Assessing the cost-effectiveness of capnography for end-tidal CO2 monitoring during in-hospital cardiac arrest: A middle-income country perspective analysis.

Study objective: To evaluate the cost-effectiveness of EtCO2 monitoring during in-hospital cardiorespiratory arrest (CA) care outside the intensive care unit (ICU) and emergency room department. Design: We performed a cost-effectiveness analysis based on a simple decision model cost analysis and reported the study using the CHEERS checklist. Model inputs were derived from a retrospective Brazilian cohort study, complemented by information obtained through a literature review. Cost inputs were gathered from both literature sources and contacts with hospital suppliers. Setting: The analysis was carried out from the perspective of a tertiary referral hospital in a middle-income country. Participants: The study population comprised individuals experiencing in-hospital CA who received cardiopulmonary resuscitation (CPR) by rapid response team (RRT) in a hospital ward, not in the ICU or emergency room department. Interventions: Two strategies were assumed for comparison: one with an RRT delivering care without capnography during CPR and the other guiding CPR according to the EtCO2 waveform. Main outcome measures: Incremental cost-effectiveness rate (ICER) to return of spontaneous circulation (ROSC), hospital discharge, and hospital discharge with good neurological outcomes. Results: The ICER for EtCO2 monitoring during CPR, resulting in an absolute increase of one more case with ROSC, hospital discharge, and hospital discharge with good neurological outcome, was calculated at Int$ 515.78 (361.57-1201.12), Int$ 165.74 (119.29-248.4), and Int$ 240.55, respectively. Conclusion: In managing in-hospital CA in the hospital ward, incorporating EtCO2 monitoring is likely a cost-effective measure within the context of a middle-income country hospital with an RRT.

Corrigendum: Assessment of risk scores to predict mortality of COVID-19 patients admitted to the intensive care unit.

[This corrects the article DOI: 10.3389/fmed.2023.1130218.].

Clinical characteristics and outcomes of COVID-19 patients with preexisting dementia: a large multicenter propensity-matched Brazilian cohort study.

BACKGROUND: Although dementia has emerged as an important risk factor for severe SARS-CoV-2 infection, results on COVID-19-related complications and mortality are not consistent. We examined the clinical presentations and outcomes of COVID-19 in a multicentre cohort of in-hospital patients, comparing those with and without dementia. METHODS: This retrospective observational study comprises COVID-19 laboratory-confirmed patients aged ≥ 60 years admitted to 38 hospitals from 19 cities in Brazil. Data were obtained from electronic hospital records. A propensity score analysis was used to match patients with and without dementia (up to 3:1) according to age, sex, comorbidities, year, and hospital of admission. Our primary outcome was in-hospital mortality. We also assessed admission to the intensive care unit (ICU), invasive mechanical ventilation (IMV), kidney replacement therapy (KRT), sepsis, nosocomial infection, and thromboembolic events. RESULTS: Among 1,556 patients included in the study, 405 (4.5%) had a diagnosis of dementia and 1,151 were matched controls. When compared to matched controls, patients with dementia had a lower frequency of dyspnoea, cough, myalgia, headache, ageusia, and anosmia; and higher frequency of fever and delirium. They also had a lower frequency of ICU admission (32.7% vs. 47.1%, p < 0.001) and shorter ICU length of stay (7 vs. 9 days, p < 0.026), and a lower frequency of sepsis (17% vs. 24%, p = 0.005), KRT (6.4% vs. 13%, p < 0.001), and IVM (4.6% vs. 9.8%, p = 0.002). There were no differences in hospital mortality between groups. CONCLUSION: Clinical manifestations of COVID-19 differ between older inpatients with and without dementia. We observed that dementia alone could not explain the higher short-term mortality following severe COVID-19. Therefore, clinicians should consider other risk factors such as acute morbidity severity and baseline frailty when evaluating the prognosis of older adults with dementia hospitalised with COVID-19.

The triggers and consequences of the Queen Bee phenomenon: A systematic literature review and integrative framework.

