Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series.

OBJECTIVE: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. METHODS: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. RESULTS: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). CONCLUSIONS: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series / Oxigenação por membrana extracorpórea venovenosa em pacientes com pneumonia por SARS-CoV-2 no Brasil: série de casos

ABSTRACT Objective: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. Methods: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. Results: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). Conclusions: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

RESUMO Objetivo: O mundo vem sofrendo com a pandemia de COVID-19. Alguns pacientes com COVID-19 desenvolvem pneumonia viral grave, necessitando ventilação mecânica e medidas para tratar a hipoxemia refratária, como estratégias de ventilação protetora, posição prona e uso de oxigenação por membrana extracorpórea venovenosa (ECMO-VV). Descrevemos uma série de casos de 30 pacientes com COVID-19 que necessitaram de ECMO-VV no Hospital Alemão Oswaldo Cruz, localizado na cidade de São Paulo, Brasil. Métodos: Foram incluídos todos os pacientes que necessitaram de ECMO-VV devido à pneumonia por COVID-19 entre março de 2020 e junho de 2021. Resultados: Antes da ECMO-VV, os pacientes apresentavam as seguintes medianas: escore SOFA de 11; escore APPS de 7; escore Respiratory ECMO Survival Prediction de 2; e escore de Murray de 3,3. A mortalidade hospitalar em 60 dias foi de 33,3% (n = 10). Conclusões: Apesar de nossos pacientes apresentarem um perfil de alta gravidade, nossos resultados foram semelhantes aos de outros estudos de coorte na literatura. Isso demonstra que a ECMO-VV pode ser uma boa ferramenta mesmo em uma situação de pandemia quando administrada em um centro experiente.

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation / Doação renal pareada no Brasil: tempo para reflexão

Abstract Introduction: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. Discussion: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. Conclusion: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.

Resumo Introdução: O transplante renal (TxR) é sabidamente o melhor tratamento para doença renal crônica. No Brasil, mais de 26 mil pacientes aguardam em lista atualmente. A doação renal pareada (DRP) oferece a um par de doador/receptor incompatível a possibilidade de trocar com outro par na mesma situação, representando uma estratégia para aumentar o número de TxR. Discussão: A DRP deixou de ser apenas uma ideia há mais de 20 anos. Atualmente é responsável por 16,2% dos TxR com doador vivo (TxRDV) nos EUA e 8% na Europa. Os resultados são semelhantes a outros TxRDV. Essa modalidade representa uma alternativa promissora, especialmente para os receptores hipersensibilizados que tendem a se acumular em lista de espera. A DRP não está limitada a países desenvolvidos. Em 2014, a Índia já publicava excelentes resultados. Na Guatemala, o primeiro TxRDV através de DRP aconteceu em 2011. Porém, a prática permanece limitada a casos isolados na América Latina. Conclusão: Programas de DRP com diferentes dimensões, regras para aceitação e critérios para alocação estão sendo desenvolvidos e expandidos mundialmente com o objetivo de atender às demandas dos pacientes. O aumento na capacidade de transplantar trazido pela DRP vem ao encontro especialmente das necessidades dos pacientes hipersensibilizados. O programa de TxR brasileiro tem maturidade para assumir o desafio de iniciar o programa de DRP, com o objetivo de beneficiar principalmente seus pacientes que estão em maior desvantagem por apresentarem baixas chances de transplante com doadores falecidos.

Baseline characteristics and evolution of Brazilian patients with atypical hemolytic uremic syndrome: first report of the Brazilian aHUS Registry.

Background: Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare disease. Therefore, studies involving large samples are scarce, making registries powerful tools to evaluate cases. We present herein the first analysis of the Brazilian aHUS Registry (BRaHUS). Methods: Analysis of clinical, laboratory, genetic and treatment data from patients inserted in the BRaHUS, from 2017 to 2020, as an initiative of the Rare Diseases Committee of the Brazilian Society of Nephrology. Results: The cohort consisted of 75 patients (40 adults and 35 pediatric). There was a predominance of women (56%), median age at diagnosis of 20.7 years and a positive family history in 8% of cases. Renal involvement was observed in all cases and 37% had low C3 levels. In the <2 years of age group, males were predominant. Children presented lower levels of hemoglobin (P = .01) and platelets (P = .003), and higher levels of lactate dehydrogenase (LDH) (P = .004) than adults. Genetic analysis performed in 44% of patients revealed pathogenic variants in 66.6% of them, mainly in CFH and the CFHR1-3 deletion. Plasmapheresis was performed more often in adults (P = .005) and 97.3% of patients were treated with eculizumab and its earlier administration was associated with dialysis-free after 3 months (P = .08). Conclusions: The cohort of BRaHUS was predominantly composed of female young adults, with renal involvement in all cases. Pediatric patients had lower hemoglobin and platelet levels and higher LDH levels than adults, and the most common genetic variants were identified in CFH and the CFHR1-3 deletion with no preference of age, a peculiar pattern of Brazilian patients.

