Human papillomavirus infection: Epidemiology, biology, host interactions, cancer development, prevention, and therapeutics.

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections worldwide. It is caused by the HPV, a DNA virus that infects epithelial cells in various mucous membranes and skin surfaces. HPV can be categorised into high-risk and low-risk types based on their association with the development of certain cancers. High-risk HPV types, such as HPV-16 and HPV-18, are known to be oncogenic and are strongly associated with the development of cervical, anal, vaginal, vulvar, penile, and oropharyngeal cancers. These types of HPV can persist in the body for an extended period and, in some cases, lead to the formation of precancerous lesions that may progress to cancer if left untreated. Low-risk HPV types, such as HPV-6 and HPV-11, are not typically associated with cancer but can cause benign conditions like genital warts. Genital warts are characterised by the growth of small, cauliflower-like bumps on the genital and anal areas. Although not life-threatening, they can cause discomfort and psychological distress. HPV is primarily transmitted through sexual contact, including vaginal, anal, and oral sex. It can also be transmitted through non-penetrative sexual activities that involve skin-to-skin contact. In addition to sexual transmission, vertical transmission from mother to child during childbirth is possible but relatively rare. Prevention of HPV infection includes vaccination and safe sexual practices. HPV vaccines, such as Gardasil and Cervarix, are highly effective in preventing infection with the most common high-risk HPV types. These vaccines are typically administered to adolescents and young adults before they become sexually active. Safe sexual practices, such as consistent and correct condom use and limiting the number of sexual partners, can also reduce the risk of HPV transmission. Diagnosis of HPV infection can be challenging because the infection is often asymptomatic, especially in men. In women, HPV testing can be done through cervical screening programs, which involve the collection of cervical cells for analysis. Abnormal results may lead to further diagnostic procedures, such as colposcopy or biopsy, to detect precancerous or cancerous changes. Overall, HPV infection is a prevalent sexually transmitted infection with significant implications for public health. Vaccination, regular screening, and early treatment of precancerous lesions are key strategies to reduce the burden of HPV-related diseases and their associated complications. Education and awareness about HPV and its prevention are crucial in promoting optimal sexual health. This study aimed to carry out a literature review considering several aspects involving HPV infection: Global distribution, prevalence, biology, host interactions, cancer development, prevention, therapeutics, coinfection with other viruses, coinfection with bacteria, association with head and neck squamous cell carcinomas, and association with anal cancer.

Molecular evolution of SARS-CoV-2 from December 2019 to August 2022.

Severe acute respiratorysyndrome coronavirus-2 (SARS-CoV-2) pandemic spread rapidly and this scenario is concerning worldwide, presenting more than 590 million coronavirus disease 2019 cases and 6.4 million deaths. The emergence of novel lineages carrying several mutations in the spike protein has raised additional public health concerns worldwide during the pandemic. The present study review and summarizes the temporal spreading and molecular evolution of SARS-CoV-2 clades and variants worldwide. The evaluation of these data is important for understanding the evolutionary histories of SARSCoV-2 lineages, allowing us to identify the origins of each lineage of this virus responsible for one of the biggest pandemics in history. A total of 2897 SARS-CoV-2 whole-genome sequences with available information from the country and sampling date (December 2019 to August 2022), were obtained and were evaluated by Bayesian approach. The results demonstrated that the SARS-CoV-2 the time to the most recent common ancestor (tMRCA) in Asia was 2019-12-26 (highest posterior density 95% [HPD95%]: 2019-12-18; 2019-12-29), in Oceania 2020-01-24 (HPD95%: 2020-01-15; 2020-01-30), in Africa 2020-02-27 (HPD95%: 2020-02-21; 2020-03-04), in Europe 2020-02-27 (HPD95%: 2020-02-20; 2020-03-06), in North America 2020-03-12 (HPD95%: 2020-03-05; 2020-03-18), and in South America 2020-03-15 (HPD95%: 2020-03-09; 2020-03-28). Between December 2019 and June 2020, 11 clades were detected (20I [Alpha] and 19A, 19B, 20B, 20C, 20A, 20D, 20E [EU1], 20F, 20H [Beta]). From July to December 2020, 4 clades were identified (20J [Gamma, V3], 21 C [Epsilon], 21D [Eta], and 21G [Lambda]). Between January and June 2021, 3 clades of the Delta variant were detected (21A, 21I, and 21J). Between July and December 2021, two variants were detected, Delta (21A, 21I, and 21J) and Omicron (21K, 21L, 22B, and 22C). Between January and June 2022, the Delta (21I and 21J) and Omicron (21K, 21L, and 22A) variants were detected. Finally, between July and August 2022, 3 clades of Omicron were detected (22B, 22C, and 22D). Clade 19A was first detected in the SARS-CoV-2 pandemic (Wuhan strain) with origin in 2019-12-16 (HPD95%: 2019-12-15; 2019-12-25); 20I (Alpha) in 2020-11-24 (HPD95%: 2020-11-15; 2021-12-02); 20H (Beta) in 2020-11-25 (HPD95%: 2020-11-13; 2020-11-29); 20J (Gamma) was 2020-12-21 (HPD95%: 2020-11-05; 2021-01-15); 21A (Delta) in 2020-09-20 (HPD95%: 2020-05-17; 2021-02-03); 21J (Delta) in 2021-02-26 (2020-11-02; 2021-04-24); 21M (Omicron) in 2021-01-25 (HPD95%: 2020-09-16; 2021-08-08); 21K (Omicron) in 2021-07-30 (HPD95%: 2021-05-30; 2021-10-19); 21L (Omicron) in 2021-10-03 (HPD95%: 2021-04-16; 2021-12-23); 22B (Omicron) in 2022-01-25 (HPD95%: 2022-01-10; 2022-02-05); 21L in 2021-12-20 (HPD95%: 2021-05-16; 2021-12-31). Currently, the Omicron variant predominates worldwide, with the 21L clade branching into 3 (22A, 22B, and 22C). Phylogeographic data showed that Alpha variant originated in the United Kingdom, Beta in South Africa, Gamma in Brazil, Delta in India, Omicron in South Africa, Mu in Colombia, Epsilon in the United States of America, and Lambda in Peru. The COVID-19 pandemic has had a significant impact on global health worldwide and the present study provides an overview of the molecular evolution of SARS-CoV-2 lineage clades (from the Wuhan strain to the currently circulating lineages of the Omicron).

