Persistent Symptoms and Disability After COVID-19 Hospitalization: Data From a Comprehensive Telerehabilitation Program.

OBJECTIVE: To report symptoms, disability, and rehabilitation referral rates after coronavirus disease 2019 (COVID-19) hospitalization in a large, predominantly older population. DESIGN: Cross-sectional study, with postdischarge telemonitoring of individuals hospitalized with confirmed COVID-19 at the first month after hospital discharge, as part of a comprehensive telerehabilitation program. SETTING: Private verticalized health care network specialized in the older population. PARTICIPANTS: Individuals hospitalized because of COVID-19. We included 1696 consecutive patients, aged 71.8±13.0 years old and 56.1% female. Comorbidities were present in 82.3% of the cases (N=1696). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Dependence for basic activities of daily living (ADL) and instrumental activities of daily living (IADL) using the Barthel Index and Lawton's Scale. We compared the outcomes between participants admitted to the intensive care unit (ICU) vs those admitted to the ward. RESULTS: Participant were followed up for 21.8±11.7 days after discharge. During postdischarge assessment, independence for ADL was found to be lower in the group admitted to the ICU than the ward group (61.1% [95% confidence interval (CI), 55.8%-66.2%] vs 72.7% [95% CI, 70.3%-75.1%], P<.001). Dependence for IADL was also more frequent in the ICU group (84.6% [95% CI, 80.4%-88.2%] vs 74.5%, [95% CI, 72.0%-76.8%], P<.001). Individuals admitted to ICU required more oxygen therapy (25.5% vs 12.6%, P<.001), presented more shortness of breath during routine (45.2% vs 34.5%, P<.001) and nonroutine activities (66.3% vs 48.2%, P<.001), and had more difficulty standing up for 10 minutes (49.3% vs 37.9% P<.001). The rehabilitation treatment plan consisted mostly of exercise booklets, which were offered to 65.5% of participants. The most referred rehabilitation professionals were psychologists (11.8%), physical therapists (8.0%), dietitians (6.8%), and speech-language pathologists (4.6%). CONCLUSIONS: Individuals hospitalized because of COVID-19 present high levels of disability, dyspnea, dysphagia, and dependence for both ADL and IADL. Those admitted to the ICU presented more advanced disability parameters.

Intra-hospital complications in acute traumatic spinal cord injury / Complicações intra-hospitalares em pacientes com lesão medular traumática aguda

There is scarce data about intra-hospital complications in acute traumatic spinal cord injury (TSCI). Objective: To report characteristics of complications in patients with TSCI in a major trauma center. Method: This is a cross-sectional study with 434 patients with acute TSCI from 2004 to 2014. Outcomes were frequency and description of complications, length of hospital stay (LOS), and causes of increased LOS. Results: Patients presented at least 1 complication in 82.2% of the cases: urinary tract infection (UTI) = 64.4%, pressure ulcers (PU) = 50.6%, and pneumonia = 23.7%. Pneumonia, intubation and cases of surgical corrections for PU were independently associated with increased LOS. Conclusion: UTIs and PUs were the most frequent complications. Investigating its causes and consequences is paramount in the care of patients with SCI. Possible reasons for such complications could comprise time, and frequency of repositioning in bed. Investigating intra-hospital complications is paramount in SCI centers.

Há poucos dados sobre complicações hospitalares em pacientes com LMT aguda. Objetivo: Reportar as características de complicações em pacientes com LMT em um grande centro de trauma. Método: Estudo transversal com 434 pacientes com LMT aguda de 2004 a 2014. Os desfechos foram a frequência e característica das complicações, o tempo de internação (TDI), e fatores associados com seu aumento. Resultados: Incidência de complicações foi 82,2%, sendo as mais frequentes: infecção do trato urinário (ITU)=64,4%, úlcera de pressão (UP)= 50,6% e pneumonia= 23,7%. Pneumonia, intubação, e ser submetido a qualquer cirurgia para UP foram independentemente associados com aumento do TDI. Conclusão: ITUs e UP foram as complicações mais prevalentes, e devem ser melhor estudadas para melhor atenção a LMT. As investigações sobre as complicações na lesão medular traumática devem ser mandatórias nos centros e unidades dedicadas ao tratamento da Lesão Medular.

Viscosupplementation for Hip Osteoarthritis: A Systematic Review and Meta-Analysis of the Efficacy on Pain and Disability, and the Occurrence of Adverse Events.

