What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care

Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39;p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136;p = 0.6), antibiotic therapy (57% versus 64%;p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%;p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5];p = 0.002) and presented a higher use of vasopressors (47% versus 36%;p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%;p < 0.001) at admission, prone positioning (45% versus 36%;p = 0.04), and hydroxychloroquine (59% versus 10%;p < 0.001) and lopinavir/ ritonavir (41% versus 10%;p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%;p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave. © 2023 Associacao de Medicina Intensiva Brasileira - AMIB. All rights reserved.

How has the sustainability of countries changed after COVID-19? Evidence from the pandemics' first year.

The Covid-19 crisis has caused several social-related issues; the sanitary is, perhaps, the most significant one. Lockdowns and vaccination were implemented to fight the Covid-19 virus. From a sustainability perspective, Covid-19 has been considered a meaningful crisis driver that has affected nations' economies and social and natural capitals. The literature presents clues that effects appear to be different among countries. Recognizing its importance as public policies for sustainability, this study aims to assess how the sustainability of countries has changed after Covid-19, focusing on countries' economic power that reflects their capacity to face the crisis. A sample of 89 countries is considered, and 2019-2020 are set as base years for data gathering, which covers the first year of the Covid-19 crisis. Sustainability is conceptually supported and represented by a 3-D cube. The natural environment is expressed by the ecological footprint (EF) method, the economic capital by the gross domestic product (GDP), and the social capital by the happiness index. Results show that sustainability of economies was negatively affected after first year of Covid-19 crisis, but in different magnitudes, according to nations' economic power. While the sustainability of the wealthiest economies was slightly changed during 2019-2020 but maintained within the named 'useful-order' world (environmentally unsustainable, productive, and happy), the poorest economies pushed about 169 million people into the worst performance, reaching the 'ineffective' world (environmentally unsustainable, unproductive, and unhappy). Numbers highlight the inequalities of sustainability performance among countries, according to their capacity to face the Covid-19 crisis. The shield of the richest evaluated countries comprising 5 % of the world population is more powerful than the shield of the poorest evaluated countries carrying 67 % of the world population. Results claims for efforts to make different policies and provide economic support differently for countries, since although we are all under the same storm, but in different boats.

SARS-CoV-2 in pediatric age group: Multiple clinical presentations and broad spectrum of severity

INTRODUCTION: Since the new coronavirus began to spread throughout the world children and adolescents were affected on a smaller scale than adults, being mostly asymptomatic carriers or having mild to moderate symptoms, with lower risk of developing serious complications. When infected, patients in the pediatric age group presented a range of varied symptoms associated with the virus, different from adults where the main clinical symptom was respiratory. METHODS: Eight patients were admitted to our pediatric intensive care unit with a diagnosis of SARS-CoV-2, confirmed by PCR or serology;of these 3 were asymptomatic or presented mild flu symptoms, 2 had clinical presentation typical of severe acute respiratory distress syndrome, 1 presented abdominal pain associated with multisystemic inflammatory syndrome, 1 had clinical presentation of acute respiratory distress syndrome and later admitted again to our service fulfilling criteria for multisystemic inflammatory syndrome and 1 presented ischemic stroke after SARSCoV- 2. Four patients with severe symptoms required ventilatory support through mechanical ventilation due to respiratory failure, in most cases, difficult to manage and with shock requiring vasoactive drugs. Unlike adults, none of the 8 patients required renal replacement therapy. No outcome evolved to death. RESULTS: The diagnosis and management of SARS-CoV-2 in pediatrics is a challenge, due to this varied clinic and little experience of professionals due to a small number of cases, making this study important for better knowledge about the disease, thus improving care.

Ischemic stroke on multisystem inflammatory syndrome associated with SARS-CoV-2

INTRODUCTION: The World Health Association declared at match 2020 that the disease caused by nCoV-2019, the SARS-Cov-2, became a pandemic infection. The majority of patients infected by this new virus presented fever, cough and dyspnea, but also were reported cases of pneumonia leading to acute distress respiratory syndrome, acute kidney injury and encephalitis. Also, some patients presented a transient ischemic attack or a brain stroke as a complication of the infection. We will report a case of a pediatric patient that evolved with ischemic stroke after infection by nCoV-2019. METHODS: An 8 years old female patient, with previous asymptomatic infection by nCoV-2019 and no past medical history, started headache, abdominal pain and persistent fever for seven days evolving to left hemiparesis. At clinical assessment presented with ocular opening only when called (Glasgow coma scale of 14), tachypnea, dyspnea, hypotension, grade 3 muscular strength on left leg and grade 0 on left arm. Due to hypotension, at emergency sector, were initiated treatment with fluid resuscitation, but patient evolved to refractory shock needing vasoactive drugs and transference to intensive care unit. Performed cranial CT scan that showed recent extensive ischemic injury on territory supplied by left middle cerebral artery and occlusion of right internal carotid artery bifurcation. On laboratory tests patient presented increased C-reactive protein (35,8 mg/dL), ferritin (807 mg/ dL), D-dimer (13,69 μg/mL), ESR (50 mm/h) and troponin (0,097 ng/mL) with negative RT-PCR for SARS-CoV-2 and serology for SARS-CoV-2 with negative IgM, negative IgA and positive IgG. Towards this clinical case, patient fulfilled criteria for Pediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 (PIMS-TS), so were initiated treatment with human immunoglobulin 2g/Kg at the 3rd day after the admission of the patient on the intensive care unit. Patient evolved hemodynamically stable, being possible to suspend vasoactive drugs at the 4th day after admission. RESULTS: Although PIMS-TS is still considered a rare outcome, recognize its clinical and laboratorial manifestations and its possible complications, like the ischemic stroke, is essential to make an adequate and a timely management during patient hospitalization.

Anosmia in COVID-19 Associated with Injury to the Olfactory Bulbs Evident on MRI.

Patients with coronavirus disease 2019 (COVID-19) may have symptoms of anosmia or partial loss of the sense of smell, often accompanied by changes in taste. We report 5 cases (3 with anosmia) of adult patients with COVID-19 in whom injury to the olfactory bulbs was interpreted as microbleeding or abnormal enhancement on MR imaging. The patients had persistent headache (n = 4) or motor deficits (n = 1). This olfactory bulb injury may be the mechanism by which the Severe Acute Respiratory Syndrome coronavirus 2 causes olfactory dysfunction.