Prescription and use of liposomal amphotericin b during the COVID-19 pandemic

Background and ImportanceThe impact of COVID-19 and its influence in the management of hospitalised patients has been indisputable. Many publications present combinations of different antimicrobials to treat the patients infections, and the liposomal amphotericin b (Amb-L) is an example of one of the most prescribed.Aim and ObjectivesTo compare the prescription and indication of AmB-L in a tertiary hospital before and during the COVID-19 pandemic.Material and MethodsObservational, retrospective, descriptive study of patients prescribed AmB-L from March-2020 to March-2021, and the comparision to the year before the pandemic.Results58 patients analysed: 40 (69%) men, median age 71 years (IQR 54.5-75.2), and 18 (31%) women, median age 63.5 years (IQR 49.5-71.25). The months in which more patients received AmB-L were: July 2020 (6/56), December 2020 (7/56) and February 2021(12/56).-39 (69.6%) CRITICAL patients. Out of these: 22 with a covid diagnosis, 14 non-covid and 3 onco-haematological. 26/39 patients received AmB-L as a targeted treatment for Candida Glabrata and Albicans(16/26), Aspergillus Fumigatus (6/26) and Mucor (4/26). As a concomitant therapy, anidulafungin and isavuconazole were the preferent ones. The most prescribed dose of AmB-L was 400 mg (5 mg/kg) with a median of 7 days of treatment (IQR 4-17.5). 86.4% out of the total experienced death.-17 (30.4%) NON-CRITICAL patients: 0 covid patients, 6 (35.3%) non-covid and 11 (64.7%) onco-haematological patients. 10 (58.8%) patients received AmB-L as empirical treatment for febrile neutropenia, with posaconazole and itraconazole as the most commonly used antifungals. The most prescribed dose was 200 mg (3.3 mg/kg) for a median of 9 days (IQR 6-16).In the previous year (March 2019 to February 2020) we observed: 17 patients received treatment with AmB-L, 53% (9/17) onco-haematological, 12 men with a median of 53 years (IQR: 38.2-59.1). Most prescribed dose: 180 mg (3mg/kg).Conclusion and RelevanceThe data observed in this period reflects how the prescription of AmB-L tripled compared to the previous year. It targets a completely different profile: unstable patients, with invasive lung disease, risk factors in critical care units, treated with high doses of AmB-L. The fact of being an antifungal with a high cost/day per patient, the way of monitoring the situation of this type of patient is a crucial strategy to guarantee efficiency and optimise pharmaceutical spending.References and/or AcknowledgementsConflict of InterestNo conflict of interest

Effect of N-acetyl cysteine in a patient cohort with severe or very severe COVID-19 pneumonia

Introduction: COVID-19, as of 9 June 2020, had been responsible for 404,396 deaths worldwide. Throughout the pandemic, IRCU and ICU directly cared for patients with severe or very severe respiratory failure due to COVID19 pneumonia. Objective(s): To determine if N-acetyl-cysteine (NAC) could be associated with lower mortality risk. Methodology: 1141 patients from March to May 2020 admitted to the ICU and IRCU of the Fundacion Jimenez Diaz were analysed. Patients with <3 days of hospital admission and those with CURB-65 equal to or <0 were excluded. A multivariate regression logistics models have been used to respond to our hypothesis and investigate the relationship between each variable and the mortality. Result(s): Of all patients analyzed, 44% received treatment with NAC associated with other drugs according to established protocols. Of these, 55% were male, most non-smokers with a mean age of 74.43 years. In table 2 we describe statistically significant predictive parameters associated with a decreased risk of mortality in severe or very severe patients with an area AUC of 0.80 Conclusion(s): Adjuvant treatment with NAC in severe or very severe COVID-19 pneumonia is associated with a significantly lower risk of mortality by 30% in elderly patients, principally males, and with associated co-morbidities.

Comprehensive micropollutant characterization of wastewater during Covid-19 crisis in 2020: Suspect screening and environmental risk prioritization strategy.

