COVID-19 fatality rates in hospitalized patients: A new systematic review and meta-analysis.

BACKGROUND: SARS-COV2 or COVID-19 disease is an infectious illness that emerged for the first time at the end of 2019, in Wuhan, China and rapidly turned out to be an international pandemic with deleterious effects all over the world. In March 2021, A. Macedo et al., has published the first meta-analysis of hospital mortality, so the authors decided to update those data at a time of emergence of new therapies and increasing vaccination rates. METHODS: As the outcome of interest was the mortality in hospitalized general patients, the authors looked for articles evaluating the clinical characteristics of those patients, consulting PUBMED (The US National Library of Medicine) and EMBASE (Medical database) in an independent selection using predefined terms of search. A meta-analysis random-effect model was estimated using Mantel-Haenszel method. Heterogeneity among studies was tested using Tau2 statistics and Chi2 statistics. RESULTS: In a first instance 25 articles were included for final analysis with a total of 103,840 patients, but as the goal was to update the anterior data, these studies were analysed together with the 21 studies of the previous meta-analysis, with a total of 114609 patients. The mortality rate of COVID-19 general patients admitted to the hospital was 16% (95% CI 12; 21, I2 =100%). CONCLUSION: Global hospital mortality of COVID-19 of general patients was 16%, with quite different rates according to the different geographic areas analysed.

Spontaneous Cervical Spondylodiscitis With Retropharyngeal Abscess and Bacteremia: A Case Report.

Retropharyngeal abscess is a deep neck infection, rarely reported in adults. Nevertheless, when it occurs, it is mostly in immunocompromised patients and it can have life-threatening complications such as airway obstruction. On the other hand, more insidious complications can develop, such as mediastinitis, spinal osteomyelitis, and epidural abscess which represent an emergency medical condition when the patient develops neurologic symptoms. All must be diagnosed early and treated promptly. Spinal infection is an ancient disease, yet, morbidity remains significant despite developments in surgical and radiologic methods and the discovery of antibiotics. Management frequently involves a combination of these to achieve the best results.  The aim of this case report, as a research design, is to describe scientific observations that we encountered in a clinical setting, expand our knowledge, and highlight the role of the interprofessional team in evaluating and managing these conditions.

Invasive Pneumococcal Disease and COVID-19 Coinfection: A Series of Cases Admitted to an Intensive Care Unit.

Pneumococcal infection is still a frequent disease. It can be classified as invasive when pneumococcus is isolated in a generally sterile fluid. Pneumonia is the most common infectious source of adult invasive pneumococcal disease (IPD), and several risk factors for IPD are well known. This case report presents three clinical cases of different manifestations of IPD. The two most severe cases had coinfection by SARS-CoV-2 at hospital admission.

Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of Portugal.

BACKGROUND: There is scarce information on incidence and case fatality of spontaneous intracerebral hemorrhage (SICH) in certain regions of the world, including in Europe. There is no community-based data on SICH in Southern Portugal. AIM: To determine the incidence and early case-fatality from SICH in Algarve, the southernmost region of Portugal. METHODS: The recommended criteria for stroke incidence studies was used to identify cases of incident first-ever SICH from January 1st to December 31st 2015 in a subregion with 280,081 inhabitants. Crude incidence rates per age group and gender; standardized rates to the European population; and age adjusted case fatality rates were calculated. RESULTS: Eighty-two first-ever cases of SICH (64.6% men) occurred. The mean age was 72.3 years (SD±12.1); women were 3 years older than men on average and had more frequently lobar SICH. The crude annual incidence rate was 29.2/100,000 (95% CI 23.4- 38.6; p<0.001); higher in men (39.7/100,000) than women (19.8/100,000). The standardized to the European population incidence was 15.1/100,000 (95% CI 3.6-18.9; p<0.05); 26.9 and 10.9/100,000 for men and women respectively. The 30-day case-fatality was 40 % (95% CI 29-51) and increased steeply with age CONCLUSION: The incidence of SICH in Southern Portugal was high, but within the figures found in some parts of Europe. However, a marked predominance of males was found and the case-fatality rate was amongst the highest reported in western countries.

The place of DPP-4 inhibitors in the treatment algorithm of diabetes type 2: a systematic review of cost-effectiveness studies.

