Multisystemic Infarctions in COVID-19: Focus on the Spleen.

The literature suggests that COVID-19 provokes arterial and venous thrombotic events, although the mechanism is still unknown. In this study, we describe patients with confirmed coronavirus infection associated with multisystemic infarction, focusing on splenic infarction. More data are required to elucidate how COVID-19 and thrombotic disease interact and so that preventive and early diagnosis strategies can be developed. LEARNING POINTS: Thrombotic disease as a complication of COVID-19 must be suspected by clinicians, and recognized and monitored by radiologists.Thrombosis is often the initial manifestation of SARS-CoV-2, hence the importance of early diagnosis to avoid complications and reduce morbidity and mortality.

Cancer patient management: Current use of next-generation sequencing in the EU TOP4.

BACKGROUND: Next-generation sequencing (NGS) is recognised by a growing audience of medical professionals as a functional diagnostic tool in oncology. However, adoption in clinical routine proceeds haphazardly in Europe. METHODS: A semi-structured interview survey was administered to 68 cancer care professionals in four EU countries between June-August and November-December 2021. Pre-screening questionnaires assessed sufficient NGS expertise, diverse geographical distribution, and professional roles. RESULTS: Our findings provide a better understanding of current clinical, regulatory, and reimbursement practices for NGS in four EU countries. CONCLUSIONS: Despite the impending European In-vitro Diagnostic Medical Devices Regulation (IVDR), tortuous national guidelines implementations and limping reimbursement policies are common traits across surveyed countries and produce disparity in access to advanced healthcare services amid regional distinctions. POLICY SUMMARY: The evident information gap between involved parties and demand for consistent national guidelines could be filled by health economics analyses tailored to local specifics to provide factual leverage for a structured adoption of NGS testing.

SARS-CoV-2 variants induce distinct disease and impact in the bone marrow and thymus of mice.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved to variants associated with milder disease. We employed the k18-hACE2 mouse model to study how differences in the course of infection by SARS-CoV-2 variants alpha, delta, and omicron relate to tissue pathology and the immune response triggered. We documented a variant-specific pattern of infection severity, inducing discrete lung and blood immune responses and differentially impacting primary lymphoid organs. Infections with variants alpha and delta promoted bone marrow (BM) emergency myelopoiesis, with blood and lung neutrophilia. The defects in the BM hematopoietic compartment extended to the thymus, with the infection by the alpha variant provoking a marked thymic atrophy. Importantly, the changes in the immune responses correlated with the severity of infection. Our study provides a comprehensive platform to investigate the modulation of disease by SARS-CoV-2 variants and underscores the impact of this infection on the function of primary lymphoid organs.

SARS-CoV-2 air and surface contamination in residential settings.

SARS-CoV-2 transmission occurs mainly indoors, through virus-laden airborne particles. Although the presence and infectivity of SARS-CoV-2 in aerosol are now acknowledged, the underlying circumstances for its occurrence are still under investigation. The contamination of domiciliary environments during the isolation of SARS-CoV-2-infected patients in their respective rooms in individual houses and in a nursing home was investigated by collecting surface and air samples in these environments. Surface contamination was detected in different contexts, both on high and low-touch surfaces. To determine the presence of virus particles in the air, two sampling methodologies were used: air and deposition sampling. Positive deposition samples were found in sampling locations above the patient's height, and SARS-CoV-2 RNA was detected in impactation air samples within a size fraction below 2.5 µm. Surface samples rendered the highest positivity rate and persistence for a longer period. The presence of aerosolized SARS-CoV-2 RNA occurred mainly in deposition samples and closer to symptom onset. To evaluate the infectivity of selected positive samples, SARS-CoV-2 viability assays were performed, but our study was not able to validate the virus viability. The presented results confirm the presence of aerosolized SARS-CoV-2 RNA in indoor compartments occupied by COVID-19 patients with mild symptoms, in the absence of aerosol-generating clinical procedures.