OBJECTIVE: To assess the efficacy of viscosupplementation (hyaluronic acid [HA]) on the pain and disability caused by hip osteoarthritis, and to determine the occurrence of adverse events. DATA SOURCES: PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov database, and specific journals up to March 2017. STUDY SELECTION: Randomized controlled trials (RCTs) comparing HA with any other intra-articular injection. DATA EXTRACTION: Performed according to Cochrane/Grades of Recommendation, Assessment, Development, and Evaluation criteria. Two authors extracted data and assessed the risk of bias and quality of evidence. A random-effects meta-analysis was conducted. DATA SYNTHESIS: Eight RCTs were retrieved (n=807): 4 comparing HA to placebo; 3 to platelet-rich plasma (PRP); 3 to methylprednisolone; and 1 to mepivacaine. Some RCTs had 3 arms. There is very low evidence that HA is not superior to placebo for pain at 3 months (standardized mean difference [SMD]=-.06; 95% CI, -.38 to .25; P=.69), and high evidence that it is not superior in adverse events (risk ratio [RR]=1.21; 95% CI, .79-1.86; P=.38). There is low evidence that HA is not superior to PRP for pain at 1 month. There is very low evidence that HA is not superior to PRP for pain at 6 and 12 months (mean difference in visual analog scale [in cm]: -.05 [95% CI, -.81 to .71], 1.0 [95% CI, -1.5 to 3.50], and .81 [95% CI, -1.11 to 2.73], respectively). There is high evidence that HA is no different from methylprednisolone for pain at 1 month (SMD=.02; 95% CI, -.18 to .22; P=.85). There is low evidence that HA is no different from methylprednisolone for Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International Responders Index at 1 month (RR=.44; 95% CI, .10-1.95; P=.28). There is high evidence that HA is no different from methylprednisolone for adverse events (RR=1.21; 95% CI, .79-1.87; P=.38). CONCLUSIONS: We do not recommend viscosupplementation for hip osteoarthritis. Compared with placebo, data show scarce evidence of its efficacy up to 3 months, and suggest no difference at 6 months. However, future RCTs could present HA as an alternative to methylprednisolone for short-term symptom relief.

Terapia de ondas de choque focal para osteoartrose de joelho: um ensaio clínico randomizado duplo-cego / Focused extracorporeal shockwave therapy (f-ESWT) for knee osteoarthritis: a double-blind randomized clinical trial

Objetivo: Avaliar eficácia da terapia de ondas de choque focal (f-ESWT) comparada ao placebo para dor e incapacidade em pacientes com osteoartrose de joelho (OA). Métodos: Ensaio clínico randomizado, duplo-cego, placebo controlado, pacientes com OA primária de joelhos realizaram exercícios (alongamentos de isquiotibiais e fortalecimento de quadríceps) e randomizados em f-ESWT ou placebo. Todos os pacientes foram submetidos a 4 sessões semanais de 7.000 pulsos, e no grupo f-ESWT a energia foi de até 0.15mJ/mm2. O desfecho primário foi a escala analógica visual (VAS) para dor em 1 mês. Os desfechos secundários foram WOMAC, TUG, Lequesne e índice de resposta OMERACT-OARSI em 1 e 3 meses; bem como VAS aos 3 meses e eventos adversos (EAs). O teste de Mann-Whitney U e o teste exato Fisher foram utilizados com alfa = 5% e poder = 80% em uma análise de intenção de tratar. Os desfechos contínuos foram relatados como média ± desvio padrão. Resultados: 18 pacientes (9 em cada grupo), idade de 60.6±8.7 com 33.3% homens. Não houve diferença significativa entre grupos em qualquer variável. F-ESWT não foi superior ao placebo em 1 mês: VAS = -2,97 ± 3,18 e -2,68 ± 2,33 cm, respectivamente, p = 0,96. Somente o TUG no 1º mês foi significativo: 9.09 ± 2.30 e 11.01 ± 2.85 seg, p = 0.01. Conclusão: f-ESWT não foi superior ao placebo para osteoartrose de joelhos. Este estudo foi insuficiente para detectar diferenças. Novos estudos devem usar WOMAC A (subescala dor) como desfecho primário e recrutar 92 pacientes.

