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PURPOSE: This study aimed to assess the impact of a bundle of care strategy on the duration of awake prone positioning (AW-PP) and other key clinical outcomes in patients with acute respiratory failure (ARF) who require high-flow nasal oxygen (HFNO). METHODS: In this secondary analysis of a prospective, multicenter cohort study, we included patients admitted with COVID-19-related ARF who required HFNO. The protocol encouraged AW-PP for as long as possible. The main exposure was a bundle of care including light sedation, monitoring, and information to patients about the strategy (bundle) compared to no bundle (control). The primary outcome was the duration of AW-PP (hours/day), while secondary outcomes included endotracheal intubation and in-hospital mortality. Directed acyclic graphs (DAGs) were employed to identify variables related to both exposure and outcomes. Four models were used to evaluate exposure-outcome associations: inverse probability of treatment weighting (IPTW), "double-robust" approximation (DR), traditional regression (TR), and mixed-effects model (MEM). RESULTS: Out of 499 patients, 197 were exposed to bundle, and 302 did not. The exposure group had a median (IQR) AW-PP duration of 16 (10-18) hours/day, compared to 10 (7-14) hours/day in the control group. Regression coefficients (95% CI) were 3.39 (1.67-5.11), 3.35 (1.55-5.14), 3.95 (2.63-5.28), and 3.72 (2.5-4.94) for IPTW, DR, TR and MEM, respectively. The odds ratios (95% CI) for intubation were 0.34 (0.15-0.76), 0.23 (0.10-0.50), 0.42 (0.23-0.77), and 0.48 (0.16-0.49), and for in-hospital mortality were 0.38 (0.11-1.27), 0.43 (0.14-1.26), 0.47 (0.22-0.91), and 0.46 (0.12-1.43) in the respective models. CONCLUSION: In the evaluated population of patients with COVID-19-related ARF, implementing a bundle-of-care strategy was associated with a longer AW-PP exposure and a reduced risk of endotracheal intubation. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov. Identifier NCT05178212. Date of registration: January 5th, 2022. STUDY TYPE: Observational.
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COVID-19 , Pacotes de Assistência ao Paciente , Posicionamento do Paciente , Humanos , Masculino , Feminino , Decúbito Ventral/fisiologia , Pessoa de Meia-Idade , COVID-19/terapia , COVID-19/complicações , Estudos Prospectivos , Idoso , Pacotes de Assistência ao Paciente/métodos , Pacotes de Assistência ao Paciente/normas , Posicionamento do Paciente/métodos , Mortalidade Hospitalar , Vigília/fisiologia , Intubação Intratraqueal/métodos , Síndrome do Desconforto Respiratório/terapia , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , SARS-CoV-2RESUMO
BACKGROUND: The COVID-19 pandemic has resulted in a critical shortage of respiratory ventilators, highlighting the urgent need to explore alternative treatment options for patients with acute respiratory distress syndrome (ARDS) caused by respiratory viruses, as an alternative to invasive mechanical ventilation (IMV) in future pandemics. OBJECTIVES: The objective of this study was to assess the effectiveness of alternative noninvasive oxygenation and ventilation strategies in comparison to invasive mechanical ventilation (IMV) in patients with virus-induced acute respiratory failure (ARF). The primary outcome was the all-cause ICU mortality rate. METHODS: A systematic review was conducted following the Cochrane guidelines and PRISMA reporting guidelines. The search encompassed databases such as Medline, Cochrane CENTRAL, and Embase to identify relevant indexed literature. Additionally, gray literature was included by consulting regulatory agencies. The included studies compared various oxygenation and ventilatory alternatives, such as high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), or noninvasive mechanical ventilation (NIMV) with IMV. An exploratory meta-analysis was performed by calculating the risk ratio (RR) by random effects and meta-regression to explore possible sources of heterogeneity and to compare ventilatory alternatives against IMV to reduce mortality, length of stay (LOS) days in ICU, nosocomial infection, and barotrauma. RESULTS: A total of forty-seven studies were included in this systematic review. NIMV had an RR of 0.70 (0.58-0.85), HFNC had an RR of 0.54 (0.42-0.71), and CPAP had an RR of 0.80 (0.71-0.90), with meta-regression models that reduced heterogeneity to 0%. For LOS days in ICU, NIMV had 0.38 (- 0.69: - 0.08) lower days and HFNC 0.29 (- 0.64: 0.06) lower days with meta-regression models that reduction heterogeneity to 0% for HFNC and 50% for NIMV. Not enough studies reported nosocomial infection or barotrauma to evaluate them in a meta-analysis. The overall quality of evidence, as assessed by GRADE evaluation, was determined to be from very low to medium certainty depending on the ventilatory strategy and outcome. CONCLUSIONS: The findings of this systematic review support the use of alternative noninvasive oxygenation and ventilation strategies as viable alternatives to conventional respiratory ventilation for managing viral-induced ARF. Although it is essential to interpret these findings with caution given the overall low to medium certainty of the evidence, the integration of these modalities as part of the management strategies of these patients could help reduce the utilization of ICU beds, invasive ventilators, and costs in both developed and developing countries.
