Use of viscoelastic tests in the intensive care unit for the evaluation of haemostasis in SARS-CoV-2 infection

Introduction: COVID-19 coagulopathy is associated with poor prognosis and a state of coexisting 'hypercoagulopathy' (HyperC) and hypofibrinolysis, only detected by viscoelastic tests (VET). VET technology has been useful in areas where conventional tests are inadequate, such as screening for HyperC, thrombotic risk assessment and systemic anticoagulants' effect. We aim to characterize the evolution profile of coagulopathy in patients with COVID-19 infection during their intensive care unit (ICU) stay. Method(s): Consecutive recruitment of adult COVID-19 patients admitted to our hospital's ICU, during a 6 months period. Patients with thrombosis in the previous 3 months, pregnancy, under hormone therapy, and congenital coagulopathies were excluded. VET were executed every 5 days, at discharge and in complications and all of them were under low weight molecular heparin (LMWH) therapy. Group 1 (G1), n = 24-less than 10 days in ICU and group 2 (G2), n = 16-more than 10 days in ICU. In G1 there was 1 death (day 3) and in G2 there were 5 deaths (between days 15 and 42). We focused current analysis on VET-Rotem parameters (see Fig. 1). Result(s): Prognostic scores APACHE II, SAPS II and SOFA were higher in G2, but surprisingly G1 patients are more obese. G2 patients had shorter aPTT and lower platelets. The variables CT-HepTem and MCF Extem-MCF-Fib-Tem present a greater difference between groups, but no statistical significance. We observed an initial correlation between basophils number (which is lower) on CT Intem and CT Hep-Tem, lost as progression to cure, probably due to cytoplasm heparin granules. As expected, VET were in accordance with HyperC: short CTs, increased MCFs, and decreased lysis. Conclusion(s): We expected to guide/adjust LMWH dosage, using Rotem profiles, however these were not corrected by LMWH, used transversally, and remained unchanged in all patients during their stay in ICU.

Sedation in the ICU: association between dexmedetomidine and 28-day mortality in patients with COVID-19

Introduction: The aim of our study is to evaluate the relationship between dexmedetomidine (DEX) use as a sedative agent in mechanical ventilated ICU patients and 28-day mortality. DEX, a selective alfa-2 adrenergic receptor agonist, widely used for its sedative and analgesic properties, has been linked to increasing parasympathetic tone, reducing the inflammatory response and oxidative stress [1]. Since severe COVID-19 is associated with an hyperinflammatory state, it is hypothesized that DEX might improve outcomes in these patients. Method(s): This is a retrospective observational study of mechanically ventilated patients admitted with COVID-19 pneumonia in the ICU of a tertiary center in Portugal, between March 2020 and December 2021. Logistic regression analysis was performed to evaluate the association of DEX use and 28-day mortality from time of intubation. Result(s): A total of 277 patients were analyzed, 151 in the DEX group and 126 in the no DEX group. Patients in the DEX group were younger (53.3 vs. 63.3 years, p < 0.001), had less comorbidities (2.8 vs. 3.5, p = 0.01), lower SOFA at admission (6.2 vs. 7.1, p = 0.01) but had a prolonged ICU stay (21.4 vs. 15.9, p < 0.001). Male gender (65.6 vs. 69.0, p = 0.54), incidence of obesity (56.3 vs. 46.8, p = 0.12), coronary artery disease (4.0 vs. 7.9, p = 0.16) and atrial fibrillation (4.0 vs. 7.1, p = 0.25) were similar between groups. PaO2/ FiO2 ratio at admission (111.1 vs. 108.1, p = 0.61), days spent in RASS < 3 (13.7 vs. 12.4, p = 0.31) and opioid use (14.8 vs. 13.1, p = 0.16) were also similar. From time of intubation, 28-day mortality in the cohort receiving DEX was 14.7% compared to 59.5% in the no DEX group (OR 0.12;95% CI 0.07-0.21;p = 0.01). Conclusion(s): Use of DEX was associated with lower 28-day mortality in COVID-19 critically ill patients requiring invasive mechanical ventilation in our study analysis. Considering the limitations of a retrospective observational study, RCTs are needed to confirm the results.