The (New) Civil Telemedicine Framework: Construction of a Healthy Regulatory Environment for New Telemedicine Practices / O (novo) marco civil da telemedicina: a construção de um ambiente regulatório saudável para as novas práticas telemédicas

O presente trabalho teve como objetivo principal fornecer subsídios para a regulamentação da telemedicina no Brasil. Com o advento da pandemia de covid-19, instrumentos normativos foram elaborados às pressas para regular a oferta de atenção médica a distância, com o uso de tecnologias da informação sincrônicas. Contudo, tanto a Lei da Telemedicina quanto a resolução do Conselho Federal de Medicina n. 2.227/2018 que a seguiu, autorizando o uso da telemedicina, foram omissas em relação às balizas e aos parâmetros que a oferta de serviços telemédicos deveriam seguir. Embora não seja propriamente um fenômeno novo no Brasil, a telemedicina historicamente se deu em um ambiente de forte insegurança jurídica. Esse cenário é deletério tanto para as empresas, que deixam de se capacitar para prestar serviços telemédicos, como para os pacientes, que se veem obrigados a desfrutar desses serviços em um ambiente pouco regulado e potencialmente lesivo. Com base nisso, este artigo elencou pontos sensíveis que merecem atenção do legislador e das partes interessadas para que haja regulamentação da telemedicina, incluindo temas como a relação telemédico-paciente, responsabilidade telemédica e das plataformas, prontuário telemédico eletrônico, entre outros. Essa regulamentação pode proporcionar mais segurança jurídica e clareza regulatória,apontando para a construção de um ambiente regulatório saudável para as novas práticas telemédicas.

The present work seeks to provide subsidies for the regulation of telemedicine in Brazil. With the outbreak of Covid-19, new normative instruments were created in a hurry to regulate the offer remote medical attention, with the use of synchronous information technologies. However, both the Brazilian Law on Telemedicine, and the Brazilian Federal Council of Medicine Regulation that followed it and authorized the use of telemedicine, were silent in relation to the limits and parameters applicable for the offer of telemedicine services. Although telemedicine services are not a new phenomenon in Brazil, they have historically been provided in an environment of strong legal uncertainty. This scenario is detrimental both for the companies that lose the opportunity to invest into capacities to offer these services, and for the patients who are obliged to use telemedicine services in a lightly regulated and potentially damaging regulatory environment. Based on these considerations, we present certain sensitive points that deserve further attention from legislators and main stakeholders concerning the regulation of telemedicine, including themes such as telephysician-patient relations, telephysician responsibility, electronic medical records, among others. The regulation of these topics can increase legal certainty and regulatory clarity and step into the Direction of the construction of a healthy regulatory environment for these new telemedicine practices.

Experimental and numerical evaluation of a new visor concept with aerodynamic sealing to protect medical professionals from contaminated droplets and aerosols.

The fast spreading of the SARS-CoV-2 virus led to a significant increase in the demand for personal protective equipment (PPE). Healthcare professionals, mainly dentists, work near the patients, increasing their risk of infection. This paper investigates the effectiveness of an air-curtain sealing effect in a newly designed visor developed to reduce the risk of contracting a respiratory infection. This PPE was developed by computational fluid dynamics (CFD) modeling. CFD results show that the aerodynamic sealing in this PPE device effectively protects the user's face by 43% from a contaminated environment. The experiments considered two different tests: one using a tracer gas (CO2 ) to simulate a gaseous contaminant inside and outside the PPE face shield and a second test using smoke to simulate aerosol transport and evaluate the PPE efficiency. The particle concentration within the aerodynamically sealed PPE was evaluated and compared with the protection efficiency of other PPE. Results show similar protection levels for particles in the 1-5 µm range between the prototype and a KN95 respirator. The combined use of this novel PPE with aerodynamic sealing and a physical mask (KN95 or surgical) produced protection efficiency values within the range of 57%-70% for particles greater than 0.5 µm. This study reveals the potential of using an air curtain combined with a face shield to reduce the risks from contaminated environments.

Soluble CD137 as a potential biomarker for severe COVID-19.

