The Use of Intraoperative Ecmo in Lung Transplantation: A Retrospective Analysis from the Largest Lung Transplant Center in Brazil

The use of extracorporeal membrane oxygenation (ECMO) presents several advantages in the intraoperative scenario during lung transplantation (LTx) and its use has increased over the last decade. The aim of the this study is to evaluate the use of ECMO at our institution throughout the years. Retrospective analysis considering the period from January/2014 to September/2022 using the REDCap database of the Lung Transplantation Group at Heart Institute - University of São Paulo - Brazil. Of the 254 lung transplants performed in this period, 37 utilized intraoperative ECMO. The recipients were mostly female (56.8%), mean age of 34.51 years old (±13.64 years - 13-65);94.6% (35) received bilateral lung transplant. The most common preoperative diagnostics were primary pulmonary hypertension (24.3%), hypersensitivity pneumonitis (18.9%) and cystic fibrosis (16.2%). The main isolated or combined reasons for ECMO use were hemodynamic instability (45.9%), hypoxemia (35.1%) and pulmonary hypertension (35.1%). Twenty one patients (56.8%) had preoperative diagnostic of pulmonary hypertension (Pulmonary Artery Systolic Pressure: 66.0 ± 19.20 mmHg). Thirty two patients (86.5%) received VA-ECMO, and 28 (87.5%) of those received central cannulation (right atrium cannulation for venous drainage and aorta cannulation for perfusion), and 4 received hybrid cannulation (common femoral vein cannulation for venous drainage and aorta cannulation for perfusion). Thirty three (89.18%) patients were decannulated and the overall survival rate were 75.56% (30 days) and 48.38% (90 days). Most of cases of ECMO use (70.27%) occurred in the last 3 years (2020-2022), propelled by the dissemination of devices and techniques due to the COVID-19 pandemic. The use of ECMO in LTx has increased in the past years at our institution, configuring an additional intraoperative resource in selected recipients. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Influence of Deep Sedation in Intensive Care Medicine Memories of Critical COVID-19 Survivors.

Introduction: Critical care survivors sustain a variety of sequelae after intensive care medicine (ICM) admission, and the Coronavirus Disease 2019 (COVID-19) pandemic has added further challenges. Specifically, ICM memories play a significant role, and delusional memories are associated with poor outcomes post-discharge including a delayed return to work and sleep problems. Deep sedation has been associated with a greater risk of perceiving delusional memories, bringing a move toward lighter sedation. However, there are limited reports on post-ICM memories in COVID-19, and influence of deep sedation has not been fully defined. Therefore, we aimed to evaluate ICM-memory recall in COVID-19 survivors and their relation with deep sedation. Materials/Methods: Adult COVID-19 ICM survivors admitted to a Portuguese University Hospital between October 2020 and April 2021 (second/third "waves") were evaluated 1 to 2 months post-discharge using "ICU Memory Tool," to assess real, emotional, and delusional memories. Results: The study included 132 patients (67% male; median age = 62 years, Acute Physiology and Chronic Health Evaluation [APACHE]-II = 15, Simplified Acute Physiology Score [SAPS]-II = 35, ICM stay = 9 days). Approximately 42% received deep sedation (median duration = 19 days). Most participants reported real (87%) and emotional (77%) recalls, with lesser delusional memories (36.4%). Deeply sedated patients reported significantly fewer real memories (78.6% vs 93.4%, P = .012) and increased delusional memories (60.7% vs 18.4%, P < .001), with no difference in emotional memories (75% vs 80.4%, P = .468). In multivariate analysis, deep sedation had a significant, independent association with delusional memories, increasing their likelihood by a factor of approximately 6 (OR = 6.274; 95% confidence interval = 1.165-33.773, P = .032), without influencing real (P = .545) or emotional (P = .133) memories. Conclusions: This study contributes to a better understanding of the potential adverse effects of deep sedation on ICM memories in critical COVID-19 survivors, indicating a significant, independent association with the incidence of delusional recalls. Although further studies are needed to support these findings, they suggest that strategies targeted to minimize sedation should be favored, aiming to improve long-term recovery.