OBJECTIVE: To conduct a systematic review of cost-effectiveness, cost-utility, and cost-benefit studies of DPP-4 inhibitors for diabetes treatment versus other antidiabetics. METHODS: Three investigators searched the CRD York, Tufts CEA Registry, and MEDLINE databases through 2015. We reviewed all potentially relevant titles and abstracts, and screened full-text articles, according to inclusion criteria. We established a quality score for each study based on a 35-item list. RESULTS: A total of 295 studies were identified, of which 20 were included. The average quality score was 0.720 on a 0-1 scale. All studies were performed in high- and middle-income countries, using a 3rd-party payer perspective and randomized clinical trials to measure effectiveness. Sitagliptin, saxagliptin and vildagliptin had an ICER below 25,000 €/QALY, as second-line and as add-ons to metformin, in comparison to sulfonylureas. When compared with sitagliptin, liraglutide (GLP-1 receptor agonist) had an ICER of up to 22,724 €/QALY for the 1.2-mg dosage, and up to 32,869 €/QALY for the 1.8-mg dosage. Insulin glargine was dominant when compared with sitagliptin. CONCLUSIONS: According to the WHO threshold applied to the country and year of each study, DPP-4 inhibitors were highly cost-effective as second-line, as add-ons to metformin, in comparison with sulfonylureas. More recent therapies (GLP-1 receptor agonists and insulin glargine) were highly cost-effective in comparison to DPP-4 inhibitors. These results were obtained, however, on the basis of a limited number of studies, relying on the same few clinical trials, and financed by manufacturers. Further independent research is needed to confirm these findings.

Facial emotional recognition in schizophrenia: preliminary results of the virtual reality program for facial emotional recognition / Reconhecimento emocional de faces na esquizofrenia: resultados preliminares do programa de realidade virtual para o reconhecimento emocional de faces

BACKGROUND: Significant deficits in emotional recognition and social perception characterize patients with schizophrenia and have direct negative impact both in inter-personal relationships and in social functioning. Virtual reality, as a methodological resource, might have a high potential for assessment and training skills in people suffering from mental illness. OBJECTIVES: To present preliminary results of a facial emotional recognition assessment designed for patients with schizophrenia, using 3D avatars and virtual reality. METHODS: Presentation of 3D avatars which reproduce images developed with the FaceGen® software and integrated in a three-dimensional virtual environment. Each avatar was presented to a group of 12 patients with schizophrenia and a reference group of 12 subjects without psychiatric pathology. RESULTS: The results show that the facial emotions of happiness and anger are better recognized by both groups and that the major difficulties arise in fear and disgust recognition. Frontal alpha electroencephalography variations were found during the presentation of anger and disgust stimuli among patients with schizophrenia. DISCUSSION: The developed program evaluation module can be of surplus value both for patient and therapist, providing the task execution in a non anxiogenic environment, however similar to the actual experience.

CONTEXTO: Pessoas diagnosticadas com esquizofrenia apresentam um défice significativo na cognição social com implicações negativas relativamente ao funcionamento interpessoal e social. A realidade virtual apresenta grandes potencialidades para a avaliação e o treino de competências em pessoas com doença mental. OBJETIVOS: Apresentar os resultados preliminares de um programa construído para avaliação do reconhecimento emocional de faces por pessoas com esquizofrenia, utilizando avatares 3D e realidade virtual. MÉTODOS: Apresentação de avatares 3D que reproduzem expressões emocionais, construídas por meio do FaceGen® e integradas num ambiente virtual tridimensional. Apresentou-se cada avatar a 12 doentes com esquizofrenia e a 12 pessoas sem patologia psiquiátrica, avaliando as respostas de reconhecimento e a atividade eletroencefalográfica frontal. RESULTADOS: Os resultados demonstraram que as expressões de alegria e raiva foram as mais bem reconhecidas pelos dois grupos, enquanto de medo e nojo foram as de maior dificuldade. Verificaram-se alterações na atividade alfa frontal para os estímulos raiva e nojo na amostra de doentes com esquizofrenia. CONCLUSÃO: Apesar de algumas expressões emocionais poderem ser melhoradas, o programa desenvolvido pode constituir uma mais-valia para o paciente e para o terapeuta, proporcionando a execução da tarefa em condições não ansiogênicas e aproximadas à experiência real.

Efeito da fotoperiodicidade na taxa de prenhez em ratos isogênicos (F344) / Effect of photoperiodicity in the pregnancy rate of isogenic rats (F344)

O uso de animais isogênicos apresenta grandes vantagens experimentais, como uniformidade fenotípica e genotípica (reduzindo o número de animais em experimentos) e histocompatibilidade, permitindo, assim, o acúmulo de informações e a repetibilidade dos experimentos. A linhagem isogênica de Rattus norvegicus Fischer 344 existe há 90 anos, entretanto pouco se sabe sobre as razões de seu baixo índice reprodutivo. O presente estudo demonstrou que ratos Fischer F344 são fotorresponsivos quanto à reprodução, tendo seus índices de prenhezes acrescidos com o aumento do fotoperíodo. Os melhores índices são obtidos quando os machos são submetidos a 14 horas de luz e fêmeas a 16 horas de luz, indicando dimorfismo sexual na fotorresponsividade.