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COVID-19 , Ventilação não Invasiva , Humanos , COVID-19/terapia , COVID-19/complicações , Ventilação não Invasiva/métodos , Síndrome do Desconforto Respiratório/terapia , Respiração Artificial/métodos , SARS-CoV-2 , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Unidades de Terapia Intensiva , Pressão Positiva Contínua nas Vias Aéreas/métodosRESUMO
Respiratory viruses, including SARS-CoV-2, influenza, parainfluenza, rhinovirus, and respiratory syncytial virus (RSV), are pathogens responsible for lower respiratory tract infections, particularly in vulnerable populations such as children and the elderly. Upon infection, these viruses are recognized by pattern recognition receptors, leading to the activation of inflammasomes, which are essential for mediating inflammatory responses. This review discusses the mechanisms by which these RNA respiratory viruses activate inflammasomes, emphasizing the roles of various signaling pathways and components involved in this process. Additionally, we highlight the specific interactions between viral proteins and inflammasome sensors, elucidating how these viruses manipulate the host immune response to facilitate infection. Understanding the dynamics of inflammasome activation in response to respiratory viruses provides critical insights for developing immunomodulatory therapeutic strategies aimed at mitigating inflammation and improving outcomes in respiratory tract infections.
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Inflamassomos , Vírus de RNA , Infecções Respiratórias , Humanos , Inflamassomos/metabolismo , Inflamassomos/imunologia , Infecções Respiratórias/imunologia , Infecções Respiratórias/virologia , Infecções Respiratórias/terapia , Animais , Vírus de RNA/imunologia , Vírus de RNA/fisiologia , Transdução de Sinais , Infecções por Vírus de RNA/imunologia , Receptores de Reconhecimento de Padrão/metabolismo , COVID-19/imunologia , COVID-19/virologia , COVID-19/terapia , Interações Hospedeiro-Patógeno/imunologia , SARS-CoV-2/imunologia , SARS-CoV-2/fisiologiaRESUMO
BACKGROUND: Patients with chronic kidney disease (CKD) have many special needs in the areas of symptom management, advanced care planning, and end-of-life care. We aimed to evaluate the palliative care (PC) provided to patients with CKD admitted with severe coronavirus disease 2019 (COVID-19) at the Clinics Hospital of the University of Sao Paulo Faculty of Medicine during the first wave of the pandemic. METHODS: A retrospective observational study was conducted in a quaternary hospital. Patients assisted by the PC team with CKD in 2020 were selected according to a protocol for identifying patient at an elevated risk of death who require PC support. The clinical and demographic characteristics, as well as the outcomes, were assessed using electronic records. RESULTS: A total of 217 patients with CKD were included in the study, of whom 44.2% were admitted to the intensive care unit (ICU). Patients with CKD had an increased relative risk (RR) of death [1.31, 95% confidence interval (CI): 1.12-1.53] but were not assisted by the PC team to a higher degree. Eighty patients with CKD (83.3%) died without being assisted by the PC team. Dialysis treatment and CKD grades were not significantly associated with PC assistance. CONCLUSIONS: Although patients with CKD experienced higher mortality rates, they did not receive PC at a significantly greater frequency and many died without receiving adequate end-of-life care during the COVID-19 pandemic in Brazil.
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COVID-19 , Cuidados Paliativos , Insuficiência Renal Crônica , Humanos , COVID-19/epidemiologia , COVID-19/terapia , Estudos Retrospectivos , Masculino , Feminino , Brasil/epidemiologia , Idoso , Pessoa de Meia-Idade , Insuficiência Renal Crônica/terapia , Insuficiência Renal Crônica/epidemiologia , SARS-CoV-2 , Pandemias , Idoso de 80 Anos ou mais , AdultoRESUMO
BACKGROUND: Rapid progression of symptoms and development of Acute Respiratory Distress Syndrome (ARDS) frequently occurred during COVID-19 pandemic, while CT-Scan was useful to assess severity of lung damage, with classic patterns like early Ground Glass Opacity and/or late consolidation. Likewise, lung injury has been related to activation of the coagulation-fibrinolysis systems and pro-inflammatory mediators; where D-Dimer acquires prognostic relevance. The present study aimed to evaluate whether the extent of lung involvement and pattern of lung injury, as determined by chest CT-scan, are related with D-Dimer; and further impact clinical prognosis in patients with ARDS due to COVID-19. METHODS: Longitudinal, prospective, observational, multi-center study. Patients diagnosed with ARDS due to COVID-19, without previous lung damage, clotting disorder and/or anticoagulants use, who were attended at the Intensive Care Unit and Internal Medicine Department from March to June 2020. Tomographic extent of lung involvement was analyzed by image software, as well as damage patterns, assessed by experienced radiologists. Endpoints included relation of lung injury with coagulopathy markers like D-Dimer, and prognostic outcome including mortality, mechanical ventilation and hospitalization time. RESULTS: One-hundred and four patients mean aged 55 years old, 66% males, main comorbidities obesity, hypertension and diabetes mellitus. Larger lung damage was associated with older age, male gender and higher pro-inflammatory mediators like leukocytes and ferritin; whilst consolidation pattern was related to higher Body Mass Index. Higher values of D-Dimer were related either to a larger extent of lung involvement or late consolidation pattern. In addition, the extent of lung involvement was related with longer hospital stay, higher requirement of mechanical ventilation (HR 0.12, p < 0.01) and mortality rate (HR 0.13, p < 0.01); whereas late consolidation was mainly associated with requirement of mechanical ventilation (HR 0.23, p < 0.01). CONCLUSION: Tomographic extent of lung involvement and the pattern of lung injury are related with coagulopathy severity markers like D-Dimer, and own prognostic clinical ability in ARDS.
