Teaching demands and resources: early childhood teachers' experiences of remote and hybrid instruction during COVID-19 in the United States

Anchored in the Job Demands-Resources (JD-R) model, this study investigated the remote and hybrid teaching experiences of seven early childhood teachers (teaching preschool-1st grade) during the 2020-2021 school year amidst COVID-19 in the United States. They were all female (Age = 33-54 years, M = 44 years). Each teacher was interviewed for 30-60 min (M = 40 min) virtually via Zoom. Thematic analysis of the data revealed three main themes linked to teaching demands: (1) the challenge of implementing developmentally appropriate practice effectively, (2) the difficulty of managing the increased teaching workload, and (3) the barriers to promoting student engagement. It also highlighted two salient themes related to teaching resources: (1) institutional support, and (2) emotional support from the students' parents. Embedded within institutional support, there were two distinct types: (1) vertical support, referring to the professional and emotional support from education leaders, and (2) horizontal support, referring to the instrumental and emotional support from fellow teachers.

Competitive cause of death in elderly breast cancer survivors

Background: Breats cancer is a major health problem in elderly ( >= 70 years) women. Increase incidence with age and the progressive increase in life expectancy mean that the numbers in elderly breast cancer diagnosis are increasing. These patients do not always receive the proper treatment and despite this the survival of this population is not always depends on cancer, there are other competing causes of death typical of the aging population. Method(s): A retrospective observational analysis of women >= age 70 diagnosed with breast carcinoma in HUPHM between 2014 and 2020 was made. Clinical, pathological data and stages at diagnosis were analyzed. We checked our patients with the national death center (official national registry) thus obtaining an exact date of death and the cause of death. Data updated in January 2023 , ensuring a minimum follow-up of 24 months. We excluded deaths from Covid or of unknown cause to avoid bias. Result(s): A total of 421 patients were analyzed, mean age of 78.6 years and median follow-up of 48 months. 28% of patients had died at the time of analysis, 11% due to cancer and 17% from other causes. If we analyze the population deceased by cancer, no deaths are detected in patients diagnosed with carcinoma in situ (4% of the population), in stage I (30% of the population) the cumulative incidence of cancer death at 5 years is 3%, 7% In stage II (30% of the population), 15% in stage III (16%) and 70% in stage IV (12%). Death by other causes are more frequent in early breast cancer, the cumulative incidence at 5 years are 10% in stage I, 22% in stage II, 44% in satge III and just 10% in stage IV. The most frequent causes of death in this population were caridovascular events and infections. There are no differences in 5-year mortality according to histological subtypes 20%, 12%, 25% and 12% for triple negative, Rh+/HER2-, RH+/her2+ and RH-/HER2+ respectively. Conclusion(s): Although elderly patients do not receive optical treatments, mortality from cancer in early stages is incidental at 5 years, a different scenario is seen in metastatic disease in which the patient's prognosis depends mainly on the oncological disease, Therefore, an effort should be made in the treatment of these patients with metastatic breast cancer since adequate treatments can have a clearly positive impact on the survival of patients. Legal entity responsible for the study: The authors. Funding(s): Has not received any funding. Disclosure: All authors have declared no conflicts of interest.Copyright © 2023

Vacina Sarscov-2 Pfizer/Biontech Precipitando Agudizacao De Trombocitopenia Imune

