology evaluation was completed via the blue dye test in order to analyze the incidence of tracheal aspiration of saliva. Results: Sedation levels and mechanical ventilation time related to tracheal aspiration were not statistically significant in this study. On the other hand, ventilation mode and tracheal aspiration showed statistical significance, and there was a higher incidence of tracheal aspiration in the pressure controlled ventilation mode. Conclusion: It was possible to observe a significant relationship between tracheal aspiration incidence and pressure controlled ventilation mode, which means the inclusion of those patients in the risk group for oropharyngeal dysphagia and their insertion in prevention protocols. The relationship between tracheal aspiration and sedation level, as well as tracheal aspiration and mechanical ventilation, were not statistically significant in this sample, needing further research.

Contexto: Muitos pacientes em uso de ventilação mecânica apresentam complicações clínicas por apresentarem aspiração traqueal. Métodos de avaliação e detecção precoce são necessários para que medidas preventivas e de segurança se estabeleçam nessa população. Objetivo: Pesquisar a incidência de aspiração traqueal de saliva em indivíduos traqueostomizados internados em unidades de terapia intensiva fazendo uso de dois modos de ventilação mecânica e com diferentes níveis de sedação. Método: Estudo prospectivo realizado com 14 pacientes não-neurológicos traqueostomizados em uso de ventilação mecânica. A amostra foi dividida em dois grupos baseada nos modos ventilatórios: ventilação por pressão de suporte e ventilação por pressão controlada. Estes dois grupos foram subdivididos em dois subgrupos, de acordo com o nível de sedação. Foi feita a avaliação fonoaudiológica por meio do teste de anilina culinária azul, a fim de analisar a incidência da aspiração traqueal de saliva. Resultados: O nível de sedação e tempo de ventilação mecânica em relação à aspiração traqueal não foram estatisticamente significantes nesse estudo. Já a relação entre modo ventilatório e aspiração traqueal apresentou significância estatística, sendo que houve incidência maior de aspiração traqueal no modo ventilação por pressão controlada. Conclusão: Pôde-se observar relação significativa entre a incidência da aspiração traqueal e o modo ventilatório ventilação por pressão controlada, o que pode implicar na inclusão desses pacientes no grupo de risco para disfagia orofaríngea e sua inserção nos protocolos de prevenção. A relação entre aspiração traqueal e níveis de sedação, bem como aspiração traqueal e tempo de ventilação mecânica não foram estatisticamente significantes nessa amostra, necessitando de futuros estudos.

Incidence of tracheal aspiration in tracheotomized patients in use of mechanical ventilation.

CONTEXT: Many patients in use of mechanical ventilation show clinical complications due to tracheal aspiration. Assessment and early methods are necessary, so that preventive and safety measures apply to this patients. OBJECTIVE: To study the incidence of tracheal aspiration of saliva in tracheotomized patients treated in intensive care unit using two modes of mechanical ventilation and with different sedation levels. METHOD: Prospective study with 14 tracheotomized non-neurological patients using mechanical ventilation. The sample was divided into two groups based on ventilation mode: pressure support ventilation and pressure controlled ventilation. Those two groups were subdivided into two others according to sedation level. The speech pathology evaluation was completed via the blue dye test in order to analyze the incidence of tracheal aspiration of saliva. RESULTS: Sedation levels and mechanical ventilation time related to tracheal aspiration were not statistically significant in this study. On the other hand, ventilation mode and tracheal aspiration showed statistical significance, and there was a higher incidence of tracheal aspiration in the pressure controlled ventilation mode. CONCLUSION: It was possible to observe a significant relationship between tracheal aspiration incidence and pressure controlled ventilation mode, which means the inclusion of those patients in the risk group for oropharyngeal dysphagia and their insertion in prevention protocols. The relationship between tracheal aspiration and sedation level, as well as tracheal aspiration and mechanical ventilation, were not statistically significant in this sample, needing further research.