Platypnea-Orthodeoxia Syndrome Due to Patent Foramen Ovale Shunt Caused by Aortic Root Dilation

Background Orthodeoxia syndrome (OS) is a rare clinical condition characterized by oxygen desaturation noted in the upright position (orthodeoxia). OS can originate in the heart, lungs, abdomen, or elsewhere due to either an intracardiac (cardiac OS) or intrapulmonary shunt, or a ventilation-perfusion mismatch. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM) and cause patent foramen ovale (PFO) shunt. Case A 77-year-old male patient was admitted to the ICU with pneumonia due to COVID-19. During the evaluation, the patient presented orthodeoxia detected by pulse oximetry, with oxygen saturation (SpO2) of 96% in supine and 70% in upright positions. COVID-19 was treated with remdesivir and corticosteroids without orthodeoxia improvement. Decision-making Pulmonary embolism was ruled out with CT Angiography. Transthoracic Echocardiogram was also normal. A microbubble contrast-enhanced Transesophageal echocardiography was done and confirmed an aortic root dilatation with atrial septal mobility leading to a significant patent foramen ovale (PFO) shunt. The patient was submitted to interventional closure of the patent foramen ovale with the resolution of orthodeoxia. Conclusion Increased Mobility of the Atrial Septum in Aortic Root Dilation can be a cause of PFO shunt and orthodeoxia [Formula presented]Copyright © 2023 American College of Cardiology Foundation

An unusual cause for hypoxemia and breathlessness

Thanks to the author's interest, complementary diagnostic tests were performed and the diagnosis was made. The author also made it possible to treat the patient through contact with the colleagues that performed the procedure. 75-year-old woman with past medical history of ischemic stroke in 2019, when complementary diagnostic tests were performed and it was found that the patient had a patent foramen ovale (PFO). Current hospitalization due to COVID-19 pneumonia, which was complicated by bacterial co-infection and intermediate-low risk right main pulmonary artery thromboembolism. The patient was successfully treated, with improvement of the clinical condition and evident imaging resolution of pulmonary cavitations and recanalization of the right pulmonary artery. However, something intriguing was observed: The patient presented dyspnea in the upright position and a decline in transcutaneous oxygen saturation from 96% in the supine position to 85% in orthostatism, with reversal of these findings with the recumbency. This led to the suspicion of platypnea-orthodeoxia syndrome. A transesophageal echocardiogram with bubble test was then performed, revealing an atrial shunt in the supine position without Valsalva maneuver. With these evidences, the diagnosis of platypnea-orthodeoxia syndrome was made. Even though the patient was >60 years, due to important right-to-left shunt, the history of stroke and the current platypnea-orthodeoxia, it was decided to close the PFO. The day after the procedure, the patient was placed in the upright position, maintaining an oxygen saturation of 96%. This case is an example that the decision of closing PFO must be individualized, not focusing only on patient's age, but also on his medical history and current situation, as indicated in the 2022 Guidelines for the Management of Patent Foramen Ovale. (Figure Presented).

Risk of SARS-CoV-2 infection in high and low-risk cohabitants, in Loures and Odivelas, Portugal : Inês Mateus Cunha

Background Effective contact tracing, vaccination, and isolation of cases of SARS-CoV-2 infection and their high-risk contacts constituted measures to contain the spread of COVID-19. In Portugal, in October 2021, low-risk cohabitants were lifted the obligation to isolate. The aim of this study was to estimate the relative risk of infection for close contacts, regarding the type of close contact and being cohabitants. Methods A descriptive longitudinal study, with an analytical component was performed. Sociodemographic and epidemiologic data from close contacts and confirmed cases in Loures and Odivelas, between October and November 2021, was collected from a regional database and from Trace COVID-19 platform. We performed a descriptive analysis and estimated the relative risk of SARS-CoV-2 positive test, stratified by type of contact and cohabitation, with 95% confidence level. Results We identified 200 confirmed cases and 428 people who were close contacts, corresponding to 502 different close contacts (59 people had contact with more than a case). From 502 close contacts, 268 were classified as low-risk and 230 as high-risk. Full time cohabitation was present in 310 of close contacts. Between contact tracing day and the next 4 weeks, 58 (10.9%) of close contacts tested positive. Risk of high-risk contacts testing positive was 2.7 [1.5-4.6], compared with low-risk contacts. Risk of cohabitants testing positive was 3.5 [1.6-7.7], compared with non-cohabitants. Risk of a high-risk cohabitant testing positive was 2.2 [1.1-4.4], compared with low-risk cohabitants. There was no higher risk of high-risk cohabitants testing positive compared with high-risk non-cohabitants. Same was true for low-risk cohabitants and non-cohabitants. Conclusions These results allow us to understand how to better stratify close contacts and apply isolation measures, according to the risk of testing positive. Further studies should be developed to assess the impact of other variables. Key messages • We identified an increased risk of testing positive in high-risk contacts, and in cohabitants. • Cohabitants could be stratified regarding being high or low-risk, with different measures being applied.

