A framework to assess potential health system resilience using fuzzy logic.

Objectives: To develop and test a framework to assess the potential of public health systems to maintain a resilient performance. Methods: Quantitative data from public databases and qualitative data from technical reports of Brazilian health authorities were used to develop the framework which was assessed and modified by experts. Fuzzy logic was used for the mathematical model to determine scores for four resilient abilities - monitoring, anticipation, learning, and response - and an aggregated coefficient of resilient potential in health care. The coefficient measures used data from before the coronavirus disease 2019 (COVID-19) pandemic. These were compared with measures of the actual performance of health systems in 10 cities in Brazil during the pandemic. Results: The coefficient of resilient potential in health care showed that the cities most affected by COVID-19 had lower potential for resilient performance before the pandemic. Some local health systems had adequate response capabilities, but other abilities were not well developed, which adversely affected the management of the spread of COVID-19. Conclusions: The coefficient of resilient potential in health care is useful to indicate important areas for resilient performance and the different types of resilience capacities that can be considered in different contexts and levels of public health systems. Regular assessment of the potential of health systems for resilient performance would help highlight opportunities for continuous improvement in health system functions during chronic stress situations, which could strengthen their ability to keep functioning in the face of sudden disturbances.

A framework to assess potential health system resilience using fuzzy logic Marco para evaluar la resiliencia potencial de un sistema de salud mediante la lógica difusa Estrutura de avaliação do potencial de resiliência dos sistemas de saúde utilizando a lógica fuzzy

Objectives. To develop and test a framework to assess the potential of public health systems to maintain a resilient performance. Methods. Quantitative data from public databases and qualitative data from technical reports of Brazilian health authorities were used to develop the framework which was assessed and modified by experts. Fuzzy logic was used for the mathematical model to determine scores for four resilient abilities – monitoring, anticipation, learning, and response – and an aggregated coefficient of resilient potential in health care. The coefficient measures used data from before the coronavirus disease 2019 (COVID-19) pandemic. These were compared with measures of the actual performance of health systems in 10 cities in Brazil during the pandemic. Results. The coefficient of resilient potential in health care showed that the cities most affected by COVID-19 had lower potential for resilient performance before the pandemic. Some local health systems had adequate response capabilities, but other abilities were not well developed, which adversely affected the management of the spread of COVID-19. Conclusions. The coefficient of resilient potential in health care is useful to indicate important areas for resilient performance and the different types of resilience capacities that can be considered in different contexts and levels of public health systems. Regular assessment of the potential of health systems for resilient performance would help highlight opportunities for continuous improvement in health system functions during chronic stress situations, which could strengthen their ability to keep functioning in the face of sudden disturbances.

Transformative dimensions of resilience and brittleness during health systems' collapse: a case study in Brazil using the Functional Resonance Analysis Method.

BACKGROUND: As health systems struggle to tackle the spread of Covid-19, resilience becomes an especially relevant attribute and research topic. More than strength or preparedness, to perform resiliently to emerging shocks, health systems must develop specific abilities that aim to increase their potential to adapt to extraordinary situations while maintaining their regular functioning. Brazil has been one of the most affected countries during the pandemic. In January 2021, the Amazonas state's health system collapsed, especially in the city of Manaus, where acute Covid-19 patients died due to scarcity of medical supplies for respiratory therapy. METHODS: This paper explores the case of the health system's collapse in Manaus to uncover the elements that prevented the system from performing resiliently to the pandemic, by carrying out a grounded-based systems analysis of the performance of health authorities in Brazil using the Functional Resonance Analysis Method. The major source of information for this study was the reports from the congressional investigation carried out to unveil the Brazilian response to the pandemic. RESULTS: Poor cohesion between the different levels of government disrupted essential functions for managing the pandemic. Moreover, the political agenda interfered in the abilities of the system to monitor, respond, anticipate, and learn, essential aspects of resilient performance. CONCLUSIONS: Through a systems analysis approach, this study describes the implicit strategy of "living with Covid-19", and an in-depth view of the measures that hampered the resilience of the Brazilian health system to the spread of Covid-19.

The impact of supervised physical exercise on chemokines and cytokines in recovered COVID-19 patients.