Introducao: Trombocitopenia Imune (PTI) e uma doenca mediada por auto anticorpos contra glicoproteinas na membrana das plaquetas causando sua destruicao, associada a inibicao da funcao dos megacariocitos. A PTI pode ser primaria ou secundaria a doencas autoimunes, doencas linfoproliferativas, infeccao, medicamentos e imunizacao. Existem descricoes de vacinas contra Hepatite B, Influenza e ate mesmo contra o coronavirus, desencadeando quadros de trombocitopenia imune. Entretanto, ha poucos casos descritos ate o momento de agudizacao da PTI apos esta vacinacao, bem como nao existe contraindicacao para seu uso nesta populacao de pacientes. Objetivo: Relatar caso raro de vacina contra SARS-CoV-2 precipitando reagudizacao da PTI. Relato de caso: Mulher de 50 anos com PTI ha 28 anos, esplenectomizada ha 17 anos por corticodependencia. Apesar da esplenectomia, a paciente apresenta quadros esporadicos de reagudizacao apos infeccoes, sempre controlados satisfatoriamente com uso de corticoide. Recebeu previamente duas doses da vacina da COVID (Coronavac), sendo liberada em consulta de rotina para tomar a 3 dose da vacina, na ocasiao com dosagem de plaquetas de 225 mil/mm3. Apos 4 dias deste exame recebeu a vacina Pfizer, evoluindo no 1degree dia com petequias em membros inferiores e cavidade oral. Tres dias apos a vacinacao procurou atendimento medico, apresentando ao hemograma plaquetas 4.000 mil/mm3. Paciente foi tratada com pulso de metilprednisolona 1g/dia por 3 dias atingindo plaquetas 216 mil/mm3 apos 4 dias, mantendo-se com plaquetometria normal ate o momento, 6 meses apos o presente relato. Discussao: Assim como outros casos de infeccoes virais associados a etiologia da trombocitopenia imune, acredita-se que o fenomeno possa ser atribuido tanto pelo mimetismo molecular quanto pela resposta imune gerada. Estudos mostraram que 13,7% dos pacientes com PTI recairam a doenca apos a vacina da COVID-19. Entretanto, nao existem referencias quanto ao tipo de vacina realizada. Todos os casos descritos foram transitorios e com boa resposta a terapia padrao, assim como a paciente deste relato. Devido a isso, a contagem de plaquetas deve ser monitorada antes e apos a vacinacao, independente do componente vacinal, e ate entao, nao e contra indicada para pacientes portadores de PTI. Conclusao: Assim, o presente relato sugere que a vacina propiciou recaida da PTI, visto que a doenca estava estavel, sem ser observado outro fator desencadeante. Apos revisao na literatura, pode ser observado casos semelhantes. Porem, ainda faltam dados para comprovacao desta associacao, alem de estabelecer o melhor esquema vacinal a ser realizado nos portadores de PTI. Copyright © 2022

Infiltracao Medular Por Leucemia Mieloide Aguda (Lma) E Tumor Solido (Ts) Metastatico: Relato De Caso

Objetivo: Descrever um caso com duas neoplasias concomitantes infiltrando medula ossea (MO), sendo uma delas hematologica e outra, TS. Material e metodos: Relato de caso por meio de coleta de dados de prontuario de paciente acompanhado no HAC. Resultados: Paciente 67 anos, masculino, tabagista (100 anos/maco), ex-etilista, historia de inalacao de tintas com benzeno (pintor de carros por 30 anos), com astenia e anemia ha 4 meses, associado a perda de 25kg. Procurou atendimento em marco/22 com diagnostico de COVID-19 e necessidade de internacao hospitalar. Evoluiu com bicitopenia sendo transferido ao HAC para investigacao. Ao exame fisico: ECOG 3. Hemograma: bicitopenia (Hb 5.8 mg/dL;plaquetas 40000/mm3;leucocitos 13000/mm3;69% blastos). TC: derrame pleural a direita;raros micronodulos pulmonares;enfisema pulmonar difuso acentuado com areas de fibrose associadas;linfonodomegalias mediastinais e hilares, lesoes osteoliticas esparsas. Mielograma: dispoese das tres linhagens, com 24% de celulas blasticas, alem de grumos de celulas nao-hematologicas (TS). Em Citometria de Fluxo (Euroflow): 16% de mieloblastos patologicos, expressando CD7, CD13, CD33, CD34, CD38, CD44, CD71, CD97, CD123. Citogenetica: 47,XY,+8. Nao foi realizada avaliacao molecular. Biopsia de MO: infiltracao macica da medula ossea por tumor solido. Imunohistoquimica com positividade para: CK7 e TTF-1 e negatividade para: CK20, PSA, PAX-8, CD10, CDX-2, GATA-3. Diagnostico final: infiltracao da MO por adenocarcinoma, favorecido sitio pulmonar, e em area residual, infiltracao por Leucemia mieloide aguda, com alteracao citogenetica associada a mielodisplasia (ELN 2022). Como tratava-se de idoso fragil, sem possibilidade de tratamento intensivo das doencas leucemica e oncologica, proposto tratamento paliativo exclusivo, com medidas de suporte. Paciente faleceu apos 2 meses do diagnostico. Discussao: A associacao de LMA com TS nao e rara. O risco de um paciente previamente tratado para TS desenvolver LMA pode ser ate 10 vezes maior que a populacao normal. Relatos de casos de TS recidivados em MO e LMA concomitantes foram descritos, com desfechos sombrios. Contudo, nao ha na literatura a descricao de LMA de novo com TS infiltrando MO concomitantes ao diagnostico. Estudo chines de 2020, analisou 12 casos de LMA associada a TS primario sincronicos, sendo: 3 etiologia pulmonar, 1 mama, 1 mola, e 7 com neoplasia de TGI. O intervalo de tempo mediano para o diagnostico das duas neoplasias foi de 4 meses. O tratamento da LMA foi realizado com quimioterapia (QT) de alta intensidade ou agente hipometilante. A sobrevida global mediana foi de 12.5 meses (porem somente 4/12 tinham TS avancado). Um estudo americano em 2009 analisou 5 pacientes com LMA e tumor de pulmao (2 com doenca avancada) sincronicos. Todos foram tratados com QT de alta intensidade, e a sobrevida media foi de 5 meses (3-21). Conclusao: Este e o primeiro relato de caso de LMA e TS metastatico infiltrando MO concomitantemente ao diagnostico. A LMA deve ser tratada prioritariamente por ser doenca altamente agressiva, levando-se em conta as condicoes clinicas do paciente, com avaliacao individual. E mesmo com tratamento intensivo, o prognostico e reservado. Copyright © 2022

