RESUMO Introdução: A pandemia por COVID-19 conduziu à readaptação e reorganização dos sistemas de saúde. Objetivos: Caraterizar o impacte da pandemia por COVID-19 nos Enfermeiros Especialistas em Enfermagem de Reabilitação; identificar o impacte da pandemia por COVID-19 nos cuidados especializados de enfermagem de reabilitação disponibilizados às populações; identificar o impacte da pandemia por COVID-19 nas estratégias de atualização técnico-científica dos Enfermeiros Especialistas em Enfermagem de Reabilitação; tendo ainda como finalidades disponibilizar informação aos decisores para uma melhor gestão de recursos humanos/profissionais; e, disponibilizar informação aos decisores para uma melhor gestão de cuidados de enfermagem especializados às populações. Metodologia: Estudo observacional, descritivo e transversal. Amostra não probabilística, de conveniência, de enfermeiros especialistas em enfermagem de reabilitação, sócios da Associação Portuguesa dos Enfermeiros de Reabilitação. Questionário online. Análise descritiva e inferencial. O questionário foi submetido para resposta durante o período entre 2 de marco de 2022 e 11 de abril de 2022, tendo obtido um total de 160 questionários respondidos. Resultados: Durante o período da pandemia pelos EEER verificou-se um impacte negativo nas dimensões “tempo para os amigos” e “tempo para o lazer pessoal”, e um impacte positivo nas dimensões “relacionamento com os colegas de trabalho” e “disponibilidade de equipamentos de proteção individual”. No futuro verificou-se uma perceção de impacte negativo nas dimensões “atividades burocráticas”, “saúde pessoal”, “tempo para os amigos”, e “tempo para o lazer pessoal”, e um impacte positivo nas dimensões “disponibilidade de equipamentos de proteção individual” e “organização do espaço físico no local de trabalho”. Conclusão: A pandemia por COVID-19 apresentou um impacte nos EEER e nos cuidados especializados prestados. Recomendam-se estudos futuros que permitam conhecer este impacte a longo prazo, ou direcionados para as intervenções autónomas dos EEER tornam-se pertinentes.

RESUMEN Introducción: La pandemia de COVID-19 motivó la readecuación y reorganización de los sistemas de salud. Objetivos: Caracterizar el impacto de la pandemia de COVID-19 en los EEER (enfermeros especialistas en enfermeria de rehabilitacion); caracterizar el impacto de la pandemia de COVID-19 en los cuidados de enfermería especializada en rehabilitación prestados a las poblaciones; caracterizar el impacto de la pandemia del COVID-19 en las estrategias de actualización técnico-científica de los EEER; e como finalidades proporcionar información a los tomadores de decisiones para una mejor gestión de los recursos humanos/profesionales; y, proporcionar información a los decisores para una mejor gestión de la atención de enfermería especializada a las poblaciones. Metodología: Estudio observacional, descriptivo y transversal. Muestra no probabilística de conveniencia de enfermeros especialistas en enfermería de rehabilitación, miembros de la Associação Portuguesa dos Enfermeiros de Reabilitação. Cuestionario en línea. Análisis descriptivo e inferencial. Resultados: Durante el período de la pandemia por los EEER, se verificó un impacto negativo en las dimensiones “tiempo para los amigos” y “tiempo para el ocio personal”, y un impacto positivo en las dimensiones “relación con los compañeros de trabajo” y “disponibilidad de equipos de protección personal”. A futuro, se percibe un impacto negativo en las dimensiones “actividades burocráticas”, “salud personal”, “tiempo para los amigos” y “tiempo para el ocio personal”, y un impacto positivo en las dimensiones “disponibilidad de medios de protección”. equipamiento individual” y “organización del espacio físico en el lugar de trabajo”. Discusión: El conocimiento del impacto sirve de guía para implementar cambios en las dinámicas de trabajo y estructuras de servicio. Conclusión: La pandemia de COVID-19 tuvo impacto en los EEER y en la atención especializada proporcionada. Futuros estudios que permitan conocer este impacto a largo plazo, o dirigidos a las intervenciones autónomas de los EEER, cobran relevancia.

