Is a tiered restrictions system an effective intervention for COVID-19 control? Results from Portugal, November-December 2020.

BACKGROUND: In November 2020, similar to other European countries, Portugal implemented a tiered restrictions system to control the COVID-19 pandemic. We aimed to compare the COVID-19 growth rate across tiers to assess the effect of a tiered restrictions system in Portugal, using models with different times between tiers assessment. Our hypothesis was that being in a higher tier brings a faster deceleration in the growth rate than being in a lower tier. METHODS: The national database of notified COVID-19 cases and publicly available data were used to analyse the effect of the tiered restrictions system on the COVID-19 incidence growth rate. The tiers were based on the European Centre for Disease Control risk classification: moderate, high, very and extremely high. We used a generalised mixed-effects regression model to estimate the growth rate ratio (GRR) for each tier, comparing the growth rates of higher tiers using moderate tier as reference. Three models were fitted using different times between tiers assessment, separated by 14 days. RESULTS: We included 156 034 cases. Very high tier was the most frequent combination in all the three moments assessed (21.2%), and almost 50% of the municipalities never changed tier during the study period. Immediately after the tiers implementation, a reduction was identified in the municipalities in high tier (GRR high tier: 0.90 [95%CI: 0.79; 1.02]) and very high tier (GRR very high tier: 0.68 [95%CI: 0.61; 0.77]), however with some imprecision in the 95% confidence interval for the high tier. A reduction in very high tier growth rate was identified two weeks (GRR: 0.79 [95%CI: 0.71; 0.88]) and four weeks (GRR: 0.77 [95%CI: 0.74; 0.82]) after the implementation, compared to moderate tier. In high tier, a reduction was also identified in both times, although smaller. CONCLUSIONS: We observed a reduction in the growth rate in very high tier after the tiered restriction system was implemented, but we also observed a lag between tiered restriction system implementation and the onset of consequent effects. This could suggest the importance of early implementation of stricter measures for pandemic control. Thus, studies analysing a broader period of time are needed.

Investigating the role of symptom valorisation in tuberculosis patient delay in urban areas in Portugal.

BACKGROUND: Diagnosis delay contributes to increased tuberculosis (TB) transmission and morbimortality. TB incidence has been decreasing in Portugal, but median patient delay (PD) has risen. Symptom valorisation may determine PD by influencing help-seeking behaviour. We aimed to analyse the association between symptom valorisation and PD, while characterising individuals who disregarded their symptoms. METHODS: A cross-sectional study was conducted among TB patients in Lisbon and Oporto in 2019 - 2021. Subjects who delayed seeking care because they did not value their symptoms or thought these would go away on their own were considered to have disregarded their symptoms. PD was categorised using a 21-day cut-off, and a 30-day cut-off for sensitivity analysis. We estimated the effect of symptom valorisation on PD through a directed acyclic graph. Then, a multivariable regression analysis characterised patients that disregarded their symptoms, adjusting for relevant variables. We fitted Poisson regression models to estimate crude and adjusted prevalence ratios (PR). RESULTS: The study included 75 patients. Median PD was 25 days (IQR 11.5-63.5), and 56.0% of participants had PD exceeding 21 days. Symptom disregard was reported by 38.7% of patients. Patients who did not value their symptoms had higher prevalence of PD exceeding 21 days compared to those who valued their symptoms [PR 1.59 (95% CI 1.05-2.42)]. The sensitivity analysis showed consistent point estimates but wider confidence intervals [PR 1.39 (95% CI 0.77-2.55)]. Being a smoker was a risk factor for symptom disregard [PR 2.35 (95% CI 1.14-4.82)], while living in Oporto [PR 0.35 (95% CI 0.16-0.75)] and having higher household incomes [PR 0.39 (95% CI 0.17-0.94)] were protective factors. CONCLUSIONS: These findings emphasise the importance of symptom valorisation in timely TB diagnosis. Patients who did not value their symptoms had longer PD, indicating a need for interventions to improve symptom recognition. Our findings also corroborate the importance of the socioeconomic determinants of health, highlighting tobacco as a risk factor both for TB and for PD.

