A risk score for predicting death in COVID-19 in-hospital infection: A Brazilian single-center study.

BACKGROUND: There is a paucity of information about Brazilian COVID-19 in-hospital mortality probability of death combining risk factors. OBJECTIVE: We aimed to correlate COVID-19 Brazilian in-hospital patients' mortality to demographic aspects, biomarkers, tomographic, echocardiographic findings, and clinical events. METHODS: A prospective study, single tertiary center in Brazil, consecutive patients hospitalized with COVID-19. We analyzed the data from 111 patients from March to August 2020, performed a complete transthoracic echocardiogram, chest thoracic tomographic (CT) studies, collected biomarkers and correlated to in-hospital mortality. RESULTS: Mean age of the patients: 67 ± 17 years old, 65 (58.5%) men, 29 (26%) presented with systemic arterial hypertension, 18 (16%) with diabetes, 11 (9.9%) with chronic obstructive pulmonary disease. There was need for intubation and mechanical ventilation of 48 (43%) patients, death occurred in 21/111 (18.9%) patients. Multiple logistic regression models correlated variables with mortality: age (OR: 1.07; 95% CI 1.02-1.12; p: 0.012; age >74 YO AUC ROC curve: 0.725), intubation need (OR: 23.35; 95% CI 4.39-124.36; p < 0.001), D dimer (OR: 1.39; 95% CI 1.02-1.89; p: 0.036; value >1928.5 ug/L AUC ROC curve: 0.731), C-reactive protein (OR: 1.18; 95% CI 1.05-1.32; p < 0.005; value >29.35 mg/dl AUC ROC curve: 0.836). A risk score was created to predict intrahospital probability of death, by the equation: 3.6 (age >75 YO) + 66 (intubation need) + 28 (C-reactive protein >29) + 2.2 (D dimer >1900). CONCLUSIONS: A novel and original risk score were developed to predict the probability of death in Covid 19 in-hospital patients concerning combined risk factors.

Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS): a Brazilian cohort.

BACKGROUND: Paediatric inflammatory multisystem syndrome (PIMS) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been described since mid-April 2020 with the first reports coming from Europe. Our objective was to describe the characteristics of patients among the Brazilian population. METHODS: A multicenter retrospective study was conducted with the participation of five pediatric rheumatology centers in Brazil during the period from March to November 2020. Children and adolescents with PIMS temporally associated with SARS-CoV-2 (TS) who met the definition criteria for the disease according to the Royal College of Paediatrics and Child Health were included. Demographic, clinical, laboratory, therapeutic characteristics and molecular and serological diagnosis of SARS-CoV-2 infection were described. RESULTS: Fifty-seven children and adolescents with PIMS-TS were evaluated, 54% female, with a median age of 8 (3-11) years. Most (86%) were previously healthy, with asthma being the main comorbidity, present in 10% of the patients. Fever was the main manifestation, present in all patients, followed by mucocutaneous and gastrointestinal features, present in 89% and 81% of the patients, respectively. Myocarditis occurred in 21% of the patients and in 68% of them required intensive care. The Kawasaki disease phenotype occurred in most patients (77%). All patients had elevated inflammatory markers, with elevated CRP being the most found (98%). Anemia and lymphopenia were present in 79% and 72%, respectively. Laboratory evidence of SARS-CoV-2 was found in 77% of the patients, with 39% positive RT-PCR and 84% positive serology for SARS-CoV-2. An immunomodulatory treatment was performed in 91% of the patients, with 67% receiving intravenous immunoglobulin (IVIG) associated with glucocorticoid, 21% receiving IVIG, and 3.5% receiving glucocorticoid. The median length of hospitalization was 10 days. CONCLUSIONS: This study showed a high morbidity of PIMS-TS in Brazilian children, with a prolonged length of hospitalization and a high rate of admission to pediatric intensive care unit. Multicenter prospective studies are needed to assess the morbidity of the disease in the medium and long term.

Selenium nutritional status and its association with SLEDAI-2K, HOMA-IR and lipid profile in Juvenile Systemic Lupus Erythematosus patients.

