Clinical characteristics and outcomes of patients hospitalized with COVID-19 in Brazil: Results from the Brazilian COVID-19 registry

OBJECTIVES

To describe the clinical characteristics, laboratory results, imaging findings, and in-hospital outcomes of COVID-19 patients admitted to Brazilian hospitals.

METHODS

A cohort study of laboratory-confirmed COVID-19 patients who were hospitalized from March 2020 to September 2020 in 25 hospitals. Data were collected from medical records using Research Electronic Data Capture (REDCap) tools. A multivariate Poisson regression model was used to assess the risk factors for in-hospital mortality.

RESULTS

For a total of 2,054 patients (52.6% male; median age of 58 years), the in-hospital mortality was 22.0%; this rose to 47.6% for those treated in the intensive care unit (ICU). Hypertension (52.9%), diabetes (29.2%), and obesity (17.2%) were the most prevalent comorbidities. Overall, 32.5% required invasive mechanical ventilation, and 12.1% required kidney replacement therapy. Septic shock was observed in 15.0%, nosocomial infection in 13.1%, thromboembolism in 4.1%, and acute heart failure in 3.6%. Age >= 65 years, chronic kidney disease, hypertension, C-reactive protein ≥ 100mg/dL, platelet count < 100×109/L, oxygen saturation < 90%, the need for supplemental oxygen, and invasive mechanical ventilation at admission were independently associated with a higher risk of in-hospital mortality. The overall use of antimicrobials was 87.9%.

CONCLUSIONS

This study reveals the characteristics and in-hospital outcomes of hospitalized patients with confirmed COVID-19 in Brazil. Certain easily assessed parameters at hospital admission were independently associated with a higher risk of death. The high frequency of antibiotic use points to an over-use of antimicrobials in COVID-19 patients.

p16INK4A expression in cervical premalignant and malignant lesions

p16INK4a is a cyclin-dependent kinase (CDK) inhibitor which decelerates cell cycle by inactivating CDKs that phosphorylate pRb. Human Papillomavirus persistent infection plays an important role on cervical carcinogenesis, mainly by the action of two viral oncoproteins, E6 and E7, which interact with p53 and pRb, respectively. Increasing expression of E6 and E7 in dysplastic cervical cells might thus be reflected by increased expression of p16INK4a. Recent studies revealed that p16INK4a expression could be a marker for dysplastic and neoplastic cervical cells. The aim of this study was to analyze p16INK4a expression in cervical preneoplastic and neoplastic lesions and correlate with lesion grade. Expression of p16INK4a was analyzed by immunohistochemistry. A total of 6 low-grade squamous intraepithelial lesion (LSIL), 21 high-grade squamous intraepithelial lesions (HSIL) and 27 cancer samples were studied. In HPV-positive cervical samples (n=48), p16INK4a expression was observed in 1 of 3 LSIL, in 18 of 19 HSIL and in all 26 cancer cases. These results are in accordance with the hypothesis that functional inactivation of pRb by HPV-E7 protein induces p16INK4a expression in cervical lesions. In our study, a statistically significant association was observed between cervical lesion grade and p16INK4a expression (P<0.001).

ABC2-SPH risk score for in-hospital mortality in COVID-19 patients: development, external validation and comparison with other available scores

OBJECTIVES

The majority of available scores to assess mortality risk of coronavirus disease 2019 (COVID-19) patients in the emergency department have high risk of bias. Therefore, this cohort aimed to develop and validate a score at hospital admission for predicting in-hospital mortality in COVID-19 patients and to compare this score with other existing ones.

METHODS

Consecutive patients (≥ 18 years) with confirmed COVID-19 admitted to the participating hospitals were included. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients admitted between March-July, 2020. The model was validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients.

RESULTS

Median (25-75th percentile) age of the model-derivation cohort was 60 (48-72) years, and in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. Seven significant variables were included in the risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO₂/FiO₂ ratio, platelet count, and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829-0.859), which was confirmed in the Brazilian (0.859 [95% CI 0.833-0.885]) and Spanish (0.894 [95% CI 0.870-0.919]) validation cohorts, and displayed better discrimination ability than other existing scores. It is implemented in a freely available online risk calculator (https://abc2sph.com/).

