Seroprevalence of SARS-CoV-2 in Emergency Department Healthcare Workers at Sírio-Libanês Hospital, Brazil.

COVID-19 has spread rapidly worldwide. Information on its prevalence and factors associated with infection are important for protecting both professionals and patients in healthcare centers. This study evaluated the seroprevalence of antibodies against SARS-CoV-2 and its association with the degree of exposure and use of personal protective equipment by healthcare professionals dedicated to the treatment of patients with flu-like illnesses in the emergency room. The research team included an analysis of healthcare professionals who underwent enzyme-linked immunosorbent assay serological testing for SARS-CoV-2 between May 28 and June 26, 2020, in the emergency room of Sírio-Libanês Hospital in São Paulo, Brazil. Participants answered individual questionnaires on occupational information, medical health history, and factors associated with exposure to the novel coronavirus. The questionnaire variables were compared based on the serological results. Of the 164 study participants, 96 (58.54%) reported at least 1 flu-like symptom and 42 (25.61%) presented serology results that were compatible with SARS-CoV-2 infection. The asymptomatic declared group accounted for 62 participants; of these, 8 (12.90%) had positive serology results (neutralizing antibody and IgG) for SARS-CoV-2. Data analysis showed a positive correlation with duration of work, safety in wearing and reusing personal protective equipment, and presence of anosmia, and showed a negative relationship with duration of mask use. Our findings suggest that the perception of symptoms by healthcare professionals is not a good screening parameter for the diagnosis of an infectious disease with respiratory symptoms, such as COVID-19. The main influencing factor for the control of infection is the elaboration of workflows and safety protocols based on simple and clear rules as well as investments in team training.

Ganglionar tuberculosis infection evolving to hemophagocytic lymphohistiocytosis after anti-programmed cell death 1 treatment for high-risk melanoma: a case report.

BACKGROUND: Hemophagocytic lymphohistiocytosis is a rare, potentially fatal syndrome of immune hyperactivation. Here we describe a ganglionar tuberculosis evolving to hemophagocytic lymphohistiocytosis following adjuvant immunotherapy in a melanoma patient. CASE PRESENTATION: A 76-year-old Caucasian male with melanoma started with fever, diffuse petechiae, splenomegaly, anemia, thrombocytopenia, hypofibrinogenemia, and hyperferritinemia 2 months following completion of adjuvant treatment with nivolumab. Positron emission tomography scan showed significant hypermetabolism in cervical, supraclavicular, mediastinal, and abdominal lymph nodes. Bone marrow aspiration demonstrated no alterations, except for a hypercellular pattern. Dexamethasone and intravenous immunoglobulin were started owing to suspicion of hemophagocytic lymphohistiocytosis. Core biopsy of the infracarinal lymph node revealed a chronic granulomatous inflammation and caseous necrosis, with positivity for Mycobacterium tuberculosis by polymerase chain reaction, and treatment for ganglionar tuberculosis was started. CONCLUSION: This case highlights the challenges involving programmed cell death 1 blockade in high-risk melanoma, in which infections, lymphoproliferative disorders, and sarcoidosis can mimic disease progression and trigger immune-related adverse events.

Stent evaluation by coronary computed tomography angiography: a comparison between Iopamidol-370 and Ioversol-320 hypo-osmolar iodine concentration contrasts.

OBJECTIVE: Qualitative and quantitative image analysis between Iopamidol-370 and Ioversol-320 in stents´ evaluation by coronary computed tomography angiography (CTA). METHODS: Sixty-five patients with low-risk stable angina undergoing stent follow-up with coronary CTA were assigned to Iopamidol I-370 (n = 33) or Ioversol I-320 (n = 32) in this prospective, double-blind, non-inferiority, randomized trial. Stent lumen image quality was graded by 5-point Likert Scale. Lumen mean attenuation was measured at native coronary segments: pre-stent, post-stent, distal segments and at coronary plaques. Lumen attenuation increase (LAI) ratio was calculated for all stents. Heart rate (HR) variation, premature heart beats (PHB), heat sensation (HS), blooming and beam hardening were also assessed. RESULTS: Image quality was similar between groups, with no significant difference (Likert score 4.48 ± 0.75 vs 4.54 ± 0.65, p = 0.5). There were similarities in LAI ratio between I-370 and I-320 (0.39 ± 0.42 vs 0.48 ± 0.44 HU, p = 0.08). Regarding lumen mean attenuation at native coronary segments, a significant difference was observed, with I-320 presenting lower values, including contrast mean attenuation in distal segments. After statistical multivariate analysis, three variables correlated with stent image quality: 1) stent diameter, 2) HR variation and 3) stent lumen LAI ratio. CONCLUSIONS: There was no significant difference between Iopamidol-370 mgI ml-1 and Ioversol-320 mgI ml-1 contrasts regarding overall stent lumen image quality, which was mainly influenced by stent diameter, HR and LAI ratio.Advances in knowledge:Coronary CTA allows adequate stents' visualization and image quality is influenced by stent diameter, HR variation and LAI ratio.Stents' image quality showed no difference between different concentration contrasts (I-370 vs. I-320); however, higher concentration contrasts may provide an improved overall visualization, especially regarding coronary distal segments.