Dynamics of epidemics from cavity master equations: Susceptible-infectious-susceptible models.

We apply the recently introduced cavity master equation (CME) to epidemic models and compare it to previously known approaches. We show that CME seems to be the formal way to derive (and correct) dynamic message passing (rDMP) equations that were previously introduced in an intuitive ad hoc manner. CME outperforms rDMP in all cases studied. Both approximations are nonbacktracking and this causes CME and rDMP to fail when the ecochamber mechanism is relevant, as in loopless topologies or scale free networks. However, we studied several random regular graphs and Erdos-Rényi graphs, where CME outperforms individual based mean field and a type of pair based mean field, although it is less precise than pair quenched mean field. We derive analytical results for endemic thresholds and compare them across different approximations.

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation.

INTRODUCTION: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. DISCUSSION: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. CONCLUSION: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.

Acute Kidney Injury Due to COVID-19 in Intensive Care Unit: An Analysis From a Latin-American Center.

Introduction: The kidney may be affected by coronavirus (COVID-19) in the setting of acute kidney injury (AKI). Data about AKI in intensive care unit (ICU) patients in Latin America are scarce. We aimed to evaluate the risk of AKI, dialysis (HD), and death in ICU COVID-19 patients in a Brazilian center. Methods: Analysis from medical records of COVID-19 patients in a Brazilian center. Results: A total of 95 patients were analyzed. There was male predominance (64.2%), median age: 64.9 years, and previous history of hypertension and diabetes in 51.6 and 27.4%, respectively. AKI was diagnosed in 54 (56.8%) patients, and 32 (59.2%) of them required HD. Mortality rate was 17.9%. AKI patients when compared with no-AKI were more frequently hypertensive/diabetic and more often needed organ support therapies. Workups depicted more anemia, lymphopenia, and higher levels of inflammatory markers and higher mortality. Comparing patients who had undergone death to survivors, they were older, more frequently diabetic, and had worse SAPS3 and SOFA scores and need for organ support therapies, AKI, and HD. Multinomial logistic regression revealed that hypertension (p = 0.018) and mechanical ventilation (p = 0.002) were associated with AKI; hypertension (p = 0.002), mechanical ventilation (p = 0.008), and use of vasopressor (p = 0.027) to HD patients; and age >65 years (p = 0.03) and AKI (p = 0.04) were risk factors for death. Conclusions: AKI was a common complication of ICU COVID-19 patients, and it was more frequent in patients with hypertension and need of organ support therapies. As well as age >65 years, AKI was an independent risk factor for death.

Effect of tocilizumab on clinical outcomes at 15 days in patients with severe or critical coronavirus disease 2019: randomised controlled trial.

OBJECTIVE: To determine whether tocilizumab improves clinical outcomes for patients with severe or critical coronavirus disease 2019 (covid-19). DESIGN: Randomised, open label trial. SETTING: Nine hospitals in Brazil, 8 May to 17 July 2020. PARTICIPANTS: Adults with confirmed covid-19 who were receiving supplemental oxygen or mechanical ventilation and had abnormal levels of at least two serum biomarkers (C reactive protein, D dimer, lactate dehydrogenase, or ferritin). The data monitoring committee recommended stopping the trial early, after 129 patients had been enrolled, because of an increased number of deaths at 15 days in the tocilizumab group. INTERVENTIONS: Tocilizumab (single intravenous infusion of 8 mg/kg) plus standard care (n=65) versus standard care alone (n=64). MAIN OUTCOME MEASURE: The primary outcome, clinical status measured at 15 days using a seven level ordinal scale, was analysed as a composite of death or mechanical ventilation because the assumption of odds proportionality was not met. RESULTS: A total of 129 patients were enrolled (mean age 57 (SD 14) years; 68% men) and all completed follow-up. All patients in the tocilizumab group and two in the standard care group received tocilizumab. 18 of 65 (28%) patients in the tocilizumab group and 13 of 64 (20%) in the standard care group were receiving mechanical ventilation or died at day 15 (odds ratio 1.54, 95% confidence interval 0.66 to 3.66; P=0.32). Death at 15 days occurred in 11 (17%) patients in the tocilizumab group compared with 2 (3%) in the standard care group (odds ratio 6.42, 95% confidence interval 1.59 to 43.2). Adverse events were reported in 29 of 67 (43%) patients who received tocilizumab and 21 of 62 (34%) who did not receive tocilizumab. CONCLUSIONS: In patients with severe or critical covid-19, tocilizumab plus standard care was not superior to standard care alone in improving clinical outcomes at 15 days, and it might increase mortality. TRIAL REGISTRATION: ClinicalTrials.gov NCT04403685.