LOCUS (LOng Covid-Understanding Symptoms, events and use of services in Portugal): A three-component study protocol.

Approximately 10% of patients experience symptoms of Post COVID-19 Condition (PCC) after a SARS-CoV-2 infection. Akin acute COVID-19, PCC may impact a multitude of organs and systems, such as the cardiovascular, respiratory, musculoskeletal, and neurological systems. The frequency and associated risk factors of PCC are still unclear among both community and hospital settings in individuals with a history of COVID-19. The LOCUS study was designed to clarify the PCC's burden and associated risk factors. LOCUS is a multi-component study that encompasses three complementary building blocks. The "Cardiovascular and respiratory events following COVID-19" component is set to estimate the incidence of cardiovascular and respiratory events after COVID-19 in eight Portuguese hospitals via electronic health records consultation. The "Physical and mental symptoms following COVID-19" component aims to address the community prevalence of self-reported PCC symptoms through a questionnaire-based approach. Finally, the "Treating and living with Post COVID-19 Condition" component will employ semi-structured interviews and focus groups to characterise reported experiences of using or working in healthcare and community services for the treatment of PCC symptoms. This multi-component study represents an innovative approach to exploring the health consequences of PCC. Its results are expected to provide a key contribution to the optimisation of healthcare services design.

Association between perception of COVID-19 risk, confidence in health services and avoidance of emergency department visits: results from a community-based survey in Portugal.

OBJECTIVES: To examine the association between the perception of COVID-19 risk, confidence in health services and avoidance of emergency department (ED) visits in Portugal during the COVID-19 pandemic. DESIGN: Community-based, cross-sectional survey. SETTING: Volunteer sample that completed the online survey between April 2020 and May 2021. PARTICIPANTS: 987 participants who perceived needing ED care. Of those, 242 reported avoiding ED visits. OUTCOME MEASURES: Logistic regression models for ED avoidance were conducted to estimate the effect of risk perception and confidence in health services, adjusted for sociodemographics, health status and time. RESULTS: The adjusted odds for ED avoidance were higher for participants lacking confidence in health service response to non-COVID-19 conditions (adjusted OR: 6.39; 95% CI 3.19 to 12.82) and COVID-19 (1.81; 1.19 to 2.77) and lower for those perceiving a low risk of being infected at a health provider (0.16; 0.07 to 0.38). CONCLUSION: In our sample, confidence in health services and risk perception of infection at a health provider were associated with the decision to avoid the ED. These results suggest that policymakers and care providers need to mitigate the negative consequences of delayed healthcare; be aware of the implications of distrust and fear from those in need of healthcare and provide equally distributed safe alternatives to ED care.

Factors Associated with COVID-19 Vaccine Hesitancy after Implementation of a Mass Vaccination Campaign.

An online cross-sectional study on COVID-19 vaccination adhesion was conducted in Portugal nine months after vaccination rollout (September-November 2021). Logistic regression was used to identify factors associated with hesitancy to take the COVID-19 vaccine in the community-based survey, "COVID-19 Barometer: Social Opinion". Hesitancy was 11%; however, of those, 60.5% stated that they intended to take the vaccine. Hesitancy was associated with factors such as lower monthly household income; no intention of taking the flu vaccine this year; perceived reasonable health status; having two or more diseases; low confidence in the health service response; worse perception of the adequacy of anti-COVID-19 government measures; low or no perceived risk of getting COVID-19; feeling agitated, anxious or sad some days; and lack of trust in the safety and efficacy of the vaccines. Confidence in vaccines, namely against COVID-19, is paramount for public health and should be monitored during vaccination rollout. Clear communication of the risks and benefits of vaccination needs improvement to increase adherence and public confidence.

COVID-19 screening in a Portuguese pediatric population.

