The coronavirus disease 2019 (COVID-19) pandemic has had a profound global impact, affecting millions of individuals. Long-term sequelae associated with this infection have been reported, compromising patients’ quality of life. This study aimed to evaluate patients with severe COVID-19 over a follow-up period of up to 26 months after discharge from the Intensive Care Unit (ICU). This retrospective and observational study included patients with severe SARS-CoV-2 infection admitted to ICU 1 of Unidade Local de Saúde de Lisboa Ocidental between January and September 2021. Participants were those who had persistent respiratory symptoms or functional limitations 3 months after discharge. Respiratory symptoms were evaluated, and respiratory function tests and chest computed tomography (CT) scans were performed. Thirty-four patients were included. Dyspnoea was the most prevalent symptom, reported by all patients during the first assessment at 4 months and by 51.5% (n = 17) at 7–10 months, showing gradual improvement. Respiratory function tests revealed reduced diffusing capacity of the lung for carbon monoxide, restrictive ventilatory impairment, and decreased muscle strength. Imaging findings showed ground-glass opacities, organizing pneumonia, and pulmonary fibrosis, with fibrotic changes persisting in 37.5% (n = 12) of patients throughout the evaluation period. While many patients with severe COVID-19 fully recover with minimal sequelae, some develop long COVID, characterised by persistent symptoms, respiratory function impairment, and imaging abnormalities beyond 12 months post-infection. These findings highlight the need for further research to understand the long-term consequences of COVID-19 and identify factors contributing to long COVID syndrome.

Coronavirus disease 2019 (COVID-19) is a pandemic infection caused by the newly discovered severe acute respiratory syndrome coronavirus 2. Remdesivir (RDV) and corticosteroids are used mainly in COVID-19 patients with acute respiratory failure. The main objective of the study was to assess the effectiveness of remdesivir with and without corticosteroids in the treatment of COVID-19 patients. We conducted a prospective observational study, including adult patients consecutively hospitalized with confirmed COVID-19 and acute respiratory failure. Patients were divided according to treatment strategy: RDV alone versus RDV with corticosteroids. The primary outcome was the time to recovery in both treatment groups. We included 374 COVID-19 adult patients, 184 were treated with RDV, and 190 were treated with RDV and corticosteroid. Patients in the RDV group had a shorter time to recovery in comparison with patients in the RDV plus corticosteroids group at 28 days after admission [11 vs. 16 days (95% confidence Interval 9.7–12.8; 14.9–17.1; p = .016)]. Patients treated with RDV alone had a shorter length of hospital stay. The use of corticosteroids as adjunctive therapy of RDV was not associated with improvement in mortality of COVID-19 patients.

Tuberculosis (TB) is a multisystemic disease caused most frequently by Mycobacterium tuberculosis. Extrapulmonary TB has become more frequent with the advent of human immunodeficiency virus (HIV) as HIV can facilitate the infection with M. tuberculosis, especially during HIV seroconversion. Here, we present the case of a 22-year-old man, from Guinea-Bissau, with a history of untreated HIV who was admitted to the intensive care unit for respiratory failure needing mechanical ventilation. Pulmonary TB was diagnosed. His stay was complicated with a hemorrhagic shock due to traumatic urethral catheterization, which led to a perforation of the capsule of the prostate. A prostatectomy was needed for bleeding control. The anatomopathological examination confirmed the presence of acid-resistant bacilli, and an extensive caseous type necrosis of the whole tissue, thus diagnosing a prostatic tuberculosis. The patient recovered after a hemorrhagic shock, a urologic and radical intervention, and some severe infectious complications.