Staines, Tavris and Jayaratne (1974) first introduced the Queen Bee Phenomenon (QBP). The term has been extensively employed to explain specific behaviors driven by organizational inequalities where women engaged in leadership positions actively restrain the opportunities of upper mobility for junior women. While the literature constantly addresses the causes and behaviors of this phenomenon, the current scholarship still lacks an integrated view of the QBP literature and a concise integrative framework that explores its triggers and consequences to advance research and provide evidence-based results to guide policy and managerial decisions. Thus, the purpose of this paper is to identify, analyze and synthesize the literature on the QBP. We conducted a systematic literature review engaging bibliometrics and content analysis. Our results highlight the current state of the art of the QBP literature and introduce a new integrative framework that shows the interplay between the triggers, traits and consequences of the QBP. We contribute to the field by integrating previous research in the field into a framework that synthesizes and connects the scattered literature. Our results are helpful for designing new organizational policies that reduce the impacts of the QBP in the workplace. The research agenda propose avenues for advancing our understanding of the phenomenon.

Temporal trends in vaccination coverage in the first year of life in Brazil / Tendência temporal das coberturas vacinais no primeiro ano de vida no Brasil

ABSTRACT Objective: The aim of this study was to analyze the temporal trends in vaccination coverage (VC) during the first year of life of children in Brazil. Methods: Data on VC for the first year of life from 2011 to 2020 for Bacille Calmette-Guerin (BCG), hepatitis B, polio, pentavalent, and triple viral vaccines at the national, regional, and state levels were obtained from the Information System of the National Immunization Program. Trends were analyzed using Prais-Winsten generalized linear regression models and average annual percent change (APC) estimates. Results: Decreasing trends were observed for the BCG (APC −3.58%; p<0.05), pentavalent (APC −4.10%; p<0.05), polio (APC −2.76%; p<0.05), and triple viral (APC −2.56%; p<0.05) vaccines in the country. Hepatitis B vaccine was the only vaccine that displayed stationary behavior (APC −4.22%; p>0.05). During the study period, no increasing trends were observed in any territory or vaccine. Conclusions: This study shows a recent significant reduction and decreasing trends in VC during the first year of life of children in Brazil, indicating the need for interventions to curb this ongoing phenomenon and to recover acceptable VC rates in the country.

RESUMO Objetivo: Analisar a tendência temporal da cobertura vacinal (CV) em crianças com idade menor ou igual a um ano no Brasil. Métodos: Foram empregados dados da CV no primeiro ano de vida de 2011 a 2020 referentes às vacinas BCG, hepatite B, poliomielite, pentavalente e tríplice viral, obtidos do Sistema de Informação do Programa Nacional de Imunizações (SI-PNI). Os dados estão agregados em nível nacional, regional e estadual. Para a análise de tendência foi utilizado o modelo de regressão linear generalizado de Prais-Winsten e foi calculada a variação percentual média anual (APC). Resultados: As tendências de CV para as vacinas BCG (APC −3,58%; p<0,05), pentavalente (APC −4,10%; p<0,05), poliomielite (APC −2,76%; p<0,05) e tríplice viral (APC −2,56%; p<0,05) foram decrescentes no país. Apenas para a CV da vacina contra hepatite B foi identificado comportamento estacionário (APC −4,22%; p>0,05). Nenhum território ou vacina apresentou tendência crescente para cobertura vacinal no período estudado no Brasil. Conclusões: Este estudo alerta sobre a redução expressiva das CV no primeiro ano de vida nos últimos anos no Brasil e sua tendência decrescente, sendo imperativa a adoção de intervenções com o fim de frear o fenômeno em curso e de resgatar níveis aceitáveis de CV no país.

Assessment of the ABC2-SPH risk score to predict invasive mechanical ventilation in COVID-19 patients and comparison to other scores.

