Acute Coronary Syndrome during the Era of Covid-19: Perspective and Implications Using Google Trends

Background Acute coronary syndrome (ACS) hospital admissions decreased during the start of the COVID-19 outbreak. There is limited information on how Google searches related to patients behavior during this time. Methods We examined de-identified data from 2019 through 2020 regarding monthly: 1) admissions for ACS from the Veterans Affairs Healthcare System;2) out of hospital cardiac arrest (OHCA) from NEMSIS public dataset;and 3) Google searches for "chest pain", "coronavirus", "chest pressure", and "hospital safe" from Google Trends. We analyzed the trends for ACS admissions, OHCA, and Google searches. Results During the early months of the first COVID-19 outbreak: 1)Veterans Affairs data showed a significant reduction in ACS admissions at a national and regional (Florida) level (Figure 1);2) NEMSIS database showed a marked increase in OHCA at a national level;and 3) Google Trends showed a significant increase in the before mentioned Google searches at a national and regional level. Conclusion ACS hospital admissions decreased during the beginning of the pandemic likely due to delayed healthcare utilization secondary to patients fear of acquiring COVID-19 infection. Concordantly, Google searches for hospital safety and ACS symptoms increased along with OHCA events during this time. Our results suggest that Google Trends may be a useful tool to predict patients behavior and increase preparedness for future events, however, statistical strategies to establish association are needed. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Development of a Non-Invasive Respiratory Support Pathway in COVID19 patients with severe respiratory failure in an Intermediate Respiratory Care Unit

The respiratory failure caused by COVID19 and the need to provide non-invasive respiratory support (NIRS) and invasive mechanical ventilation (IMV) has saturated the Intensive Care Units (ICU). In our hospital, an Intermediate Respiratory Care Unit (IMCU) and a protocol (Figure 1) were created to coordinate escalation to NIRS and referral to ICU. The aim of this study was to evaluate the result of implementing this protocol in the IMCU. Retrospective observational cohort study between May 2021 to January 2022, included 174 patients with need NIRS in IMCU (143 receiving HFNC, 23 combining CPAP/HFNC and 8 BIPAP/HFNC). 141 met requirements for cardiopulmonary resuscitation (CPR). The average age was 60 +/-16 years, 67% (117) were male. The median stay in IMCU was 10.5 [8,15] days, requiring NIRS a median of 5 [3,8] days. 39 patients were transferred to the ICU and 28% (11) required IMV in a mean of 3 +/- 2 days after transfer. The mortality rate among patients CPR was 4% (6/141). Prior to the creation of the IMCU 3,172 COVID+ patients were admitted, with a mortality of 20.3%. 10% were admitted to the ICU due to HFNC or NIV requirements, with a mortality rate of 32.5%. This study supports the clinical benefit of creating an IMCU in collaboration with ICU, achieving low mortality rates by monitoring and providing NIRS in COVID19 patients with severe respiratory failure. (Figure Presented).

Characterization of an aging Puerto Rican cohort with cancer: Analyzing sociodemographic factors and concomitant comorbidities. [R]

