Characteristics of ST-Elevation Myocardial Infarction during the SARS-CoV-2 Outbreak

Abstract Background The SARS-CoV-2 outbreak has led to radical transformation in social, economic, and healthcare systems. This may lead to profound indirect consequences on clinical presentation and management of patients with ST-segment-elevation myocardial infarction. Objectives The objective of this study was to describe the characteristics, management, and outcomes of patients admitted with acute myocardial infarction with ST-segment elevation (STEMI), in two tertiary reference hospitals during the SARS-CoV-2 outbreak and compare them with patients admitted in the previous year. Methods We analyzed data from a multicenter STEMI registry from reference centers in the South Region of Brazil from March 2019 to May 2021. The beginning of the COVID-19 outbreak was considered to be March 2020 and compared to the same period in 2019. Only patients with STEMI submitted to primary percutaneous coronary intervention (PCI) were included in the analysis. Mortality rates were compared with chi-square test. All hypothesis tests had a two-sided significance level of 5%. Results A total of 1169 patients admitted with STEMI were enrolled in our registry, 635 of whom were admitted during the pandemic period. The mean age of our sample was 61.6 (± 12.4) years, and 66.7% of patients were male. Pain-to-door time and door-to-balloon time were longer during the pandemic period. However, there was no difference in mortality rates or major adverse cardiovascular outcomes (MACE). Conclusions We observed a stable incidence of STEMI cases in our registry during the SARS-CoV-2 outbreak with higher pain-to-door time and door-to-balloon time, without any influence on mortality rates however.

Wood Flour Modified by Poly(furfuryl alcohol) as a Filler in Rigid Polyurethane Foams: Effect on Water Uptake.

The use of lignocellulosic fillers in rigid polyurethane foams (RPUFs) has been receiving great attention due to their good mechanical and insulation properties and the high sustainable appeal of the obtained cellular polymers, although high water uptakes are found in most of these systems. To mitigate this detrimental effect, RPUFs filled with wood flour (2.5% wt) were fabricated with the addition of furfuryl alcohol (FA) to create a polymer grafted with the wood filler. Two concentrations of FA (10 wt% and 15 wt%) were investigated in relation to the wood flour, and the RPUFs were characterized for cell morphology, density, compressive properties, thermal stability, and water uptake. The introduction of wood flour as a filler decreased the cell size and increased the anisotropy index of the RPUFs and, in addition to that, the FA grafting increased these effects even more. In general, there were no significant changes in both mechanical and thermal properties ascribed to the incorporation of the fillers. On the other hand, a reduction of up to 200% in water uptake was ascribed to the FA-treated fillers.

Comparison of Admission Lung Ultrasound and Left Ventricular End-Diastolic Pressure in Patients Undergoing Primary Percutaneous Coronary Intervention.

[Figure: see text].

Man vs. machine: Predicting hospital bed demand from an emergency department.

BACKGROUND: The recent literature reports promising results from using intelligent systems to support decision making in healthcare operations. Using these systems may lead to improved diagnostic and treatment protocols and to predict hospital bed demand. Predicting hospital bed demand in emergency department (ED) attendances could help resource allocation and reduce pressure on busy hospitals. However, there is still limited knowledge on whether intelligent systems can operate as fully autonomous, user-independent systems. OBJECTIVE: Compare the performance of a computer-based algorithm and humans in predicting hospital bed demand (admissions and discharges) based on the initial SOAP (Subjective, Objective, Assessment, Plan) records of the ED. METHODS: This was a retrospective cohort study that compared the performance of humans and machines in predicting hospital bed demand from an ED. It considered electronic medical records (EMR) of 9030 patients (230 used as a testing set, and hence evaluated both by humans and by an algorithm, and 8800 used as a training set exclusively by the algorithm) who visited the ED of a tertiary care and teaching public hospital located in Porto Alegre, Brazil between January and December 2014. The machine role was played by Support Vector Machine Classifier and the human prediction was performed by four ED physicians. Predictions were compared in terms of sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUROC). RESULTS: All graders achieved similar accuracies. The accuracy by AUROC for the testing set was 0.82 [95% confidence interval (CI) of 0.77-0.87], 0.80 (95% CI: 0.75-0.85), 0.76 (95% CI: 0.71-0.81) for novice physicians, machine, experienced physicians, respectively. Processing time per test EMR was 0.00812±0.0009 seconds. In contrast, novice physicians took on average 156.80 seconds per test EMR, while experienced physicians took on average 56.40 seconds per test EMR. CONCLUSIONS: Our data indicated that the system could predict patient admission or discharge states with 80% accuracy, which was similar the performance of novice and experienced physicians. These results suggested that the algorithm could operate as an autonomous and independent system to complete this task.