Background: Predicting the need for invasive mechanical ventilation (IMV) is important for the allocation of human and technological resources, improvement of surveillance, and use of effective therapeutic measures. This study aimed (i) to assess whether the ABC2-SPH score is able to predict the receipt of IMV in COVID-19 patients; (ii) to compare its performance with other existing scores; (iii) to perform score recalibration, and to assess whether recalibration improved prediction. Methods: Retrospective observational cohort, which included adult laboratory-confirmed COVID-19 patients admitted in 32 hospitals, from 14 Brazilian cities. This study was conducted in two stages: (i) for the assessment of the ABC2-SPH score and comparison with other available scores, patients hospitalized from July 31, 2020, to March 31, 2022, were included; (ii) for ABC2-SPH score recalibration and also comparison with other existing scores, patients admitted from January 1, 2021, to March 31, 2022, were enrolled. For both steps, the area under the receiving operator characteristic score (AUROC) was calculated for all scores, while a calibration plot was assessed only for the ABC2-SPH score. Comparisons between ABC2-SPH and the other scores followed the Delong Test recommendations. Logistic recalibration methods were used to improve results and adapt to the studied sample. Results: Overall, 9,350 patients were included in the study, the median age was 58.5 (IQR 47.0-69.0) years old, and 45.4% were women. Of those, 33.5% were admitted to the ICU, 25.2% received IMV, and 17.8% died. The ABC2-SPH score showed a significantly greater discriminatory capacity, than the CURB-65, STSS, and SUM scores, with potentialized results when we consider only patients younger than 80 years old (AUROC 0.714 [95% CI 0.698-0.731]). Thus, after the ABC2-SPH score recalibration, we observed improvements in calibration (slope = 1.135, intercept = 0.242) and overall performance (Brier score = 0.127). Conclusion: The ABC2-SPHr risk score demonstrated a good performance to predict the need for mechanical ventilation in COVID-19 hospitalized patients under 80 years of age.

COVID-19 outcomes in people living with HIV: Peering through the waves.

OBJECTIVE: To evaluate clinical characteristics and outcomes of COVID-19 patients infected with HIV, and to compare with a paired sample without HIV infection. METHODS: This is a substudy of a Brazilian multicentric cohort that comprised two periods (2020 and 2021). Data was obtained through the retrospective review of medical records. Primary outcomes were admission to the intensive care unit, invasive mechanical ventilation, and death. Patients with HIV and controls were matched for age, sex, number of comorbidities, and hospital of origin using the technique of propensity score matching (up to 4:1). They were compared using the Chi-Square or Fisher's Exact tests for categorical variables and the Wilcoxon for numerical variables. RESULTS: Throughout the study, 17,101 COVID-19 patients were hospitalized, and 130 (0.76%) of those were infected with HIV. The median age was 54 (IQR: 43.0;64.0) years in 2020 and 53 (IQR: 46.0;63.5) years in 2021, with a predominance of females in both periods. People Living with HIV (PLHIV) and their controls showed similar prevalence for admission to the ICU and invasive mechanical ventilation requirement in the two periods, with no significant differences. In 2020, in-hospital mortality was higher in the PLHIV compared to the controls (27.9% vs. 17.7%; p = 0.049), but there was no difference in mortality between groups in 2021 (25.0% vs. 25.1%; p > 0.999). CONCLUSIONS: Our results reiterate that PLHIV were at higher risk of COVID-19 mortality in the early stages of the pandemic, however, this finding did not sustain in 2021, when the mortality rate is similar to the control group.

Educação Permanente em Saúde: implementação do protocolo gerenciado da sepse em uma Unidade de Pronto-Atendimento