Predicting Hospital Admission and Prolonged Length of Stay in Older Adults in the Emergency Department: The PRO-AGE Scoring System.

STUDY OBJECTIVE: We developed prediction models for hospital admission and prolonged length of stay in older adults admitted from the emergency department (ED). METHODS: This was a retrospective cohort study of patients aged 70 years or older who visited a geriatric ED in Brazil (N=5,025 visits). We randomly allocated participants to derivation and validation samples in a 2:1 ratio. We then selected 21 variables based on their clinical relevance and generated models to predict the following outcomes: hospital admission and prolonged length of stay, defined as the upper tertile of hospital stay. We used backward stepwise logistic regressions to select our final predictors and developed risk scoring systems based on the relative values of their ß coefficients. RESULTS: Overall, 57% of the participants were women, 31% were hospitalized, and 1% died in the hospital. The upper tertile of hospital stay was greater than 7 days. Hospital admission was best predicted by a model including male sex, aged 90 years or older, hospitalization in the previous 6 months, weight loss greater than or equal to 5% in the previous year, acute mental alteration, and acute functional decline. The prediction of prolonged length of stay retained the same variables, except male sex, which was substituted for fatigue. The final scoring system reached areas under the receiver operating characteristic curve of 0.74 for hospital admission and 0.79 for prolonged length of stay, and their accuracies were confirmed in the validation models. CONCLUSION: The PRO-AGE scoring system predicted hospital admission and prolonged length of stay in older adults with good accuracy, using a simple approach and only 7 easily obtained clinical variables.

Successive blood pressure measurements to evaluate suspected and treated hypertension.

INTRODUCTION: According to the published literature, blood pressure (BP) measurements performed in the outpatient clinical setting are often inaccurate. The white coat effect and improper technique are the main causes of this imprecision. Construction of a set of readings without them could improve the accuracy of BP measurement. OBJECTIVE: To evaluate the accuracy and agreement of successive office BP measurements using the awake blood pressure average (ABPa) as the gold standard. METHODS: BP was measured in 852 patients using three techniques: in office (OBPa); seven successive measurements performed by a nurse using an automatic device; and 24 h of ambulatory BP monitoring. BP averages (BPa) were obtained from the nurse's measurements: 1-2BPa (first and second), 3-7BPa (third to seventh), and 1-7BPa (first to seventh). OBPa and successive measurements were tested against ABPa by calculating the following: average difference in BP of 1-2BPa, 3-7BPa and OBPa, and the area under the curve. RESULTS: Among the 834 patients eligible, 374 (43.9%) were considered to be hypertensive on the basis of the ABPa (≥135/85 mmHg). 3-7BPa showed the lowest average difference (4/3 mmHg). By contrast, OBPa showed the highest result (21/11 mmHg). The mean difference with 1-2BPa was 8/4 mmHg. The areas under the curve were better with 3-7BPa (0.82-0.85) and 1-2BPa (0.82-0.83) than OBPa (0.67-0.71) for both systolic and diastolic BP. CONCLUSION: All means from successive measurements showed a better precision than OBPa, even the two first readings. However, more research needs to be carried out before recommendation of the use of this technique in routine practice.

Disseminating cardiopulmonary resuscitation training by distributing 9,200 personal manikins.