Objective: To assess the efficacy of focused extracorporeal shockwave therapy (f-ESWT) when compared to placebo for pain and disability in patients with knee osteoarthritis (OA). Methods: Randomized, parallel, double-blind, placebo-controlled clinical trial. Patients with primary knee OA were given a set of exercises (hamstring stretching and quadriceps strengthening) and randomized into f-ESWT or placebo (sham probe). All patients were submitted to 4 weekly sessions of 7,000 pulses, and in the f-ESWT group energy was up to 0.15mJ/mm2. Primary outcome was visual analog scale (VAS) for pain at 1 month. Secondary outcomes were WOMAC, TUG, Lequesne's index and OMERACT-OARSI responder index at 1 and 3 months; as well as VAS at 3 months and adverse events (AEs). Both patients and outcome assessors were blinded. Mann-Whitney U test and Fisher's exact test were used with alpha=5% and power=80% in an intention-to-treat analysis. Continuous outcomes were reported as mean± standard deviation. Results: 18 patients were included (9 in each group), aging 60.6±8.7, with 33.3% males. There was no significant difference at baseline across groups in any variables. f-ESWT was not superior to placebo at 1 month: VAS=-2.97±3.18 and -2.68±2.33cm, respectively, p=0.96. TUG at 1 month had significant differences: 9.09±2.30 and 11.01±2.85sec, p=0.01. No serious AEs were observed. Conclusions: f-ESWT was not superior to placebo for knee OA. This RCT was underpowered to detect differences in this study. New RCTs should use WOMAC A (pain subscale) as primary outcome and recruit at least 92 patients.

Long-acting muscarinic antagonists vs. long-acting ß 2 agonists in COPD exacerbations: a systematic review and meta-analysis.

OBJECTIVE: To determine whether long-acting muscarinic antagonists (LAMAs) provide superior therapeutic effects over long-acting ß2 agonists (LABAs) for preventing COPD exacerbations. METHODS: This was a systematic review and meta-analysis of randomized clinical trials involving patients with stable, moderate to severe COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria, treated with a LAMA (i.e., tiotropium bromide, aclidinium, or glycopyrronium), followed for at least 12 weeks and compared with controls using a LABA in isolation or in combination with a corticosteroid. RESULTS: A total of 2,622 studies were analyzed for possible inclusion on the basis of their title and abstract; 9 studies (17,120 participants) were included in the analysis. In comparison with LABAs, LAMAs led to a greater decrease in the exacerbation rate ratio (relative risk [RR] = 0.88; 95% CI: 0.84-0.93]; a lower proportion of patients who experienced at least one exacerbation (RR = 0.90; 95% CI: 0.87-0.94; p < 0.00001); a lower risk of exacerbation-related hospitalizations (RR = 0.78; 95% CI: 0.69-0.87; p < 0.0001); and a lower number of serious adverse events (RR = 0.81; 95% CI: 0.67-0.96; p = 0.0002). The overall quality of evidence was moderate for all outcomes. CONCLUSIONS: The major findings of this systematic review and meta-analysis were that LAMAs significantly reduced the exacerbation rate (exacerbation episodes/year), as well as the number of exacerbation episodes, of hospitalizations, and of serious adverse events.

Long-acting muscarinic antagonists vs. long-acting β 2 agonists in COPD exacerbations: a systematic review and meta-analysis / Antagonistas muscarínicos de longa duração vs. β 2 -agonistas de longa duração em exacerbações da DPOC: revisão sistemática e meta-análise

ABSTRACT Objective: To determine whether long-acting muscarinic antagonists (LAMAs) provide superior therapeutic effects over long-acting β2 agonists (LABAs) for preventing COPD exacerbations. Methods: This was a systematic review and meta-analysis of randomized clinical trials involving patients with stable, moderate to severe COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria, treated with a LAMA (i.e., tiotropium bromide, aclidinium, or glycopyrronium), followed for at least 12 weeks and compared with controls using a LABA in isolation or in combination with a corticosteroid. Results: A total of 2,622 studies were analyzed for possible inclusion on the basis of their title and abstract; 9 studies (17,120 participants) were included in the analysis. In comparison with LABAs, LAMAs led to a greater decrease in the exacerbation rate ratio (relative risk [RR] = 0.88; 95% CI: 0.84-0.93]; a lower proportion of patients who experienced at least one exacerbation (RR = 0.90; 95% CI: 0.87-0.94; p < 0.00001); a lower risk of exacerbation-related hospitalizations (RR = 0.78; 95% CI: 0.69-0.87; p < 0.0001); and a lower number of serious adverse events (RR = 0.81; 95% CI: 0.67-0.96; p = 0.0002). The overall quality of evidence was moderate for all outcomes. Conclusions: The major findings of this systematic review and meta-analysis were that LAMAs significantly reduced the exacerbation rate (exacerbation episodes/year), as well as the number of exacerbation episodes, of hospitalizations, and of serious adverse events.