ABSTRACT Introduction: COVID-19 pandemic led to the readaptation and reorganization of health systems. Aims: Characterize the impact of the COVID-19 pandemic on the NSRN (nurses specialized in rehabilitation nursing); characterize the impact of the COVID-19 pandemic on specialized rehabilitation nursing care provided to populations; to characterize the impact of the COVID-19 pandemic on the technical-scientific updating strategies of the NSRN; and also as aims to provide information to decision-makers for better management of human/professional resources; and, to provide information to decision makers for better management of specialized nursing care for populations. Methodology: Observational, descriptive and cross-sectional study. Non-probabilistic, convenience sample of nurses specializing in rehabilitation nursing, members of the Associação Portuguesa dos Enfermeiros de Reabilitação. Online questionnaire. Descriptive and inferential analysis. Results: During the period of the pandemic by the NSRN, we verified a negative impact on the dimensions “time for friends” and “time for personal leisure”, and a positive impact on the dimensions “relationship with coworkers” and “availability of equipment for individual protection”. In the future, there is a perception of a negative impact on the dimensions “bureaucratic activities”, “personal health”, “time for friends”, and “time for personal leisure”, and a positive impact on the dimensions “availability of protective equipment individual” and “organization of the physical space in the workplace”. Discussion: Acknowledgement of the impact serves as guidance for implementing changes in work dynamics and service structures. Conclusion: The COVID-19 pandemic had an impact on the NSRN and on the specialized care provided. Future studies that allow knowing this impact in the long term, or directed to the autonomous interventions of the NSRN, become pertinent.

Resumo A colocação endoscópica de próteses esofágicas metálicas auto-expansíveis é um tratamento paliativo eficaz da estenose maligna, tendo também sido usada com sucesso em indicações benignas, como no caso de estenoses refratárias do esófago ou de perfurações e deiscências iatrogénicas. Apesar de várias décadas de evolução e não obstante existir uma grande variedade de escolha de próteses esofágicas, ainda está por desenvolver a prótese ideal que apresente simultaneamente uma eficácia elevada e uma incidência reduzida de complicações como migração, crescimento tecidular ou necrose por pressão. Este artigo fornece uma visão global de como esta evolução ocorreu e aborda as características de algumas das próteses atualmente existentes no mercado, como o seu material e tipo de construção, padrão de força axial e radial, cobertura e dimensões, que poderão ajudar a compreender e a evitar a ocorrência desses eventos adversos. São analisados os sistemas de libertação e técnicas de introdução das próteses metálicas auto-expansíveis, com alguns truques e dicas relativas à colocação das próteses e abordagem de eventos adversos.

Abstract Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are re-viewed, as well as some tips and tricks regarding placement and management of adverse events.

Abstract Introduction: With the increase of esophageal and gastric cancer, surgery will be more often performed. Anastomotic leakage (AL) is one of the most feared postoperative complications of gastroesophageal surgery. It can be managed by conservative, endoscopic (such as endoscopic vacuum therapy and stenting), or surgical methods, but optimal treatment remains controversial. The aim of our meta-analysis was to compare (a) endoscopic and surgical interventions and (b) different endoscopic treatments for AL following gastroesophageal cancer surgery. Methods: Systematic review and meta-analysis, with search in three online databases for studies evaluating surgical and endoscopic treatments for AL following gastroesophageal cancer surgery. Results: A total of 32 studies comprising 1,080 patients were included. Compared with surgical intervention, endoscopic treatment presented similar clinical success, hospital length of stay, and intensive care unit length of stay, but lower in-hospital mortality (6.4% [95% CI: 3.8-9.6%] vs. 35.8% [95% CI: 23.9-48.5%]. Endoscopic vacuum therapy was associated with a lower rate of complications (OR 0.348 [95% CI: 0.127-0.954]), shorter ICU length of stay (mean difference −14.77 days [95% CI: −26.57 to −2.98]), and time until AL resolution (17.6 days [95% CI: 14.1-21.2] vs. 39.4 days [95% CI: 27.0-51.8]) when compared with stenting, but there were no significant differences in terms of clinical success, mortality, reinterventions, or hospital length of stay. Conclusions: Endoscopic treatment, in particular endoscopic vacuum therapy, seems safer and more effective when compared with surgery. However, more robust comparative studies are need-ed, especially for clarifying which is the best treatment in specific situations (according to patient and leak characteristics).