OBJECTIVES: Community members should be trained so that witnesses of cardiac arrests are able to trigger the emergency system and perform adequate resuscitation. In this study, the authors evaluated the results of cardiopulmonary resuscitation (CPR) training of communities in four Brazilian cities, using personal resuscitation manikins. METHODS: In total, 9,200 manikins were distributed in Apucarana, Itanhaém, Maringá, and São Carlos, which are cities where the populations range from 80,000 to 325,000 inhabitants. Elementary and secondary school teachers were trained on how to identify a cardiac arrest, trigger the emergency system, and perform chest compressions. The teachers were to transfer the training to their students, who would then train their families and friends. RESULTS: In total, 49,131 individuals were trained (6.7% of the population), but the original strategy of using teachers and students as multipliers was responsible for only 27.9% of the training. A total of 508 teachers were trained, and only 88 (17.3%) transferred the training to the students. Furthermore, the students have trained only 45 individuals of the population. In Maringá and São Carlos, the strategy was changed and professionals in the primary health care system were prepared and used as multipliers. This strategy proved extremely effective, especially in Maringá, where 39,041 individuals were trained (79.5% of the total number of trainings). Community health care providers were more effective in passing the training to students than the teachers (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). CONCLUSIONS: Instruction of CPR using personal manikins by professionals in the primary health care system seems to be a more efficient strategy for training the community than creating a training network in the schools.

O escore de risco de sangramento como preditor de mortalidade em pacientes com síndromes coronarianas agudas / The bleeding risk score as a mortality predictor in patients with acute coronary syndrome

FUNDAMENTO: A ocorrência de sangramento aumenta a mortalidade intra-hospitalar em pacientes com síndromes coronarianas agudas (SCAs), e há uma boa correlação entre os escores de risco de sangramento e a incidência de eventos hemorrágicos. No entanto, o papel dos escores de risco de sangramento como fatores preditivos de mortalidade é pouco estudado. OBJETIVO: Analisar o papel do escore de risco de sangramento como fator preditivo de mortalidade intra-hospitalar numa coorte de pacientes com SCA tratados num centro terciário de cardiologia. MÉTODOS: Dos 1.655 pacientes com SCA (547 com SCA com supra de ST e 1.118 com SCA sem supra de ST), calculou-se o escore de risco de sangramento ACUITY/HORIZONS prospectivamente em 249 pacientes e retrospectivamente nos demais 1.416. Informações sobre mortalidade e complicações hemorrágicas também foram obtidas. RESULTADOS: A idade média da população estudada foi 64,3 ± 12,6 anos e o escore de risco de sangramento médio foi 18 ± 7,7. A correlação entre sangramento e mortalidade foi altamente significativa (p < 0,001; OR = 5,29), assim como a correlação entre escore de sangramento e hemorragia intra-hospitalar (p < 0,001; OR = 1,058), e entre escore de sangramento e mortalidade intra-hospitalar (OR ajustado = 1,121, p < 0,001, área sob a curva ROC 0,753; p < 0,001). O OR ajustado e a área sob a curva ROC para a população com SCA com supra de ST foram 1,046 (p = 0,046) e 0,686 ± 0,040 (p < 0,001), respectivamente, e para SCA sem supra de ST foram 1,150 (p < 0,001) e 0,769 ± 0,036 (p < 0,001), respectivamente. CONCLUSÃO: O escore de risco de sangramento é um fator preditivo muito útil e altamente confiável para mortalidade intra-hospitalar em uma grande variedade de pacientes com SCAs, especialmente aqueles com angina instável ou infarto agudo do miocárdio sem supra de ST.

BACKGROUND: It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. OBJECTIVE: The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. METHODS: Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained. RESULTS: Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). CONCLUSIONS: Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

The bleeding risk score as a mortality predictor in patients with acute coronary syndrome.

BACKGROUND: It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. OBJECTIVE: The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. METHODS: Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained. RESULTS: Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). CONCLUSIONS: Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

Clinical characteristics and long-term outcome of patients with acute coronary syndromes and Takayasu arteritis.