The use of isogenic animals presents great experimental advantages, as phenotypic and genotypic uniformity (reducing the number of experimental animals) and histocompatibility, thus allowing, the accumulation of information, and the repeatability of the experiments. The isogenic strain of Rattus norvegicus Fischer 344 has existed for 90 years, however the reasons of its low reproductive index are not knew. The present study has demonstrated that Fischer F344 rats are photoresponsive regarding reproduction, having improved its pregnancy index with the increase of the photoperiod. The best indexes were achieved when the males had been submitted to 14 hours of light and females to 16 hours of light, indicating sexual dimorphism in photoresponsivity.

Homocysteine is a risk factor in predialysis patients when associated with malnutrition and inflammation.

The increased level of plasma total homocysteine (tHcy) in chronic kidney disease patients has been reported as a new and independent risk factor for cardiovascular disease. However, after the description of reverse epidemiology in the renal population, the association of tHcy and nutrition became less clear. We evaluated the association between homocysteine, nutritional status, and inflammation, and their impact on mortality in 95 predialysis patients. High sensitivity C-Reactive Protein (hs-CRP), interleukin 6 (IL-6), Tumor Necrosis Factor α (TNF-α)], and tHcy were evaluated, as was the nutritional status by the modified Subjective Global Nutritional Assessment (mSGA). We divided our population in four groups according to their tHcy and mSGA values being above or below the mean level and found the lowest survival in the group with tHcy and mSGA above the mean level, as well as higher levels of IL-6 (P = .03) and TNF-α (P = .045). Higher levels of homocysteine can be associated with higher mortality in predialysis patients, as long as they are associated with malnutrition and inflammation.

Statins and vitamin D: a friendly association in pre-dialysis patients.

The increased mortality rate observed in patients with chronic kidney disease is related to the high prevalence of cardiovascular disease in this population. Recently, it has been shown that interventional therapy with statins and/or vitamin D could improve the outcomes of these patients. The aim of this study was to identify the risk factors for mortality in a group of patients with chronic kidney disease (stages 4 and 5--pre-dialysis) and verify whether vitamin D and statins could change the outcome. We included 95 patients (mean age--69.4) with stages 4 and 5 (pre-dialysis) of our "low-clearance" outpatient clinic, with an average eGFR of 16.9 ml/min and a mean follow-up of 24.1 months. Several biological, nutritional, laboratory and inflammatory parameters were analysed at baseline. Our population was divided into three groups: G-I, patients not medicated with either vitamin D or statins; G-II, patients medicated with either vitamin D or statins; and G-III, patients medicated with vitamin D and statins. We found (ANOVA) that the serum levels of pre-albumin (P = 0.018) and PTH (P = 0.03) were lower in G-I. Concerning the inflammatory parameters, G-I showed higher levels of hsCRP (P = 0.014) and a trend to higher IL-6 levels (P = 0.077). We found the actuarial survival at 30 months (Kaplan-Meier), to be 56.4% in G-I, 82.3% in G-II and 100% in G-III (log rank = 13.08 P = 0.0014). Using the Cox proportional hazards model, we found that the existence of coronary artery disease (P = 0.0001) and the absence of medication with vitamin D and/or statins (P = 0.005) independently influenced the mortality of our patients. In conclusion, we found, in our study, that patients under vitamin D and statins (with a synergistic effect) were less inflamed and showed a lower mortality rate.

Impact of RIFLE classification in liver transplantation.

Acute renal failure (ARF) is common after orthotopic liver transplantation (OLT). The aim of this study was to evaluate the prognostic value of RIFLE classification in the development of CKD, hemodialysis requirement, and mortality. Patients were categorized as risk (R), injury (I) or failure (F) according to renal function at day 1, 7 and 21. Final renal function was classified according to K/DIGO guidelines. We studied 708 OLT recipients, transplanted between September 1992 and March 2007; mean age 44 +/- 12.6 yr, mean follow-up 3.6 yr (28.8% > or = 5 yr). Renal dysfunction before OLT was known in 21.6%. According to the RIFLE classification, ARF occurred in 33.2%: 16.8% were R class, 8.5% I class and 7.9% F class. CKD developed in 45.6%, with stages 4 or 5d in 11.3%. Mortality for R, I and F classes were, respectively, 10.9%, 13.3% and 39.3%. Severity of ARF correlated with development of CKD: stage 3 was associated with all classes of ARF, stages 4 and 5d only with severe ARF. Hemodialysis requirement (23%) and mortality were only correlated with the most severe form of ARF (F class). In conclusion, RIFLE classification is a useful tool to stratify the severity of early ARF providing a prognostic indicator for the risk of CKD occurrence and death.