Molecular evolution of the human monkeypox virus.

Recently, in 2022, new cases of human monkeypox virus (hMPXV) occurred in Europe and North America. The first case was reported in Europe in May 2022, and subsequently, more than 50 000 new cases were confirmed in 100 countries. Currently, the classification of hMPXV according to the nextstrain occurs in five big clades (1A, A.1, A.2, A.1.1, and B.1). According to the resurgence of smallpox-like disease caused by hMPXV and the spread of the virus to the European and American continents, in the present study, we review and summarize the molecular evolution of the hMPXV, determining the molecular evolution of the main clades. A total of 442 hMPXV whole-genome sequences with available information from the country and sampling date (between October 2017 and 2022), were obtained and evaluated using the Bayesian method. The clade B.1 which is currently circulating was the most frequent (n = 415; 93.9%). The other clades presented the following frequencies: 1A (n = 13; 2.9%), A.1 (n = 10; 2.3%), A.2 (n = 3; 0.7%) and A.1.1 (n = 1; 0.2%) The overall nucleotide divergence of hMPXV was 5.590e-5. The 1A clade was detected between 2017 and 2020. A.1 was observed, and between 2019 and 2022 some A.2 sequences were detected. In 2022, the great predominance of B.1 was observed. The common ancestor of the hMPXV belongs to the clade 1A and the time to the Most Recent Common Ancestor (tMRCA) was 2017-04-04 (Highest Posterior Density 95% (HPD95%): 2017-03-09; 2017-08-04) on the West African continent. The tMRCA of A.1 was 2018-05-21 (HPD95%: 2018-05-20; 2018-07-04) with divergence of 6.885e-5 substitutions per site per year. This clade was of West African origin but was eventually detected in European countries. Also, A.2 was detected with sequences of North America and showed tMRCA of 2019-07-15 (HPD95%: 2018-11-18; 2020-02-24). A.1.1 showed tMRCA from 2021 to 06-05 (HPD95%: 2021-06-05; 2021-11-26) and this clade was detected in North America and was the precursor for the globally spreading B.1 which tMRCA was 2022-04-26 (HPD95%: 2022-02-27; 2022-04-26). hMPXV has been spread from West Africa to the United Kingdom, Israel, Singapore, the USA, Canada, Portugal, Spain, Ireland, France, Belgium, the Netherlands, Switzerland, Germany, Italy, Slovenia, Austria, the Republic Czech, Sweden, and Finland. hMPXV also reached countries such as Brazil, Mexico, Australia, and Taiwan. The common ancestor of the hMPXV belongs to the clade 1A with origin in the West African continent. Clade B.1 was responsible for the recent widespread worldwide. Immunization to prevent the spread of hMPXV is not yet available to the public, future studies should focus on the development of effective vaccines to contain the spread of this virus.

Molecular evolution of dengue virus: a Bayesian approach using 1581 whole-genome sequences from January 1944 to July 2022.