Asymmetric Multifractal Cross-Correlation Dynamics between Fiat Currencies and Cryptocurrencies

This paper performs the asymmetric multifractal cross-correlation analysis to examine the COVID-19 effects on three relevant high-frequency fiat currencies, namely euro (EUR), yen (YEN) and the Great Britain pound (GBP), and two cryptocurrencies with the highest market capitalization and traded volume (Bitcoin and Ethereum) considering two periods (Pre-COVID-19 and during COVID-19). For both periods, we find that all pairs of these financial assets are characterized by overall persistent cross-correlation behavior (alpha xy(0) > 0.5). Moreover, COVID-19 promoted an increase in the multifractal spectrum's width, which implies an increase in the complexity for all pairs considered here. We also studied the Generalized Cross-correlation Exponent, which allows us to verify that there is no asymmetric behavior between Bitcoin and fiat currencies and between Ethereum and fiat currencies. We conclude that investing simultaneously in major fiat currencies and leading cryptocurrencies can reduce the portfolio risk, leading to improvement in the investment results.

Anti-persistent adherence dynamic of the COVID-19 vaccines

This research explores the multifractal dynamics of time series of the daily number of vaccinees for COVID-19, considering six European countries (Belgium, Denmark, France, Germany, Greece and Italy) using the Multifractal Detrended Fluctuations Analysis (MF-DFA). We calculate the multifractal spectrum f(alpha) and apply a fourth-degree polynomial regression fit to estimate the complexity parameters that describe the degree of multifractality of the underlying process. We found that the multifractal dynamics of all these countries are characterized by strongly anti-persistent behavior (alpha (0) < 0.5) a lower degree of multifractality, and small fluctuations are dominant in the multifractal spectrum. From an immunization perspective, it means that a panorama that encompasses the population's behaviour is marked by the dynamics of anti-persistent adherence to COVID-19 vaccines. Our findings confirm that the period of immunization of the population that adhered to the vaccination campaigns is short and that the application of new doses of vaccines must obey this phenomenology to keep people safe. In addition, we used the multifractal efficiency coefficient to rank countries that are most proactive in developing campaigns that promote greater adherence and loyalty to COVID-19 vaccines. Our findings indicate that Germany, Belgium and France were more efficient than Greece, Denmark and Italy.

Anxiety symptoms in critically ill COVID-19 survivors and its association with post-discharge health concerns

Introduction: Evidence suggest that critically ill COVID-19 patients are at higher risk of developing anxiety symptoms, which may be related to or exacerbated by patients concerns regarding their health status and recovery. Objective(s): To assess anxiety symptoms in critically ill COVID-19 survivors, 1-2 months after hospital discharge and to analyze its association with concerns reported by patients regarding their own health status and recovery. Method(s): In the framework of MAPA prospective research, this preliminary study included COVID-19 patients admitted in the Intensive Care Medicine Department (ICMD) of a University Hospital. Patients were excluded if they had an ICMD length of stay (LoS) <=24h, terminal illness, major auditory impairment or inability to communicate at the evaluation time. Participants were assessed at a scheduled telephone follow-up appointment, with Generalized Anxiety Disorder Scale (GAD-7). Additional questions were asked to assess the survivors' post-discharge concerns regarding discrimination against for COVID-19, infection of a family member, re-infection or sequelae related to COVID-19. Result(s): Eighty-three patients were included (median age=63 years;63% male) and 24% had anxiety symptoms. Anxiety scores were higher in survivors who reported being afraid of being discriminated against for COVID-19 (30% vs 10%;p=0.034), being re-infected (100% vs 79%;p=0.032) and having sequelae (94% vs 44%;p<0.001). Conclusion(s): These findings revealed that anxiety is common in COVID-19 survivors and is associated with post-discharge patients concerns that may limit patient daily living. This study emphasizes the importance of psychological assessment and follow-up of the COVID-19 survivors, in order to support these patients recovery.