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly pathogenic infection responsible for the world pandemic in 2020. COVID-19 is characterized by an increased number of critically ill patients with a high risk of health care system collapse. Therefore, the search for severity biomarkers and potential therapies is crucial. In this study, we evaluated SARS-CoV-2 -induced cytokines, cytokines receptors and growth factors profile, in critical COVID-19 patients admitted in intensive care unit (ICU) aiming to identify potential biomarkers and therapeutic targets. We designed a prospective study enrolling 62 adults with severe COVID-19 during the first two Brazilian COVID-19 waves (from May to July 2020 and December 2020 to May 2021), convenience samples recruitment in first 24 hours and then, every 4 days until day 20 of ICU admission from a tertiary hospital in São Paulo, Brazil. Controls were healthy blood donors. Whole blood was used to evaluate 17 cytokines, cytokines receptors and growth factors. Due to low mortality rate, we used the need of mechanical ventilation as primary endpoint. In our analysis, we found a different pattern in soluble CD137 (sCD137) in critically ill patients with COVID-19, with a direct relationship between increased levels and worse clinical outcome. sCD137 was related with increased risk of mechanical ventilation and World Health Organization (WHO) clinical score for disease severity. CD137 is a tumor necrosis factor receptor (TNF) family member, mainly responsible for T-cell activation. Soluble isoforms of immune checkpoints competitively regulate function of their membrane-bound counterparts. Our study demonstrated the onward increase in sCD137 levels during severe SARS-CoV-2 infection and its correlation with worse outcomes, suggesting sCD137 as a potential reliable severity biomarker.

Common variable immunodeficiency and its inflammatory neurological manifestations: A case report and literature review.

BACKGROUND: Common variable immunodeficiency disorders (CVID) are a group of primary immunodeficiencies characterized by impaired immunoglobulin production and dysregulated immune response. Neurological manifestations have been described in a few patients, and little is known about its clinic and therapeutic approach. Thus, this work aimed to review the literature on it and to help differentiate CVID from its mimics, especially sarcoidosis. METHODS: We described a case report and included a literature review of inflammatory neurological involvement in CVID. RESULTS: A 32-year-old female patient with a medical history of recurrent bacterial infections, temporal focal epilepsy and granulomatous lung disease under study, and cervix squamous cell carcinoma, was initially admitted to the emergency department due to intracranial hypertension. After excluding infectious and neoplastic etiologies, the most likely hypothesis was that granulomatous pulmonary, cerebral, and leptomeningeal inflammatory involvement were associated with sarcoidosis. Two years later, a diagnosis of CVID was made, and the patient was secondarily diagnosed with Granulomatous and Lymphocytic Interstitial Lung Disease (GLILD) and related inflammatory brain disease - both complications of CVID. After starting targeted treatment with immunoglobulin replacement and pulse glucocorticoids followed by a chronic taper, the patient became stable. However, three consecutive failures in immunoglobulin intake during the COVID-19 pandemic led to disease recurrence with relapse of neurological manifestations. CONCLUSION: This case illustrates the complex multiple organ manifestations of CVID. When granulomatous conditions arise in these patients, a rare lung disease arising in the context of CVID, the GLILD disease with multisystem involvement, should be taken into consideration. Early treatment with combined steroids and immunotherapy seems to be effective in controlling CVID's neurological manifestations.

Differentially expressed plasmatic microRNAs in Brazilian patients with Coronavirus disease 2019 (COVID-19): preliminary results.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is known that host microRNAs (miRNAs) can be modulated to favor viral infection or to protect the host. Herein, we report preliminary results of a study aiming at identifying differentially expressed plasmatic miRNAs in Brazilian patients with COVID-19. METHODS AND RESULTS: miRNAs were extracted from the plasma of eight patients with COVID-19 (four patients with mild COVID-19 and four patients with severe/critical COVID-19) and four healthy controls. Patients and controls were matched for sex and age. miRNA expression levels were detected using high-throughput sequencing. Differential miRNA expression and enrichment analyses were further evaluated. A total of 18 miRNAs were differentially expressed between patients with COVID-19 and controls. miR-4433b-5p, miR-6780b-3p, miR-6883-3p, miR-320b, miR-7111-3p, miR-4755-3p, miR-320c, and miR-6511a-3p were the most important miRNAs significantly involved in the PI3K/AKT, Wnt/ß-catenin, and STAT3 signaling pathways. Moreover, 42 miRNAs were differentially expressed between severe/critical and mild patients with COVID-19. miR-451a, miR-101-3p, miR-185-5p, miR-30d-5p, miR-25-3p, miR-342-3p, miR-30e-5p, miR-150-5p, miR-15b-5p, and miR-29c-3p were the most important miRNAs significantly involved in the Wnt/ß-catenin, NF-κß, and STAT3 signaling pathways. CONCLUSIONS: If validated by quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) in a larger number of participants, the miRNAs identified in this study might be used as possible biomarkers for the diagnosis and severity of COVID-19.