OBJECTIVE: To assess the characteristics of suspected coronavirus disease 19 (COVID-19) and the rate of confirmed COVID-19 in a pediatric population at the beginning of the pandemic in Portugal. STUDY DESIGN: Suspected COVID-19 pediatric cases that were tested in a Portuguese hospital between March 17 and April 2 2020 were included in this descriptive retrospective study. The analyzed data included socio-demographic parameters, characteristics of the household, underlying medical conditions and symptoms. RESULTS: Ninety-four patients were included and all of them were symptomatic and treated without hospitalization. The most common symptoms were cough (80%;n=75), rhinorrhea (72%;n=68) and fever (60%;n=56). There was only one positive for SARS-CoV-2 in a five-year-old child with mild illness without epidemiologic linkage. CONCLUSION: This study showed a low rate of confirmed COVID-19 in children. The causes for this low rate can be multifactorial and illustrates how differently this virus spreads in the pediatric population.

COVID-19 screening in a Portuguese pediatric population / Detección de COVID-19 en una población pediátrica portuguesa

ObjectiveTo assess the characteristics of suspected coronavirus disease 19 (COVID-19) and the rate of confirmed COVID-19 in a pediatric population at the beginning of the pandemic in Portugal.Study designSuspected COVID-19 pediatric cases that were tested in a Portuguese hospital between March 17 and April 2 2020 were included in this descriptive retrospective study. The analyzed data included socio-demographic parameters, characteristics of the household, underlying medical conditions and symptoms.ResultsNinety-four patients were included and all of them were symptomatic and treated without hospitalization. The most common symptoms were cough (80%;n=75), rhinorrhea (72%;n=68) and fever (60%;n=56). There was only one positive for SARS-CoV-2 in a five-year-old child with mild illness without epidemiologic linkage.ConclusionThis study showed a low rate of confirmed COVID-19 in children. The causes for this low rate can be multifactorial and illustrates how differently this virus spreads in the pediatric population.

ObjetivoEvaluar las características en casos sospechosos y la tasa de casos confirmados de enfermedad por coronavirus 19 (COVID-19) en una población pediátrica al inicio de la pandemia en Portugal.MétodosEn este estudio descriptivo-retrospectivo se incluyeron casos pediátricos sospechosos de COVID-19 que se testearon en un hospital portugués entre el 17 de marzo y el 2 de abril de 2020. Los datos fueron analizados bajo parámetros sociodemográficos, características del hogar, condiciones médicas subyacentes y síntomas.ResultadosSe incluyeron 94 pacientes, todos sintomáticos y tratados sin hospitalización. Los síntomas más frecuentes fueron tos (80%; n=75), rinorrea (72%; n=68) y fiebre (60%; n=56). Solo hubo un caso positivo para SARS-CoV-2, un niño de 5 años con una enfermedad leve, sin vínculo epidemiológico.ConclusiónEste estudio mostró una baja tasa de casos confirmados de COVID-19 en niños. Las causas de esta baja tasa pueden ser multifactoriales e ilustran cuán diferente se propaga este virus en la población pediátrica.

Factors Associated with the Patient's Decision to Avoid Healthcare during the COVID-19 Pandemic.

The COVID-19 pandemic has resulted in changes in healthcare use. This study aimed to identify factors associated with a patient's decision to avoid and/or delay healthcare during the COVID-19 pandemic. We used data from a community-based survey in Portugal from July 2020 to August 2021, "COVID-19 Barometer: Social Opinion", which included data regarding health services use, risk perception and confidence in health services. We framed our analysis under Andersen's Behavioural Model of Health Services Use and utilised Poisson regression to identify healthcare avoidance associated factors. Healthcare avoidance was high (44%). Higher prevalence of healthcare avoidance was found among women; participants who reported lower confidence in the healthcare system response to COVID-19 and non-COVID-19; lost income during the pandemic; experienced negative emotions due to physical distancing measures; answered the questionnaire before middle June 2021; and perceived having worse health, the measures implemented by the Government as inadequate, the information conveyed as unclear and confusing, a higher risk of getting COVID-19, a higher risk of complications and a higher risk of getting infected in a health institution. It is crucial to reassure the population that health services are safe. Health services should plan their recovery since delays in healthcare delivery can lead to increased or worsening morbidity, yielding economic and societal costs.

A Case-Control Study of Contextual Factors for SARS-CoV-2 Transmission.