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COVID-19 , Produtos de Degradação da Fibrina e do Fibrinogênio , Síndrome do Desconforto Respiratório , Tomografia Computadorizada por Raios X , Humanos , COVID-19/complicações , COVID-19/sangue , COVID-19/mortalidade , COVID-19/terapia , Masculino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Feminino , Pessoa de Meia-Idade , Estudos Prospectivos , Síndrome do Desconforto Respiratório/sangue , Idoso , Prognóstico , Estudos Longitudinais , SARS-CoV-2 , Pulmão/diagnóstico por imagem , Pulmão/patologia , Respiração Artificial , Adulto , Biomarcadores/sangueRESUMO
BACKGROUND: Cirrhosis has been pointed out as a clinical entity that leads to worse clinical prognosis in COVID-19 patients. However, this concept is controversial in the literature. We aimed to evaluate clinical outcomes by comparing patients with cirrhosis to those without cirrhosis in a Brazilian cohort. METHODS: Data from 20,164 COVID-19 inpatients were collected from 41 hospitals in Brazil between March to September 2020 and March 2021 to August 2022. We compared 117 patients with cirrhosis to 632 matched controls. A propensity score model was used to adjust for potential confounding variables, incorporating some predictors: age, sex at birth, number of comorbidities, hospital of admission, whether it was an in-hospital clinical manifestation of COVID-19, and admission year. Closeness was defined as being within 0.16 standard deviations of the logit of the propensity score. RESULTS: The median age was 61 (IQR 50-70) years old, and 63.4% were men. There were no significant differences in the self-reported symptoms. Patients with cirrhosis had lower median hemoglobin levels (10.8 vs. 13.1 g/dl), lower platelets (127,000 vs. 200,000 cells/mm3), and leukocyte counts, as well as lower median C-reactive protein (63.0 vs. 76.0 p = 0.044) when compared to controls. They also had higher mortality compared to matched controls (51.3% vs. 21.7%, p < 0.001). They also had higher frequencies of admission in an intensive care unit (51.3% vs. 38.0%, p = 0.007), invasive mechanical ventilation (43.9% vs. 26.6%, p < 0.001), dialysis (17.9% vs. 11.1%, p = 0.038), septic shock (23.9% vs. 14.9%; p = 0.015) and institution of palliative care (19.7% vs. 7.4%; p < 0.001). CONCLUSIONS: This study has shown that COVID-19 inpatients with cirrhosis had significantly higher incidence of severe outcomes, as well as higher frequency of institution of palliative care when compared to matched controls. Our findings underscore the need for these patients to receive particular attention from healthcare teams and allocated resources.
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COVID-19 , Cirrose Hepática , Pontuação de Propensão , SARS-CoV-2 , Humanos , COVID-19/mortalidade , COVID-19/epidemiologia , COVID-19/complicações , COVID-19/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Brasil/epidemiologia , Cirrose Hepática/mortalidade , Cirrose Hepática/epidemiologia , Idoso , Estudos de Coortes , Hospitalização/estatística & dados numéricos , Prognóstico , ComorbidadeRESUMO
INTRODUCTION: Acute kidney injury (AKI) in the setting of COVID-19 is associated with worse clinical and renal outcomes, with limited long-term data. AIM: To evaluate critically ill COVID-19 patients with AKI that required nephrologist consultation (NC-AKI) in a tertiary hospital. METHODS: Prospective single-center cohort of critically ill COVID-19 adult patients with NC-AKI from May 1st, 2020, to April 30th, 2021. Kidney replacement therapy (KRT), recovery of kidney function, and death at 90-day and 1-year follow-up were evaluated. RESULTS: 360 patients were included, 60.6% were male, median age was 66.0 (57.0-72.0) years, 38.1% had diabetes, and 68.6% had hypertension. AKI stages 1, 2, and 3 were detected in 3.6%, 5.6%, and 90.8% of patients, respectively. KRT was indicated in 90% of patients. At the 90-day follow-up, 88.1% of patients died and 10.0% had recovered kidney function. Female gender (p = 0.047), older age (p = 0.047), AKI stage 3 (p = 0.005), requirement of KRT (p < 0.0001), mechanical ventilation (p < 0.0001), and superimposed bacterial infection (p < 0.0001) were significantly associated death within 90 days. At 1 year, mortality was 89.3%. Amongst surviving patients, 72% recovered kidney function, although with significantly lower eGFR compared to baseline (85.5 ± 23.6 vs. 65.9 ± 24.8 mL/min, p = 0.003). CONCLUSION: Critically ill COVID-19 patients with NC-AKI presented a high frequency of AKI stage 3 and KRT requirement, with a high 90-day mortality. Surviving patients had high rates of recovery of kidney function, with a lower eGFR at one-year follow-up compared to baseline.