Background: Advances in critical care medicine have increased survival and quality of life in patients admitted to Intensive Care Unit (ICU). However, critically ill hemato-oncological (HO) patients still have a high risk of mortality, and stigma of poor prognosis may affect triage to ICU admission and clinical decisions. The available scoring systems are not specific for that population and the risk factors for adverse outcomes in HO patients remain poorly defined. Aims: The aim of our study is to analyze the risk factors for ICU mortality of HO patients. Methods: This retrospective, single-center study included 124 critically ill patients with HO diseases admitted in a polyvalent ICU between January 1st 2008 and December 31st 2021. Data regarding demographics, HO disease and therapy, disease severity scores, clinical and laboratorial parameters at admission, and organ support therapies instituted during ICU stay were collected from the ICU database. We compared data collected between survivors (n= 93) and non-survivors (n = 49). Univariate and multivariate logistic regression models were used to evaluate the potential risk factors for ICU mortality. Statistical tests were two-sided; p-values <0.05 were considered significant. Results: Median age was 65,5 [27-92] years and 60,5% (75) of patients were male. The majority of patients were admitted from other hospitals (39,5%), followed by medical hospital wards (29,8%). Most patients had non-Hodgkin lymphoma (37,9%), Acute Myeloid Leukemia (18,5%) and Hodgkin lymphoma (12.1%). 63,7% of patients were under treatment, 40,3% of which were under intermediate chemotherapy (Cht), and 23,4% under intensive Cht. The average time of hospital stay pre-ICU was 11,4 days (d) [CI 95% 8,9-13,8], and in the ICU was 8,9 [7,1-10,8]. The main reason for admission in the ICU was septic shock (47,6%), followed by respiratory failure (23,4%). Invasive mechanical ventilation (IMV) in the ICU was used for 62,1% of the patients, vasopressors for 66,9%, and renal replacement therapy (RRT) was used for 36,3%. ICU mortality rate was 39,5%. On univariate analysis, we identified as risk factors in the ICU for death the following factors: neutropenia (HR 1,73, CI 95% 0,98-3,1, p=0.06), sepsis or septic shock at ICU admission (HR 2,15, CI 95% 1,18-3,9, p=0.012), length of pre-ICU hospitalization >13 d (HR 1,43, CI 95% 0,81-2,55, p=0,22), Acute Physiology And Chronic Health Evaluation (APACHE) > 26 (HR 5,68, CI 95% 2,54-12,72, p<0,001), Simplified Acute Physiology Score II (SAPSII) score > 58 (HR 4,01, CI 95% 2,04-7,89, p<0,001), need of IMV (HR 3,60, CI 95% 1,41-9,81, p=0,007), vasopressors (HR 18,39, CI 95% 2,56-133,98, p=0,004) and RRT (HR 2,54, CI 95% 1,42-4,55, p=0,002). Factors including gender, ECOG, higher number of comorbidities, type of HO disease, need of ChT in the ICU or pre-admission ChT and fever at admission showed no significant impact (HR 10,45, CI 95% 1,40-78,00, p=0,022). Summary/Conclusion: In this study, characteristics of the underlying hematological malignancy didn’t have influence in the mortality, while the severity of infection, namely septic shock, and the need of organ supportive therapies correlated with mortality. Our findings reinforce that triage decisions solely based on the age or type of HO disease are not justified, but instead should be based on a multidisciplinary approach with intensivists and experienced hemato-oncologists.

Patients with lymphoproliferative diseases are at an increased risk of an incomplete immune response following vaccination or SARS-CoV-2 infection and might develop persistent viral infection and severe COVID-19 disease. We present a case of successful treatment of persistent and mechanical-ventilation-requiring SARS-CoV-2 infection in a del17+ CLL patient using exogenous antibodies.

Background and objective With the increasing incidence of cancer and the rise in the survival rates of cancer patients, more and more oncological candidates are being considered for admission to intensive care units (ICU). Several studies have demonstrated no difference in the outcomes of cancer patients compared to non-cancer patients. Our study aimed to describe and analyze the outcomes related to cancer patients in a polyvalent ICU. Methods We conducted a retrospective study of consecutive oncological patients admitted to a polyvalent ICU (2013-2017). Cox model and receiver operating characteristic (ROC) curve analysis were performed to analyze the results. Results A total of 236 patients were included in the study; the mean age of the patients was 53.5 ± 15.3 years, and 65% of them were male. The main cancer types were those related to the central nervous system (CNS; 31%), as well as gastrointestinal (18%), genitourinary (17%), and hematological (15%). Curative/diagnostic surgeries (49%) and sepsis/septic shock (17%) were the main reasons for admission. The Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) scores in hematological patients vs. solid tumors were as follows: 30 vs. 20 and 63 vs. 38, respectively (p<0.005). Vasopressors, invasive mechanical ventilation (IMV), and renal replacement therapy (RRT) were used more widely in hematological patients compared to solid-tumor patients. Length of stay was longer in hematological patients vs. solid-tumor patients (12.8 vs. 7 days, p=0.002). The median overall survival in hematological patients was one month and that in solid-tumor patients was 5.8 months (p<0.005). The survival rate at six months was better than described in the existing literature (48 vs. 32.4%). Conclusion Both SAPS II and APACHE II scores were reasonably accurate in predicting mortality, demonstrating their value in cancer patients.

