ABSTRACT Objective: To evaluate survival and direct medical costs of patients admitted in private hospitals with COVID-19 during the first wave. Methods: A retrospective, observational study analyzing survival and the economic data retrieved on hospitalized patients with COVID-19. Data from March 2020 to December 2020. The direct cost of hospitalization was estimated using the microcosting method with each individual hospitalization. Results: 342 cases were evaluated. Median age of 61.0 (95% CI 57.0-65.0). 194 (56.7%) were men. The mortality rate was higher in the female sex (p = 0.0037), ICU (p < 0.001), mechanical ventilation (p<0.001) and elderly groups. 143 (41.8%) patients were admitted to the ICU (95% CI 36.6%-47.1%), of which 60 (41.9%) required MV (95% CI 34.0%-50.0%). Global LOS presented median of 6.7 days (95% CI 6.0-7.2). Mean costs were US$ 7,060,00 (95% CI 5,300.94-8,819,00) for each patient. Mean cost for patients discharged alive and patients deceased was US$ 5,475.53 (95% CI 3,692.91-7,258.14) and US$ 12,955.19 (95% CI 8,106.61 -17,803.76), respectively (p < 0.001). Conclusions: Patients admitted with COVID-19 in these private hospitals point to great economic impact, mainly in the elderly and high-risk patients. It is key to better understand such costs in order to be prepared to make wise decisions during the current and future global health emergencies.

Abstract Terahertz (THz) spectroscopy is an emerging technology that is that is bringing a number of technical breakthroughs in several scientific applications. This review aimed to describe potential applications of THz spectroscopy at the biochemistry and molecules detection for food industry, environment monitoring and diagnostics, and present the importance of such technological platform in disease control and Public Health.

RESUMO A pandemia do novo coronavírus (SARS-CoV-2) vem causando estragos em todo o planeta. As populações estão sendo forçadas a quarentena - e assim mantidas - como medida de precaução para conter o surto da doença COVID-19. O principal objetivo da quarentena é evitar a sobrecarga dos hospitais, o que pode ser determinante para o atendimento aos pacientes COVID-19. O vírus não tem propagação uniforme pelo planeta, e no Brasil não é diferente. Contudo, as pessoas continuam a adoecer por outras causas não relacionadas ao SARS-CoV-2, demandando atendimento médico-hospitalar. Assim, os governos estão avaliando e liberando regiões para a realização de cirurgias eletivas em Estados e Municípios onde a COVID-19 está sob controle. Nesse contexto, há preocupação inerente à transmissão SARS-CoV-2 entre pacientes e prestadores de serviços de saúde, uma vez que há poucas informações sobre testes obrigatórios a serem realizados em pacientes com indicação cirúrgica. Esse problema é causado principalmente porque todos os pacientes durante o período de incubação são assintomáticos e, portanto, difíceis de serem avaliados. Assim sendo, os autores avaliam a literatura pertinente à microbiologia do SARS-CoV-2 e discutem a necessidade de testar esses pacientes com testes mais utilizados até o momento.

ABSTRACT The new coronavirus (SARS-CoV-2) pandemic has been wreaking havoc all over the planet. In a precautionary measure, populations have been forced and kept under quarantine to contain the outbreak of the COVID-19 disease. The quarantine primary goal is to avoid the overload to the hospitals, which should be available for the care of COVID-19 patients. However, the virus does not have a uniform spread throughout the planet, and Brazil is no different. Although all the world’s attention is now on the COVID-19 pandemic, there is no similar pattern of spread, and other diseases are still a real problem. Given the risks of transmission between patients and healthcare providers, there is a great challenge for healthcare institutions who must balance resources to assure safe care to patients and professionals while they take care of other disease patients, and perform surgical procedures that need to be carried out. Under such circumstances, as COVID-19 can also present pre- or asymptomatic transmission, it can be challenging to identify patients who are carrying and spreading the virus. Studies and information on mandatory testing for who are candidates to undergo elective surgery are scarce. Thus, the authors have reviewed the literature, and discuss the need to test these patients under the current context.

