The bioethical controversy over triage during the COVID-19 pandemic

The COVID-19 pandemic has put public health systems in crisis due to the accelerated increase in admissions to emergency services and intensive care units (ICU). This demand for critical care in a global health emergency has led to the need for triage methods to adequately select the patients most likely to survive the disease with better quality of life and years of survival. However, problematic decisions about triage are not merely a medical matter, but a bioethical decision that involves considering other social criteria to select patients fairly and equitably. These decisions must be deliberate and endorsed by hospital bioethics committees, they should not be taken solely by the health personnel in charge. This article addresses the problem in a general way and refers to the situation in Mexico, based on available data. The use of random and first-come arrival methods at the hospital is questioned for not being the fairest and most efficient in the use of scarce critical medicine resources during this pandemic. It also discusses the feasibility of using, together with medical criteria, the criteria of "social utility", some of which have already been applied in cases of waiting lists in organ transplants, in cases of tie-breaking and to help a more careful selection of patients to increase the number of people benefited in the ICU and the quality of life of the survivors. © 2022 Universitat de Barcelona, Observatorio de Bioetica y Derecho. All rights reserved.

In bed hybrid tracheostomy procedure in COVID-19 patients. Technique and results

Background: COVID-19 pandemic, results in a great number of critically ill patients requiring long-lasting periods of invasive mechanical ventilatory support;tracheostomy is considered during their hospital stay, to free patients from ventilatory support and optimize the resources, we developed a safe in bed hybrid tracheostomy procedure to avoid the operating room and minimize SARS-CoV2 transmission due to aerosols exposure. Method(s): We developed this protocol using PDCA (Plan, Do, Check, Act) in order to perform a safe in bed hybrid tracheostomy: percutaneous tracheostomy + flexible bronchoscopy. We used the Ciaglia Blue Rhino technique and flexible bronchoscopy. We analyzed: Gender, age, body mass index, intubation days, ventilatory parameters, procedure time, apnea time, oxygen saturation, complications and patient clinical evolution. Statistical evaluation: Fisher test, U Mann-Whitney, T test, logistic regression and Kaplan-Meier curves. Result(s): From march 2020 to February 2021, 292 patients underwent hybrid tracheostomy;Tracheostomy was successfully completed in all patients: 211 men (72.2%);81 women (27.8%), age 58.5 years old, intubation days before tracheostomy 23 days (19 to 28 days), 133 patients (45.5%) deaths due to COVID19 complications. Procedure time 6 to 14 minutes (mean 9 minutes), apnea time 147 to 360 seconds (mean 240 seconds), O2 saturation 66%-96% (mean 87%), PaO2/fiO2 106-194 (mean 142), SOFA 4-6 (mean 5). No complications due to the trachesotomy. Conclusion(s): In bed hybrid tracheostomy procedure implementation with the PDCA cycles is safe, with good results, zero procedure complications and a good and rapid learning curve.

Return of the Dark Side: A Case Of ECMO Support in Advanced HIV/AIDS for Severe ARDS from SARS-CoV2, Pneumocystis Jirovecii(PJP) and CMV Pneumonitis