Dengue is a viral disease transmitted by mosquitoes that has spread rapidly across all continents in recent years. There are four distinct but closely related serotypes of the virus that causes dengue (DENV-1, DENV-2, DENV-3, and DENV-4). In the present study, we evaluated temporal spreading and molecular evolution of dengue virus (DENV) serotypes. Bayesian coalescent analysis was performed to study viral evolution, and it was estimated that the most recent common ancestor of DENV-1 was present in 1884 in Southeast Asia, that of DENV-2 was present in 1723 in Europe, that of DENV-3 was present in 1921 in Southeast Asia, and that of DENV-4 was present in 1876 in Southeast Asia. DENV appears to have originated in Spain in approximately 1682, and it was disseminated in Asia and Oceania in approximately 1847. After this period, the virus was introduced into North America in approximately 1890. In South America, it was first disseminated to Ecuador in approximately 1897 and then to Brazil in approximately 1910. Dengue has had a significant impact on global health worldwide, and the present study provides an overview of the molecular evolution of DENV serotypes.

Success and failure after surgery of degenerative disease of the lumbar spine: an operational definition based on satisfaction, pain, and disability from a prospective cohort.

BACKGROUND: To describe success and failure (S&F) after lumbar spine surgery in terms equally understandable across the entire health ecosystem. METHODS: Back and leg pain and disability were prospectively recorded before and up to 12 months after the procedure. Satisfaction was recorded using a Likert scale. Initially, patients were classified as satisfied or unsatisfied. Optimal satisfaction/unsatisfaction cutoff values for disability and pain were estimated with ROC curves. Satisfied and unsatisfied groups underwent a second subdivision into four subcategories: success (satisfied AND pain and disability concordant with cutoff values), incomplete success (satisfied AND pain and disability nonconformant with cutoff values), incomplete failure (unsatisfied AND pain and disability nonconformant with cutoff values), and failure (unsatisfied AND pain and disability concordant with cutoff values). RESULTS: A total of 486 consecutive patients were recruited from 2019-2021. The mean values of preoperative PROMs were ODI 42.2 (+ 16.4), NPRS back 6.6 (+ 2.6) and NPRS leg 6.2 points (+ 2.9). Of the total, 80.7% were classified as satisfied, and 19.3% were classified as unsatisfactory. The optimal disability and pain cutoff values for satisfaction/unsatisfaction (NPRS = 6, AND ODI = 27) defined a subdivision: 59.6% were classified as success, 20.4% as incomplete success, 7.1% as incomplete failure and 12.4% as failure. The descriptions of each group were translated to the following: success-all patients were satisfied and presented no or only mild to tolerable pain and no or borderline disability; incomplete success - all patients were satisfied despite levels of pain and/or disability worse than ideal for success; incomplete failure - all patients were not satisfied despite levels of pain and/or disability better than expected for failure; failure - all patients were unsatisfied and presented moderate to severe pain and disability. CONCLUSION: It is possible to report S&F after surgery for DDL with precise and meaningful operational definitions focused on the experience of the patient.

The critical illness polyneuropathy in septic patients with prolonged weaning from mechanical ventilation: is the diaphragm also affected? A pilot study.

BACKGROUND: Critical illness myopathy and/or neuropathy (CRIMYNE) is a common alteration seen in the ICU. The currently available bedside methods of measuring respiratory and peripheral muscle function in critically ill patients are somewhat inadequate. The objective of this study was to evaluate the presence of diaphragmatic and peripheral CRIMYNE in septic patients with prolonged weaning from mechanical ventilation (MV). METHODS: Cohort prospective study with an entry period of 6 months. In 2 Brazilian medical-surgical ICUs, septic patients ≥ 18 years of age, dependent on MV ≥ 14 days, requiring prolonged weaning from MV, awake (Richmond Agitation Sedation Scale ≥ -2), and with no previous history of polyneuropathy or myopathy were included. Electrophysiological studies of the limbs and also of the respiratory system by phrenic nerve conduction and needle electromyography of the diaphragm were performed in all subjects. RESULTS: Twelve subjects were enrolled during 6 months of study. The electrophysiological signs of peripheral CRIMYNE occurred in 9 subjects, 7 of whom died in the ICU. Three subjects developed critical illness polyneuropathy, 4 critical illness myopathy, and 2 both. Only one subject who developed peripheral CRIMYNE did not present diaphragmatic involvement, whereas no subject developed diaphragm involvement alone. Thus, electrophysiological signs of diaphragmatic CRIMYNE occurred in 8 of the 9 subjects with peripheral CRIMYNE. Upon clinical examination, 8 subjects were not able to moves their limbs against gravity, and these findings were related to the presence of peripheral and diaphragmatic dysfunction. CONCLUSIONS: Our pilot findings suggested that CRIMYNE is common in septic patients with prolonged weaning from MV (MV ≥ 14 d). The inability to move limbs against gravity is frequently associated with peripheral and diaphragmatic CRIMYNE, and the findings of CRIMYNE in peripheral electrophysiological tests are associated with diaphragmatic involvement.

Central venous saturation is a predictor of reintubation in difficult-to-wean patients.