Infiltracao Do Sistema Nervoso Central: Desafio Terapeutico Nas Doencas Linfoproliferativas B Cronicas

Introducao: O acometimento do sistema nervoso central (SNC) e raro nas doencas linfoproliferativas B cronicas, sendo mais frequente a recaida nos linfomas nao-Hodgkin agressivos, porem a era pos Rituximab promoveu um ganho para esse perfil de pacientes. Objetivo: Relatar o envolvimento de SNC em 04 pacientes com doencas linfoproliferativas B cronicas e indolentes e revisar a literatura. Relato de caso: Caso 1: Homem, 53 anos, com leucemia linfoide cronica (LLC) Binet A desde 2012 e delecao 17p, apresentou crise convulsiva e rebaixamento neurologico em 12/2021. O liquor mostrou 18,3% de celulas B CD5+, CD19+, CD200+, recebeu imunoquimio intratecal e ibrutinibe sem resposta, LCR ainda infiltrado. Caso 2: Homem, 56 anos, com LLC Binet A desde 07/2021 evoluiu com abrupta piora cognitiva, RNM encefalica previa normal, novo exame em 02/2022 mostrou lesoes expansivas infiltrativas e nodulares intra-axiais bilaterais, compativeis com LNHDGCB (BCL-2+, CD20+, c-Myc+, Ki-67+, MUM1+), LCR normal, tratado com metotrexate (MTX) em altas doses, sem resposta. Caso 3: Mulher, 56 anos, com LNH folicular EC IVA em 2019, recebeu 06 ciclos de R-CHOP e manutencao por 02 anos, em remissao clinica. Em 04/2022 cursou com rapido agravo neurologico. A RNM mostrou lesoes na substancia branca nos hemisferios cerebrais, LCR infiltrado por celulas CD19, CD23, CD20, CD10 positivas, tratada com Ara C em altas doses, regressao das lesoes encefalicas, LCR ainda infiltrado. Caso 4 - Homem, 64 anos, com linfocitose, assintomatico desde 2011, IF de SP CD5- CD20+, CD22+, CD79b+, CD200+, evoluiu em 01/2022 subitamente com rebaixamento neurologico, entubado, LCR com 52,8% de linfocitos B CD19+, CD 20+, CD200+. Intercorreu com infeccao pelo SARS-Cov 19, complicacoes clinicas e obito. Discussao: O envolvimento do SNC nas doencas linfoproliferativas, tanto na apresentacao inicial ou na recidiva, e raro, podendo ser leptomeningeo disseminado e/ou parenquimatoso. Raramente descrito, o acometimento meningeo na LLC e objeto de discussao quanto ao impacto prognostico e ao tratamento. A infiltracao do SNC e mais descrita nos linfomas agressivos em cerca de 5% dos casos. Descrevemos 04 casos com envolvimento SNC em patologias de comportamento tipicamente indolente. Lemma et al. exploraram o papel dos marcadores biologicos que podem conferir as celulas do linfoma tropismo pelo SNC, altos niveis de Integrina alpha 10 e PTEN em amostras de tecido foram associadas a este tropismo, enquanto a expressao de CD44 e caderina-11 parecem ser protetivas, estes dados sao preliminares e precisam de validacao. A apresentacao clinica e heterogenea, desde alteracao comportamental, cefaleia, meningismo, hidrocefalia, e hipertensao intracraniana. No tratamento do linfoma primario de SNC o MTX e fundamental, mas ainda nao ha consenso em relacao a profilaxia e ao protocolo padrao nas recaidas. Fica claro que a dose de MTX IT parece insuficiente para tratar as formas parenquimatosas. Quando ha envolvimento meningeo, a via IT pode ser usada, mas os dados sobre os resultados nao sao conclusivos. Conclusao: O tratamento dos pacientes que apresentam infiltracao SNC permanece um desafio principalmente nos linfomas indolentes, considerando a dificuldade de padronizar tratamento eficaz, de menor toxicidade e a gravidade das sequelas por vezes irreversiveis. O mecanismo associado a invasao e a predilecao de alguns casos pelo SNC permanece incerto. Copyright © 2022