ECMO offering is limited to advanced HIV/AIDS patients. The Covid-19 pandemic exposed primary care shortage with resurgence of STDs, including HIV. At the same time, immunocompromised hosts with COVID-19 infection carried worse outcomes. We report a case of successful use of VV-ECMO in a newly diagnosed HIV/AIDS patient with severe ARDS as bridge to respiratory and immunologic recovery A 36-year-old white male diagnosed with moderate COVID-19 pneumonia in early August 2022, treated with steroids and remdesivir, found with HIV/AIDS stage 3 (CD4 of 28/5%) and high viral load (7 million cop/mL). Respiratory status declined to require invasive mechanical ventilation (MV) and unsuccessful trial of proning. Due to persistent hypoxemia, VV- ECMO was initiated in late August 2022. HIV antiretroviral therapy (ARV) was bictegravir/emtricitabine/tenofovir, then Dolutegravir + emtricitabine/tenofovir to enable nasogastric administration. Empirically treated with Bactrim and continued steroids for PJP, confirmed positive by PCR, in addition to high CMV titers in blood (129.000 IU/mL) and BAL (42.000 IU/mL), suggestive of CMV pneumonitis co-infection treated with Ganciclovir IV. Tracheostomy was performed on day 15. ECMO run faced formidable challenges including circuit insufficiency in the settings of possible Immune Reconstitution Inflammatory Syndrome with elevated cardiac output, managed with addition of right jugular vein return cannula;RV failure secondary to Pulmonary HTN, supported with inotropes and inhaled pulmonary vasodilators;uncertain ECMO pharmacodynamics for ARV and high sedative demands;thrombocytopenia (HIV and iatrogenic) deriving in spontaneous small subdural hematoma with no sequela. After 7 weeks of ECMO therapy, MV via tracheostomy was transitioned to High Flow Nasal Cannula while improving ECMO settings towards circuit weaning, HIV and CMV had virtually suppressed (252 cop/mL and 751 IU/mL, respectively), and CD4 increased to 122/18% COVID-19 pandemic propelled the use of ECMO therapy for severe ARDS and spotlighted healthcare access disparities with resurgence of vulnerable populations such the advanced HIV/AIDS patients. High-volume ECMO centers are acquiring expertise to enable survival of complex patients historically deprived of high-end therapies [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

The impact of SARS-CoV-2 pandemic on suicidal ideation admissions: a single adolescent and young adult psychiatry center experience

Introduction: The COVID-19 pandemic and the lockdown brought about a sense of fear and anxiety around the globe. This phenomenon led to both short and long term psychosocial and mental health implications for children and adolescents. Objective(s): To evaluate the effect of COVID-19 pandemic on hospital admissions for suicidal ideation in a Portuguese adolescent and young adult psychiatry service. Method(s): We conducted a single-center, retrospective study including adolescent and young adult patients (15-25 years old) admitted to our service with suicidal ideation within a year before and a year after the declaration date of SARS-CoV-2 disease as a pandemic. Patients were divided in two groups: Group A - patients admitted before the pandemic (March 11, 2019 and March 11, 2020) and Group B - patients admitted after the pandemic declaration (March 12, 2020 and March 12, 2021). The groups characteristics and outcomes were assessed and compared. Result(s):A total of 647 admissions were assessed (Group A, n=372 and Group B, n=275). Demographic characteristics were similar between groups. 75 patients (vs 25 patients) were admitted with suicidal ideation in the year before the pandemic. There was a lower proportion of patients admitted with suicidal ideation during the year after the pandemic year - OR 0.374 (95% CI 0.228-0.614, P<0.001). Conclusion(s): Our study showed a decrease in admissions for suicidal ideation in this service in the year after the pandemic. More studies are needed to understand the factors that may justify this decline and evaluate the longer effects of this pandemic in mental health.

Persistently positive PCR after COVID-19. How to diagnose reinfections? [Spanish]

Persistence of a long-term positive polymerase chain reaction (PCR) test in patients with severe coronavirus-associated respiratory syndrome may interfere with the diagnosis of reinfections, causing false positives of the disease, with the potential implications to determine the need for isolation and, consequently, for Public Health. In these field notes we present the experience of a patient with positive PCR of eight months of evolution to which an erroneous diagnosis of COVID-19 reinfection was made due to a gastrointestinal disease, resulting in a Campylobacter jejuni infection.

Mask use during high impact exercise in the pandemic

Background: The use of masks is one of the measures to protect against the Covid-19 pandemic. The type of mask and how to use it during physical exercise has generated controversy. This work aims to analyse the effect of the use of masks in the practice of high intensity physical exercise.

