Epidemiología de COVID-19 en un hospital de tercer nivel mexicano / COVID-19 epidemiology in a Mexican tertiary care hospital

Resumen Introducción: A consecuencia de COVID-19, numerosos hospitales sufrieron una reconversión para la atención de esta enfermedad. Objetivo: Analizar el comportamiento epidemiológico hospitalario de COVID-19 entre marzo y agosto de 2020. Métodos: En una serie de casos se analizó el comportamiento epidemiológico de COVID-19 en un hospital de tercer nivel, para lo cual se estimaron frecuencias simples de casos, porcentajes e incidencia por cada 100 egresos hospitalarios. Resultados: De 491 sujetos con prueba positiva para SARS-CoV-2, 156 (31.7 %) fueron hospitalizados por datos clínicos de enfermedad moderada a grave. La edad promedio fue de 59.1 años; 121 casos (75 %) egresaron por mejoría y 32 (20.5 %), por defunción. El promedio de edad de quienes fallecieron fue de 69.7 años y el grupo etario más afectado fue el de 60 a 80 años (45.4 %). La letalidad calculada fue de 20.5 por 100 egresos hospitalarios, mientras que la calculada tomando en cuenta los pacientes positivos (ambulatorios y hospitalizados) fue de 6.5. Conclusiones: El comportamiento epidemiológico de COVID-19 fue similar al descrito en otros estudios; sin embargo, la letalidad y la mortalidad están por encima de la media nacional. Está pendiente el análisis de estas y de los factores que las favorecieron en nuestra población.

Abstract Introduction: As a result of COVID-19, many hospitals underwent a conversion for the care for this disease Objective: To analyze COVID-19 hospital epidemiological behavior from March to August 2020. Methods: Through a series of cases, COVID-19 epidemiological behavior at the hospital was analyzed, for which simple case rates, percentages and incidence of COVID-19 per 100 hospital discharges were estimated. Results: Out of 491 subjects who tested positive for SARS-CoV-2, 156 (31.7 %) were hospitalized for clinical data of moderate to severe disease. Average age was 59.1 years; 121 cases (75 %) were discharged due to improvement, and 32 (20.5 %), due to death. Average age of those who died was 69.7 years, and the most affected age group was 60 to 80 years (45.4 %). Calculated lethality was 20.5 per 100 hospital discharges, while that calculated taking into account positive patients (outpatients and hospitalized patients) was 6.5. Conclusions: COVID-19 epidemiological behavior was similar to that described in other studies; however, lethality and mortality are above national average. The analysis of this and of the factors that favored it in our population is pending.

Determinantes sociales de la salud asociados a la severidad y mortalidad en pacientes con COVID-19 / Social determinants of health associated with severity and mortality in patients with COVID-19

Resumen Introducción: Históricamente, las pandemias han tenido como resultado tasas de mortalidad más altas en las poblaciones más vulnerables. Los determinantes sociales de la salud (DSS) se han asociado a la morbimortalidad de las personas en diferentes niveles. Objetivo: Determinar la relación entre los DSS, la severidad de COVID-19 y la mortalidad por esta enfermedad. Métodos: Estudio retrospectivo en el que se recolectaron datos de pacientes con COVID-19 en un hospital público de Chile. Las variables sociodemográficas relacionadas con los DSS estructurales se clasificaron según las siguientes categorías: sexo, edad (< 65 años, ≥ 65 años), educación secundaria (completada o no), condición de trabajo (activo, inactivo) e ingreso económico (< USD 320, ≥ USD 320). Resultados: Fueron incluidos 1012 casos con COVID-19 confirmados por laboratorio. La edad promedio fue de 64.2 ± 17.5 años. La mortalidad de la muestra total fue de 14.5 %. La edad, nivel educativo, desempleo e ingresos tuvieron fuerte asociación con la mortalidad (p < 0.001). Conclusiones: Los hallazgos refuerzan la idea de que los DSS deben considerarse una prioridad de salud pública, por lo que los esfuerzos políticos deben centrarse en reducir las desigualdades en salud para las generaciones futuras.

