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The present chapter focuses on the mechanisms of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, pathogenesis, and the possible therapeutic strategies targeted to the viral receptors, purinergic and kallikrein-kinin systems. SARS-CoV-2 spike protein binds with high affinity to the human ACE2 receptor on host cells, but it can also interact with other receptors and enzymes. Following viral infection, a plethora of subsequent molecular and cellular alterations occurs in the host. These alterations, which include the cytokine and bradykinin storms, as well as exacerbated ATP signalling, have been implicated in the genesis and progression of the signs and symptoms observed in COVID-19 patients. These routes and systems provide important targets for developing specific and effective anti-COVID-19 drugs, as well as reveal a novel understanding of pathogenesis and tropism of SARS-CoV-2. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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Background: Coronavirus disease 2019 (COVID-19) has been associated with significant morbidity and mortality, with cardiovascular involvement being usual. Elevations in cardiac Troponin-I level has proposed as an independent biomarker for mortality among patients with COVID-19. Aim(s): To evaluate the role of high sensivity Troponin-I (hs-TnI) level at hospital admission in predicting 30 day in-hospital mortality and 6-month mortality in patients hospitalized with a COVID-19 diagnosis. Method(s): We performed a retrospective single-center cohort study including consecutive patients aged 18 years and older who were admitted for COVID-19, during a 1-year period (n=818). We excluded patients with acute coronary syndrome (n=23), patients with acute heart failure (n=42), and patients in which hs-TnI level was not dosed at admission (n=163). Patients were divided into two groups according to hs-TnI levels: Hs-TnI <19.8 vs hs-TnI >=19.8 pg/mL. Primary outcomes were 30-day in-hospital mortality and 6-months mortality. According to the data distribution, appropriate statistical tests were conducted to compare independent samples. Multivariable logistic regression was used to analyze mortality risk. Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of hs-TnI as a predictor of mortality. (Figure 1). Result(s): This cohort included 590 patients. Mean age was 71 >=+/-15 years and 52.4% were men. Overall, 209 patients (35.4%) had elevated hs- TnI levels and 381 patients had normal hs-TnI levels. Individuals in the hs-TnI >=19.8 pg/mL group were older (80+/-11 vs 66+/-14 years, p<0.001) and presented higher prevalence of chronic heart failure (24.9% vs 7.1%, p<0.001), hypertension (77.0% vs 57.5%, p<0.001), atrial fibrillation/flutter (19.1% vs 5.5%, p<0.001), prior stroke (12.4% vs 5.2%, p=0.001) and ischemic heart disease (12.4% vs 3.7%, p<0.001). There was no difference in length of hospital stay between the groups (8.0 [IQR 9.6] in hs-TnI 19.8 pg/mL group vs 9.0 [IQR 8.0] normal hs-TnI group, p=0.669). Troponin-I was the only independent predictor of in-hospital mortality (OR 3.80, CI 95%: 2.44-5.93, p<0.001), see Table 1. The troponin levels had the highest area under the receiver operating characteristic curv (AUC) with an AUC of 0.705 (95% CI: 0.667-0.742, p<0.001) for association with the inhospital mortality (figure 1). There was no difference in 6-months mortality between the two groups. Conclusion(s): Acute myocardial injury is common in patients hospitalized with COVID-19. In the present study a TnI level >=19.8 pg/mL was predictor of 30 days in-hospital mortality, suggesting that raised levels of this biomarker is associated with adverse prognosis. This tool might be useful for COVID-19 patient risk stratification. Further studies are needed to provide robust data and reliable recommendations on this theme.
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Covid19 pandemic has stimulated both the discussion on the use of IT related teaching tools and the exposure of the student population to vulnerabilities linked to cybersecurity literacy. The study presented is based on the assumption that the use of gamification as an element or tool that promotes learning within digital environments may be feasible, and more specifically may function as a teaching element on issues related to cybersecurity for students, especially for higher education students. In order to quantify the openness of students to such a tool path, quantitative methodology was used, and a survey was carried out in two Polytechnic Institutions (PI), achieving a sample of 95 students, and seeking perceptions on positive impacts resulting from the creation of a game scenario for better learning. The statistical analysis conducted tested hypotheses regarding representations and practices about gamification and cybersecurity. Results show that students, regardless of their higher education course, clearly understand what Gamification is and its goals, and also that students adopt good cybersecurity practices according to their higher education course. This last result goes accordingly with the supposition that gamification can and should be used in cybersecurity literacy.