INTRODUCTION: Monitoring of disease activity and the best therapeutic approach are a challenge in Takayasu arteritis (TA). When associated with acute coronary syndromes (ACS), the best interventional treatment has not been established. The objective of this study was to describe the baseline characteristics, clinical manifestations, treatment and long-term outcome of patients with TA and ACS. METHODS: We retrospectively analyzed eight patients between 2004 and 2010. The following data were obtained: age, gender, clinical and electrocardiographic manifestations, Killip class, risk factors for ACS, markers of myocardial necrosis (CK-MB and troponin), creatinine clearance, left ventricular ejection fraction, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate [ESR]), medication during hospital stay, angiographic findings, treatment (medical, percutaneous or surgical) and long-term outcome. Statistical data were expressed as percentages and absolute values. RESULTS: All eight patients were women, median age 49 years. Typical chest pain was present in 37.5%. Elevated ESR was observed in 85.7%. Three patients underwent coronary artery bypass grafting, three underwent percutaneous coronary angioplasty (two with bare-metal stents and one with a drug-eluting stent) and two were treated medically. In-hospital mortality was 25%. There were no deaths during a mean follow-up of 30 months. CONCLUSIONS: In our study, patients who were discharged home had good outcomes in long-term follow-up with medical, percutaneous or surgical treatment. ESR appears to be associated with ACS in TA.

Rare manifestation of acute pulmonary edema associated with acute lupus myocarditis.

Systemic Lupus Erythematosus (SLE) is the most common systemic autoimmune disease, occurring more frequently in women, usually aged between 16 and 55 years 1, 2. Although classically the kidneys are the organs most affected in SLE, cardiopulmonary circulation and the heart may also be affected significantly 3. In this context, the occurrence of acute pulmonary edema associated with lupus myocarditis is rare and specific immunosuppressive therapy remains unclear.

Manifestação rara de edema agudo de pulmão associado à miocardite lúpica aguda - relato de caso / Unusual clinical manifestation of acute pulmonary edema associated to acute lupic myocarditis - case report

O lupus eritematoso sistêmico (LES) é a mais comum das doenças auto-imunes sistêmicas. Embora os rins classicamente sejam os órgãos mais acometidos no LES, o coração também pode ser afetado de forma significativa. Entretanto, a ocorrência de edema agudo de pulmão associado à miocardite lúpica é rara e de tratamento imunossupressor específico ainda incerto. O presente relato de caso revisa a literatura quanto a manifestações lúpicas do sistema cardiopulmonar, seu diagnóstico e tratamento, e descreve uma paciente lúpica jovem que evoluiu com edema agudo de pulmão decorrente de uma miopericardite lúpica aguda. O rápido diagnóstico pôde permitir o emprego da terapêutica imunossupressora adequada com reversão completa da disfunção miocárdica. Em pacientes jovens com quadro sugestivo de edema agudo de pulmão, o diagnóstico de LES deve ser considerado. O uso de pulsoterapia com corticóide endovenoso mostrou-se eficaz e seguro para o tratamento da manifestação cardíaca extrema.

Systemic lupus erythematosus is the most common systemic autoimmune disease. Although kidneys are the mainorgans affected, heart may suffer injury too. However, acute pulmonary edema associated to lupic myocarditis is rare and its specific immunosuppressive treatment is still undefined. The present case report reviews literature about lupic manifestations in heart and lungs, their diagnosis and treatment, and describes an young lupic patient that had pulmonary edema due toacute lupic myopericarditis. Prompt diagnosis enabled correct immunosuppressive therapy that resulted in a complete reversion of myocardial disfunction. Lupus is a possible diagnosis in young patients with pulmonary edema. The use of intravenous pulse therapy with corticosteroids was safe and efficient to healing of this severe myocardial manifestation.

Manifestação rara de edema agudo de pulmão associado à miocardite lúpica aguda / Rare manifestation of acute pulmonary edema associated with acute lupus myocarditis

O lupus eritematoso sistêmico (LES) é a mais comum das doenças auto-imunes sistêmicas, ocorrendo com maior freqüência no sexo feminino, usualmente na faixa etária entre 16 e 55 anos1,2. Embora os rins classicamente sejam os órgãos mais acometidos no LES, o coração e a circulação cardiopulmonar também podem ser afetados de forma significativa3. Nesse contexto, a ocorrência de edema agudo de pulmão associado à miocardite lúpica é rara e de tratamento imunossupressor específico ainda incerto.