Real-world use of different pembrolizumab regimens (3 weekly versus 6 weekly) in non-small cell lung cancer (NSCLC) patients

Background and objectives: Pembrolizumab monotherapy given 3-weekly (3w) (200mg) is approved for the treatment of nonsmall cell lung cancer (NSCLC). In June 2019, NICE endorsed the 6w regimen (400mg) based on computer modelling data (Lala, Eur J Cancer 2020), which has been used during the COVID-19 pandemic to reduce hospital visits. This study compared immune-related adverse events (irAEs), discontinuation rates, and patient experience of 3w vs 6w patients treated at The Christie NHS Foundation Trust, Manchester, UK. Methodology: Pharmacy records were used to identify NSCLC patients treated with pembrolizumab, 1st, 2nd or 3rd line. IrAEs and discontinuation rates were analysed using Kaplan Meier curves to compare the 3w vs 6w cohorts. A sample of the cohort who received 3w then 6w undertook a questionnaire assessing patient experience. Results: 38 patients received pembrolizumab 6w, and 91 received pembrolizumab 3w, of the 3w, 51 switched to 6w. Baseline characteristics were similar. Any grade irAEs and G1-2 irAEs were significantly higher in the 6w cohort (p=0.006 and p=0.04, respectively). Both cohorts showed low rates of G3-5 irAEs at 6 months, 2.3% vs 14.5%, 3w vs 6w, p=0.3. Discontinuation rates at 6 months due to any irAES, G1-2 irAEs or G3-5 irAEs were insignificant in both cohorts (3w to 6w respectively): 4.5% vs 11.2%, p=0.2;2.8% vs 8.7%, p=0.4;2.0% vs 2.5%, p=0.3. Quality of life questionnaires showed stability (60%) or improvement (20%) in the 6w cohort compared to 3w. 90% said their mental health did not differ between regimens. 45% and 40% of patients preferred 6w and 3w respectively, 15% had no preference. Conclusion: NSCLC patients treated with 6w pembrolizumab appear to experience more low-grade irAEs compared to 3w. Highgrade irAEs and discontinuation rates due to irAEs were insignificant in both cohorts. Patients preferred the 6w regiment and found it tolerable.

The creation of a participatory guarantee system in times of a pandemic (COVID-19), in the state of Alagoas

The process of creating a Participatory Guarantee System (SPG) in the state of Alagoas has mobilized a diversity of subjects in the territories, such as family farmers, agrarian reform and land credit settlers, indigenous people, campers and landowners. The effective participation of the members of the participatory system is one of the guiding principles of the SPG, which, due to the current reality of the public health crisis caused by the pandemic (COVID-19), had to be improved through digital technologies. The present study aims to highlight the strategies used to carry out a relevant step in the process of creating the GSP, referring to the choice of the name that will represent the network of farmers and collaborators within the Participatory Conformity Assessment Organization (OPAC) at the national level. national. To face the difficulty of accessing the internet in rural communities, as well as the restricted access to cell phones and computers, three digital tools were used, specific to each stage of the process. The methodology was considered effective and ensured the participatory character of the SPG "baptism" process, which became known as SPG Bem Viver.