Major Complex Trait for Early De Novo Programming 'CoV-MAC-TED' Detected in Human Nasal Epithelial Cells Infected by Two SARS-CoV-2 Variants Is Promising to Help in Designing Therapeutic Strategies.

BACKGROUND: Early metabolic reorganization was only recently recognized as an essentially integrated part of immunology. In this context, unbalanced ROS/RNS levels connected to increased aerobic fermentation, which is linked to alpha-tubulin-based cell restructuring and control of cell cycle progression, were identified as a major complex trait for early de novo programming ('CoV-MAC-TED') during SARS-CoV-2 infection. This trait was highlighted as a critical target for developing early anti-viral/anti-SARS-CoV-2 strategies. To obtain this result, analyses had been performed on transcriptome data from diverse experimental cell systems. A call was released for wide data collection of the defined set of genes for transcriptome analyses, named 'ReprogVirus', which should be based on strictly standardized protocols and data entry from diverse virus types and variants into the 'ReprogVirus Platform'. This platform is currently under development. However, so far, an in vitro cell system from primary target cells for virus attacks that could ideally serve for standardizing the data collection of early SARS-CoV-2 infection responses has not been defined. RESULTS: Here, we demonstrate transcriptome-level profiles of the most critical 'ReprogVirus' gene sets for identifying 'CoV-MAC-TED' in cultured human nasal epithelial cells infected by two SARS-CoV-2 variants differing in disease severity. Our results (a) validate 'Cov-MAC-TED' as a crucial trait for early SARS-CoV-2 reprogramming for the tested virus variants and (b) demonstrate its relevance in cultured human nasal epithelial cells. CONCLUSION: In vitro-cultured human nasal epithelial cells proved to be appropriate for standardized transcriptome data collection in the 'ReprogVirus Platform'. Thus, this cell system is highly promising to advance integrative data analyses with the help of artificial intelligence methodologies for designing anti-SARS-CoV-2 strategies.

From Plant Survival Under Severe Stress to Anti-Viral Human Defense - A Perspective That Calls for Common Efforts.

Reprogramming of primary virus-infected cells is the critical step that turns viral attacks harmful to humans by initiating super-spreading at cell, organism and population levels. To develop early anti-viral therapies and proactive administration, it is important to understand the very first steps of this process. Plant somatic embryogenesis (SE) is the earliest and most studied model for de novo programming upon severe stress that, in contrast to virus attacks, promotes individual cell and organism survival. We argued that transcript level profiles of target genes established from in vitro SE induction as reference compared to virus-induced profiles can identify differential virus traits that link to harmful reprogramming. To validate this hypothesis, we selected a standard set of genes named 'ReprogVirus'. This approach was recently applied and published. It resulted in identifying 'CoV-MAC-TED', a complex trait that is promising to support combating SARS-CoV-2-induced cell reprogramming in primary infected nose and mouth cells. In this perspective, we aim to explain the rationale of our scientific approach. We are highlighting relevant background knowledge on SE, emphasize the role of alternative oxidase in plant reprogramming and resilience as a learning tool for designing human virus-defense strategies and, present the list of selected genes. As an outlook, we announce wider data collection in a 'ReprogVirus Platform' to support anti-viral strategy design through common efforts.

ROS/RNS Balancing, Aerobic Fermentation Regulation and Cell Cycle Control - a Complex Early Trait ('CoV-MAC-TED') for Combating SARS-CoV-2-Induced Cell Reprogramming.