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Aim: The impact of a delay from treatment decision to surgery in colorectal cancer is unknown. The COVID-19 pandemic has provided a unique opportunity to ethically research the topic. This study aimed to compare the short-term oncological outcomes for colorectal cancer patients undergoing delayed versus non-delayed surgery. Method(s): This international prospective cohort study included consecutive colorectal cancer patients with a treatment decision for curative surgery, from February to July 2020. A delayed surgery was defined as being performed > 4 weeks after treatment decision. Further delays of 6 and 8 weeks after treatment decision were analysed. Surgical delays were analysed only in patients who did not receive neoadjuvant therapy. The primary outcome measure was poor oncological outcome, defined as progression to unresectable disease or positive resection margins. Result(s): Overall, 5453 patients from 47 countries were included, of which 9.6% (522/5453) did not receive the planned operation. Of the operated patients, 15.6% (767/4931) received neoadjuvant therapy. From the patients who went straight to surgery, 38.7% (1611/4164) were delayed beyond four weeks. Delayed patients were more likely to be older, male, more comorbid, have a higher BMI. Rectal cancers and early stage patients were more exposed to delay. After adjustment, delay was not associated with increased risk of a poor oncological outcome (OR = 0.89 (0.68-1.17, P = 0.415). Longer delays also did not show worse outcomes. Conclusion(s): One in ten colorectal cancer patients did not receive their planned operation during the COVID-19 pandemic. Delay to surgery did not impair short-term oncological outcomes and seems safe to be used during future pandemic waves if needed. Further research is needed to assess the long-term effects of surgical delay.
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Early evidence suggests that the COVID-19 pandemic may have reduced the proportion of individuals submitted to cervical, colorectal and breast cancer screening. However, the recovery from the pandemic impact was very heterogeneous. We aim to explore the impact of the pandemic on cancer screening and estimate the time to recover lost screening opportunities in Portugal. We used an interrupted time series to analyze the impact of the pandemic on the implementation of cancer screening. The study population was the eligible individuals screened for cervical, colorectal and breast cancer by month and health region between 2018 and 2021. We used Poisson regression with health region random effects to estimate the trend before and after the first lockdown (March 2020) and the impact of the first lockdown. We predicted the counterfactual evolution without a pandemic to estimate lost screening opportunities. The first lockdown resulted in 93,1% (95%CI 92,9-93,2), 89,4% (95%CI 89,2-89,5) and 84,1% (95%CI 83,8-84,3) decrease in the proportion of expected cervical, colorectal and breast cancer screening tests. Nonetheless, we document an increased trend difference between pre and post lockdown of 6,0% (95%CI 5,9-6,0) and 5,3% (95%CI 5,3-5,4), 3,7% (95%CI 3,6-3,7) per month. However, by December 2021, there are still many lost screening opportunities due to the pandemic - 293k cervical cytology tests (42,2% less than expected), 247k fecal occult blood tests (28,7%) and 388k mammograms (38,4%). The first lockdown resulted in an abrupt decrease in cancer screening. However, we document an increase in the cancer screening trend after the pandemic. Nevertheless, there are still considerable lost screening opportunities after 2 years. Key messages • The pandemic caused a massive disruption in cancer screening. Although there was an increase in screening trends after the first lockdown, 2 years later, many lost screening opportunities remain. • Population-based screenings need to increase the outputs to account for lost screening opportunities due to the pandemic.
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Prevent and control healthcare-associated infections (HAIs) is a priority in healthcare assistance, not only due to present COVID-19 pandemic. Annually, around 3.2 million patients are affected by one of these infections and it is estimated that without controlling them, by 2050, 10 million more people could die every year, with especial relevance among elderly with infectious situations representing a third of mortality in people over 65 years old. Higher Education Institutions (HEI) in healthcare area have an important role in this panorama, by preparing students to be future professionals, stimulating them to have an innovative and entrepreneurial approach to today’s real-life challenges. A mixed-methods research was conducted, at European level (in Portugal, Finland, Poland and Spain), to facilitate learning of good practices on HAIs prevention and control while developing innovative solutions. 1475 participants were enrolled, from all partner HEI: 79 professors and mentors were interviewed (individual or focus group), 1326 final year nursing students made a self-report inventory (application of InovSafeCare Scale) and 70 students participated on focus group (agile piloting of the Model). The result of this research is a pedagogical model that mixes dimensions and methods that take nursing students closer to the demands of HAIs prevention and control and capacitates them to transfer knowledge to work settings with an innovative and entrepreneurial perspective – the InovSafeCare Model. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.