Evolution of Primary Health Care appointments in mainland Portugal in 2020

Background The COVID-19 pandemic has had an impact on the Portuguese Health Care System. During the first months of the pandemic, there was a great reduction in the number of health rendering services. (1) The aim of this study is to analyse the evolution of Primary Health Care appointments in mainland Portugal, during the whole year of 2020 and to compare it to the period of 2015-2019. The type of appointment and the number of users will also be characterized. Methods An observational, descriptive-retrospective, longitudinal, quantitative study was performed. ‘Portal da Transparência' was used as the source of free access data about the Portuguese National Health Service. Results The results which are here presented are comparing the year 2020 to the average of 2015-2019. In mainland Portugal, in 2020, there were 7% more Primary Health Care appointments (PHCA). Although there were less PHCA during the first five months of 2020, there was a rise in the number of PHCA since June 2020. In 2020, 59% were distance PHCA, a rise of 113% compared to the average of 2015-2019. There was a fall of 38% on presential PHCA in 2020. The number of presential PHCA was inferior in each month of 2020, in comparison to the homologous month of the average of 2015-2019. The month with less presential PHCA was April 2020 (less 72% than the average of 2015-2019). Regarding domiciliary PHCA, there was a 36% reduction.In mainland Portugal, the number of Primary Health Care users with, at least, one face-to-face or distance PHCA, in 2020 was 6,661,927, 3% less than the average of 2015-2019. Conclusions The transition from presential PHCA to distance PHCA that occurred in 2020 due to the COVID-19 pandemic allowed the follow-up of most of the patients. However, there is a need to assess if distance PHCA are as effective as presential PHCA and which are its effects in communities' health. (1) Vieira A et al. Excesso de mortalidade, mortalidade colateral e resposta dos serviços de saúde em Portugal em tempos de COVID-19 Key messages In 2020, in mainland Portugal, there was an increase on distance Primary Health Care appointments and a decrease on presential ones. Its impact on population’s health should be assessed.

Exploring blended learning tools to transform a laboratory course unit in engineering: Challenges, setbacks and rewards

To boost students’ engagement on learning outcomes, promote active peer learning, and adopt more dynamic teaching practices, a module of a laboratory course unit (TPL) in engineering was reformulated exploring blended learning. This reformulation was even more challenging than initially anticipated as it was implemented during the Covid-19 pandemic. As TPL learning practises are based on the operation of laboratory modules mimicking heat and mass transfer phenomena, asynchronous and on-line synchronous learning classes and face-to-face laboratory classes were outlined. To promote the asynchronous learning, a full script of TPL and pitch and longer videos presenting, respectively, each work and its practical operation process were formerly prepared and available online. Students were required to work in group to define the variables and conditions to be evaluated in each laboratory module, organize and plan the experimental activities, create data recording documents, and later present and argue their options in virtual synchronous classes. In the face-to-face classes, different activities were performed in a rotating system, scheduled and tuned in the online classes. It was also aimed in-situ promoting peer discussion of the data and reports elaboration, goals not attained due to the pandemic restrictions, as only two students of each group were present in each hands-on class and in sequential times. TPL reformulation was a tough and time-consuming task since 73 students were enrolled, divided into 3 shifts, each one with 5 groups of five students. Students individual learning evolution was inferred through online quizzes that were periodically made available. A final inquiry, launched to obtain students` opinion about this transformation endeavour highlighted the script, videos, and the prompt teachers’ feedback on the reports as the most fruitful and important aspects for students’ engagement and guide their learning pathway. The rationale behind this paper was to disclose this transformation experience and share information and strategies that can be used in the teaching/learning of laboratory classes. © 2021 University of Minho. All rights reserved.

Endodontic treatment during the COVID-19 pandemic - perception and behaviour of dental professionals

This study evaluated the impact of COVID-19 on the endodontic treatment routine. It was a cross-sectional study using an online questionnaire applied to endodontists to collect information about practical modifications during endodontic treatment to protect professionals and patients against the COVID-19 outbreak. A total 1105 participants from Brazil participated in the survey. More than 90% of respondents identify the high risk of COVID-19 infection to dentists and the need to change some clinical practices. Most respondents (60.1%) are partially following social isolation. The need for a change in Personal Protective Equipment (PPE) during dental appointments was mentioned by 97.1% of respondents. The use of minimal adequate PPE during the pandemic period was associated with the area of residence and marital status of participants. Only 30% of respondents say they use the minimal adequate PPE. Most respondents will change cavity access preparation to reduce virus dissemination. Other changes in endodontic appointments were described in the survey: greater attention to biosafety measures, duration of dental appointments, and duration of intervals between appointments. Endodontists still need to identify the best arrangement for performing their procedures safely during the COVID-19 pandemic. Specific guidelines require detailed information for each specialty and its procedures.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome.

