Ventilator-associated pneumonia (VAP) is a prevailing nosocomial infection in critically ill patients requiring invasive mechanical ventilation (iMV). The impact of VAP is profound, adversely affecting patient outcomes and placing a significant burden on healthcare resources. This study assessed for the first time the contemporary VAP epidemiology in Portugal and its burden on the healthcare system and clinical outcomes. Additionally, resource consumption (duration of iMV, intensive care unit (ICU), hospital length of stay (LOS)) and empirical antimicrobial therapy were also evaluated. This multicenter, retrospective study included patients admitted to the hospital between July 2016 and December 2017 in a participating ICU, who underwent iMV for at least 48 h. Patients with a VAP diagnosis were segregated for further analysis (n = 197). Control patients, ventilated for >48 h but without a VAP diagnosis, were also included in a 1:1 ratio. Cumulative VAP incidence was computed. All-cause mortality was assessed at 28, 90, and 365 days after ICU admission. Cumulative VAP incidence was 9.2% (95% CI 8.0–10.5). The all-cause mortality rate in VAP patients was 24.9%, 34.0%, and 40.6%, respectively, and these values were similar to those observed in patients without VAP diagnosis. Further, patients with VAP had significantly longer ICU (27.5 vs. 11.0 days, p < 0.001) and hospital LOS (61 vs. 35.9 days, p < 0.001), more time under iMV (20.7 vs. 8.0 days, p < 0.001) and were more often subjected to tracheostomy (36.5 vs. 14.2%; p < 0.001). Patients with VAP who received inappropriate empirical antimicrobials had higher 28-day mortality, 34.3% vs. 19.5% (odds ratio 2.16, 95% CI 1.10–4.23), although the same was not independently associated with 1-year all-cause mortality (p = 0.107). This study described the VAP impact and burden on the Portuguese healthcare system, with approximately 9% of patients undergoing iMV for >48 h developing VAP, leading to increased resource consumption (longer ICU and hospital LOS). An unexpectedly high incidence of inappropriate, empirical antimicrobial therapy was also noted, being positively associated with a higher mortality risk of these patients. Knowledge of the Portuguese epidemiology characterization of VAP and its multidimensional impact is essential for efficient treatment and optimized long-term health outcomes of these patients.

Background: We aimed to explore immune parameters in COVID-19 patients admitted to the intensive care unit (ICU) to identify distinctive features in patients with cardiac injury. Methods: A total of 30 COVID-19 patients >18 years admitted to the ICU were studied on days D1, D3 and D7 after admission. Cardiac function was assessed using speckle-tracking echocardiography (STE). Peripheral blood immunophenotyping, cardiac (pro-BNP; troponin) and inflammatory biomarkers were simultaneously evaluated. Results: Cardiac dysfunction (DYS) was detected by STE in 73% of patients: 40% left ventricle (LV) systolic dysfunction, 60% LV diastolic dysfunction, 37% right ventricle systolic dysfunction. High-sensitivity cardiac troponin (hs-cTn) was detectable in 43.3% of the patients with a median value of 13.00 ng/L. There were no significant differences between DYS and nDYS patients regarding mortality, organ dysfunction, cardiac (including hs-cTn) or inflammatory biomarkers. Patients with DYS showed persistently lower lymphocyte counts (median 896 [661–1837] cells/µL vs. 2141 [924–3306] cells/µL, p = 0.058), activated CD3 (median 85 [66–170] cells/µL vs. 186 [142–259] cells/µL, p = 0.047) and CD4 T cells (median 33 [28–40] cells/µL vs. 63 [48–79] cells/µL, p = 0.005), and higher effector memory T cells (TEM) at baseline (CD4%: 10.9 [6.4–19.2] vs. 5.9 [4.2–12.8], p = 0.025; CD8%: 15.7 [7.9–22.8] vs. 8.1 [7.7–13.7], p = 0.035; CD8 counts: 40 cells/µL [17–61] vs. 10 cells/µL [7–17], p = 0.011) than patients without cardiac dysfunction. Conclusion: Our study suggests an association between the immunological trait and cardiac dysfunction in severe COVID-19 patients.