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Aim: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Method: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351;best case 196, worst case 816) or non-cancer surgery (733;best case 407, worst case 1664). Both exceeded the NNV in the general population (1840;best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusions: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.
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Background: Respiratory syncytial virus (RSV) is the main cause of acute bronchiolitis. The peak of the infection is historically described in the autumn/winter season. The 2020 COVID-19 pandemic seems to have modified the seasonality of some respiratory viruses. The first case of SARS-CoV-2 infection diagnosed in Portugal was in March 2020. School closure and the use of masks are some of the pointed reasons for a decreased number of RSV infections observed in the autumn/winter season post the beginning of the pandemic. Interestingly, there are now a few studies from around the globe showing the resurgence of RSV infections in the spring/summer season that followed. Aim: To characterize the population of RSV infected infants admitted to a tertiary hospital before and after the beginning of the COVID-19 pandemic. Methods: A retrospective, descriptive, study was performed. All the RSV infected infants who were admitted to a Portuguese tertiary hospital from January 2017 to August 2021 were evaluated. The diagnosis of RSV infection was made through polymerase chain reaction of nasal secretions. Data such as age, gender, reason for admission, comorbidities, viral coinfection, bacterial superinfection, oxygen therapy, admission at Intensive Care Unit, ventilatory support and length of hospital stay were analyzed. Results: The data of a total of 354 patients was analyzed. The median age was 4 months (min 9 days, max 4 years), 50% were male. Before the COVID-19 pandemics (between 2017 and 2019), the peak of RSV infections used to occur in the months of December and January (medium of 25 and 28 cases per month, respectively). However, in December 2020 and January 2021 there was no detection of RSV. Nonetheless, a peak of RSV infection was verified in July and August 2021 (18 and 15 cases per month, respectively). The number of patients admitted for non-respiratory motifs, but in whom RSV was detected during the course of hospital stay, increased in 2021 (39%), comparing to 2017 (0%), 2018 (3%), 2019 (8%) or 2020 (3%), p<0,05. The number of viral coinfections was higher in 2021 (50%) comparing to 2017 (29%), 2019 (19%) or 2020 (18%), p<0,05. The patients admitted in 2021 were older (12 months average) than patients admitted in 2017 (5 months average) or 2018 (6 months average), p<0,05. Conclusions: RSV seasonality was modified by the COVID-19 pandemic, with an increase of the hospital admissions being registered in the summer of 2021. Our tertiary hospital's numbers reproduce what is being described in other places of the world. Subsequent studies are needed to verify the behavior of RSV infections in the next seasons, to understand if RSV infections are becoming more or less severe and to analyze the impact of SARS-CoV-2 virus on the virulence of RSV.
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An effective control of the COVID-19 pandemic requires a thorough epidemiological interview of reported cases. The interviewer's skills and preparation directly affect the outcome of the investigation. This study applied a self-assessment survey of the COVID-19 patient interviewing skills on a local public health department workforce. The findings may be used to improve the quality of the interview process and the overall response to the pandemic at a community level. A 50-item questionnaire using a four-point Likert scale was adapted from the COVID-19 Patient Interview Skills Assessment Form created by the Centers for Disease Control and Prevention (CDC) and applied to 50 healthcare workers involved in epidemiological investigation of COVID-19 cases in Almada and Seixal, two municipalities of the Lisbon Metropolitan Area, from January to April of 2021. The most frequently executed steps concern checking patient data in advance (92%), questioning symptoms (97.2%), contact tracing (100%) and determining isolation periods for high risk contacts (100%). Least performed tasks include confirming the testing technique used (50%), asking about hospitalization (44.4%), assessing conditions for home isolation (44%), explaining how to self-monitor symptoms (61%) and checking if the patient understood the instructions (47%). In addition, 8% admitted to not always keeping patient information confidential. While caution is necessary as the data was limited to a single public health local department, our findings show that a majority of healthcare workers fulfill the essential steps of an epidemiological investigation. Areas in need of improvement include inquiring about infection severity, assessing social conditions for quarantine and confirming instructions for self-monitoring and follow-up. In line with CDC recommendations, we believe regular evaluation and feedback of case investigators' skills are crucial to quality assurance of a public health department. Key messages A detailed interview provides critical data for monitoring infected individuals and quickly trace, test and isolate those who might have been exposed, thus breaking chains of transmission. The results of this assessment can be used to introduce training measures such as shadowing and role-playing to ensure continued improvement in epidemiological investigations.