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Injúria Renal Aguda , COVID-19 , Estado Terminal , Centros de Atenção Terciária , Humanos , Injúria Renal Aguda/terapia , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/etiologia , Masculino , Feminino , COVID-19/complicações , COVID-19/mortalidade , COVID-19/terapia , Pessoa de Meia-Idade , Centros de Atenção Terciária/estatística & dados numéricos , Idoso , Estudos Prospectivos , Terapia de Substituição Renal , SARS-CoV-2 , Fatores de Tempo , Recuperação de Função FisiológicaRESUMO
BACKGROUND: Despite many years of investigation into mesenchymal stem cells (MSCs) and their potential for treating inflammatory conditions such as COVID-19, clinical outcomes remain variable due to factors like donor variability, different tissue sources, and diversity within MSC populations. Variations in MSCs' secretory and proliferation profiles, and their proteomic and transcriptional characteristics significantly influence their therapeutic potency, highlighting the need for enhanced characterization methods to better predict their efficacy. This study aimed to evaluate the biological characteristics of MSCs from different tissue origins, selecting the most promising line for further validation in a K18-hACE2 mouse model of SARS-CoV-2 infection. METHODS: We studied nine MSC lines sourced from either bone marrow (hBMMSC), dental pulp (hDPMSC), or umbilical cord tissue (hUCMSC). The cells were assessed for their proliferative capacity, immunophenotype, trilineage differentiation, proteomic profile, and in vitro immunomodulatory potential by co-culture with activated lymphocytes. The most promising MSC line was selected for further experimental validation using the K18-hACE2 mouse model of SARS-CoV-2 infection. RESULTS: The analyzed cells met the minimum criteria for defining MSCs, including the expression of surface molecules and differentiation capacity, showing genetic stability and proliferative potential. Proteomic analysis revealed distinct protein profiles that correlate with the tissue origin of MSCs. The immunomodulatory response exhibited variability, lacking a discernible pattern associated with their origin. In co-culture assays with lymphocytes activated with anti-CD3/CD28 beads, all MSC lines demonstrated the ability to inhibit TNF-α, to induce TGF-ß and Indoleamine 2,3-dioxygenase (IDO), with varying degrees of inhibition observed for IFN-γ and IL-6, or induction of IL-10 expression. A module of proteins was found to statistically correlate with the potency of IL-6 modulation, leading to the selection of one of the hUCMSCs as the most promising line. Administration of hUCMSC to SARS-CoV-2-infected K18 mice expressing hACE2 was effective in improving lung histology and modulating of a panel of cytokines. CONCLUSIONS: Our study assessed MSCs derived from various tissues, uncovering significant variability in their characteristics and immunomodulatory capacities. Particularly, hUCMSCs demonstrated potential in mitigating lung pathology in a SARS-CoV-2 infection model, suggesting their promising therapeutic efficacy.
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COVID-19 , Modelos Animais de Doenças , Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais , SARS-CoV-2 , Animais , Células-Tronco Mesenquimais/metabolismo , Células-Tronco Mesenquimais/citologia , COVID-19/terapia , COVID-19/virologia , COVID-19/imunologia , COVID-19/patologia , COVID-19/metabolismo , Camundongos , Humanos , Transplante de Células-Tronco Mesenquimais/métodos , Diferenciação Celular , Enzima de Conversão de Angiotensina 2/metabolismo , Enzima de Conversão de Angiotensina 2/genética , Proliferação de Células , Polpa Dentária/citologia , Polpa Dentária/metabolismo , Polpa Dentária/virologia , Citocinas/metabolismoRESUMO
Premature dropout from psychotherapy can harm patients and increase mental health costs. This study identified predictors of dropout in brief online psychotherapy for essential workers during the COVID-19 pandemic. This was a secondary analysis of a randomized trial on 4-week CBT or IPT protocols. Participants provided sociodemographic data and completed the Patient-Reported Outcomes Measurement Information System and Burnout Assessment Tool Short-Form. Predictors were analyzed in three blocks: sociodemographic, clinical, and therapist characteristics using bivariable and multivariable analyses. The sample included 804 individuals who attended at least the first session of either CBT (n = 403) or IPT (n = 401). A total of 17.2% (n = 138) of the participants dropped out during the protocol. Significant predictors of dropout included having children (IRR = 1.48; 95% CI: 1.07-2.05; p = 0.016), residing in specific regions of Brazil (Northeast IRR = 1.44; 95% CI:1.04-2.00; p = 0.02 and Midwest IRR = 1.73; 95%CI: 1.13-2.64; p = 0.01), therapist male sex (IRR = 2.04; 95% CI: 1.47-2.83; p = < 0.001), second wave of Covid-19 (IRR = 1.54; 95% CI: 1.01-2.34; p = 0.04) and low life satisfaction (IRR = 1.63; 95% CI: 1.06-2.50; p = 0.02). Our findings underscore the necessity for culturally tailored strategies, support for those with children, and targeted therapy for individuals with low life satisfaction. Implementation of these strategies may reduce dropout rates and improve treatment outcomes for essential workers in crisis.