Systemic Lupus Erythematosus (SLE) is the most common systemic autoimmune disease, occurring more frequently in women, usually aged between 16 and 55 years1,2. Although classically the kidneys are the organs most affected in SLE, cardiopulmonary circulation and the heart may also be affected significantly3. In this context, the occurrence of acute pulmonary edema associated with lupus myocarditis is rare and specific immunosuppressive therapy remains unclear.

Preoperative B-type natriuretic peptide, and not the inflammation status, predicts an adverse outcome for patients undergoing heart surgery.

OBJECTIVES: B-type natriuretic peptide (BNP) and inflammatory markers are implicated in the pathophysiology of both ischemic cardiomyopathy and complications after cardiac surgery with cardiopulmonary bypass (CPB). The purpose of this study was to assess preoperative and postoperative levels of BNP, interleukin-6 (IL-6), interleukin-8 (IL-8), P-selectin, intercellular adhesion molecule (ICAM), C-reactive protein (CRP) in patients undergoing cardiac surgery with CPB and investigate their variation and ability to correlate with immediate outcome. METHODS: Plasma levels of these markers were measured preoperatively, 6 and 24 h after CBP in 62 patients. Main endpoints were requirements for intra-aortic balloon pump, intensive care unit (ICU) stay longer than five days, ventilator dependence >24 h, requirement for dobutamine, hospital stay >10 days, clinical complications (infection, myocardial infarction, renal failure, stroke and ventricular arrhythmias) and in-hospital mortality. RESULTS: Preoperative BNP levels correlate with longer ICU stay (P = 0.003), longer ventilator use (P = 0.018) and duration of dobutamine use (P < 0.001). The receiver-operating characteristic curve demonstrated BNP levels >190 pg/ml as predictor of ICU >5 days and BNP levels >20.5 pg/ml correlated with dobutamine use, with areas under the curve of 0.712 and 0.842, respectively. Preoperative levels of ICAM-1 were associated with in-hospital mortality (P = 0.042). In the postoperative period, was found association between CRP, IL-6 and P-selectin with ventilation duration (P = 0.013, P = 0.006, P < 0.001, respectively) and P-selectin with ICU stay (P = 0.009). CONCLUSIONS: BNP correlates with clinical endpoints more than inflammatory markers and can be used as a predictor of early outcome after heart surgery.

Doença neoplásica como fator de risco para tromboembolismo / Cancer as a risk factor for thromboembolic disease

Tromboembolismo venoso é um evento potencialmente fatal, que complica a evolução de 20 por cento dos pacientes com neoplasia, causando impacto significativo na qualidade de vida e nos desfechos clínicos desses pacientes. A fisiopatologia da associação entre trombose e câncer é complexa. As neoplasias estão associadas a estado de hipercoagulabilidade secundário à liberação de citocinas inflamatórias, ativação do sistema de coagulação, expressão de proteínas hemostáticas nas células tumorais, inibição de anticoagulantes naturais e alteração no processo fibrinolítico. Os fatores de risco associados ao tromboembolismo venoso podem ser relacionados ao paciente, à doença ou às intervenções terapêuticas. O uso profilático de heparinas e fondaparinux está indicado em pacientes selecionados de acordo com o tipo de neoplasia e da terapia utilizada. O tratamento dos pacientes oncológicos com tromboembolismo venoso é desafiador: as complicações associadas ao uso de anticoagulantes são significativamente maiores, podem interferir com o tratamento antineoplásico e têm impacto negativo na qualidade de vida.

Venous thromboembolism is a serious and potentially fatal disorder, which complicates the course of 20% of cancer patients, and has a significant impact on the quality of life and clinical outcomes of these patients. The pathophysiology of the association between thrombosis and cancer is complex. Malignancy is associated with a baseline hypercoagulable state secondary to the release of inflammatory cytokines, activation of the clotting system, expression of hemostatic proteins on tumor cells, inhibition of natural anticoagulants and impaired fibrinolysis. Several risk factors have been identified as contributing to venous thromboembolism and may be related to the patient characteristics, to the disease, and to the therapeutic interventions. The use of heparins and fondaparinux is indicated for selected cancer patients according to the types of malignancies and treatments. The treatment of venous thromboembolism in patients with cancer is challenging: the complications associated with the use of anticoagulants are significantly higher, may interfere with anticancer therapy and have a negative impact on quality of life.