Admission Bedside Lung Ultrasound Reclassifies Mortality Prediction in Patients With ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Early risk stratification is essential for in-hospital management of ST-segment-elevation myocardial infarction. Acute heart failure confers a worse prognosis, and although lung ultrasound (LUS) is recommended as a first-line test to assess pulmonary congestion, it has never been tested in this setting. Our aim was to evaluate the prognostic ability of admission LUS in patients with ST-segment-elevation myocardial infarction. METHODS: LUS protocol consisted of 8 scanning zones and was performed before primary percutaneous coronary intervention by an operator blinded to Killip classification. A LUS combined with Killip (LUCK) classification was developed. Receiver operating characteristic and net reclassification improvement analyses were performed to compare LUCK and Killip classifications. RESULTS: We prospectively investigated 215 patients admitted with ST-segment-elevation myocardial infarction between April 2018 and June 2019. Absence of pulmonary congestion detected by LUS implied a negative predictive value for in-hospital mortality of 98.1% (93.1-99.5%). The area under the receiver operating characteristic curve of the LUCK classification for in-hospital mortality was 0.89 (P=0.001), and of the Killip classification was 0.86 (P<0.001; P=0.05 for the difference between curves). LUCK classification improved Killip ability to predict in-hospital mortality with a net reclassification improvement of 0.18. CONCLUSIONS: In a cohort of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, admission LUS added to Killip classification was more sensitive than physical examination to identify patients at risk for in-hospital mortality. LUCK classification had a greater area under the receiver operating characteristic curve and reclassified Killip classification in 18% of cases. Moreover, absence of pulmonary congestion on LUS provided an excellent negative predictive value for in-hospital mortality.

Uso do escore HAS-BLED em um ambulatório de anticoagulação de um hospital terciário / Use of HAS-BLED score in an anticoagulation outpatient Clinic of a tertiary hospital

Fundamento: O escore HAS-BLED foi desenvolvido para avaliar o risco em um ano de sangramento maior em pacientes com fibrilação atrial (FA) anticoagulados com antagonistas da vitamina K (AVK). Objetivo: O objetivo deste estudo foi avaliar a capacidade do escore HAS-BLED e de seus componentes em predizer sangramento maior em pacientes atendidos em um ambulatório de anticoagulação de um hospital terciário. Métodos: Foi realizado um estudo coorte retrospectivo com pacientes com FA tratados com AVK. Análise de regressão logística foi realizada para avaliar a capacidade de cada componente do escore em predizer sangramento maior. O nível de significância adotado em todos os testes foi de 5%. Resultados: Foram estudados 263 pacientes com média de idade de 71,1 ± 10,5 anos ao longo de um período de tratamento de 237,6 pacientes-ano. A mediana do escore HAS-BLED foi de 2 (1-3). A incidência de sangramento maior foi de 5,7%, sendo mais elevada nos pacientes de alto risco que nos pacientes de baixo risco (9,6 vs. 3,1%; p = 0,052). A área sob a curva ROC foi de 0,70 (p = 0,01). Um ponto de corte ≥ 3 mostrou sensibilidade de 66,7%, especificidade de 62,1%, valor preditivo positivo de 9,6% e valor preditivo negativo de 96,9%. Sobrevida livre de sangramento maior foi menor no grupo de alto risco (p = 0,017). Na análise multivariada, o único preditor independente de sangramento maior entre os componentes do escore foi o uso concomitante de antiplaquetários (OR 5,13, IC95%: 1,55-17,0; p = 0,007). Conclusão: O escore HAS-BLED foi capaz de prever sangramento maior na população de pacientes com FA estudada. Entre os componentes do escore, atenção especial deve ser dada para o uso concomitante de antiplaquetários, que mostrou associação independente. Em pacientes com FA em uso de AVK como terapia anticoagulante, o uso de antiplaquetários deve ser realizado somente naqueles pacientes com avaliação risco-benefício favorável