A Educação Permanente em Saúde é caracterizada pela inserção dos sujeitos no processo de aprendizagem, tornando a formação dos profissionais de saúde um processo importante na qualidade do cuidado e na segurança do paciente. Uma das maiores demandas das unidades de Pronto Atendimento é o tratamento por infecções bacterianas que atinge tanto o público mais idoso quanto o mais jovem, sendo esse espaço um local propício para o desenvolvimento de estratégias que visem melhorar a identificação precoce e realizar o acompanhamento necessário desses casos. O presente artigo tem como objetivo relatar a experiência de discentes do Programa de Educação para o Trabalho em Saúde da Universidade Federal do Oeste da Bahia e da Secretaria Municipal de Saúde em uma Unidade de Pronto Atendimento, durante o período de julho a dezembro de 2022, de forma a colaborar na construção da gestão do cuidado de Sepse. Discentes dos cursos de Ciências Biológicas, Farmácia, Medicina e Nutrição tiveram a oportunidade de auxiliar nas quatro fases pertencentes ao Protocolo Sepse: Reconhecimento, Ressuscitação, Reavaliação e Referenciamento. Ao final, foram realizados oficinas, treinamentos e produção de materiais que auxiliaram a equipe profissional da pronto atendimento e do Programa Melhor em Casa na prevenção do quadro de Sepse, assim como identificação e tratamento precoce dos casos existentes. O envolvimento dos estudantes colaborou na gestão do cuidado dos casos de sepse no município ao integrar protocolos pautados cientificamente em práticas atualizadas e oportunizar a ampliação dos saberes e rotinas profissionais a partir da Educação Permanente em Saúde.

Assessment of risk scores to predict mortality of COVID-19 patients admitted to the intensive care unit.

Objectives: To assess the ABC2-SPH score in predicting COVID-19 in-hospital mortality, during intensive care unit (ICU) admission, and to compare its performance with other scores (SOFA, SAPS-3, NEWS2, 4C Mortality Score, SOARS, CURB-65, modified CHA2DS2-VASc, and a novel severity score). Materials and methods: Consecutive patients (≥ 18 years) with laboratory-confirmed COVID-19 admitted to ICUs of 25 hospitals, located in 17 Brazilian cities, from October 2020 to March 2022, were included. Overall performance of the scores was evaluated using the Brier score. ABC2-SPH was used as the reference score, and comparisons between ABC2-SPH and the other scores were performed by using the Bonferroni method of correction. The primary outcome was in-hospital mortality. Results: ABC2-SPH had an area under the curve of 0.716 (95% CI 0.693-0.738), significantly higher than CURB-65, SOFA, NEWS2, SOARS, and modified CHA2DS2-VASc scores. There was no statistically significant difference between ABC2-SPH and SAPS-3, 4C Mortality Score, and the novel severity score. Conclusion: ABC2-SPH was superior to other risk scores, but it still did not demonstrate an excellent predictive ability for mortality in critically ill COVID-19 patients. Our results indicate the need to develop a new score, for this subset of patients.

Potential and limitations of machine meta-learning (ensemble) methods for predicting COVID-19 mortality in a large inhospital Brazilian dataset.

The majority of early prediction scores and methods to predict COVID-19 mortality are bound by methodological flaws and technological limitations (e.g., the use of a single prediction model). Our aim is to provide a thorough comparative study that tackles those methodological issues, considering multiple techniques to build mortality prediction models, including modern machine learning (neural) algorithms and traditional statistical techniques, as well as meta-learning (ensemble) approaches. This study used a dataset from a multicenter cohort of 10,897 adult Brazilian COVID-19 patients, admitted from March/2020 to November/2021, including patients [median age 60 (interquartile range 48-71), 46% women]. We also proposed new original population-based meta-features that have not been devised in the literature. Stacking has shown to achieve the best results reported in the literature for the death prediction task, improving over previous state-of-the-art by more than 46% in Recall for predicting death, with AUROC 0.826 and MacroF1 of 65.4%. The newly proposed meta-features were highly discriminative of death, but fell short in producing large improvements in final prediction performance, demonstrating that we are possibly on the limits of the prediction capabilities that can be achieved with the current set of ML techniques and (meta-)features. Finally, we investigated how the trained models perform on different hospitals, showing that there are indeed large differences in classifier performance between different hospitals, further making the case that errors are produced by factors that cannot be modeled with the current predictors.

Mechanical ventilation and death in pregnant patients admitted for COVID-19: a prognostic analysis from the Brazilian COVID-19 registry score.