Abstract Background Care for the critically ill patient with Cardiovascular Disease (CVD) requires a unique management approach, as the theoretical critical threshold for decompensation is lower and inherent adaptive mechanisms may be compromised. We aimed to characterize the prognostic impact of CVD in patients admitted to an Intensive Care Unit (ICU). Methods We performed a cohort study of consecutive patients admitted to an ICU from January to December 2019. Patients were stratified as follows: (1) established CVD – presence of either atrial fibrillation, heart failure, coronary artery disease and/or peripheral artery disease; (2) at higher risk of CVD – known arterial hypertension, dyslipidemia, diabetes mellitus and/or current smoking, in the absence of established CVD; and (3) at lower risk of CVD – i.e. none of the above. The co-primary endpoints were all-cause death in ICU and death during index hospitalization. Results During 2019, there were 334 admissions in ICU, comprising a total of 296 patients (mean age 67±15 years, 58.1% male). Overall, 69 (23.3%) and 108 (36.5%) died in ICU and during index hospitalization, respectively. Compared to patients at lower risk of CVD, those at higher CVD risk or with established CVD had markers of more severe disease, as noted by higher risk scores (e.g., SAPS-II 35.0±20.0 vs. 43.5±22.3 vs. 52.6±20.0; p<0.001), higher rates of mechanical ventilation (41.5 vs. 57.3 vs. 63.9%; p=0.020), shock during ICU stay (34.0 vs. 52.7 vs. 66.9%; p<0.001) and acute kidney injury (26.4 vs. 35.5 vs. 57.9%; p<0.001), respectively, as well as higher death rates in ICU (5.7 vs. 21.8 vs. 31.6%; p=0.001) and index hospitalization (9.4 vs. 37.3 vs. 46.6%; p<0.001). In multivariate analysis, adjusted for age and cause of admission, established CVD independently predicted the risk of all-cause death in ICU (HR: 2.084; 95% CI: 1.136–3.823; p=0.018) and during index hospitalization (HR 1.712; CI: 1.009–2.889; p=0.046). The analysis for the group of patients at higher risk of CVD yielded similar results to the abovementioned. Conclusion Roughly 4 in every 5 patients admitted in ICU were at risk of or had established CVD. The presence of either of the above independently predicted a two- to three-fold higher risk of death during hospitalization. Our findings emphasize the considerable burden of CVD in ICU and underscore the importance of comprehensive management of the complex critically ill patient. Funding Acknowledgement Type of funding sources: None.