Resumo Introdução: Com o aumento da incidência de cancro esofágico e gástrico, a cirurgia será mais frequentemente realizada. As deiscências anastomóticas (DA) são uma das complicações pós-operatórias mais temidas da cirurgia gastroesofágica. Podem ser tratadas com métodos conservadores, endoscópicos (como terapêutica endoscópica por vácuo e colocação de próteses) ou cirúrgicos, mas a melhor abordagem ainda é controversa. O objetivo da nossa meta-análise foi a comparação a) entre intervenções endoscópicas e cirúrgicas e b) entre diferentes tratamentos endoscópicos para a DA após cirurgia oncológica gastroesofágica. Métodos: Revisão sistemática e meta-análise, com pesquisa em 3 bases de dados online de estudos que avaliassem tratamentos cirúrgicos e endoscópicos da DA após cirurgia oncológica gastroesofágica. Resultados: Um total de 32 estudos englobando 1,080 pacientes foram incluídos. Comparativamente à intervenção cirúrgica, o tratamento endoscópico apresentou sucesso clínico, duração do internamento hospitalar e do internamento na unidade de cuidados intensivos semelhantes, mas menor mortalidade intra-hospitalar (6.4% [95% CI: 3.8-9.6%] vs. 35.8% [95% CI: 23.9-48.5%]). A terapêutica endoscópica por vácuo associou-se a menor taxa de complicações (OR 0.348 [95% CI: 0.127-0.954]), menor duração do internamento na UCI (diferença média - 14.77 dias [95% CI: −26.57 to −2.98]) e do tempo até resolução da DA (17.6 dias [95% CI: 14.1-21.2] vs. 39.4 dias [95% CI: 27.0-51.8]) quando comparada com as próteses endoscópicas, mas não houve diferenças significativas em termos de sucesso clínico, mortalidade, reintervenções ou duração do internamento hospitalar. Conclusões: O tratamento endoscópico, em particular a terapêutica endoscópica por vácuo parece ser mais segura e efetiva em comparação com a cirurgia. Porém, estudos comparativos mais robustos são necessários, especialmente para clarificar qual o melhor tratamento em situações específicas (consoante as caraterísticas do paciente e da deiscência).

Abstract Introduction: Anastomotic leakage after esophagectomy is associated with high mortality and impaired quality of life. Aim: The objective of this work was to determine the effec-tiveness of management of esophageal anastomotic leakage (EAL) after esophagectomy for esophageal and gastro-esophageal junction (GEJ) cancer. Methods: Patients submitted to esophagectomy for esophageal and GEJ cancer at a tertiary oncology hospital between 2014 and 2019 (n = 119) were retrospectively reviewed and EAL risk factors and its management outcomes determined. Results: Older age and nodal disease were identified as independent risk factors for anastomotic leak (adjusted OR 1.06, 95% CI 1.00-1.13, and adjusted OR 4.89, 95% CI 1.09-21.8). Patients with EAL spent more days in the intensive care unit (ICU; median 14 vs. 4 days) and had higher 30-day mortality (15 vs. 2%) and higher in-hospital mortality (35 vs. 4%). The first treatment option was surgical in 13 patients, endoscopic in 10, and conservative in 3. No significant differences were noticeable between these patients, but sepsis and large leakages were tendentially managed by surgery. At follow-up, 3 patients in the surgery group (23%) and 9 in the endoscopic group (90%) were discharged under an oral diet (p = 0.001). The in-hospital mortality rate was 38% in the surgical group, 33% in the conservative group, and 10% in endoscopic group (p = 0.132). In patients with EAL, the presence of septic shock at leak diagnosis was the only predictor of mortality (p = 0.004). ICU length-of-stay was non-significantly lower in the endoscopic therapy group (median 4 days, vs. 16 days in the surgical group, p = 0.212). Conclusion: Risk factors for EAL may help change pre-procedural optimization. The results of this study suggest including an endoscopic approach for EAL.