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus, which induces a high release of pro-inflammatory chemokines and cytokines, leading to severe systemic disorders. Further, evidence has shown that recovered COVID-19 patients still have some symptoms and disorders from COVID-19. Physical exercise can have many health benefits. It is known to be a potent regulator of the immune system, which includes frequency, intensity, duration, and supervised by a professional. Given the confinement and social isolation or hospitalization of COVID-19 patients, the population became sedentary or opted for physical exercise at home, assuming the guarantee of the beneficial effects of physical exercise and reducing exposure to SARS-CoV-2. This study aimed to investigate the effects of a supervised exercise protocol and a home-based unsupervised exercise protocol on chemokine and cytokine serum levels in recovered COVID-19 patients. This study was a prospective, parallel, two-arm clinical trial. Twenty-four patients who had moderate to severe COVID-19 concluded the intervention protocols of this study. Participants were submitted to either supervised exercise protocol at the Clinical Hospital of the Federal University of Pernambuco or home-based unsupervised exercise for 12 weeks. We analyzed serum levels of chemokines (CXCL8/IL-8, CCL5/RANTES, CXCL9/MIG, CCL2/MCP-1, and CXCL10/IP-10) and cytokines (IL-2, IL-4, IL-6, IL-10, IL-17A, TNF-α, and IFN-γ). Before the interventions, no significant differences were observed in the serum levels of chemokines and cytokines between the supervised and home-based unsupervised exercise groups. The CXCL8/IL-8 (p = 0.04), CCL2/MCP-1 (p = 0.03), and IFN-γ (p = 0.004) levels decreased after 12 weeks of supervised exercise. In parallel, an increase in IL-2 (p = 0.02), IL-6 (p = 0.03), IL-4 (p = 0.006), and IL-10 (p = 0.04) was observed after the supervised protocol compared to pre-intervention levels. No significant differences in all the chemokines and cytokines were found after 12 weeks of the home-based unsupervised exercise protocol. Given the results, the present study observed that supervised exercise was able to modulate the immune response in individuals with post-COVID-19, suggesting that supervised exercise can mitigate the inflammatory process associated with COVID-19 and its disorders. Clinical trial registration: https://ensaiosclinicos.gov.br/rg/RBR-7z3kxjk, identifier U1111-1272-4730.

Visit and Management of Historic Gardens during COVID-19 from the Owners/Managers Perspective: Portugal as a Case Study

Gardens around the world, including in Portugal, were enjoying a growth in visitor numbers before the COVID-19 pandemic. The closing of the gates was followed by an immediate fall in visitor numbers and consequent loss of income. However, this disruptive period also acted as a challenge and an opportunity for tourist attractions such as gardens to adapt and reinvent themselves in the wake of new demands imposed by COVID-19, aiming to restore the trust of visitors and maintain or increase the public's engagement with gardens and consequently maintain its sustainability. Taking this framework into account, the purpose of this study is to ascertain the impact of the pandemic on visiting and managing gardens, especially in terms of the precautions applied when they reopened and the measures taken to keep them functioning and reaching people during this period. To accomplish this, a literature review has been carried out and a survey questionnaire subsequently applied to the managers or owners of a selected group of Portuguese historic gardens regarded as major tourist attractions. The findings show that a drop in visitors and income were the immediate and the main negative impacts, having both negative and positive consequences for the maintenance of spaces. Gardens were also able to adapt and continue to function under adverse conditions as well as to incorporate safety requirements in their reopening periods. However, not all gardens responded in the same way to the challenges posed by the pandemic with regard to their relationship with the public. Two groups of gardens were recognized: one that remained passive and took no relevant actions in this period, and another more pro-active group that implemented or reinforced strategies to encourage visits both physical and virtual, and to strengthen their connection with the public, particularly in the digital domain. Respondents also note that they recorded a positive response from the public, specifically local residents. The vast majority agree that gardens became popular places immediately after the lockdown periods;future studies on garden visitors could consolidate this finding. In the post-COVID period, the gardens' challenge is to maintain or improve their connection and interaction with audiences achieved during the pandemic, especially the national and local communities.