Risk factors for nosocomial infections in COVID-19 ICU population

Introduction: The aim of this study is to identify the factors associated with an increased risk of developing nosocomial infections (NI) in COVID-19 patients admitted with pulmonary involvement in the ICU. NI in COVID-19 ICU population are an important cause of morbidity and mortality worldwide and its prompt identification might lead to its prevention and better outcomes. Method(s): This is a retrospective observational study of patients admitted with COVID-19 pneumonia in the ICU of a tertiary center in Portugal, between March 2020 and December 2021. We considered NI as any infection acquired > 48 h post ICU admission. Clinical, analytical and baseline patient data were evaluated. Logistic regression analysis was performed to correlate patient related variables with the development of NI. Result(s): A total of 338 patients were enrolled, from which 167 (47.9%) presented with NI. Baseline characteristics are described in Table 1. In the logistic regression analysis, older age (OR 1.13;95% CI 1.03-1.25;p = 0.013), coronary artery disease (CAD) (OR 28.7;95% CI 1.92-429;p = 0.02), obesity (OR 3.14;95% CI 0.86-11.42;p = 0.008), chronic liver disease (CLD) (OR 104.33;95% CI 1,.04-1008.49;p = 0.04), use of dexamethasone (OR 21.89;95% CI 3.04-157.85;p = 0.002) and days in RASS < 3 (OR 1.4;95% CI 1.05-1.86;p = 0.02) were associated with an increased risk of developing NI in the ICU. Surprisingly, SOFA at admission, days of invasive mechanical ventilation, days of sedation and PaO2/ FiO2 ratio at admission, although statistically significantly different between groups, did not correlate with the risk of infection. Conclusion(s): We identified prolonged deep sedation, corticosteroid use, and patient characteristics (CAD, obesity, CLD, older age) as independent risk factors for NI development in COVID-19 critically ill patients. It is also noteworthy to point out for the presence of confounding variables, including the excessive workload in the ICU during this period, leading to an increase in NI numbers.

Outcomes of renal replacement therapy in critically ill COVID-19 patients

Introduction: Our goal is to describe outcomes of critically ill COVID-19 patients submitted to renal replacement therapy (RRT), in particular the association of RRT with mortality. Multi-system organ failure or direct kidney injury caused by SARS-CoV-2 is associated with the development of acute kidney injury (AKI) which subsequently increases the need for RRT and may affect the outcomes. Method(s): This is a retrospective observational study of 338 critically ill patients admitted with COVID-19 pneumonia in the ICU of a tertiary center in Portugal, between March 2020 and December 2021. Clinical, analytical and baseline patient characteristics were evaluated. Logistic regression analysis was performed to correlate patient data with the need for RRT and ICU mortality. Result(s): From a total of 338 patients, 5% required RRT (n = 16), 25% of which received intermittent hemodialysis (n = 4) and 87,5% continuous veno-venous hemofiltration (n = 14). Baseline characteristics are described in Table 1. In our sample, 61 patients (18%) presented with acute AKI, from whom 14 (23%) were submitted to RRT. From all the patients receiving RRT, 10 (62.5%) did not have pre-existing chronic kidney disease. In the logistic regression analysis, AKI (OR 45.4;95% CI 7.7-269.5;p < 0.001), higher SOFA (OR 1.24;95% CI 103-1.51;p = 0,03), creatinine (OR 2.01;95% CI 1.4-3.0;p < 0.001) and C-reactive protein (OR 1.09;95% CI 1.02-1.16;p = 0,01) on admission were associated with the need for RRT. Additionally, ICU mortality associated with RRT was 75% compared to 28.3% in the group not submitted to RRT (OR 7.6;2.4-24.2;p = 0.001). Conclusion(s): The need for RRT in critically ill COVID-19 patients is associated with an increased mortality rate in our study. We were also able to identify AKI, higher SOFA, creatinine and C-reactive protein at admission as risk factors for RRT. However, due to the retrospective nature of our analysis and our small sample size, more studies on this topic are needed to confirm these results.