In a perspective entitled 'From plant survival under severe stress to anti-viral human defense' we raised and justified the hypothesis that transcript level profiles of justified target genes established from in vitro somatic embryogenesis (SE) induction in plants as a reference compared to virus-induced profiles can identify differential virus signatures that link to harmful reprogramming. A standard profile of selected genes named 'ReprogVirus' was proposed for in vitro-scanning of early virus-induced reprogramming in critical primary infected cells/tissues as target trait. For data collection, the 'ReprogVirus platform' was initiated. This initiative aims to identify in a common effort across scientific boundaries critical virus footprints from diverse virus origins and variants as a basis for anti-viral strategy design. This approach is open for validation and extension. In the present study, we initiated validation by experimental transcriptome data available in public domain combined with advancing plant wet lab research. We compared plant-adapted transcriptomes according to 'RegroVirus' complemented by alternative oxidase (AOX) genes during de novo programming under SE-inducing conditions with in vitro corona virus-induced transcriptome profiles. This approach enabled identifying a major complex trait for early de novo programming during SARS-CoV-2 infection, called 'CoV-MAC-TED'. It consists of unbalanced ROS/RNS levels, which are connected to increased aerobic fermentation that links to alpha-tubulin-based cell restructuration and progression of cell cycle. We conclude that anti-viral/anti-SARS-CoV-2 strategies need to rigorously target 'CoV-MAC-TED' in primary infected nose and mouth cells through prophylactic and very early therapeutic strategies. We also discuss potential strategies in the view of the beneficial role of AOX for resilient behavior in plants. Furthermore, following the general observation that ROS/RNS equilibration/redox homeostasis is of utmost importance at the very beginning of viral infection, we highlight that 'de-stressing' disease and social handling should be seen as essential part of anti-viral/anti-SARS-CoV-2 strategies.

Opinions, beliefs and knowledge of people with multiple sclerosis on COVID-19 pandemic and vaccine.

BACKGROUND: Considering the potential COVID-19 impact on pwMS health and the importance of vaccination for this population, we decided to assess: (a) pwMS' beliefs and knowledge on COVID-19 pandemic; (b) their acceptance towards COVID-19 vaccination and (c) pwMS' opinions on general vaccination. METHODS: Observational study, based on a cross-sectional (10-20th September 2020) online survey, conducted in a cohort of pwMS' followed at two Portuguese hospitals. The survey included measures to characterize the sample and a questionnaire designed to assess the topics defined for this study. RESULTS: 270 respondents completed the full survey (response rate 58.2%). pwMS greatest concern during the pandemic was an aggravation of MS, especially by patients older than 50 years old. Almost 40% of the patients older than 50 felt that the pandemic negatively affected their MS related medical assistance. Most patients believed they would recover from COVID-19 infection. More than half of the responders feared a MS aggravation if they got COVID-19; this was more pronounced in patients with progressive MS. About 12% of the participants did not want to be vaccinated and almost 40% was unsure. Regarding vaccines in general, almost a third of the participants feared their side effects or MS related complications. CONCLUSION: Having knowledge of pwMS' opinions on COVID-19 pandemic impact and vaccination is useful to better address these issues. Fears and expectations towards vaccination must be discussed with pwMS.

Patients with COVID-19 who experience a myocardial infarction have complex coronary morphology and high in-hospital mortality: Primary results of a nationwide angiographic study.