OBJECTIVE: To evaluate the predictive value of central venous saturation to detect extubation failure in difficult-to-wean patients. DESIGN: Cohort, multicentric, clinical study. SETTING: Three medical-surgical intensive care units. PATIENTS: All difficult-to-wean patients (defined as failure to tolerate the first 2-hr T-tube trial), mechanically ventilated for >48 hrs, were extubated after undergoing a two-step weaning protocol (measurements of predictors followed by a T-tube trial). Extubation failure was defined as the need of reintubation within 48 hrs. INTERVENTIONS: The weaning protocol evaluated hemodynamic and ventilation parameters, and arterial and venous gases during mechanical ventilation (immediately before T-tube trial), and at the 30th min of spontaneous breathing trial. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients were enrolled in the study over a 6-mo period. Reintubation rate was 42.5%. Analysis by logistic regression revealed that central venous saturation was the only variable able to discriminate outcome of extubation. Reduction of central venous saturation by >4.5% was an independent predictor of reintubation, with odds ratio of 49.4 (95% confidence interval 12.1-201.5), a sensitivity of 88%, and a specificity of 95%. Reduction of central venous saturation during spontaneous breathing trial was associated with extubation failure and could reflect the increase of respiratory muscles oxygen consumption. CONCLUSIONS: Central venous saturation was an early and independent predictor of extubation failure and may be a valuable accurate parameter to be included in weaning protocols of difficult-to-wean patients.

Protocol implementation for venous thromboembolism prophylaxis: a before-and-after study in medical and surgical patients. / Implementação de protocolo para profilaxia de tromboembolismo venoso: um estudo antes e depois em pacientes clínicos e cirúrgicos.

OBJECTIVE: This study aimed to assess the adequacy of venous thromboembolism (VTE) prophylaxis prescription after a protocol implementation. METHODS: This was a before-and-after study conducted in a tertiary care hospital in Rio Grande do Sul, Southern Brazil. Medical and surgical inpatients aged 18 years or older were assessed for VTE risk and subsequently for thromboprophylaxis adequacy, according to their risk. The evaluations occurred before and after the protocol strategy implementation; it consisted of an online platform to access the protocol, a public posting of the protocol diagram, clinical alerts on the medical staff TV, e-mail alerts, and pop-up alerts on the computerized physician order entry system. The main outcome measure was the adequacy of VTE prophylaxis prescription according to the protocol. RESULTS: A total of 429 patients were evaluated for thromboprophylaxis adequacy (213 before and 216 after). The prevalence of adequacy increased from 54% to 63% (pre and post-intervention, respectively), and after adjustment for patient type and phase of the study, the prevalence ratio reached (PR)=1.20, 95% confidence interval (CI) 1.02-1.42. CONCLUSION: The results showed that the overall appropriateness of thromboprophylaxis prescription was weakly improved. Despite these results, this study provides evidence to date a bunch of strategies for protocol implementations in private institutions in middle-income countries with an open medical staff, as there are few studies investigating these simple and pragmatic interventions.

OBJETIVO: Este estudo visou avaliar a adequação da prescrição de profilaxia de tromboembolismo venoso (TEV) após a implementação do protocolo. MÉTODOS: Trata-se de um estudo antes e depois realizado em um hospital de cuidados terciários no Rio Grande do Sul, Brasil. Pacientes clínicos e cirúrgicos internados, com 18 anos ou mais, foram avaliados para o risco de TEV e, posteriormente, para adequação da tromboprofilaxia, de acordo com o risco. As avaliações ocorreram antes e depois de uma estratégia de implementação de protocolo, que consistiu em uma plataforma on-line para acessar o protocolo, uma postagem pública do diagrama do protocolo, alertas clínicos na sala de convívio médico, alertas de e-mail e alertas pop-up no sistema informatizado de prescrição médica. O Desfecho principal foi a adequação da prescrição de profilaxia do TEV de acordo com o protocolo. RESULTADOS: Foram avaliados 429 pacientes para adequação da tromboprofilaxia (213 antes e 216 depois). A prevalência de adequação aumentou de 54% para 63% (pré e pós-intervenção, respectivamente) e após o ajuste por tipo de paciente e fase do estudo, a razão de prevalência atingiu (RP) = 1,20, intervalo de confiança de 95% (IC) 1,02-1,42. CONCLUSÕES: os resultados mostraram que a adequação geral da prescrição de tromboprofilaxia foi discretamente melhorada. Apesar desses resultados, este estudo fornece evidências, até o momento, de uma série de estratégias para implementar o protocolo em instituições privadas em países de renda média com uma equipe médica aberta, pois há poucas pesquisas investigando esse tipo de intervenção simples e pragmática.

Clinical characteristics and predictors of mechanical ventilation in patients with COVID-19 hospitalized in Southern Brazil. / Características clínicas e preditores de ventilação mecânica em pacientes com COVID-19 hospitalizados no sul do país.