Background: Incidence of cancer is constantly increasing in the United States, and Puerto Rico is no exception. The island is currently experiencing low birth rates, signifying that its population is primarily composed of aging citizens that experience a growing need for access to healthcare and medical literature, especially in those with cancer. In this study, we aimed to characterize an aging Puerto Rican cohort with a diagnosis of cancer. Method(s): A questionnaire with sociodemographic and medical inquiries was administered to participants receiving an mRNA vaccine at a COVID-19 vaccination clinic between December 2020 and June 2021. Participants of age 60+ with a diagnosis of cancer, along with their comorbidities, were identified. Multivariate analyses were executed. This study is IRB approved. Result(s): A total of 100 aging participants with a diagnosis of cancer were included: 55 were female and 45 were male, with a mean age of 72.70+/-8.07 (age range: 61-95). When assessing race, participants identified as follows: 68% White, 23% Black or African American, 8% other race, and 1% American Indian or Alaska Native. Concerning ethnicity, 97% identified as Hispanic or Latino, while 3% did not regard themselves as such. When evaluating the cancer diagnoses provided, 27% of female participants had breast cancer and 7% had some form of gynecologic malignancy. Whereas, in males, 42% indicated a diagnosis of prostate cancer. Regarding concomitant comorbidities, 45% of participants had hypertension, 30% had diabetes mellitus, 18% had hypothyroidism, 15% had asthma, and 3% had chronic obstructive pulmonary disease. There was no statistically significant difference when comparing sex and prevalence of concomitant diabetes mellitus or hypertension (p=0.2125). There was also no statistically significant difference when assessing racial identity and presence of concomitant diabetes mellitus or hypertension (p=0.7373). Out of 91 participants who answered the health insurance inquiry, 82% possessed private insurance, 13% had public insurance, and 4% did not have insurance. There was no statistically significant difference when assessing private, public, or no health insurance status and the presence of concomitant diabetes mellitus or hypertension (p=0.9086). Conclusion(s): Data evidenced a diverse aging Puerto Rican cohort with cancer, showing a predominance in prostate cancer in men and breast cancer in women. Analysis suggested that the presence of concomitant diabetes mellitus or hypertension in an aging population with cancer was not linked to sex or racial identity. Additionally, the type or lack of health insurance did not influence the prevalence of concomitant diabetes mellitus or hypertension. Characterizing the aging Hispanic population in Puerto Rico and the United States is important, as these studies could be beneficial in the future approach, understanding and treatment of this population with historically limited medical data available.

Intradialityc hypotension in intermittent and prolonged Kidney Replacement Therapies in patients with acute respiratory distress syndrome due to COVID-19

Background: Intradialytic hypotension (IH) is a relatively common complication in patients with acute kidney injury (AKI) who undergoes Kidney Replacement Therapy (KRT) and it could be the potential factor for non-recovery due to ischemic events. It is known that high ultrafiltration rate (UFR) is associated with worse outcomes, a recent recommendation to limit UFR to less than 13 ml/hr/kg has been widely accepted among nephrologists. Continuous kidney replacement therapy (CKRT) is the modality of choice in critically ill patients with hemodynamic instability;however, during COVID 19 pandemic a shortage of resources was evident and other modalities such as sustained low-efficiency dialysis was used in this population. As of today, there is not a universally accepted definition of IH, accordingly a safe UFR goal in critically ill patients it is still unknown in the different KRT modalities. The aim of this study was to analyze the differences in demographical, clinical and KRT prescriptions among critically ill patients with AKI related COVID-19 who developed intradialytic hypotension. Method(s): A prospective, observational, single-center study was performed between April 2020 and December 2021. Critically ill patients with COVID-19 and AKI who required KRT were included. Blood and dialysate flow rates, dialysate temperature, dialysate sodium, bicarbonate and potassium prescriptions were recorded. Body weight and height were obtained from the medical records. Body mass index (BMI) were calculated and interpretated according to WHO recommendations. Ideal body weight (IBW) was calculated using Hamwi equations. Intradialytic hypotension was defined as KDOQI;drop in SBP >= 20mmHg drop in SBP or > 10mmHg in MAP. Result(s): Two hundred sixty-three patients were included in the study, the majority were male, the average age was 60 years and a third of the population was diabetic. A total of 1,942 sessions were prescribed (289 hemodiafiltration (HDF), 1,455 intermittent hemodialysis (IHD), 198 prolonged intermittent renal replacement therapy (PIRRT)). Development of hypotension were reported in 1,059 sessions (55%). No differences between all modalities of KRT were observed HDF 15% vs 15%, IHD 74% vs 76% and PIRRT 11% vs 9% respectively for hypotension or non-hypotension groups (p = 0.27). Differences were statistically significant for sex (p=<0.001), age (p=0.054), UFR prescription (p=<0.001), norepinephrine use (p=<0.001) and dialysate bicarbonate (p=0.001). Age, gender male, and norepinephrine doses were independently associated with the development of hypotension in multivariate logistic regression. Linear regression for norepinephrine and development of hypotension beta0.61 (95% CI 0.38-0.85, p<0.001). Conclusion(s): In our study, the prevalence of intradialytic hypotension was greater than reported in literature probably associated with an exaggerated inflammatory response and need for mechanical ventilation. KRT modality and UFR were not associated with development IDH, however the main risk factor associated was norepinephrine initial dose. Further prospective studies are needed for assessment of a safe ultrafiltration rate in critically-ill patients.