OBJECTIVES: We aimed to explore angiographic patterns and in-hospital outcomes of patients with concomitant coronavirus disease-19 (COVID-19) and myocardial infarction (MI). BACKGROUND: Patients with COVID-19 may experience MI during the course of the viral infection. However, this association is currently poorly understood. METHODS: This is a multicenter prospective study of consecutive patients with concomitant COVID-19 and MI who underwent coronary angiography. Quantitative and qualitative coronary angiography were analyzed by two observers in an independent core lab. RESULTS: A total of 152 patients were included, of whom 142 (93.4%) had COVID-19 diagnosis confirmation. The median time between symptom onset and hospital admission was 5 (1-10) days. A total of 83 (54.6%) patients presented with ST-elevation MI. The median angiographic Syntax score was 16 (9.0-25.3) and 69.0% had multi-vessel disease. At least one complex lesion was found in 73.0% of patients, 51.3% had a thrombus containing lesion, and 57.9% had myocardial blush grades 0/1. The overall in-hospital mortality was 23.7%. ST-segment elevation MI presentation and baseline myocardial blush grades 0 or 1 were independently associated with a higher risk of death (HR 2.75, 95%CI 1.30-5.80 and HR 3.73, 95%CI 1.61-8.61, respectively). CONCLUSIONS: Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition.

Alprostadil associated with low molecular weight heparin to treat limb ischemia caused by SARS-CoV2

The current coronavirus pandemic has already taken a great toll globally, causing massive morbidity and mortality. One of its severe forms is a thrombophilic state that can damage several systems. This article reports the case of 60-year-old female patient who presented with mild flu symptoms, which turned out to be a SARS-CoV2 infection, and ended up developing arterial thrombosis with limb ischemia in a private care hospital in Sorocaba, São Paulo, Brazil. Considering this progression, we decided to intervene with low molecular weight heparin and Alprostadil, achieving a good clinical outcome. Our description aims to identify key points and clinical signs that offer evidence of the therapeutic window and a treatment option for coagulatory presentations of COVID-19. Resumo A atual pandemia de coronavírus já gerou danos profundos ao redor do mundo, causando grande quantidade de morbidades e mortes. Uma das manifestações das formas graves da doença é o estado trombofílico, que pode provocar danos em vários sistemas. Este artigo relata o caso de uma paciente do sexo feminino, 60 anos de idade, que foi internada em um serviço hospitalar privado com sintomas gripais inespecíficos leves, mas que progrediu com trombose arterial e isquemia de membros causada pelo SARS-CoV2. Devido à essa evolução, foi optada pela administração concomitante de heparina de baixo peso molecular e Alprostadil, com bom desfecho clínico. Nossa descrição objetiva identificar pontos-chave e sinais clínicos que evidenciem essa janela terapêutica, bem como uma opção de tratamento para as apresentações coagulatórias da COVID-19.

Alprostadil associated with low molecular weight heparin to treat limb ischemia caused by SARS-CoV2.

The current coronavirus pandemic has already taken a great toll globally, causing massive morbidity and mortality. One of its severe forms is a thrombophilic state that can damage several systems. This article reports the case of 60-year-old female patient who presented with mild flu symptoms, which turned out to be a SARS-CoV2 infection, and ended up developing arterial thrombosis with limb ischemia in a private care hospital in Sorocaba, São Paulo, Brazil. Considering this progression, we decided to intervene with low molecular weight heparin and Alprostadil, achieving a good clinical outcome. Our description aims to identify key points and clinical signs that offer evidence of the therapeutic window and a treatment option for coagulatory presentations of COVID-19.

A atual pandemia de coronavírus já gerou danos profundos ao redor do mundo, causando grande quantidade de morbidades e mortes. Uma das manifestações das formas graves da doença é o estado trombofílico, que pode provocar danos em vários sistemas. Este artigo relata o caso de uma paciente do sexo feminino, 60 anos de idade, que foi internada em um serviço hospitalar privado com sintomas gripais inespecíficos leves, mas que progrediu com trombose arterial e isquemia de membros causada pelo SARS-CoV2. Devido à essa evolução, foi optada pela administração concomitante de heparina de baixo peso molecular e Alprostadil, com bom desfecho clínico. Nossa descrição objetiva identificar pontos-chave e sinais clínicos que evidenciem essa janela terapêutica, bem como uma opção de tratamento para as apresentações coagulatórias da COVID-19.