OBJECTIVE: This study aims to describe the clinical characteristics and predictors of mechanical ventilation of adult inpatients with COVID-19 in a single center. METHODS: A retrospective cohort study was performed and included adult inpatients hospitalized from March 17th to May 3rd, 2020, who were diagnosed with SARS-CoV-2 infection. Clinical and demographic characteristics were extracted from electronic medical records. RESULTS: Overall, 88 consecutive patients were included in this study. The median age of the patients was 63 years (IQR 49 - 71); 59 (67%) were male, 65 (86%) had a college degree and 67 (76%) had at least one comorbidity. Twenty-nine (33%) patients were admitted to the intensive care unit, 18 (20%) patients needed mechanical ventilation, and 9 (10.2%) died during hospitalization. The median length of stay in the intensive care unit and the median duration of mechanical ventilation was 23 and 29.5 days, respectively. An age ≥ 65 years was an independent risk factor for mechanical ventilation (OR 8.4 95%CI 1.3 - 55.6 p = 0.02). CONCLUSION: Our findings describe the first wave of Brazilian patients hospitalized for COVID-19. Age was the strongest predictor of respiratory insufficiency and the need for mechanical ventilation in our population.

OBJETIVO: Descrever as características clínicas e os preditores de ventilação mecânica em pacientes adultos internados com COVID-19. MÉTODOS: Conduziu-se um estudo de coorte retrospectiva com inclusão de pacientes hospitalizados entre 17 de março e 3 de maio de 2020, que tiveram o diagnóstico de infecção pelo SARS-CoV-2. As características clínicas e demográficas foram extraídas de registros em prontuário eletrônico. RESULTADOS: Incluíram-se no estudo 88 pacientes consecutivos. A mediana da idade dos pacientes foi de 63 anos (IQR: 49 - 71); 59 (67%) pacientes eram do sexo masculino, 65 (86%) tinham educação universitária e 67 (76%) tinham, no mínimo, uma comorbidade. Dentre eles, 29 (33%) pacientes foram admitidos à unidade de terapia intensiva, 18 (20%) necessitaram de ventilação mecânica e nove (10,2%) morreram durante a hospitalização. O tempo mediano de permanência na unidade de terapia intensiva e o tempo mediano de ventilação mecânica foram, respectivamente, de 23 e 29,5 dias. Idade acima ou igual a 65 anos foi fator de risco independente para ventilação mecânica (RC: 8,4; IC95% de 1,3 - 55,6; valor de p = 0,02). CONCLUSÃO: Nossos achados descrevem a primeira onda de pacientes brasileiros hospitalizados por COVID-19. Em nossa população, idade foi o maior preditor de insuficiência respiratória e necessidade de ventilação mecânica.

Association between electromyographical findings and intensive care unit mortality among mechanically ventilated acute respiratory distress syndrome patients under profound sedation. / Associação entre achados eletromiográficos e mortalidade na unidade de terapia intensiva em pacientes com síndrome do desconforto respiratório agudo mecanicamente ventilados sob sedação profunda.

OBJECTIVE: To evaluate whether electromyographical findings could predict intensive care unit mortality among mechanically ventilated septic patients under profound sedation. METHODS: A prospective cohort study that consecutively enrolled moderate-severe acute respiratory distress syndrome (partial pressure of oxygen/fraction of inspired oxygen < 200) patients who were ≥ 18 years of age, dependent on mechanical ventilation for ≥ 7 days, and under profound sedation (Richmond Agitation Sedation Scale ≤ -4) was conducted. Electromyographic studies of the limbs were performed in all patients between the 7th and the 10th day of mechanical ventilation. Sensory nerve action potentials were recorded from the median and sural nerves. The compound muscle action potentials were recorded from the median (abductor pollicis brevis muscle) and common peroneal (extensor digitorum brevis muscle) nerves. RESULTS: Seventeen patients were enrolled during the seven months of the study. Nine patients (53%) had electromyographic signs of critical illness myopathy or neuropathy. The risk of death during the intensive care unit stay was increased in patients with electromyographical signs of critical illness myopathy or neuropathy in comparison to those without these diagnostics (77.7% versus 12.5%, log-rank p = 0.02). CONCLUSION: Electromyographical signs of critical illness myopathy or neuropathy between the 7th and the 10th day of mechanical ventilation may be associated with intensive care unit mortality among moderate-severe acute respiratory distress syndrome patients under profound sedation, in whom clinical strength assessment is not possible.