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COVID-19 , Terapia Cognitivo-Comportamental , Pacientes Desistentes do Tratamento , Humanos , COVID-19/psicologia , COVID-19/epidemiologia , COVID-19/terapia , Masculino , Feminino , Terapia Cognitivo-Comportamental/métodos , Adulto , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Pacientes Desistentes do Tratamento/psicologia , Pessoa de Meia-Idade , SARS-CoV-2/isolamento & purificação , Psicoterapia Breve/métodos , Brasil/epidemiologia , Pandemias , Pessoal de Saúde/psicologiaRESUMO
OBJECTIVE: To compare pre-extubation physiological characteristics and ultrasound variables between patients intubated for COVID-19 compared to a clinical population and those intubated for other reasons. METHODS: This was a secondary analysis of a prospective cohort study of patients undergoing invasive mechanical ventilation (IMV) for more than 48 h. Patients were divided into two groups: those intubated for COVID-19-induced ARDS and those intubated for other clinical reasons. Ultrasound assessment of lung and diaphragm function was performed before extubation. The results were compared between the two groups of patients. RESULTS: In comparison with the patients without COVID-19, those with the disease were younger (a median age of 58 [46-76] years vs. a median age of 75 [69-85] years; p = 0.01), had fewer comorbidities (a median Charlson Comorbidity Index of 2 [1-4] vs. a median Charlson Comorbidity Index of 5 [4-6]; p < 0.01), and were less severely ill at admission (a median APACHE II score of 9 [8-14] vs. a median APACHE II score of 18 [13-22]; p < 0.01). In addition, the median duration of IMV was longer in the COVID-19 patients (11 [9-23] days vs. 6 [3-8] days; p < 0.01). Although extubation success rates were similar between the COVID-19 and non-COVID-19 groups (22 [71%] vs. 35 [77.8%]), median lung ultrasound score differed between the two groups (23 [18-25] vs. 15 [11-18]; p < 0.01), as did median diaphragmatic excursion (2.1 [1.7-2.4] vs. 1.7 [1.2-2.0]; p < 0.01). CONCLUSIONS: Although patients with COVID-19 requiring ventilatory support are younger and have fewer comorbidities than those intubated for other clinical reasons, they experience longer hospital stays. Although lung ultrasound score can differ between patients with and without COVID-19, these differences do not significantly translate into extubation success rates. Therefore, the utility of ultrasound scores in weaning COVID-19 patients from IMV needs further study.
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COVID-19 , Diafragma , Pulmão , Respiração Artificial , Ultrassonografia , Desmame do Respirador , Humanos , COVID-19/diagnóstico por imagem , COVID-19/terapia , COVID-19/complicações , Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Pessoa de Meia-Idade , Masculino , Feminino , Idoso , Estudos Prospectivos , Ultrassonografia/métodos , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , Idoso de 80 Anos ou mais , SARS-CoV-2 , ExtubaçãoRESUMO
OBJECTIVE: This study compared the outcomes of two cohorts of patients with coronavirus disease 2019 (COVID-19) who received COVID-19 convalescent plasma transfusions between 2020 and 2021. METHODS: This retrospective study was conducted at a tertiary hospital in São Paulo, Brazil. We included a retrospective cohort of patients who received convalescent compassionate plasma, and another group of patients from a previous clinical study. We collected clinical and laboratory data on the day of and 5 days after transfusion. Patients with hematological or immunological conditions were excluded. Statistical significance was set at p<0.05. RESULTS: COVID-19 convalescent plasma did not affect the outcomes of patients with severe COVID-19 when comparing the two cohorts transfused with different volumes and titers of neutralizing antibodies. Despite improvements in some laboratory parameters, no effect on clinical outcomes was observed. Dialysis negatively affected the length of intensive care unit stay, hospitalization, and mechanical ventilation use. Each higher point on the day 0 World Health Organization scale reduced the probability of hospital and intensive care unit discharge and the risk of mechanical ventilation discontinuation. CONCLUSION: Dialysis and the assessed clinical severity represented by the World Health Organization scale on day 0 influenced the outcomes, whereas COVID-19 convalescent plasma transfusion did not.
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Soroterapia para COVID-19 , COVID-19 , Imunização Passiva , Índice de Gravidade de Doença , Humanos , COVID-19/terapia , Imunização Passiva/métodos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Brasil , Resultado do Tratamento , Idoso , SARS-CoV-2/imunologia , Adulto , Respiração Artificial/estatística & dados numéricos , Respiração Artificial/métodos , Tempo de Internação/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricosRESUMO
This study compared the efficacy and tolerability of three enteral formulas in critically ill patients with COVID-19 who were ventilated and in the prone position: (a) immunomodulatory (IMM), (b) ω3 and (c) maltodextrins (MD). Primary outcome was the percentage of patients who received both 80 % of their protein and calorie targets at 3 d after enrolment. Secondary, mechanical ventilation-free time, ICU mortality and markers of nutritional status. Tolerance of enteral nutrition was evaluated by diarrhoea and gastroparesis rate. A total of 231 patients were included, primary outcome achieved was in ω3 group (76·5 % v. 59·7 and 35·2 %, P < 0·001) v. IMM and MD groups. Mechanical ventilation-free time was longer in ω3 and MD groups: 23·11 (sd 34·2) h and 22·59 (sd 42·2) h v. 7·9 (sd 22·6) h (P < 0·01) in IMM group. Prealbumin final was 0·203 ± 0·108 g/L and 0·203 ± 0·095 g/L in IMM and ω3 groups v 0·164 ± 0·070 g/L (p < 0·01) MD group. Transferrin were 1·515 ± 0·536 g/L and 1·521 ± 0·500 g/L in IMM and ω3 groups v 1·337 ± 0·483 g/L (p < 0·05) MD group. Increase of lymphocytes was greater in ω3 group: 1056·7 (sd 660·8) cells/mm3v. 853·3 (sd 435·9) cells/mm3 and 942·7 (sd 675·4) cells/mm3 (P < 0·001) in IMM and MD groups. Diarrhoea and gastroparesis occurred in 5·1 and 3·4 %, respectively. The findings of this study indicate that enteral nutrition is a safe and well-tolerated intervention. The ω3 formula compared with IMM and MD did improve protein and calorie targets.
