Hand Surgical Simulation in the Pandemic Era: A Systematic Review

Introduction: The COVID-19 pandemic and duty hour restrictions have illuminated a role for surgical simulation in trainees that permits meaningful technical experience outside the operating room. There is a need for the implementation of surgical simulation infrastructure adjacent to clinical training with practical considerations for complexity and cost. This systematic review analyzes surgical simulations that train hand surgical techniques and procedures with subjective or objective competency assessment. Method(s): A systematic review was conducted according to PRISMA- P guidelines using the PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane databases. Selected search terms included procedures relevant to the field of hand surgery and various types of simulation training. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were extracted. Result(s): Of 2,519 articles, 40 met inclusion criteria. Models were described as: synthetic benchtop/3D-printed (40.0%), animal (22.5%), cadaveric (20.0%), augmented and virtual reality (AR/ VR;12.5%), and other computer simulation (12.5%). Three models incorporated both a physical benchtop component and an AR/ VR component. The procedures most represented included tendon repair (30.0%), fracture fixation (27.5%), wrist arthroscopy (15.0%), and carpal tunnel release (15.0%). Sixty-five percent of articles emphasized the importance of surgical simulation in a surgeon's training. Conclusion(s): A diversity of surgical simulation models exist for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting.

Anterior interosseous nerve syndrome following infection with COVID-19: a case report.

BACKGROUND: Various neurological manifestations associated with coronavirus disease 2019 have been increasingly reported. Herein, we report a rare case of anterior interosseous nerve syndrome, which occurred 5 days after the onset of coronavirus disease 2019. CASE PRESENTATION: A 62-year-old Asian woman with a history of coronavirus disease 2019 who developed a complete motor deficit in the left flexor pollicis longus and pronator quadratus without sensory deficits. The symptoms appeared as a sudden onset fatigue and severe pain of the left arm, 5 days after the onset of coronavirus disease 2019. She noticed paralysis of the left thumb at 2 weeks after the onset of coronavirus disease 2019. Electromyography assessment of the anterior interosseous nerve-dominated muscles revealed neurogenic changes such as positive sharp wave and fibrillation in flexor pollicis longus and pronator quadratus, confirming the diagnosis of anterior interosseous nerve syndrome. There were no other diseases that could have resulted in peripheral nerve palsy. We performed a functional reconstruction surgery of the thumb by tendon transfer from the extensor carpi radialis longus to the flexor pollicis longus. The patient reported a good patient-reported outcome (2.27 points in QuickDASH Disability/Symptom scoring and 5 points in Hand20 scoring) at final follow-up (1 year after the surgery). CONCLUSION: This case highlights the need for vigilance regarding the possible development of anterior interosseous nerve syndrome in patients with coronavirus disease 2019. Tendon transfer from extensor carpi radialis longus to flexor pollicis longus can provide good functional recovery for unrecovered motor paralysis after anterior interosseous nerve syndrome.

Just Keep Swimming...Just Keep Swimming

History: We present a 15-year-old right hand dominant high school swimmer with no significant past medical history, who complains of right elbow pain along the distal biceps' tendon for a 2 months. Pain was insidious in onset, sharp, intermittent, and described as a 0 to 6 out of 10. The patient has been swimming more frequently over the last few months to prepare for competition and noticed progressive pain with swimming. He went on vacation and then was diagnosed with a COVID-19 infection and took an additional 2 weeks off due to fatigue. He returned to sport without re-integration and increased his swimming intensity to 1 to 2 hours daily, which worsened his pain. Performing the butterfly and breaststroke provoke symptoms and cessation of activity reduces the pain. Denies pain at rest. He took Advil which did not reduce his pain. Denies acute trauma, prior injuries, or paresthesias. Physical Exam: Inspection of right elbow: no swelling or signs of discoloration. Palpation: Tenderness at the distal biceps tendon but can hook the tendon without pain. No shoulder or wrist tenderness. Active Range of Motion: Elbow extension 0 degrees, elbow flexion 130 degrees, supination and pronation normal. Normal shoulder and wrist ROM. Muscle strength: 5/5 grip, wrist extension, and wrist flexion. Pain elicited with resisted elbow flexion at the distal humerus. Maneuvers: pain with distal humerus squeeze. Negative Maudsley and negative Cozen test. Differential Diagnosis: 36. Distal Biceps Tendonitis/Tear 37. Stress Reaction of the Distal Humerus 38. Medial Epicondyle Apophysitis 39. Capitellar Osteochondritis Dissecans 40. Radiocapitellar Plica Syndrome Test Results: x-ray right elbow: AP and Lateral views indicate no abnormalities to the bones, alignment, or soft tissue structures. MRI right elbow No IVCON: Biceps tendon intact. There is periosteal edema and endosteal aspect marrow edema along the medial aspect of the distal diaphysis and metaphysis of the humerus. Several small foci of increased cortical signal. No fractures, joint effusion, or chondral defects. Findings comparable to Fredrickson grade 4a distal humerus diametaphysis stress injury. Final Diagnosis: Right Elbow Supracondylar Grade 4a Stress Reaction. Discussion(s): Actives that involve repetitive motion are susceptible to overuse injuries. Cases of upper extremity stress reactions in swimmers have been documented along the inferior angle of the scapula, upper ribs, and olecranon. Stress reactions along the distal humerus in swimmers is not well documented. This pathology has been seen in baseball players, cricket bowlers, and tennis players. In swimming, the butterfly technique requires significant endurance and athletic strength. During a sprint, fast synchronized upper extremity revolutions occurring up to 60 cycles perminute counterforcewater surface area friction leading to excessive loading forces even at 50 meter distances. Outcome(s): The patient was withheld from upper body work outs and swimming for 6 weeks. VitaminDand Calcium levels were drawn revealing a normal calcium level (10.2), but a vitamin D level of 28.1. Patient was started on 600 IU of Vitamin D and 1300 mg of Calcium daily. The patient started a return to swim program and returned to full competition at 7 months post presentation. Follow-Up: At 6 weeks, started an upper extremity low impact non-aquatic physical therapy program. Then a slow progressive return to swimming was initiated at 50% effort for 4 weeks. At 10 weeks, a return to sport plan including 200 m all strokes except butterfly, progressed to 250 m at week 2, 300 m at week 3, and 350 m at week 4. Finally, initiated speed work in =0 to 100 m increments and elbow loading workouts.