Background: HAS-BLED s core was developed to assess 1-year major bleeding risk in patients anticoagulated with vitamin K antagonists (VKA) due to atrial fibrillation (AF). Objective: Of this study was to assess the ability of HAS-BLED score and its components to predict major bleeding in patients treated in an anticoagulation outpatient clinic of a tertiary hospital. Methods: A retrospective cohort study on AF patients treated with VKA was conducted. Logistic regression analysis was performed to evaluate the ability of individual score components to predict major bleeding. The significance level adopted in all tests was 5%. Results: We studied 263 patients with a mean age of 71.1 ± 10.5 years over a period of 237.6 patients-year. Median HAS-BLED score was 2 (1-3). The overall incidence of major bleeding was 5.7%, and it was higher among high-risk HAS-BLED score patients than in low risk patients (9.6 vs. 3.1%; p = 0.052). Area under the ROC curve was 0.70 (p = 0.01). Cut-off point ≥ 3 showed sensibility of 66.7%, specificity of 62.1%, positive predictive value of 9.6% and negative predictive value of 96.9%. Major bleeding-free survival was lower in high-risk group (p = 0.017). In multivariate analysis, concurrent antiplatelet use was the only independent predictor of major bleeding among score components (OR 5.13, 95%CI: 1.55-17.0; p = 0.007). Conclusion: HAS-BLED score was able to predict major bleeding in this cohort of AF patients. Among score components, special attention should be given for concomitant antiplatelet use, which was independently associated to this outcome. Antiplatelets in AF patients under VKA anticoagulation should be used in selected patients with favorable risk-benefit assessment

Acute tubulointerstitial nephritis with severe renal impairment associated with multisystem IgG4-related disease.

The IgG4-related disease has a wide clinical spectrum where multiple organs can be affected, and the diagnosis depends on typical histopathological findings and an elevated IgG4 expression in plasma cells in the affected tissue. We describe the clinical presentation and evolution of a patient with acute tubulointerstitial nephritis, severe kidney failure and systemic manifestations such as lymphadenomegaly and chronic pancreatitis. The diagnosis was confirmed by the clinical picture and kidney and lymph node histopathology, in which immunohistochemistry of the lymphoid tissue showed policlonality and increased expression of IgG4, with a IgG4/total IgG ratio > 80%. The patient was treated with prednisone at a dose of 60 mg/day, followed by mycophenolate mofetil, and showed clinical and renal function improvement at 6 months of follow-up. The high index of suspicion of IgG4-related disease with multisystem involvement and the early treatment of this condition are essential to improve the prognosis of affected patients. Resumo A doença relacionada à IgG4 tem um espectro clínico amplo em que múltiplos órgãos podem ser afetados, e o diagnóstico depende de achados histopatológicos típicos e elevada expressão de IgG4 em plasmócitos no tecido afetado. Descrevemos o quadro clínico e a evolução de um paciente com nefrite túbulo-intersticial aguda, insuficiência renal grave e manifestações sistêmicas como linfoadenomegalias e pancreatite crônica. O diagnóstico foi confirmado pelas características clínicas e pela histopatologia renal e de linfonodo, na qual a imunohistoquímica mostrou tecido linfoide com policlonalidade e expressão aumentada de IgG4, com uma relação IgG4/IgG total > 80%. O paciente foi tratado com prednisona na dose de 60 mg/dia, seguido de micofenolato mofetil, e apresentou melhora clínica e da função renal depois de 6 meses de tratamento. O alto índice de suspeição da doença relacionada ao IgG4 com comprometimento multissistêmico e o tratamento precoce desta condição são primordiais para a melhora do prognóstico destes pacientes.

