Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection.

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

Intensive support recommendations for critically-ill patients with suspected or confirmed COVID-19 infection / Recomendações de suporte intensivo para pacientes graves com infecção suspeita ou confirmada pela COVID-19

ABSTRACT In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

RESUMO Em dezembro de 2019, uma série de pacientes com pneumonia grave foi identificada em Wuhan, província de Hubei, na China. Esses pacientes evoluíram para síndrome respiratória aguda grave e síndrome do desconforto respiratório agudo. Posteriormente, a COVID-19 foi atribuída a um novo betacoronavírus, o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2). Cerca de 20% dos pacientes com diagnóstico de COVID-19 desenvolvem formas graves da doença, incluindo insuficiência respiratória aguda hipoxêmica, síndrome respiratória aguda grave, síndrome do desconforto respiratório agudo e insuficiência renal aguda e requerem admissão em unidade de terapia intensiva. Não há nenhum ensaio clínico randomizado controlado que avalie potenciais tratamentos para pacientes com infecção confirmada pela COVID-19 no momento da publicação destas recomendações de tratamento. Dessa forma, essas recomendações são baseadas predominantemente na opinião de especialistas (grau de recomendação de nível C).

Time-To-Treatment of Acute Coronary Syndrome and Unit of First Contact in the ERICO Study.

BACKGROUND: To the best of our knowledge, there are no studies evaluating the influence of the unit of the first contact on the frequency and time of pharmacological treatment during an acute coronary syndrome (ACS) event. OBJECTIVES: The main objective was to investigate if the unit of first contact influenced the frequency and time of aspirin treatment in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. METHODS: We analyzed the pharmacological treatment time in 830 ERICO participants - 700 individuals for whom the hospital was the unit of first contact and 130 who initially sought primary care units. We built logistic regression models to study whether the unit of first contact was associated with a treatment time of less than three hours. RESULTS: Individuals who went to primary care units received the first aspirin dose in those units in 75.6% of the cases. The remaining 24.4% received aspirin at the hospital. Despite this finding, individuals from primary care still had aspirin administered within three hours more frequently than those who went to the hospital (76.8% vs 52.6%; p<0.001 and 100% vs. 70.7%; p=0.001 for non ST-elevation ACS and ST-elevation myocardial infarction, respectively). In adjusted models, individuals coming from primary care were more likely to receive aspirin more quickly (odds ratio: 3.66; 95% confidence interval: 2.06-6.51). CONCLUSIONS: In our setting, individuals from primary care were more likely to receive aspirin earlier. Enhancing the ability of primary care units to provide early treatment and safe transportation may be beneficial in similar settings.

Time-To-Treatment of Acute Coronary Syndrome and Unit of First Contact in the ERICO Study / Tempo para Tratamento durante Síndrome Coronariana Aguda e Unidade de Primeiro Contato no Estudo ERICO

Abstract Background: To the best of our knowledge, there are no studies evaluating the influence of the unit of the first contact on the frequency and time of pharmacological treatment during an acute coronary syndrome (ACS) event. Objectives: The main objective was to investigate if the unit of first contact influenced the frequency and time of aspirin treatment in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. Methods: We analyzed the pharmacological treatment time in 830 ERICO participants - 700 individuals for whom the hospital was the unit of first contact and 130 who initially sought primary care units. We built logistic regression models to study whether the unit of first contact was associated with a treatment time of less than three hours. Results: Individuals who went to primary care units received the first aspirin dose in those units in 75.6% of the cases. The remaining 24.4% received aspirin at the hospital. Despite this finding, individuals from primary care still had aspirin administered within three hours more frequently than those who went to the hospital (76.8% vs 52.6%; p<0.001 and 100% vs. 70.7%; p=0.001 for non ST-elevation ACS and ST-elevation myocardial infarction, respectively). In adjusted models, individuals coming from primary care were more likely to receive aspirin more quickly (odds ratio: 3.66; 95% confidence interval: 2.06-6.51). Conclusions: In our setting, individuals from primary care were more likely to receive aspirin earlier. Enhancing the ability of primary care units to provide early treatment and safe transportation may be beneficial in similar settings.