Resumen Introducción: Se informa que las complicaciones relacionadas con la endoscopía retrógrada endoscópica (CPRE) son tan altas como el 12%, la tasa de perforación intestinal relacionada con la CPRE es de 0,3 al 1,0%, y está relacionada con una mortalidad de hasta 25%. El propósito de este estudio es Revisar nuestra experiencia en 7 años con el manejo de perforaciones duodenales relacionadas a CPRE. Material y métodos: Se realizó una revisión de expedientes de pacientes que experimentaron perforaciones duodenales post-CPRE y que además fueron sometidos a esfinterotomía con precorte. La revisión abarco un periodo de 7 años y se describen como principales resultados el manejo no quirúrgico (incluido endoscópico y médico) y el manejo quirúrgico así como diagnóstico y mortalidad hospitalaria. Resultados: Se encontraron 10 casos de perforación duodenal post-CPRE desde marzo 2012 hasta febrero 2019, se descartaron 2 casos por ser perforaciones debidas a migración de endoprótesis biliar, quedando en total 8 casos para el estudio. 5 mujeres y 3 hombres con una edad promedio de 66 años. La principal indicación del estudio fue el riesgo alto de coledocolitiasis en 50%, El diagnóstico de perforación duodenal se realizó el 100% en un periodo mayor de 24 horas, el estudio mas útil para el diagnóstico fue la Tomografía con contraste. Al 100% de los casos se colocó prótesis biliar plástica l, solo 3 pacientes presentaron pancreatitis post-CPRE y 1 caso requirió revisión por hemorragia post esfinterotomía. 6 casos presentaron perforaciones tipo II, 3 pacientes requirieron cirugía de urgencia, otros 3 solo recibieron manejo medico endoscópico y 2 pacientes requirieron tratamiento paliativo. Estos últimos fueron las únicas 2 defunciones durante el estudio. Conclusiones: La valoración previa del paciente y de los procedimientos de alto riesgo nos permitirían clasificar a los pacientes con alto riesgo de perforación y con ello poder emplear una vigilancia más estrecha para un diagnóstico y tratamiento oportuno, ya que mientras más tarde sea el tratamiento existe mayor morbimortalidad de acuerdo a los reportes en la literatura. Afortunadamente nuestra tasa e perforaciones no es tan alta pero aún sigue siendo una de las complicaciones más temibles para los endoscopistas.

Resumen Introducción: La gastrostomía endoscópica percutánea (PEG) es un procedimiento quirúrgico endoscópico seguro y efectivo para el acceso enteral, y es una excelente alternativa a la gastrostomía quirúrgica. Sin embargo, se han informado complicaciones agudas y crónicas de PEG. El objetivo de este estudio fue determinar si existe relación el riesgo nutricio y/o los niveles de albúmina con la presencia de complicaciones y mortalidad intrahospitalaria. Material y métodos: Se realizó una revisión de expedientes de pacientes pertenecientes a nuestra unidad hospitalaria y que fueron sometidos a gastrostomías endoscópicas y quirúrgicas tanto abiertas como laparoscópicas y analizar la relación entre el riesgo nutricio, los niveles de albúmina y la presencia de complicaciones relacionadas con la gastrostomía. La revisión abarco un periodo de 1 año y se describen como principales resultados el riesgo nutricio, los niveles de albúmina, la presencia o no de complicaciones y la mortalidad intrahospitalaria. Resultados: Se realizaron 28 gastrostomías durante el periodo de estudio, 18 endoscópicas y 10 quirúrgicas, en un total de 22 pacientes, de los cuales el 45.4 % son hombres. La principal indicación fueron pacientes con antecedentes de accidentes vasculares cerebrales con incapacidad para deglutir. Se presentaron complicaciones en el 50% de los pacientes. 27.2% pertenecen a los procedimientos endoscópicos y 22.7% en los procedimientos quirúrgicos. El promedio de albúmina del grupo endoscópico fue de 2.87 g/dl y del grupo quirúrgico 2.03%, ambos grupos con riesgo nutricio bajo. Mostrando relación de aumento en las complicaciones del catéter en pacientes con riesgo nutricio bajo (p= 0.023) sin embargo los niveles de albúmina < 3 g/dl no alcanzaron significancia estadística (p= 0.86). Conclusiones: La evaluación del riesgo nutricio podría ser utilizada como factor predictor para complicaciones en la realización de gastrostomías tanto endoscópicas como quirúrgicas. Sin embargo aún hacen falta más estudios de mayor peso para poder reforzar esta relación.