Depression and health-related quality of life in critical COVID-19 survivors

Introduction: Long-term neuropsychiatric consequences of critical illness are well known. Therefore, it is expected that critical COVID-19 patients might also present several psychiatric symptoms such as depression, with inevitable negative effect on healthrelated quality of life (HRQoL), commonly used as an indicator of illness and treatment impact. Objective(s): To identify depressive symptoms in critical COVID-19 survivors and to examine its association with HRQoL domains. Method(s): This preliminary study involved critical COVID-19 patients admitted into the Intensive Care Medicine Department (ICMD) of a University Hospital, between October and December of 2020. Patients with an ICMD length of stay (LoS)<=24h, terminal illness, major auditory loss, or inability to communicate at the follow-up time were excluded. From 1-2 months after discharge, all participants were evaluated by telephone at follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EuroQol 5-dimension 5-level EQ-5D-5L (HRQoL). This study is part of the longitudinal MAPA project. Result(s): Eighty-three patients were included with a median age of 63 years (range: 31-86) and the majority were male (63%). The most reported problems on EQ-5D-5L domains were usual activities (82%) and mobility (76%). About 27% presented depressive symptoms, and with more problems of self-care (68%vs41%;p=0.029), pain/discomfort (86%vs49%;p=0.002), and anxiety/depression (96%vs54%;p<0.001). Conclusion(s): These preliminary results are in line in previous studies in critical COVID-19 survivors, with depression being associated with worse HRQoL. Bearing this in mind, follow-up approaches with an early screening and treatment of these psychiatric symptoms will be fundamental to optimize the recovery of these patients.

Delirium and health-related quality of life in severe COVID-19 survivors

Introduction: Severe COVID-19 survivors experience long-term neuropsychiatric morbidity, particularly those who developed delirium, with a negative impact on health-related quality of life (HRQoL). Objective(s): To identify the cases of delirium in severe COVID-19 patients and to describe its association with post-hospital discharge HRQoL. Method(s): In the context of the longitudinal MAPA project, we included adult patients (>= 18 years old) admitted with COVID-19 to the Intensive Care Medicine Department (ICMD) of a Portuguese University Hospital (October 2020-April 2021). Exclusion criteria were: ICMD length of stay <=24h, terminal illness, major auditory loss, or inability to communicate at the time of assessment. Delirium during ICMD stay was ascertained based on patients' clinical records. HRQoL was evaluated using the 5-Level EQ-5D questionnaire (EQ-5D-5L), at a scheduled telephone follow-up appointment on average 1-2 months after hospital discharge. Result(s): Overall, 124 patients were included with a median age of 62 (range: 24-86) years, being mostly male (65%). About 19% had delirium, 42% were deeply sedated and 43% required invasive mechanical ventilation. Most survivors reported problems on the EQ-5D-5L domains: usual activities (85%), mobility (73%) and anxiety/depression (65%). Patients with delirium reported more pain/discomfort (75%vs46%;p=0.011) and considerably anxiety/ depression (83%vs60%;p=0.032). Conclusion(s): These findings pointed that COVID-19 patients who experienced delirium reported worse HRQoL, regarding pain/discomfort and anxiety/depression. This study highlights the importance of not only prevention but also early screening of delirium during hospital stay, as well as the crucial role of the timely interventions at discharge, in order to minimize delirium longterm impacts.

Depressive symptoms and health-related quality of life in critical COVID-19 survivors: Preliminary results of 1-year follow-up