Challenges and dilemmas of creative tourism in the 21st century: How can we preserve it from the massive offer?

Although there are not data to attest to the growth of various Creative Tourism experiences worldwide, the expectation of their increase is consistent with the strength of the nowadays markets and the strategies and changes needed to sustain this growth at the twenty-first century. So, it will be relevant to follow the new trends, changes and challenges that will shape the future path of Creative Tourism. In the context of the European Union, economic prosperity and well-being should respond to twin digital and green transitions that should prepare society to mitigate problems that arise from pandemic situations, such as the recent COVID-19. How do we follow new and future experiences, and how can institutions be positioned without jeopardising the massification of this segment? As with cultural tourism, this segment of creative initiatives can and should develop ways to avoid these possible mass derivations and adjust the preservation of its sustainability in the future. What strategy needs to be adapted so that future risks of vulgarisation will be avoided even within the possible new trends? What will be the role of the Southern European countries? This final chapter envisages promoting critical thinking about the role of Creative Tourism for local and regional development. The discussion focuses on how to prevent massification and how to respond to new challenges and saturated formulas and in accordance with the digital area of the twenty-first century. Also, it promotes some solutions based on short-term strategies to be outlined and on a TIN (Think, Integrate and Network) model, which can be replicated in many countries in Europe and in the rest of the world. © 2022 Paula Remoaldo, Vitor Ribeiro, Juliana Alves, Elaine Borges Scalabrini and Helder Lopes. All rights reserved.

Blockchain Assisted Voting in Academic Councils

Councils are a common organisational structure of Portuguese Universities and Polytechnic Institutes. They make the key decisions, in these organisations, by nominal voting at assembly meetings. The COVID pandemic forced the remote work upon most organisations, including universities and polytechnic institutes. Assuming that a remote assembly requires additional efforts in order to guarantee the integrity of the majority decisions taken by votes expressed by its members, opportunity arises for the use of a blockchain-assisted voting system. Benefits of blockchain, such as verifiability, immutability, tamper resistant, and its distributed nature appear to be a good fit. We propose a novel blockchain-assisted system to support the decision making of academic councils that operate by nominal voting in assemblies, gathering remotely and online. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Validation of the North America expert consensus statement on reporting CT findings for COVID-19 in individuals with lung cancer.

The aim of our study was to validate the use of the standardized Radiological Society of North America (RSNA) reporting system in individuals with known lung cancer who presented to the emergency department with suspected COVID-19. We included patients aged 18 years or older from the Cancer Institute of the State of São Paulo (ICESP) with a confirmed diagnosis of lung cancer, admitted to the emergency department and undergoing chest computed tomography (CT) for suspicion of COVID-19. Comparison between SARS-CoV2 RT-PCR across RSNA categories was performed in all patients and further stratified by diagnosis of lung cancer progression. Among 58 individuals included in the analysis (65±9 years, 43% men), 20 had positive RT-PCR. Less than a half (43%) had no new lung findings in the CT. Positive RT-PCR was present in 75% of those with typical findings according to RSNA and in only 9% when these findings were classified as atypical or negative (P<0.001). Diagnostic accuracy was even higher when stratified by the presence or absence of progressive disease (PD). Extent of pulmonary inflammatory changes was strongly associated with higher mortality, reaching a lethality of 83% in patients with >25% of lung involvement and 100% when there was >50% of lung involvement. The lung involvement score was also highly predictive of prognosis in this population as was reported for non-lung cancer individuals. Collectively, our results demonstrated that diagnostic and prognostic values of chest CT findings in COVID-19 are robust to the presence of lung abnormalities related to lung cancer.

