Case Study of Two Post Vaccination SARS-CoV-2 Infections with P1 Variants in CoronaVac Vaccinees in Brazil.

The rapid development of efficacious and safe vaccines against coronavirus disease 2019 (COVID-19) has been instrumental in mitigating the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Moreover, the emergence of SARS-CoV-2 variants raised concerns on the efficacy of these vaccines. Herein, we report two cases of breakthrough infections with the P1 variant in patients vaccinated with CoronaVac, which is one of the two vaccines authorized for emergency use in the Brazilian immunization program. Our observations suggest that the vaccine reduced the severity of the disease and highlight the potential risk of illness following vaccination and subsequent infection with the P1 variant as well as for continued efforts to prevent and diagnose infection in vaccinated persons.

Presentation of fatal stroke due to SARS-CoV-2 and dengue virus coinfection.

Herein, we report a case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and dengue coinfection, presented as a fatal stroke in our hospital, in São José do Rio Preto, São Paulo State, a Brazilian city hyperendemic for dengue viruses and other arthropod-borne viruses (arboviruses) and currently facing a surge of SARS-CoV-2 cases. This case is the first described in the literature and contributes to the better understanding of clinical presentations of two important diseases in a tropical setting.

Study protocol for the Balanced Solution versus Saline in Intensive Care Study (BaSICS): a factorial randomised trial.

BACKGROUND: The effectiveness and safety of balanced crystalloid fluids compared with saline (0.9% sodium chloride) as a fluid of choice in critically ill patients remain unclear. The effects of different fluid infusion rates on outcomes are also unknown. OBJECTIVES: To test the hypothesis that a balanced crystalloid solution, compared with saline, decreases 90-day all-cause mortality among critically ill patients; and to test the hypothesis that slow, compared with rapid, infusion rate decreases 90-day mortality in this population of patients. METHODS: The Balanced Solution versus Saline in Intensive Care Study (BaSICS) is a pragmatic, 2 ??2 factorial, randomised controlled trial. A total of 11 000 patients will be recruited from at least 100 Brazilian intensive care units. Patients will be randomised to receive Plasma-Lyte 148 or saline, and to rapid infusion (999 mL/h) or slow infusion (333 mL/h). Study fluids will be used for resuscitation episodes (at rapid or slow infusion rates), dilution of compatible medications and maintenance solutions. Patients, health care providers and investigators will be blinded to the solutions being tested. The rate of bolus infusion will not be blinded. OUTCOMES: The primary outcome is 90-day all-cause mortality. Secondary outcomes are: incidence of renal failure requiring renal replacement therapy within 90 days, incidence of acute kidney injury (Kidney Disease: Improving Global Outcomes stages 2 and 3), incidence of non-renal organ dysfunction assessed by Sepsis-related Organ Failure Assessment score at Days 3 and 7, and number of mechanical ventilationfree days within the first 28 days after randomisation. RESULTS AND CONCLUSIONS: The BaSICS trial will provide robust evidence on whether a balanced crystalloid, compared with saline, improves important patient outcomes in critically ill patients. BaSICS will also provide relevant information on whether bolus infusion rate affects outcomes in this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02875873.

Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study.

BACKGROUND: This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS: This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS: Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS: Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Validation of four prognostic scores in patients with cancer admitted to Brazilian intensive care units: results from a prospective multicenter study.

OBJECTIVE: The aim of the present study was to validate the Simplified Acute Physiology Score II (SAPS II) and 3 (SAPS 3), the Mortality Probability Models III (MPM(0)-III), and the Cancer Mortality Model (CMM) in patients with cancer admitted to several intensive care units (ICU). DESIGN: Prospective multicenter cohort study. SETTING: Twenty-eight ICUs in Brazil. PATIENTS: Seven hundred and seventeen consecutive patients (solid tumors 93%; hematological malignancies 7%) included over a 2-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Discrimination was assessed by area under receiver operating characteristic (AROC) curves and calibration by Hosmer-Lemeshow goodness-of-fit test. The main reasons for ICU admission were postoperative care (57%), sepsis (15%) and respiratory failure (10%). The ICU and hospital mortality rates were 21 and 30%, respectively. When all 717 patients were evaluated, discrimination was superior for both SAPS II (AROC = 0.84) and SAPS 3 (AROC = 0.84) scores compared to CMM (AROC = 0.79) and MPM(0)-III (AROC = 0.71) scores (P < 0.05 in all comparisons). Calibration was better using CMM and the customized equation of SAPS 3 score for South American countries (CSA). MPM(0)-III, SAPS II and standard SAPS 3 scores underestimated mortality (standardized mortality ratio, SMR > 1), while CMM tended to overestimation (SMR = 0.48). However, using the SAPS 3 for CSA resulted in more precise estimations of the probability of death [SMR = 1.02 (95% confidence interval = 0.87-1.19)]. Similar results were observed when scheduled surgical patients were excluded. CONCLUSIONS: In this multicenter study, the customized equation of SAPS 3 score for CSA was found to be accurate in predicting outcomes in cancer patients requiring ICU admission.

Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study.

OBJECTIVE: To evaluate the characteristics and outcomes of patients with cancer admitted to several intensive care units. Knowledge on patients with cancer requiring intensive care is mostly restricted to single-center studies. DESIGN: : Prospective, multicenter, cohort study. SETTING: Intensive care units from 28 hospitals in Brazil. PATIENTS: A total of 717 consecutive patients included over a 2-mo period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 667 (93%) patients with solid tumors and 50 (7%) patients had hematologic malignancies. The main reasons for intensive care unit admission were postoperative care (57%), sepsis (15%), and respiratory failure (10%). Overall hospital mortality rate was 30% and was higher in patients admitted because of medical complications (58%) than in emergency (37%) and scheduled (11%) surgical patients (p < .001). Adjusting for covariates other than the type of admission, the number of hospital days before intensive care unit admission (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.01-1.37), higher Sequential Organ Failure Assessment scores (OR, 1.25; 95% CI, 1.17-1.34), poor performance status (OR, 3.40; 95% CI, 2.19 -5.26), the need for mechanical ventilation (OR, 2.42; 95% CI, 1.51-3.87), and active underlying malignancy in recurrence or progression (OR, 2.42; 95% CI, 1.51-3.87) were associated with increased hospital mortality in multivariate analysis. CONCLUSIONS: This large multicenter study reports encouraging survival rates for patients with cancer requiring intensive care. In these patients, mortality was mostly dependent on the severity of organ failures, performance status, and need for mechanical ventilation rather than cancer-related characteristics, such as the type of malignancy or the presence of neutropenia.

Delirium recognition and sedation practices in critically ill patients: a survey on the attitudes of 1015 Brazilian critical care physicians.

PURPOSE: The aim of the study was to characterize the practices of Brazilian ICU physicians toward sedation and delirium. MATERIALS AND METHODS: A cross-sectional survey was conducted among a convenience sample of critical care physicians between April and June 2008. RESULTS: One thousand fifteen critical care physicians responded. Sedation scoring systems were used by 893 (88.3%) of the respondents. The Ramsay and Richmond Agitation-Sedation Scale were used by 81.9% and 6.8% of the respondents, respectively. Most respondents did not discuss sedation targets (62.8%) or practice daily sedative interruption (68.3%) in most patients. More than half of the respondents (52.7%) used a sedation protocol, and the most used sedatives were midazolam (97.8%), fentanyl (91.5%), and propofol (55%). A significant rate of the respondents (42.7%) estimated that more than 25% of patients under mechanical ventilation have delirium, but 53.5% occasionally assessed patients for delirium. Thirteen percent used specific delirium scales, with the Confusion Assessment Method for intensive care unit (ICU) being the most applied. Delirium was often treated with haloperidol (88.1%); however, atypical antipsychotics (36.3%) and benzodiazepines (42.3%) were also used. CONCLUSIONS: Despite the recent advances in knowledge of sedation and delirium, most of them are still not translated into clinical practice. Significant variation in practice is observed among ICU physicians and represents a potential target for future research and educational interventions.

A multicentre, prospective study to evaluate costs of septic patients in Brazilian intensive care units.