BACKGROUND: The assessment of clinical prognosis of pregnant COVID-19 patients at hospital presentation is challenging, due to physiological adaptations during pregnancy. Our aim was to assess the performance of the ABC2-SPH score to predict in-hospital mortality and mechanical ventilation support in pregnant patients with COVID-19, to assess the frequency of adverse pregnancy outcomes, and characteristics of pregnant women who died. METHODS: This multicenter cohort included consecutive pregnant patients with COVID-19 admitted to the participating hospitals, from April/2020 to March/2022. Primary outcomes were in-hospital mortality and the composite outcome of mechanical ventilation support and in-hospital mortality. Secondary endpoints were pregnancy outcomes. The overall discrimination of the model was presented as the area under the receiver operating characteristic curve (AUROC). Overall performance was assessed using the Brier score. RESULTS: From 350 pregnant patients (median age 30 [interquartile range (25.2, 35.0)] years-old]), 11.1% had hypertensive disorders, 19.7% required mechanical ventilation support and 6.0% died. The AUROC for in-hospital mortality and for the composite outcome were 0.809 (95% IC: 0.641-0.944) and 0.704 (95% IC: 0.617-0.792), respectively, with good overall performance (Brier = 0.0384 and 0.1610, respectively). Calibration was good for the prediction of in-hospital mortality, but poor for the composite outcome. Women who died had a median age 4 years-old higher, higher frequency of hypertensive disorders (38.1% vs. 9.4%, p < 0.001) and obesity (28.6% vs. 10.6%, p = 0.025) than those who were discharged alive, and their newborns had lower birth weight (2000 vs. 2813, p = 0.001) and five-minute Apgar score (3.0 vs. 8.0, p < 0.001). CONCLUSIONS: The ABC2-SPH score had good overall performance for in-hospital mortality and the composite outcome mechanical ventilation and in-hospital mortality. Calibration was good for the prediction of in-hospital mortality, but it was poor for the composite outcome. Therefore, the score may be useful to predict in-hospital mortality in pregnant patients with COVID-19, in addition to clinical judgment. Newborns from women who died had lower birth weight and Apgar score than those who were discharged alive.

Analysis of combined prevention measures on HIV/AIDS incidence in Brazil (1980-2020) / Análise de medidas de prevenção combinadas sobre a incidência de HIV/AIDS no Brasil (1980­2020)

Introduction: The Human Immunodeficiency Virus (HIV) attacks the immune system, with acquired immunodeficiency syndrome (AIDS) being the most advanced clinical manifestation. Prevention strategies have evolved over time in response to scientific advancements. From an institutional perspective, the Unified Health System (SUS) provides tools for Combined Prevention to the entire Brazilian population, universally and free of charge. However, despite therapeutic advances, HIV/AIDS remains a significant public health problem. Objective: To analyze the impact of Combined Prevention measures on the incidence of HIV/AIDS in Brazil from 1980 to 2020. Methods: Quantitative, observational, longitudinal, and retrospective study. Descriptive and multivariate analyses were conducted, specifically employing linear regression techniques. The variables of interest included case incidence and the distribution of: tests for sexually transmitted infections (STIs), condoms, post-exposure prophylaxis for HIV (PEP), and pre-exposure prophylaxis for HIV (PrEP). Publicly available data were sourced from governmental repositories. Results: The country has accumulated 1,037,878 infection cases, with an average of 25,947 new cases per year. Regarding prophylaxis inputs, five out of six variables demonstrated a negative correlation with the incidence rate, with only the distribution of male condoms showing a positive correlation. The analysis of the effect of PrEP was not statistically significant. Conclusion:Brazil has reduced the incidence of the disease as Combined Prevention measures have advanced. More time is needed to assess the impact of PrEP on the incidence of new cases.