Abstract Background Severity of disease scoring systems, namely the Simplified Acute Physiology Score (SAPS) and Acute Physiology and Chronic Health Evaluation (APACHE), are widely used to predict mortality in Intensive Care Units (ICU). Yet, neither score includes chronic HF in their model. We aimed to evaluate whether these scores perform well in risk prediction of death of patients previously diagnosed with heart failure (HF). Methodology This is a single-center retrospective cohort of patients admitted to an ICU in 2019. Those whose admission lasted <24 hours were excluded from analysis. The SAPS II and APACHE II scores were calculated using data from the first 24 hours of ICU admission, imputing the worst variable obtained within this timeframe. HF was defined according to the ESC recommendations. In order to assess the performance of the scores, Receiver Operating Characteristic (ROC) Curves were used to predict the risk of death in ICU in HF compared to the non-HF population. Results A total of 267 patients were hospitalized in ICU for a period over 24 hours in 2019 (mean age 67±16 years; 58.8% males; 21.7% with chronic HF; 33.7% admitted for sepsis). Compared to patients without HF, those with chronic HF were older (74±13 vs. 65±16 years; p<0.001) and had higher risk scores (mean SAPS II: 43.2±21.7 vs. 56.5±20.7; p<0.001; mean APACHE II: 19.8±10.0 vs. 25.1±10.0; p<0.001). Moreover, these patients were at higher risk of meaningful events during hospitalization (e.g. acute kidney injury: 38.0 vs. 66.1%; p<0.001; shock at any time: 52.4 vs. 67.8%; p=0.036). Furthermore, patients with HF had a trend towards higher mortality rates in ICU (17.3 vs. 28.8%; p=0.051) and a significantly higher death in overall hospitalization (30.8 vs. 45.8%; p=0.032). ROC curves performed well in predicting the risk of ICU death regardless of HF (SAPS II – AUC 0.78 vs. 0.81; p=0.36; APACHE II – AUC 0.75 vs. 0.78; p=0.37). Conclusion Approximately 1 in every 4 patients admitted to the ICU had chronic HF. Traditional risk scoring systems (SAPS II and APACHE II) performed well regardless of HF. While these results are reassuring as far as risk stratification accuracy is concerned, HF patients remained at a higher risk for worse outcomes. Therefore, prognostic tools with a therapeutic clinical applicability are urgently needed to improve the outcome of this population. Funding Acknowledgement Type of funding sources: None.

Objectives Since the outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the pressure to minimise its impact on public health has led to the implementation of different therapeutic strategies, the efficacy of which for the treatment of coronavirus disease 2019 (COVID-19) was unknown at the time. Remdesivir (REM) was granted its first conditional marketing authorisation in the EU in June 2020. The European Medicines Agency (EMA) and local health authorities all across the EU have since strongly recommended the implementation of pharmacovigilance activities aimed at further evaluating the safety of this new drug. The objective of this study was to evaluate adverse drug reactions (ADRs) attributed to either REM or hydroxychloroquine (HCQ) in patients hospitalised for COVID-19 in Centro Hospitalar de Lisboa Ocidental, a Portuguese hospital centre based in Lisbon. We present the preliminary results reporting plausible adverse effects of either HCQ or REM. Methods An observational cohort study was carried out between 16 March and 15 August 2020. Participants were divided into two cohorts: those prescribed an HCQ regimen, and those prescribed REM. Suspected ADRs were identified using an active monitoring model and reported to the Portuguese Pharmacovigilance System through its online notification tool. The ADR cumulative incidence was compared between the two cohorts. Results The study included 149 patients, of whom 101 were treated with HCQ and the remaining 48 with REM. The baseline characteristics were similar between the two cohorts. A total of 102 ADRs were identified during the study period, with a greater incidence in the HCQ cohort compared with the REM cohort (47.5% vs 12.5%; p<0.001). Causality was assessed in 81 ADRs, all of which were considered possible. Conclusions Real-world data are crucial to further establish the safety profile for REM. HCQ is no longer recommended for the treatment of COVID-19.

Although septic embolization associated with infective endocarditis is relatively frequent, mycotic cerebral aneurysms are a rare and potentially fatal complication. The authors report the case of a woman admitted with a cerebral haemorrhage due to mycotic aneurysm rupture, which led to a subacute infective endocarditis diagnosis. The patient underwent craniotomy with aneurysm excision and mitral valvuloplasty due to severe valvular insufficiency, with a favorable clinical outcome. The authors make a brief review, highlighting the challenge of the management of these patients, especially at surgical approach, which requires an individualized therapy strategy based on patient evolution.

