University Pharmacy: from the foundation to the Pandemic times of Covid-19

Abstract The University Pharmacy Program (FU), from the Federal University of Rio de Janeiro (UFRJ), was created based on the need to offer a curricular internship to students of the Undergraduate Course at the Faculty of Pharmacy. Currently, it is responsible for the care of about 200 patients/day, offering vacancies for curricular internships for students in the Pharmacy course, it has become a reference in the manipulation of many drugs neglected by the pharmaceutical industry and provides access to medicines for low-income users playing an important social function. Research is one of the pillars of FU-UFRJ and several master and doctoral students use the FU research laboratory in the development of dissertations and theses. As of 2002, the Pharmaceutical Care extension projects started to guarantee a rational and safe pharmacotherapy for the medicine users. From its beginning in 1982 until the current quarantine due to the COVID-19 pandemic, FU-UFRJ has been adapting to the new reality and continued to provide patient care services, maintaining its teaching, research, and extension activities. The FU plays a relevant social role in guaranteeing the low-income population access to special and neglected medicines, and to pharmaceutical and education services in health promotion.

Diagnósticos/resultados e intervenções de enfermagem para pacientes com COVID-19: estudo documental retrospectivo / Nursing diagnoses/outcomes and interventions for patients with COVID-19: a retrospective documentary study / Diagnósticos/resultados e intervenciones de enfermería para pacientes con COVID-19: estudio documental retrospectivo

OBJETIVO: Construir Diagnósticos/Resultados e Intervenções de Enfermagem utilizando a Classificação Internacional para a Prática de Enfermagem em pacientes com infecção por coronavírus. MÉTODO: Estudo exploratório, descritivo, do tipo documental retrospectivo, desenvolvido em unidades de pronto atendimento do município de João Pessoa -Paraíba. A amostra foi composta por 187 prontuários e a coleta de dados foi realizada entre junho e agosto de 2020. A análise dos dados ocorreu por meio de estatística descritiva, média, amplitude e desvio padrão. RESULTADO: Foram identificados 12 Diagnósticos/Resultados de Enfermagem (Dispneia, Febre, Tosse, Dor Muscular, Dor na cabeça, Diarreia, Olfato prejudicado, Paladar prejudicado, Falta de apetite, Deglutição, prejudicada, Dor notórax e Vômito) e 36 Intervenções de Enfermagem direcionadas aos pacientes acometidos por coronavírus. CONCLUSÃO: A identificação de Diagnósticos/Resultados e Intervenções de Enfermagem se faz indispensável para subsidiar a assistência, sobretudo no cenário atual da pandemia do COVID-19, contribuindo com a operacionalização do Processo de Enfermagem.

OBJECTIVE: To elaborate Nursing Diagnoses/Outcomes and Interventions using the International Classification for Nursing Practice in patients with coronavirus infection. METHOD: An exploratory, descriptive, retrospective and documentary study, developed in emergency care units in the municipality of João Pessoa -Paraíba. The sample consisted of 187 medical records and data collection was carried out between June and August 2020. Data analysis was performed using descriptive statistics, mean, range and standard deviation. RESULT: A total of 12 Nursing Diagnoses/Outcomes (Dyspnea, Fever, Cough, Muscle Pain, Headache, Diarrhea, Impaired Smell, Impaired Taste, Lack of Appetite, Impaired Swallowing, Chest Pain and Vomiting) and 36 Nursing Interventions targeted at patients affected by coronavirus were identified. CONCLUSION: The identification of Nursing Diagnoses/Outcomes and Interventions is indispensable to support care, especially in the current scenario of the COVID-19 pandemic, contributing to the operationalization ofthe Nursing Process.