Resumo Introdução: A deiscência anastomótica após esofagectomia está associada a uma elevada taxa de mortalidade e qualidade de vida comprometida. Objetivo: Avaliar a eficácia da abordagem da deiscência de anastomose esofágica após esofagectomia por neoplasia do esófago e da junção esofagogastrica (JEG). Métodos: Foram revistos retrospetivamente todos os doentes submetidos a esofagectomia por neoplasia do esófago e da JEG num hospital terciário entre 2014 e 2019 (n = 119) e analisados os fatores de risco e as diferentes abordagens na deiscência anastomótica. Resultados: A idade avançada e a presença de metastização ganglionar foram identificados como fatores de risco independentes para deiscência anastomótica (OR 1.06, 95% IC 1.00-1.13 e 4.89, IC 1.09-21.8). Os doentes com deiscência anastomótica estiveram mais dias internados na unidade de cuidados intensivos (UCI) (mediana 14 vs. 4 dias) e tiveram uma mortalidade aos 30 dias e intrahospitalar mais elevada (15% vs. 2% e 35% vs. 4%, respectivamente). A primeira abordagem terapêutica foi cirúrgica em 13 doentes, endoscópica em 10 e conservadora em 3. Não foram encontradas diferenças estatisticamente significativas entre estes doentes, com uma tendência para a presença de sépsis e de deiscências de maior dimensão nos doentes abordados cirurgicamente. Durante o seguimento, 3 doentes do grupo cirúrgico (23%) e 9 do grupo endoscópico (90%) tiveram alta hospitalar sob dieta oral (p = 0.001). A taxa de mortalidade intra-hospitalar foi de 38% no grupo cirúrgico, 33% no grupo conservador e 10% no grupo endoscópico (p = 0.132). Nos doentes com deiscência anastomótica, a presença de choque sético ao diagnóstico foi o único preditor de mortalidade (p = 0.004). O tempo de internamento na UCI não foi significativamente menor no grupo sub-metido a tratamento endoscópico (mediana de 4 dias vs. 16 dias no grupo cirúrgico, p = 0.212). Conclusão: A identificação de fatores de risco para deiscência anastomótica após esofagectomia pode ajudar a alterar a optimização pré-procedimento. Os resultados deste estudo sugerem incluir uma abordagem endoscópica nos doentes com deiscência anastomótica.

ABSTRACT Severe forms of atopic dermatitis can be associated with food allergy and other atopic diseases. We report the clinical case of a female teenager with allergic rhinoconjunctivitis and severe asthma, referred for evaluation of atopic dermatitis, that presented skin lesions only partially responsive to systemic corticosteroids and phototherapy, with multiple exacerbations and hospitalization. Exacerbation of skin lesions, nausea and vomiting on eating eggs, milk and shellfish. Skin prick test, specific IgE and ImmunoCAP®-ISAC test were performed, showing polysensitization to aeroallergens and food allergens. The spirometry showed moderately severe obstructive syndrome. Due to the eczema severity, dupilumab was started with marked improvement of skin lesions after only two weeks; at five months, she reintroduced egg into the diet; at seven months, the spirometry was normal. This case supports the effectiveness of dupilumab in treating atopic dermatitis, severe asthma and the acquisition of tolerance to food allergy, the latter with still limited therapeutic options.

