COVID-19 in kidney transplant recipients: what have we learned one year later? A cohort study from a tertiary center

Introduction: Kidney transplant (KT) recipients have a high risk for adverse outcomes from infections, such as COVID- 19. Methods: We have retrospectively reviewed all KT recipients with documented COVID-19 between March 1, 2020, and March 15, 2021, and analyzed patients' characteristics, clinical course, treatment, and outcomes. Results: We identified 123 patients, 72% were male, with a mean age of 54.5±13.0 years. Twenty percent were asymptomatic, 7% had a nosocomial transmission, and 36% of the remainder required hospitalization. Almost all admitted patients received oxygen, 30% required invasive mechanical ventilation (IMV), more than a half had acute kidney injury, with 10% requiring dialysis, and 20% died. Incidence was comparable to that of the Portuguese population, but the mortality rate was almost four times higher (SMR of 3.768 (95% CI:1.723-7.154). Higher body mass index (OR 1.275, P=0.001), lower baseline graft function (OR 0.968, P=0.015), and nosocomial transmission (OR 13.836, P=0.019) were associated with oxygen demand, whereas female gender (OR 3.801, P=0.031) and lower baseline kidney graft function (OR 0.955, P=0.005), but not body mass index, were associated with IMV and/or death. Conclusion: Mortality rate in KT patients was higher than in the general population and lower baseline kidney function was the most consistent marker for adverse outcomes.

Uso De Acalabrutinib Em Paciente Transplantado Renal Com Linfoma Do Manto R/R

Introducao: Linfoma de celulas do manto (MCL) e uma doenca rara, mais frequente em homens, com idade media ao diagnostico de 68 anos. A terapia para MCL nao e curativa e praticamente todos os pacientes terao doenca refrataria ou recorrente. Quimioimunoterapia e a principal modalidade de tratamento de 1 linha, combinada a consolidacao com transplante autologo de medula ossea nos pacientes elegiveis. Mais recentemente, com a incorporacao de novas drogas na pratica clinica, ha mais opcoes de tratamento a partir da 2 linha, como os inibidores de tirosina quinase de Bruton (iBTK) e inibidor de bcl-2. Objetivos: Relatar um caso de paciente com MCL R/R, com historico de transplante renal e uso de imunossupressores, tratado com acalabrutinib com necessidade de ajuste de dose. Relato de caso: RCM, masculino, 70 anos, coronariopata, transplantado renal de doador cadaver em janeiro de 2018 devido a doenca renal cronica dialitica por sindrome hemolitico-uremica atipica em 2014, em uso de tacrolimus, micofenolato de mofetila e prednisona. Poucos meses apos o transplante apresentou linfocitose (14.900) e esplenomegalia, sem sintomas B. Biopsia de medula ossea mostrou infiltracao por MCL, positivo para CD20, BCL-2 e ciclina-D1. Na ocasiao, o paciente encontrava-se assintomatico e a doenca foi caracterizada como MCL leucemizado e indolente, foi optado por acompanhamento ambulatorial. Apos dois anos, apresenta linfocitose progressiva, aumento da esplenomegalia e trombocitopenia. Realizou tratamento com 6 ciclos de R-CHOP (ate 29/10/2020), atingindo resposta parcial. Apresentava 2,73% de linfocitos B monoclonais ao final do tratamento. Devido ao uso concomitante de imunossupressores para profilaxia de rejeicao do enxerto renal, durante a pandemia de COVID-19, optou-se por nao realizar manutencao com rituximabe. Apresentou recaida precoce, novamente com linfocitose progressiva e esplenomegalia 6 meses apos o termino do tratamento de 1 linha. Em junho de 2021 iniciou tratamento de 2 linha com iBTK de 2geracao - acalabrutinibe 200 mg/dia. Atingiu resposta hematologica com rapida normalizacao da linfocitose e resolucao da esplenomegalia, porem evoluiu com diarreia cronica, perda de peso e desnutricao, com prejuizo a qualidade de vida. Diante dos possiveis diagnosticos diferenciais - infeccao oportunista em paciente severamente imunossuprimido, infiltracao colonica por linfoma ou toxicidade medicamentosa, foi submetido a colonoscopia, com resultado normal, tornando toxicidade medicamentosa a principal hipotese. A dose do acalabrutinibe foi reduzida para 100 mg/dia em 20/04/22. Desde entao houve melhora da diarreia, o paciente voltou a ganhar peso e mantem resposta hematologica completa. Discussao e conclusao: Nao ha descricao de interacao entre acalabrutinib e inibidores de calcineurina, sirolimus e micofenolatomofetil. A posologia recomendada de acalabrutinibe e 100 mg de 12/12h, de forma universal. Pacientes transplantados em uso de imunossupressores nao foram incluidos nos estudos clinicos que levaram a aprovacao da droga para uso na pratica clinica. Esse caso ilustra que em cenarios especificos pode ser necessario realizar ajuste de dose para reduzir o risco de efeitos colaterais, sem prejuizo na eficacia do tratamento. Copyright © 2022