Estimation of the number of preventable COVID-19 deaths in relation to the restrictive measures adopted in America

Introduction: In America, the United States was particularly affected by the COVID-19 pandemic. Objectives: To estimate how many daily COVID-19 deaths per 100,000 population would have been avoided if each one of five restrictive measures had been implemented at the time of diagnosis and to estimate a multiple linear regression model predictive of the number of deaths per 100,000 population based on the measures adopted by the countries. Methods: A simple linear regression was performed between the days elapsed since the first COVID-19 diagnosed case and the implementation of each of the five restrictive measures by the 27 American countries studied and the number of COVID-19 deaths per 100,000 population. Results: For each day between the first COVID-19 reported case and the adoption of restrictive measures, between 0.250 (p = 0.021) and 0.600 (p = 0.001) patients per 100,000 population died, depending on the measure in question. Conclusions: Adoption of restrictive measures and social distancing are necessary for reducing the number of people infected with COVID-19 and their mortality. In addition, promptness of their establishment is essential in order to reduce the number of deaths.

Neuroimage and autonomic abnormalities in patients with CoVID-19 happy hypoxemia

Objective: To describe the autonomic and SNC manifestations of patients with coronavirus disease 2019 (COVID-19) and happy hypoxemia. Background: Happy hypoxemia is the absence of dyspnea despite low oxygen saturation. Several hypotheses for its occurrence include potential viral neuroinvasion, autonomic dysfunction, and cortical ischemic damage. Design/Methods: We studied prospectively nine patients with COVID-19 who arrived at the ER with very low oxygen saturation (50-79%) and no dyspnea complaints. Patients were invited to participate and underwent a full clinical history, brain MRI with gadolinium, and 24H-Holter with spectroscopy while hospitalized and bed-ridden. We used Pearson's coefficient correlation for the correlation analysis. Results: Two patients were excluded from the study because they no longer wished to participate and one because he had FA. we analyzed six patients (66% women) with a mean age of 59 years old (47-83). Two patients had high blood pressure, one patient had a history of tuberculosis, and one had Down Syndrome. Upon arrival at the ER, the mean oxygen saturation was 67% and PaO2 59.3 (47-83). One patient (14%) complain of headache and none of anosmia or ageusia. Four patients underwent a brain MRI that showed gadolinium enhancement of the olfactory bulbs and white matter lesions. One patient also had a left insular lesion. Three patients had abnormal SDNN<100 (83ms, 30-146), and one had RMSSD <15. Vagally mediated changes reflected in HRv were significantly lower in patients with lower blood O2 saturation (SDDN p=0.002, r=.95, HF p=0.009, r=.92, LF/HF ns, -0.42). Conclusions: Patients with happy hypoxemia had decreased heart rate variability that correlated with the degree of hypoxemia, suggesting altered modulation of vagal tone and autonomic dysregulation. All the patients had olfactory bulb enhancement. In our patients, hyposmia /anosmia did not correlate with olfactory bulb hyperintensities or happy hypoxemia.