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COVID-19 , Estado Terminal , Nutrição Enteral , Estado Nutricional , Humanos , Nutrição Enteral/métodos , Estado Terminal/terapia , Masculino , Feminino , COVID-19/terapia , COVID-19/complicações , Pessoa de Meia-Idade , Idoso , SARS-CoV-2 , Respiração Artificial , Polissacarídeos , Resultado do Tratamento , Ácidos Graxos Ômega-3/administração & dosagem , Gastroparesia/terapia , Diarreia/terapia , Unidades de Terapia IntensivaRESUMO
INTRODUCTION: Post-COVID-19 condition, or syndrome, also known as long COVID, is an infection-associated chronic condition that can develop after a SARS-CoV-2 infection and last at least 3 months to years. Despite representing a high burden for the Unified Health System (SUS), which has affected millions of Brazilians, it has received limited attention in Brazil. Prevalence studies to date have failed to include a broad representation of the population, and there has been insufficient exploration of the impact on people's lives and the burden of and barriers to accessing health services. This article presents the research protocol for the quantitative component of a mixed methods project to produce evidence to inform SUS's provision of care for long COVID. The protocol was designed to study long COVID in SUS patients hospitalised for COVID-19 in a large city in Southeast Brazil to capture symptoms and factors associated with the syndrome, effects on quality of life and employment, health needs, use of health services and barriers to accessing necessary healthcare. METHODS AND ANALYSIS: An ambidirectional cohort study to capture data retrospectively and prospectively from adults previously discharged from SUS hospitals for COVID-19. The study involves up to two telephone surveys with the patients or proxies selected from a sampling plan for population estimates. Survey questions include baseline and follow-up data on demographic, socioeconomic, comorbidities, work status, health-related quality of life, vaccination status, long COVID symptoms, healthcare needs, use and barriers to access. Descriptive and appropriate multivariable analyses will be employed. ETHICS AND DISSEMINATION: The project was approved by the Research Ethics Committees of participant institutions and by the Brazilian National Research Ethics Commission. All participants provided verbal consent. We plan to publish articles in scientific journals and multimedia resources for SUS professionals and the general population.
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COVID-19 , Acessibilidade aos Serviços de Saúde , SARS-CoV-2 , Humanos , Brasil/epidemiologia , COVID-19/epidemiologia , COVID-19/terapia , Síndrome de COVID-19 Pós-Aguda , Necessidades e Demandas de Serviços de Saúde , Projetos de Pesquisa , Adulto , Qualidade de Vida , Estudos Retrospectivos , Estudos de CoortesRESUMO
PURPOSE: The optimal physiologic parameters to monitor after a session of awake prone positioning in patients with acute respiratory failure are not well understood. This study aimed to identify which early physiologic changes after the first session of awake prone positioning are linked to the need for invasive mechanical ventilation or death in patients with acute respiratory failure. METHODS: We performed a secondary analysis of a prospective cohort study of adult patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) treated with awake prone positioning. We assessed the association between relative changes in physiological variables (oxygenation, respiratory rate, pCO2 and respiratory rate-oxygenation [ROX] index) within the first 6 h of the first awake prone positioning session with treatment failure, defined as endotracheal intubation and/or death within 7 days. RESULTS: 244 patients [70 female (29%), mean age 60 (standard deviation [SD] 13) years] were included. Seventy-one (29%) patients experienced awake prone positioning failure. ROX index was the main physiologic predictor. Patients with treatment failure had lower mean [SD] ROX index at baseline [5 (1.4) versus 6.6 (2.2), p < 0.0001] and within 6 h of prone positioning [5.6 (1.7) versus 8.7 (2.8), p < 0.0001]. After adjusting for baseline characteristics and severity, a relative increase of the ROX index compared to baseline was associated with lower odds of failure [odds ratio (OR) 0.37; 95% confidence interval (CI) 0.25-0.54 every 25% increase]. CONCLUSION: Relative changes in the ROX index within 6 h of the first awake prone positioning session along with other known predictive factors are associated with intubation and mortality at day 7.
