Long-term functional outcome of severe COVID19 pneumonia treated with venovenous extracorporeal membrane oxygenation support - learnings from a single centre

Objectives: Implementation of venovenous extracorporeal membrane oxygenation (VVECMO) allowed survival of patients with severe respiratory failure associated with SARS-CoV-2 infection. However, VVECMO treatment is usually associated with long ICU stays, prolonged sedation, and neuromuscular blockage days. Functional disability, due to delirium and acquired muscle weakness, is frequently an inevitable burden causing long term disability. This study aims to analyse main characteristics of patients under ECMO due to COVID-19 pneumonia, their outcomes and functional status six months after ICU discharge. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients receiving VVECMO for SARS-CoV-2 infection were included. Epidemiological and clinical data were reviewed. Functional status at 6 months after ICU discharge was assessed with modified Rankin Scale (mRS). Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9, mean SAPS II was 35.6+/-13.6. Mean time from intubation to cannulation was 5+/-5.6 days in 91 patients;awake-ECMO was performed in 2 patients. Mean ECMO run duration was 33.1+/-30 days (longest ECMO run was 194 days). A period of awake-ECMO was performed on 36.5% of patients, during 16.4+/-21.2 days. ICU-acquired weakness was diagnosed on 64.5% of patients and delirium on 63.4%. Mortality was 24.7% (23 patients) with only 1 patient deceased in hospital after ICU discharge. At 6 months follow-up, all patients were still alive and most of them (65.1%) were independent on all daily activities (mRS <= 2). Conclusion(s): Patients with severe COVID-19 treated with VVECMO support had very good functional outcomes at six-month follow-up. Despite long ICU length-of-stay, high incidence of delirium and acquired muscle weakness, full recovery at six-month post-ICU discharge was achievable in most patients.

Membrane dysfunction in patients with severe COVID-19 treated with venovenous extracorporeal membrane oxygenation - analysis from a pooled data from a single centre

Objectives: It is well known that severe COVID-19 is associated with complex immunological and inflammatory dysregulation. Both these physiopathological events translate to a high risk of major thrombotic or hemorrhagic events. In patients treated with venovenous extracorporeal membrane oxygenation (VVECMO), membrane dysfunction might affect systemic oxygenation and limit its duration-expectancy. This study aimed to assess the possible causes of extracorporeal membrane failure in COVID-19 patients and its impact on outcome. Method(s): Retrospective, single-center, observational case-control study involving adult COVID-19 patients admitted to an ECMO referral centre in a tertiary university hospital. All patients required VVECMO for acute respiratory failure, including 48 cases who needed one or more extracorporeal membrane exchanges and 45 controls (no membrane exchange). These two groups were compared for demographic characteristics, severity of the disease using validated scores (SAPS II and SOFA), duration of ECMO run, coagulation assessment, cumulative anticoagulation dose, associated complications, and outcomes (ICU and hospital mortality). Result(s): Most patients were males (71.0%) and younger than 50 years (79.5%). Median ECMO run duration was significantly longer in the case group (35.0 vs 14.0 days, p <0.001), as well as ICU length-of-stay (45.5 vs 28 days, p <0.001). Membrane exchange tended to be associated with sepsis (56% vs 33%, p=0.037), major hemorrhage (58% vs 43%, p=0.022), heparin-induced thrombocytopenia (25% vs 9%, p=0.054), higher D-dimer title (17.36 ng/dL vs 7.5 ng/dL, p=0.07) and lower platelet counts (133.000/muL vs 154.000/muL). Median SAPS II (32.0 vs 33.0, p=0.20) and the mortality (27% vs 24%, p >0.99) were similar between these groups. Conclusion(s): In patients with SARS-CoV-2 pneumonia and severe hypoxemia treated with VVECMO support the emergence of infection, coagulopathy and inflammation were associated with high risk of membrane dysfunction. No impact on mortality could be confirmed from these data. Anticoagulation monitoring and dosing strategies should be reinforced to promote membrane protection.

Determinants of death in patients with COVID-19 pneumonia treated with venovenous extracorporeal membrane oxygenation support

Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.