Micropollutants monitoring in wastewater can serve as a picture of what is consuming society and how it can impact the aquatic environment. In this work, a suspect screening approach was used to detect the known and unknown contaminants in wastewater samples collected from two wastewater treatment plants (WWTPs) located in the Basque Country (Crispijana in Alava, and Galindo in Vizcaya) during two weekly sampling campaigns, which included the months from April to July 2020, part of the confinement period caused by COVID-19. To that aim, high-resolution mass spectrometry was used to collect full-scan data-dependent tandem mass spectra from the water samples using a suspect database containing >40,000 chemical substances. The presence of > 80 contaminants was confirmed (level 1) and quantified in both WWTP samples, while at least 47 compounds were tentatively identified (2a). Among the contaminants of concern, an increase in the occurrence of some compounds used for COVID-19 disease treatment, such as lopinavir and hydroxychloroquine, was observed during the lockdown. A prioritization strategy for environmental risk assessment was carried out considering only the compounds quantified in the effluents of Crispijana and Galindo WWTPs. The compounds were scored based on the removal efficiency, estimated persistency, bioconcentration factor, mobility, toxicity potential and frequency of detection in the samples. With this approach, 33 compounds (e.g. amantadine, clozapine or lopinavir) were found to be considered key contaminants in the analyzed samples based on their concentration, occurrence and potential toxicity. Additionally, antimicrobial (RQ-AR) and antiviral (EDRP) risk of certain compounds was evaluated, where ciprofloxacin and fluconazole represented medium risk for antibiotic resistance (1 > RQ-AR > 0.1) in the aquatic ecosystems. Regarding mixture toxicity, the computed sum of toxic unit values of the different effluents (> 1) suggest that interactions between the compounds need to be considered for future environmental risk assessments.

Double invisibility: the effects of hidden unemployment on vulnerable populations in southern European countries during the COVID-19 pandemic

The COVID-19 crisis has been characterised by an increased fragility of the labour market, especially in the Southern European countries. Nevertheless, official data do not accurately capture the real upheavals of their labour markets. In this context, this paper compares the labour market performance of vulnerable populations (youth, women and migrants) in three Southern European countries with a cross-analysis of data over time. To this end, we have developed an alternative hidden unemployment indicator that recovers and includes unemployed persons from the categories of involuntary underemployment and inactivity. Our analyses include data from Spain, Portugal, and Italy, and take the European Union-Labour Force Survey (EU-LFS) as their basis. Our results show that the impact of unemployment in the South of Europe is best measured when using an extended indicator, particularly when analysing the cases of vulnerable collectives. This tool shows great analytical potential for unveiling hidden unemployment in the context of the COVID-19 pandemic.

COVID-19 epidemic in Santander 2020: an epidemiological analysis with a province perspective

Introduction: The first case of COVID-19 was reported in Santander on March 15, 2020.

STROKE AFTER COVID-19 ERA: IS THERE A “STROKE WAVE” RESULTING FROM THE PANDEMIC?

Background and aims: The pandemic caused by SARS-COV2 is responsible for a considerable impact on stroke care. During this time many other non-COVID diseases have been neglected. Primary health care centers collapsed in some regions and the control and monitoring of vascular risk factors has been difficult. On the other hand, it is also known that covid infection leads to a certain prothrombotic state that could result in subsequent strokes. Our objective is to evaluate the effect of the SARS-CoV-2 pandemic on stroke unit admission rates. Methods: Temporal admission rates in the stroke unit of a regional hospital were analyzed from 2019, 2020 and 2021. The type of stroke, baseline characteristics and treatments received were recorded. Results: Stroke unit admission rates were similar between 2019 and 2020: 397 and 408 patients respectively. However, in 2021 the number of stroke admission, Ischemic or hemorrhagic, has incremented by more than 30% (p-value 0,005), with 589 attended patients. Hemorrhagic stroke rates were 15.62%, 10.70% and 16.98% in the three years respectively. Conclusions: During the first year of SARS-CoV-2 pandemic the use of health services for neurological emergencies was reduced, included the number of admissions at the stroke unit. However, we are experiencing a significant increase in the number of strokes, which now far exceeds prepandemic levels. It remains to be determined whether the cause of this huge increase in stroke cases is related to suboptimal vascular risks factor control, to COVID-related factors or to optimal population response following stroke campaigns in the region.