Shoulder Weakness Following Intramuscular COVID- 19 Vaccine

History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.

Beyond Articular Cartilage: A Systematic Review of the Extracellular Matrix in Other Components of the Osteoarthritic Joint

Background/Aims Traditionally viewed from the perspective of cartilage degeneration, osteoarthritis is increasingly seen as a disease of global joint dysfunction. Connective tissue extracellular matrix (ECM) is a crucial determinant of joint mechanobiology, providing cells with scaffolding, topographical cues, and a reservoir of soluble factors. While ECM dysregulation has been extensively studied in osteoarthritic cartilage, it remains poorly defined in other joint tissues. Here, we systematically review the composition, architecture, and remodelling of non-cartilage soft joint tissue ECM in human osteoarthritis and animal disease models. Methods A systematic search strategy was run through the MEDLINE, EMBASE and Scopus databases on 30 October 2020 and repeated on 1 October 2021. The search criteria included disease nomenclature, relevant tissues, as well as structural ECM components and architectural features. All papers were independently screened by two reviewers on the Covidence platform according to predefined eligibility criteria. Relevant clinical, demographic, and biological data were extracted from included studies, which were assessed for bias using the OHAT Risk of Bias Rating Tool for Human and Animal Studies. Results 148 of 8,156 identified studies met all eligibility criteria. 113 papers evaluated human osteoarthritis;of 35 animal studies, the most frequently used models involved surgical joint destabilisation in small mammals. ECM was best defined in menisci, ligaments, and synovium;fewer papers assessed skeletal muscles, tendons, and fat pads. Compared to the healthy joint, osteoarthritis is associated with qualitative and quantitative alterations in structural ECM components, most notably collagens and proteoglycans. In recent years, whole proteome sequencing has been employed to address these changes systematically. The mechanical properties of ECM change significantly in osteoarthritis in response to post-translational modifications, extensive calcification, and the marked loss of matrix organisation across the joint. Notably, some aspects of ECM remodelling in these tissues appear to precede discernible cartilage dysregulation. Similar ECM dysregulation is also observed in animal models, although intermodel variability in arthritogenic precipitant and the range of reported outcomes make comparisons difficult. Many studies are limited by significant bias, notably in the infrequent reporting of investigator blinding, and in the poor demographic matching of osteoarthritic and control patients. Encouragingly, the quality of methodology reporting and use of age-matched control populations have improved in recent years. Conclusion Current data provide compelling evidence of whole joint ECM changes in osteoarthritis and importantly suggest that these changes occur early in the disease process. How ECM dysfunction affects the behaviour of tissue-resident cells remains less well understood. Our work will support the design of disease-relevant biomaterials used to model osteoarthritis in vitro, helping to address this issue, by more accurately recreating the extracellular environment. Furthermore, the development of imaging modalities sensitive to connective tissue ECM changes warrants investigation from both diagnostic and prognostic perspectives.

Post-COVID-19 vaccination Guillain-Barre syndrome with sensory ataxia, gaze-evoked nystagmus, mental-status change and positive pathological reflex

Background: Various neurological disorders have been reported after vaccination against coronavirus disease 2019, one of which is Guillain-Barre Syndrome (GBS). Case Presentation: We report a case of a 73-year-old woman who developed GBS and extra-GBS manifestations 19 days after the second dose of BNT162b2 mRNA vaccine. She presented lower limb predominant muscle weakness and loss of tendon reflexes. Nerve conduction study showed acute motor and sensory axonal neuropathy. In addition, she developed notable deep sensory ataxia, and showed positive pathological reflex, gaze-evoked nystagmus and altered consciousness, which suggested brainstem involvement. Conclusion(s): This is the first coronavirus disease 2019 vaccine-related GBS complicated with such central nervous system manifestations.Copyright © 2023 Japanese Society for Neuroimmunology.