Background: Knowledge on the settings and activities associated with a higher risk of SARS-CoV-2 transmission is essential to inform decision-making. We thus designed a case-control study to identify relevant settings for community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Portugal. Methods: We evaluated 1,088 cases, identified through the national surveillance system, and 787 community controls, recruited using random digit dialing. Sociodemographic characteristics, individual protective measures, and activities or visited settings were obtained through telephone interview. We report sex-, age-, education-, and citizenship-adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Results: Household overcrowding (aOR = 1.47; 95% CI 1.14-1.91) and work in senior care (4.99; 1.30-33.08) increased while working remotely decreased the risk of infection (0.30; 0.22-0.42). Going to restaurants/other dining spaces (0.73; 0.59-0.91), grocery stores (0.44; 0.34-0.57) or hair salons (0.51; 0.39-0.66), or the use of public transportation did not present a higher risk of infection (0.98; 0.75-1.29), under existing mitigation strategies. Lower education ( ≤ 4 years vs. tertiary education: 1.79; 1.33-2.42) and no Portuguese citizenship (5.47; 3.43-9.22) were important risk factors. Conclusions: The utilization of public transportation, restaurants, and commercial spaces was not associated with increased risk of infection, under capacity restrictions, physical distancing, use of masks, and hygiene measures. Overcrowding, foreign citizenship, low education and working on-site were positively associated with SARS-CoV-2 infection.

Double jeopardy from the COVID-19 pandemic: risk of exposure and income loss in Portugal.

BACKGROUND: Increasing evidence indicates that the first wave of the COVID-19 pandemic had immediate health and social impact, disproportionately affecting certain socioeconomic groups. Assessing inequalities in risk of exposure and in adversities faced during the pandemic is critical to inform targeted actions that effectively prevent disproportionate spread and reduce social and health inequities. This study examines i) the socioeconomic and mental health characteristics of individuals working in the workplace, thus at increased risk of COVID-19 exposure, and ii) individual income losses resulting from the pandemic across socioeconomic subgroups of a working population, during the first confinement in Portugal. METHODS: This study uses data from 'COVID-19 Barometer: Social Opinion', a community-based online survey in Portugal. The sample for analysis comprised n = 129,078 workers. Logistic regressions were performed to estimate the adjusted odds ratios (AOR) of factors associated with working in the workplace during the confinement period and with having lost income due to the pandemic. RESULTS: Over a third of the participants reported working in the workplace during the first confinement. This was more likely among those with lower income [AOR = 2.93 (2.64-3.25)], lower education [AOR = 3.17 (3.04-3.30)] and working as employee [AOR = 1.09 (1.04-1.15)]. Working in the workplace was positively associated with frequent feelings of agitation, anxiety or sadness [AOR = 1.14 (1.09-1.20)] and perception of high risk of infection [AOR = 11.06 (10.53-11.61)]. About 43% of the respondents reported having lost income due to the pandemic. The economic consequences affected greatly the groups at increased risk of COVID-19 exposure, namely those with lower education [AOR = 1.36 (1.19-1.56)] and lower income [AOR = 3.13 (2.47-3.96)]. CONCLUSIONS: The social gradient in risk of exposure and in economic impact of the pandemic can result in an accumulated vulnerability for socioeconomic deprived populations. The COVID-19 pandemic seems to have a double effect in these groups, contributing to heightened disparities and poor health outcomes, including in mental health. Protecting the most vulnerable populations is key to prevent the spread of the disease and mitigate the deepening of social and health disparities. Action is needed to develop policies and more extensive measures for reducing disproportionate experiences of adversity from the COVID-19 pandemic among most vulnerable populations.

Tuberculosis amongst foreign-born and nationals: different delays, different risk factors.