Absenteeism in the Portuguese National Health Service during the COVID-19 pandemic

Objective: The COVID-19 pandemic posed innumerous challenges to the Portuguese National Health Service (NHS), including the absence of essential workers for health organizations. Therefore, the present work intended to quantify the absenteeism among the NHS workers during the period of COVID-19 pandemic (2019-2020). Method(s): This work used data from the NHS Transparency Portal, regarding the number of healthcare professionals and the number of absence days in the period of analysis. Absenteeism was compared, before and during the pandemics, in absolute numbers and as a percentage of workforce working days. Additionally, this work analyzed the main reported absence categories. Result(s): Results showed an 25% increase in absenteeism among NSH workers, from 2019 to 2020. The highest number of absence days were registered in May 2020, summing 598.323 days. Sickness, parental leaves and accident at work or an occupational disease were the most frequent absenteeism categories reported. Conclusion(s): Several factors might explain the excess of absence days among the NSH workers, during the pandemics, but some of them are likely to be associated with COVI-19 infection, either directly or indirectly. These absent rates might lead to increased difficulties and constraints in healthcare organizations, threatening the adequate response to the pandemics.

Plasmaferese Terapeutica: Analise Do Perfil Dos Procedimentos Realizados Pelo Centro De Hematologia E Hemoterapia Do Ceara Durante a Pandemia Do Covid

Objetivo: Analisar o perfil dos procedimentos de plasmaferese realizados pelo servico de aferese terapeutica. Material e metodo: Estudo descritivo e exploratorio com abordagem quantitativa. Analise retrospectiva e analitica realizada no Centro de Hematologia e Hemoterapia do Ceara, entre o periodo de janeiro de 2020 a dezembro de 2021. Os dados apresentados foram coletados a partir dos registros preenchidos em cada procedimento e tabulados em planilhas de excel mensalmente. As variaveis estudadas foram: indicacoes, genero, numero de sessoes, liquido de reposicao e reacoes adversas relacionadas aos procedimentos. Resultados: No periodo em estudo foram realizados 1.058 procedimentos, atendendo 203 pacientes. As principais indicacoes foram: sindrome de Guillain Barre 38 (18,7%), neuromielite optica 34 (16,7%), rejeicao mediada por anticorpo em transplante renal 20 (9,8%), recaida de glomeruloesclerose segmentar focal pos transplante renal 20 (9,8%), purpura trombocitopenica trombotica, (PTT) 17 (8,3%), miastenia gravis 16 (7,8%), encefalites imunes 13 (6,4%), mielites 11 (5,4%), vasculites 11 (5,4%), esclerose multipla 6 (2,9%), sindrome de Isaac 3 (1,4%), hiperviscosidade 6 (2,9%), esteatose hepatica da gravidez 4 (1,9%), sindrome de Goodpasture 1 (0,5%), Anti HLA pre transplante de medula ossea 1 (0,5%) e hipertrigliceridemia 1 (0,5%). Do total de pacientes, 76 (37,4%) eram do sexo masculino 127 (62,5%) do sexo feminino. O liquido de reposicao mais utilizado foi solucao salina com albumina, em 851 (80,4%) das sessoes. As principais reacoes adversas foram: hipotensao, parestesia e tremores, prurido e urticarias quando no procedimento foi utilizado o plasma como liquido de reposicao. O servico teve uma media mensal de 44,08 procedimentos. Discussao: A plasmaferese e uma tecnica que permite remover o plasma atraves de equipamento automatizado com finalidade terapeutica. Esse componente e substituido por outra solucao de acordo com a indicacao, acontecendo uma troca plasmatica e retirada de anticorpos e/ou toxinas. As indicacoes sao baseadas no guideline da ASFA- American Society for Apheresis. O numero de sessoes e definido de acordo com a recomendacao estabelecida no guidelin e e conforme avaliacao do medico hemoterapeuta e equipe assistente. Foi observado uma diferenca significativa em relacao ao genero, provavelmente relacionado ao carater imune das principais indicacoes e a relacao das doencas autoimunes com o sexo feminino. A plasmaferese e um procedimento capaz de reduzir a morbidade e mortalidade do paciente critico. O grande numero de procedimentos realizados mesmo durante a pandemia pode estar relacionado a reducao da disponibilidade de imunoglobulina humana no Brasil nos ultimos anos. Conclusao: Neste estudo, observamos aumento do numero de procedimentos de plasmaferese durante a pandemia de COVID. O numero de atendimentos foi maior ao sexo feminino do que ao sexo masculino e o liquido de reposicao mais utilizado foi solucao salina com albumina. Os procedimentos foram realizados ambulatorialmente e no ambito hospitalar, tanto em unidades COVID, como em unidades nao COVID, garantindo o acesso a aferese terapeutica nos casos em que ela foi necessaria. Copyright © 2022