Acute tubulointerstitial nephritis with severe renal impairment associated with multisystem IgG4-related disease / Nefrite túbulo-intersticial aguda com insuficiência renal grave associada à doença multissistêmica por IgG4

Abstract The IgG4-related disease has a wide clinical spectrum where multiple organs can be affected, and the diagnosis depends on typical histopathological findings and an elevated IgG4 expression in plasma cells in the affected tissue. We describe the clinical presentation and evolution of a patient with acute tubulointerstitial nephritis, severe kidney failure and systemic manifestations such as lymphadenomegaly and chronic pancreatitis. The diagnosis was confirmed by the clinical picture and kidney and lymph node histopathology, in which immunohistochemistry of the lymphoid tissue showed policlonality and increased expression of IgG4, with a IgG4/total IgG ratio > 80%. The patient was treated with prednisone at a dose of 60 mg/day, followed by mycophenolate mofetil, and showed clinical and renal function improvement at 6 months of follow-up. The high index of suspicion of IgG4-related disease with multisystem involvement and the early treatment of this condition are essential to improve the prognosis of affected patients.

Resumo A doença relacionada à IgG4 tem um espectro clínico amplo em que múltiplos órgãos podem ser afetados, e o diagnóstico depende de achados histopatológicos típicos e elevada expressão de IgG4 em plasmócitos no tecido afetado. Descrevemos o quadro clínico e a evolução de um paciente com nefrite túbulo-intersticial aguda, insuficiência renal grave e manifestações sistêmicas como linfoadenomegalias e pancreatite crônica. O diagnóstico foi confirmado pelas características clínicas e pela histopatologia renal e de linfonodo, na qual a imunohistoquímica mostrou tecido linfoide com policlonalidade e expressão aumentada de IgG4, com uma relação IgG4/IgG total > 80%. O paciente foi tratado com prednisona na dose de 60 mg/dia, seguido de micofenolato mofetil, e apresentou melhora clínica e da função renal depois de 6 meses de tratamento. O alto índice de suspeição da doença relacionada ao IgG4 com comprometimento multissistêmico e o tratamento precoce desta condição são primordiais para a melhora do prognóstico destes pacientes.

Sample size for estimating average trunk diameter and plant height in eucalyptus hybrids / Tamanho de amostra para a estimação da média do diâmetro do tronco e da altura de plantas em híbridos de eucalipto

ABSTRACT: In eucalyptus crops, it is important to determine the number of plants that need to be evaluated for a reliable inference of growth. The aim of this study was to determine the sample size needed to estimate average trunk diameter at breast height and plant height of inter-specific eucalyptus hybrids. In 6,694 plants of twelve inter-specific hybrids it was evaluated trunk diameter at breast height at three (DBH3) and seven years (DBH7) and tree height at seven years (H7) of age. The statistics: minimum, maximum, mean, variance, standard deviation, standard error, and coefficient of variation were calculated. The hypothesis of variance homogeneity was tested. The sample size was determined by re sampling with replacement of 10,000 re samples. There was an increase in the sample size from DBH3 to H7 and DBH7. A sample size of 16, 59 and 31 plants is adequate to estimate DBH3, DBH7 and H7 means, respectively, of inter-specific hybrids of eucalyptus, with amplitude of confidence interval of 95% equal to 20% of the estimated mean.