Catheter-related bacteremia in hemodialysis: which preventive measures to take?

BACKGROUND: The use of tunneled hemodialysis catheters as definitive vascular access is becoming increasingly more widespread, reaching 25% of all dialysis patients in some countries. The rate of infectious morbidity and mortality is much higher when catheters are used than when patients are dialyzed through grafts or native fistulas, and it is generally agreed that implementing appropriate preventive measures would do more to lower its incidence. METHODS: A prospective, randomized, open-label, long-term follow-up clinical trial was conducted to compare the efficacy of dressing the exit site with antibiotic ointment (AO) versus catheter antimicrobial locking (AL) in preventing catheter-related bacteremia (CRB), both associated with strict standard precautions and appropriate catheter care. A total of 141 tunneled catheters, newly implanted in 116 consecutive patients, were followed during a 2-year period. Patients were randomly distributed into one of three arms, with group A receiving AO prophylaxis, group B treated with a heparin + gentamicin (5.2 mg/ml) lock (AL) and group C receiving both AO and AL prophylaxis. RESULTS: Group A had a significantly lower infection-free time survival curve (p < 0.02, Kaplan-Meier) with a catheter survival of 103.9 days and a significantly higher number of CRB (9 episodes, p < 0.02, chi(2)). Group B had 130.7 mean infection-free days and 1 episode of CRB. Group C had 127.3 mean infection-free days and 5 episodes of CRB. No toxicity or other adverse events were observed during this 2-year period, and the efficacy of the preventive measures remained stable throughout. CONCLUSION: Antimicrobial lock is superior to AO as a CRB preventive measure. The use of lock and ointment in the same catheter was not associated with additive effects.

Inflammation, homocysteine and carotid intima-media thickness.

INTRODUCTION: Cardiovascular disease is the main cause of morbidity and mortality in chronic renal patients. Carotid intima-media thickness (CIMT) is one of the most accurate markers of atherosclerosis risk. In this study, the authors set out to evaluate a population of chronic renal patients to determine which factors are associated with an increase in intima-media thickness. METHODS: We included 56 patients (F=22, M=34), with a mean age of 68.6 years, and an estimated glomerular filtration rate of 15.8 ml/min (calculated by the MDRD equation). Various laboratory and inflammatory parameters (hsCRP, IL-6 and TNF-alpha) were evaluated. All subjects underwent measurement of internal carotid artery intima-media thickness by high-resolution real-time B-mode ultrasonography using a 10 MHz linear transducer. RESULTS: Intima-media thickness was used as a dependent variable in a simple linear regression model, with the various laboratory parameters as independent variables. Only parameters showing a significant correlation with CIMT were evaluated in a multiple regression model: age (p=0.001), hemoglobin (p=00.3), logCRP (p=0.042), logIL-6 (p=0.004) and homocysteine (p=0.002). In the multiple regression model we found that age (p=0.001) and homocysteine (p=0.027) were independently correlated with CIMT. LogIL-6 did not reach statistical significance (p=0.057), probably due to the small population size. CONCLUSION: The authors conclude that age and homocysteine correlate with carotid intima-media thickness, and thus can be considered as markers/risk factors in chronic renal patients.

Anaemia correction in predialysis elderly patients: influence of the antihypertensive therapy on darbepoietin dose.

Anaemia and hypertension are common in patients with chronic renal insufficiency. The correction of anaemia with erythropoiesis stimulating agents (ESA) can improve survival and decrease the decline of renal function. Angiotensin converting-enzyme inhibitors (ACEI) and angiotensin II receptor blockers (AIIRA) can also slow the progression of renal failure, but the blockade of the renin-angiotensin system can worsen anaemia. The aim of our study was to assess the impact of antihypertensive therapy (ACEI plus AIIRA) in the requirements of darbepoietin in a group of elderly predialysis patients. We included 71 patients (m = 39, f = 32), mean age of 76.3 years with a mean creatinine clearance of 17.5 ml/min. Patients were divided in two groups according to their antihypertensive therapy: G-I patients under ACEI or AIIRA therapy and G-II normotensive patients or hypertensive patients under antihypertensive drugs other than ACEI or AIIRA. The groups were compared regarding demographic, nutritional, biochemical and inflammatory parameters. We also compared the mean darbepoietin dose. In GI the mean dose of darbepoietin was higher than in GII (0.543 vs. 0.325 microg/kg/week, P = 0.032). We did not find any difference regarding other parameters analysed. We conclude that ACEI and AIIRA can increase the needs of darbepoietin in predialysis elderly patients. However, when formally indicated to treat hypertension in a specific patient, they should not be switched to another antihypertensive agent. Instead, in such cases, higher doses of ESA should be used, if necessary.