Analysis of government agencies and stakeholders' twitter communications during the first surge of COVID-19 in Brazil.

BACKGROUND: Official authorities are in charge of communicating with the public in a consistent and coherent manner. The impact of social media on managing the coronavirus 2019 (COVID-19) pandemic potentially influenced social behavior in Brazil. OBJECTIVE: Using Twitter, this study analyzes communications about the COVID-19 pandemic from official agencies of the Brazilian government and key public sector decision-makers. METHOD: We captured public Twitter messages about COVID-19 exchanged between authorities at the federal, state, and municipal levels of government. These messages were further classified into guidance and information messages or disinformation messages. Finally, through analysis of tweets and their frequency, we evidenced the level of information generated by the three levels of government. RESULTS: Our analyses show an underestimation of the magnitude of the pandemic by Brazilian government authorities. None of the spheres of government anticipated the imminent health crisis, did not issue good recommendations and guidelines, and did not take preventive actions. CONCLUSION: The lack of governmental actions and adequate guidance in Brazil has led to an explosive increase in infected people and deaths. Surprisingly, this was not due to technical or structural reasons. It resulted from conflicting communication strategies implemented by the federal, state, and municipal governments in attempts to minimize the effects of COVID-19 on their local health structures.

Unveiling conflicting strategies in the Brazilian response to COVID-19: A cross-sectional study using the Functional Resonance Analysis Method.

By the time the present study was completed, Brazil had been the second epicenter of COVID-19. In addition, the actions taken to respond to the pandemic in Brazil were the subject of extensive debate, since some diverged from recommendations from health authorities and scientists. Since then, the resulting political and social turmoil showed conflicting strategies to tackle the pandemic in Brazil, with visible consequences in the numbers of casualties, but also with effects on the resilience of the overall health system. Thus, this article explores the actions taken in Brazil to cope with the pandemic from a systems analysis perspective. The structure of the domain was analyzed using Work Domain Analysis, and the activated functions were analyzed using the Functional Resonance Analysis Method, identifying the variability resulting from the conflicting strategies carried out and the consequences to the capacity of the Brazilian health system to respond resiliently to the pandemic. Results of the study show that functions that overlapped the operation of the overall system were introduced, causing the health system to operate under conflicting objectives, in which functions were created to restrict the outcomes of each other during the entire COVID-19 crisis.

Interactions between e-commerce users during the COVID-19 pandemic period: What came and what remained.

BACKGROUND: During the COVID-19 pandemic, the online sales industry experienced record-breaking growth. The number of businesses that decided to enter the e-commerce market for the first time was enormous. At the height of the quarantine, Brazil was registering a new virtual store every minute. This was an unanticipated and unplanned expansion. OBJECTIVE: This study aims to identify existing challenges in human interactions with e-commerce, such as the difficulties faced during the pandemic and improvements to ensure growth of, and confidence in, this type of business. METHODS: An exploratory study of e-commerce data and an online survey using the snowball non-probabilistic method were developed to research the growth of, and issues in, Brazilian users' interaction with e-commerce, comparing findings before and after the pandemic restrictions. RESULTS: Some businesses were not prepared, and the lack of experience among workers contributed to businesses not delivering on their promises. The acceleration of e-commerce demonstrates the need to guarantee that Brazil can effectively use e-commerce to capitalize on digital supply chain opportunities and enhance their role in its economic expansion, while remaining human-centered. CONCLUSIONS: For users' needs to be met, companies and online workers must understand people's needs and behaviors in order to provide excellent service.

Platelet proteome reveals features of cell death, antiviral response and viral replication in covid-19.

