Abstract Background Diagnosis of pulmonary embolism (PE) constitutes a challenge for practitioners. Current practice involves use of pre-test probability prediction rules. Several strategies to optimize this process have been explored. Objectives To explore whether application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-dimer (DD) would have reduced the number of computed tomography pulmonary angiography (CTPA) examinations performed in patients with suspected PE. Methods A retrospective cross-sectional study of adult patients taken for CTPA under suspicion of PE in 2018 and 2020. The PERC rule and age-adjusted DD were applied. The number of cases without indications for imaging studies was estimated and the operational characteristics for diagnosis of PE were calculated. Results 302 patients were included. PE was diagnosed in 29.8%. Only 27.2% of ‘not probable’ cases according to the Wells criteria had D-dimer assays. Age adjustment would have reduced tomography use by 11.1%, with an AUC of 0.5. The PERC rule would have reduced use by 7%, with an AUC of 0.72. Conclusions Application of age-adjusted D-dimer and the PERC rule to patients taken for CTPA because of suspected PE seems to reduce the number of indications for the procedure.

Resumo Contexto O diagnóstico de embolia pulmonar (EP) representa um desafio para o profissional. A prática atual envolve o uso de modelos de previsão de probabilidade pré-teste e, para otimizar esse processo, várias estratégias têm sido exploradas. Objetivos Investigar se a aplicação dos critérios de exclusão de EP (pulmonary embolism rule-out criteria, PERC) e do D-dímero (DD) ajustado para idade diminui o número de angiografias computadorizadas (ATCs) pulmonares realizadas em pacientes com suspeita de EP. Métodos Estudo transversal retrospectivo com pacientes adultos submetidos a ATC pulmonar com suspeita de EP em 2018 e 2020. Foram aplicados os critérios PERC e o DD ajustado para idade. Foi estimado o número de casos não indicados para exames de imagem, e foram calculadas as características operacionais para o diagnóstico de EP. Resultados Foram incluídos 302 pacientes, dos quais 29,8% apresentaram diagnóstico de EP. Apenas 27,2% dos casos não prováveis de acordo com os critérios de Wells apresentaram DD; o ajuste implicou em uma diminuição de ACTs de 11,1%, com área sob a curva de 0,5. Os critérios PERC diminuiriam em 7%, com área sob a curva de 0,72. Conclusões A aplicação do DD ajustado para idade e dos critérios PERC em pacientes submetidos a ATC pulmonar por suspeita de EP parece diminuir a indicação para tais exames.

Resumen El género Gemella spp corresponde a cocos gram positivos, anaerobios facultativos, catalasa negativos, no móviles y no formadores de esporas, usualmente comensales de la cavidad oral, que no suelen ser patógenos en pacientes inmunocompetentes. Sin embargo, puede comportarse como germen oportunista en pacientes inmunosuprimidos o con otros factores de riesgo como mala higiene dental, cirugía gastrointestinal, enfermedades metabólicas entre otras, y se asocia con endocarditis, meningitis y en menor medida compromiso pulmonar. La información respecto a la susceptibilidad antimicrobiana es limitada y se asemeja a la de S viridans, por lo que la penicilina y ampicilina son los medicamentos de elección, sin tener claridad en cuanto a duración del tratamiento, usualmente considerando llevar a 4 semanas o hasta el drenaje de la colección. Éste reporte de caso describe una paciente con tuberculosis en tratamiento, que desarrolla una infección invasiva con documentación de empiema y bacteriemia secundaria por Gemella morbillorum, representando la asociación poco común de ésta infección bacteriana con tuberculosis.

Abstract Gemella spp. corresponds to gram positive cocci, facultative anaerobes, negative catalase, non mobile and non spore producers, part of colonizing flora of the oral cavity that are not common pathogens in immunocompetent patients. Nevertheless it may behave as an opportunistic germ in immunosuppressed patients or with other risk factors that include bad dental hygiene, bowel surgery, and metabolic diseases among others. It’s associated with infections such as endocarditis, meningitis and less frecuently can implicate the lung. The information regarding antimicrobial susceptibility is limited and resembles S viridans, so penicillin and ampicillin are the medications of choice, without being clear about the duration of treatment, usually giving 4 weeks or until collection drain. This case report describes a patient with known tuberculosis diagnosis and under treatment, that develops an invasive infection with empyema and secondary bloodstream infection by Gemella morbillorum, depicting a previously uncommon but described association of this bacterial infection with tuberculosis.

RESUMEN Introducción: El trauma cráneo-encefálico (TEC) es uno de los desórdenes neurológicos más comunes actualmente. Presenta consecuencias tan devastadoras que el39% de los pacientes mueren a causa del trauma. De los sobrevivientes, el60% tendrán déficit en las competencias cognitivas o motoras. Objetivo: Analizar a través de la evidencia actual el manejo del TEC severo y el desenlace clínico logrado con el uso del lactato sódico hipertónico. Metodología: Se realizó una búsqueda en bases de datos de literatura científica como EMBASE, PubMed/Medline, OVID y Science Direct para elaborar un artículo de reflexión, usando las palabras « traumatic brain injury», ^hypertonic sodium lactate», «metabolism in brain injury », «management of traumatic brain injury », haciendo hincapié en los beneficios potenciales del lactato sódico hipertónico, sin tener en cuenta la fecha de publicación. Resultados: El lactato sódico hipertónico ha demostrado impactar de forma exitosa el pronóstico sombrío del TEC, modulando la hipertensión endocraneana y disfunción metabólica oxidativa cerebral, lo cual se ha demostrado en modelos in vitro, en animales y en humanos. Conclusión: Los esfuerzos por mejorar los desenlaces clínicos han llevado a buscar nuevas alternativas del manejo del TEC, derivadas del entendimiento de la fisiopatología. De allí surge el lactato como terapia prometedora en el manejo del TEC, dados sus múltiples efectos endocrino-metabólicos moduladores de la lesión secundaria.

ABSTRACT Introduction: Traumatic brain injury (TBI) is one of the most common neurological disorders at the present time. The consequences are so devastating that up to 39% of the patients die from trauma and 60% of the survivors will have cognitive and/or motor deficits. Objective: To analyse the current evidence on the management of severe traumatic brain injury and the clinical outcome achieved with the use of hypertonic sodium lactate. Methodology: A search of the scientific literature was conducted in the EMBASE, PubMed/Medline, OVID and Science Direct databases with the aim of preparing a reflection article, using the words "traumatic brain injury", "hypertonic sodium lactate", "metabolism in brain injury", "management of traumatic brain injury", focusing on the potential benefits of hypertonic sodium lactate, regardless of the date of publication. Results: The use of hypertonic sodium lactate has been shown to have a successful impact on the dismal prognosis of TBI, modulating intracranial hypertension and cerebral oxidative metabolic dysfunction. This has been proven in vitro, in animal models, and in humans. Conclusion: Efforts to find better clinical outcomes in patients with TBI have confirmed the need for new management alternatives supported by the understanding of the pathophysiology. Given its multiple modulating endocrine-metabolic effects on secondary injury, lactate has been found to be a promising therapy in the management of TBI.