RESUMO Objetivo: Determinar se long-acting muscarinic antagonists (LAMAs, antagonistas muscarínicos de longa duração) são superiores a long-acting β2 agonists (LABAs, β2-agonistas de longa duração) na prevenção de exacerbações da DPOC. Métodos: Revisão sistemática e meta-análise de ensaios clínicos controlados aleatórios com pacientes com DPOC estável, de moderada a grave, conforme os critérios da Global Initiative for Chronic Obstructive Lung Disease, tratados com LAMA (brometo de tiotrópio, aclidínio ou glicopirrônio), acompanhados durante pelo menos 12 semanas e comparados a controles que usaram LABA isoladamente ou com um corticosteroide. Resultados: Foram analisados 2.622 estudos para possível inclusão com base em seu título e resumo; 9 estudos (17.120 participantes) foram incluídos na análise. Em comparação com LABAs, LAMAs resultaram em maior diminuição da razão da taxa de exacerbações [risco relativo (RR) = 0,88; IC95%: 0,84-0,93]; menor proporção de pacientes que apresentaram pelo menos uma exacerbação (RR = 0,90; IC95%: 0,87-0,94; p < 0,00001); menor risco de hospitalizações em virtude de exacerbação da doença (RR = 0,78; IC95%: 0,69-0,87; p < 0,0001) e menor número de eventos adversos sérios (RR = 0,81; IC95%: 0,67-0,96; p = 0,0002). A qualidade geral das evidências foi moderada para todos os desfechos. Conclusões: O principal achado desta revisão sistemática e meta-análise foi que LAMAs reduziram significativamente a taxa de exacerbações (episódios de exacerbação/ano), os episódios de exacerbação, as hospitalizações e os eventos adversos sérios.

Short-term effects of fine particulate matter pollution on daily health events in Latin America: a systematic review and meta-analysis.

OBJECTIVES: Ambient air pollution is among the leading risks for health worldwide and by 2050 will largely overcome deaths due to unsafe sanitation and malaria, but local evidence from Latin America (LA) is scarce. We aimed to summarize the effect of short-term exposure to fine particulate air pollution (PM2.5) on morbidity and mortality in Latin America and evaluate evidence coverage and quality, using systematic review and meta-analysis. METHODS: The comprehensive search (six online databases and hand-searching) identified studies investigating the short-term associations between PM2.5 and daily health events in LA. Two reviewers independently accessed the internal validity of the studies and used random-effect models in the meta-analysis. RESULTS: We retrieved 1628 studies. Nine were elected for the qualitative analysis and seven for the quantitative analyses. Each 10 µg/m3 increments in daily PM2.5 concentrations was significantly associated with increased risk for respiratory and cardiovascular mortality in all-ages (polled RR = 1.02, 95% CI, 1.02-1.02 and RR = 1.01, 95% CI , 1.01-1.02, respectively). CONCLUSIONS: Short-term exposure to PM2.5 in LA is significantly associated with increased risk for respiratory and cardiovascular mortality. Evidence is concentrated in few cities and some presented high risk of bias.

A comparison between pulse pressure variation and right end diastolic volume index as guides to resuscitation in a model of hemorrhagic shock in pigs.

BACKGROUND: Different hemodynamic parameters including static indicators of cardiac preload as right ventricular end-diastolic volume index (RVEDVI) and dynamic parameters as pulse pressure variation (PPV) have been used in the decision-making process regarding volume expansion in critically ill patients. The objective of this study was to compare fluid resuscitation guided by either PPV or RVEDVI after experimentally induced hemorrhagic shock. METHODS: Twenty-six anesthetized and mechanically ventilated pigs were allocated into control (group I), PPV (group II), or RVEDVI (group III) group. Hemorrhagic shock was induced by blood withdrawal to target mean arterial pressure of 40 mm Hg, maintained for 60 minutes. Parameters were measured at baseline, time of shock, 60 minutes after shock, immediately after resuscitation with hydroxyethyl starch 6% (130/0.4), 1 hour and 2 hours thereafter. The endpoint of fluid resuscitation was determined as the baseline values of PPV and RVEDVI. Statistical analysis of data was based on analysis of variance for repeated measures followed by the Bonferroni test (p < 0.05). RESULTS: Volume and time to resuscitation were higher in group III than in group II (group III = 1,305 +/- 331 mL and group II = 965 +/- 245 mL, p < 0.05; and group III = 24.8 +/- 4.7 minutes and group II = 8.8 +/- 1.3 minutes, p < 0.05, respectively). All static and dynamic parameters and biomarkers of tissue oxygenation were affected by hemorrhagic shock and nearly all parameters were restored after resuscitation in both groups. CONCLUSION: In the proposed model of hemorrhagic shock, resuscitation to the established endpoints was achieved within a smaller amount of time and with less volume when guided by PPV than when guided by pulmonary artery catheter-derived RVEDVI.