Early triage echocardiography to predict outcomes in patients admitted with COVID-19: a multicenter study.

INTRODUCTION: Cardiac involvement seems to impact prognosis of COVID-19, especially in critically ill patients. We aimed to assess the prognostic value of right ventricular (RV) and left ventricular (LV) dysfunction, evaluated by bedside triage echocardiography (echo), in patients admitted to emergency departments (ED) in the US with COVID-19. We also assessed the feasibility of using cloud imaging for sharing and interpreting echocardiograms. METHODS: Patients admitted to three reference EDs with confirmed COVID-19 underwent triage echo within 72 h of symptom onset with remote interpretation. Clinical and laboratory data, as well as COVID-19 symptoms, were collected. The association between echo variables, demographics and clinical data with all-cause hospital mortality and intensive care unit (ICU) admission was assessed using logistic regression. RESULTS: Three hundred ninety-nine patients were enrolled, 41% women, with a mean age of 62±16 years. Mean oxygen saturation on presentation was 92.3± 9.2%. Compared to in-hospital survivors, non-survivors were older, had lower oxygen saturation on presentation, were more likely to have a chronic condition and had lower LV ejection fraction (50.3±19.7% vs. 58.0±13.6%) (P < .05). In the cohort, 101 (25%) patients had moderate/severe LV dysfunction, 131 (33%) had moderate/severe RV dysfunction. Advanced age and lower oxygen saturation were independently associated with death and ICU admission. LV and RV function, or other echo variables, were not independent predictors of outcomes. CONCLUSION: In patients admitted with COVID-19 undergoing early echo triage, the independent predictors of death and ICU admission were age and oxygen saturation. The inclusion of echo variables did not improve prediction of unfavorable outcomes.

Influenza vaccination strategy in acute coronary syndromes: the VIP-ACS trial.

AIMS: To evaluate whether a strategy of double-dose influenza vaccination during hospitalization for an acute coronary syndrome (ACS) compared with standard-dose outpatient vaccination (as recommended by current guidelines) would further reduce the risk of major cardiopulmonary events. METHODS AND RESULTS: Vaccination against Influenza to Prevent cardiovascular events after Acute Coronary Syndromes (VIP-ACS) was a pragmatic, randomized, multicentre, active-comparator, open-label trial with blinded outcome adjudication comparing two strategies of influenza vaccination following an ACS: double-dose quadrivalent inactivated vaccine before hospital discharge vs. standard-dose quadrivalent inactivated vaccine administered in the outpatient setting 30 days after randomization. The primary outcome was a hierarchical composite of all-cause death, myocardial infarction, stroke, unstable angina, hospitalization for heart failure, urgent coronary revascularization, and hospitalization for respiratory causes, analysed by the win ratio method. Patients were followed for 12 months. During two influenza seasons, 1801 participants were included at 25 centres in Brazil. The primary outcome was not different between groups, with 12.7% wins in-hospital double-dose vaccine group and 12.3% wins in the standard-dose vaccine group {win ratio: 1.02 [95% confidence interval (CI): 0.79-1.32], P = 0.84}. Results were consistent for the key secondary outcome, a hierarchical composite of cardiovascular death, myocardial infarction and stroke [win ratio: 0.94 (95% CI: 0.66-1.33), P = 0.72]. Time-to-first event analysis for the primary outcome showed results similar to those of the main analysis [hazard ratio 0.97 (95% CI: 0.75-1.24), P = 0.79]. Adverse events were infrequent and did not differ between groups. CONCLUSION: Among patients hospitalized with an ACS, double-dose influenza vaccination before discharge did not reduce cardiopulmonary outcomes compared with standard-dose vaccination in the outpatient setting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov number: NCT04001504.

Clinical and electrocardiographic outcomes evaluated by telemedicine of outpatients with clinical suspicion of COVID-19 treated with chloroquine compounds in Brazil†.