BACKGROUND: Delay in Tuberculosis (TB) diagnosis affects foreign-born and nationals in different ways, especially in low-incidence countries. This study characterises total delay and its components amongst foreign-born individuals in Portugal. Additionally, we identify risk factors for each type of delay and compare their effects between foreign-born and nationals. METHODS: We analysed data from the Portuguese TB surveillance system and included individuals with pulmonary TB (PTB), notified between 2008 and 2017. We described patient, healthcare, and total delays. Cox regression was used to identify factors associated with each type of delay. All analyses were stratified according to the origin country: nationals (those born in Portugal) and foreign-born. RESULTS: Compared with nationals, foreign-born persons presented statistically significant and longer median total and patient delays (Total: 67 vs. 63; Patient: 44 vs. 36 days), and lower healthcare services delays (7 vs. 9 days). Risk factors for delayed diagnosis differed between foreign-born and nationals. Being unemployed, having drug addiction, and having comorbidities were identified as risk factors for delayed diagnosis in national individuals but not in foreigners. Alcohol addiction was the only factor identified for healthcare delay for both populations: foreign-born (Hazard Ratio 1.34 [95% confidence interval 1.17;1.53]); nationals (Hazard Ratio 1.20 [95% confidence interval 1.13;1.27]). CONCLUSIONS: Foreign-born individuals with PTB take longer to seek health care. While no specific risk factors were identified, more in-depth studies are required to identify barriers and support public health intervention to address PTB diagnosis delay in foreign-born individuals.

Factors Associated with COVID-19 Vaccine Hesitancy.

It is critical to develop tailored strategies to increase acceptability of the COVID-19 vaccine and decrease hesitancy. Hence, this study aims to assess and identify factors associated with COVID-19 vaccine hesitancy in Portugal. We used data from a community-based survey, "COVID-19 Barometer: Social Opinion", which includes data regarding intention to take COVID-19 vaccines, health status, and risk perception in Portugal from September 2020 to January 2021. We used multinomial regression to identify factors associated with intention to delay or refuse to take COVID-19 vaccines. COVID-19 vaccine hesitancy in Portugal was high: 56% would wait and 9% refuse. Several factors were associated with both refusal and delay: being younger, loss of income during the pandemic, no intention of taking the flu vaccine, low confidence in the COVID-19 vaccine and the health service response during the pandemic, worse perception of government measures, perception of the information provided as inconsistent and contradictory, and answering the questionnaire before the release of information regarding the safety and efficacy of COVID-19 vaccines. It is crucial to build confidence in the COVID-19 vaccine as its perceived safety and efficacy were strongly associated with intention to take the vaccine. Governments and health authorities should improve communication and increase trust.

Hyperbaric oxygen therapy for hypoxic-ischemic encephalopathy in non-fatal drowning.

Paroxysmal autonomic instability syndrome with dystonia (PAISD) is a possible complication that worsens the prognosis of hypoxic-ischemic encephalopathy related to non-fatal drowning. There are case reports of hyperbaric oxygen (HBO2) therapy enhancing recovery in such cases. We report a case of a 5-year-old boy admitted to the Pediatric Intensive Care Unit after a non-fatal drowning. He was transferred under mechanical ventilation and sedation, with hemodynamic instability and hypothermia. On admission he had a Glasgow Coma Score of 6. On the fifth day of admission he presented episodes of dystonia with decerebration posture, diaphoresis, tachycardia and hypertension, sometimes with identified triggers, suggesting PAISD. The episodes were difficult to control; multiple drugs were needed. Electroencephalography showed diffuse slow wave activity, and cranioencephalic magnetic resonance imaging showed hypoxia-related lesions, suggesting hypoxic-ischemic encephalopathy. Early after admission the patient started physiotherapy combined with normobaric oxygen therapy. Subsequently he started HBO2 therapy at 2 atmospheres, with a total of 66 sessions. Dystonia progressively subsided, with gradual discontinuation of therapy. He also showed improvement in spasticity, non-verbal communication and cephalic control. This case highlights the diagnostic and therapeutic challenges of PAISD and the potential benefit of HBO2 therapy, even in the subacute phase, in recovery of hypoxic-ischemic encephalopathy.

The Association Between Chronic Disease and Serious COVID-19 Outcomes and Its Influence on Risk Perception: Survey Study and Database Analysis.