Abstract Introduction: Historically, pandemics have resulted in higher mortality rates in the most vulnerable populations. Social determinants of health (SDH) have been associated with people morbidity and mortality at different levels. Objective: To determine the relationship between SDH and COVID-19 severity and mortality. Methods: Retrospective study, where data from patients with COVID-19 were collected at a public hospital in Chile. Sociodemographic variables related to structural SDH were classified according to the following categories: gender, age (< 65 years, ≥ 65 years), secondary education (completed or not), work status (active, inactive) and income (< USD 320, ≥ USD 320). Results: A total of 1,012 laboratory-confirmed COVID-19 cases were included. Average age was 64.2 ± 17.5 years. Mortality of the entire sample was 14.5 %. Age, level of education, unemployment and income had a strong association with mortality (p < 0.001). Conclusions: The findings reinforce the idea that SDH should be considered a public health priority, which is why political efforts should focus on reducing health inequalities for future generations.

Scenario of elective colorectal oncology surgeries during the COVID-19 pandemic / Cenário das cirurgias colorretais oncológicas eletivas em meio à pandemia de COVID-19

The COVID-19 pandemic has changed the world health scenario, causing numerous problems related to the overload of services. In this scenario, the approach to oncological diseases becomes a challenge, considering the risk of progression of cancer disease and death due to delay in diagnosis and treatment. Faced with this exceptional situation, coloproctology services have been forced to change their routine to adapt to the new reality, considering risks and benefits in the conduct of these patients. Thus, the experience of the coloproctology service at the Santa Casa de São Paulo, São Paulo, state of São Paulo, Brazil, during the beginning of the COVID-19 pandemic is described, evaluating the possibility of maintaining elective oncological surgeries through selection by directed anamnesis. Method: Retrospective cohort study with prospective collection comparing colorectal surgery for cancer before and during the pandemic from December 2019 to July 2020. Results: In total, 81 patients were included. During the pandemic, 41 patients were operated on with 2 perioperative contaminations by COVID-19. Both length of stay and complications were not different between groups. Conclusion: Since there was no increase in COVID-19 morbidity and mortality in elective oncology surgeries with patients screened for guided anamnesis, it is worth considering this method for maintaining surgical procedures even in the event of apandemic. (AU)

A pandemia do COVID-19 modificou o cenário mundial da saúde, ocasionando inúmeros problemas relacionados à sobrecarga dos serviços. Neste contexto, a abordagem das doenças oncológicas se tornou um desafio, tendo em vista que o atraso no diagnóstico e no tratamento oncológico resulta emmaior risco de progressão de doença e óbito. Frente a esta situação excepcional, os serviços de coloproctologia foram obrigados a mudar a rotina, considerando riscos e benefícios na condução dos pacientes. Assim, descreve-se a experiência do serviço de coloproctologia da Santa Casa de São Paulo, São Paulo, SP, Brasil, durante o início da pandemia de COVID-19, avaliando a possibilidade de manutenção das cirurgias eletivas oncológicas através da seleção por anamnese dirigida. Método: Coorte retrospectiva com coleta prospectiva comparando cirurgias colorretais oncológicas realizadas de dezembro de 2019 a julho de 20202, comparando casos operados antes e durante a pandemia. Resultados: No total, 81 pacientes foram incluídos. Durante a pandemia, 41 pacientes foram operados, com duas contaminações perioperatórias por COVID-19. Nem o tempo de internação nem as complicações foram diferentes entre os grupos. Conclusão: Uma vez que não houve aumento da morbimortalidade por COVID-19 nas cirurgias oncológicas eletivas com pacientes triados por anamnese dirigida, vale considerar este método para a manutenção dos procedimentos cirúrgicos mesmo em vigência da pandemia. (AU)

Subfenótipos baseados em dados clínicos de beira-leito de pacientes críticos com COVID-19: um estudo de coorte / Bedside clinical data subphenotypes of critically ill COVID-19 patients: a cohort study