Introdução: O vírus da imunodeficiência humana (HIV) ataca o sistema imunológico. A síndrome da imunodeficiência adquirida (AIDS) é a manifestação clínica mais avançada. As estratégias de prevenção evoluíram ao longo do tempo conforme os avanços científicos. Do ponto de vista institucional, o Sistema Único de Saúde (SUS) disponibiliza ferramentas de prevenção combinada a toda a população brasileira de forma gratuita e universal. Contudo, apesar de todos os avanços terapêuticos, o HIV/AIDS continua sendo um grave problema de saúde pública. Objetivo: Analisar as medidas de prevenção combinada sobre a incidência de HIV/AIDS no Brasil no período entre 1980 e 2020. Métodos: Quantitativo, observacional, longitudinal e retrospectivo. Estatisticamente, foram realizadas análises descritiva e multivariada, mais especificamente a técnica de correção linear. As variáveis de interesse foram a incidência de caso e as distribuições de: testes para infecções sexualmente transmissíveis (IST), preservativos, profilaxia pós-exposição sexual ao HIV (PEP) e a profilaxia pré-exposição ao HIV (PrEP). Os dados utilizados são de caráter público e obtidos em repositórios governamentais. Resultados: O país acumula 1.037.878 casos de infecção, com média de 25.947 novos casos por ano. Quanto aos insumos de profilaxia, cinco das seis variáveis demonstraram correlação negativa com a taxa de incidência. Apenas a distribuição de preservativos masculinos teve correlação positiva. A análise do efeito da PrEP não foi estatisticamente significativa. Conclusão: O Brasil tem reduzido a incidência da doença à medida que avançam as medidas de prevenção combinada. É necessário mais tempo para analisar o impacto da PrEP na incidência de novos casos

COVID-19 outcomes in people living with HIV: Peering through the waves

Abstract Objective To evaluate clinical characteristics and outcomes of COVID-19 patients infected with HIV, and to compare with a paired sample without HIV infection. Methods This is a substudy of a Brazilian multicentric cohort that comprised two periods (2020 and 2021). Data was obtained through the retrospective review of medical records. Primary outcomes were admission to the intensive care unit, invasive mechanical ventilation, and death. Patients with HIV and controls were matched for age, sex, number of comorbidities, and hospital of origin using the technique of propensity score matching (up to 4:1). They were compared using the Chi-Square or Fisher's Exact tests for categorical variables and the Wilcoxon for numerical variables. Results Throughout the study, 17,101 COVID-19 patients were hospitalized, and 130 (0.76%) of those were infected with HIV. The median age was 54 (IQR: 43.0;64.0) years in 2020 and 53 (IQR: 46.0;63.5) years in 2021, with a predominance of females in both periods. People Living with HIV (PLHIV) and their controls showed similar prevalence for admission to the ICU and invasive mechanical ventilation requirement in the two periods, with no significant differences. In 2020, in-hospital mortality was higher in the PLHIV compared to the controls (27.9% vs. 17.7%; p = 0.049), but there was no difference in mortality between groups in 2021 (25.0% vs. 25.1%; p > 0.999). Conclusions Our results reiterate that PLHIV were at higher risk of COVID-19 mortality in the early stages of the pandemic, however, this finding did not sustain in 2021, when the mortality rate is similar to the control group.

Frequency and burden of neurological manifestations upon hospital presentation in COVID-19 patients: Findings from a large Brazilian cohort.

BACKGROUND: Scientific data regarding the prevalence of COVID-19 neurological manifestations and prognosis in Latin America countries is still lacking. Therefore, the study aims to understand neurological manifestations of SARS-CoV 2 infection and outcomes in the Brazilian population. METHODS: This study is part of the Brazilian COVID-19 Registry, a multicentric cohort, including data from 37 hospitals. For the present analysis, patients were grouped according to the presence of reported symptoms (i.e., headache; anosmia and ageusia; syncope and dizziness) vs. clinically-diagnosed neurological manifestations (clinically-defined neurological syndrome: neurological signs or diagnoses captured by clinical evaluation) and matched with patients without neurological manifestations by age, sex, number of comorbidities, hospital of admission, and whether or not patients had underlying neurological disease. RESULTS: From 6,635 hospitalized patients with COVID-19, 30.8% presented reported neurological manifestations, 10.3% were diagnosed with a neurological syndrome and 60.1% did not show any neurological manifestations. In patients with reported symptoms, the most common ones were headache (20.7%), ageusia (11.1%) and anosmia (8.0%). In patients with neurological syndromes, acute encephalopathy was the most common diagnosis (9.7%). In the matched analysis, patients with neurological syndromes presented more cases of septic shock (17.0 vs. 13.0%, p = 0.045), intensive care unit admission (45.3 vs. 38.9%, p = 0.023), and mortality (38.7 vs. 32.6%, p = 0.026; and 39.2 vs. 30.3%, p < 0.001) when compared to controls. CONCLUSION: COVID-19 in-hospital patients with clinically defined neurological syndromes presented a higher incidence of septic shock, ICU admission and death when compared to controls.