OBJETIVO: Avaliar se os achados eletromiográficos podem prever a mortalidade na unidade de terapia intensiva em pacientes sépticos sob ventilação mecânica e sedação profunda. MÉTODOS: Conduziu-se estudo prospectivo de coorte, que inscreveu, de forma consecutiva, pacientes com síndrome do desconforto respiratório agudo moderada a grave (pressão parcial de oxigênio/fração inspirada de oxigênio < 200) com idade ≥ 18 anos, dependentes de ventilação mecânica por 7 ou mais dias, e mantidos sob sedação profunda (escala de agitação e sedação de Richmond ≤ -4). Realizaram-se estudos eletromiográficos dos membros inferiores em todos os pacientes entre o sétimo e o décimo dia de ventilação mecânica. Registraram-se os potenciais de ação dos nervos sensitivos nos nervos mediano e sural, bem como os potenciais de ação compostos para os nervos mediano (músculo abdutor curto do polegar) e fibular comum (músculo extensor curto dos dedos). RESULTADOS: Foram inscritos 17 pacientes durante os 7 meses de duração do estudo. Nove pacientes (53%) tinham sinais eletromiográficos de miopatia ou polineuropatia da doença crítica. O risco de óbito durante o tempo de permanência na unidade de terapia intensiva foi mais elevado nos pacientes com sinais eletromiográficos de miopatia ou polineuropatia da doença crítica, em comparação com aqueles sem esses diagnósticos (77,7% versus 12,5%; log-rank p = 0,02). CONCLUSÃO: A presença de sinais eletromiográficos de miopatia ou polineuropatia da doença crítica, entre o sétimo e décimo dias de ventilação mecânica, pode se associar com mortalidade na unidade de terapia intensiva em pacientes com síndrome do desconforto respiratório agudo moderada a grave mantidos sob sedação profunda, nos quais não é possível proceder à avaliação clínica da força muscular.

Hospital mortality rates between 2015 and 2022: a comparison between the pre-pandemic and pandemic period shows that COVID-19 is a critical health problem

Introduction: COVID-19 caused 6.2 million deaths in the world. The present study aims to evaluate hospital mortality rates from 2015 to 2022, to compare the pre and during the pandemic period.Methods: The study was carried out in a private hospital in southern Brazil. 174,013 hospital discharges between January 2015 and March 2022 were analyzed. Pearson's chi-squared test was performed to evaluate the mortality rate by year. Differences between mortality rates before and during the pandemic was tested with Student's t-test. P-values < 0.05 for all tests were considered significant.Results: Mortality rates were 2.29% in 2015; 2.37% in 2016; 2.25% in 2017; 2.31% in 2018; 2.46% in 2019; 3.45% in 2020; 3.58% in 2021 and 2.77% in 2022 (p< 0.01). The mortality for 2020 and 2021 was higher than in the other years (3.50% ± 0.14 vs 2.34% ± 0.05; p < 0.01).Conclusion: The mortality rates were significantly higher in the years 2020 and 2021, demonstrating that COVID-19 is a critical health problem.

Impact of mechanical ventilation on quality of life and functional status after ICU discharge: A cross-sectional study.

OBJECTIVE: To evaluate the impact of the need for mechanical ventilation (MV) and its duration throughout ICU stay on the quality of life (QoL) and physical functional status (PFS) after the immediate ICU discharge. METHOD: This was a cross-sectional study including all subjects consecutively discharged from the ICU during 1-year period. During the first week after ICU discharge, QoL was assessed through WHOQoL-Bref questionnaire and PFS through the Karnofsky Performance Status and modified-Barthel index, and retrospectively compared with the pre-admission status (variation [Δ] of indexes). RESULTS: During the study, 160 subjects met the inclusion criteria. Subjects receiving MV presented PFS impairment (Δ Karnofsky Performance Status [-19.7 ± 20.0 vs. -14.9 ± 18.2; p=0.04] and Δ modified-Barthel index [-17.4 ± 12.8 vs. -13.2 ± 12.9; p=0.05]) compared with those who did not receive MV. Duration of MV was a good predictor of PFS (Δ Karnofsky Performance Status [-14.6-1.12 * total days of MV; p=0.01] and Δ modified-Barthel index [-14.2-0.74 * total days of MV; p=0.01]). QoL, assessed by WHOQoL-Bref, showed no difference between groups (14.0 ± 1.8 vs. 14.5 ± 1.9; p=0.14), and the duration of MV did not influence QoL (WHOQoL-Bref scale [14.2-0.05* total days of MV; p=0.43]). CONCLUSION: Need for MV and duration of MV decrease patient PFS after ICU discharge.

Corrigendum to "Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes".

[This corrects the article DOI: 10.1155/2016/6568531.].

Quality of life after intensive care unit: a multicenter cohort study protocol for assessment of long-term outcomes among intensive care survivors in Brazil. / Qualidade de vida pós-unidades de terapia intensiva: protocolo de estudo de coorte multicêntrico para avaliação de desfechos em longo prazo em sobreviventes de internação em unidades de terapia intensiva brasileiras.

OBJECTIVE: To establish the prevalence of physical, cognitive and psychiatric disabilities, associated factors and their relationship with the qualities of life of intensive care survivors in Brazil. METHODS: A prospective multicenter cohort study is currently being conducted at 10 adult medical-surgical intensive care units representative of the 5 Brazilian geopolitical regions. Patients aged ≥ 18 years who are discharged from the participating intensive care units and stay 72 hours or more in the intensive care unit for medical or emergency surgery admissions or 120 hours or more for elective surgery admissions are consecutively included. Patients are followed up for a period of one year by means of structured telephone interviews conducted at 3, 6 and 12 months after discharge from the intensive care unit. The outcomes are functional dependence, cognitive dysfunction, anxiety and depression symptoms, posttraumatic stress symptoms, health-related quality of life, rehospitalization and long-term mortality. DISCUSSION: The present study has the potential to contribute to current knowledge of the prevalence and factors associated with postintensive care syndrome among adult intensive care survivors in Brazil. In addition, an association might be established between postintensive care syndrome and health-related quality of life.