Introduction: A higher risk of mental health consequences in critical COVID-19 patients is expected due to several reasons, including prolonged mechanical ventilation with exposure to high sedation. In this context, post-discharge depression has been reported in previous COVID-19 studies, with a profound impact on patients' health-related quality of life (HRQoL). Objective(s): To identify depressive symptoms in COVID-19 survivors 1-year after hospital discharge and to analyse its association with HRQoL. Method(s): As part of the longitudinal MAPA project, this study enrolled critical COVID-19 patients admitted in the Intensive Care Medicine Department of a University Hospital (March-May 2020). Participants were assessed through telephone by an intensive care nurse and a psychologist, with the Patient Health Questionnaire (PHQ-9) (depressive symptoms), EuroQol five-dimension fivelevel questionnaire (EQ-5D-5L) and EQ-Visual Analogue Scale (EQ-VAS) (global health status patient record). Result(s): A sample of 55 survivors (median age=66 years;69% males) were included, with 20% showing depressive symptoms. Pain/discomfort (67%) and anxiety/depression (67%) were the most EQ-5D-5L domains reported. Survivors scoring for depression had more problems in all HRQoL areas (mobility:91%vs.48%, p=0.015;self-care:64%vs.27%, p=0.035;usual activities:91%vs.50%, p=0.017;pain/discomfort:100%vs.59%, p=0.010;anxiety/depression:100% vs.59%, p=0.010). Moreover, they had a lower EQ-VAS median, corresponding a worse self-perception of health status (50vs.80, p=0.010). Conclusion(s): Even after 1-year, a significant proportion of survivors presented depressive symptoms with repercussions in all HRQoL dimensions and association with worse self-perception of global quality of life. Taking this in mind, early screening and treatment of depression in COVID-19 survivors will be crucial, minimizing its impact on quality of life.

PRIMEIRO DIAGNÓSTICO DE FEBRE DO NILO OCIDENTAL EM HUMANO EM MINAS GERAIS: RELATO DE CASO

Introdução: O vírus do Nilo Ocidental, inicialmente isolado em Uganda em 1937, constitui uma das arbovirose de maior distribuição atual (1). No Brasil, há registros de casos humanos apenas no Piauí, onde dez pessoas foram diagnosticadas de 2014 a 2020 (1). A transmissão ocorre pela picada de mosquito Culex e aves migratórias são os principais hospedeiros (1). Apenas 20 a 40% dos pacientes infectados cursam com sintomas, geralmente leves, como náusea, vômito, cefaleia, mialgia, exantema, febre e adinamia (2). Com maior gravidade, a forma neuroinvasiva cursa com encefalite, meningite ou paralisia flácida (2). O diagnóstico pode ser obtido por sorologia ou PCR séricos, mas na doença neuroinvasiva os testes também devem ser realizados no líquor (2). Objetivo: Relatar o primeiro caso humano de febre do Nilo Ocidental (FNO) diagnosticado em Minas Gerais. Descrição do caso: Paciente de sexo feminino, 78 anos, covid-19 confirmado há 19 dias, procurou atendimento informando diplegia facial, disfagia e tetraparestesia, com tetraparesia há 2 dias. Informa que sintomas gripais iniciaram 10 dias após vacinação covid-19, sendo medicada com sintomáticos, sem sinais de gravidade. Após liberação de isolamento, permaneceu com dor e parestesia em MMII, ascendente e progressiva. Nega fenômenos isquêmicos ou hemorrágicos, alergias, viagens recentes, porém identificou ave morta em quintal da residência. Hipertensa, em uso de losartana e metoprolol. Durante internação, houve piora do quadro neurológico, disfonia, tetraplegia e insuficiência respiratória. Foi tratada com imunoglobulina, esteve 18 dias internada, com melhora paulatina do déficit motor, disfagia e fala. Como parte da investigação de síndrome febril inexplicada com quadro neurológico, foi realizado rastreio de arboviroses no líquor, confirmando-se o diagnóstico de febre do Nilo Ocidental por PCR. Comentários: Como apenas 1-2% dos casos de FNO são diagnosticados, a vigilância e o rastreio de doenças neuroinvasivas por arboviroses permitem compreender a dinâmica de transmissão do agravo no Brasil, com vistas à suspeita, notificação, investigação e manejo adequado.

P.0811 Factors and outcomes associated with delirium in critically ill COVID-19 patients