Coronavirus disease 2019 (COVID-19) has affected over 400 million people worldwide, leading to 6 million deaths. Among the complex symptomatology of COVID-19, hypercoagulation and thrombosis have been described to directly contribute to lethality, pointing out platelets as an important SARS-CoV-2 target. In this work, we explored the platelet proteome of COVID-19 patients through a label-free shotgun proteomics approach to identify platelet responses to infection, as well as validation experiments in a larger patient cohort. Exclusively detected proteins (EPs) and differentially expressed proteins (DEPs) were identified in the proteomic dataset and thus classified into biological processes to map pathways correlated with pathogenesis. Significant changes in the expression of proteins related to platelet activation, cell death, and antiviral response through interferon type-I were found in all patients. Since the outcome of COVID-19 varies highly among individuals, we also performed a cross-comparison of proteins found in survivors and nonsurvivors. Proteins belonging to the translation pathway were strongly highlighted in the nonsurvivor group. Moreover, the SARS-CoV-2 genome was fully sequenced in platelets from five patients, indicating viral internalization and preprocessing, with CD147 as a potential entry route. In summary, platelets play a significant role in COVID-19 pathogenesis via platelet activation, antiviral response, and disease severity.

Desinformação na pandemia de Covid-19: similitudes informacionais entre Trump e Bolsonaro

A pesquisa empírica teve como objetivo investigar as possíveis similitudes informacionais entre o ex-presidente dos Estados Unidos e o presidente do Brasil, em virtude do alinhamento político-ideológico entre, respectivamente, Donald Trump e Jair Bolsonaro, que tiveram um posicionamento contraditório no combate à Covid-19. A fim de elucidar a questão de pesquisa, foram coletados dados de postagens nos perfis dos dois no Facebook e os pronunciamentos oficiais nos websites dos governos americano e brasileiro desde o primeiro dia de notificação nos países para realizar a Análise de Conteúdo através do programa IRaMuTeQ, com base no arcabouço teóricoconceitual sobre desinformação. O resultado das análises apresentou similitudes informacionais entre o ex-presidente e o presidente, bem como semelhanças no discurso controverso e em atitudes contrárias às medidas defendidas pela Organização Mundial de Saúde.Alternate : This empirical research aimed to investigate possible informational similarities between the former president of the United States and the president of Brazil, due to the political-ideological alignment between Donald Trump and Jair Bolsonaro, who had a contradictory position in the fight against Covid-19. In order to elucidate the research question, data were collected from posts on the profiles of presidents on Facebook and official pronouncements on government websites since the first day of notification in countries to carry out Content Analysis through the program IRaMuTeQ, based on the theoretical-conceptual framework on disinformation. The results of the analyzes showed informational similarities between the two presidents, as well as similarities in the controversial speech and in attitudes contrary to the measures advocated by the World Health Organization.

Detection of squawks in respiratory sounds of mechanically ventilated COVID-19 patients.

Mechanically ventilated patients typically exhibit abnormal respiratory sounds. Squawks are short inspiratory adventitious sounds that may occur in patients with pneumonia, such as COVID-19 patients. In this work we devised a method for squawk detection in mechanically ventilated patients by developing algorithms for respiratory cycle estimation, squawk candidate identification, feature extraction, and clustering. The best classifier reached an F1 of 0.48 at the sound file level and an F1 of 0.66 at the recording session level. These preliminary results are promising, as they were obtained in noisy environments. This method will give health professionals a new feature to assess the potential deterioration of critically ill patients.

On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis.

As COVID-19 spread across Brazil, it quickly reached remote regions including Amazon's ultra-peripheral locations where patient transportation through rivers is added to the list of obstacles to overcome. This article analyses the pandemic's effects in the access of riverine communities to the prehospital emergency healthcare system in the Brazilian Upper Amazon River region. To do so, we present two studies that by using a Resilience Engineering approach aimed to predict the functioning of the Brazilian Mobile Emergency Medical Service (SAMU) for riverside and coastal areas during the COVID-19 pandemic, based on the normal system functioning. Study I, carried out before the pandemic, applied ethnographic methods for data collection and the Functional Resonance Analysis Method - FRAM for data analysis in order to develop a model of the mobile emergency care in the region during typical conditions of operation. Study II then estimated how changes in variability dynamics would alter system functioning during the pandemic, arriving at three trends that could lead the service to collapse. Finally, the accuracy of predictions is discussed after the pandemic first peaked in the region. Findings reveal that relatively small changes in variability dynamics can deliver strong implications to operating care and safety of expeditions aboard water ambulances. Also, important elements that add to the resilient capabilities of the system are extra-organizational, and thus during the pandemic safety became jeopardized as informal support networks grew fragile. Using FRAM for modelling regular operation enabled prospective scenario analysis that accurately predicted disruptions in providing emergency care to riverine population.