Aims: To evaluate clinical and electrocardiographic outcomes of patients with COVID-19, comparing those using chloroquine compounds (chloroquine) to individuals without specific treatment. Methods: Outpatients with suspected COVID-19 in Brazil who had at least one tele-electrocardiography (ECG) recorded in a telehealth system were enrolled in two arms (Group 1: chloroquine and Group 2: without specific treatment) and one registry (Group 3: other treatments). Outcomes were assessed through follow-up calls (phone contact, days 3 and 14) and linkage to national mortality and hospitalization databases. The primary outcome was composed of: hospitalization, intensive care admission, mechanical ventilation, and all-cause death, and the ECG outcome was the occurrence of major abnormalities by the Minnesota code. Significant variables in univariable logistic regression were included in 4 models: 1-unadjusted; 2-adjusted for age and sex; 3-model 2 + cardiovascular risk factors and 4-model 3 + COVID-19 symptoms. Results: In 303 days, 712 (10.2%) patients were allocated in group 1, 3,623 (52.1%) in group 2 and 2,622 (37.7%) in group 3; 1,969 had successful phone follow-up (G1: 260, G2: 871, and G3: 838). A late follow-up ECG was obtained for 917 (27.2%) patients [group 1: 81 (11.4%), group 2: 512 (14.1%), group 3: 334 (12.7%)]. In adjusted models, chloroquine was independently associated with greater chance of the composite clinical outcome: phone contact (model 4): OR = 3.24 (95% CI 2.31-4.54), p < 0.001. Chloroquine was also independently associated with higher mortality, assessed by phone + administrative data (model 3): OR = 1.67 (95% CI 1.20-2.28). However, chloroquine did not associate with the occurrence of major ECG abnormalities [model 3; OR = 0.80 (95% CI 0.63-1.02, p = 0.07)]. Abstracts with partial results of this work was accepted in the American Heart Association Scientific Sessions, November 2022, in Chicago, IL, USA. Conclusion: Chloroquine was associated with a higher risk of poor outcomes in patients suspected to have COVID-19 when compared to those who received standard care. Follow-up ECGs were obtained in only 13.2% of patients and did not show any significant differences in major abnormalities amongst the three groups. In the absence of early ECG changes, other side effects, late arrhythmias or deferral of care may be hypothesized to explain the worse outcomes.

Racial disparity in excess mortality in Brazil during COVID-19 times.

We evaluated the impact of the COVID-19 pandemic on excess mortality by race/skin colour in Brazil, between epidemiological weeks 12 and 50 of 2020. We compared the 2020 point estimate and the expected point estimate applying 2019 mortality rates to the 2020 population. There was an excess of 187 002 deaths (+20.2%) compared to the expected. Excess mortality was 26.3% (23.3-29.3%) among blacks/browns compared to 15.1% (14.1-16.1%) among whites (58.9% of excess among black/browns). Age-standardized rates increased from 377 to 419/100 000 among blacks/browns compared to 328 to 398/100 000 in whites, resulting in 9% relative risk. Excess mortality in Brazil depicts a considerable gap, with increased mortality in all age groups in the black/brown population.

Impact of a large-scale telemedicine network on emergency visits and hospital admissions during the coronavirus disease 2019 pandemic in Brazil: Data from the UNIMED-BH system.