Single centre, cross-sectional assessment of airway hemorrhage in a cohort of patients with COVID19-associated ARDS under Venovenous extracorporeal membrane oxygenation

Objectives: Airway hemorrhage (AH) frequently complicates extracorporeal membrane oxygenation (ECMO) treatment. Inflammation, coagulopathy and antithrombotic therapy are contributing factors. Patients with COVID-19- associated ARDS (CARDS) supported with ECMO present all these features. We aim to characterize the incidence and the clinical and prognostic impact of AH. Method(s): Review of a cohort of patients with CARDS treated with ECMO support at a single ECMO centre between March 2020-February 2022 (n=92). AH was defined as a clinically significant hemorrhage fit demanded interruption of anticoagulation, transfusional support or bronchoscopy. Univariate analysis was performed using GraphPadPrism. Result(s): One third (n= 31) of patients with CARDS treated with ECMO had clinically significant AH. Patients who developed AH had significantly longer ICU length-of-stay (LoS), ECMO run and invasive mechanical ventilation (IMV) duration. Significant differences in coagulation and inflammatory markers were detected between patients with early (<72h) versus late (>9 days) onset of AH (Table 1). Mortality at day 90, demographics, comorbidities, CT scan pattern and clinical severity indexes were similar between patients with and without AH (NAH). Conclusion(s): In patients with severe CARDS treated with ECMO support, the occurrence of airway hemorrhage leads to clinically important morbidity but does not increase mortality. Distinct pathways may be involved in the development of early v. late AH. (Table Presented).

Portugália airlines: The case of the Turin route

Of all the Portuguese private airlines that for many years competed with TAP Air Portugal (the Portuguese owned state airline) only Portugália Airlines (PGA) resisted the hegemony of the Portuguese flag carrier until it was bought by TAP itself. Portugália Airlines, a private airline, managed to maintain its operation, even against the power of the state company. This case study shows how PGA operated certain routes (here the Turin example, in Italy) as a survival strategy. The approach is exploratory and based on an observational description of facts. In view of the recent events caused by COVID 19, the pandemic has brought about a change in business models, also providing the warning that anyone who does not have a clear strategy, dies at birth. The case study leaves some interesting clues to explore. © 2023, IGI Global. All rights reserved.

National Policies and Territorial Cohesion

Since March 2020, the European Union has launched a wide range of initiatives to tackle the COVID‐19 pandemic, mainly through two complementary channels "through creating a new set of initiatives aimed specifically at resolving and or mitigating the effects of the pandemic in terms of public health, but also the resulting economic and social effects [and] by mobilizing a set of policies and public policy instruments to combat the effects of the pandemic, with the purpose of allocating resources to the new needs of the European economy and society” (Neto in Europa XXI J Regional Sci Territorial Policies 38:33–50, 2020). The main objectives of this chapter are: (i) to analyse the extent to which the new European rationale of policies to respond to the economic and social impacts of the pandemic, and in particular the European Recovery and Resilience Facility, enabled the emergence of a new generation of strategies and national public policies, which, within the framework of the great principles of the European Union that guide recovery, seek to provide specific answers to the way in which each member state was affected by the pandemic and how it conceives its recovery process;(ii) Carry out a comparative analysis of the intervention rationales of the Recovery and Resilience Plans (RRP) of a set of Member States;(iii) Evaluate how each of these RRPs establishes and/or foresees, or not, some model of articulation with the respective Partnership Agreements 2014–2020 and 2021–2027 of the Cohesion Policy;(iv) Analyse to what extent each RRP assumes or determines, or not, a territorialisation of its intervention. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

An effective Approach for Pneumonia Detection using Convolution Vision Transformer

Early detection of pneumonia in patients through effective medical imaging may enable timely remedial measures and reduce the severity of the infection. There is an increase in cases among new-borns, teenagers and also people with health issues in recent years. The COVID-19 pandemic also revealed the major impact pneumonia had on the lungs and the consequences of delayed detection. The presence of the infection in the lungs is examined through images of Chest X-ray, however, for an early diagnosis of the infection, this paper proposes an automated model as a more effective alternative. Convolutional Vision Transformer (CVT) which gives an accuracy of 97.13%, and is a robust combination of Convolution and Vision Transformer (ViT), is suggested in this paper as a potential model to detect pneumonia early in patients. © 2022 IEEE.