Orthopaedic Hand Surgical Simulation Training: A Review

In recent years, new orthopaedic surgical simulation and virtual reality (VR) training models have emerged to provide unlimited education medium to an unlimited number of trainees with no time limit, especially in response to trainee work-hour restrictions. Surgical simulators range from simple wooden boxes to animal and cadaver models to three-dimensional-printed and VR simulators. The coronavirus disease 2019 pandemic further highlighted the need for at-home learning tools for orthopaedic surgical trainees. Advancement in simulating shoulder and knee arthroscopies using VR simulators surpasses the other fields in orthopaedic surgery. Despite the high degree of precision needed to operate at a microscopic level involving vessels, nerves, and the small bones of the hand, the simulation tools have limited advancement in the field of orthopaedic hand surgery. This narrative review summarizes the status of surgical simulation and training techniques available to orthopaedic hand surgical trainees, factors affecting their application, and areas in hand surgery that still lag behind their surgical subspecialty counterparts.

A Case of Sars-Cov-2 Omicron Variant Associated Acute Encephalomyelitis

With the ongoing pandemic of SARS-CoV-2 many neurological complications in relation to COVID-19 infection as well as immune-mediated and vaccine-associated phenomena have been described. To our knowledge, there has been no publication of a case of SARS-CoV-2 Omicron variant associated acute encephalomyelitis. We present a case of a 73-year-old woman with no relevant Background history who is otherwise fit and well and fully vaccinated. She suffered from mild COVID symptoms and had a positive PCR test with presumptive Omicron variant on day 2. Five days into her respiratory illness she developed in quick suc- cession sensory disturbances of hands and feet, bilateral asymmetric flaccid leg weakness, and mild arm weakness. She had absent deep tendon reflexes in the legs and diminished deep tendon reflexes in the right arm. MRI of brain and spine showed signal changes in the brainstem, cervical and low thoracic cord in keeping with acute encephalomyelitis. Her CSF showed an inflammatory picture with raised protein of 1.27g/L and no cells. At the time of submission, the patient received treatment with five days of intravenous steroids followed by ongoing plasma exchange and no comment on treatment response can be made at this stage.

A novel approach to low-energy calcaneal tuberosity avulsion fractures in patients with fragile bone quality: A report of two cases

Maintaining reduction of a calcaneal tuberosity avulsion fracture is challenged by the powerful force exerted upon the bone fragment by the Achilles tendon. Low-demand, elderly patients with osteoporotic bone usually undergo a low-energy mechanism when this fracture pattern occurs. Likely attributable to poor bone quality, the rate of early fixation failure has been documented to be as high as 40%. We present the cases of two 65-year-old female patients who each sustained a calcaneal tuberosity avulsion fracture. Both patients underwent a low-energy mechanism of injury and had a medical history of many comorbidities. The first patient underwent a partial calcaneal ostectomy and tenotomy after failing open reduction internal fixation (ORIF). The second patient primarily underwent a partial calcaneal ostectomy and tenotomy. Postoperatively, after the incision site was fairly healed, both patients could bear weight as tolerated. This method of excision and release may allow for decreased risk of skin compromise and return trips to the operating room for failed ORIF. In low-demand patients with low-energy calcaneal avulsion type fractures and osteoporotic bone, this technique may be the preferred surgical option.Copyright © 2022 The Author(s)

[Distal biceps brachii rupture in a patient with COVID-19]

INTRODUCTION: distal biceps tendon injury commonly occurs in male patients between the fifth and sixth decade of life. The mechanism of the injury is an eccentric contraction with the elbow in flexion of 90 degrees. For its surgical treatment, several options have been described in the literature with different approaches, type of suture to be used and various methods of fixing the repair of the distal biceps tendon. The musculoskeletal clinical manifestations of COVID-19 are fatigue, myalgia, arthralgia, but the musculoskeletal effects of COVID-19 remain unclear. CASE REPORT: 46-year-old COVID-19 positive male patient with acute distal biceps tendon injury and secondary to minimal trauma, with no other risk factors. The patient was treated surgically following orthopedic and safety guidelines for the patient and medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision in a reliable option and our case of a low morbidity, few complications and a good cosmetic option. CONCLUSION: the management of orthopedic pathologies in COVID-19 positive patients is increasing as well as the ethical and orthopedic implications of the management of these injuries and/or the delay of their care during the pandemic.