Coronavirus COVID-19 infection and breastfeeding: an exploratory review

Background: The new coronavirus disease is an infectious disease caused by the SARS-Cov-2 virus, considered by the World Health Organization (WHO) an international public health emergency that may have negative consequences during breastfeeding. The objective of this work is to investigate the action plan on breastfeeding in postpartum women with SARS-CoV-2 and her newborn.

EARLY ONSET COLORECTAL CANCER: RACIAL DISPARITIES & PRESENTATION TO HEALTH SYSTEM

Purpose/Background: Early onset CRC (EO CRC), patients <50yo, is increasing in incidence. Diagnosis is driven by symptoms as the patients are ineligible for screening. Where patients access the health system is unclear. Hypothesis/Aim: We hypothesize that non-white patients with EO CRC present at disproportionate rates to the Emergency Department (ED). Methods/Interventions: Our institutional tumor board registry was reviewed for patients who were presented from August 2020-August 2021. Clinical chart review for race, sex, age, hospital presentation, site of malignancy, and access to health system: primary care, emergency department, outside referral, were extracted. Access to the health system was determined by who ordered the diagnostic colonoscopy or imaging study. Results/Outcome(s): One-hundred ninety-seven patients with colon and rectal adenocarcinoma were discussed at tumor board between August 2020-August 2021 (Table 1). Fifty-seven were EO and 140/197 were age >50. The sex distribution was approximately equal across ages. Of those <50 the median age was 45, and non-white patients were disproportionally represented with 47% Hispanic, 17.5% Black, 10.5% Asian patients. Non-white EO patients were more likely to present through the ED (16/34) relative to white EO patients (1/13). Of all EO patients 17 presented through the Emergency Department, 24 through primary care providers, 11 were referred in from an outside facility, and 2 diagnosed internationally (Figure). Limitations: This is an exploratory, retrospective single institution review of patients discussed at multidisciplinary tumor board over a single year. The population includes a safety-net institution and may not reflect presentation patterns at other hospitals. The cohort size is underpowered for meaningful statistical comparison. The cohort was generated during the COVID-19 pandemic. Conclusions/Discussion: Patients with early onset colorectal cancer are referred for colonoscopic or imaging diagnostics through their primary care doctors, followed by the Emergency Department. Non-white patients, compared to other groups, access the healthcare system through the ED. However, whether this observation is due to the absence of a PCP access, due to restricted screening/diagnostic guidelines, or due to colonoscopic provider availability is unclear. Hispanic patients are disproportionately represented in our early onset cohort relative to the demographics of the hospital referral base. While the study is underpowered, it is provocative for requiring further investigation. Resources to heighten the suspicion for malignancy in patients presenting to our emergency departments and primary care offices, especially in young, non-white populations, may expedite access to diagnosis and definitive therapy for these patients. (Figure Presented).

PCR persistentemente positiva tras la COVID-19. inverted question mark Como diagnosticar las reinfecciones?

Persistence of a long-term positive polymerase chain reaction (PCR) test in patients with severe coronavirus-associated respiratory syndrome may interfere with the diagnosis of reinfections, causing false positives of the disease, with the potential implications to determine the need for isolation and, consequently, for Public Health. In these field notes we present the experience of a patient with positive PCR of eight months of evolution to which an erroneous diagnosis of COVID-19 reinfection was made due to a gastrointestinal disease, resulting in a Campylobacter jejuni infection.

Digital surveillance tools for contact tracking of infected persons by SARS-CoV-2

Background: In times of pandemic, case management and tracking people with contact can be differential elements for controlling the spread. The objective of this review was to evaluate the digital tools used to track contacts of people infected with SARS-CoV-2.

Impact of SARS-CoV-2 (COVID-19) on the mental health of healthcare professionals: a systematic review

Background: In times of this global pandemic situation, population's mental health is compromised, especially in those groups that are at the forefront of defense against the virus such as healthcare professionals. The objective of this study was to analyze the impact of the SARS-CoV-2 outbreak on healthcare professionals' mental health.