Medicines' sales and shortages during the COVID-19 outbreak: A nationwide retrospective analysis

Background: The COVID-19 is a worldwide public health emergency. A possible direct result of this international outbreak is the disruption of medicine supply chains, which may also have consequences in the increase of drug shortages. Community pharmacies can contribute to early identification and report of medicines' supply and demand problems. Purpose(s): The aim of this study is to characterise the impact of COVID-19 on the outpatient medicines' sales and shortages during the initial outbreak Methods: A retrospective, time-trend analysis of medicine sales and shortages was performed from the 1st February to 30th April 2020 and its homologous period. Portuguese daily new laboratory confirmed COVID-19 cases and major national emergency measures were recorded. All data were subjected to rescaling using the min-max normalisation method to become comparable. Data analysis was performed using Microsoft Excel. Result(s): The COVID-19 outbreak resulted in an increased demand for medicines, with a peak reached just after the World Health Organization declaration of the state of pandemic. By the end of March, sales had already dropped to proportions similar to those of 2019. The maximum proportion of drug shortages was reached about one week after the sales peak and by the end of the study period its values were below those recorded in the pre-COVID-19 period. Conclusion(s): Data suggest medicines' sales and shortages were initially impacted by the COVID-19 outbreak in Portugal, although by the end of the study period, medicine markets had normalised. The long-term impacts of this pandemic on medicines' sales and shortages are unknown and should continue to be closely monitored.

Can COVID-19 outbreak be anticipated by community pharmacy sales? A retrospective analysis

Background: In large-scale community transmission, such as severe acute respiratory syndrome of the COVID-19, monitoring geographic trends and estimating the transmission intensity is critical to support decisions on actions to be taken. Though major efforts are concentrated on testing the populations, the availability and timing of this data pose a clear limitation to realtime monitoring. Purpose(s): This study proposes a retrospective analysis to develop a novel methodology to detect and monitor the COVID-19 epidemiological activity using a selected subset of over-the-counter (OTC) products sold in community pharmacies in Portugal. Previous studies have successfully demonstrated this approach to different epidemiological outbreaks as individuals tend to self-manage the symptoms. Method(s): The subset of OTC products was selected considering therapeutic indication for symptoms of infection by SARS-CoV-2 and the trends observed for diagnosed cases in Portugal. The similarities between the trends of the subset of products and the daily new-suspected and new-confirmed cases of COVID-19, respectively, were assessed using lagged spearman correlation analysis. The trend of the subset of products selected presented high and statistically significant correlations to new-suspected and new-confirmed cases lagging 14-16 days (correl.>0.82;p<0.001). Highest correlation to both new-suspected and new-confirmed cases was found lagging 15 days (0.879 and 0.888, respectively;p<0.001). Conclusion(s): The study supports the use of the methodology presented to anticipate the trends of COVID-19 outbreaks in Portugal, both locally and nationwide, considering representativity of the presence of community pharmacies to the distribution of populations.

Sars-Cov-2 Vaccine Safety in Adolescents with Inflammatory Rheumatic and Musculoskeletal Diseases and Adults with Juvenile Idiopathic Arthritis: Data from the Eular Covax Physicianreported Registry

Introduction/Background: There is a lack of data on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccination safety in children and young people (CYP) with rheumatic and musculoskeletal diseases (RMDs) as they were excluded from initial vaccine trials. Vaccination guidance is based on data from adults with or CYP without RMDs. Description/Method: Our objective was to describe the safety of SARS-COV-2 vaccination in adolescents with inflammatory RMDs and adults with JIA. We described patient characteristics, flares, and adverse events in adolescent cases under 18 with inflammatory RMDs and adult cases aged 18 or above with JIA submitted to the European Alliance of Associations for Rheumatology (EULAR) COVAX registry. Discussion/Results: Thirty-six adolescent cases were reported from 4 countries, mostly female (58%) with JIA (42%: 28% non-systemic JIA, 14% systemic JIA) and a median age of 15 [IQR: 14.5, 17]. Most were in remission (64%) or had minimal (22%) disease activity at the time of vaccination. Over half of the adolescent group (56%) reported early reactogenic-like AEs. One mild polyarthralgia flare and one serious AE of special interest (malaise) were reported. No CYP reported SARS-CoV-2 infection post-vaccination. No cases of paediatric inflammatory multi-system syndrome or myocarditis adverse events were reported. Seventy-four adult JIA cases were reported from 11 countries;73% were female with a median age of 26 [IQR: 23, 31]. Eight-five percent had ns-JIA and 15% had s-JIA. Almost two thirds (62%) reported early reactogenic-like AEs and two flares were reported (mild polyarthralgia and moderate uveitis). No serious AEs of special interest were reported among adults with JIA. Three 20-30 year old females were diagnosed with SARS-CoV-2 post-vaccination;all fully recovered. Key learning points/Conclusion: In this observational registry dataset, SARS-CoV-2 vaccines appeared safe in adolescents with RMDs and adults with JIA, with a low frequency of disease flares, serious AEs, and SARS-CoV-2 re-infection seen in both populations.