ABSTRACT The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

ABSTRACT Background: Early antibiotic switch and early discharge protocols have not been widely studied in Latin America. Our objective was to describe real-world treatment patterns, resource use, and estimate opportunities for early switch from intravenous to oral antibiotics and early discharge for patients hospitalized with methicillin-resistant Staphylococcus aureus complicated skin and soft-tissue infections. Materials/methods: This retrospective medical chart review recruited 72 physicians from Brazil to collect data from patients hospitalized with documented methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections between May 2013 and May 2015, and discharged alive by June 2015. Data collected included clinical characteristics and outcomes, hospital length of stay, methicillin-resistant Staphylococcus aureus-targeted intravenous and oral antibiotic use, and early switch and early discharge eligibility using literature-based and expert-validated criteria. Results: A total of 199 patient charts were reviewed, of which 196 (98.5%) were prescribed methicillin-resistant Staphylococcus aureus -active therapy. Only four patients were switched from intravenous to oral antibiotics while hospitalized. The mean length of methicillin-resistant Staphylococcus aureus-active treatment was 14.7 (standard deviation, 10.1) days, with 14.6 (standard deviation, 10.1) total days of intravenous therapy. The mean length of hospital stay was 22.2 (standard deviation, 23.0) days. The most frequent initial methicillin-resistant Staphylococcus aureus-active therapies were intravenous vancomycin (58.2%), intravenous clindamycin (19.9%), and intravenous daptomycin (6.6%). Thirty-one patients (15.6%) were discharged with methicillin-resistant Staphylococcus aureus -active antibiotics of which 80.6% received oral antibiotics. Sixty-two patients (31.2%) met early switch criteria and potentially could have discontinued intravenous therapy 6.8 (standard deviation, 7.8) days sooner, and 65 patients (32.7%) met early discharge criteria and potentially could have been discharged 5.3 (standard deviation, 7.0) days sooner. Conclusions: Only 2% of patients were switched from intravenous to oral antibiotics in our study while almost one-third were early switch eligible. Additionally, one-third of hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections were early discharge eligible indicating opportunity for reducing intravenous therapy and days of hospital stay. These results provide insight into possible benefits of implementation of early switch/early discharge protocols in Brazil.

Abstract Introduction: Colorectal cancer is one of the most prevalent cancers worldwide in men as well as in women. Colonoscopy is the best study in order to detect colorectal neoplasms, however the precision of the study could turn out suboptimal. The quality of bowel preparation is critical in order to guarantee the success of the procedure. An alternative bowel preparation modality is the use of a split-dose regime, which has shown an improvement in the scales of bowel preparation and a probable increase in polyp detection. Some studies have shown that one of the most important factors in bowel preparation is the education of the patient. Objective: To determine de effectiveness of the split-dose bowel preparation versus the single dose modality in adult patients undergoing a colonoscopy and which will be evaluated using the Boston Bowel Preparation Scale. Materials and methods: In order to do this prospective and randomized pilot study we included patients from the Hospital General “Dr. Manuel Gea González” that had to undergo a colonoscopy from May 2019 with a deadline of January 2020, over the age of 18 years, any sex, calculating a total of 50 patients per group. Inferential statistical analysis was applied. Results: A total of 47 patients have been recruited up until now, 29 of the are part of the single dose group and 18 are parte of the split-dose group. There was no significant statistical difference when comparing the demographic variables between both groups. The adherence to each regimen was similar in both groups. A total of 64.3% of the patients in the single dose group had lesions identified in comparison with de split dose group in which 63.2% of the patients had no lesions reported, with a significant statistical difference (p=0.04). Deferment was similar in both groups and no adverse events were reported in either group. The probability of finding a lesion with an acceptable Boston score (>= 6) in patients in the single dose group was greater, with an OR of 3.03 (IC 95% 0.54- 17.21), although without significant statistical difference (p=0.21). Conclusion: It will be necessary to wait for the final results of this pilot study and according to those results evaluate the need to perform a larger study due to the fact that we did find a tendency to detect a greater amount of lesions in the single dose group, but because of the size of the sample up until now we are unable to have definite conclusions.