We report a clinical case of a 39-year old male, without any known previous medical condition but with occupational exposure to paints and dust cement, who presented an autoimmune pulmonary alveolar proteinosis (PAP) triggered by exposure to toxic inhalation at his workplace. PAP is a rare lung disease characterized by intra-alveolar abnormal accumulation of surfactant. The presence of a crazy-paving pattern in high-resolution computed tomography scan brings the suspicion of PAP although histopathology results of bronchoalveolar lavage are always required for its final diagnosis. The autoimmune form of PAP due to toxic inhalation, such as the one here described, is rare and it is usually difficult to establish a causal relationship.

Background and importance In the context of the COVID-19 pandemic, many patients avoided moving from their homes, even to acquire essential drugs, such as antiretroviral therapy (ART). High adherence (more than 95%) is essential to acquire viral suppression and is associated with reduced mortality and morbidity. Furthermore, poor ART adherence is the first cause of therapeutic failure in HIV patients and HIV drug resistant strains. Aim and objectives To evaluate and characterise the effect of the COVID-19 pandemic on adherence to ART and identify the main factors that influenced adherence during the pandemic. Material and methods A retrospective, transversal, comparative study was conducted over the first semester of 2019 and 2020. HIV patients receiving ART were included. Exclusion criteria were: deaths, initiated ART during or after the first semester in 2019 and transfer to another hospital. To measure adherence, dispensing records were analysed. Registered variables were sex, risk factors that could compromise adherence and pill numbers. Data were obtained from the electronic medical records. For the statistical analysis, the paired t test was used to determine if there were differences in patient adherence before and after the COVID-19 pandemic. Results 100 patients were analysed during the study period, with an average age of 48.9±12.3 years and 61% were men. ART adherence was 67% in 2019 (67% male non-adherent) whereas in 2020 it was 43% (58% male non-adherent). Comparing both years, there was a decrease of 24% in the adherence rate, which was significant (p=0.006). The main reasons for this reduction were: rescheduling of doctor appointments or blood tests, mandatory confinement due to COVID-19 or fear of using the hospital facilities. Conclusion and relevance The study results suggested that the COVID-19 pandemic affected HIV patient adherence. All efforts made to ensure continuity of treatment (medication delivery in the community and hospital pharmacies, teleconsultation) were not enough. It is important that pharmacists continue to promote therapeutic adherence and education about COVID-19. The main limitation of the study was the reduced sample used. It is highly important to monitor patients with ART to ensure their adherence rate and to understand how and why the COVID-19 pandemic affected their treatment. Further research is needed to know the real impact of the COVID-19 pandemic on the health of HIV patients. Conflict of interest No conflict of interest

The Lazarus phenomenon, or auto-resuscitation, refers to the spontaneous return of circulation (ROSC) after failed cardiopulmonary resuscitation (CPR). First described in 1982, it remains rare and poorly understood, with clinical and ethical implications regarding death declaration and organ donation. Proposed mechanisms include pulmonary hyperinflation, delayed drug effects, myocardial stunning, and absent reflexive brainstem activity. We present the case of a 71-year-old man admitted after cranial and thoracic trauma from a fall. He exhibited mild hypoxemia and confusion but suffered a cardiorespiratory arrest while awaiting further evaluation. CPR was initiated per Advanced Life Support (ALS) protocol. Cardiac tamponade was ruled out by bedside echocardiography. After 20 minutes of asystole with low capnography values, CPR was halted, and death was declared. Approximately one minute later, the patient spontaneously achieved ROSC but without respiratory drive. He was stabilized and transferred to the ICU. Imaging revealed subarachnoid hemorrhage, frontal bone and C7 fractures, and rib fractures, but no pneumothorax or hemothorax. Despite interventions, he ultimately died. Possible mechanisms for ROSC include relief of intrathoracic pressure, delayed drug effects, and improved cerebral perfusion after cervical collar removal. This case highlights the need for caution in declaring death and further research into auto-resuscitation.