Absence among National Health Service workers during the COVID-19 pandemic in Portugal : Joana Alves

Background By March 2020, the first Covid-19 cases were detected in Portugal. While the National Health Service (NHS) faced an increased demand for health care, anecdotal evidence showed that the NHS absenteeism rose. This might be explained by outbreaks in healthcare units, COVID-19 infection due to close contact with patients, self-isolation and quarantines, and family challenges originated by lockdowns. The present work aimed to quantify the absenteeism among NHS workers during the COVID-19 pandemic in Portugal. Methods This study used data for the number of NHS workers and absence days (2015-2021), from the Portuguese NHS Transparency Portal and the Strategy and Planning Office. Absenteeism was compared, before and after the pandemic onset, in absolute terms, and as absence rates (number of absent days as a percentage of potential workforce days). Additionally, we performed an interrupted time series analysis, by fitting a Poisson regression model with level change. We controlled for data seasonality using Fourier terms (pairs of sine and cosine functions). Results From 2015 until March 2020, the average monthly absence rate was of 12.2, rising to 14.4 in the remaining period. This represented an increase of 18% in the absence rate. The interrupted time series showed an increase of 10.8% in the NHS absenteeism after the pandemic onset [Relative risk =1.10;95% confidence interval (CI) 1.10-1.11;p < 0.01]. When accounting for seasonality in the data, the model showed an increase of 11.0% in the NHS absenteeism [Relative risk =1.11;95% CI 1.01-1.22;p < 0.05]. Conclusions These results highlight the excess of absence days among the NHS workers during the COVID-19 pandemic. In future healthcare crises, health professionals should be protected, by assuring a safe workplace and making protective equipment available. Only then will be possible to reduce constraints in healthcare assistance, guarantee the adequate response, and contain the absence costs. Key messages During the COVID-19 pandemic in Portugal, the NHS absenteeism increased by 11% (p < 0.05). The absence rates might have threatened healthcare assistance, and increased the healthcare costs.

Augmented Reality and Its Use as a Helping Tool in Education

This work suggests the use of Augmented Reality in education to provide an additional tool to help students’ understanding of studied content through visual stimulation, while capturing their attention and motivating them to complete tasks proposed. This assistance can be especially important for online laboratories—whether remote, virtual or hybrid—since activities in these environments are often performed with no tutors present—as they can usually be done at any time and place. Due to the COVID-19 pandemic, it was not possible to apply studied theories inside classrooms;therefore, a form was structured on Google Forms and shared with 30 educators from different areas and levels of education, seeking to hear their perceptions about the use of technology in their classes. Then there was an analysis and selection of seven AR applications for both Android and iOS operating systems, which were compared to check which one seems to have greater efficiency when being handled by educators. It was concluded that the Augmania™ software would be the best option for these professionals to create AR projects and activities to be performed in their classrooms, since it presents a simple and intuitive interface, while also offering different possibilities to augment information. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Application for coping with COVID-19 by health professionals in home care