Development and validation of the MMCD score to predict kidney replacement therapy in COVID-19 patients.

BACKGROUND: Acute kidney injury (AKI) is frequently associated with COVID-19, and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalised COVID-19 patients, and to assess the incidence of AKI and KRT requirement. METHODS: This study is part of a multicentre cohort, the Brazilian COVID-19 Registry. A total of 5212 adult COVID-19 patients were included between March/2020 and September/2020. Variable selection was performed using generalised additive models (GAM), and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. Accuracy was assessed using the area under the receiver operating characteristic curve (AUC-ROC). RESULTS: The median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalisation. The temporal validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. The geographic validation cohort had similar age and sex; however, this cohort had higher rates of ICU admission, AKI, need for KRT and in-hospital mortality. Four predictors of the need for KRT were identified using GAM: need for mechanical ventilation, male sex, higher creatinine at hospital presentation and diabetes. The MMCD score had excellent discrimination in derivation (AUROC 0.929, 95% CI 0.918-0.939) and validation (temporal AUROC 0.927, 95% CI 0.911-0.941; geographic AUROC 0.819, 95% CI 0.792-0.845) cohorts and good overall performance (Brier score: 0.057, 0.056 and 0.122, respectively). The score is implemented in a freely available online risk calculator ( https://www.mmcdscore.com/ ). CONCLUSIONS: The use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalised COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation.

COVID-19 risk areas associated with social vulnerability in northeastern Brazil: an ecological study in 2020.

INTRODUCTION: COVID-19 is a major public health concern in this century. The causative agent SARS-CoV-2, is highly contagious and spreads continuously across territories. Spatial analysis is of enormous importance in the process of understanding the disease and its transmission mechanisms. We aimed to identify the risk areas for COVID-19 and analyze their association with social vulnerability in Maceió, Alagoas. The study was conducted in 2020. METHODOLOGY: This is an ecological study to evaluate the incidence, mortality and case fatality rate of COVID-19 and their relationship with 12 indicators of human development and social vulnerability. Multivariate and spatial statistics were applied. A 95% confidence interval and a 5% confidence level were considered. RESULTS: The spatial scan statistic revealed the existence of six high-risk clusters for the incidence of COVID-19. The regression model showed that social indicators, such as literacy of people, residents of private households, households with more than four residents, and resident brown population, were associated with COVID-19 transmission in Maceió-AL. The disease affected localities whose populations are exposed to a context of intense socioeconomic vulnerability. CONCLUSIONS: Based on the results, it is necessary to adopt measures that take into account the social determinants of health in order to minimize the damage caused by the pandemic.

O efeito das medidas de distanciamento social sobre a incidência de COVID-19 no Brasil: Uma análise multissetorial / The effect of social distancing measures on the incidence of COVID-19 in Brazil: A multisectoral analysis

Objetivo: Este artigo estima o impacto das medidas de distanciamento social sobre a incidência de COVID-19 a partir de uma perspectiva multissetorial. Métodos: O desenho de pesquisa utiliza um modelo de regressão em painel para analisar a relação entre restrições de mobilidade em diferentes setores econômicos e a dinâmica longitudinal da doença nos estados do Brasil. Resultados: Os principais resultados indicam que apenas os coeficientes das variáveis que representam os setores de restaurantes (p-valor < 0,05), compras (p-valor < 0,05) e transporte (p-valor < 0,001) obtiveram significância estatística. Em especial, o transporte (ß= -0,674) é a variável que mais influencia a variação do número de casos de COVID-19. Conclusões: As evidências reportadas nesta pesquisa podem auxiliar o processo de tomada de decisão dos gestores governamentais a respeito da eficácia de intervenções não farmacológicas como instrumento para reduzir a disseminação da COVID-19 (AU)