Resumo Fundamento: Em nosso conhecimento, não há estudos que avaliam a influência da unidade de primeiro contato na frequência e tempo para o tratamento farmacológico durante um evento de síndrome coronariana aguda (SCA). Objetivos: O principal objetivo foi investigar se a unidade de primeiro contato influencia a frequência e o tempo para tratamento com aspirina no estudo "Estratégia de Registro de Insuficiência Coronariana" (ERICO). Métodos: Analisamos o tempo para o tratamento farmacológico em 830 participantes do estudo ERICO - 700 indivíduos cuja primeira unidade de contato foi o hospital, e 130 que procuraram, num primeiro momento, unidades de atenção primária. Construímos modelos de regressão logística para estudar se a unidade de primeiro contato estava associada a um tempo de tratamento de menos de três horas. Resultados: Indivíduos que buscaram unidades de atenção primária receberam a primeira dose de aspirina nestas unidades em 75,6% dos casos. Os outros 24,4% receberam a aspirina no hospital. Apesar deste achado, indivíduos de unidades de atenção primária receberam aspirina em três horas mais frequentemente do que aqueles que foram ao hospital (76,8% vs 52,6%; p<0,001 e 100% vs, 70,7%; p=0,001 para SCA sem elevação do segmento ST e infarto agudo do miocárdio com elevação do ST, respectivamente). Em modelos ajustados, indivíduos vindos de unidades de atenção primária tinham mais probabilidade de receber aspirina mais rapidamente (razão de chances: 3,66; 95% intervalo de confiança: 2,06-6,51). Conclusões: Neste contexto, indivíduos provenientes de unidades de atenção primária tinham maior chance de receber aspirina mais rapidamente. O aprimoramento da capacidade das unidades de atenção primária para proporcionar tratamento precoce e transporte seguro pode ser benéfico em contextos similares.

One-year Mortality after an Acute Coronary Event and its Clinical Predictors: The ERICO Study / Mortalidade em um Ano após Evento Coronário Agudo e seus Preditores Clínicos: O estudo ERICO

Information about post-acute coronary syndrome (ACS) survival have been mostly short-term findings or based on specialized, cardiology referral centers.

One-year Mortality after an Acute Coronary Event and its Clinical Predictors: The ERICO Study.

BACKGROUND: Information about post-acute coronary syndrome (ACS) survival have been mostly short-term findings or based on specialized, cardiology referral centers. OBJECTIVES: To describe one-year case-fatality rates in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort, and to study baseline characteristics as predictors. METHODS: We analyzed data from 964 ERICO participants enrolled from February 2009 to December 2012. We assessed vital status by telephone contact and official death certificate searches. The cause of death was determined according to the official death certificates. We used log-rank tests to compare the probabilities of survival across subgroups. We built crude and adjusted (for age, sex and ACS subtype) Cox regression models to study if the ACS subtype or baseline characteristics were independent predictors of all-cause or cardiovascular mortality. RESULTS: We identified 110 deaths in the cohort (case-fatality rate, 12.0%). Age [Hazard ratio (HR) = 2.04 per 10 year increase; 95% confidence interval (95%CI) = 1.75­2.38], non-ST elevation myocardial infarction (HR = 3.82 ; 95%CI = 2.21­6.60) or ST elevation myocardial infarction (HR = 2.59; 95%CI = 1.38­4.89) diagnoses, and diabetes (HR = 1.78; 95%CI = 1.20­2.63) were significant risk factors for all-cause mortality in the adjusted models. We found similar results for cardiovascular mortality. A previous coronary artery disease diagnosis was also an independent predictor of all-cause mortality (HR = 1.61; 95%CI = 1.04­2.50), but not for cardiovascular mortality. CONCLUSION: We found an overall one-year mortality rate of 12.0% in a sample of post-ACS patients in a community, non-specialized hospital in São Paulo, Brazil. Age, ACS subtype, and diabetes were independent predictors of poor one­year survival for overall and cardiovascular-related causes.

Valor prognóstico dos padrões eletrocardiográficos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST: Estudo ERICO-ECG / Prognostic value of electrocardiographic patterns in patients with non ST-elevation acute coronary syndrome

Introdução: Alguns autores estudaram o valor prognóstico do eletrocardiograma inicial na sobrevida em longo prazo dos pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. O valor prognóstico de outros traçados eletrocardiográficos na fase intra-hospitalar do tratamento foi menos estudado. Objetivos: Avaliar o papel no prognóstico clínico dos registros eletrocardiográficos obtidos durante o evento índice dos participantes do estudo Estratégia de Registro de Insuficiência Coronariana (ERICO) com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Métodos: Foram analisados e classificados, de acordo com o Código de Minnesota, os traçados eletrocardiográficos intra-hospitalares de 634 participantes do estudo ERICO com síndrome coronariana aguda sem supradesnivelamento do segmento ST, no período de fevereiro de 2009 a dezembro de 2013. Foram classificados como alterados os traçados eletrocardiográficos com infradesnivelamento do segmento ST > 1mm e/ou com onda T negativa > 1mm. Foram construídos modelos de regressão de Cox brutos e ajustados, para estudar se o padrão eletrocardiográfico foi um preditor independente de desfechos clínicos (morte por qualquer causa, morte por causa cardiovascular, morte por infarto agudo do miocárdio, e desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal). Resultados: A mediana de seguimento foi de 3 anos. Encontramos uma tendência não significativa para a associação entre a presença de alteração de segmento ST no eletrocardiograma inicial com o desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal [Hazard Ratio (HR) ajustado: 1,64, intervalo de confiança de 95% (IC 95%): 1,00-2,70, p = 0,052]. Encontramos um risco significativamente maior de morte por infarto do miocárdio em indivíduos com alterações do segmento ST no eletrocardiograma final (HR ajustado: 2,04; IC 95%: 1,06-3,92). Os...