[Pcr persistentemente positiva tras la COVID-19. ¿Cómo diagnósticar las reinfecciones?]

Persistence of a long-term positive polymerase chain reaction (PCR) test in patients with severe coronavirus-associated respiratory syndrome may interfere with the diagnosis of reinfections, causing false positives of the disease, with the potential implications to determine the need for isolation and, consequently, for Public Health. In these field notes we present the experience of a patient with positive PCR of eight months of evolution to which an erroneous diagnosis of COVID-19 reinfection was made due to a gastrointestinal disease, resulting in a Campylobacter jejuni infection.

COVID-19 and climate variability, a critical combination for the Guatemalan agricultural sector

This study explored the impacts of the preventive isolation decreed by the national government, based on the perception of MAGA extension technicians from various departments and municipalities of Guatemala in productive systems of food security and of economic importance for three types of farmers: Infra-subsistence, Subsistence, and Surplus. Based on the information collected it was possible to estimate how much these farmers could be affected if in the medium term will suffer some type of climatic impact on their productive systems. The results of the study show that isolation and other measures taken by the COVID 19 pandemic generated impacts, mostly negative, on systems farmers of Guatemala. The impacts were greater for infra farmers, followed by subsistence farmers, and surplus farmers respectively. This shows the need to generate strategies and investments focused on the characteristics of the different types of farmers to allow economic recovery.

Related health factors of psychological distress during the COVID-19 pandemic in Spain

Measures to prevent and contain the COVID-19 health crisis include population confinement, with the consequent isolation and interruption of their usual activities. The aim of the study is to analyse psychological distress during the COVID-19 pandemic. For this, a cross-sectional observational study with a sample of 4180 people over the age of 18 during quarantine was developed. Variables considered were sociodemographic variables, physical symptoms, health conditions, COVID-19 contact history and psychological adjustment. The data were collected through a self-developed questionnaire and the General Health Questionnaire (GHQ-12). Bivariate analyses were performed, including Chi-Squared test and Student's T-test. Predictive ability was calculated through logistic regression. Results obtained showed a high level of psychological distress (72.0%), with a higher percentage in women and people of lower middle age. Statistically significant differences were found in the variable working situation (X2 = 63.139, p 0.001, V = 0.123) and living with children under the age of 16 (X2 = 7.393, p = 0.007, V = 0.042). The predictive variables with the highest weight were sex (OR = 1.952, 95% IC = (1.667, 2.286)), presence of symptoms (OR = 1.130, 95% CI = (1.074, 1.190)), and having had close contact with an individual with confirmed COVID-19 (OR = 1.241, 95% CI = (1.026, 1.500)). These results could enrich prevention interventions in public health and, in particular, in mental health in similar pandemic situations.

Communicating with families of emergency room inpatients during covid-19 pandemic

The current pandemic situation has led to a very important public health crisis that has altered social, economic and political aspects. These great changes have been reflected locally at a direct level, altering the working protocols of health centers. The process of health information for patients and communication with family members has also been affected by the therapeutic isolation of people infected with the SARS-Cov-2 virus. In the Adult Emergency Unit of the University Virgen del Rocio Hospital, where it was previously offered in person at established times, during the pandemic such process has been carried out by telephone, and not always systematically, because of the pressure of care. Being able to establish communication channels both to give the patient's health information to family members, and to get communication as close as possible between patient and family members, is essential to cover certain needs that appear in critical situations.

Risk factors for elderly people and recommendations for health professionals during the covid-19 health crisis

After declaring the state of alarm in Spain due to the CQVID-19 pandemic, people above 60 were declared a risk group, being the most extensive and punished population sector during the health crisis. Current scientific evidence indicates that isolation measures as a prevention method, the stigma that may arise from belonging to a risk group or the effects of the disease itself on the Person's social and family environment generate significant adverse effects on health, both physical and psychological, in elderly people. The evidence indicates the need for interventions from healthcare authorities and healthcare workers for the prevention of health issues such as the promotion of physical activity, coping strategies training, fighting against aging stereotypes or the adaptation of information and the media used to inform this group of the population, among others.