Objective: To present the development and validation of an application to guide health professionals on Personal Protective Equipment donning and doffing in the context of the COVID-19 pandemic, as well as the guidelines in this regard that they are able to pass on to patients in home visit. Methods: The application validation was performed with 55 health professionals (nurses, physiotherapists and physicians) who were on the front line to combat COVID-19 in home care, using the Delphi technique. For data analysis, Content Validity Index and Cronbach's alpha coefficient were adopted. Results: Most judges assessed the application from inadequate to fully adequate in the first assessment. After corrections according to suggestions, the application was reassessed as adequate to fully adequate. The mean Cronbach's alpha coefficient was 0.942, characterizing the instrument's internal consistency. Content Validity Index in the first assessment ranged from 0.935 to 0.939, and in the second assessment it was 1.0. Conclusion: The Orienta COVID-19 application was validated by professionals who were on the front line in the fight against COVID-19 with consensus among judges in the second assessment.

Online learning or emergency remote teaching?: Reflections on online learning as pedagogical innovation in a higher education institution

Following the recent measures implemented worldwide as result of the pandemic caused by COVID-19, educational institutions needed to implement online learning practices, demanding a rapid appropriation of digital skills by teachers and students. The Polytechnic Institute of Portalegre, in Portugal, was one of the higher education institutions (IES) that organized a transition process for this teaching model. The objectives of the study focused on the characterization of the online learning process, including the practice of online learning and the students' perspectives regarding the future of online learning. The results obtained, from 420 validated questionnaires, point to a positive evaluation of this pedagogical experience, with some particularities listed in certain areas of the teaching and learning process, suggesting an in-depth analysis on the level of digital skills on the part of teachers and students in order to consolidate distance learning as a true pedagogical innovation process and not just as an "emergency remote teaching" experience. © 2022, IGI Global.

Impact of the COVID-19 Pandemic on Adherence to Exercise Prescription: The case of Cardiac Rehabilitation Programs

Cardiac Rehabilitation Programs (CRPs) are an important tool of secondary prevention and their implementation within health services, despite the uneven geographical distribution, has been receiving attention from decision-makers in recent years. Adherence to the CRPs is one of the great challenges faced by the multidisciplinary team, and there are several strategies to maintain adherence, particularly in CRP-Phase III, which occurs outside the hospital environment. One of the strategies followed is the use of remote performance monitoring and recording of possible alert symptoms. With the pandemic due to COVID-19, these challenges have become even more evident as Phase II programs have been suspended, thus increasing the importance of the home-based CRPs. In this work, the results of a study aiming to understand the impact of the pandemic on adherence to the prescription of exercise and the perception of patients regarding the effects of physical activity on health conditions are shown. The results indicate that the pandemic did not have a major effect on the adherence to home-based exercises, in particular, in patients undergoing programs using a telemonitoring system. Moreover, the perception of the importance of physical activity for health and well-being was reinforced in the context of the pandemic. © 2022 Croatian Society MIPRO.

SARS-CoV-2 variant strains and viral phylodynamics of ORF1a-1b genetic aspects in South America

Bioinformatics tools for online sequence analysis of variants have been used worldwide for the phylogenetic approach of SARS-Cov-2 and their variants. The purpose of this work is to contribute to the settlement of the SARS-CoV-2 genetic of the South America pandemic, presenting the ORF1a-1b evaluation. We proposed and reviewed two online bioinformatics pipelines for viral phylodynamic and phylogeographic analysis with an interactive visualization platform. The phylodynamics evaluation of South America shows a strong viral capacity to evoke immunity and an impressive multiplicity of variants in rapid expansion with mutations of potential importance, including ORF 1a-1b. They showed stately vital for infection and lethality, spreading and raising your frequency in South America from 1% to 20-30% in one year of pandemic occurrence. © 2021 IEEE.