Resumen Introducción: El cáncer colorrectal es uno de los cánceres más prevalentes a nivel mundial tanto en hombres como en mujeres. La colonoscopia es el estudio más certero para la detección de neoplasias colorrectales, sin embargo, su precisión puede ser subóptima. La calidad de la preparación intestinal es crítica para garantizar el éxito del procedimiento. Una modalidad alterna que se ha utilizado es el régimen de dosis dividida que ha mostrado una mejoría en las escalas de preparación colónica y un probable aumento de la detección de adenomas. Algunos estudios muestran que uno de los factores más relevantes en la preparación del colon es la educación del paciente. Objetivo: Determinar la eficacia del uso de régimen de preparación colónica de “dosis dividida” versus el régimen de “dosis única” en pacientes adultos a quienes se realice colonoscopia evaluado mediante la escala de Boston para preparación colónica. Material y métodos: Para realizar este estudio piloto, prospectivo y aleatorizado se incluyeron pacientes del Hospital General “Dr. Manuel Gea González” que requirieron colonoscopia de manera programada desde mayo del 2019 con fecha límite de enero 2020, mayores de 18 años, cualquier sexo y la muestra total se calculó en 50 pacientes por grupo con asignación aleatoria. Para análisis de los grupos se usó estadística inferencial. Resultados: Se han incluido 47 pacientes hasta el momento, 29 se incluyeron en el grupo de dosis única y 18 en el grupo de dosis dividida. No se encontraron diferencias estadísticamente significativas en las variables demográficas de la población. Se revisó el grado de adherencia a cada régimen, sin encontrar diferencia estadísticamente significativa. Al analizar los hallazgos endoscópicos, un 64.3% de los pacientes en el grupo de dosis única tuvieron algún tipo de lesión y en el grupo de dosis dividida un 63.2% no tuvieron lesión con una diferencia estadísticamente significativa (p=0.04). El diferimiento fue similar en ambos grupos y en ninguno de los dos grupos se reportaron eventos adversos. La probabilidad de encontrar lesiones con un Boston aceptable (≥6) en pacientes de dosis única fue mayor, con una ORa de 3.03 (IC 95% 0.54 - 17.21), aunque sin diferencia estadísticamente significativa(p=0.21). Conclusiones: Será necesario esperar los resultados finales del estudio piloto y de acuerdo con ello valorar hacer el estudio con un mayor número de pacientes ya que si se encontró una tendencia hacia mayor detección de lesiones con el régimen de dosis única, aunque por el tamaño de muestra incluido hasta el momento no es posible tener conclusiones definitivas.

Abstract Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure. McCune et. al., in 1968, introduced this technique for the first time as a therapeutic tool. Up until now there are no guidelines for the diagnostic and therapeutic indications of ERCP and endoscopic ultrasound in children, however, recent studies have shown that these procedures in this age group have increased. In Mexico we have little experience with ERCP in children, and according to this we reporte de case of a 20 month year old patient in which diagnostic and therapeutic ERCP was performed. Objective: To describe the case of a 20 month year old patient with high risk of choledocholithiasis which underwent diagnostic and therapeutic ERCP. Material and methods: A male, 20 month year old patient was hospitalized presenting obstructive jaundice at the Instituto Nacional de Pediatric (INP) under the care of the Nutrition and Gastroenterology department. After the initial work up that included different blood tests and an abdominal ultrasound an ERCP was performed at the Hospital General “Dr. Manuel Gea González” finding abundant biliary sludge and detritus. The patient was kept under observation at the INP without presenting any complications. Results: The diagnostic and therapeutic ERCP was performed successfully. Conclusion: The procedure was used as a therapeutic tool and reported successful. The patient did not present complications after the procedure. The use of ERCP in Mexico is used poorly and rarely reported.