Investigation of the effect of COVID-19 on upper extremity trauma

Aim: Our study aims to evaluate the upper extremity trauma that admitted to our hospital from April 11, 2020, to June 1, 2020, the days when the restrictions were applied in Turkey, and to investigate the effect of COVID-19 on upper extremity trauma by comparing with the data of a year ago between the same dates. Material(s) and Method(s): Demographic information, trauma details, and region, and the treatment method of patients with any upper extremity trauma who were over the age of 18 and admitted to the hospital between April 11, 2019, and June 1, 2019 (2019-Before Restrictions) and between April 11, 2020, and June 1, 2020 (2020-Lockdown) were examined retrospectively. Result(s): In 2019-Before Restrictions, 218 patients and in the 2020-Lockdown, 163 patients were admitted to the hospital due to upper extremity trauma. The number of hospital admissions with upper extremity trauma during the 2020-Lockdown was 25.22% less than that of those in 2019-Before Restrictions, (p<0.05). While the number of patients admitted to the hospital due to fractures in the upper extremity during 2019-Before Restrictions, was 89 (Open Fracture=32, Closed Fracture=57), this number was observed to decrease to 48 (Open Fracture=11, Closed Fracture=37) in the 2020-Lockdown (p<0.05). Discussion(s): It was determined that there was a decrease in upper extremity trauma during 2020-Lockdown compared to the same dates of the previous year. It is possible to state that quarantine practices applied to prevent the spread of COVID-19 affect the decrease in upper extremity trauma.Copyright © 2022, Derman Medical Publishing. All rights reserved.

The influence of the Covid pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom.

OBJECTIVES: Management strategies of the Covid pandemic included isolation to prevent transmission. This study aimed to determine if the pandemic of 2020 influenced the epidemiology of Achilles Tendon Rupture (ATR). METHODS: The demographics of presentations from the local population to xxx hospital, Shropshire, United Kingdom with an ATR were analysed and compared together with the season, month, and year of the injury. RESULTS: From 2009 to 2019 there was no significant change in the incidence of ATR over time with mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase in 2021 to 22.4 per 100,000. In 2021, there was an increase in injuries from March with numbers maintained until October. The most common activity of ATR was Team sport (36.2%), followed by Activities of Daily Living (28.9%), Other physical activities (21.0%) and Racket sports (13.9%). In 2020 there was the lowest number of injuries sustained in Team and Racket sports, however in 2021 they accounted for over half of Injuries. CONCLUSIONS: There were significantly more patients sustaining ATR in 2021, the year after the covid pandemic and mandatory isolation. This was considered to be related to altered activity and Team and Racket sports during 2020. LEVELS OF EVIDENCE: IV Case series.

Acute flaccid myelitis diagnosed after IVIG: a diagnostic dilemma

Case Report: A 4-year-old African American male presented to an outside emergency department (ED) following sudden inability to move left upper extremity. Past medical history was unremarkable and routine vaccinations were up to date. Radiograph of affected extremity ruled out fractures and patient was discharged to follow up with primary care physician. Two days later mother brought him to our ED due to persistent left upper extremity paralysis, poor appetite, and subjective fever. On exam his left arm was warm and tender to dull and sharp touch;he had definite loss of active movement, hypotonia and absence of deep tendon reflexes. The patient had winging of left scapula and could not shrug left shoulder. MRI of cervical and thoracic spine showed enlargement of spinal cord from C2-C6 level with gray matter hyperintensity, slightly asymmetric to the left. Laboratory studies showed leukocytosis (14 000/mcL) and CSF studies showed pleocytosis of 89 WBC/mcL (93.3% mononuclear cells and 6.7% polymorphonuclear cells), 0 RBCs, normal glucose and protein, and a negative CSF meningoencephalitis multiplex PCR panel. Due to high suspicion of demyelinating or autoimmune condition he was treated with high dose steroids and IVIG. Subsequently neuromyelitis optica was ruled out as aquaporin-4 receptor antibodies (AB) and myelin oligodendrocyte glycoprotein AB were normal. CSF myelin basic protein and oligoclonal bands were absent ruling out demyelinating disorders. CSF arboviruses IgM and West Nile IgM were negative. He showed minimal improvement in left upper extremity movement but repeat spinal cord MRI one week later showed improved cord thickness with less hyperintensity. Respiratory multiplex PCR was negative including enteroviruses. Repeat CSF studies after IVIG showed increased IgG index and IgG synthesis suggestive of recent spinal cord infection, consistent with acute flaccid myelitis (AFM). Pre-IVIG blood PCR was invalid for enteroviruses due to PCR inhibitors found in the sample. Blood post-IVIG was negative for mycoplasma IgM, West Nile IgM, and arboviruses IgM. Enterovirus panel titers (post-IVIG) were positive for coxsackie A (1:32), coxsackie B type 4 (1:80) and 5 (1:320), echovirus type 11 (1:160) and 30 (1:80) as well as positive for poliovirus type 1 and 3. These titers could not distinguish acute infection from patient's immunity or false-positives as a result of IVIG. He was discharged with outpatient follow-up visits with neurology, infectious disease, occupational and physical therapy, showing only mild improvement after discharge. Discussion(s):With the anticipated resurgence of AFM after the peak of COVID-19 pandemic, our case illustrates the need to consider this diagnostic possibility in patients with flaccid paralysis. It is important to remember CSF IgG synthesis is not affected by IVIG. In addition when treatment plans include IVIG, appropriate samples should be collected before IVIG to facilitate accurate work-up for infectious diseases. Copyright © 2023 Southern Society for Clinical Investigation.