OBJETIVO: Elaborar diagnósticos/resultados e intervenciones de enfermería utilizando la Clasificación Internacional para la práctica de enfermería en pacientes con infección por coronavirus. MÉTODO: Estudio exploratorio, descriptivo, del tipo documental retrospectivo, desarrollado en unidades de emergencia de la ciudad de João Pessoa, Paraíba. La muestra estuvo conformada por 187 historias clínicas y la recolección de datos se realizó entre junio y agosto de 2020. El análisis de los datos se realizó mediante estadística descriptiva, media, amplitud y desviación estándar. RESULTADOS: Se identificaron 12 Diagnósticos /Resultados de Enfermería (Disnea, Fiebre, Tos, Dolor Muscular, Dolor de Cabeza, Diarrea, Deterioro del sentido del Olfato, Deterioro del sentidodel Gusto, Falta de Apetito, Deterioro de la deglución, Dolor Torácico y Vómitos) y 36 Intervenciones de Enfermería dirigidas a pacientes afectados por coronavirus. CONCLUSIÓN: Identificar Diagnósticos/Resultados e Intervenciones de Enfermería es fundamental para la atención, especialmente en el escenario actual de la pandemia de COVID-19, dado que contribuye a la operacionalización del Proceso de Enfermería.

Covid Longa e Pós-Covid / Long Covid and Post-Covid

Revisão acerca dos termos "long COVID", em português, "COVID Longa", "COVID Pós-Aguda", "Pós-COVID", ou "Síndrome de COVID Crônica". Ainda não há consenso na literatura sobre os termos. Raveendran (2021), Greenhalgh e colaboradores (2020), consideram a existência de dois estágios distintos após a fase aguda da infecção pelo SARS-CoV-2. Nalbandian e colaboradores (2021), consideraram a COVID PósAguda como a persistência de sintomas ou o desenvolvimento de sequelas após 4 semanas de início dos sintomas da doença. Baig (2021) defende o uso do termo Chronic COVID Syndrome (CCS) ­ em português Síndrome de COVID Crônica (SCC) ­ em analogia a outras doenças infecciosas e não-infecciosas da Medicina que apresentam progressão de sintomas de uma fase inicial a outra mais prolongada. Existem ainda, a proposta apresentada por Peñas e colaboradores (2021) que consideram o tempo, a partir do início de sintomas, como fator mais relevante na classificação. Para além do consenso acerca da nomenclatura a ser utilizada faz-se necessário pesquisas que examinem fatores de risco e mecanismos envolvidos no desenvolvimento de COVID Longa, bem como as medidas para prevenir e tratar adequadamente tal complicação (ALJAHDHAMI et al., 2021).

Review of the terms "long COVID", in Portuguese, "COVID Longa", "COVID Pós-Aguda", "Post-COVID", or "Chronic COVID Syndrome". There is still no consensus in the literature about the terms. Raveendran (2021), Greenhalgh et al. (2020), consider the existence of two distinct stages after the acute phase of infection by SARS-CoV-2. Nalbandian et al. (2021) considered PostAcute COVID as the persistence of symptoms or the development of sequelae after 4 weeks of onset of disease symptoms. Baig (2021) defends the use of the term Chronic COVID Syndrome (CCS) ­ in Portuguese Chronic COVID Syndrome (SCC) ­ in analogy to other infectious and non-infectious diseases in Medicine that present progression of symptoms from an initial phase to another more prolonged. There are still the submitted proposal by Peñas et al. (2021) who consider the time, from the onset of symptoms, as the most relevant factor in the classification. In addition to the consensus on the nomenclature to be used, research is needed to examine risk factors and mechanisms involved in the development of COVID Longa, as well as measures to prevent and adequately treat such complication (ALJAHDHAMI et al., 2021).

Haemophagocytic syndrome and COVID-19.