OBJETIVO: Avaliar a prevalência de incapacidades físicas, cognitivas e psiquiátricas, fatores associados e sua relação com qualidade de vida em pacientes sobreviventes de internação em unidades de terapia intensiva brasileiras. MÉTODOS: Um estudo de coorte prospectivo multicêntrico está sendo conduzido em dez unidades de terapia intensiva adulto clínico-cirúrgicas representativas das cinco regiões geopolíticas do Brasil. Pacientes com idade ≥ 18 anos que receberam alta das unidades de terapia intensiva participantes e permaneceram internados na unidade de terapia intensiva por 72 horas ou mais, nos casos de internação clínica ou cirúrgica de urgência, e por 120 horas ou mais, nos casos de internação cirúrgica eletiva, serão incluídos de forma consecutiva. Estes pacientes serão seguidos por 1 ano, por meio de entrevistas telefônicas estruturadas 3, 6 e 12 meses pós-alta da unidade de terapia intensiva. Dependência funcional, disfunção cognitiva, sintomas de ansiedade e depressão, sintomas de estresse pós-traumático, qualidade de vida relacionada à saúde, re-hospitalizações e mortalidade em longo prazo serão avaliados como desfechos. DISCUSSÃO: O presente estudo tem o potencial de contribuir para o conhecimento a respeito da prevalência e dos fatores associados à síndrome pós-cuidados intensivos na população de pacientes adultos sobreviventes de internação em unidades de terapia intensiva brasileiras. Ademais, a associação entre síndrome pós-cuidados intensivos e qualidade de vida relacionada à saúde poderá ser estabelecida.

COVID-19: hypernatremia is a significant predictor of mortality

Introduction: Coronavirus disease 2019 (COVID-19) pandemic spread rapidly, creating a worrisome scenario worldwide. In hospitalized patients, dysnatremia (hyponatremia and/or hypernatremia) is the most common electrolyte disturbance, reported in 30­40% of cases and associated with a poor prognosis. This study aimed to evaluate the association between dysnatremia and mortality in hospitalized patients infected with SARS-COV-2. Methods: Retrospective longitudinal study that analyzed data from hospital records of 1,000 patients with COVID-19 (median age, 62.5 years; 57.1% men), including 109 (10.9%) deaths. Kaplan-Meier survival curves and Cox proportional hazard models with Hazard Ratio (HR) with 95% confidence intervals (95%CI) were applied to confirm the association between dysnatremia (hyponatremia and/or hypernatremia) and death. Results: Hypernatremia was detected in 83 (76.1%) of the patients who died, with a cumulative reduction in survival (p < 0.01) and a 2.42-fold increased mortality risk (95%CI: 1.45­2.91). In the multivariable analysis, hypernatremia was the main factor associated with increased mortality (HR: 1.50; 95%CI: 1.23­1.81). Long length of stay (LOS) (HR: 1.54; 95%CI: 1.21­1.78), old age (HR: 1.63; 95%CI: 1.28­1.88), and chronic kidney disease (HR: 1.77; 95%CI: 1.21­3.30) were also associated with death. Conclusion: Hypernatremia during hospitalization is an important risk factor for poor prognosis and an increased mortality risk. LOS, old age, and chronic kidney disease could also be used for risk stratification in patients with COVID-19.

Behavior of lung ultrasound findings during spontaneous breathing trial. / Comportamento dos achados de ultrassonografia pulmonar durante tentativa de respiração espontânea.

OBJECTIVE: We aimed to investigate a potential association between B-lines and weaning failure. METHODS: Fifty-seven subjects eligible for ventilation liberation were enrolled. Patients with tracheostomy were excluded. Lung ultrasound assessments of six thoracic zones were performed immediately before and at the exnd of the spontaneous breathing trial. B-predominance was defined as any profile with anterior bilateral B-pattern. Patients were followed up to 48 hours after extubation. RESULTS: Thirty-eight individuals were successfully extubated; 11 failed the spontaneous breathing trial and 8 needed reintubation within 48 hours of extubation. At the beginning of the T-piece trial, B-pattern or consolidation was already found at the lower and posterior lung regions in more than half of the individuals and remained non-aerated at the end of the trial. A trend toward loss of lung aeration during spontaneous breathing trials was observed only in the spontaneous breathing trial-failure group (p = 0.07), and there was higher B-predominance at the end of the trial (p = 0.01). CONCLUSION: A loss of lung aeration during the spontaneous breathing trial in non-dependent lung zones was demonstrated in subjects who failed to wean.