COVID-19 pneumonia in kidney transplant recipients-Where we are?

In late December 2019, China reported cases of respiratory illness in humans that involved a novel coronavirus SARS-CoV-2. On March 20, 2020, the first coronavirus disease 2019 (COVID-19) in Brazil was diagnosed, and by now, we present the report on the first case of COVID among transplant recipients in our country. A liver and kidney transplant patient with SARS-CoV-2 pneumonia without respiratory failure was treated in a clinical multimodal strategy consisting of symptomatic support therapy, immunosuppression reduction, use of anti-coronavirus drugs and heparin leading to a progressive improvement of patient symptoms till discharge. The authors also present a comprehensive review of published cases.

Theory of Nonequilibrium Local Search on Random Satisfaction Problems.

We study local search algorithms to solve instances of the random k-satisfiability problem, equivalent to finding (if they exist) zero-energy ground states of statistical models with disorder on random hypergraphs. It is well known that the best such algorithms are akin to nonequilibrium processes in a high-dimensional space. In particular, algorithms known as focused, and which do not obey detailed balance, outperform simulated annealing and related methods in the task of finding the solution to a complex satisfiability problem, that is to find (exactly or approximately) the minimum in a complex energy landscape. A physical question of interest is if the dynamics of these processes can be well predicted by the well-developed theory of equilibrium Gibbs states. While it has been known empirically for some time that this is not the case, an alternative systematic theory that does so has been lacking. In this Letter we introduce such a theory based on the recently developed technique of cavity master equations and test it on the paradigmatic random 3-satisfiability problem. Our theory predicts the qualitative form of the phase boundary between the satisfiable (SAT) and unsatisfiable (UNSAT) region of the phase diagram where the numerics of a focused Metropolis search and cavity master equation cannot be distinguished.

Exploring the diluted ferromagnetic p-spin model with a cavity master equation.

We introduce an alternative solution to Glauber multispin dynamics on random graphs. The solution is based on the recently introduced cavity master equation (CME), a time-closure turning the, in principle, exact dynamic cavity method into a practical method of analysis and of fast simulation. Running CME once is of comparable computational complexity as one Monte Carlo run on the same problem. We show that CME correctly models the ferromagnetic p-spin Glauber dynamics from high temperatures down to and below the spinoidal transition. We also show that CME allows an alternative exploration of the low-temperature spin-glass phase of the model.

Representaciones sociales de líderes comunitarios sobre el consumo de sustancias psicoactivas en un sector marginal de la comuna 18 de la ciudad de Cali-Colombia en el año 2018 / Social representations of community leaders on the consumption of psychoactive substances in a marginal sector of the ciyi of Cali

el objetivo primordial de este estudio fue Comprender las representaciones sociales de los líderes de organizaciones de base comunitaria sobre el consumo de sustancias psicoactivas en un sector barrial de la comuna 18 en la ciudad de Cali. Método: Se desarrolló un estudio bajo un enfoque investigativo cualitativo y su diseño se asumió como un estudio de representaciones sociales, el cual se suscribe al paradigma interpretativo-constructivista. Resultados: Las representaciones sociales son una especie de conocimiento de sentido común por medio del cual los individuos y las comunidades convierten una realidad física en construcciones perceptibles de aquello que les rodean, convirtiendo lo extraño en familiar. Esta descripción está basada en el proceso de codificación y categorización que se teje alrededor de los componentes de las Representaciones Sociales, a saber; La información, las actitudes y el campo de la representación social.