Tools linked to informal learning: opportunities to strengthen personal learning environments of university students during the times of pandemic

Informal learning is gaining relevance for the acquisition of professionally valuable skills. In this sense, ICT in general, and the construction of a personal learning environment (PLE) in particular, become allies to this end. Moreover, they have been key during the times of pandemic when formal education institutions all over the planet have been forced to close. The present study has the objective of describing the tools used by students for the purpose of searching for information, creating content, and sharing and interacting in informal environments. The methodology follows a quantitative approach under a non-experimental and transactional design. A questionnaire is applied to a probabilistic stratified sample (n=1187) comprising university students from different programs at the Universidad Nacional (Costa Rica). The main findings suggest that the search and management of information, in addition to the tools used for sharing and interacting, are the components related to a higher number of digital resources, while being less used in activities related to content creation. Between groups, differences regarding the usage of tools have been detected according to the variables of sex, age and field of study. It is recommended that universities introduce new methodologies, and promote more efficient strategies that enable raising awareness about the relevance of learning with technology, as well as to recognize the contributions of complementary informal learning to formal education. The combination of both aspects will facilitate continuous and permanent learning for the acquisition of professional skills, especially within the framework of the limitations and demands derived by the global pandemic situation caused by the COVID-19.

Experience with the use of siltuximab in patients with SARS-CoV-2 infection.

OBJECTIVE: The study aims to describe characteristics and clinical outcome of patients with SARS-CoV-2 infection that received siltuximab according to a protocol that aimed to early block the activity of IL-6 to avoid the progression of the inflammatory flare. METHODS: Retrospective review of the first 31 patients with SARS-CoV-2 treated with siltuximab, in Hospital Clinic of Barcelona or Hospital Universitario Salamanca, from March to April 2020 with positive polymerase-chain reaction (PCR) from a nasopharyngeal swab. RESULTS: The cohort included 31 cases that received siltuximab with a median (IQR) age of 62 (56-71) and 71% were males. The most frequent comorbidity was hypertension (48%). The median dose of siltuximab was 800 mg ranging between 785 and 900 mg. 7 patients received siltuximab as a salvage therapy after one dose of tocilizumab. At the end of the study, a total of 26 (83.9) patients had been discharged alive and the mortality rate was 16.1% but only 1 out of 24 that received siltuximab as a first line option (4%). CONCLUSIONS: Siltuximab is a well-tolerated alternative to tocilizumab when administered as a first line option in patients with COVID-19 pneumonia within the first 10 days from symptoms onset and high C-reactive protein.

Acute myocardial infarction in four secondary care hospitals in Cuba in the COVID- 19 era

Introduction: The clinico-epidemiological characteristics in the diagnosis, evolution and treatment of patients with acute myocardial infarction in the COVID-19 era depend on several factors. Objectives: To determine the behavior of some clinico-epidemiological variables in the management of patients with acute myocardial infarction during de COVID-19 pandemic. Methods: An observational study was carried out in four secondary care hospitals in Cuba. The following variables were used: number of admission due to acute myocardial infarction, hospital mortality, delay longer than four hours from the beginning of the symptoms to the arrival to the first medical assistance, and thrombolysis percentage. Two groups were defined, those admitted from March 1st to September 30th, 2019 ( Group I) and those admitted in the same period, but from 2020 ( Group II). Comparisons between both groups were made using the chi square test. Results: There was a decrease of 53 admissions due to acute myocardial infarction in Las Tunas ( 112 vs. 159;p<0.05), with an increase in the number of admissions in the Hospital Enrique Cabrera in patients from Group II ( 98 vs. 68;p<0.05). The number of deaths and hospital mortality in Group II increased in all the centers in relation to Group I. In most of the hospitals there was an increase of the time elapsed from the beginning of the symptoms to the arrival to the first medical assistance. Thrombolysis percentage in Group II was higher than 50% in most of the centers. Conclusions: The characteristics of COVID-19 may modify the clinical and epidemiological aspects in the management of patients with acute myocardial infarction.