Impact of the Covid-19 pandemic context on the microbiological epidemiology and management of flexor sheath phlegmons.

INTRODUCTION: The COVID-19 pandemic in France has recently modified the patients' lifestyles, as well as methods of medical and surgical management. This could explain subsequent changes to the microbiological spectrum, the severity, as well as the scalability of phlegmons of the flexor tendon sheath. The objective of this study was to construct an epidemiological and bacteriological inventory of these hand infections, and to compare the clinical and microbiological data, before and after the COVID-19 pandemic. HYPOTHESIS: The hypothesis of this work was that the phlegmons of the flexor tendon sheath presented specific microbiological characteristics in the tropical environment of our University Hospital Center, and that these characteristics could have changed with the recent introduction of hydro-alcoholic solution (HAS) associated to the COVID-19 pandemic. MATERIAL AND METHODS: The preoperative epidemiological data of our patients were collected between January 2016 and December 2020. The stage of severity, according to the classification of Michon, the use of hydro-alcoholic solution, as well as the early clinical evolution were collected. The cohort was then divided into two groups in order to compare the microbiological profiles, the management and the clinical evolution of patients in the pre-COVID period with those in the post-COVID period. RESULTS: A total of 199 patients were included, 154 patients in the pre-COVID period and 26 in the post-COVID period. We found a majority of MSSA (58.3%, N=105) and negative samples comprised 18.9% (N=34). No statistically significant difference was found between the two groups regarding the bacteriological results. The clinical course was judged to be favorable in 93.5% of cases in the pre-COVID group compared to 80.8% in the post-COVID group (p=0.046). The use of HAS (p<0.0001), as well as the initial stage of severity according to Michon, were significantly higher in group 2 (p=0.04). DISCUSSION: The COVID-19 pandemic has not shown any change in the microbiological spectrum, despite the now daily use of HAS in everyday life. The postoperative clinical evolution was significantly less favorable after the onset of COVID and could be explained by an increase in cases with a more advanced initial stage of severity. LEVEL OF EVIDENCE: IV, Observational epidemiological study.

Os Valores De Referencia Do D-Dimero No Contexto Da Covid-19: O Que Sabemos Ate Agora?

Objetivos: Correlacionar a associacao entre a infeccao pelo SARS-CoV-2, a coagulacao intravascular disseminada e a relacao do D-dimero com o agravamento do quadro clinico em pacientes com a COVID-19. Materiais e Metodos: Trata-se de uma revisao de literatura realizada pela analise de onze artigos publicados entre 2020 e 2022, nas linguas portuguesa e inglesa obtidos atraves das bases de dados PubMed e SciELO. Os descritores utilizados na pesquisa estao de acordo com o Sistema de Descritores em Ciencias da Saude (DeCS) e sao respectivamente "Coagulacao Intravascular Disseminada" e "COVID-19". Resultados: O SARS-CoV-2, agente etiologico responsavel pela COVID-19, pode causar um estado de hipercoagulabilidade devido ao seu efeito no aumento de citocinas inflamatorias. Sendo o D-dimero um produto de degradacao da fibrina, que tem sua producao influenciada pela inflamacao, este se torna um importante marcador de gravidade para diagnostico e manejo de eventos tromboticos. Uma das principais complicacoes dessa disfuncao da hemostasia no COVID-19 e o Tromboembolismo Pulmonar (TEP), que foi observado em cerca de 25% dos casos graves com maiores elevacoes do D-dimero. Ademais, a Coagulacao Intravascular Disseminada (CIVD) se enquadra como outra complicacao que ocorre, principalmente, nos casos em que a infecao e fatal, sendo relatada em 71,4% dos pacientes que vieram a obito e 0,6% dos sobreviventes. Niveis de D-dimero aumentados mais de 6 vezes o limite da normalidade foram associados com desenvolvimento de sindrome do desconforto respiratorio agudo, piora do padrao radiologico e aumento da mortalidade. Ainda, os valores desse parametro variavam entre 2.614 mug/L e 3.780 mug/L nos pacientes que vieram a obito, enquanto nos sobreviventes, na maioria das vezes, nao ultrapassavam 1.705 mug/L. Corroborando a isso, alguns estudos consideraram valores de D-dimero acima de 1.500 mug/L na admissao um ponto de corte para prever um maior risco de mortalidade dos pacientes com COVID-19. Discussao: Em caso de manifestacao grave da infeccao, pode repercutir em sepse, sendo uma circunstancia em que o sistema antitrombina, a proteina C e o inibidor da via do fator tecidual e a fibrinolise estao disfuncionais, ocorrendo um desbalanco do sistema de coagulacao. Ademais, a hipoxia fomentada pela infeccao pode ser outro fator contributivo para essa disfuncao. Esse estado pro-trombotico e denominado Coagulopatia Induzida pela Sepse (SIC) e precede a CIVD, uma condicao caracterizada por uma excessiva ativacao da trombina com formacao e deposicao de fibrina na microvasculatura. As formas mais graves de COVID-19 estao relacionadas com a SIC, que esta presente na maioria dos casos mais fatais. Tendo em vista que os marcadores laboratoriais podem se encontrar bastante alterados em decorrencia do desequilibrio da coagulacao provocado pela SIC, a avaliacao laboratorial por meio do monitoramento do D-dimero se torna importante para a profilaxia de eventos tromboembolicos mediante uso da terapia anticoagulante, sendo assim, quanto mais estudos forem feitos acerca do tema, melhor a indicacao dessa terapeutica aos pacientes. Conclusao: Desse modo, segundo os artigos pesquisados, houve uma importante relacao entre os niveis de D-dimero e um pior prognostico, sendo os pacientes mais susceptiveis a desenvolver CIVD e ao desenvolvimento de fenomenos tromboembolicos como TEP, e, consequentemente, estes estariam mais indicados a receber profilaxia anticoagulante. Copyright © 2022