OBJECTIVES: To assess nutritional status regarding selenium in adolescents with Juvenile Systemic Lupus Erythematosus (jSLE) and analyze possible associations with disease activity, insulin resistance and lipid profile. METHODS: This was an observational, cross-sectional study of 31 female adolescents with jSLE and 31 healthy female volunteers as a comparison group. We obtained demographic, anthropometric (weight, stature, waist, and neck circumferences), and clinical data (disease activity measured by SLEDAI-2K) from both groups; laboratory data including: lipid profile, plasma selenium, erythrocyte glutathione peroxidase activity (GPx), plasma malondialdehyde (MDA), ultrasensitive C-reactive protein (usCRP), insulin levels, and glycemia (Homeostasis Model Assessment for Insulin Resistance-HOMA-IR). RESULTS: Mean age at diagnosis of jSLE group was 15.9±1.7 years, with mean disease duration of 3.6±2.6 years. 48% of patients and controls had below-reference Se levels (≤46mcg/L). GPx was more frequently below reference levels (<4.171U/L) in the jSLE group, compared to controls. A ROC curve was used to assess the power of the variables to discriminate between both groups; insulin (AUC = 0.712; CI 95% 0.584-0.840), waist-to-height ratio (AUC = 0.704; CI 95% 0.572-0.837), and HOMA-IR (AUC = 0.689; CI 95% 0.556-0.822) were the variables with the greatest discriminatory power. Linear regression showed an independent inverse association between Se levels and c-LDL; no such correlation was found for GPx activity. SLEDAI-2 K and HOMA-IR showed no association with levels of Se and GPx activity. CONCLUSIONS: Approximately, 50% of jSLE adolescents had below reference Se levels. The frequency of inadequate GPx values was higher in patients, compared to controls. There was an independent inverse association between Se and c-LDL levels in both groups; this was not the case for HOMA-IR and SLEDAI-2K. The data show the importance of assessing Se nutritional status in jSLE patients.

Impact of Obesity and Visceral Fat on Mortality in Hematopoietic Stem Cell Transplantation.

RATIONALE: Many studies have shown the importance of body composition parameters, muscle, and fat mass, evaluated by several methods in hematopoietic stem cell transplantation (HSCT) outcomes. Ultrasound (US) is an efficient and low-cost method to evaluate body composition, even though there have not been many studies in HSCT. OBJECTIVES: Our goal was to investigate the muscle, visceral fat (VF), and echogenicity before HSCT and after engraftment, evaluated by US and its association with outcomes. METHODS: All adult patients with hematological malignances admitted for HSCT autologous and allogeneic were eligible to enter this prospective study. Their thigh muscle thickness, VF, and echogenicity were evaluated by US on the first day of hospitalization (baseline) and after engraftment (15-25 days post-HSCT). RESULTS: We evaluated 50 patients; 42% were male and 58% had undergone allogeneic HSCT. Most patients were <55 years old (68%) and had normal body mass index (50%). We found a significant reduction of right and left muscle thickness (P < .001) and echogenicity (P = .002) after engraftment compared with baseline. Our elderly patients had significantly bigger right-thigh muscle thickness (P = .02) and more VF (P = .009). The following data were higher in obese patients: right and left muscle thickness (P < .001), VF (P = .003), and echogenicity (P = .04). Death in the first 100 days had a positive association with obesity (P = 0.001) and VF (P = .002). VF was the only variable independent of HSCT type and age in mortality risk. CONCLUSION: Obesity and VF had an important impact in mortality. US could be a useful tool and strategy for evaluating body composition in HSCT patients.

Monitoring self-reported adherence to antiretroviral therapy in public HIV care facilities in Brazil: A national cross-sectional study.