A Atuacao Do Psicologo No Pronto Socorro Adulto E O Apoio Aos Pacientes E Familiares Na Pandemia Covid-19

A atuacao do psicologo no pronto socorro nao se refere apenas a atencao direta ao paciente, refere-se tambem atencao que e dispensada a familia e a equipe de saude, dentro de sua atuacao profissional. O psicologo promove mudancas, atividades curativas e de prevencao, minimizando o sofrimento do impacto da hospitalizacao, principalmente em tempos que o paciente e a familia nao podem estar juntos em um momento tao delicado. O presente trabalho foi idealizado a partir da experiencia do recebimento das familias no PSA nos tempos de COVID-19 no Hospital Samaritano Higienopolis. Como resultado dessas praticas, esse trabalho pretendeu reunir uma analise de dados referentes aos meses de trabalho, com o objetivo central de propiciar uma reflexao acerca da importancia do apoio psicologico no hospital geral durante a pandemia COVID-19. De setembro de 2020 a janeiro de 2022, foram realizados 2147 atendimentos aos pacientes e familiares, somando 541 familiares atendidos no programa de cuidados especiais ao obito, 129 pacientes e familiares em saude mental com COVID, 323 pacientes e familiares no protocolo de cuidados paliativos, 110 pacientes e familiares da oncologia, 625 pacientes e familiares em protocolo idoso fragil. Por esses dados, podemos perceber que em nosso hospital, a equipe de psicologia esta inserida de forma que abrange grande parte dos pacientes hospitalizados. O acompanhamento psicologico a familia durante a pandemia foi essencial pois o momento de crise acometido pelo sentimento de impotencia frente ao adoecer de seu ente querido resultava em intenso sofrimento psiquico e fragil estado emocional geral, aos pacientes, familiares e tambem as equipes de saude. Nessa medida, incluimos um fluxo constituido pelo recebimento afetuoso do familiar ja no Pronto Socorro Adulto, favorecimento de rituais de despedida nesse momento de separacao, realizacao de prontuario afetivo, transicao de cuidados a equipe das Unidades de Terapia Intensiva, acompanhamento do paciente nos exames diagnosticos, preparo para internacao nas Unidades COVID, preparo para intubacao (tambem com rituais de despedida atraves de video chamada), acompanhamento psicologico do paciente e acompanhamento remoto aos familiares. Constatamos que a flexibilizacao do fazer psicologico a partir dessa nova realidade, foi fundamental, pois o acolhimento a familia e a possibilidade de trocas imediatas com a equipe moldou o cenario do Pronto Socorro favorecendo o melhor cuidado. Copyright © 2022

Digital transformation in school management: the legacy that strategic actions in the 2020s leave for future pandemics

With the outbreak of social withdrawal due to the pandemic, many countries have undergone drastic transformations in various spheres. In education, face-to-face classes were transformed into distance learning. However, this sudden change caused several problems for students and teachers. Given these events, the purpose of this article was to propose exceptional actions to improve the transition from face-to-face classes to virtual classes. For this, the elements that positively and negatively impacted education in the Covid-19 pandemic were identified in the literature. These elements were then clustered into four strategies, these being: redesign of pedagogical practices, psychological and social support, technological infrastructure in virtual teaching, and school management to cope with the pandemic scenario. The multiple case study method was used, investigating five technical schools located in the state of São Paulo (Brazil). With this, it was possible to propose 10 exceptional actions aimed at the transition from face-to-face classes to virtual classes. The main novelty of this article was the proposition of actions to motivate the school community against the impacts of the pandemic, building memory in its agents, making them more prepared for unexpected events. © 2022 Brazilian Institute for Information in Science and Technology. All rights reserved.