Comparativo De Diagnostico E Mortalidade Em Idosos Por Leucemias No Estado Do Parana Antes E Depois Da Pandemia De Covid-19

Introducao: A pandemia de COVID-19, causada pelo SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) trouxe um desafio para a populacao geral, sem condicoes de qualquer tipo de planejamento, porem sendo evidente o maior impacto em paises subdesenvolvidos como o Brasil, que apresentava capacidade mais limitada para lidar com casos criticos, levando ao colapso dos sistemas de saude em varias localidades. Entao, considerando que a febre e um dos principais sintomas de COVID-19 e tambem um sintoma comum nas leucemias e tambem considerando que a populacao idosa envolve uma maior complexidade devido sua fragilidade e multicomorbidades, e valido a analise no diagnostico e na mortalidade pelas leucemias comparando com ano pre-pandemico. Objetivos: Analisar, atraves dos dados disponiveis publicamente no Departamento de Informatica do Sistema Unico de Saude (DATASUS) e no Sistema de Informacao de Mortalidade (SIM), do ano de 2020, o impacto da pandemia de COVID-19 no diagnostico e mortalidade de leucemias no estado do Parana e comparar com o mesmo periodo de 2019, ultimo ano antes da pandemia. Material e Metodos: Constituiu-se de estudo transversal e descritivo. A populacao alvo foi de pacientes, de faixa etaria maior que 60 anos, com diagnostico de leucemia, firmado no estado do Parana, no periodo de 2019, ano pre-pandemia, e no ano seguinte, em 2020, primeiro apos a pandemia de COVID-19. Resultados: Em 2019, o estado do Parana registrou 198 novos casos de leucemia em idosos, sendo a maioria dado na faixa etaria entre 60 e 64 anos. No mesmo ano, foram registrados 303 obitos tendo como causa a leucemia, a maioria deles em pacientes com 80 anos ou mais. Ja em 2020, o Estado registrou 171 novos casos de leucemia, novamente com a maioria entre 60 e 64 anos. Os obitos foram contabilizados em 305, sendo a maioria na faixa etaria de 70 a 79 anos. Discussao: O numero de diagnosticos no estado do Parana reduziu apos o inicio da pandemia de COVID-19, semelhante a outros lugares do mundo com mesmo comportamento, tendo explicacao baseada talvez no respeito dos pacientes ao isolamento social e ao colapso dos sistemas de saude que necessitaram realocar recursos e funcionarios para o atendimento direto das sindromes respiratorias. A mortalidade parece nao ter sido afetada no Estado, apesar de pacientes idosos serem mais vulneraveis as complicacoes de COVID-19 e a um maior numero de internacoes, motivos pelos quais os pacientes mais idosos poderiam ter um atraso no inicio da terapia ou aumento na mortalidade por leucemias no periodo apos inicio da pandemia. Conclusao: Faz-se necessario, entao, manutencao da atencao com o diagnostico de leucemias na populacao idosa, mas tambem cautela em relacao a morbidade causada por esta, considerando maior vulnerabilidade dessa classe e maior susceptibilidade ao virus de COVID-19, que pode levar a atrasos e suspensao de esquemas de tratamento. Copyright © 2022

O Impacto Da Pandemia De Covid-19 No Diagnostico De Neoplasias Hematologicas No Estado Da Paraiba: Um Comparativo De Tres Anos