INTRODUCTION: Patient adherence to antiretroviral therapy (ART) is critical for HIV treatment success. Monitoring rates of adherence in public HIV outpatient care facilities can improve outcomes in Brazil where ART is universally available. METHODS: We conducted a national cross-sectional survey of ART adherence in 2010. Participants were selected using a multistage probability sample. First, HIV outpatient care facilities were stratified according to 7 Organizational Quality Classification (OQC) groups and regions. Second, 1 or 2 facilities were selected per region for each OQC group. Finally, patients were randomly selected at each facility. In a first component, patients were invited to answer to a web-based questionnaire (WebAd-Q), a validated self-reported tool that includes 3 questions on adherence to ART in the past 7 days (time scheduling-timing, drug regimen-medication, and pill counts-dose), herein named indicators of potential nonadherence (IPN). In addition, a subsample of participants were interviewed in order to obtain further data on sociodemographic and clinical characteristics (second component). The proportion of each IPN was estimated using weighted data to account for the sampling design with 95% confidence interval (CI) and descriptive analysis was carried out. RESULTS: Fifty-five facilities were chosen and 2424 patients completed the WebAd-Q in the first component of the study, while 598 patients were interviewed for the second component. The weighted proportions of the IPN were 50.9%, 31.8%, and 19.5%, for timing, medication, and dose, respectively, while11.7% had all 3 indicators, varying from 5.9% in the Southeast and 21.9% in the Northeast regions. Overall, 61.1% of the patients had at least 1 IPN (95% CI: 58.5-63.7%). Patients reporting depression symptoms, illicit drug use and those who missed medical appointments had worse nonadherence outcomes. CONCLUSIONS: Overall, there was a high proportion of all indicators IPN and timing was the main component associated with low adherence. Although these indicators may not necessarily indicate individual nonadherence, they represent a worrisome scenario in the public Brazilian HIV care facilities. On a routine basis, these facilities can identify gaps in providing counseling and ART orientation to their clientele and develop innovative strategies to prevent nonadherence.

Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans.

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.

Thromboelastometry versus standard coagulation tests versus restrictive protocol to guide blood transfusion prior to central venous catheterization in cirrhosis: study protocol for a randomized controlled trial.

BACKGROUND: Liver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far. The aim of this study is to compare three transfusion strategies (routine coagulation test-guided - ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis. METHODS/DESIGN: Design and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil. INCLUSION CRITERIA: adults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis. DISCUSSION: This study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02311985 . Retrospectively registered on 3 December 2014.

Lifetime use of illicit drugs and associated factors among Brazilian schoolchildren, National Adolescent School-based Health Survey (PeNSE 2012).

OBJECTIVE: This study aimed at describing the prevalence of illicit drug use among 9th grade students in the morning period of public and private schools in Brazil, and assessing associated factors. METHOD: The Brazilian survey PeNSE (National Adolescent School-based Health Survey) 2012 evaluated a representative sample of 9th grade students in the morning period, in Brazil and its five regions. The use of illicit drugs at least once in life was assessed for the most commonly used drugs, such as marijuana, cocaine, crack, solvent-based glue, general ether-based inhalants, ecstasy and oxy. Data were subjected to descriptive analysis, and Pearson's χ² test and logistic regression was used in the multivariate analysis. RESULTS: The use of illicit drugs at least once in life was reported by 7.3% (95%CI 5.3 - 9.4) of the respondents. Logistic regression was used for multivariate analysis and the evidences suggest that illicit drug use is associated to social conditions of greater consumption power, the use of alcohol and tobacco, behaviors related to socialization, such as having friends or sexual activity, and also the perception of loneliness, loose contact between school and parents and experiences of abuse in the family environment. The outcome was inversely associated with close contact with parents and parental supervision. CONCLUSION: In addition to the association with the processes of socialization and consumption, the influence of family and school is expressed in a particularly protective manner in different records of direct supervision and care.

Psychoactive substance use, family context and mental health among Brazilian adolescents, National Adolescent School-based Health Survey (PeNSE 2012).

OBJECTIVE: To evaluate the association between the consumption of psychoactive substances (tobacco, alcohol and illicit drugs) and demographic variables, mental health and family context among school-aged children. METHODS: The National Adolescent School-based Health Survey was held with a national sample of 109,104 students. Data regarding demographic variables, family background and mental health were collected. Logistic regression was used to evaluate the associations of interest. RESULTS: Multivariate analyses showed that alcohol consumption was higher among girls, drug experimentation was more frequent among boys and that there was no difference between sexes for smoking. Being younger and mulatto were negatively associated with the use of tobacco, alcohol and illicit drugs. Also negatively associated with such risk behaviors were characteristics of the family context represented by: living with parents, having meals together and parental supervision (when parents know what the child does in their free time). Moreover, characteristics of mental health such as loneliness and insomnia were positively associated with use of tobacco, alcohol and illicit drugs. Not having friends was positively associated with use of tobacco and illicit drugs and negatively associated with alcohol use. CONCLUSIONS: The study shows the protective effect of family supervision in the use of tobacco, alcohol and drugs and, on the contrary, the increasing use of substances according to aspects of mental health, such as loneliness, insomnia and the fact of not having friends. The study's findings may support actions from health and education professionals, as well as from the government and families in order to prevent the use of these substances by adolescents.