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The pandemic caused by SARS-CoV-2 brought to society a health crisis that drastically affected the global economy and brought more restrictive measures to food supply establishments, which are classified as essential activities. However, they had to adapt to the new hygienic-sanitary operating protocol, established through regulations published by the Federal and State Governments in order to reduce the chances of viral spread. The objective of the study was to evaluate the hygienic and sanitary conditions of fish sold in fish markets in the city of Nova Iguacu/RJ, through questionnaires on the application of good marketing and handling practices, during the lockdown related to the coronavirus pandemic. An observational "checklist" type questionnaire was used to assess the hygienic and sanitary conditions of fish in 13 fish markets located in 7 districts of Nova Iguacu/RJ. It was observed that in 92% of the establishments visited had materials and equipment in disuse in the outdoor area, had failures in conservation, sanitation and adequate maintenance, without vector and pest control, without a suitable container for waste collection, lack of personal cleanliness and did not present the amount of flaky ice adequate to coat the fish. Thus, it was possible to check that the establishments did not follow the basic rules of hygiene and safety of the fish to reduce the dissemination of the coronavirus, confirming that the commercialization of fish in the fish markets visited in the municipality of Nova Iguacu/RJ does not meet the recommended standards of hygiene and packaging of the products sold. Therefore, the relevance of this study is to provide fishmongers in the municipality of Nova Iguacu, practical and viable guidelines for adapting to the legislation, with the main objective of updating and favoring the reinforcement of Good Handling Practices through an illustrative folder distributed later on visits to establishments.
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COVID-19 can cause persistent ill-health. Around a quarter of people who have had the virus experience symptoms that continue for at least a month but one in 10 are still unwell after 12 weeks. This has been described by patient groups as "Long COVID". Our understanding of how to diagnose and manage Long COVID is still evolving but the condition can be very debilitating. It is associated with a range of overlapping symptoms including generalized chest and muscle pain, fatigue, shortness of breath, and cognitive dysfunction, and the mechanisms involved affect multiple system and include persisting inflammation, thrombosis, and autoimmunity. It can affect anyone, but women and health care workers seem to be at greater risk. Long COVID has a serious impact on people's ability to go back to work or have a social life. It affects their mental health and may have significant economic consequences for them, their families and for society. Policy responses need to take account of the complexity of Long COVID and how what is known about it is evolving rapidly. Areas to address include: The need for multidisciplinary, multispecialty approaches to assessment and management;Development, in association with patients and their families, of new care pathways and contextually appropriate guidelines for health professionals, especially in primary care to enable case management to be tailored to the manifestations of disease and involvement of different organ systems;The creation of appropriate services, including rehabilitation and online support tools;Action to tackle the wider consequences of Long COVID, including attention to employment rights, sick pay policies, and access to benefit and disability benefit packages;Involving patients both to foster self-care and self-help and in shaping awareness of Long COVID and the service (and research) needs it generates;and Implementing well-functioning patient registers and other surveillance systems;creating cohorts of patients;and following up those affected as a means to support the research which is so critical to understanding and treating Long COVID.
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Introduction: Ever since the first positive case was identified on March 2nd in Lousada, a region close to the border of our catchment area, we reacted immediately by systematically repurposing our surgical wards. Objective: Describe the changed made by our Vascular Surgery Department from March 13 to May 14. Methods: We collected clinical, operative, and consultation volume data from March 13 to May 14 and we compared it with the historical averages. We also reviewed the documents related to the planification activity. Results: At the peak of the outbreak, weadopted a split-team policy and encouraged completeteam segregation to reduce the risk of intradepartmental cross-contamination. Non-ambulatory surgical volume decreased by 54.8% (from 31 cases to 14 cases), and the ambulatory surgical activity was cancelled. Our in-person consultation volume decreased 86.4%;73 consultations were completed by phone, in which the patient was never evaluated in-person. In the emergency room the main difference between the pre-pandemic to the pandemic was in the number of patients observed without vascular pathology (82 versus 28). Conclusions: The adaptation to C0VID-19 pandemic reduced significantly the surgical production of our Vascular Surgery Department.