Introduction: Evidence demonstrates that 25-33% of hospitalized patients with COVID-19 develop delirium [1,2], with rates up to 65% in critically ill patients [3]. Several potential reasons, including the use of deep sedation and invasive mechanical ventilation (IMV), as well as the restrictions to limit infection transmission, such as prohibition of family visits and minimal contact with health staff were identified [4]. Although factors and outcomes associated with delirium are well documented, limited data are available regarding severe COVID-19 patients. Aims: This study aims to estimate the rates of delirium in critically ill COVID-19 patients and to analyze factors that may be associated with its development, as well as to examine long-term outcomes. Methods: From March to May 2020 (in COVID-19 first wave), all adult patients (≥18y.o.) admitted due to COVID-19, in the Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ), in Porto, Portugal, were assessed, unless they had a ICMD length of stay (LoS) ≤24h, terminal illness or major sensory loss or inability to communicate at the time of follow-up. Participants were evaluated during a scheduled telephone follow-up appointment with a comprehensive protocol, including: Six-item Cognitive Impairment Test (6CIT) (cognitive impairment);Patient Health Questionnaire (PHQ-9) (symptoms of depression);General Anxiety Disorder (GAD-7) (symptoms of anxiety);and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) (health-related quality of life-HRQoL), which includes EQ-Visual Analogue Scale (EQ-VAS) (global health status patient perception). Data on acute illness severity, sedative/analgesic drugs use, respiratory support and major complications (including delirium, nosocomial infections and difficulty weaning from mechanical ventilation) during ICMD stay, were obtained from hospital electronic records review. Patients with and without delirium were compared, using Mann-Whitney test for continuous variables, and Chi-square or Fisher tests for paired categorical variables (significance level of 0.05). This study is part of an ongoing larger multidisciplinary research project (MAPA-Mental Health in Critically ill patients with COVID-19). Results: The sample included 59 patients (median age=65 years;66.1% male). Delirium was registered in almost half of the sample (49.2%). Patients with delirium were significantly older (median=72 vs. 62;p=0.010) and presented more nosocomial infections (82.8% vs 53.3%;p=0.032) particularly ventilator-associated pneumonia (75.9% vs. 33.3%;p=0.003). Also, they were significantly more likely to be deeply sedated (89.7% vs 60%;p=0.021), more often required IMV (89.7% vs 60%;p=0.021). Moreover, those with delirium stayed longer in the hospital (median=67 vs 37 days;p=0.014). Concerning HRQoL, assessed at follow-up appointment, patients who have developed delirium reported more problems in self-care (48.3% vs 10%;p=0.003) and in everyday activities (79.3% vs 53.3%;p=0.035) after hospital discharge. Nevertheless, no statistically significant differences were found for cognitive impairment, symptoms of anxiety and depression. Conclusions: Delirium was common in this critically ill COVID-19 sample, namely in older patients, who have been deeply sedated, invasively ventilated or had major ICU complications. It was associated with longer hospital stay and worse HRQoL. Recognizing potential associated factors will allow the identification of high-risk patients that should be targeted for early screening with preventive interventions to minimize the adverse outcomes associated to delirium in critical COVID-19 patients. No conflict of interest

COVID-19 prevalence and outcomes in people with MS taking disease modifying therapies: A population study using NHS England data

Background: The effects of MS disease modifying therapies (DMTs) on COVID-19 morbidity and mortality have been studied in clinician-reported registries, but the true prevalence of SARSCoV-2 infection and its outcomes in the MS population receiving DMTs are unknown. Objectives: To assess the prevalence of SARS-CoV-2 infection and its outcomes, and their association with individual DMTs among all MS patients receiving DMTs in England. Aims: To understand the magnitude of COVID-19's impact on a population of MS patients receiving DMTs. Methods: We analysed merged national databases to ascertain the rate of SARS-CoV-2 positive tests and COVID-19 in-hospital mortality among all MS patients receiving DMTs in England from 1/02/2020 to 27/03/2021. The National Health Service (NHS) England and NHS Improvement collect prescribing and dispensing data on all MS DMTs. Public Health England collects data on all SARS-CoV-2 tests and COVID-19 in-hospital deaths. Further clinical data collection on a random sample of patients who tested positive (cases) or were not tested (controls) for SARS-CoV-2 is ongoing in multiple centres to establish risk factors of adverse COVID-19 outcomes without selection bias. Results: A total of 35556 MS patients had received a DMT. Their mean (standard deviation) age was 44 (12) years. A total of 16,108 patients (45.3%) were tested for SARS-CoV-2, and 2000 (5.6%) tested positive with a mean age of 42 (12) years. Twentysix patients with a positive test (1.3%) died in hospital. Their mean age was 54 (16) years. The age-standardised mortality ratio (95% confidence interval) of the MS versus the general population was 1.2 (0.7-1.7). There was no clear difference between individual DMTs in their rates of positive tests or inhospital mortality. Detailed data on 79 randomly selected patients with a positive test has been collected at two centres so far. Their mean age is 44 (11) years and 55 (69.6%) are women. Five were hospitalised due to COVID-19 out of whom one was admitted to an intensive therapy unit and died. Data will be updated and reanalysed prior to ECTRIMS 2021. Conclusions: So far, COVID-19 does not appear to significantly increase the risk of mortality in MS patients on DMTs compared to the general population, in this large population study.