INTRODUCTION: Triage by on-demand telemedicine is a strategy for healthcare surge control in the COVID-19 pandemic. We aimed to assess the impact of a large-scale COVID-19 telemedicine system on emergency department (ED) visits and all-cause and cardiovascular hospital admissions in Brazil. METHODS: From March 18-May 18, 2020 we evaluated the database of a cooperative private health insurance, with 1.28 million clients. The COVID-19 telemedicine system consisted of: a) mobile app, which redirects to teleconsultations if indicated; b) telemonitoring system, with regular phone calls to suspected/confirmed COVID-19 cases to monitor progression; c) emergency ambulance system (EAS), with internet phone triage and counselling. ED visits and hospital admissions were recorded, with diagnoses assessed by the Diagnosis Related Groups method. COVID-19 diagnosis and deaths were identified from the patients' registries, and outcomes assessed until June 1st. RESULTS: In 60 days, 24,354 patients accessed one of the telemedicine systems. The most frequently utilized was telemonitoring (16,717, 69%), followed by teleconsultation (13,357, 55%) and EAS (687, 3%). The rates of ED and hospital admissions were: telemonitoring 19.7% (3,296) and 4.7% (782); teleconsultation 17.3% (2,313) and 2.4% (318) and EAS: 55.9% (384) and 56.5% (388) patients. At total 4.1% (1,010) had hospital admissions, 36% (363) with respiratory diseases (44 requiring mechanical ventilation) and 4.4% (44) with cardiovascular diagnoses. Overall, 277 (1.1%) patients had confirmed COVID-19 diagnosis, and 160 (0.7%) died, 9 with COVID-19. CONCLUSION: Telemedicine resulted in low rates of ED visits and hospital admissions, suggesting positive impacts on healthcare utilization. Cardiovascular admissions were remarkably rare.

Impact of the COVID-19 pandemic on hospital admissions for cardiovascular diseases in a large Brazilian urban center.

INTRODUCTION: The COVID-19 pandemic has had a great impact on the behavior of individuals and the organization of health systems. This study analyzed the COVID-19 pandemic's effect on public hospitalizations for cardiovascular diseases (CVD) in a large city in Brazil, Belo Horizonte, MG, with approximately 2.5 million inhabitants. METHODS: In a time-series analysis, this study used administrative data from the national "Hospital Information System" from 2010 to February 2020 to estimate the expected number of hospitalizations for CVD by month during the COVID-19 pandemic in Belo Horizonte in 2020 using the Auto-Regressive Integrated Moving Average model. For CVD, this study compared the expected number of hospital admissions, intensive care use, deaths during hospitalization, and mean length of stay with the observed number during the period. RESULTS: There were 6,517 hospitalizations for CVD from March to December 2020, a decrease of 16.3% (95% CI: 4.7-25.3) compared to the projected. The number of intensive care hospitalizations for CVD fell 24.1% (95% CI 13-32.7). The number of deaths also decreased (17.4% [80% CI: 0 - 0.30]), along with the reduction in hospitalizations, as did the length of stay for CVD hospitalizations. These reductions, however, were not significant. CONCLUSIONS: Hospitalizations for CVD were 16.3% lower than expected in a large Brazilian city, possibly due to the fear of getting infected or going to hospitals. Public campaigns informing how to proceed in case of CVD show that prompt urgent attention is essential to mitigate the indirect effects of the pandemic on CVD.

Impact of COVID-19 Pandemic on the Sexual Function of Health Professionals From an Epicenter in Brazil.

INTRODUCTION: The pandemic caused by the COVID-19 resulted in worldwide social isolation and leading to significant personal distress, particularly among health professionals on the front lines. Those factors' relevance and their impact on sexual function in this population have not yet been established. AIM: To evaluate the impact of the pandemic on sexual function in healthcare professionals and medical students at a reference center in the treatment of COVID-19 in Brazil. METHODS: A cross-sectional analysis with online questionnaires about sexual function was sent to health professionals and medical students from the HC-FMUSP medical complex. The questionnaire evaluated Total Sexual and Masturbatory Frequency prior and during the pandemic, libido and sexual satisfaction changes with a detailed inquire about demographics and personal factors. An objective assessment of sexual function was also made using the validated sexual quotient questionnaires. MAIN OUTCOME MEASURES: Differences in intercourse frequency, libido, and overall sexual satisfaction, in a sample of healthcare professionals particularly vulnerable to the pandemic effects. RESULTS: A total of 1,314 responses were available with a mean age of 37 years. Worsening of sexual satisfaction was reported by 44.5% of the participants, with the following associated factors: Lower libido, missing Nightlife, Higher Masturbatory Frequency, and isolation from the partner. Remaning sexualy actively and having higher sexual frequency appear to decrease the chance of worsening sexual function. Worsening of Libido was reported by 37% and had several associated factors, including missing of Nightlife, older age, isolation from the partner among others. Being male and sexually active was associated with a smaller chance of reporting lower libido. CONCLUSION: We were able to observe a sharp drop in Libido and General Sexual Satisfaction. Although an increase in pornography consumption and masturbatory frequency did occur, these factors were not associated with greater sexual satisfaction. The impact of COVID-19 on this population's sexual health is not to be underestimated and should be further studied in the follow-up of the pandemic. Neto RP, Nascimento BCG, Carvalho dos Anjos Silva G, et al. Impact of COVID-19 Pandemic on the Sexual Function of Health Professionals From an Epicenter in Brazil. Sex Med 2021;9:100408.

Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities.

INTRODUCTION: During the COVID-19 pandemic, excess mortality has been reported, while hospitalisations for acute cardiovascular events reduced. Brazil is the second country with more deaths due to COVID-19. We aimed to evaluate excess cardiovascular mortality during COVID-19 pandemic in 6 Brazilian capital cities. METHODS: Using the Civil Registry public database, we evaluated total and cardiovascular excess deaths, further stratified in specified cardiovascular deaths (acute coronary syndromes and stroke) and unspecified cardiovascular deaths in the 6 Brazilian cities with greater number of COVID-19 deaths (São Paulo, Rio de Janeiro, Fortaleza, Recife, Belém, Manaus). We compared observed with expected deaths from epidemiological weeks 12-22 of 2020. We also compared the number of hospital and home deaths during the period. RESULTS: There were 65 449 deaths and 17 877 COVID-19 deaths in the studied period and cities for 2020. Cardiovascular mortality increased in most cities, with greater magnitude in the Northern capitals. However, while there was a reduction in specified cardiovascular deaths in the most cities, the Northern capitals showed an increase of these events. For unspecified cardiovascular deaths, there was a marked increase in all cities, which strongly correlated to the rise in home deaths (r=0.86, p=0.01). CONCLUSION: Excess cardiovascular mortality was greater in the less developed cities, possibly associated with healthcare collapse. Specified cardiovascular deaths decreased in the most developed cities, in parallel with an increase in unspecified cardiovascular and home deaths, presumably as a result of misdiagnosis. Conversely, specified cardiovascular deaths increased in cities with a healthcare collapse.

The impact of COVID-19 on the plastic surgery activity in a high-complexity university hospital in Brazil: the importance of reconstructive plastic surgery during the pandemic.

BACKGROUND: The Hospital das Clínicas - University of Sao Paulo Medical School (HCFMUSP) is the largest university hospital complex in Brazil. HCFMUSP has been converted into a reference center for coronavirus disease 2019. The Division of Plastic Surgery postponed non-essential surgeries and outpatient consultations, accomplishing new guidelines (ANG) of national and international organizations. Even with these challenges arising from the pandemic, alternatives were considered to maintain institutional characteristics. This study aims to analyze this new scenario and the impact on patients' assistance and Plastic Surgery residents training. METHODS: Total number of surgeries, type of procedures, and outpatient consultations in 2020, before (pre-ANG) and after (post-ANG) ANG, were compared with the same period in 2019 (2019-pre and 2020-post). RESULTS: A marked reduction in the total number of surgeries and outpatient consultations was observed in the post-ANG period. In the post-ANG period, 267 operations were performed (26.7 ± 20.3/week), while in the 2019-post period, 1036 surgeries were performed (103.6 ± 9.7/week) (p = 0.0002). Similarly, 1571 consultations were conducted in the post-ANG period (157.1 ± 93.6/week), while in the 2019-post period, 3907 were performed (390.7 ± 43.1/week) (p = 0.0003). However, in the post-ANG period, an increase in the proportion of reconstructive compared with aesthetic surgery was observed. The maintenance of highly complex procedures such as microsurgical transplants was also identified. CONCLUSIONS: The predominant profile of reconstructive surgeries at the Division of Plastic Surgery allowed the continuity of procedures at all technical complexity levels, patient care maintenance, and Plastic Surgery residents training.Level of evidence: not ratable.