Assuntos
COVID-19 , Insuficiência Respiratória , Humanos , Decúbito Ventral/fisiologia , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Idoso , COVID-19/complicações , COVID-19/fisiopatologia , COVID-19/terapia , Insuficiência Respiratória/terapia , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/etiologia , Posicionamento do Paciente/métodos , Vigília/fisiologia , Respiração Artificial/métodos , Hipóxia/fisiopatologia , Hipóxia/terapia , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/fisiopatologia , Síndrome do Desconforto Respiratório/mortalidade , Intubação Intratraqueal/métodos , Intubação Intratraqueal/estatística & dados numéricos , Taxa Respiratória , SARS-CoV-2RESUMO
OBJECTIVE: To map the scientific evidence on the care offered to health service users with Long Covid-19. METHOD: This is a scoping review based on the methods of the Joanna Briggs Institute. Primary studies were included, in Portuguese, English and Spanish, published between December 2019 and June 2023, in the Virtual Health Library, Web of Science, Scopus, PUBMED, SciELO and LITCovid LongCovid databases. RESULTS: Of the ١٣ articles analyzed, it stands out that the care provided to patients with Long Covid is associated with drug prescription, indication of physical exercises, telerehabilitation and physiotherapy. CONCLUSION: A fragmentation was identified in the care provided to users of health services with Long Covid, with care directed only at isolated symptoms, without addressing the biopsychosocial care that people with this condition need.
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COVID-19 , Humanos , COVID-19/terapia , Atenção à Saúde/organização & administração , Síndrome de COVID-19 Pós-Aguda , Modalidades de Fisioterapia , Telerreabilitação/organização & administraçãoRESUMO
INTRODUCTION: The type of admission to the Intensive Care Unit (ICU) influences the prognosis of patients with severe pneumonia and, in the case of patients with COVID-19 pneumonia, this is still unexplored. The objective of this study was to determine the differences between early and late ICU admission. METHODOLOGY: A retrospective cohort study of patients with COVID-19 pneumonia at two high-complexity hospitals in Colombia. Early ICU admission (EICUA) was defined as direct admission from the emergency department or within the first 24 hours of admission. Late ICU admission (LICUA) was defined as admission from the hospitalization service after 24 hours of arrival. A robust Cox regression was performed for the variable recovery time, to determine the impact of the ICU admission type in the hazard rate. RESULTS: 68.2% were EICUA patients and 31.8% were LICUA patients. Recovery and duration of hospital stay were significantly lower in EICUA than in LICUA (9 vs 15 days, p = 0.0001, and 10 vs 15.5 days, p < 0.0001, respectively). However, the duration of ICU stay (7 vs 9 days, p = 0.131) and the invasive mechanical ventilation requirement (48.9% vs 54.9%, p = 0.374) were not statistically significant. The 30-day follow-up showed no difference between the EICUA and LICUA (alive 97% vs 94.6%, p = 0.705). CONCLUSIONS: Mortality between EICUA and LICUA patients with COVID-19 pneumonia showed no statistically significant differences. However, the recovery time, the probability intensity of instant recovery, and the duration of hospital stay were better in EICUA than in LICUA. Neither EICUA nor LICUA affects the final status (death) of patients.
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COVID-19 , Unidades de Terapia Intensiva , Tempo de Internação , Humanos , COVID-19/mortalidade , COVID-19/terapia , Estudos Retrospectivos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Colômbia/epidemiologia , Idoso , Tempo de Internação/estatística & dados numéricos , SARS-CoV-2 , Admissão do Paciente/estatística & dados numéricos , Fatores de Tempo , Respiração Artificial/estatística & dados numéricos , Adulto , Prognóstico , Hospitalização/estatística & dados numéricosRESUMO
BACKGROUND: COVID-19 is associated with prolonged disability, particularly after critical illness. This study aimed to assess and compare disability post-hospital discharge of subjects who were invasively ventilated versus those who were not, following ICU admission due to COVID-19. This study also explored variables associated with long-term disability. METHODS: In this prospective cohort study, subjects with COVID-19 who received invasive ventilation, noninvasive ventilation, or high-flow nasal cannula during ICU stay were assessed with the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 at 3 and 6 months post-hospital discharge. Data were analyzed collectively and stratified as subjects with and without invasive mechanical ventilation. Analysis of variance and multiple regression analyses were applied. RESULTS: The subjects (N = 43) were mainly male, middle age, and overweight. Subjects who were invasively ventilated (n = 21) had decreased physical function compared to those who were not during hospital assessments. From 3-6 months after discharge, all WHODAS domains and the overall score decreased in both groups (P < .001), indicating disability recovery. The participation domain, which assesses joining in society, was the only domain that remained worse in the ventilation group compared to the no ventilation group (P = .01). No interaction was found between time and the study groups, suggesting that the recovery trajectory was similar. At 6 months, considering the entire cohort, 70% and 56% had no disability in self-care and getting along domains, respectively, while 42% exhibited moderate to severe disability in the participation domain. According to the overall WHODAS score, 86% of subjects still had some level of disability at 6 months. In multivariate analyses, the overall WHODAS score along with the household and participation domains showed significant positive correlations, indicating higher disability, with corticosteroid use. CONCLUSIONS: Disability persisted at 6 month post-hospital discharge for ICU survivors of COVID-19, regardless of the need for invasive mechanical ventilation. Participation was the only domain that showed higher disability among those who received invasive ventilation.