BACKGROUND Osteomyelitis (OM) due to carbapenemase-producing Klebsiella pneumoniae (CPKp) is a very rare but severe condition, particularly among patients with hematologic malignancies and stem cell transplant recipients, who are especially at risk of developing nosocomial infections caused by this bacterium. CASE REPORT We describe 2 cases of acute and chronic OM by CPKp in adults with hematologic disorders. Patient 1, with acute lymphoblastic leukemia, developed bacteremia due to multidrug CPKp after induction chemotherapy. Despite pathogen-directed antibiotic treatment, blood cultures remained positive for CPKp, with an increase in its resistance pattern, and worsening of clinical condition. A pelvic computed tomography revealed air bubbles in the femoral head and ilium, suggestive of OM, and bone culture was positive for pandrug-resistant CPKp. The clinical condition deteriorated rapidly and the patient died. Patient 2, with aplastic anemia, developed multidrug CPKp bacteremia after immunosuppressive therapy, with good response to pathogen-directed antibiotic treatment. Ten months later, she underwent a hematopoietic stem cell transplant, and at the time of neutrophil engraftment, an abscess developed in the right thigh. An extensively drug-resistant CPKp was isolated from the pus, and antibiotics were started, without clinical improvement. A magnetic resonance of the thigh revealed an intraosseous abscess, suggestive of OM, and after debridement surgery and 6 weeks of parenteral antibiotics, she was successfully discharged home. CONCLUSIONS OM due to CPKp is uncommonly reported. These 2 cases illustrate the complex management of OM by CPKp in immunocompromised hematologic patients, and the importance of clinical suspicion for a prompt diagnosis, early treatment, and successful outcome.

Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively.

OBJECTIVE:Treatment limitation, as well as do-not-resuscitate (DNR) directives, are difficult but important to improve patients' quality of life and minimize dysthanasia. We aimed to study the approach to withholding, withdrawal, and DNR decisions, patients' characteristics, and process documentation in a general Intensive Care Unit (ICU) in Portugal.METHODS:A retrospective analysis of data regarding the limitation of treatment decisions collected from previously-designed forms and complemented by medical record consultation.RESULTS:A total of 1602 patients were admitted to the ICU between 2011 and 2016. DNR decisions were documented in 127 cases (7.9%). Patients with treatment limitations were older and had higher Simplified Acute Physiology Score II. The most frequent diagnosis preceding these decisions was sepsis (52.0%, n = 66); the most common main reason for limiting treatment was a poor prognosis of acute illness. Of the patients to whom a DNR was implemented, 117 (92.1%) died in the ICU (40.1% of the total number of ICU deaths), and hospital mortality was 100%. Participants in these decisions, as well as types of treatment withdrawn and their respective timings, were not registered in medical records.CONCLUSION:Treatment limitation and DNR decisions were relatively common, in line with other Southern European studies, but behind Northern European and North American centers. Patients with these limitations were older and more severely ill than patients without such decisions. Documentation of these processes should be clear and detailed, either in specific forms or computerized clinical records; there is room for improvement in this area.

Rationale: When and whether nutritional requirements can be attained by parenteral nutrition (PN) in the acute care setting is still a question for debate. Many clinical variables may determine either under- or overfeeding. Guidelines for evidence-based nutritional care in the ICU are still under construction.

Advances inmedicine have increased the survival of pretermneonates, that are constantly submitted to invasive procedures, such as heelsticks, insertion of indwelling venous and arterial catheters, causing repetitive painful experiences in the neonate period. However, the consequence of early painful experiences in the peripheral nervous system remains unexplored. We aimed to evaluate the possible alterations in the sural nerves of male and female adult Wistar rats, after painful stimulation in the neonatal period.Wistar ratswere followed birth to 180 days of life, separated in 4 groups: 1) Control-male group; 2) Control-female group; 3) Pain-male group; 4) Pain-female group. Pain groups received repetitive needle insertion in plantar and lateral area of the right paw, twice a day for 15 days starting at birth. Control groups were stimulated with a cotton swab, twice per day for 15 days starting at birth. When animals completed 180 days of life, they were killed, and the sural nerves were dissected, and prepared for light microscopy. Visual morphometry was performed with the aid of computer software tomeasure the fascicular andmyelinated fiber parameters (fascicular area, number and density of myelinated fibers and Schwann cell nuclei, area and diameter of myelinated fibers and respective axons and g ratio). Female rats from the pain group show smaller sural nerve, myelinated fibers, and myelinated axon areas compared to female controls. Furthermore, the myelinated fibers diameter distribution shows that the female pain group present larger number of smaller fiber. Males showed no significant difference between groups. These results suggest that male and females can respond on different ways to neonatal injury with females showing changes in peripheral sensory nerve morphometry. In conclusion, noxious stimuli in the neonatal period in rats can cause important peripheral nervous system alterations that persist on adults in a sex-dependent manner.