Adequação das práticas do laboratório de cateterismo durante a pandemia de COVID-19: O protocolo do Instituto Dante Pazzanese de Cardiologia

Introdução A pandemia global da doença de coronavírus 2019 (COVID-19) causada pelo novo vírus de síndrome respiratória aguda grave coronavírus 2 (SARS-CoV-2) começou em Wuhan, China, em dezembro de 2019 e afetou mais de 4,4 milhões de pessoas em todo o mundo, com 302.169 mortes até o dia 16 de maio de 2020.1 Embora os sintomas respiratórios sejam a apresentação mais comum de COVID-19, o envolvimento cardíaco é uma característica proeminente dessa doença, ocorrendo em 20% a 30% dos pacientes hospitalizados e contribuindo para 40% dos óbitos.2-4 O envolvimento cardíaco relacionado à COVID-19 tem sido documentado por elevações em biomarcadores cardíacos e frequentemente apresenta alterações no segmento ST-T no eletrocardiograma (ECG) de 12 derivações, motivo pelo qual a equipe do laboratório de cateterismo é frequentemente ativada. Além disso, as atividades do laboratório de cateterismo devem continuar no atendimento a pacientes não COVID-19 que apresentam síndrome coronariana aguda (SCA) verdadeira, infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) e doença cardíaca isquêmica estável muito sintomática. Devido à escalada no número de casos de COVID-19 na cidade de São Paulo, epicentro da doença no Brasil, reformularam-se a logística e as práticas no laboratório de cateterismo cardíaco do Instituto Dante Pazzanese de Cardiologia, que entraram em vigor em abril de 2020 e continuarão durante o período da pandemia. Os objetivos são fornecer atendimento otimizado à população que necessita de procedimentos cardíacos invasivos durante a pandemia, com a proteção adequada aos profissionais de saúde (PS), pacientes e seus familiares. Os protocolos aqui descritos representam os esforços multidisciplinares e dinâmicos do Departamento de Cardiologia Invasiva do Instituto Dante Pazzanese de Cardiologia validados pelo Comitê de Controle de Infecção da instituição. Essas práticas estão sujeitas a alterações em função do estado epidemiológico local, a fase da epidemia e a disponibilidade de equipamento de proteção individual (EPI). Estes protocolos podem não se aplicar a outras localidades sem casos (ou casos esporádicos) de COVID-19 ou a serviços que atendem diferentes perfis populacionais com logísticas e disponibilidade de EPI diversas.

Effectiveness of Prone Positioning in Nonintubated Intensive Care Unit Patients With Moderate to Severe Acute Respiratory Distress Syndrome by Coronavirus Disease 2019.

BACKGROUND: In the treatment for severe acute respiratory distress syndrome (ARDS) from coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) recommends prone positioning (PP) during mechanical ventilation for periods of 12-16 h/d to potentially improve oxygenation and survival. In this prospective observational study, we evaluated the ability of long PP sessions to improve oxygenation in awake intensive care unit (ICU) patients with moderate or severe ARDS due to COVID-19. METHODS: The study was approved by the ethics committee of Galicia (code No. 2020-188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the ICU at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible until the patient felt too tired to maintain that position. Light sedation was administered with dexmedetomidine. The following information was collected: number and duration of PP sessions; tissue O2 saturation (StO2) and blood gases before, during, and following a PP session; need of mechanical ventilation; duration of ICU admission; and ICU outcome. Linear mixed-effects models (LMM) were fit to estimate changes from baseline with a random effect for patient. RESULTS: Seven patients with moderate or severe ARDS by COVID-19 were included. All patients received at least 1 PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. Dexmedetomidine was used in all PP sessions. Oxygenation increased in all 16 sessions performed in the 7 patients. The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FIO2) significantly increased during PP (change from baseline 110 with 97.5% confidence interval [CI], 19-202) and, after PP, albeit not significantly (change from baseline 38 with 97.5% CI, -9.2 to 85) compared with previous supine position. Similarly, tissue oxygenation underwent a small improvement during PP (change from baseline 2.6% with 97.5% CI, 0.69-4.6) without significant changes after PP. Two patients required intubation. All patients were discharged from the ICU. CONCLUSIONS: We found that PP improved oxygenation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients and may be a simple strategy to improve oxygenation trying to reduce the number of patients in mechanical ventilation and the length of stay in the ICU, especially in COVID-19 pandemic.