BACKGROUND: COVID-19, a viral respiratory disease first reported in December 2019, quickly became a threat to global public health. Further understanding of the epidemiology of the SARS-CoV-2 virus and the risk perception of the community may better inform targeted interventions to reduce the impact and spread of COVID-19. OBJECTIVE: In this study, we aimed to examine the association between chronic diseases and serious outcomes following COVID-19 infection, and to explore its influence on people's self-perception of risk for worse COVID-19 outcomes. METHODS: This study draws data from two databases: (1) the nationwide database of all confirmed COVID-19 cases in Portugal, extracted on April 28, 2020 (n=20,293); and (2) the community-based COVID-19 Barometer survey, which contains data on health status, perceptions, and behaviors during the first wave of COVID-19 (n=171,087). We assessed the association between relevant chronic diseases (ie, respiratory, cardiovascular, and renal diseases; diabetes; and cancer) and death and intensive care unit (ICU) admission following COVID-19 infection. We identified determinants of self-perception of risk for severe COVID-19 outcomes using logistic regression models. RESULTS: Respiratory, cardiovascular, and renal diseases were associated with mortality and ICU admission among patients hospitalized due to COVID-19 infection (odds ratio [OR] 1.48, 95% CI 1.11-1.98; OR 3.39, 95% CI 1.80-6.40; and OR 2.25, 95% CI 1.66-3.06, respectively). Diabetes and cancer were associated with serious outcomes only when considering the full sample of COVID-19-infected cases in the country (OR 1.30, 95% CI 1.03-1.64; and OR 1.40, 95% CI 1.03-1.89, respectively). Older age and male sex were both associated with mortality and ICU admission. The perception of risk for severe COVID-19 disease in the study population was 23.9% (n=40,890). This was markedly higher for older adults (n=5235, 46.4%), those with at least one chronic disease (n=17,647, 51.6%), or those in both of these categories (n=3212, 67.7%). All included diseases were associated with self-perceptions of high risk in this population. CONCLUSIONS: Our results demonstrate the association between some prevalent chronic diseases and increased risk of worse COVID-19 outcomes. It also brings forth a greater understanding of the community's risk perceptions of serious COVID-19 disease. Hence, this study may aid health authorities to better adapt measures to the real needs of the population and to identify vulnerable individuals requiring further education and awareness of preventive measures.

COVID-19 screening in a Portuguese pediatric population.

OBJECTIVE: To assess the characteristics of suspected coronavirus disease 19 (COVID-19) and the rate of confirmed COVID-19 in a pediatric population at the beginning of the pandemic in Portugal. STUDY DESIGN: Suspected COVID-19 pediatric cases that were tested in a Portuguese hospital between March 17 and April 2 2020 were included in this descriptive retrospective study. The analyzed data included socio-demographic parameters, characteristics of the household, underlying medical conditions and symptoms. RESULTS: Ninety-four patients were included and all of them were symptomatic and treated without hospitalization. The most common symptoms were cough (80%;n=75), rhinorrhea (72%;n=68) and fever (60%;n=56). There was only one positive for SARS-CoV-2 in a five-year-old child with mild illness without epidemiologic linkage. CONCLUSION: This study showed a low rate of confirmed COVID-19 in children. The causes for this low rate can be multifactorial and illustrates how differently this virus spreads in the pediatric population.

COVID-19 screening in a Portuguese pediatric population / Detección de COVID-19 en una población pediátrica portuguesa

OBJECTIVE: To assess the characteristics of suspected coronavirus disease 19 (COVID-19) and the rate of confirmed COVID-19 in a pediatric population at the beginning of the pandemic in Portugal. STUDY DESIGN: Suspected COVID-19 pediatric cases that were tested in a Portuguese hospital between March 17 and April 2 2020 were included in this descriptive retrospective study. The analyzed data included socio-demographic parameters, characteristics of the household, underlying medical conditions and symptoms. RESULTS: Ninety-four patients were included and all of them were symptomatic and treated without hospitalization. The most common symptoms were cough (80%; n = 75), rhinorrhea (72%; n = 68) and fever (60%; n = 56). There was only one positive for SARS-CoV-2 in a five-year-old child with mild illness without epidemiologic linkage. CONCLUSION: This study showed a low rate of confirmed COVID-19 in children. The causes for this low rate can be multifactorial and illustrates how differently this virus spreads in the pediatric population