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COVID-19 , Avaliação da Deficiência , Unidades de Terapia Intensiva , Respiração Artificial , Sobreviventes , Humanos , COVID-19/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Prospectivos , Sobreviventes/estatística & dados numéricos , Idoso , SARS-CoV-2 , Estado Terminal , Alta do PacienteRESUMO
Death processes have been progressively transferred to hospital spaces due to biomedicalization and the use of technologies, generating important challenges for healthcare systems. The COVID-19 pandemic exposed the lack of unified criteria and principles for a dignified death in the hospital. This study corresponds to a narrative review using Higgins & Green's methodological framework as a reference. A systematized search was carried out with the question: What are the elements considered in the decision-making of hospital teams regarding access and use of life support technology and dying processes in adult critically ill patients? The searches conducted during October 2022 in MEDLINE/PubMed, Scopus, Science Direct, CINAHL, Biblioteca Virtual en Salud (BVS), Cochrane Library, and Scielo identified 1499 records for screening, and 148 were retrieved for full-text review. Eighty-four articles were included in the review, identifying seven categories. The evidence shows variability in decision-making associated with the clinical status of the patient, the criteria of the medical professional, added to structural elements of the health system and political-legal aspects. The literature recommends reflexive, dynamic, flexible, and individualized decision-making processes that consider the patient's preferences, clinical judgment, prognosis, and available resources. Communication, advance care planning, interdisciplinary discussions, external consultations, and the involvement of ethical committees are crucial throughout the process.
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COVID-19 , Tomada de Decisão Clínica , Estado Terminal , Cuidados para Prolongar a Vida , Assistência Terminal , Adulto , Humanos , COVID-19/mortalidade , COVID-19/terapia , Estado Terminal/mortalidade , Estado Terminal/terapia , Tomada de Decisões , Pandemias , Equipe de Assistência ao PacienteRESUMO
Convalescent Plasma (CP) from patients who recovered from COVID-19 may present neutralizing antibodies against viral protein S of SARS-CoV-2 and emerged as a potential therapeutic alternative for patients with severe infection at the beginning of the COVID-19 pandemic breakout. Thus, this study aimed to evaluate the effect and safety of CP treatment in patients with severe COVID-19. METHODS: We designed a quasi-experimental study that included 156 patients with SARS-CoV-2 infection confirmed by RT-qPCR and severe symptoms who received CP. As a control group, we selected a historical cohort of 113 individuals admitted with COVID-19 and severe symptomatology before the starting date of the study. Clinical status and mortality during the study period were recorded. RESULTS: There were no adverse reactions to CP administration. In the CP group, days on mechanical ventilation were significantly lower than the control group (2.8±5.08 days vs. 4.7±6.19 days; p= 0.0081). Moreover, a significant difference was observed in the number of days stayed in the critical patient unit (CPU) in CP vs. controls (4.2±5.47 vs. 5.8±6.39 days, p= 0.0281). CONCLUSIONS: We observed no association between CP administration and survival at 14 days. Treatment with CP was safe and not associated with adverse events. In addition, using CP was associated with a reduction in both stay at the CPU and connection to mechanical ventilation.
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Soroterapia para COVID-19 , COVID-19 , Imunização Passiva , SARS-CoV-2 , Humanos , COVID-19/terapia , Imunização Passiva/métodos , Imunização Passiva/efeitos adversos , Masculino , Chile/epidemiologia , Feminino , Projetos Piloto , Pessoa de Meia-Idade , SARS-CoV-2/imunologia , Índice de Gravidade de Doença , Idoso , Adulto , Pandemias , Resultado do Tratamento , Respiração Artificial/estatística & dados numéricosRESUMO
OBJECTIVE: To compare the effectiveness of the awake-prone position on relevant clinical outcomes in patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen between different waves in Argentina. METHODS: This multicenter, prospective cohort study included adult patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen. The main exposure position was the awake-prone position (≥ 6 hours/day) compared to the non-prone position. The primary outcome was endotracheal intubation, and the secondary outcome was in-hospital mortality. The inverse probability weighting-propensity score was used to adjust the conditional probability of treatment assignment. We then adjusted for contextual variables that varied over time and compared the effectiveness between the first and second waves. RESULTS: A total of 728 patients were included: 360 during the first wave and 368 during the second wave, of whom 195 (54%) and 227 (62%) remained awake-prone for a median (p25 - 75) of 12 (10 - 16) and 14 (8 - 17) hours/day, respectively (Awake-Prone Position Group). The ORs (95%CIs) for endotracheal intubation in the Awake-Prone Position Group were 0.25 (0.13 - 0.46) and 0.19 (0.09 - 0.31) for the first and second waves, respectively (p = 0.41 for comparison between waves). The ORs for in-hospital mortality in the awake-prone position were 0.35 (0.17 - 0.65) and 0.22 (0.12 - 0.43), respectively (p = 0.44 for comparison between waves). CONCLUSION: The awake-prone position was associated with a reduction in the risk of endotracheal intubation and in-hospital mortality. These effects were independent of the context in which the intervention was applied, and no differences were observed between the different waves.