OFFICE BASED TRANSPERINEAL LASER ABLATION FOR BENIGN PROSTATIC HYPERPLASIA: 3 & 6 MONTHS OUTCOMES

INTRODUCTION AND OBJECTIVE: BPH affects tens of millions of men across the world. Most procedures require either general or regional anesthesia or a transurethral approach. Herein, we present the 3 & 6 months results of NCT04760483 is a phase I prospective, single center, interventional pilot study evaluating transperineal laser ablation (TPLA) of BPH tissues, carried in Office setting under local anesthesia. A detailed step by step video depiction of this procedure is available at the AUA video library. The objectives call for safety, feasibility, and impact in pertinent outcomes measures, such as Uroflowmetry, IPSS, Hematuria, Erectile function, and ejaculation METHODS: The study contemplated accrual of 20 men between 50 and 80 years with prostate volumes between 30 and 120 cc, IPSS scores >9, peak flows between 5 and 15 cc/s and void residuals under <250 ml. Any patient neurological conditions, history of any surgical intervention or urinary retention were excluded. IPSS assessments, Flow studies and prostate volume measures were conducted at 3 months. Herein we present the results. Bayesian analysis for continuous measurements were performed and non-parametric differences were evaluated using chi2 tests. RESULTS: Patients enrolled between December 2020 and February of 2021. The median (IQR) for age and BMI was 68 (58,73) and 29 (27,31), respectively. These parameters for room time, ablation time, watts and total joules were 29 (23,32), 9 minutes (7,12), 6 (5,7) watts and 3,400 (2,600, 3600) joules, respectively. 8(40%) were discharged with a Foley due to elevated residuals. 16 patients had erections and ejaculations before and 3 months after TPLA. 17/20 (85%) had significant improvement in their urinary profile after TPLA (See TABLE for details). One of the initial responders suffered from COVID- 19 infection and developed a CVA that hindered his urinary function. CONCLUSIONS: TPLA in the office setting is feasible and safe. Three month outcomes showed subjective and objective sustained improvement in over 80% of patients for at least 6 months. Furthermore, erections or ejaculations were not affected. This novel and promising approach demands further evaluation in phase II-III trials. (Figure Presented).

Drugs used during the COVID-19 first wave in Vitoria-Gasteiz (Spain) and their presence in the environment.

The city of Vitoria-Gasteiz was one of the probable first entrances of the SARS-CoV2 in Spain, one of the worst affected countries in the world during the first COVID 19 wave. Driven by the urgency of the situation, multiple drugs with antiviral activity were used off label. Sadly, most of these treatments were of little or no benefit and thus, the number of patients suffering from COVID-19 attended in intensive care units (ICUs) multiplied. After being administered to patients, a variable proportion of these drugs reach the environment where they may have detrimental effects, although this aspect is usually ignored by healthcare professionals. In this study we measured the patterns of hospital drug use in the city of Vitoria-Gasteiz (Spain) during the first COVID-19 wave pandemic, focusing on those with antiviral activity and those used in the ICUs. Subsequently, we measured concentrations of selected drugs in the city's wastewater treatment plant influent and effluent and estimated the potential risk for the environment. The hospital use of certain antivirals and drugs used for sedo-analgesia were dramatically increased during the first wave (cisatracurium was multiplied by 25 and lopinavir/ritonavir by 20). A mean of 1.632 daily defined doses of hydroxychloroquine were used during the period of February-May 2020. In this study we report the first positive detection of hydroxychloroquine ever in the environment. We also show the second positive report of lopinavir. Low risk was estimated for hydroxychloroquine, lopinavir and ritonavir (Risk quotients (RQ) <1), and medium risk for azithromycin (RQ 0f 0.146).