Transversality exercises for a design didactic proposal. The case of Visual Design integrating workshop in times of pandemic

As a result of the quarantine decreed at the beginning of 2020 to contain the Covid-19 pandemic, educational institutions had to turn face-to-face processes to classes mediated by new technologies and virtual tools. To respond to this challenge, a Visual Design group of professors at Universidad de Caldas put forward a pedagogical proposal in the teaching of design that was applied in the Integrating workshop held during the first period of 2020 with the seventh semester students. Transversality is the common denominator of this didactics design, which consisted in integrating most of the semester courses in the same space under a curricular model of the program that allowed nourishing and complementing content among professors and contributed to knowledge in a project comprehensive process under a practical and purposeful methodology. The proposal was consolidated as a laboratory of didactic strategies through the development of ten projects devised by the group of students, implementing Design Thinking, which resulted in an innovative teaching strategy that represents a viable trend for the teaching of design. The conditions of the academic period were conducive to achieving a truly transversal process that yielded, among its results, a better appropriation of the concepts and contents required for the exercise of the discipline by allowing to confront and relate the themes of each course for the resolution of a specific design problem. © 2022 Universidad de Caldas. All rights reserved.

Explanation of Multi-Label Neural Networks with Layer-Wise Relevance Propagation

Neural networks are considered a black-box model as their strength in modeling complex interactions makes its operation almost impossible to explain. Still, neural networks remain very interesting tools as they have shown promising performance in various classification tasks. Layer-wise relevance propagation is a technique that, based on a propagation approach, is able to explain the predictions obtained by a neural network. In this work, we propose four adaptations of this technique to operate on multi-label neural networks. The proposed methods provide new ways of distributing the relevance between the output layer and the preceding ones. The efficacy of these adaptations is demonstrated after an experimental study. The study is carried out based on existing evaluation criteria in the literature that measure the explanation's quality. These methods are applied to a case study in which a neural network is used to detect secondary coinfections in patients infected with SARS-CoV-2. Overall, the proposed methods provide a post-hoc interpretability stage of the results. © 2022 IEEE.

Clinical outcomes in patients with a diagnosis of pneumonia related to SARS-CoV-2 managed with a high-flow cannula, a clinical experience. (CANALF study)

Introduction: The inclusion of non-invasive ventilatory support systems in the management of ARDS in adults during the current pandemic, has been a lifeline given the lack of resources in the current international health situation. Systems such as the high flow nasal cannula have proven not to be just a temporary ventilatory system while awaiting invasive mechanical ventilation, on the contrary it has been shown that the high flow nasal cannula is an effective therapy tool in ARDS. Objective: To provide an easy guideline for the management of high-flow cannulas in hospitalized patients with severe pneumonia due to ATS criteria secondary to SARS COV2-COVID 19. Materials and methods: This is a prospective, single-centre observational study, including 59 patients, all with a diagnosis of SARS-CoV-2-related pneumonia between January and April 2021. The patients were initially managed in an intermediate care unit with high nasal cannula flow (HFNC). Results: We were able to show that there is a statistically significant correlation between age > 65 years and respiratory rate ≥28 and mortality;likewise, between age > 50 years, NEWS > 6 and again a respiratory rate ≥28 with treatment failure. Conclusions: HFNC in respiratory failure related to coronavirus disease 2019 should become a viable management alternative, particularly in settings with limited access to intensive care unit resources, taking the indications into account and recognizing that a high percentage of patients who receive it can be successfully weaned without the need for invasive mechanical ventilation. © 2022 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo

Acute Disseminated Encephalomyelitis in a Puerto Rican patient with positive SARS-Cov-2: Casualty or Causality?