RESUMO Objetivo: Identificar apresentações mais graves de COVID-19. Métodos: Pacientes consecutivamente admitidos à unidade de terapia intensiva foram submetidos à análise de clusters por meio de método de explorações sequenciais Resultados: Analisamos os dados de 147 pacientes, com média de idade de 56 ± 16 anos e Simplified Acute Physiological Score 3 de 72 ± 18, dos quais 103 (70%) demandaram ventilação mecânica e 46 (31%) morreram na unidade de terapia intensiva. A partir do algoritmo de análise de clusters, identificaram-se dois grupos bem definidos, com base na frequência cardíaca máxima [Grupo A: 104 (IC95% 99 - 109) batimentos por minuto versus Grupo B: 159 (IC95% 155 - 163) batimentos por minuto], frequência respiratória máxima [Grupo A: 33 (IC95% 31 - 35) respirações por minuto versus Grupo B: 50 (IC95% 47 - 53) respirações por minuto] e na temperatura corpórea máxima [Grupo A: 37,4 (IC95% 37,1 - 37,7)ºC versus Grupo B: 39,3 (IC95% 39,1 - 39,5)ºC] durante o tempo de permanência na unidade de terapia intensiva, assim como a proporção entre a pressão parcial de oxigênio no sangue e a fração inspirada de oxigênio quando da admissão à unidade de terapia intensiva [Grupo A: 116 (IC95% 99 - 133) mmHg versus Grupo B: 78 (IC95% 63 - 93) mmHg]. Os subfenótipos foram distintos em termos de perfis inflamatórios, disfunções orgânicas, terapias de suporte, tempo de permanência na unidade de terapia intensiva e mortalidade na unidade de terapia intensiva (com proporção de 4,2 entre os grupos). Conclusão: Nossos achados, baseados em dados clínicos universalmente disponíveis, revelaram dois subfenótipos distintos, com diferentes evoluções de doença. Estes resultados podem ajudar os profissionais de saúde na alocação de recursos e seleção de pacientes para teste de novas terapias.

Abstract Objective: To identify more severe COVID-19 presentations. Methods: Consecutive intensive care unit-admitted patients were subjected to a stepwise clustering method. Results: Data from 147 patients who were on average 56 ± 16 years old with a Simplified Acute Physiological Score 3 of 72 ± 18, of which 103 (70%) needed mechanical ventilation and 46 (31%) died in the intensive care unit, were analyzed. From the clustering algorithm, two well-defined groups were found based on maximal heart rate [Cluster A: 104 (95%CI 99 - 109) beats per minute versus Cluster B: 159 (95%CI 155 - 163) beats per minute], maximal respiratory rate [Cluster A: 33 (95%CI 31 - 35) breaths per minute versus Cluster B: 50 (95%CI 47 - 53) breaths per minute], and maximal body temperature [Cluster A: 37.4 (95%CI 37.1 - 37.7)°C versus Cluster B: 39.3 (95%CI 39.1 - 39.5)°C] during the intensive care unit stay, as well as the oxygen partial pressure in the blood over the oxygen inspiratory fraction at intensive care unit admission [Cluster A: 116 (95%CI 99 - 133) mmHg versus Cluster B: 78 (95%CI 63 - 93) mmHg]. Subphenotypes were distinct in inflammation profiles, organ dysfunction, organ support, intensive care unit length of stay, and intensive care unit mortality (with a ratio of 4.2 between the groups). Conclusion: Our findings, based on common clinical data, revealed two distinct subphenotypes with different disease courses. These results could help health professionals allocate resources and select patients for testing novel therapies.

SARS-CoV-2 infection in a pediatric patient with cystic fibrosis / Infección por SARS-CoV-2 en un paciente pediátrico con fibrosis quística