Plasma Exchange: An Effective Rescue Therapy in Critically Ill Patients With Coronavirus Disease 2019 Infection

OBJECTIVES: Infection by severe acute respiratory syndrome coronavirus-2 can induce uncontrolled systemic inflammation and multiple organ failure. The aim of this study was to evaluate if plasma exchange, through the removal of circulating mediators, can be used as rescue therapy in these patients. DESIGN: Single center case series. SETTING: Local study. SUBJECTS: Four critically ill adults with coronavirus disease 19 pneumonia that failed conventional interventions. INTERVENTIONS: Plasma exchange. Two to six sessions (1.2 plasma volumes). Human albumin (5%) was used as the main replacement fluid. Fresh frozen plasma and immunoglobulins were administered after each session to avoid coagulopathy and hypogammaglobulinemia. MEASUREMENTS AND MAIN RESULTS: Serum markers of inflammation and macrophage activation. All patients showed a dramatic reduction in inflammatory markers, including the main cytokines, and improved severity scores after plasma exchange. All survived to ICU admission. CONCLUSIONS: Plasma exchange mitigates cytokine storm, reverses organ failure, and could improve survival in critically ill patients with coronavirus disease 2019 infection.

Tocilizumab reduces the risk of ICU admission and mortality in patients with SARS-CoV-2 infection.

OBJECTIVE: In some patients the immune response triggered by SARS-CoV-2 is unbalanced, presenting an acute respiratory distress syndrome which in many cases requires intensive care unit (ICU) admission. The limitation of ICU beds has been one of the major burdens in the management around the world; therefore, clinical strategies to avoid ICU admission are needed. We aimed to describe the influence of tocilizumab on the need of transfer to ICU or death in non-critically ill patients. METHODS: A retrospective study of 171 patients with SARS-CoV-2 infection that did not qualify as requiring transfer to ICU during the first 24h after admission to a conventional ward, were included. The criteria to receive tocilizumab was radiological impairment, oxygen demand or an increasing of inflammatory parameters, however, the ultimate decision was left to the attending physician judgement. The primary outcome was the need of ICU admission or death whichever came first. RESULTS: A total of 77 patients received tocilizumab and 94 did not. The tocilizumab group had less ICU admissions (10.3% vs. 27.6%, P=0.005) and need of invasive ventilation (0 vs 13.8%, P=0.001). In the multivariable analysis, tocilizumab remained as a protective variable (OR: 0.03, CI 95%: 0.007-0.1, P=0.0001) of ICU admission or death. CONCLUSIONS: Tocilizumab in early stages of the inflammatory flare could reduce an important number of ICU admissions and mechanical ventilation. The mortality rate of 10.3% among patients receiving tocilizumab appears to be lower than other reports. This is a non-randomized study and the results should be interpreted with caution.

Real-life use of remdesivir in hospitalized patients with COVID-19.

OBJECTIVE: Controversial results on remdesivir efficacy have been reported. We aimed to report our real-life experience with the use of remdesivir from its availability in Spain. METHODS: We performed a descriptive study of all patients admitted for ≥48 hours with confirmed COVID-19 who received remdesivir between the 1st of July and the 30th of September 2020. RESULTS: A total of 123 patients out of 242 admitted with COVID-19 at our hospital (50.8%) received remdesivir. Median age was 58 years, 61% were males and 56.9 % received at least one anti-inflammatory treatment. No adverse events requiring remdesivir discontinuation were reported. The need of intensive care unit admission, mechanical ventilation and 30-days mortality were 19.5%, 7.3% and 4.1%, respectively. CONCLUSIONS: In our real-life experience, the use of remdesivir in hospitalized patients with COVID-19 was associated with a low mortality rate and good safety profile.

Research tendencies about mental disorder symptoms during the COVID-19 pandemic Tendências da investigação sobre sintomas de transtornos mentais durante a pandemia por COVID-19