Geotourism in the Forno Grande State Park, State of Espírito Santo: Impacts caused by the social isolation of COVID-19

Protected Areas contribute to the preservation of natural resources, promoting the implementation of activities related to ecological and geological tourism. The objective was to characterize the main geotouristic and ecotouristic attractions of the Forno Grande State Park (Parque Estadual Forno Grande - PEFG) and to evaluate the environmental impacts on the stretch of the trail from the Visitor Center to the Yellow Wells, resulting from the visitation before the COVID-19 pandemic and absence of visitation for four months during the pandemic. For this, we sought to describe, based on in situ observations and bibliographic consultation, the geosystemic aspects of the PEFG. For the evaluation of environmental impacts, the check-list method performed on February 27th and July 26th, 2020 was used. From the first evaluation, points with water accumulation, damaged stringers, erosion grooves, root exposure, and soil compaction were identified. In the second evaluation, some positive impacts were verified, especially in relation to the amount of litter deposited on the trail floor. On the other hand, there was a greater accumulation of plant remains in the trail corridor, due to the lack of visitation. In some of the stretches, a reduction in the size of erosion grooves was observed. There was also more evidence of the presence of wild animals, such as footprints and excrement along the trail. Therefore, there are challenges to be faced for the geoconservation of the PEFG, which include a multidisciplinary and holistic vision aiming to achieve sustainability through geotourism and in the expectation that it can contribute to the preservation of the biotic and abiotic environment. © 2022 Universidade de Sao Paulo. All rights reserved.

Gamification for Infectious Diseases Medical Education: Creating a Videogame to Teach COVID 19 Diagnosis and Treatment to Medical Students

Background. Brazillian authorities reported a total of 16.3 million cases and 454. 000 deaths during COVID-19 pandemic in Brazil by may 2021. It became necessary to educate healthcare professionals on diagnosis and treatment of the syndrome. Game based learning surfaced as an effective alternative, since it promotes critical thinking and problem solving skills. A team of Brazilian and Peruvian students, physicians, designers and programmers gathered to create a decision based computer game that simulates a hospital scenario and allows medical students to analise, make decisions and receive feedback. This work describes the creative process and showcase the initial version of the software. Methods. Professors and students of Medicine, Information Technology (IT), Design and Architecture from Brazil and Peru assembled a team in order to develop the computer game. Clinical cases were created by the medical students and professors, comprising medical procedures for the treatment and management of COVID 19, and a video game script was developed exploring gamification principles of challenge, objectivity, persistence, failure, reward and feedback. Algorithms (image 1) were created, under supervision of professors of Medicine, to define possible courses of action and outcomes (e.g. gain or loss of points, improvement or worsening of the patient). Students of Design created artistic elements, and IT students programmed with a game engine software. This fluxogram, written in portuguese, describes in detail all the possible courses of actions that can be exercised by the player. It is created by a team of Professors of Medicine and medical students, in accordance with evidence-based guidelines. Primarily, this document guides the programmers and designers throughout the development phase of the game. Results. Initially, an expandable minimum viable product was obtained. The game, visualized on image 2, consists in a non-playable character and a playable character (i.e. doctor), with a scenario and a dialogue script simulating a clinical examination of a COVID 19 patient. The player can interact with certain elements within the game, e.g. the computer and other characters, to retrieve test results or start dialogues with relevant information. Hospital scenario and dialogue window between doctor (player in black) and patient (non playable character) are displayer in the game engine software (Unity 2D). On the bottom half of the screen, the dialogue box allows the player to collect the patient's medical history. The player can interact with certain elements to obtain relevant information to make decision and progress in the game. Conclusion. The game allows medical students to practice diagnosis and treatment of COVID 19. Future versions will include assessment reports of player's actions, and a new score system will be implemented. New diseases will be incorporated in the gameplay to match the variety of scenarios offered by real hospitals and patients. Artificial intelligence will be employed to optimize gameplay, feedback and learning.

Recycling of Reinforced Glass Fibers Waste: Current Status.

In this paper, a review of the current status and future perspectives for reinforced glass fiber waste is undertaken, as well as an evaluation of the management hierarchy for these end-of-life materials. Waste levels are expected to increase in the coming years, but an improvement of collection routes is still necessary. The recycling processes for these materials are presented. The associated advantages and disadvantages, as well as the corresponding mechanical characteristics, are described. Although mechanical shredding is currently the most used process, there is a potential for thermal processes to be more competitive than others due to the fiber quality after the recycling process. However, the energy requirements of each of the processes are not yet well explained, which compromises the determination of the economic value of the recycled fibers when included in other products, as well as the process feasibility. Nevertheless, the work of some authors that successfully integrated recycled glass fibers into other elements with increased mechanical properties is evaluated. Future recommendations for the recycling of glass fiber and its commercialization are made.