Evolution of Peruvian gynecology up to the Bicentennial, and the future

A brief overview of the evolution of gynecology in Peru in the last 200 years is done. Following the medicine and surgery practiced by the inhabitants in the pre-Hispanic era, known through their huacos and archeological sites, and after the development of diagnostic and operative gynecology with the systematic use of the speculum in the 19th century, which made possible interventions such as uterine curettage and posterior colpotomy for the drainage of pelvic abscesses, the history of Peruvian gynecology would begin in 1878, when Lino Alarco performed the first gynecological surgery by laparotomy to remove an ovarian tumor. Néstor Corpancho, in his service at the Hospital de Santa Ana, was the first to perform myomectomies by laparotomy, as well as hysterectomies. In 1879, the Chair of Gynecology was created in the Faculty of Medicine of the Universidad Nacional Mayor de San Marcos, and later the first modern operating room was installed in Peru. In 1898, Constantino T. Carvallo initiated the training of brilliant gynecologists, which was later continued with the schooling of specialists and access to updated medical information. Current COVID-19 pandemic requires monitoring of women's short and long term health, their gestations and newborns' lives, greater investment in health, trained professionals in emergency and person-centered health, research on diseases and their prevention, learn more about genetics, immunology, metabolic syndrome and related comorbidities (obesity, hypertension, diabetes mellitus), how to prolong healthy life, use nanotechnology, artificial intelligence, robotics, and more.

Covid-19 in hospitalized kidney transplant recipients: Clinical course, prognostic factors and differences between first and second waves

Purpose: The aim was to describe the clinical course and management of SARSCoV-2 infection in kidney transplant recipients (KTR) hospitalized with COVID-19, identify risk factors for severity, and analyze the differences between first (March-June) and second (Aug-Nov,2020) waves. Methods: Retrospective, single-center study in 48 KTR (24 in each wave) admitted with COVID-19. Baseline features, immunosuppression, clinical findings, laboratory and radiological data and therapies were analyzed to identify risk factors for “severe COVID” (requiring oxygen reservoir bag, high-flow nasal cannula and/or invasive mechanical ventilation). Results: Age was 58.9 ± 13 years, 75% were male, 60.5 (24-143) months after KT. 20.8% were nosocomial and there were 2 “reinfections”. Main symptoms were fever (71%), dyspnea (56%), cough (48%) and diarrhea (40%). 87.5% developed pneumonia, 77% needed supplemental oxygen, 14.6% were admitted to ICU (12.5% for invasive ventilation) and 8.3% died. Table 1 shows main differences in KTR with severe COVID. In multivariable regression analysis with different models including age, sex, blood group, comorbidity, immunosuppression, RAS blockers and:1) SatO2, platelets and LDH at admission: only everolimus (adjusted OR: 204, p 0.047) as independent predictor for severity.2) clinical course: everolimus (adjusted OR: 61.7, p 0.021) and poor clinical course at one week (adjusted OR: 546, p 0.015) were associated with severe COVID.In the second wave the patients consulted earlier (p 0.029) and SARS-CoV-2 infection was less severe (p 0.001) with less use of reservoir (p 0.008), lower inflammatory markers at admission [CRP (p 0.010), IL-6 (p 0.048) and ferritin (p 0.045)], and more mild cases without oxygen need (p 0.048). There were fewer pneumonia at admission and 48h after, but no differences at one-week, and more patients were treated with steroids (79% vs 42%, p 0.017). Conclusions: Everolimus could represent a risk factor for severity in KTR hospitalized with COVID-19. In the second wave there was a wider use of steroids, though SARS-CoV-2 infection was less severe.

Thrombotic thrombocytopenia following ChAdOx1 nCov-19 vaccination

Serious thromboembolic events with concurrent thrombocytopenia, sometimes accompanied by bleeding, have occurred very rarely following administration of the ChAdOx1 nCoV-19 vaccine. We report the case of a 59-year-old male with an unremarkable medical history who presented to the emergency department with increasing breathlessness five days after receiving the first dose of ChAdOx1 nCov-19. The patient's blood results showed mild thrombocytopenia and a very high D-dimer, and a pulmonary embolism was confirmed through a CT pulmonary angiogram, which led to a provisional diagnosis of vaccine-induced immune thrombotic thrombocytopenia. The condition was then treated with immunoglobulin and intravenous argatroban in line with the guidance from the Expert Haematology Panel focussed on Vaccine-induced Thrombosis and Thrombocytopenia before conversion to apixaban.