Objective: This article estimates the impact of social distancing measures on the incidence of COVID-19 from a multisectoral perspective. Methods: The research design uses a panel regression model to analyze the relationship between mobility restrictions in different economic sectors and the longitudinal dynamics of the infection across Brazilian states. Results: The main results indicate that only the coefficients for the restaurant (p-value < 0.05), shopping (p-value < 0.05), and transport sectors (p-value < 0.001) reached statistical significance. In particular, transport (ß = -0.674) is the variable with the strongest impact on the variation in the number of COVID-19 cases. Conclusions: The evidence reported in this research can assist the decision-making process of government managers regarding the effectiveness of non-pharmacological interventions as a tool to reduce the spread of COVID-19

Smile Transformation with Composite Resin by Semi-Direct Technique: a Case Report / Transformação Do Sorriso Com Resina Composta Por Técnica Semi-Direta: Relato De Caso

Composite veneers stand out in modern dentistry for their practicality, time-saving and excellent optical properties. This work describes the operative steps for the realization of veneers in composite resin in an academic clinical environment using a semi-direct technique. A 21-yearold female patient attended the clinic-school complaining of aesthetic dissatisfaction with her smile. In the clinical dental evaluation, multiple diastemas were observed in the upper anterior teeth, and resin cement residues from orthodontic bracket bonding. In addition, the patient expressed an interest in having bigger and whiter teeth. In view of the complaints reported by the patient, the following treatment sequence was proposed: 1. Removal of residual resin cement from all teeth; 2. Tooth whitening; 3. Confection of composite resin veneers using the semi-direct technique on the upper teeth (canine to canine). The die stone that had already been made for the home bleaching procedure was used for esthetic rehabilitation. The 6 veneers were made using a nanoparticulate resin. The veneers were cemented and adjusted. The 12-month follow-up showed an excellent marginal adaptation and an excellent aesthetic and function quality. The semi-direct technique may be considered a therapeutic option based on the conservation of sound tooth structure, minimal emotional stress during clinical work and excellent final optical and mechanical properties. Simplicity and practicality of the technique allow reproducibility and excellent results at a lower cost when compared to dental ceramics. (AU)

As facetas em resina composta destacam-se na odontologia moderna por sua praticidade, economia de tempo e excelentes propriedades ópticas. Este trabalho descreve as etapas operatórias para a realização de facetas em resina composta em ambiente clínico acadêmico utilizando a técnica semi-direta. Paciente do sexo feminino, 21 anos, compareceu à clínica-escola com queixa de insatisfação estética com seu sorriso. Na avaliação clínica odontológica, foram observados múltiplos diastemas nos dentes anteriores superiores e resíduos de cimento resinoso proveniente da colagem de braquetes ortodônticos. Além disso, a paciente manifestou interesse em ter dentes maiores e mais brancos. Diante das queixas relatadas pela paciente, foi proposta a seguinte sequência de tratamento: 1. Remoção do cimento resinoso residual detodos os dentes; 2. Clareamento dental; 3. Confecção de facetas de resina composta pela técnica semi-direta nos dentes superiores (canino a canino). O modelo de gesso já confeccionado para o clareamento caseiro foi utilizado para a reabilitação estética. As 6 facetas foram confeccionadas utilizando resina nanoparticulada. As facetas foram cimentadas e ajustadas. O seguimento de 12 meses mostrou uma excelente adaptação marginal e uma excelente qualidade estética e funcional. A técnica semi-direta pode ser considerada uma opção terapêutica baseada na conservação da estrutura dentária sadia, mínimo estresse emocional durante o trabalho clínico e excelentes propriedades ópticas e mecânicas finais. A simplicidade e praticidade da técnica permitem reprodutibilidade e excelentes resultados a um custo menor quando comparado às cerâmicas odontológicas. (AU)

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry.

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.