Primary and secondary haemophagocytic lymphohistiocytosis (HLH) are hyperferritinaemic hyperinflammatory syndromes with a common terminal pathway triggered by different etiopathogenetic factors. HLH is characterised by a decreased capacity of interferon gamma production with an activated NK phenotype profile similar to other hyperinflammatory syndromes. Viruses are closely linked to the development of HLH as infectious triggers, and the break of tolerance to self-antigens is considered a critical mechanism involved in the development of immune-mediated conditions triggered by viral infections. Emerging studies in patients with COVID-19 are suggesting a key role of monocytes/macrophages in the pathogenesis of this viral infection, and there is a significant overlap between several features reported in severe COVID-19 and the features included in the HLH-2004 diagnostic criteria. Therefore, SARS-Cov-2, as other respiratory viruses, may also be considered a potential etiological trigger of HLH. The frequency of HLH in adult patients with severe COVID-19 is lower than 5%, although this figure could be underestimated considering that most reported cases lacked information about some specific criteria (mainly the histopathological criteria and the measurement of NK cell function and sCD25 levels). Because HLH is a multi-organ syndrome, the diagnostic approach in a patient with severe COVID-19 in whom HLH is suspected must be carried out in a syndromic and holistic way, and not in the light of isolated clinical or laboratory features. In COVID-19 patients presenting with persistent high fever, progressive pancytopenia, and hepatosplenic involvement, together with the characteristic triad of laboratory abnormalities (hyperferritinaemia, hypertriglyceridaemia, and hypofibrinogenaemia), the suspicion of HLH is high, and the diagnostic workup must be completed with specific immunological and histopathological studies.

Application of Bayesian phylogenetic inference modelling for evolutionary genetic analysis and dynamic changes in 2019-nCoV.

The novel coronavirus (2019-nCoV) has recently caused a large-scale outbreak of viral pneumonia both in China and worldwide. In this study, we obtained the entire genome sequence of 777 new coronavirus strains as of 29 February 2020 from a public gene bank. Bioinformatics analysis of these strains indicated that the mutation rate of these new coronaviruses is not high at present, similar to the mutation rate of the severe acute respiratory syndrome (SARS) virus. The similarities of 2019-nCoV and SARS virus suggested that the S and ORF6 proteins shared a low similarity, while the E protein shared the higher similarity. The 2019-nCoV sequence has similar potential phosphorylation sites and glycosylation sites on the surface protein and the ORF1ab polyprotein as the SARS virus; however, there are differences in potential modification sites between the Chinese strain and some American strains. At the same time, we proposed two possible recombination sites for 2019-nCoV. Based on the results of the skyline, we speculate that the activity of the gene population of 2019-nCoV may be before the end of 2019. As the scope of the 2019-nCoV infection further expands, it may produce different adaptive evolutions due to different environments. Finally, evolutionary genetic analysis can be a useful resource for studying the spread and virulence of 2019-nCoV, which are essential aspects of preventive and precise medicine.

Hemophagocytic lymphohistiocytosis: a review inspired by the COVID-19 pandemic.

Hemophagocytic syndrome (HPS) or hemophagocytic lymphohistiocytosis (HLH) is an acute and rapidly progressive systemic inflammatory disorder characterized by cytopenia, excessive cytokine production, and hyperferritinemia. Common clinical manifestations of HLH are acute unremitting fever, lymphadenopathy, hepatosplenomegaly, and multiorgan failure. Due to a massive cytokine release, this clinical condition is considered as a cytokine storm syndrome. HPS has primary and acquired (secondary, reactive) forms. Its primary form is mostly seen in childhood and caused by various mutations with genetic inheritance and, therefore, is called familial HLH. Secondary HLH may be caused in the presence of an underlying disorder, that is, secondary to a malignant, infectious, or autoimmune/autoinflammatory stimulus. This paper aims to review the pathogenesis and the clinical picture of HLH, and its severe complication, the cytokine storm, with a special emphasis on the developed classification criteria sets for rheumatologists, since COVID-19 infection has clinical symptoms resembling those of the common rheumatologic conditions and possibly triggers HLH. MED-LINE/Pubmed was searched from inception to April 2020, and the following terms were used for data searching: "hemophagocytic syndrome" OR "macrophage activation syndrome" OR "hemophagocytic lymphohistiocytosis", OR "cytokine storm". Finally, AND "COVID-19" was included in this algorithm. The selection is restricted to the past 5 years and limited numbers of earlier key references were manually selected. Only full-text manuscripts, published in an English language peer-reviewed journal were included. Manuscript selection procedure and numbers are given in Fig. 2. Briefly, the database search with the following terms of "Hemophagocytic syndrome" OR "Macrophage activation syndrome" OR "Hemophagocytic lymphohistiocytosis" OR "Cytokine storm" yielded 6744 results from inception to April 2020. The selection is restricted to the past 5 years and only limited numbers of earlier key references were selected, and this algorithm resulted in 3080 manuscripts. The addition of (AND "COVID-19") resulted in 115 publications of which 47 studies, together with four sections of an online book were used in the final review. No statistical method was used. HLH is triggered by genetic conditions, infections, malignancies, autoimmune-autoinflammatory diseases, and some drugs. In COVID-19 patients, secondary HLH and cytokine storm may be responsible for unexplained progressive fever, cytopenia, ARDS, neurological and renal impairment. Differentiation between the primary and secondary forms of HLH is utterly important, since primary form of HLH requires complicated treatments such as hematopoietic stem cell transplantation. Further studies addressing the performance of HScore and other recommendations in the classification of these patients is necessary.