BACKGROUND: Sepsis has a high prevalence within intensive care units, with elevated rates of morbidity and mortality, and high costs. Data on sepsis costs are scarce in the literature, and in developing countries such as Brazil these data are largely unavailable. OBJECTIVES: To assess the standard direct costs of sepsis management in Brazilian intensive care units (ICUs) and to disclose factors that could affect those costs. METHODS: This multicentre observational cohort study was conducted in adult septic patients admitted to 21 mixed ICUs of private and public hospitals in Brazil from 1 October 2003 to 30 March 2004. Complete data for all patients admitted to the ICUs were obtained until their discharge or death. We collected only direct healthcare-related costs, defined as all costs related to the ICU stay. Enrolled patients were assessed daily in terms of cost-related expenditures such as hospital fees, operating room fees, gas therapy, physiotherapy, blood components transfusion, medications, renal replacement therapy, laboratory analysis and imaging. Standard unit costs (year 2006 values) were based on the Brazilian Medical Association (AMB) price index for medical procedures and the BRASINDICE price index for medications, solutions and hospital consumables. Medical resource utilization was also assessed daily using the Therapeutic Intervention Scoring System (TISS-28). Indirect costs were not included. RESULTS: With a mean (standard deviation [SD]) age of 61.1 +/- 19.2 years, 524 septic patients from 21 centres were included in this study. The overall hospital mortality rate was 43.8%, the mean Acute Physiology And Chronic Health Evaluation II (APACHE II) score was 22.3 +/- 5.4, and the mean Sequential Organ Failure Assessment (SOFA) score at ICU admission was 7.5 +/- 3.9. The median total cost of sepsis was $US 9632 (interquartile range [IQR] 4583-18 387; 95% CI 8657, 10 672) per patient, while the median daily ICU cost per patient was $US 934 (IQR 735-1170; 95% CI 897, 963). The median daily ICU cost per patient was significantly higher in non-survivors than in survivors, i.e. $US 1094 (IQR 888-1341; 95% CI 1058, 1157) and $US 826 (IQR 668-982; 95% CI 786, 854), respectively (p < 0.001). For patients admitted to public and private hospitals, we found a median SOFA score at ICU admission of 7.5 and 7.1, respectively (p = 0.02), and the mortality rate was 49.1% and 36.7%, respectively (p = 0.006). Patients admitted to public and private hospitals had a similar length of stay of 10 (IQR 5-19) days versus 9 (IQR 4-16) days (p = 0.091), and the median total direct costs for public ($US 9773; IQR 4643-19 221; 95% CI 8503, 10 818) versus private ($US 9490; IQR 4305-17 034; 95% CI 7610, 11 292) hospitals did not differ significantly (p = 0.37). CONCLUSIONS: The present study provides the first economic analysis of direct costs of sepsis in Brazilian ICUs and reveals that the cost of sepsis treatment is high. Despite similar ICU management, there was a significant difference regarding patient outcome between private and public hospitals. Finally, the median daily costs of non-survivor patients were higher than survivors during ICU stay.

Patients with ischaemic, mixed and nephrotoxic acute tubular necrosis in the intensive care unit--a homogeneous population?

INTRODUCTION: Acute tubular necrosis (ATN) is usually studied as a single entity, without distinguishing between ischaemic, nephrotoxic and mixed aetiologies. In the present study we evaluated the characteristics and outcomes of patients with ATN by aetiological group. METHOD: We conducted a retrospective comparison of clinical features, mortality rates and risk factors for mortality for the three types of ATN in patients admitted to the general intensive care unit of a university hospital between 1997 and 2000. RESULTS: Of 593 patients with acute renal failure, 524 (88%) were classified as having ATN. Their mean age was 58 years, 68% were male and 52% were surgical patients. The overall mortality rate was 62%. A total of 265 patients (51%) had ischaemic ATN, 201 (38%) had mixed ATN, and 58 (11%) had nephrotoxic ATN. There were no differences among groups in terms of age, sex, APACHE II score and reason for ICU admission. Multiple organ failure was more frequent among patients with ischaemic (46%) and mixed ATN (55%) than in those with nephrotoxic ATN (7%; P < 0.0001). The complications of acute renal failure (such as, gastrointestinal bleeding, acidosis, oliguria and hypervolaemia) were more prevalent in ischaemic and mixed ATN patients. Mortality was higher for ischaemic (66%; P = 0.001) and mixed ATN (63%; P = 0.0001) than for nephrotoxic ATN (38%). When ischaemic ATN patients, mixed ATN patients and all patients combined were analyzed by multivariate logistic regression, the independent factors for mortality identified were different except for oliguria, which was the only variable universally associated with death (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.64-5.49 [P = 0.0003] for ischaemic ATN; OR 1.96, 95% CI 1.04-3.68 [P = 0.036] for mixed ATN; and OR 2.53, 95% CI 1.60-3.76 [P < 0.001] for all patients combined]). CONCLUSION: The frequency of isolated nephrotoxic ATN was low, with ischaemic and mixed ATN accounting for almost 90% of cases. The three forms of ATN exhibited different clinical characteristics. Mortality was strikingly higher in ischaemic and mixed ATN than in nephrotoxic ATN. Although the type of ATN was not an independent predictor of death, the independent factors related to mortality were different for ischaemic, mixed and all patients combined. These data indicate that the three types of ATN represent different patient populations, which should be taken into consideration in future studies.