RESUMO A dermatite atópica pode estar associada à alergia alimentar e outras doenças atópicas. Relatamos o caso clínico de adolescente, sexo feminino, com rinoconjuntivite e asma grave alérgicas, referenciada para estudo de dermatite atópica, que apresentava lesões cutâneas apenas parcialmente responsivas a corticoterapia sistémica e fototerapia, com várias exacerbações e uma hospitalização. História de exacerbação das lesões cutâneas, náuseas e vómitos com a ingestão de ovos inteiros, leite e marisco. Foram realizados testes cutâneos por picada e IgE específicas, bem como teste ImmunoCAP®-ISAC, que mostraram polissensibilização a aeroalergénios e alergénios alimentares. Espirometria com síndrome obstrutiva moderadamente grave. Devido à gravidade do eczema, iniciou-se tratamento com dupilumab, com melhoria acentuada das lesões cutâneas logo após 2 semanas; aos 5 meses, reintrodução do ovo na dieta; aos 7 meses, normalização da espirometria. Este caso suporta a eficácia do dupilumab no tratamento da dermatite atópica, asma grave e aquisição de tolerância na alergia alimentar, esta ainda com opções terapêuticas limitadas.

ABSTRACT Point-of-care ultrasound aims to enhance physical examination findings with real-time information from the ultrasound. Peritoneal dialysis catheter-related infections are a frequent complication of peritoneal dialysis and a major predisposing factor to peritonitis. The diagnosis of peritoneal dialysis catheter-related infections is made with physical examination, but physical findings usually lack sensitivity or specificity. This is a single-center observational study that aimed to evaluate the accuracy of point-of-care ultrasound for the diagnosis of peritoneal dialysis catheter-related infections. Sixteen peritoneal dialysis patients with peritoneal dialysis catheter-related infections clinical suspicion were enrolled in this study, as well as nine controls. Peritoneal dialysis catheter-related infection was defined as a purulent discharge with or without inflammatory signs in the peritoneal dialysis catheter exit-site or subcutaneous tunnel, and a positive microbiological culture collected from the exit-site. Point-of-care ultrasound was considered positive when an anechoic collection in relation to the external cuff or catheter tunnel was identified. Physical examination findings were coded using the Exit-site Scoring System. A total of 13 peritoneal dialysis catheter-related infections were diagnosed. The mean Exit-site Scoring System score for the suspected cases of peritoneal dialysis catheter-related infections was 2,82 ± 1,22, and the most commonly encountered sign was purulent discharge. All of the cases of peritoneal dialysis catheter-related infections had a positive point-of-care ultrasound. In contrast, none of the controls had a positive point-of-care ultrasound (p < 0,001). The area under the receiver operating characteristic curve of physical examination for the diagnosis of peritoneal dialysis catheter-related infections was 0,6 (95% CI 0,37-0,84). In contrast, point-of-care ultrasound had an AUROC of 0,91 (95% CI: 0,73-1) for the diagnosis of peritoneal dialysis catheter-related infections. Nephrologist-performed point-of-care ultrasound is feasible and superior to physical examination for the diagnosis of peritoneal dialysis catheter-related infections.

ABSTRACT Dialysis-associated immune dysfunction makes chronic kidney disease patients both susceptible to severe Coronavirus disease 19 (Covid19) and to a weaker response to vaccination. Previously infected patients are thought to sustain stronger and more durable humoral responses than vaccinated patients. Four months after a two dose-regimen of the Pfizer/BioNTech SARS-CoV-2 mRNA vaccine (BNT162b2), we evaluated the SARS-CoV-2 spike immunoglobin G (IgG-S1) antibody levels in previously infected peritoneal dialysis patients and compared them with infection naïve PD patients. A total of 79 peritoneal dialysis patients were analyzed, of which 11 had a previous history of Covid19. We have verified that the median titer of the IgG-S1 in previously infected patients (14310 AU/mL) was significantly superior to that in infection naïve patients (760,05 AU/mL) (p < 0,001). Previous Covid19 was the only significant predictor of IgG-S1 levels in a multivariate linear regression model (p < 0,001). These results may impact vaccination strategies for peritoneal dialysis patients regarding the future administration of BNT162b2 booster doses. In conclusion, previously infected peritoneal dialysis patients who have completed a two-dose regimen of the BNT162b2 may be well suited without a third, booster dose for longer than infection naïve peritoneal dialysis patients. This strategy could make additional doses available around the world.