OBJETIVO: Evaluar las características en casos sospechosos y la tasa de casos confirmados de enfermedad por coronavirus 19 (COVID-19) en una población pediátrica al inicio de la pandemia en Portugal. MÉTODOS: En este estudio descriptivo-retrospectivo se incluyeron casos pediátricos sospechosos de COVID-19 que se testearon en un hospital portugués entre el 17 de marzo y el 2 de abril de 2020. Los datos fueron analizados bajo parámetros sociodemográficos, características del hogar, condiciones médicas subyacentes y síntomas. RESULTADOS: Se incluyeron 94 pacientes, todos sintomáticos y tratados sin hospitalización. Los síntomas más frecuentes fueron tos (80%; n = 75), rinorrea (72%; n = 68) y fiebre (60%; n = 56). Solo hubo un caso positivo para SARS-CoV-2, un niño de 5 años con una enfermedad leve, sin vínculo epidemiológico. CONCLUSIÓN: Este estudio mostró una baja tasa de casos confirmados de COVID-19 en niños. Las causas de esta baja tasa pueden ser multifactoriales e ilustran cuán diferente se propaga este virus en la población pediátrica

Partial Red Blood Cell Exchange in Children and Young Patients with Sickle Cell Disease: Manual Versus Automated Procedure.

INTRODUCTION: The benefits of manual versus automated red blood cell exchange have rarely been documented and studies in young sickle cell disease patients are scarce. We aim to describe and compare our experience in these two procedures. MATERIAL AND METHODS: Young patients (≤ 21 years old) who underwent manual- or automated-red blood cell exchange for prevention or treatment of sickle cell disease complications were included. Clinical, technical and hematological data were prospectively recorded and analyzed. RESULTS: Ninety-four red blood cell exchange sessions were performed over a period of 68 months, including 57 manual and 37 automated, 63 for chronic complications prevention, 30 for acute complications and one in the pre-operative setting. Mean decrease in sickle hemoglobin levels was higher in automated-red blood cell exchange (p < 0.001) and permitted a higher sickle hemoglobin level decrease per volume removed (p < 0.001), while hemoglobin and hematocrit remained stable. Ferritin levels on chronic patients decreased 54%. Most frequent concern was catheter outflow obstruction on manual-red blood cell exchange and access alarm on automated-red blood cell exchange. No major complication or alloimunization was recorded. DISCUSSION: Automated-red blood cell exchange decreased sickle hemoglobin levels more efficiently than manual procedure in the setting of acute and chronic complications of sickle cell disease, with minor technical concerns mainly due to vascular access. The threshold of sickle hemoglobin should be individualized for clinical and hematological goals. In our cohort of young patients, the need for an acceptable venous access was a limiting factor, but iron-overload was avoided. CONCLUSION: Automated red blood cell exchange is safe and well tolerated. It permits a higher sickle hemoglobin removal efficacy, better volume status control and iron-overload avoidance.