OBJETIVO: Investigar potencial associação entre a presença de linhas B e a falha do desmame. MÉTODOS: Foram inscritos 57 pacientes elegíveis para liberação da ventilação. Excluíram-se pacientes com traqueostomia. Realizou-se avaliação ultrassonográfica pulmonar de seis zonas torácicas imediatamente antes e após o final da tentativa de respiração espontânea. Definiu-se a predominância de linhas B como qualquer perfil com padrão B bilateral anterior. Os pacientes foram seguidos por 48 horas após a extubação. RESULTADOS: Foram extubados com sucesso 38 pacientes; 11 tiveram falha da tentativa de respiração espontânea; e 8 necessitaram de reintubação dentro de 48 horas após extubados. No início da tentativa com peça T, já se observava padrão B ou consolidação nas regiões posterior e inferior dos pulmões em mais de metade dos indivíduos, que permaneceram não aeradas ao final da tentativa. Observou-se certa tendência à perda da aeração pulmonar durante a tentativa de respiração espontânea apenas no grupo com falha da tentativa de respiração espontânea (p = 0,07), assim como maior predominância de padrão B ao final da tentativa (p = 0,01). CONCLUSÃO: A perda de aeração pulmonar durante a tentativa de respiração espontânea em áreas pulmonares não dependentes foi demonstrada em pacientes que tiveram falha do desmame.

Mortality of Adult Critically Ill Subjects With Cancer.

BACKGROUND: Cancer patients may require intensive care support for postoperative care, complications associated with underlying malignancy, or toxicities related to cancer therapy. The higher mortality rates found in this population than in the population of ICU patients without cancer may be attributable to confounding due to a higher prevalence of multiple organic dysfunctions at ICU admission in patients with malignancy; however, data regarding this hypothesis are scarce. Accordingly, we performed the present study to compare the crude and propensity score-matched mortality rates between adult subjects with and without cancer admitted to a mixed medical-surgical ICU. METHODS: We conducted a retrospective analysis of a comprehensive longitudinal ICU database in a tertiary referral hospital in Southern Brazil. All adult subjects who were admitted to the ICU from January 2008 to December 2014 were evaluated. Crude and propensity score-matched all-cause 30-d mortality rates of critically ill subjects with cancer were compared with those of critically ill subjects without cancer. RESULTS: A total of 4,221 subjects were evaluated. The survival analysis revealed that the crude mortality rate was higher among subjects with cancer than among subjects without cancer (18.7% vs 10.2%, P < .001). However, after matching by propensity score, the 30-d mortality rates of subjects with and without cancer were similar (18.5% vs 15.2%, P = .17). CONCLUSIONS: The present study failed to show an association between malignancy and all-cause 30-d mortality rate in adult subjects admitted to a mixed medical-surgical ICU. The propensity score-matched analysis showed no evidence of excessive mortality due to cancer diagnosis.

Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes.

Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, P = 0.003). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge.

Inhalation injury after exposure to indoor fire and smoke: The Brazilian disaster experience.

OBJECTIVE: To describe the pre-hospital, emergency department, and intensive care unit (ICU) care and prognosis of patients with inhalation injury after exposure to indoor fire and smoke. MATERIALS AND METHODS: This is a prospective observational cohort study that includes patients admitted to seven ICUs after a fire disaster. The following data were collected: demographic characteristics; use of fiberoptic bronchoscopy; degree of inhalation injury; percentage of burned body surface area; mechanical ventilation parameters; and subsequent events during ICU stay. Patients were followed to determine the ICU and hospital mortality rates. RESULTS: Within 24h of the incident, 68 patients were admitted to seven ICUs. The patients were young and had no comorbidities. Most patients (n=35; 51.5%) only had an inhalation injury. The mean ventilator-free days for patients with an inhalation injury degree of 0 or I was 12.5±8.1 days. For patients with an inhalation injury degree of II or III, the mean ventilator-free days was 9.4±5.8 days (p=0.12). In terms of the length of ICU stay for patients with degrees 0 or I, and patients with degrees II or III, the median was 7.0 days (5.0-8.0 days) and 12.0 days (8.0-23.0 days) (p<0.001), respectively. In addition, patients with a larger percentage of burned surface areas also had a longer ICU stay; however, no association with ventilator-free days was found. The patients with <10% of burned body surface area showed a mean of 9.2±5.4 ventilator-free days. The mean ventilator-free days for patients who had >10% burned body surface area was 11.9±9.5 (p=0.26). The length of ICU stay for the <10% and >10% burned body surface area patients was 7.0 days (5.0-10.0 days) and 23.0 days (11.5-25.5 days) (p<0.001), respectively. CONCLUSIONS: We conclude that burn patients with inhalation injuries have different courses of disease, which are mainly determined by the percentage of burned body surface area.