ABSTRACT COVID-19 is a pandemic and life-threatening respiratory disease. Chronic kidney disease is a probable risk factor for more severe COVID-19, but outcomes in the peritoneal dialysis population are scarce. We analyzed our peritoneal dialysis center COVID-19 cases from March 2020 to January 2021, before full vaccination with the Pfizer BNT 162b2 mRNA vaccine in February 2021. There were 13 cases of COVID-19 out of 96 patients on peritoneal dialysis (cumulative incidence 13,5 cases per 1000 patients-month). Nine were considered mild (76,9%), two moderate (15,4%) and one severe/critical (7,7%). There was one asymptomatic case. The most common presenting signs and symptoms were myalgia, cough, fever, asthenia, hypotension, and loss of smell and/or taste. Only one patient required oxygen in the ICU. There was a hospitalization rate of 30,8% (three mild and one severe/critical) and a median time of hospitalization until discharge, or death, of 6 days. The most common reason for hospitalization was hypotension and asthenia, without respiratory failure (three mild out of four hospitalizations). One patient died (7,7%) and 12 patients recovered well (92,3%). Of eleven patients presenting with COVID-19 symptoms, nine reported persisting symptoms for over one month (81,8%). In conclusion, COVID-19 in patients under peritoneal dialysis had a relatively benign course with symptoms mainly unrelated to the respiratory tract.

Abstract Gitelman's syndrome is characterized by a mutation of SLC12A3 gene, which encodes the NaCl cotransporter of distal convoluted tubule resulting in hypokalaemia. During pregnancy its approach and treatment become a challenge. We report the case of a pregnant woman, with a history of previous abortions, who needed a tight analytical control with several hospital admissions throughout pregnancy and more agressive and controled oral and intravenous therapy, which allowed to preserve a good fetal development and normal delivery without complications. This disease in pregnant women has a good prognosis, although it imposes the need of a tight multidisciplinar follow-up.

RESUMO O objetivo deste estudo foi descrever as variações semanais no tipo e duração do treinamento, bem como parâmetros relacionados ao bem-estar, em jogadores de elite de voleibol. Vinte e quarto jovens jogadores de elite de voleibol da seleção Francesa (idade: 17,8 ± 1,0 anos) foram monitorados diariamente, e o tipo de treinamento, a duração do treinamento, a participação em partidas e o status de bem-estar foram medidos durante 22 semanas. A duração do treinamento de voleibol variou de 100 a 510 minutos por semana, enquanto a duração do treinamento de força e condicionamento variou de 97 a 262 minutos por semana. Os níveis de fadiga variaram de 1,5 a 2,8 A.U., e a dor muscular tardia (DMT) variou de 1,5 a 2,5 A.U. Correlação positiva grande foi encontrada entre sono e duração do jogo (r = 0,64) e entre estresse e volume semanal (r = 0,52). Além disso, uma correlação positiva moderada foi encontrada entre fadiga e duração da partida (r = 0,36), entre sono e volume semanal (r = 0,35), entre DMT e duração da partida (r = 0,43), entre estresse e treinamento de força (r = 0,42), treinamento de voleibol (r = 0,35), e duração da partida (r = 0,47). O presente estudo revelou variações naturais no volume de treinamento ao longo da temporada e dependência moderada entre treinamento semanal/duração da partida e status de bem-estar.

ABSTRACT The purpose of this study was to describe weekly variations in the type and duration of training, as well as wellness-related parameters, in elite volleyball players. Twenty-four youth elite volleyball players from the French national team (age: 17.8 ± 1.0 y.o.) were monitored daily, and the type of training, training duration, participation in matches, and wellness status were measured over 22 weeks. Volleyball training duration varied from 100 to 510 minutes per week, while strength and conditioning training duration varied from 97 to 262 minutes per week. Fatigue levels varied from 1.5 to 2.8 A.U., and delayed onset muscle soreness (DOMS) varied from 1.5 to 2.5 A.U. Large positive correlation were found between sleep and match duration (r = 0.64) and between stress and weekly volume (r = 0.52). Additionally, moderate positive correlation were found between fatigue and match duration (r = 0.36); between sleep and weekly volume (r = 0.35); between DOMS and match duration (r = 0.43); between stress and strength training (r = 0.42), volleyball training (r = 0.35), and match duration (r = 0.47). The present study revealed natural variations in training volume across the season and moderate dependency between weekly training/match durations and wellness status.