Introducao: Os canceres sao doencas geneticas cujo fenotipo maligno resulta de uma alteracao que e transmitida da celula alterada para suas celulas filhas, rompendo uma serie de barreiras fisiologicas para perpetuar. Atualmente, o cancer e encarado como um problema de saude publica em nivel global e, como outras doencas de curso menos agudo, o diagnostico e o tratamento do cancer tambem foram afetados pela pandemia de COVID-19 (coronavirus disease). Objetivos: Analisar, atraves dos dados disponiveis publicamente no Departamento de Informatica do Sistema Unico de Saude (DATASUS), dos anos de 2020 e 2021, o impacto da pandemia de COVID-19 no diagnostico de neoplasias malignas no estado da Paraiba e comparar com os mesmos periodos de 2019, ultimo ano antes da pandemia. Material e Metodos: Constituiu-se de estudo transversal e descritivo. A populacao alvo foi de pacientes, de todas as faixas etarias, com diagnostico de neoplasia hematologica, firmado no estado da Paraiba, no periodo de 2019, ano pre-pandemia, e no bienio 2020-2021, anos apos a pandemia de COVID-19. Resultados: Em 2019 a Paraiba registrou 403 novos casos de neoplasias hematologicas, sendo 213 no sexo masculino (52,8%). Os tipos mais comuns foram os linfomas nao-Hodgkin, correspondendo a 28,53%, seguido pelas leucemias (24,56%). Quanto ao estadiamento, a maioria dos diagnosticos foi no estagio II (11,6%), com o campo "Ignorado" correspondendo a 59,8%. O tempo medio entre o diagnostico e o inicio do tratamento foi menor que 30 dias (36,22%). Ja em 2020, o Estado registrou 439 novos casos, sendo 234 no sexo masculino (53,3%). Neste ano, os tipos mais comuns foram novamente os linfomas nao-Hodgkin, correspondendo a 32,11%, seguido pelas leucemias (28,7%). O estadiamento se deu no estagio 1 em sua maioria, correspondendo a 14,57%, com o campo ignorado neste ano tendo atingido a marca de 57,4%. O tempo medio entre o diagnostico e o inicio do tratamento foi menor que 30 dias (34,39%). No segundo ano apos a pandemia, em 2021, a Paraiba registrou 450 novos casos de neoplasias hematologicas, sendo 280 no sexo masculino (62,22%). Neste ano, o tipo mais comum foram as leucemias (32,44%) seguido dos linfomas nao-Hodgkin (29,33%). A maioria dos diagnosticos se deu no estagio III (10,66%) e o tempo medio entre o diagnostico e o inicio do tratamento foi maior que dois meses na maioria dos casos, correspondendo a 42,88%. Discussao: A pandemia de COVID-19 trouxe diversas repercussoes para a area da saude, mais do que aquelas implicadas tao somente pela infeccao que o virus SARS-CoV-2 traz em si, porem nao afetou o numero dos diagnosticos de neoplasias hematologicas no estado da Paraiba. Cabe pontuar que aumentou o tempo entre o diagnostico e o inicio do tratamento, bem como houve mais diagnosticos em estagios mais avancados da doenca, talvez pela realocacao de recursos e infraestrutura redirecionados para atendimento das sindromes respiratorias agudas. Conclusao: Apesar de nao haver impactado no numero de diagnosticos, a pandemia de COVID-19 trouxe impactos prognosticos, com maior tempo ate inicio do tratamento e com diagnosticos em estagios mais avancados de doenca. Tambem cabe destacar a quantidade de dados computados nos campos dados como "Ignorado", "Nao aplica" ou "Outros", o que dificulta a analise fidedigna dos dados epidemiologicos. Copyright © 2022