Psychiatric disorders during acute hospital treatment of COVID-19 - a case series

IntroductionCoronavirus disease (COVID-19) has been associated with the development mental and behavioural symptoms and psychiatric disorders. This association is stronger in severe cases of the disease and in those needing inpatient treatment, particularly in intensive care units (ICU).ObjectivesTo determine the incidence of psychiatric disorders in a Portuguese hospital-based sample of patients with COVID-19. To describe relevant demographic and clinical data.MethodsWe reviewed all COVID-19 inpatients assessed by liaison psychiatry at our hospital between April and September 2020. Patients admitted due to a psychiatric disorder were excluded from the analysis. We reviewed medical records and retrieved relevant clinical data. ICD-10 was used to classify diagnoses.ResultsWe identified 36 cases with a mean age of 62.64 years-old (SD 19.23). The most common disorder was delirium, which occurred in 41.7% of our sample (15 patients), followed by adjustment disorder (22.2%, n=8), and depressive episode (16.7%, n=8). Most patients had no personal (61.1%, n=22) nor family (75%, n=27) history of a psychiatric disorder. Mean length of admission was 36.89 days (SD 28.91). Seventeen cases (47.22%) had at least one risk factor for severe COVID-19 disease and 14 (38.89%) were admitted at some point to the ICU.ConclusionsIn our sample, delirium was the main cause for mental or behavioural symptoms in COVID-19 patients. However, we observed a wide array of presentations in our center. A larger sample would allow to better characterize this often-overlooked symptoms and identify risk factors to psychiatric syndromes.DisclosureNo significant relationships.

Post-discharge depressive symptoms and health-related quality of life of critical COVID-19 survivors

IntroductionSurvivors of critical illness stay frequently experience long-term mental health morbidity, suggesting that many critically ill patients with COVID-19 may also show a high prevalence of psychiatric conditions.ObjectivesTo describe depression in COVID-19 survivors 4-months post-hospital discharge and to examine its association with health-related quality of life (HRQoL).MethodsThis pilot study involved COVID-19 adult patients admitted in Intensive Care Medicine Service (ICMS) of a University Hospital. Exclusion criteria were: ICMS length of stay (LoS)≤24h, terminal illness, major sensory loss and inability to communicate at the time of assessment. All participants were evaluated at ICMS scheduled telephone follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EQ-5D-5L (HRQoL). Critical-illness severity was assessed with APACHE-II and SAPS-II.ResultsTwenty patients were included with a median age of 62(range: 24-77) y.o., the majority male (75%) and married (70%). Median (range) APACHE-II and SAPS-II was 17 (5-34) and 32.5 (7-77), respectively, and LoS was 18 (4-58) days. Overall, 25% patients presented depression symptoms and most reported problems on EQ-5D-5L domains of pain/discomfort (65%), anxiety/depression (55%) and mobility (50%). Depression scores were higher in patients with problems in EQ-5D-5L domains of usual activities (median 4 vs 1.5;p=0.046), pain/discomfort (median 0 vs 4;p=0.004) and anxiety/depression (median 4 vs 0;p<0.001).ConclusionsThese preliminary findings show that depression is frequent in COVID-19 survivors and it is associated with worse HRQoL. This pilot study highlights the importance of psychological assessment and treatment of COVID-19 survivors, in order to minimize its negative impact on HRQoL, optimizing their recovery.