ABSTRACT Operational tolerance in kidney transplantation is characterized by stable serum creatinine < 1.7 mg/dL and proteinuria < 1 g/day in the absence of immunosuppression or immunodeficiency for over one year. However, simultaneous donor specific antibodies are common and serum creatinine is a poor surrogate of early lesions. Consequently, subclinical rejections will meet operational tolerance criteria if sérum creatinine remains stable. We report a patient with operational tolerance criteria followed by biopsy-proven chronic active antibody mediated rejection, discussing the intricate challenges of immunosuppression management.

Abstract Background and objectives An epidural blood patch is used to treat postdural puncture and liquor hypotension headache. We report the use of an epidural blood patch in a critical pediatric patient. Case report A 10-year-old girl with acute leukemia developed venous cerebral thrombosis with hemorrhagic transformation one month after intrathecal chemotherapy. Given the unusual clinical and imagiological evolution even after decompressive craniectomy, we suspected cerebrospinal fluid hypotension. Spine imaging revealed signs of post-lumbar puncture fistula; we hence performed a blind blood patch. Conclusions Recognizing cerebrospinal fluid hypotension in critical pediatric patients is important. Less-conventional life-saving measures, such as a blind blood patch, may be considered in such patients.

ABSTRACT Peritoneal dialysis (PD) relies on adequate function of PD catheter. Mechanical complications are a major cause of dropout among PD patients. A prompt timing and an appropriate intervention may overcome these problems with catheter salvage, without interrupting PD treatment. Many Portuguese centers still lack a proper articulation between nephrology and surgical departments. We describe current available surgical approaches in the implantation of PD catheters, management of mechanical complications, exit‑site infections and other abdominal surgical procedures. Our aim is to reinforce the need for an established protocol of action between these departments as occurs with vascular access in hemodialysis.

ABSTRACT Peritonitis is a serious complication in peritoneal dialysis, usually secondary to an infectious cause. Chemical peritonitis is rarer. No case exclusively attributed to vancomycin has been reported in the last 20 years. Data from 4 consecutive patients diagnosed with culture‑negative peritonitis following administration of intraperitoneal vancomycin between May and June 2019 were retrospectively recorded. All patients were treated with 2 grams of intraperitoneal vancomycin after a break in aseptic technique and developed a cloudy effluent. No patient was previously known to be allergic to vancomycin. All had a clear dialysate before vancomycin. All developed an elevated leukocyte count in the dialysate. All had sterile cultures. All resumed a clear effluent with less <100 cells/μL after vancomycin cessation, and in two there were no further administrations. In one, a new drug challenge led to recrudescence of abdominal pain and reappearance of a cloudy sterile effluent. In another, vancomycin from a different lot was administrated 3 days after, no symptoms developed and dialysate cell count remained normal. The pathogenic mechanisms underlying chemical peritonitis are not fully known. The clinical course is typically benign. Management seems to be limited to drug withdrawal. If unrecognized, chemical peritonitis may ultimately lead to unnecessary catheter removal.

ABSTRACT Arteriovenous fistulas (AVFs) are the first-choice vascular access for most HD patients. Up to 60% of AVFs do not mature adequately, mostly due to stenosis. Surgical and endovascular techniques can rescue up to 80% of these AVFs from primary failure, allowing them to be safely and effectively used in HD, preserving venous capital, and avoiding placement of CVCs and associated complications. This article reviews and summarizes the existing literature, offering a practical approach on early identification, treatment, and monitoring of immature AVFs.