Introdução: Os benefícios da transfusão permuta parcial manual versus automatizada encontram-se pouco documentados e existem poucos estudos em jovens com doença falciforme. Pretendemos descrever e comparar a nossa experiência com os dois procedimentos. Material e Métodos: Foram incluídos jovens (≤ 21 anos) que realizaram transfusão permuta parcial-manual ou -automatizada para prevenção ou tratamento de complicações da doença falciforme. Dados clínicos, técnicos e valores hematológicos foram recolhidos de forma prospectiva e analisados. Resultados: Realizaram-se 94 transfusões permuta parcial num período de 68 meses, 57 manuais e 37 automatizadas, 63 para prevenção de complicações crónicas, 30 por complicações agudas e uma no contexto pré-operatório. A redução média da hemoglobina S foi superior na transfusão permuta parcial-automatizada (p < 0,001) e permitiu uma redução de hemoglobina S por volume permutado superior (p < 0,001), mantendo valores de hemoglobina e hematócrito estáveis. Os valores de ferritina dos doentes crónicos diminuíram em 54%. A principal preocupação foi a obstrução do lúmen do cateter na transfusão permuta parcial-manual e os alarmes de pressão do acesso na transfusão permuta parcial-automatizada. Não houve complicações major nem aloimunização. Discussão: A transfusão permuta parcial-automatizada reduziu a hemoglobina S de forma mais eficiente que a transfusão permuta parcial-manual em doentes com complicações da doença falciforme, existindo pequenos problemas relacionados com o acesso vascular. O valor alvo de hemoglobina S deve ser individualizado segundo a clínica e os objetivos hematológicos. Na nossa coorte de jovens, a necessidade de um acesso venoso aceitável foi a principal limitação, mas a sobrecarga de ferro foi evitada. Conclusão: A transfusão permuta parcial automatizada é segura e bem tolerada. Permite uma maior eficácia na redução da hemoglobina S, um melhor controlo da volemia e a evicção da sobrecarga de ferro.

Rhabdomyolysis as a manifestation of a metabolic disease: a case report. / Rabdomiólise como manifestação de uma doença metabólica: relato de caso.

Rhabdomyolysis is a process of muscle destruction that can present with varying clinical manifestations. In pediatric patients, its main etiology is infectious diseases. We present a previously healthy adolescent who was admitted to our emergency department with a four-day history of myalgia, muscle weakness and dark urine. At presentation, she was dehydrated. Blood analysis revealed acute renal failure and increased muscular enzymes. She was transferred to our pediatric intensive care unit. Medical therapies for correction of dehydration and the ionic and metabolic consequences of renal failure were performed. Due to oliguria, renal replacement therapy was initiated. An etiological investigation revealed a beta-oxidation defect. Metabolic diseases are a known cause of rhabdomyolysis. Muscular destruction should be diagnosed early in order to avoid its potential consequences. Generally, the treatment of rhabdomyolysis is conservative, although in some situations, a more invasive approach is needed.

Rabdomiólise como manifestação de uma doença metabólica: relato de caso / Rhabdomyolysis as a manifestation of a metabolic disease: a case report

RESUMO A rabdomiólise é um processo de destruição muscular com manifestações clínicas variáveis. Em pacientes pediátricos, tem como principal etiologia as doenças infecciosas. Apresentamos o caso de uma adolescente previamente saudável, que foi admitida ao nosso pronto-socorro com histórico de 4 dias com mialgia, fraqueza muscular e urina escura. Na avaliação inicial, apresentava-se desidratada. Os exames de sangue revelaram insuficiência renal aguda e aumento de enzimas musculares. A paciente foi transferida para nossa unidade de terapia intensiva pediátrica. Foi realizado tratamento clínico para correção da desidratação e das consequências iônicas e metabólicas da insuficiência renal. Em razão da oligúria, deu-se início à terapia de substituição renal. A investigação etiológica revelou um defeito da betaoxidação. Sabe-se que doenças metabólicas podem provocar rabdomiólise. A destruição muscular deve ser identificada precocemente, para evitar suas potenciais consequências. Em geral, o tratamento da rabdomiólise é conservador, embora em algumas situações seja necessária uma abordagem mais invasiva.

ABSTRACT Rhabdomyolysis is a process of muscle destruction that can present with varying clinical manifestations. In pediatric patients, its main etiology is infectious diseases. We present a previously healthy adolescent who was admitted to our emergency department with a four-day history of myalgia, muscle weakness and dark urine. At presentation, she was dehydrated. Blood analysis revealed acute renal failure and increased muscular enzymes. She was transferred to our pediatric intensive care unit. Medical therapies for correction of dehydration and the ionic and metabolic consequences of renal failure were performed. Due to oliguria, renal replacement therapy was initiated. An etiological investigation revealed a beta-oxidation defect. Metabolic diseases are a known cause of rhabdomyolysis. Muscular destruction should be diagnosed early in order to avoid its potential consequences. Generally, the treatment of rhabdomyolysis is conservative, although in some situations, a more invasive approach is needed.