Objective: NA Background: Acute disseminated encephalomyelitis (ADEM) is an inflammatory disease of the central nervous system thought to be caused by environmental factors to genetic susceptible individuals, where there is autoimmunity towards myelin components. Given the wide variety of symptoms, etiology and mimickers, ADEM is a diagnosis of exclusion, making difficult a prompt diagnosis. The pathogenesis associated between COVID-19 and ADEM is unknown, however, it could be secondary to immune-mediated mechanisms or molecular mimicry, creating a neuro-inflammatory response. Design/Methods: A previously healthy 22-year-old Puerto Rican male presented to the ED with altered mental status, incoherent speech, imbalance, and dizziness of 2 months progression. Neurological examination was remarkable for slow mentation, positive right Hoffman, left leg weakness and bilateral sustained clonus. Brain MRI showed innumerable foci of increased T2/FLAIR signal intensity throughout supra and infratentorial gray and white matter, none showing contrast enhancement. CSF with evidence of high protein levels, WBC of 7 (100% mononuclear) and normal glucose levels. Extensive workup for evaluation of infectious, demyelinating, inflammatory and vascular etiologies came back negative. Patient with recent history of gastrointestinal symptoms, reason why COVID-19 IgG/IgM Rapid Test was performed with positive IgG results 2 months prior to our evaluation. Patient was treated with intravenous steroids and intravenous immunoglobulin, with marked clinical improvement. Results: NA Conclusions: Here we present a case of atypical coronavirus disease 2019 (COVID-19) manifestation of a Puerto Rican male patient that 2 weeks after detecting SARS-COV-2 on his blood neurological symptoms started to develop. This is the first case of a young Puerto Rican patient without any other comorbidities where an association of COVID-19 infection and ADEM was found. Since ADEM if a diagnosis exclusion, it is vital to being able to distinguish this syndrome when it comes to a patient with history of COVID-19 infection and vaccine for prompt management.

Digital solutions for teachers in a hurry: ICT tools to energize the virtual classroom

In a world highly influenced by new technologies, the COVID-19 pandemic has increased the need to incorporate ICT tools and resources into educational practice. Currently there is a wide range of technological possibilities for use in teaching. However, the abundance and heterogeneity of didactic apps and virtual platforms can be overwhelming. Teachers nowadays face the challenge of adapting to an unknown environment without the proper training and guidance on key tools and methodologies. This article is intended as a support for teachers who have to transition rapidly to teaching in virtual environments and identifies key online teaching tools.

Applications of Computational Intelligence in the Studies of Covid-19

Health is an extremely important aspect in the United Nations Sustainable Development Goals because there is not possible progress for humankind without it. The Covid19 pandemic has evidenced to what extent society can be affected in all its facets when suddenly a phenomenon affects human's health. In this chapter, it is analyzed how computational intelligence techniques have allowed developing different studies about this disease, creating several prediction models and formulating new knowledge about it. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Layer-Wise Relevance Propagation in Multi-label Neural Networks to Identify COVID-19 Associated Coinfections

COVID-19 has been affected worldwide since the end of 2019. Clinical studies have shown that a factor that increases its lethality is the existence of secondary infections. Coinfections associated with the infection SARS-CoV-2 are classified into bacterial infections and fungal infections. A patient may develop one, both, or neither. From a machine learning point of view, this is considered a multi-label classification problem. In this work, we propose a multi-label neural network able to detect such infections in a patient with SARS-CoV-2 and thus provide the medical community with a diagnosis to guide therapy in these patients. However, neural networks are often considered a “black box” model, as their strength in modeling complex interactions, also make their operation almost impossible to explain. Therefore, we propose three adaptations of the Layer-wise Relevance Propagation algorithm to explain multi-label neural networks. The inclusion of this post-hoc interpretability stage made it possible to identify significant input variables in a classifier output. © 2021, Springer Nature Switzerland AG.