Resumen Introducción: La colangiopancreatografía retrógrada endoscópica (CPRE) es un procedimiento diagnóstico y terapéutico. Fue en el año de 1968 cuando McCune et. al., introdujo la técnica por primera vez como herramienta diagnóstica. Hasta este momento no existen guías clínicas sobre las indicaciones diagnósticas y terapeúticas del ultrasonido endoscópico y CPRE en niños, sin embargo, estudios recientes han mostrado que la realización de estos procedimientos en este grupo de edad, se han incrementado. En México se tiene poca experiencia de CPRE en niños, por lo que presentamos el caso de un paciente de 20 meses de edad al que se le realiza CPRE diagnóstica y terapéutica. Objetivo: Exponer el caso clínico de un paciente pediátrico de 20 meses de edad con riesgo alto de coledocolitiasis al cual se le realizó CPRE diagnóstica y terapéutica. Material y métodos: Paciente masculino de 20 meses de edad ingresado por ictericia obstructiva en el servicio de Gastroenterología y Nutrición del Instituto Nacional de Pediatría (INP), al cual, concluyendo el abordaje inicial, incluyendo laboratorios y ultrasonido de hígado y vías biliares, se realiza CPRE en el Hospital General “Dr. Manuel Gea González”. Se realiza CPRE con salida de abundante lodo biliar y detritus. El paciente permaneció en observación en el INP, sin presentar ninguna complicación. Resultados: Se realiza la CPRE diagnóstica y terapéutica de manera exitosa. Conclusiones: El estudio fue exitoso como herramienta terapéutica y el paciente no presentó complicaciones posterior al mismo. El uso de CPRE en México continúa siento.

Abstract Introduction: High variceal hemorrhage (HAV) in the cirrhotic patient is the most direct complication of portal hypertension and leads to high morbidity and mortality, however recent data suggest an improvement in these indicators when instituting advances in prophylaxis and treatment, however clinicians have poor adherence to the management guidelines of patients withacute variceal bleeding and this increases the morbidity and mortality of these patients. There are few epidemiological studies, however in several studies in Mexico consider variceal hemorrhage as the most frequent cause of high digestive bleeding. Objective: To describe the etiology, incidence and success rate in endoscopic treatment in patients with HAV. Material and methods: It is a retrospective descriptive observational study in patient who were asked for their endoscopic study due to high digestive bleeding. The study was conducted in the period from December 2017 to March 2019 in the Gastrointestinal endoscopy service of the Dr. Manuel Gea González General Hospital. Sociodemographic data were taken. 4095 endoscopies were performed, of which 2661 were due to high digestive bleeding and at the time of the study only 1.197 Panedoscopies were by HA V representing 45% of the studies. Results: The average age was 45 years (SD 13.07 2). The endoscopic diagnosis was very similar with 40% for small esophageal varices of BAVENO VI and esophageal varices with 40% each; followed with 15% for esophageal varices with gastric varices and only 5% with gastric varices. Patients with small esophageal varices of BAVENO were linked by 20% because they had poor prognosis data; large gastric varices were ligated in 80% of the cases, 1% argon plasma and 10% with sclerotherapy; GOV 1 gastric varices 80% were sclerosed withcyanoacrylate, 20% were ligated; GOV, VGA1, VGA2 were all used Cyanoacrylate, with a success rate in the treatment 90-95%. Conclusions: In our population, HV represents 4 5% of cases of high digestive bleeding. The frequency between small and large esophageal varices was similar with 40% each. The success rate was 90-95%, similar to the literature in India but lower in developed countries.