Introduction: Some authors have studied the prognostic value of initial electrocardiogram in long-term survival of patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The prognostic value of other in-hospital electrocardiographic tracings has been less studied. Objectives: To describe the association between electrocardiogram abnormalities (in ST-segment and T wave) during the index event and outcomes in patients with NSTE ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort. Methods: We analyzed and classified, according to the Minnesota Code, in-hospital ECG tracings of 634 ERICO participants with NSTE-ACS, from February 2009 to December 2013. We considered as altered electrocardiographic tracings with ST-segment depression > 1 mm and / or negative T wave > 1 mm. We built crude and adjusted Cox regression models to study if ECG pattern was an independent predictor for clinical outcomes (death from any cause, death from cardiovascular causes, death from acute myocardial infarction, and combined outcome of fatal or new nonfatal myocardial infarction). Results: Median follow-up was 3 years. We found a trend for the association between initial ECG tracing and the combined outcome of fatal or new nonfatal myocardial infarction [Hazard Ratio (HR) adjusted: 1,64, confidence interval 95% (95% CI): 1,00-2,70, p = 0,052]. We found a significantly higher risk of death due myocardial infarction in patients with ST-segment abnormalities in the final ECG tracing (adjusted HR: 2,04; 95% CI: 1,06 to 3,92). Individuals with ST-segment abnormalities in any tracing had significant higher risk for fatal or new nonfatal myocardial infarction (adjusted HR: 1,71; 95% CI: 1,04 2,79). When the T wave changes were included in the classification, there was no significant association with long-term prognosis. Conclusions: We found significant associations between ECG patterns and worse long-term prognosis. Sequential evaluation of...

Transient elevation of ST-segment due to pneumothorax and pneumopericardium.

ST-segment elevation, observed in the critically ill patients, almost always raises the suspicion of ischemic heart disease. However, nonischemic myocardial and non-myocardial problems in these patients may also lead to ST-segment elevation. Pneumothorax and pneumopericardium have been rarely reported as a cause of transient ST-segment elevation. The authors report the case of a patient admitted to the emergency care unit because of a respiratory failure requiring mechanical ventilatory support. As the patient showed signs of clinical deterioration, a pneumothorax was clinically diagnosed. Chest radiography after thorax drainage also disclosed a pneumopericardium. The 12-lead electrocardiogram recorded before the thoracic drainage revealed an ST-segment elevation, which normalized after the surgical procedure. Ischemic myocardial biomarkers were negative. The authors call attention to the right-sided pneumothorax associated with pneumopericardium as an unusual cause of ST-segment elevation.

Strongyloides stercoralis disseminated infection and schistosomiasis in an AIDS patient.

Strongyloides stercoralis hyperinfection syndrome is classically associated with impaired host response and implies in an overburden of larvae in its usual cycle. It has been recognized as a severe and potentially fatal condition in immunocompromised individuals, especially those using oral corticosteroids. Infection with Schistosoma mansoni not only increases the susceptibility to HIV infection, but also promotes progression to disease. The association of the most severe forms of strongyloidiasis and AIDS is scarcely described, even more when S. mansoni is also associated. The authors describe a case of a 34-year-old previously healthy male, admitted to the emergency department with a history of hematemesis associated with dyspnea, hemoptysis, and fever. He referred homosexual relations for 6 years. Physical examination showed an ill-looking patient, and was remarkable for tachycardia, tachypnea, diaphoresis, and pulse oximetry of 70% in room air. Lungs examination revealed the presence of rales in the left base. Chest radiography showed a diffuse and bilateral reticulo-nodular pattern. HIV serology was positive. Empirical antimicrobial therapy and corticosteroids were initiated. On the third day of hospitalization, petechiae appeared over the periumbilical area, but no further investigation was undertaken because the patient died soon after. The autopsy findings were compatible with S. stercoralis disseminated infection, a hepatic intestinal chronic form of schistosomiasis, and septic shock as the primary cause of death. The authors call attention to this infrequent association.