Health Promotion in the context of the COVID 19 Pandemic

The COVID-19 pandemic is a social and especially health problem whose appearance has made it possible to highlight the circulation of other epidemics affecting the population and the socioeconomic and structural crisis present in different countries. Attention is aimed at counteracting the disease through prevention measures at the community level to reduce the spread of the virus and prevent new infections. This context proposes health promotion as the basis to rethink the education processes of the population for the assessment of their health. This document reviews the evolution of the health and different approaches to health promotion;orientations that the health policies developed during the appearance of pandemics that occurred in the world through times;the challenges that countries are facing, and the social behaviors observed during the current pandemic. With this background, some lessons learned from the political, scientific, and social aspects outlined and some general considerations raised, from the scenario presented by COVID-19, on the importance of assuming health as a social right and duty and health promotion of health. Health is a process that allows individuals and communities to develop learning strategies to protect their health and act on its social determinants;Likewise, elements of the communication process directly related to health promotion to guide the lives of citizens.

Obesity is a strong risk factor for short-term mortality and adverse outcomes in Mexican patients with COVID-19: a national observational study.

Conflicting results have been obtained through meta-analyses for the role of obesity as a risk factor for adverse outcomes in patients with coronavirus disease-2019 (COVID-19), possibly due to the inclusion of predominantly multimorbid patients with severe COVID-19. Here, we aimed to study obesity alone or in combination with other comorbidities as a risk factor for short-term all-cause mortality and other adverse outcomes in Mexican patients evaluated for suspected COVID-19 in ambulatory units and hospitals in Mexico. We performed a retrospective observational analysis in a national cohort of 71 103 patients from all 32 states of Mexico from the National COVID-19 Epidemiological Surveillance Study. Two statistical models were applied through Cox regression to create survival models and logistic regression models to determine risk of death, hospitalisation, invasive mechanical ventilation, pneumonia and admission to an intensive care unit, conferred by obesity and other comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease, asthma, immunosuppression, hypertension, cardiovascular disease and chronic kidney disease). Models were adjusted for other risk factors. From 24 February to 26 April 2020, 71 103 patients were evaluated for suspected COVID-19; 15 529 (21.8%) had a positive test for SARS-CoV-2; 46 960 (66.1%), negative and 8614 (12.1%), pending results. Obesity alone increased adjusted mortality risk in positive patients (hazard ratio (HR) = 2.7, 95% confidence interval (CI) 2.04-2.98), but not in negative and pending-result patients. Obesity combined with other comorbidities further increased risk of death (DM: HR = 2.79, 95% CI 2.04-3.80; immunosuppression: HR = 5.06, 95% CI 2.26-11.41; hypertension: HR = 2.30, 95% CI 1.77-3.01) and other adverse outcomes. In conclusion, obesity is a strong risk factor for short-term mortality and critical illness in Mexican patients with COVID-19; risk increases when obesity is present with other comorbidities.

Mechanisms of infection by SARS-CoV-2, inflammation and potential links with the microbiome

The pandemic SARS coronavirus 2 utilizes efficient mechanisms to establish infection and evade the immune system. Established infection leads to severe inflammation in susceptible patients, the main hallmark of progression to severe coronavirus disease (COVID-19). Knowledge of the mechanisms of disease has expanded rapidly. As inflammation emerges as the central pathophysiological feature in COVID-19, elucidating how the immune system, lungs and gut communicate and interact with microbial components of the ecological niches that conform the human microbiome will shed light on how inflammation and disease progression are promoted. Studying the microbiome in COVID-19 could allow scientists to identify novel approaches to prevent severe inflammation by targeting components of the human microbiome. Innovation in the aforementioned is needed to combat this pandemic.

Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75-0.87])) and PROFUND (AUC-ROC = 0.67 [0.6-0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90-98%]), PROFUND (93 % [77-98%]), and their combination (100 % [82-100%]); whereas CURB-65 (74 % [51-88%]), and its combination with PROFUND (80 % [50-94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

Effectiveness of a On-site Medicalization Program for Nursing Homes With COVID-19 Outbreaks.

BACKGROUND: Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHOD: A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in 4 nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of "clean" and "contaminated" areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital. RESULTS: Two hundred and seventy-two of 457 (59.5%) residents and 85 of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital occurred in 77%, 72.5%, and 29% of patients diagnosed before the start of MP, with respect to 97%, 83.7%, and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR = 15 [3-81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR = 28 [5-160]). All outbreaks were controlled in 39 [37-42] days. CONCLUSIONS: A coordinated on-site MP of nursing homes with COVID-19 outbreaks achieved a higher SOPC rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.