Abstract Background: Cystic fibrosis (CF) is a potentially mortal disease characterized by a chronic pulmonary disease with persistent airway infection. Children with this disease are more susceptible to respiratory infections due to the limitation in mucociliary transport and anatomical disruption of the bronchial tree. SARS-CoV-2 causes COVID-19, a respiratory illness related to exacerbations of chronic pulmonary pathologies in children, such as CF and asthma. There are not enough case reports on pediatric patients with SARS-CoV-2 infection and CF, for which we share our experience. Case report: A 22-month-old male patient diagnosed with CF presented in the hospital with cough, fever, and increased respiratory work. The patient received supplemental oxygen and antibiotic and antiviral therapy. Positive results for type B influenza and RT-PCR (reverse transcription-polymerase chain reaction) for SARS-CoV-2 were obtained. Due to the persistence of respiratory difficulty, high-flow therapy was initiated, with a good response. After an episode of hypoxemia, bradycardia, and increased respiratory work secondary to accumulated secretions, orotracheal intubation and invasive mechanical ventilation were performed. The patient evolved with clinical and gasometric improvement. After 10 days of in-hospital antibiotic management with adequate clinical evolution, the patient was discharged to complete oral treatment and home isolation. Conclusions: We present a case of chronic respiratory disease and SARS-CoV-2 infection with severity criteria in a pediatric patient. The evolution was favorable with timely support management and antibiotic therapy in a third-level hospital.

Resumen Introducción: La fibrosis quística es una afección potencialmente mortal caracterizada por enfermedad pulmonar crónica con infección persistente de las vías aéreas. Los niños con esta enfermedad son más susceptibles a infecciones respiratorias debido a la limitación en el transporte mucociliar y la distorsión anatómica del árbol bronquial. El SARS-CoV-2 (coronavirus tipo 2 del síndrome agudo respiratorio grave) es el virus causante de la COVID-19, enfermedad respiratoria que puede estar relacionada con exacerbaciones de patologías pulmonares crónicas en niños, como la fibrosis quística y el asma. No hay suficientes reportes de casos de pacientes pediátricos con infección por SARS-CoV-2 y fibrosis quística, por lo cual se comparte la presente experiencia. Caso clínico: Paciente de sexo masculino de 22 meses de edad con diagnóstico de fibrosis quística que presentó tos, fiebre y aumento en el trabajo respiratorio. A su ingreso se inició manejo con oxígeno suplementario y tratamiento antibiótico y antiviral. Se obtuvo prueba positiva para influenza tipo B y para SARS-CoV-2 por RT-PCR (reacción en cadena de la polimerasa de transcriptasa inversa). Ante un episodio de hipoxemia, bradicardia y mayor trabajo respiratorio, requirió intubación orotraqueal y ventilación mecánica invasiva. El paciente evolucionó con mejoría clínica y gasométrica. Después de 10 días de manejo antibiótico intrahospitalario, con adecuada evolución clínica, egresó para completar tratamiento por vía oral y aislamiento en casa. Conclusiones: Se presenta el caso de un paciente pediátrico con enfermedad respiratoria crónica de base e infección por SARS-CoV-2 con criterios de gravedad. El paciente evolucionó favorablemente con el manejo de soporte oportuno y terapia de antibióticos en un hospital de tercer nivel.

Isquemia arterial aguda de membros superiores em pacientes diagnosticados com COVID-19: série de casos / Acute upper limb arterial ischemia in patients diagnosed with COVID-19: case series

Resumo A infecção pelo coronavírus 2 causador da síndrome respiratória aguda grave (SARS-CoV-2) em humanos foi detectada pela primeira vez em Wuhan, na China, em 2019 e dispersada mundialmente ao longo de 2020. As diferentes manifestações clínicas, com amplo espectro de apresentação, desde infecções assintomáticas até formas graves que podem levar a óbito, são desafiadoras. Este trabalho objetiva descrever uma série de quatro casos de isquemia arterial aguda dos membros superiores em pacientes diagnosticados com COVID-19, os quais foram manejados clinicamente com anticoagulação, antiagregação plaquetária e uso de prostanoides. Dois pacientes receberam alta hospitalar com regressão e delimitação da área isquêmica, sem necessidade de intervenção cirúrgica, e dois pacientes faleceram em decorrência de complicações pulmonares. Uma adequada compreensão da fisiopatologia dessa doença pode favorecer um melhor manejo clínico de suas complicações.