Resumen Introducción: La hemorragia alta variceal (HAV) en el paciente cirrótico es la complicación más directa de la hipertensión portal y conlleva una alta morbimortalidad, sin embargo datos recientes sugieren una mejoría en estos indicadores al instituir avances en la profilaxis y tratamiento, sin embargo los clínicos tienen un pobre apego a los lineamientos de manejo del paciente con sangrado variceal agudo y esto hace que incremente la morbimortalidad de estos pacientes. Se cuenta con pocos estudios epidemiológicos, sin embargo en varios estudios en México consideran la Hemorragia variceal como la causa más frecuente de sangrado digestivo alto. Objetivo: Describir la etiología, incidencia y tasa de éxito en el tratamiento endoscópico en los pacientes con HAV. Material y métodos: Es un estudio observacional descriptivo retrospectivo en pacientes a los cuales se les solicito su estudio endoscópico por sangrado digestivo alto. El estudio fue realizado en el periodo de Diciembre del 2017 a marzo 2019 en el servicio de endoscopia Gastrointestinal del Hospital General Dr. Manuel Gea González. Se tomaron datos sociodemográficos. Se realizaron 4095 endoscopias de las cuales 2,661 fueron por sangrado digestivo alto y al momento de concluir el estudio solamente 1,197 Panedoscopias fueron por HAV representando un 45% de los estudios. Resultados: La media de edad fue 45 años (DE 13.072). El diagnostico endoscópico fue muy similar con un 40% para Varices esofágicas pequeñas de BAVENO VI y Varices esofágicas con un 40% cada una; seguida con un 15% para varices esofágicas con varices gástricas y solamente un 5% con varices gástricas. Los pacientes con varices esofágicas pequeñas de BAVENO se ligaron en un 20% porque tenían datos de mal pronóstico; las varices gástricas grandes se ligaron en 80% de los casos, 1% argón plasma y 10% con escleroterapia; las varices gástricas GOV 1 el 80% se escleroso con cianoacrilato, 20% se ligaron; GOV, VGA1, VGA2 todas se utilizó Cianoacrilato, con una tasa de éxito en el tratamiento 90-95%. Conclusiones: En nuestra población la HV representa un 45% de los casos de Sangrado digestivo alto. La frecuencia entre las varices esofágicas pequeñas y grandes fue similar con 40% cada una. La tasa de éxito en fue de 90-95% una tasa similar a la literatura de la india pero inferior en los países desarrollados.

Abstract Background: The ideal therapeutic option for ventilator associated pneumonia caused by carbapenem-resistant Enterobacteriaceae is not defined. The aim of this study was to assess mortality-associated risk factors in patients with VAP by CRE and determine the outcome of several treatment options. Methods: This was a retrospective study performed in two tertiary hospitals involving patients with VAP caused by CRE between January 2010 and August 2014. The outcomes were mortality within 30 days of VAP diagnosis and overall mortality during hospital admission. Risk factors for mortality were assessed by comparing variables of survivors and non-survivors. Results: One hundred and twelve patients with CRE-VAP were included, 73 (65%) male, median age 56 years. The 30-day mortality was 57.1% and the overall hospital mortality was 67%. In the binary logistic regression analysis, only age >50 years was independently associated to increased mortality. Polymyxin was the most used drug (47.5%), followed by tigecycline (29.2%) and aminoglycosides (2.4%). Combined therapy with two active drugs was used by 17 patients (20.8%). No therapeutic option was independently associated to survival. However, combined therapy with two active drugs was superior to the therapy with a single active drug when inappropriate therapy was the comparator (p = 0.044). The addition of carbapenem was not associated with increased survival. Conclusion: The best therapeutic option for VAP by CRE is still not completely defined, but the therapy with at least two active drugs was superior in this study.