C-reactive protein levels correlate with mortality and organ failure in critically ill patients.

STUDY OBJECTIVES: C-reactive protein (CRP) is an acute-phase protein, the blood levels of which increase rapidly in response to infection, trauma, ischemia, burns, and other inflammatory conditions. Although used frequently in the ICU as a sepsis marker, the relation of CRP levels to organ damage is not well known. This study assessed the association between early serum CRP concentrations and the development of organ failure and mortality in ICU patients. DESIGN: A prospective cohort study. SETTING: A 31-bed ICU in a university hospital. PATIENTS: All 313 patients admitted to the ICU during the 4-month study period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients with high CRP levels at ICU admission had more severe organ dysfunction (higher sequential organ failure assessment scores, days of renal extracorporeal support therapy), longer ICU stays, and higher mortality rates than patients with normal ICU admission CRP levels. CRP concentrations were correlated with the presence and number of organ failures. ICU admission serum CRP levels > 10 mg/dL were associated with a significantly higher incidence of respiratory (65% vs 28.8%, p < 0.05), renal (16.6% vs 3.6%, p < 0.05), and coagulation (6.4% vs 0.9%, p < 0.05) failures, and with higher mortality rates (36% vs 21%, p < 0.05) than CRP levels < 1 mg/dL. In patients with CRP concentrations > 10 mg/dL on ICU admission, a decrease in CRP level after 48 h was associated with a mortality rate of 15.4%, while an increased CRP level was associated with a mortality rate of 60.9% (relative risk, 0.25; 95% confidence interval, 0.07 to 0.91; p < 0.05). CONCLUSIONS: In a heterogeneous ICU population, elevated concentrations of serum CRP on ICU admission are correlated with an increased risk of organ failure and death. Moreover, persistently high CRP concentrations are associated with a poor outcome. Serial measurements may be helpful to identify those patients who require more aggressive interventions to prevent complications.

Descompensaçäo cardíaca pós-intoxicaçäo exógena por estricnina: relato de caso / Cardiac descompensation from exogenous intoxication by strychnine: case report

Apresentamos o caso de um paciente intoxicado por estricnina que evoluiu com Insuficiência Cardíaca Congestiva diagnosticada através de ecocardiograma e parâmetros hemodinâmicos conseguidos através de cateter de Swan-Ganz. A intoxicaçao por estricnina nao é comumente encontrada devido à proibiçao de sua comercializaçao, especial atençao tem sido dada a esta droga devido ao seu uso na manufatura de drogas como a cocaína. Alguns autores mostram que a estricnina age sobre centros vasomotores alterando pressao arterial durante as convulsoes, outros mostraram arritmias durante as convulsoes, mas nao comprovaram a existência de cardiotoxidade pela estricnina. A monitorizaçao hemodinâmica foi de bastante auxílio neste caso nao só no sentido de guiar a terapêutica mas também no diagnóstico diferencial do edema pulmonar que, em se tratando de paciente hígido e jovem poderia facilmente ser rotulado como edema "nao cardiogênico". Embora a intoxicaçao por estricnina seja de altíssima mortalidade, com o suporte hemodinâmico e respiratório adequado proporcionamos uma recuperaçao total do paciente, sem seqüela neurológica, renal e pulmonar.