Introduction: Social representations are a kind of common sense knowledge by means of which individuals and communities convert a physical reality into perceptible constructions of what surrounds them, converting the strange into familiar. The main objective of this study was to understand the social representations of the leaders of community-based organizations on the consumption of psychoactive substances in a neighborhood sector of commune 18 in the city of Cali. Method: A study was developed under a qualitative research approach and its design was assumed as a study of social representations, which subscribes to the interpretive-constructivist paradigm. Results: The community leaders defined the two-dimensional phenomenon, on the one hand; a health problem, evidencing a series of scientific knowledge in the participants, which influences the constitution of the Social Representation of psychoactive substance consumption as a disease, and on the other hand, a social problem given that it is associated with social determinants and of policies that are outside the scope of consumption itself. Conclusion: The Social Representations that leaders and community-based organizations attribute to the use of psychoactive substances in the sector of the commune 18 are characterized by being made up of meanings that are woven between a scientific knowledge about the consumption of substances, an institutional discourse and the moral assessment system established in the context of the community.

El fracaso escolar como un síntoma afectivo en niños y niñas bajo condiciones de orfandad / School failure as a affective symptom in children and girls under conditions of orphanhood

El presente artículo emerge a partir de una revisión crítica acerca de los conceptos de fracaso escolar y la experiencia de orfandad, estableciendo las limitaciones actuales con que se aborda el fenómeno educativo y la conceptualización sobre la infancia huérfana. De esta forma, se cuestionan las dimensiones afectivas y traumáticas que subyacen al fracaso escolar. Al final, se invita a la investigación empírica para abordar el fenómeno preguntando si es posible considerar que la experiencia de abandono en niños y niñas, con todas sus vivencias de maltrato y deprivación, pueda estar relacionada con las dificultades en el aprendizaje y en últimas con el fracaso escolar.

This paper emerges from a critical review of the concepts of school failure and experience orphans, establishing the current limitations with the educational phenomenon and the conceptualization of the orphaned children is addressed. Thus, the emotional and traumatic dimensions underlying question school failure. In the end, they are invited to empirical research to address the phenomenon wondering if you might consider the experience of abandonment in children, with all their experiences of abuse and deprivation, it can be related to learning difficulties and ultimately with school failure.

Acerca de la imposibilidad de la prevención del consumo y abuso de sustancias psicoactivas. ¿una Invitación a la discusión en las ciencias sociales? / The impossibility of prevention and psychoactive substance abuse. An invitation to social sciences to this discussion?

El presente artículo pretende inducir a una discusión crítica acerca de las nociones conceptuales de la prevención aplicados al fenómeno del consumo de sustancias psicoactivas. Se realizó un recorrido teórico sobre las nociones acerca de la enfermedad y como estas preceden el concepto de prevención. De la misma se abordan aproximaciones al término de prevención y algunos de los modelos existentes, los cuales han sido bandera de las ciencias de la salud y finalmente estableciendo puntos de encuentro y desencuentro, lo cual abre un espacio necesario para que las ciencias sociales realicen sus portaciones. Finalmente, se discute sobre la imposibilidad de la prevención bajo el marco conceptual y metodológico existente.

This article aims to induce a critical discussion of the conceptual notions of prevention applied to the phenomenon of psychoactive substances. A theoretical course on notions about the disease was made and how are you precede the concept of prevention. Similarly the term prevention approaches are discussed and some of the existing models, which have been the projects of health sciences and finally establishing points of convergence and divergence, which opens up a space needed for the social sciences to make their contributions. Finally, there is the discussion about the impossibility of prevention under the existing conceptual and methodological framework.

[Evolution of the health system in Mexico]. / La transformación del sistema de salud y el Seguro Popular.

This text is a summary of how the health system evolves in Mexico since the first institutions to date. Primarily addresses the problems that led to the creation of the Social Protection in Health System or Seguro Popular in 2003, as well as its objectives, performance, challenges faced and strategies that have been implemented over the past eight years. Also shown are the main results that have been achieved in health since the creation of Seguro Popular: membership of vulnerable groups, universal coverage, medical coverage and impact on out of pocket expenses and catastrophic expenses. The text concludes with the current vision of the health system; by which means, the objectives set out in the long run to Mexico.

Del vínculo materno y otras relaciones adictivas / Of the maternal bond and other addictive relationships

Este estudio tuvo como objetivo explorar la significación de la figura materna y su posible relación con la dependencia a sustancias psicoactivas en adolescentes institucionalizados en la Fundación Hogares Claret. La investigación asumió una perspectiva psicoanalítica de corte cualitativo, la población la conformaron tres adolescentes.

This study aimed to explore the significance of the maternal figure and its possible relationship with dependence on psychoactive substances in institutionalized adolescents at the Fundación Hogares Claret. The research assumed a qualitative psychoanalytic perspective, the population was made up of three adolescents.