Background: Enterobacteris a common nosocomial microorganism and its carbapenem's resistance has increased. The management of these cases is unclear.Objective: We evaluated 16 patients with KPC-producing Enterobacter aerogenesinfections, detailing the site of infection, therapy, clinical and epidemiological data.Methods: A retrospective and descriptive study. Clinical data were revised and KPC-2 detection was by molecular methods. Risk factors associated with mortality were compared using appropriate tests according to variable type with a significance level of 0.05.Results: The 30-day mortality rate was 37.5% with no association with inadequate treatment. Age (p= 0.004) and Charlson score of comorbidities (p= 0.048) were independent risk factors associated with death in the multivariate analysis. The odds ratio for age >43 years was 3.00 (95% CI: 1.02-9.32) and for Charlson score >3 was 2.00 (95% CI: 1.08-3.71). Five strains were pan-resistant based on automated susceptibility tests. All patients were treated with monotherapy.Conclusion: The clinician should be alert to carbapenem-resistant Enterobacteriaceaeinfection in older patients with comorbidities. The mortality is high and we believe that prompt and adequate therapy must be employed.

ObjetivoAnálise dos casos de síndrome de encefalopatia posterior reversível (PRES) internados em um Serviço de Neurologia durante oito anos.MétodoEstudo restrospectivo observacional num hospital central do norte de Portugal.ResultadosIdentificaram-se 14 casos, idade média de 52,3 anos. Os factores precipitantes foram: eclâmpsia, hipertensão arterial isolada, traumatismos vertebro-medulares com disfunção autonómica, síndrome de Guillain-Barré, sépsis, sarcoidose e criptococose pulmonar e fármacos. A maioria dos doentes apresentou lesões edematosas de predomínio posterior, contudo 64,2% apresentaram lesões frontais e 42,8% apresentaram também lesões cerebelosas. Quatro doentes tinham lesões isquémicas agudas e um apresentou lesões hemorrágicas. Durante o seguimento, 10 doentes recuperaram totalmente, 2 recuperaram com sequelas, 1 teve recidiva e 2 faleceram durante o internamento.ConclusãoA PRES apresenta muitos factores precipitantes. As designações posterior e reversível deverão ser reequacionadas dado que a PRES afecta outras zonas do cérebro e nem sempre é reversível, apresentado complicações e mortalidade não negligenciáveis.

ObjectiveAnalyze the cases of posterior reversible encephalopathy syndrome (PRES) admitted in a Neurology Department during an 8-year period.MethodRetrospective observational study in a central hospital in the north of Portugal.Results14 patients were identified, mean age 52.3 years. Precipitating factors included: eclampsia, isolated arterial hypertension, spinal trauma and autonomic dysreflexia, Guillain-Barré syndrome, sepsis, sarcoidosis and pulmonary cryptococcosis and drugs. Most patients presented posterior-predominant vasogenic edema lesions, however 64.2% presented frontal lesions and in 42.8% cerebellum was involved. Four patients also had acute ischemic lesions and 1 had hemorrhagic lesions. During follow-up 10 patients recovered fully, 2 recovered partially, 1 suffered a recurrence and 2 died in hospital.ConclusionPRES has many etiological factors. The terms posterior and reversible should be revised because PRES frequently involves other brain regions and it is not always reversible. PRES patients may develop life-threatening complications and mortality is not negligible.

BACKGROUND: Local epidemiological data are always helpful when choosing the best antibiotic regimen, but it is more complex than it seems as it may require the analysis of multiple combinations. The aim of this study was to demonstrate a simplified mathematical calculation to determine the most appropriate antibiotic combination in a scenario where monotherapy is doomed to failure. METHODS: The susceptibility pattern of 11 antibiotics from 216 positive blood cultures from January 2012 to January 2013 was analyzed based on local policy. The length of hospitalization before bacteremia and the unit (ward or intensive care unit) were the analyzed variables. Bacteremia was classified as early, intermediate or late. The antibiotics were combined according to the combination model presented herein. RESULTS: A total of 55 possible mathematical associations were found combining 2 by 2, 165 associations with 3 by 3 and 330 combinations with 4 by 4. In the intensive care unit, monotherapy never reached 80% of susceptibility. In the ward, only carbapenems covered more than 90% of early bacteremia. Only three drugs combined reached a susceptibility rate higher than 90% anywhere in the hospital. Several regimens using four drugs combined reached 100% of susceptibility. CONCLUSIONS: Association of three drugs is necessary for adequate coverage of empirical treatment of bacteremia in both the intensive care unit and the ward.