RESUMO: Em povoamentos florestais de eucalipto, é importante determinar o número de plantas a serem avaliadas para que as inferências sobre o crescimento das plantas sejam confiáveis. O objetivo deste trabalho foi determinar o tamanho de amostra (número de plantas) necessário para a estimação da média do diâmetro do tronco e da altura de planta de híbridos interespecíficos de eucalipto. Em 6.694 plantas de doze híbridos interespecíficos de eucalipto, foram mensurados os diâmetros do tronco à altura do peito aos três (DAP3) e aos sete anos (DAP7) e a altura de planta aos sete anos de idade (H7). Após, foram calculadas as estatísticas: mínimo, máximo, média, variância, desvio-padrão, erro-padrão e coeficiente de variação. A seguir, testaram-se as hipóteses de homogeneidade entre as variâncias. Depois, foi determinado o tamanho de amostra por meio de reamostragem, com reposição de 10.000 reamostras. Há aumento do tamanho de amostra para a estimação da média do DAP3, da H7 e do DAP7, nessa ordem. Para a estimação da média do DAP3, do DAP7 e da H7 dos híbridos interespecíficos de eucalipto, com amplitude do intervalo de confiança de 95% igual a 20% da estimativa da média, 16, 59 e 31 plantas, respectivamente, são suficientes.

Resistência ao impacto da madeira de nogueira-pecã em diferentes condições de umidade / Impact strength of nogueira-pecã wood on different moisture conditions

Os estudos de resistência da madeira ao impacto referem-se à eficiência com que este material absorve energia de um impacto e dissipa-a sem danos a sua estrutura. Dessa forma, o objetivo deste estudo foi avaliar a influência do teor de umidade na resistência ao impacto da madeira de nogueira-pecã (Carya illinoinensis). Para tanto, foram utilizadas árvores procedentes de duas regiões fisiográficas do estado do Rio Grande do Sul. Os corpos de prova, em condições de equilíbrio a 12% de umidade e saturados, foram submetidos ao impacto utilizando-se pêndulo de CHARPY, e avaliados quanto à resistência oferecida com a aplicação da carga nos planos tangencial e radial e posições de retirada (medula - casca) nas toras, para as duas regiões fisiográficas em cada condição de umidade. Para auxiliar na interpretação dos dados, determinou-se a massa específica aparente a 12% e saturada, trabalho absorvido, coeficiente de resiliência e a cota dinâmica. Pôde-se verificar, por meio dos resultados, que a madeira de nogueira-pecã é mais resistente ao impacto na condição saturada.

The studies of wood impact strength refers to the efficiency of this material in absorb impact energy and dissipate it without structural damages. The present study aimed to evaluate the influence of moisture content on the impact strength of nogueira-pecã (Carya illinoinensis) wood. For this, trees from two physiographic regions of state of Rio Grande do Sul were used. The samples, stabilized at 12% of moisture content and in green conditions (saturated), were submitted to impact tests through a CHARPY pendulum, and were evaluated for the resistance to the application of loads in the tangential and radial sections, and in the positions of the log (pith-bark) for the two physiographic regions at each moisture condition. Moreover, the apparent specific gravity at 12% and in green conditions (saturated), the absorbed work, the resilience coefficient and the dynamic quote were determined. The main results showed that the nogueira-pecã wood is more resistant to the impact when it is in green conditions.

Idade de segregação do lenho juvenil e adulto pela variação da massa específica de açoita-cavalo / Estimating the age of demarcation of young and mature wood in açoita-cavalo

O presente trabalho teve como objetivo estimar a idade de segregação do lenho de Luehea divaricata Mart. (açoita-cavalo) por meio da variação radial da massa específica. Para o desenvolvimento do estudo, foram coletadas dez árvores de duas regiões do Estado do Rio Grande do Sul. Foi retirado um disco por árvore, com aproximadamente 2cm de espessura a 0,10m de altura do tronco. De cada disco, retirou-se, com auxílio de uma serra-fita, uma bagueta central de 2,0cm de largura, bem orientada no sentido radial, incluindo a medula no centro, dividiu-se então a bagueta em duas amostras "A" e "B". A massa específica foi obtida da relação entre peso seco e volume úmido. O volume úmido foi determinado de acordo com a norma ASTM D 2395 - 93, 1995. A segregação dos lenhos foi encontrada por regressão linear simples dos dados de variação da massa específica no sentido medula-casca. Foi feita uma regressão linear na faixa crescente dos dados e outra na faixa decrescente. A intersecção das retas extrapoladas foi adotada como idade de segregação. Os resultados obtidos mostraram que o lenho de açoita-cavalo segrega em aproximadamente 26 anos para a região da Depressão Central e 23 anos para a região da Encosta Superior do Nordeste. Nos dados de variação de massa específica, foi feita uma análise de variância multifatorial. Constatou-se que há diferença significativa entre lenhos e entre regiões. Por outro lado, as amostras A e B de cada árvore não foram estatisticamente diferentes entre si.