Recombinant myxoma virus infection associated with high mortality in rabbit farming (Oryctolagus cuniculus).

Myxomatosis is an emergent disease in the Iberian hare, having been considered a rabbit disease for decades. Genome sequencing of the strains obtained from Iberian hares with myxomatosis showed these to be distinct from the classical ones that circulated in rabbits since the virus introduction in Europe, in 1952. The main genomic difference in this natural recombinant hare myxoma virus (ha-MYXV) is the presence of an additional 2.8 kb region disrupting the M009L gene and adding a set of genes homologous to the myxoma virus (MYXV) genes M060R, M061R, M064R, M065R and M066R originated in Poxviruses. After the emergence of this recombinant virus (ha-MYXV) in hares, in the summer of 2019, the ha-MYXV was not detected in rabbit surveys, suggesting an apparent species segregation with the MYXV classic strains persistently circulating in rabbits. Recently, a group of six unvaccinated European rabbits (Oryctolagus cuniculus cuniculus) from a backyard rabbitry in South Portugal developed signs of myxomatosis (anorexia, dyspnoea, oedema of eyelids, head, ears, external genitals and anus, and skin myxomas in the base of the ears). Five of them died within 24-48 hr of symptom onset. Molecular analysis revealed that only the recombinant MYXV was present. This is the first documented report of a recombinant hare myxoma virus in farm rabbits associated with high mortality, which increases the concern for the future of both the Iberian hare and wild rabbits and questions the safety of the rabbit industry. This highlights the urgent need to evaluate the efficacy of available vaccines against this new MYXV.

Community health workers' attitudes, practices and perceptions towards the COVID-19 pandemic in brazilian low-income communities.

BACKGROUND: Community Health Workers (CHW) are a category of social workers described in many countries' health systems as responsible for engaging people in their residences and communities, and other non-clinical spaces to enable access to health services, especially in low-income areas. These professionals have been exposed to numerous new risks during the COVID-19 pandemic. OBJECTIVE: This study describes how the COVID-19 pandemic is perceived by CHWs who work in poor communities or slums in Brazil. METHODS: We conducted an online survey with a random sample of 775 CHWs operating in 368 municipalities of the 26 Brazilian states. At a confidence level of 95%, results of the survey were subject to a maximum sampling error of 4%. RESULTS: Our data indicate that the negationist agenda increases the challenges to the performance of CHWs within low-income communities, preventing the consensus on the necessity of social distancing, business closures and other measures to face the COVID-19 pandemic. CONCLUSION: The pandemic imposes unexpected challenges on the usual modes of interaction of public health officers with poor communities. This study provides evidence that these challenges have been ignored or minimized in Brazilian policy prescriptions for primary care in the face of the COVID-19 pandemic.

A Wearable Stethoscope for Long-Term Ambulatory Respiratory Health Monitoring.

Lung sounds acquired by stethoscopes are extensively used in diagnosing and differentiating respiratory diseases. Although an extensive know-how has been built to interpret these sounds and identify diseases associated with certain patterns, its effective use is limited to individual experience of practitioners. This user-dependency manifests itself as a factor impeding the digital transformation of this valuable diagnostic tool, which can improve patient outcomes by continuous long-term respiratory monitoring under real-life conditions. Particularly patients suffering from respiratory diseases with progressive nature, such as chronic obstructive pulmonary diseases, are expected to benefit from long-term monitoring. Recently, the COVID-19 pandemic has also shown the lack of respiratory monitoring systems which are ready to deploy in operational conditions while requiring minimal patient education. To address particularly the latter subject, in this article, we present a sound acquisition module which can be integrated into a dedicated garment; thus, minimizing the role of the patient for positioning the stethoscope and applying the appropriate pressure. We have implemented a diaphragm-less acousto-electric transducer by stacking a silicone rubber and a piezoelectric film to capture thoracic sounds with minimum attenuation. Furthermore, we benchmarked our device with an electronic stethoscope widely used in clinical practice to quantify its performance.