Perspective Covid-19 ARDS: challenges in care, recommendations & review of research / Covid-19: Desafíos, recomendaciones, revisión e investigación

Though physicians and care providers are familiar with the management of ARDS, however, when it occurs as a sequale of COVID-19, COVID-19 ARDS has different features and there remains uncertainty on the consensus of management. To answer this question on how it compares and contrasts with ARDS from other causes, we deliver a review of the published literature and our own clinical experience from managing patients with COVID-19 ARDS in DR Congo and India. A PubMed search was conducted on 05-7-2020 using the systematic review filter to identify articles that were published using MeSH terms COVID-19 and ARDS. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Those were compared and reviewed to the existing practices by the various treating specialists and recommendations were made. Specifically, we discuss the COVID-19 ARDS, its risk factors and pathophysiology, lab diagnosis, radiological findings, rational of recommendation of drugs proposed so far, oxygenation and ventilation strategies and the psychological ramifications of the disease. Because of the high mortality in mechanically ventilated patients, the above recommendations and findings direct the potential for improvement in the management of patients with COVID-19 ARDS.

Aunque los médicos y los proveedores de atención están familiarizados con el manejo de ARDS, cuando ocurre una complicación de COVID-19, existe incertidumbre sobre el manejo y curso que va a seguir. Para responder a esta pregunta sobre cómo se compara y contrasta con el SDRA por otras causas, entregamos una revisión de la literatura publicada y nuestra propia experiencia clínica en el manejo de pacientes con SDRA COVID-19 en la República Democrática del Congo e India. Se realizó una búsqueda en PubMed el 05 de julio de 2020 utilizando el método sistemático con filtro de revisión para identificar artículos que se publicaron utilizando términos MeSH COVID-19 y SDRA. Se seleccionaron revisiones sistemáticas o metanálisis de una búsqueda sistemática de literatura que contenga diagnóstico, pronóstico y manejo estrategias en MEDLINE / PubMed. Aquellos fueron comparados y revisados para las prácticas existentes por los diversos especialistas en tratamiento y recomendaciones que fueron hechos. Específicamente, discutimos el ARDS COVID-19, sus factores de riesgo, fisiopatología, diagnóstico de laboratorio, hallazgos radiológicos, racionalidad de recomendación de los fármacos propuestos hasta el momento, las estrategias de oxigenación y ventilación y las complicaciones psicológicas de la enfermedad. Debido a la alta mortalidad de los paciente en ventilación mecánica las recomendaciones y los hallazgos anteriores se dirigen a la potencial de mejora en el manejo de pacientes con COVID-19.

Comparison of 2 Triage Scoring Guidelines for Allocation of Mechanical Ventilators.