Spontaneous pneumomediastinum in COVID-19 patients. Case series.

Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

A bibliometric study on scientific production about COVID-19 in Ecuadorian institutions

During 2020, the pandemic caused by the SARS-CoV-2 virus has had considerable health-related impacts, as well as other economic, social, political, educational, and cultural effects. Due to their structural conditions, developing countries, such as Ecuador, are especially vulnerable to these circumstances. In this sense, the academy is one of the key agents in the responses that could and may be generated to cope with this crisis. This article presents a bibliometric review of the main trends within the scientific production generated by Ecuadorian authors about the covid-19 pandemic. The objective of the article is to present an overview of the main dynamics of Ecuadorian scientific production on this subject. For this purpose, we analyzed the academic documents indexed within the Scopus database in the period between January and October 2020, using the R package in R and VOSviewwe. The results show the development of an emerging corpus of literature, despite the complications caused by the pandemic. This literature is driven mainly by international cooperation. However, there are important gaps in studies on the social problems caused by the pandemic.

Bivalirudin as Therapeutic Anticoagulation in COVID-19 Patients on ECMO

Due to the inherent thrombotic risk associated with the ECMO circuit, therapeutic anticoagulation is recommended. While unfractionated heparin is commonly used due to wide availability, the use of bivalirudin, a direct thrombin inhibitor, is gaining popularity. The benefits of bivalirudin over heparin include: Relatively organ-independent metabolism, inhibition of fibrin-bound and freely circulating thrombin, rapid clearance, and less resistance. Early reports in the COVID-19 pandemic suggest a hypercoagulable state. Particular attention should be paid to adequate anticoagulation in the high-risk patients with SARs-CoV-2 on ECMO support. To date, there are few reports discussing the use of bivalirudin in COVID ECMO patients. Bivalirudin is the anticoagulation of choice for the maintenance of patients on ECMO at our institution. We conducted a retrospective analysis of the first 20 patients with COVID that required ECMO support. Data was collected on outcomes related to hemostasis. Standard protocol for ECMO patients includes screening duplex ultrasound at regular intervals following decannulation to evaluate for thromboembolism. Three patients did not receive screening due to terminal weans. Of the remaining 17 patients, 7 had confirmed acute venous thromboembolism. Four patients had hemorrhage requiring intervention;two cases of epistaxis, one intra-abdominal bleeding, and one cannulation site bleeding. One patient developed nonfatal intracranial hemorrhage that did not require intervention. Only two patients developed renal failure requiring temporary renal replacement therapy. This is in comparison to the 24% rate noted in the ELSO COVID-19 database. Our findings suggest bivalirudin is an alternative to heparin for appropriate COVID ECMO patients.

[Pregnancy care during COVID-19 epidemic, a drive for change?]

Prenatal care, understood as routine care provided during pregnancy, should be based on basic pillars, such as taking into account the sociocultural context in which such care is offered, ensuring that the service is appropriate, accessible and of high quality, and also with care personalized. According to World Health Organization, the minimum number of recommended visits during pregnancy should be eight, with the different professionals involved in the process, in addition to preparing for childbirth or maternal education. Since the pandemic erupted due to SARS-CoV-2, many of the usual social health services have had to adapt to provide safety and prevent infection, a priority in vulnerable groups where pregnant women are found. Professionals have had to adapt to telematics care, thus attending consultations to reduce the mobility of pregnant women to health centers, thus avoiding unnecessary risks. Therefore, all this situation has opened a virtual field of work that, although previously carried out in different areas, now more than ever acquires special relevance and for which professional training is necessary, as a complement to face-to-face appointments.