BACKGROUND: Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome. PATIENTS AND METHODS: Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method. RESULTS: In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission. CONCLUSION: Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

Longitudinal analysis of biochemical and haematological features of cancer patients with COVID-19

Background: Cancer patients (pts) are at increased risk of severe COVID-19 infection and death. Older pts, men and those with haematological malignancies and receiving anti-tumour therapy within 14 days appear to be at highest risk for poor outcomes. In general populations, severe COVID-19 infection has been associated with neutrophilia, raised lactate dehydrogenase (LDH) and C-reactive protein (CRP). Cancer and its treatment affect many haematological and biochemical parameters. We examined whether COVID-19 infection affected these compared to pts’ baseline parameters by longitudinal tracking. We also investigated whether changes were associated with poor outcome. Methods: Consecutive pts with solid or haematological malignancies presenting with index symptoms and testing positive for SARS-CoV-2 at a tertiary oncology centre were identified following institutional board approval. Clinical and laboratory data were extracted from the pt record. Paired T-tests were used for longitudinal sampling and ANOVA/Chi squared for outcomes. Results: 52 pts tested positive (27 male, 25 female;median age 63). 80.5% had solid cancers, and 19.5% haematological. 31/52 pts were lymphopenic prior to infection. Comparing mean pre-infection counts (6 months-14 days=PRE) with mean counts from the 5 days following positive test (DURING) lymphocyte counts significantly decreased during infection (p<0.0001). Platelets were significantly reduced DURING vs. PRE COVID-19 (p=0.0028). 17/52 pts developed transient (median 2 days) neutropenia (<2x109/L) DURING infection (6 pts <1x109/L, 2 pts <0.5x109/L), 8/17 attributed to cancer/cancer therapy, the rest had no underlying cause. 8/17 pts received growth factor support. Reduced lymphocytes/neutrophils/platelets at diagnosis were not associated with oxygen requirement (O2) or death. Different CRP trajectories were observed when comparing pts grouped by discharge/ O2/death. Higher CRP and LDH at diagnosis were associated with admission (p=0.02 CRP/0.2 LDH), O2 (p=0.0002 CRP/p<0.01 LDH) and death (p=0.069 CRP/p=0.04 LDH). Updated analysis will be presented. Conclusions: Infection with SARS-CoV-2 commonly affects haematological parameters in cancer pts. High CRP and LDH are associated with poor outcomes. Legal entity responsible for the study: The Christie NHS Foundation Trust. Funding: Has not received any funding. Disclosure: R. Lee: Speaker Bureau/Expert testimony, Research grant/Funding (self): Bristol Myers Squibb;Speaker Bureau/Expert testimony: Astra Zeneca. A. Armstrong: Shareholder/Stockholder/Stock options, Husband has shares: Astra Zeneca. T. Cooksley: Speaker Bureau/Expert testimony: Bristol Myers Squibb. All other authors have declared no conflicts of interest.

The importance of environments and surfaces hygienization in pandemic times (Covid-19): a microbiological analysis in places for physical activity practice