This study aims to estimate the age of segregation of young and mature wood of Luehea divaricata Mart., using the radial variation of specific gravity. To the development of this study were collected ten trees from two regions of the state of Rio Grande do Sul. Discs with thickness of 2cm at 0.1m of height from the base of the trunk were used. From each disk, with the aid of a band saw, a central ribbon 2.0cm wide, and oriented in the radial direction was taken, including the pith, then splitted into two samples "A" and "B". The specific gravity was calculated as ratio between dry weight and wet volume. The wet volume was determined according to ASTM D 2395 - 93, 1997. The age of segregation was found by simple linear regression of the data of variation of specific gravity from pith to bark. The intersection of extrapolated lines was adopted as the age of segregation. The results showed that the wood segregates in 26 year for the region of Central Depression and in 23 years for the Northeast Upper Hillside. Was made a multifactorial analysis of variance in the specific gravity data, showing that there are statistical difference between regions and woods. However, there are no statistical difference between samples.

Propriedades físico-mecânicas da madeira de canafístula aos 10 anos de idade / Physical and mechanical properties of 10 years old wood trees of canafístula

A presente pesquisa objetivou caracterizar as propriedades físico-mecânicas da madeira de canafístula (Peltophorum dubium (Spreng.) Taub.) proveniente de árvores com 10 anos, por meio da determinação da massa específica básica, da retratibilidade, do módulo de elasticidade e do módulo de ruptura em flexão estática, do módulo de elasticidade em compressão perpendicular, da resistência máxima à compressão paralela à grã, da dureza de Janka, da resistência máxima ao cisalhamento e da resistência ao choque. A determinação da massa específica básica e da retratibilidade seguiu as normas COPANT 30:1-004 (1971) e 30:1-005 (1971), respectivamente, e os ensaios mecânicos seguiram as normas ASTM D 143-94 (2000) e NF B 51-009 (1942). A massa específica básica e o coeficiente de anisotropia encontrado para a espécie permitiram classificar sua madeira como leve e medianamente estável, respectivamente; já os valores médios das propriedades mecânicas encontradas definem a madeira como de resistência fraca a média. As características tecnológicas determinadas indicam que sua madeira, quando proveniente de plantios jovens, deve ser utilizada com cautela em situações que exijam elevada estabilidade dimensional e resistência mecânica, sendo, portanto, aconselhável seu corte em idades mais avançadas.

This research aimed to characterize the physic-mechanical properties of the canafístula wood (Peltophorum dubium (Spreng.) Taub.) from 10 years' old trees. There was determined the specific gravity, shrinkage, modulus of elasticity and modulus of rupture in static bending, modulus of elasticity in compression perpendicular to the grain, compression strength parallel to the grain, hardness, shear and impact resistance. Specific gravity and shrinkage determination were conducted according to COPANT 30:1:004 (1971) and 30:1-005 (1971), respectively, and the mechanical tests followed ASTM D 143-94 (2000) and NF B51-009 (1942). The specific gravity and the ratio of tangential to radial shrinkage observed, ranked the wood as light and moderately stable, respectively, since the average values of mechanical properties classified the wood as weak to average strength. The technological characteristics observed indicate that when the wood is originated from short rotation plantation, it should be used with caution in situation which requires high dimensional stability and mechanical strength, suggesting the need of older trees.