Objetivo: Realizar una revisión sistemática de la tendencia de investigación sobre síntomas de trastornos mentales durante la pandemia por COVID-19. Métodos: Se recuperaron artículos publicados entre el 31 de diciembre 2019 y el 3 de mayo 2020, en Pubmed, SCOPUS, EBSCO, PsycINFO, Science Direct, Redalyc y Web of Science, seleccionando, conforme a la metodología PRISMA, un total de 16 artículos, al descartarse duplicados o estudios no empíricos. Resultados: La mayoría se realizaron en China, el tamaño de la muestra osciló entre 20 y 7236 participantes, en su mayoría adolescentes y adultos, entre 12 a 80 años, con muestreo no probabilístico por conveniencia. La tendencia de los síntomas y trastornos más estudiados fueron ansiedad (28%), depresión (23%), estrés (15.3%), trastorno del sueño-vigilia (9.6%) y trastorno por estrés postraumático (5.7%), asociados con el consumo de sustancias psicoactivas, bajo rendimiento académico, pérdida de trabajo, calidad del sueño, bajo autocuidado y baja percepción del estado de salud durante la pandemia. Conclusiones: Los síntomas y trastornos de ansiedad, depresión y estrés son los más frecuentes. Algunas limitaciones son la ausencia de medición previa a la pandemia o cuarentena y el uso de muestreo no aleatorio, para hacer generalización de resultados. Es necesario formular investigaciones de intervención para mitigar el impacto psicológico. Los sistemas de salud deben ofrecer programas de prevención y de promoción de la salud, que consideren factores psicosociales dirigidos a la población general, pacientes y personal sanitario, para disminuir la prevalencia de estas dificultades, en particular, para Iberoamérica, en donde es escasa la producción científica al respecto. Objective: To carry out a systematic review of the research trend on mental disorders symptoms during the COVID -19 pandemic. Methods: Articles published between December 31, 2019 and May 3, 2020 were retrieved in Pubmed, SCOPUS, EBSCO, PsycINFO, Science Direct, Redalyc, and Web of Science, selected according to the PRISMA methodology, a total of 16 articles by ruling out duplicates or non-empirical studies. Results: Most were carried out in China, the sample size ranged between 20 and 7236 participants, mostly adolescents and adults, between 12 and 80 years old, with non-probability sampling for convenience. The most studied symptoms and disorders were anxiety (28%), depression (23%), stress (15.3%), sleep-wake disorder (9.6%) and post-traumatic stress disorder (5.7%), associated with psychoactive substance use, low academic performance, job loss, sleep quality, low self-care, and low perception of health status during the pandemic. Conclusions: The symptoms and disorders of anxiety, depression, and stress are the most frequent. Some limitations are the absence of pre-pandemic or quarantine measurement and the use of non-random sampling to generalize the results. Intervention research needs to be formulated to mitigate the psychological impact. Health systems must offer prevention and health promotion programs that consider psychosocial factors aimed at the general population, patients, and health personnel, to decrease the prevalence of these difficulties, particularly for Latin America where about scientific production is scarce. Objetivo: Realizar uma revisão sistemática da tendência de investigação sobre sintomas de transtornos mentais durante a pandemia por COVID-19. Métodos: Se recuperaram artigos publicados entre 31 de dezembro 2019 e 3 de maio 2020, em Pubmed, SCOPUS, EBSCO, PsycINFO, Science Direct, Redalyc e Web of Science, selecionando, conforme à metodologia PRISMA, um total de 16 artigos, ao descartar-se duplicados ou estudos não empíricos. Resultados: A maioria se realizaram na China, o tamanho da amostra oscilou entre 20 e 7236 participantes, na sua maioria adolescentes e adultos, entre 12 a 80 anos, com amostragem não probabilístico por conveniência. A tendência dos sintomas e transtornos mais estudados foram ansiedade (28%), depressão (23%), estresse (15.3%), transtorno do sono-vigília (9.6%) e transtorno por estresse pós-traumático (5.7%), associados com o consumo de substâncias psicoativas, sob rendimento acadêmico, perda de trabalho, qualidade do sono, baixo autocuidado e baixa percepção do estado de saúde durante a pandemia. Conclusões: Os sintomas e transtornos de ansiedade, depressão e estresse são os mais frequentes. Algumas limitações são a ausência de medição prévia à pandemia ou quarentena e o uso de amostragem não aleatório, para fazer generalização de resultados. É necessário formular investigações de intervenção para mitigar o impacto psicológico. Os sistemas de saúde devem oferecer programas de prevenção e de promoção da saúde, que considerem fatores psicossociais dirigidos à população geral, pacientes e pessoal sanitário, para diminuir a prevalência destas dificuldades, em particular, para Ibero América, onde é escassa a produção científica ao respeito.