The objective of this study was to analyse microbiological organisms in different locations and regions for physical activity in the city of Joao Pessoa, Brazil. Samples were collected on various objects used, such as: mattresses, drinking fountains, gloves, cell phones and others. The samples were collected in Joao Pessoa-PB, following the Standard Operating Procedure-SOP/ Microbiology of a specialized laboratory. The collection took place in the five macro-regions: North, South, East, West and Center. For each region samples were collected in one public place (square), a private one (gym) and one school (public or private), totaling fifteen collected sites and 450 samples. The following microorganisms were studied in all analyzed surfaces: Bacillus sp, Escherichia Coli, Klebsiella spp or Enterobacter spp and Coag. Neg. Staphylococcus. All regions had a high contamination level by some microorganism. The highest rates were found in the western, central and northern regions - 96, 94 and 93% respectively. The Coag. Neg.Staphylococcus presented the highest and lowest incidence rates in the South and East regions, with 43.33 and 6.67%, respectively, as well as Klebsiella spp or Enterobacter spp, which presented high levels. It is concluded that there is a microorganisms' contamination in the most varied places and regions where physical activity practices are developed, with a predominance of Coag. Neg.Staphylococcus and Klebsiella spp or Enterobacter spp. These results lead to a warning about the hygiene importance in places for physical activity practice, especially in pandemic times (COVID-19), since almost all the evaluated surfaces were contaminated.

Information sources of Brazilian undergraduate dental students during the COVID-19 outbreak: a cross-sectional study

Aim: This cross-sectional study aimed to investigate where Brazilian dental students seek information about COVID-19 by a self-administered web-based questionnaire. Methods: A social network campaign on Instagram was raised to approach the target population. The dental students responded to a multiple-response question asking where or with whom they get information about COVID-19. The possible answers were government official websites or health and education institutions websites, TV Programs, professors, social media, scientific articles, health professionals, and family members. The data were analyzed by descriptive statistics, and the frequency distributions of responses were evaluated by gender, age, type of institution, and year of enrollment. Results: A total of 833 valid responses were received. The main source of information used by the dental students were government official websites or health and education institutions websites, which were reported by 739 (88.7%) participants. In the sequence, 477 (57.3%) participants chose health professionals while 468 (56.2%) chose scientific articles as information sources. The use of social media was reported by 451 (54.1%) students, while TV programs were information sources used by 332 (39.9%) students. The least used information sources were professors, reported by 317 (38.1%) students, and family members, chosen only by 65 (7.8%) participants. Conclusion: Brazilian dental students rely on multiple information sources to stay informed about COVID-19, mainly focusing their information-seeking behavior on governmental and health professional’s websites. © 2021. All Rights Reserved.

Endodontic treatment during COVID-19 pandemic - Economic perception of dental professionals

Aim: This study evaluated, by the application of questionnaires, the impact of the COVID-19 pandemic on the clinical routine and inspection by the competent authorities, on the flow of patients in the office, as well as on possible changes in Endodontic treatment costs and the amounts charged to patients. Methods: This cross-sectional study was conducted from May 2nd, 2020 to May 6th, 2020, using an online questionnaire with a convenience sample. The inclusion criterion was professionals who perform endodontic treatments in daily clinical practice and who professional setting is private practice. The questionnaire brought questions about the impact on costs and the amount charged to the patient. Results: A total of 1042 questionnaires were answered from all the different states of Brazil, by professional who usually perform Endodontic treatment, and who is working in private practice. A total of 1010 (96.9%) respondents affirm it was necessary to modify the protective equipment in endodontic treatment due to pandemic and longer intervals between appointments was cited by 922 (88.5%), economically affecting the dental practice. There was no association between routine changes and economic impacts with gender, professional experience, area of residence or education level. Conclusion: In conclusion, most dental professionals recognized changes in the routine of endodontic treatment during the COVID-19 pandemic. They have a perception of increase in endodontic costs, and reduction in the volume of patients. © 2021. All Rights Reserved.

Photobiomodulation therapy to treat neuropathic oral pain after contagion by COVID-19

Objective: The purpose of this short communication is to show that although photobiomodulation in the treatment of neurophathic oral pain after COVID-19 contagion could be an option, photobiomodulation is not a new technique. PBMT was used with different protocols and pain was assessed using VAS (visual analogue scale-0 until 10) before and after the consultation. Results: Evolution of VAS during the sessions showed a decrease in painful symptomatology as treatment was performed. Conclusion: Based on the results obtained in the present case report, we concluded that PBMT with the parameters used in this clinical case was an effective, noninvasive and a new option of treatment for neuralgia resulting from COVID-19. © 2021, Universidade Estadual Paulista, Institute of Science and Technology of Sao Jose dos Campos. All rights reserved.