Abstract Infection by coronavirus 2, cause of the severe acute respiratory syndrome (SARS-CoV-2) in humans, was detected for the first time in Wuhan, China, in 2019, and spread globally over the course of 2020. Its different clinical manifestations are challenging, with a wide spectrum of presentations, ranging from asymptomatic infections to severe forms that can result in death. The objective of this study is to describe a series of four cases of acute arterial ischemia involving the upper limbs in patients diagnosed with COVID-19, which were managed clinically with anticoagulation, platelet antiaggregation, and prostanoids. Two patients were discharged from hospital with regression and delimitation of the ischemic zone, without needing surgical intervention, while two patients died from pulmonary complications. Adequate understanding of the pathophysiology of this disease could support better clinical management of its complications.

Características clínicas e preditores de ventilação mecânica em pacientes com COVID-19 hospitalizados no sul do país / Clinical characteristics and predictors of mechanical ventilation in patients with COVID-19 hospitalized in Southern Brazil

RESUMO Objetivo: Descrever as características clínicas e os preditores de ventilação mecânica em pacientes adultos internados com COVID-19. Métodos: Conduziu-se um estudo de coorte retrospectiva com inclusão de pacientes hospitalizados entre 17 de março e 3 de maio de 2020, que tiveram o diagnóstico de infecção pelo SARS-CoV-2. As características clínicas e demográficas foram extraídas de registros em prontuário eletrônico. Resultados: Incluíram-se no estudo 88 pacientes consecutivos. A mediana da idade dos pacientes foi de 63 anos (IQR: 49 - 71); 59 (67%) pacientes eram do sexo masculino, 65 (86%) tinham educação universitária e 67 (76%) tinham, no mínimo, uma comorbidade. Dentre eles, 29 (33%) pacientes foram admitidos à unidade de terapia intensiva, 18 (20%) necessitaram de ventilação mecânica e nove (10,2%) morreram durante a hospitalização. O tempo mediano de permanência na unidade de terapia intensiva e o tempo mediano de ventilação mecânica foram, respectivamente, de 23 e 29,5 dias. Idade acima ou igual a 65 anos foi fator de risco independente para ventilação mecânica (RC: 8,4; IC95% de 1,3 - 55,6; valor de p = 0,02). Conclusão: Nossos achados descrevem a primeira onda de pacientes brasileiros hospitalizados por COVID-19. Em nossa população, idade foi o maior preditor de insuficiência respiratória e necessidade de ventilação mecânica.

Abstract Objective: This study aims to describe the clinical characteristics and predictors of mechanical ventilation of adult inpatients with COVID-19 in a single center. Methods: A retrospective cohort study was performed and included adult inpatients hospitalized from March 17th to May 3rd, 2020, who were diagnosed with SARS-CoV-2 infection. Clinical and demographic characteristics were extracted from electronic medical records. Results: Overall, 88 consecutive patients were included in this study. The median age of the patients was 63 years (IQR 49 - 71); 59 (67%) were male, 65 (86%) had a college degree and 67 (76%) had at least one comorbidity. Twenty-nine (33%) patients were admitted to the intensive care unit, 18 (20%) patients needed mechanical ventilation, and 9 (10.2%) died during hospitalization. The median length of stay in the intensive care unit and the median duration of mechanical ventilation was 23 and 29.5 days, respectively. An age ≥ 65 years was an independent risk factor for mechanical ventilation (OR 8.4 95%CI 1.3 - 55.6 p = 0.02). Conclusion: Our findings describe the first wave of Brazilian patients hospitalized for COVID-19. Age was the strongest predictor of respiratory insufficiency and the need for mechanical ventilation in our population.

Afectación respiratoria por coronavirus (COVID-19) / Respiratory involvement by coronavirus (COVID-19)

In December 2019, an epidemic of cases with unexplained lower respiratory infections detected in Wuhan, China was first reported to the WHO China Office. The respiratory picture presents in various ways, from asymptomatic or paucisymptomatic forms, to clinical conditions characterized by respiratory failure that require mechanical ventilation and support in the ICU, with multi-organ and systemic manifestations in terms of sepsis, septic shock and multiple organ dysfunction syndromes. The etiological agent was identified as a virus belonging to the coronavirus family (CoV) with a high contagion capacity that determined its rapid spread, triggering a pandemic with high morbidity and mortality. This review attempts to address the basics of this disease.