Importance: In the current setting of the coronavirus disease 2019 pandemic, there is concern for the possible need for triage criteria for ventilator allocation; to our knowledge, the implications of using specific criteria have never been assessed. Objective: To determine which and how many admissions to intensive care units are identified as having the lowest priority for ventilator allocation using 2 distinct sets of proposed triage criteria. Design, Setting, and Participants: This retrospective cohort study conducted in spring 2020 used data collected from US hospitals and reported in the Philips eICU Collaborative Research Database. Adult admissions (N = 40 439) to 291 intensive care units from 2014 to 2015 who received mechanical ventilation and were not elective surgery patients were included. Exposures: New York State triage criteria and original triage criteria proposed by White and Lo. Main Outcomes and Measures: Sequential Organ Failure Assessment (SOFA) scores were calculated for admissions. The proportion of patients who met initial criteria for the lowest level of priority for mechanical ventilation using each set of criteria and their characteristics and outcomes were assessed. Agreement was compared between the 2 sets of triage criteria, recognizing differences in stated criteria aims. Results: Among 40 439 intensive care unit admissions of patients who received mechanical ventilation, the mean (SD) age was 62.6 (16.6) years, 54.9% were male, and the mean (SD) SOFA score was 4.5 (3.7). Using the New York State triage criteria, 8.9% (95% CI, 8.7%-9.2%) were in the lowest priority category; these lowest priority admissions had a mean (SD) age of 62.9 (16.6) years, used a median (interquartile range) of 57.3 (20.1-133.5) ventilator hours each, and had a hospital survival rate of 38.6% (95% CI, 37.0%-40.2%). Using the White and Lo triage criteria, 4.3% (95% CI, 4.1%-4.5%) were in the lowest priority category; these admissions had a mean (SD) age of 68.6 (13.2) years, used a median (interquartile range) of 61.7 (24.3-142.8) ventilator hours each, and had a hospital survival rate of 56.2% (95% CI, 53.8%-58.7%). Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.20 (95% CI, 0.18-0.21). Conclusions and Relevance: Use of 2 initially proposed ventilator triage guidelines identified approximately 1 in every 10 to 25 admissions as having the lowest priority for ventilator allocation, with little agreement. Clinical assessment of different potential criteria for triage decisions in critically ill populations is important to ensure valid and equitable allocation of resources.

Prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with COVID-19: a prospective observational study.

BACKGROUND: In acute respiratory distress syndrome (ARDS) unrelated to COVID-19, two phenotypes, based on the severity of systemic inflammation (hyperinflammatory and hypoinflammatory), have been described. The hyperinflammatory phenotype is known to be associated with increased multiorgan failure and mortality. In this study, we aimed to identify these phenotypes in COVID-19-related ARDS. METHODS: In this prospective observational study done at two UK intensive care units, we recruited patients with ARDS due to COVID-19. Demographic, clinical, and laboratory data were collected at baseline. Plasma samples were analysed for interleukin-6 (IL-6) and soluble tumour necrosis factor receptor superfamily member 1A (TNFR1) using a novel point-of-care assay. A parsimonious regression classifier model was used to calculate the probability for the hyperinflammatory phenotype in COVID-19 using IL-6, soluble TNFR1, and bicarbonate levels. Data from this cohort was compared with patients with ARDS due to causes other than COVID-19 recruited to a previous UK multicentre, randomised controlled trial of simvastatin (HARP-2). FINDINGS: Between March 17 and April 25, 2020, 39 patients were recruited to the study. Median ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air (PaO2/FiO2) was 18 kpa (IQR 15-21) and acute physiology and chronic health evaluation II score was 12 (10-16). 17 (44%) of 39 patients had died by day 28 of the study. Compared with survivors, patients who died were older and had lower PaO2/FiO2. The median probability for the hyperinflammatory phenotype was 0·03 (IQR 0·01-0·2). Depending on the probability cutoff used to assign class, the prevalence of the hyperinflammatory phenotype was between four (10%) and eight (21%) of 39, which is lower than the proportion of patients with the hyperinflammatory phenotype in HARP-2 (186 [35%] of 539). Using the Youden index cutoff (0·274) to classify phenotype, five (63%) of eight patients with the hyperinflammatory phenotype and 12 (39%) of 31 with the hypoinflammatory phenotype died. Compared with matched patients recruited to HARP-2, levels of IL-6 were similar in our cohort, whereas soluble TNFR1 was significantly lower in patients with COVID-19-associated ARDS. INTERPRETATION: In this exploratory analysis of 39 patients, ARDS due to COVID-19 was not associated with higher systemic inflammation and was associated with a lower prevalence of the hyperinflammatory phenotype than that observed in historical ARDS data. This finding suggests that the excess mortality observed in COVID-19-related ARDS is unlikely to be due to the upregulation of inflammatory pathways described by the parsimonious model. FUNDING: US National Institutes of Health, Innovate UK, and Randox.