O Impacto Da Pandemia De Covid-19 No Atendimento Do Paciente Com Leucemia

Objetivo: Analisar comparativamente as caracteristicas relativas aos gastos destinados a saude para tratamento de pacientes internados por Leucemias antes, durante e apos a pandemia de COVID-19 no Piaui. Materiais e Metodos: O estudo ecologico, de carater descritivo e retrospectivo. Os dados utilizados foram obtidos mediante o Departamento de Informatica do Sistema Unico de Saude (DATASUS), em que foi analisado o perfil de internacoes ocasionadas por leucemias, os gastos empreendidos com esses pacientes, o tempo medio de permanencia, a quantidade total de internacoes e o numero de obitos no periodo de janeiro de 2019 a maio de 2022. Os dados foram agrupados no Microsoft Excel, realizada analise estatistica descritiva, frequencia absoluta e relativa. Resultados: Durante a pandemia, houve reducao de 14,6% no numero de internacoes (779 em 2019 e 665 em 2020) e de 35,5% no valor total gasto com pacientes portadores de Leucemia no estado do Piaui (R$ 2.287.368,42 em 2019 e R$ 1.476.495,97 em 2020). A tendencia foi seguida nos anos de 2021 e 2022 (R$ 1.367.601,50 em 2021 e R$ 611.316,64 ate maio 2022). A media de permanencia em 2019 foi de 8,6 dias, enquanto no periodo de pandemico e pos-pandemico reduziu para 8 dias. O numero de obitos tambem obteve queda de 34,3% quando comparado ao ano anterior da pandemia de COVID-19 (67 obitos em 2019 e 44 obitos em 2020). Discussao: As leucemias compoem um grupo heterogeneo de neoplasias hematologicas resultantes da transformacao total ou parcial das celulas blasticas. Essa doenca tem o carater de alta prevalencia e taxa de mortalidade consideravel, tornando-se imprescindivel tomar estrategias a fim de assegurar a deteccao precoce, que e obtido com a associacao do diagnostico precoce com o rastreamento, segundo a organizacao mundial de saude. O diagnostico precoce acontece quando se tem profissionais bem treinados e uma populacao bem-informada acerca dos sinais e sintomas das leucemias e com acesso garantido as unidades de saude, enquanto o rastreio e uma busca ativa entre um grupo especifico de pessoas que tem maiores chances de virem a desenvolver. Durante a pandemia essa deteccao precoce foi prejudicada e, contrariando as estatisticas, os numeros de novos casos diminuiu, consequencia do foco das campanhas e da deteccao precoce ter sido direcionado ao COVID-19, sugerindo tambem subnotificacoes, os numeros de internacoes caiu, consequencia da falta de leitos, que eram destinados aos pacientes com sindromes respiratorias no periodo de 2020. A queda nos gastos tambem e consequencia da propria diminuicao das internacoes, mas tambem das verbas para saude publica terem sido mais direcionadas para dar suporte ao tratamento dos pacientes com COVID-19. Isso pode ser inferido atraves da analise de custo medio por paciente. Por fim, a queda do numero de obitos tambem foi alta, mas se manteve inalterada entre 2020 e 2021, o que sugere falta de autopsia e ate subnotificacao e notificacoes erroneas, tendo em vista que pacientes leucemicos sao mais propensos a infeccoes, como a propria COVID. Infere-se que os pacientes leucemicos do Piaui tenham ido a obito e notificados como por COVID ou procurado assistencia em maiores polos de saude em outros estados. Conclusao: Apos a analise comparativa dos dados coletados, pode-se concluir que houve uma diminuicao significativa, tanto na quantidade e tempo medio de internacoes e na mortalidade, quanto nos gastos para cuidar desses pacientes. Copyright © 2022

O Psicologo No Pronto Socorro E as Emergencias Em Saude Mental Pos Pandemia

Embora os transtornos depressivos e de ansiedade, bem como os casos de TEPT ja se constituissem como endemicos no Brasil, com a pandemia da Coronavirus Disease 2019 (COVID 19), o aumento de casos foi exponencial. Na fase inicial da pandemia na China (2020), houve um aumento de 50% de pacientes apresentando sintomas moderados a severos de ansiedade, depressao e estresse. No inicio de maio de 2020, segundo a Associacao Brasileira de Psiquiatria, 48% dos psiquiatras apontavam um aumento de cerca de 25% no numero de consultas, sendo que 89% desses pacientes com diagnostico previo apresentavam sintomas agravados. Este trabalho tem como objetivo apresentar o aumento da incidencia de pacientes atendidos com queixas psicologicas nas unidades de pronto atendimento (Pronto Socorro) e os esforcos emergenciais em nivel de gestao e acompanhamento psicologico da nova realidade no Hospital Geral, referenciada como 4onda da pandemia Covid 19. Os dados coletados referem-se ao periodo de janeiro a julho de 2021, comparando-se ao ano de 2022, tendo sido avaliados 772 pacientes. A partir de avaliacao psicologica clinica e levantamento de prontuarios de atendimentos psicologicos no Pronto Socorro Adulto, comparando-se os anos de 2021 e 2022, constatou-se um aumento medio de 27,5% pacientes no periodo, com prevalencia de sintomas que incluiam mal estar subito e sensacoes de perigo recorrentes e imprevisiveis, incapacidade de relaxar, sensacoes de sufocamento, dor toracica, distorcoes cognitivas e intensa angustia de morte. Historia de doencas psiquiatricas diagnosticadas;perdas financeiras advindas da pandemia;temor aumentado e exacerbado de ser infectado pelo virus, adoecer e morrer;luto patologico (pela perda de familiares e amigos);sobrecarga e fadiga;estresse;ma qualidade do sono;desesperanca;comportamentos evitativos e irritabilidade tambem constituiram os achados clinicos. A sistematizacao da presenca do Psicologo como profissional de referencia no Pronto Socorro, foi fator fundamental para o melhor cuidado e encaminhamento seguro dos casos. Entender como se apresentou a pandemia em termos de estagios de evolucao do problema foi fundamental para nos preparar para o implemento de estrategias de controle. Passamos a avaliar a situacao critica como momentos encadeados e progressivos, o que facilitou o entendimento de especificidades de fatores estressores relativos a pandemia e o cuidado que deveria ser prestado intra e pos crise. Copyright © 2022