Bullying and associated factors among Brazilian adolescents: analysis of the National Adolescent School-based Health Survey (PeNSE 2012).

OBJECTIVE: To estimate the prevalence of bullying from the victim's perspective in Brazilian school children and to analyze its association with individual and family context variables. METHODS: An analysis of the data on 109,104 adolescents, obtained by the National Adolescent School-based Health Survey, held in schools in 2012, was carried out. An association model between bullying and explanatory variables was tested in different contexts: sociodemographic, risk behaviors, mental health and family context. Univariate and multivariate analyzes were performed, calculating the Odds Ratio and confidence intervals. RESULTS: The prevalence of bullying found in this study was of 7.2% (95%CI 6.6 - 7.8). A higher chance of bullying was found among male students (OR = 1.58; 95%CI 1.51 - 1.66), with an inverse relation between age and bullying, with the magnitude of risk among adolescents younger than 13 years of age being higher when compared to those with 16 years of age or more. Of individual risk behaviors, only being a smoker remained in the final model (OR = 1.11; 95%CI 1.01 - 1.23). Mental health variables associated with bullying were: feeling lonely (OR = 2.66; 95%CI 2.52 - 2.81), insomnia (OR = 1.92; 95%CI 1.80 - 2.05), not having friends (OR = 1.71; 95%CI 1.54 - 1.89), and, in the family context, those who skip class without telling their parents (OR = 1.13; 95%CI 1,07 - 1,19) and those who suffer physical abuse by family members (OR = 2.03; 95%CI 1.91 - 2.146). CONCLUSION: Bullying was associated to male students, younger, of black color, smokers, with mental health vulnerabilities and victims of domestic violence. This suggests the need for a holistic approach from education and health professionals, parents and the community in seeking measures for the prevention of bullying.

Situations of violence experienced by students in the state capitals and the Federal District: results from the National Adolescent School-based Health Survey (PeNSE 2012).

OBJECTIVE: To describe violent events experienced by school-aged adolescents in school, around the school and in the family context, and to compare the results of the National Adolescent School-based Health Survey of 2009 and 2012. METHODS: Indicators related to violence involving teenagers were analyzed. The prevalence rates and confidence intervals of 95% were calculated for events of interest according to gender and type of school (public or private) and regions. RESULTS: Prevalence rates were: insecurity in the route between home-school (9.1%), insecurity in school (8.0%), physical assault in the last 12 months (18.2%), engaging in fights in the last 12 months (20.7%), fighting with a cold weapon (8.3%), fighting with firearms (6.9%), physical assault by a family member (11.6%) and having been seriously injured in the last 12 months (10.3%). The situations of violence were more prevalent among male students from public schools. The comparison with the 2009 survey showed increased prevalence in all the variables studied. CONCLUSION: Teenagers are exposed to different forms of violence, and the data from the National Survey of School Health can support the planning of preventive actions.

Factors associated with injuries in adolescents, from the National Adolescent School-based Health Survey (PeNSE 2012).

OBJECTIVE: To estimate the prevalence of injuries among teenagers and to examine the associated risk factors, such as sociodemographic characteristics, risk behaviors, family ties and other factors. METHOD: The prevalence of the outcome (injury) was estimated with a 95%confidence interval. In order to verify factors associated with the injury, a bivariate analysis was made with estimated odds ratio (OR) and its respective confidence intervals. Then, a multivariate analysis was carried out, only with variables whose descriptive level was equal to or lower than 5% (p < 0.05) remaining in the model. RESULTS: The study of injury in adolescents, based on the data from the National Adolescent School-based Health Survey (PeNSE), pointed out that 10.3% of the teenagers suffered severe injuries in the past 12 months, such as cuts or perforations, broken bones or dislocated joints. The following variables remained independently associated with "suffering severe injuries": being a male teenager; black, mulatto or indigenous race/color and working. Factors related to family ties are significant when the relations are fragile amongst members: adolescents that are injured the most are the ones who suffer most aggressions at home, who skip classes without notifying their parents, those who do not live with their parents and have low family control. The most relevant aspects of mental health are insomnia and loneliness. The factors associated to the exposure to situations of violence that remained in the model were: insecurity in school and in the route home-school; getting a ride with someone inebriated; drinking and driving motorized vehicles; not wearing the seatbelt; not wearing a helmet and being bullied. Among the factors of individual behavior, the following can be emphasized: use of alcohol, cigarettes, trying illicit drugs and early sexual intercourse. CONCLUSION: The analysis of the determinants for suffering injuries in childhood and adolescence shows the complex relationship between associated factors, which points to the need for action towards several aspects to reduce social inequalities, strengthen family ties and prevent violent contexts and individual risk factors.

Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians.

BACKGROUND: Focused echocardiographic examinations performed by intensivists and emergency room physicians can be a valuable tool for diagnosing and managing the hemodynamic status of critically ill children. The aim of this study was to evaluate the learning curve achieved using a theoretical and practical training program designed to enable pediatric intensivists and emergency physicians to conduct targeted echocardiograms. METHODS: Theoretical and practical training sessions were conducted with 16 pediatric intensivist/emergency room physicians. The program included qualitative analyses of the left ventricular (LV) and right ventricular (RV) functions, evaluation of pericardial effusion/cardiac tamponade and valvular regurgitation and measurements of the distensibility index of the inferior vena cava (dIVC), ejection fraction (EF) and cardiac index (CI). The practical training sessions were conducted in the intensive care unit; each student performed 24 echocardiograms. The students in training were evaluated in a practical manner, and the results were compared with the corresponding examinations performed by experienced echocardiographers. The evaluations occurred after 8, 16 and 24 practical examinations. RESULTS: The concordance rates between the students and echocardiographers in the subjective analysis of the LV function were 81.3% at the first evaluation, 96.9% at the second evaluation and 100% at the third evaluation (p < 0.001). For the dIVC, we observed a concordance of 46.7% at the first evaluation, 90.3% at the second evaluation and 87.5% at the third evaluation (p = 0.004). The means of the differences between the students' and echocardiographers' measurements of the EF and CI were 7% and 0.56 L/min/m2, respectively, after the third stage of training. CONCLUSIONS: The proposed training was demonstrated to be sufficient for enabling pediatric physicians to analyze subjective LV function and to measure dIVC, EF and CI. This training course should facilitate the design of other echocardiography training courses that could be implemented in medical residency programs to improve these physicians' technical skills and the care of critically ill patients.

[Hyperhomocysteinemia in children and adolescents with systemic lupus erythematosus: evolutive evaluation]. / Hiperhomocisteinemia em crianças e adolescentes com lúpus eritematoso sistêmico: avaliação evolutiva.

INTRODUCTION: One of the mechanisms implicated in the pathogenesis of coronary heart disease in patients with juvenile systemic lupus erythematosus (SLE) is the hyperhomocysteinemia. Our aim was to follow patients with juvenile SLE and to identify the presence and the persistence of hyperhomocysteinemia. METHODS: We studied 18 patients with juvenile SLE (median age 13.5 y). A survey of demographic and clinic data was performed based on patients records. The plasma homocysteine concentration was performed twice with a median interval of 1.5 years (1.3-2.5) and association with nutritional status, disease activity, renal involvement and use of methotrexate was sought. The plasma homocysteine concentration was also evaluated in 59 healthy controls, sex and age-matched to the patients. RESULTS: Of the 18 patients with juvenile SLE, 16 (88.9%) were female and 13 (72.2%) had renal involvement. Five out of 18 patients (27.8%) persisted with increased concentration of plasma homocysteine (above the 90th percentile of the healthy group). The elevated concentration of homocysteine did not show statistically significant association neither with renal involvement (in the first dosage, p=0.676 and in the second, p=0.500), disease activity (in the first dosage, p=0.630 and in the second, p=0.182), overweight/obesity (in the first dosage, p=0.485 and in the second, p=0.288) nor with short stature (in the first dosage, p=0.202 and in the second, p=0.500). CONCLUSION: This study emphasizes the persistence of elevated concentration of homocysteine in some patients with juvenile SLE and the need for evaluations of therapeutic strategies and nutritional education aiming to reduce risk factors of cardiovascular disease.