2030 Sustainable Development Goals and higher education: A digital experience in the context of the Interdisciplinary Service-Learning

The digital revolution has played a decisive role in economic and social development. With Covid-19, the need to maintain services and organizations working, adjusting to the social distancing rules, forced institutions to develop new strategies using technologies. In this context, CapacitAmente Project was developed at Universidade Católica Portuguesa, integrating teachers and students from Social Work and Psychology dedicated to promoting continuous training to employees of social solidarity institutions. Using the Service-Learning methodology to implement this interdisciplinary project, a set of actions were developed anchored in the 2030 Agenda for Sustainable Development, in close collaboration with United Nations University. This project constitutes a potential contribution of good practices for Digital Governance, making theoretical and practical knowledge accessible to all without discrimination, supporting the formulation of policies and the provision of services for the SDGs. © 2022 ACM.

Telehealth maintains access to early phase clinical trials during the Covid-19 pandemic

Aims: The COVID-19 pandemic substantially disrupted healthcare globally. Quarantine, travel restrictions, health worker furloughs and institutional mandates to limit non-essential clinical activity significantly impacted upon trials recruitment abroad. The purpose of this review was to compare the demographics and enrolment for patients referred to The Kinghorn Cancer Centre (TKCC) Phase 1 Unit between January 2020 and March 2022, with historical data from the same institution from the twelve months prior to determine the impact of COVID-19 on Phase 1 activity. Method(s): A single institutional retrospective study was performed utilising a purpose-built Phase 1 database. Data extracted from electronic medical records and trials electronic data capture software included patient demographics, date and method of first review, consent date, screen-failure rate, date to enrolment, duration on trial and outcome post-trial. Analyses were performed in SPSS V26.0. Result(s): Four hundred and thirty-four patients were referred/seen in the Phase 1 unit between January 2020 and March 2022 (16/month), of which 341 (79%) were consented/screened onto a Phase 1 trial and 157 (46%) proceeded to treatment. The proportion initial consultations using telehealth increased from 11.3% to 45.3% pre-post pandemic (P < 0.0001). However, the proportion of interstate referrals or regional/remote referrals did not change likely to widespread increase in telehealth utilisation. Pandemic-induced lockdowns decreased absolute numbers of Phase 1 referrals in the short term, however did not influence enrolment or screen failure rates. Further mitigation strategies successfully employed at our Phase 1 unit included treatment-athome, teleconsenting, Phase 1 coordinators/investigators working in split teams, and remote monitoring. Conclusion(s): The COVID-19 pandemic did not impact upon the demographics of Phase 1 referrals to a major metropolitan hospital, however absolute numbers of referrals were influenced by lockdowns/ outbreaks. Telehealth was successful at maintaining access to trials for patients in need and should be continued to allow equity of access to Phase 1 trials.

The Emergence of CKD After COVID-19 Related AKI

Background: Acute kidney injury (AKI) can eventually progress into chronic kidney disease (CKD) and end-stage kidney disease (ESKD). COVID-19 is a multisystemic disorder that often causes AKI. The purpose of this study is to assess the frequency and association of clinical variables in patients who developed CKD and ESKD after COVID-19-related AKI. Method(s): We performed a one-year follow-up study with 182 survivor patients admitted to the ward and intensive care unit (ICU) with COVID-19 between April 2020 and March 2021 at Hospital Sao Paulo, Brazil. Patients aged >= 18 years with COVID-19 confirmed on RT-PCR were included. Patients with ESKD before hospitalization were excluded. AKI and CKD were defined according to the KDIGO criteria. We evaluated the frequency of AKI. After it, we compared some clinical variables and outcomes in two subgroups: CKD after CoV-AKI, and non-CKD after COVID-19. Univariate and multivariate analyses were performed. Result(s): 137 (75.3%) patients developed AKI. Of these, 56 (30.8%) needed kidney replacement terapy (KRT) in-hospital. There were higher frequencies of diabetes and hypertension with lower eGFR (84.2+/-24.9, 94.4+/-29.9 ml/min;p=0.08) and mean arterial pressure (74.9+/-9.6, 79.1+/-7.7 mmHg;p=0.03) at baseline in CKD after CoV-AKI group. Hypertension was independently associated with CKD in binary logistic regression [OR: 4.472, 95% CI:1356-13886;p=0.001]. We further observed that all patients who progressed to ESKD (n=7;3.9%) had non-dialytic CKD exacerbated by COVID-19 requiring KRT. Conclusion(s): Hypertension was the independent clinical factor associated with progression to CKD after COVID-19-related AKI. All patients who progressed to ESKD had CKD exacerbated by COVID-19 requiring KRT.