CONCLUSIONS

An easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation was designed and validated for early stratification of in-hospital mortality risk of patients with COVID-19.

The Economic Impact of COVID-19 Treatment at a Hospital-level: Investment and Financial Registers of Brazilian Hospitals

Background: The economic impact associated with the treatment strategies of coronavirus disease-2019 (COVID-19) patients by hospitals and health-care systems in Brazil is unknown and difficult to estimate. This research describes the investments made to absorb the demand for treatment and the changes in occupation rates and billing in Brazilian hospitals. Methods: This research covers the initial findings of "COVID-19 hospital costs and the proposition of a bundled reimbursement strategy for the health-care system," which includes 10 hospitals. The chief financial officer, the chief medical officer, and hospital executives of each participating hospital provided information regarding investments attributed to COVID-19 patient treatment. The analysis included variations in occupation rates and billing from 2019 to 2020 observed in each institution, and the investments for medical equipment, individual protection materials and building construction per patient treated. Results: The majority of hospitals registered a decrease in hospitalization rates and revenue from 2019 to 2020. For intensive care units (ICUs), the mean occupancy rate ranged from 88% to 83%, and for wards, it ranged from 85% to 73%. Monthly average revenue decreased by 10%. The mean hospital investment per COVID-19 inpatient was I$6800 (standard deviation 7664), with the purchase of ventilators as the most common investment. For this item, the mean, highest and lowest acquisition cost per ventilator were, respectively, I$31 468, I$48 881 and I$17 777. Conclusion: There was significant variability in acquisition costs and investments by institution for responding to the COVID-19 pandemic. These findings highlight the importance of continuing microeconomic studies for a comprehensive assessment of hospital costs. Only with more detailed analyses, will it be possible to define and drive sustainable strategies to manage and reimburse COVID-19 treatment in health-care systems.

Protocolos de triagem avançada no serviço de emergência: revisão sistemática e metanálise

Objective

To evaluate the effectiveness of using advanced triage protocols on the length of stay, safety and satisfaction of the patients and professionals in the emergency department.

Method

A systematic review with meta-analysis of randomized clinical trials included in the Embase, BVS, PubMed, CINAHL, Cochrane Library databases and in the gray literature, using Review Manager 5.4. Studies that analyzed length of stay in their outcomes were included and the studies excluded were those that considered other triage protocols.

Results

26,672 peer-reviewed studies were found and ten were included in the meta-analysis. For the patients’ length of stay, seven studies were included in the meta-analysis (n=8,229), showing a 36-minute reduction (-0.36[-0.55;-0.17] p=0.002), a result with low certainty of evidence, favorable to the intervention, varying between -0.53 (-0.81;- 0.25) and -0.29 (-0.50;-0.07) in the analysis of the subgroups. Regarding the exams requested, five studies were included (n=2,270), indicating that there is no significant difference between the groups (odds ratio 0.94 [0.64;1.38]). Four studies (n=6,094) analyzed the patients’ and the professionals’ satisfaction, indicating a favorable result to the intervention.

Conclusion

The advanced triage protocol reduced length of stay in the emergency room without compromising care safety and quality, although more randomized clinical studies on the theme are needed. Registered in PROSPERO (CRD42019142640).

Effect of environmental enrichment on behavioral and morphological outcomes following neonatal hypoxia-ischemia in rodent models: A systematic review and meta-analysis

Neonatal hypoxia-ischemia (HI) is a major cause of mortality and morbidity in newborns and, despite recent advances in neonatal intensive care, there is no definitive treatment for this pathology. Once preclinical studies have shown that environmental enrichment (EE) seems to be a promising therapy for children with HI, the present study conducts a systematic review and meta-analysis of articles with EE in HI rodent models focusing on neurodevelopmental reflexes, motor and cognitive function as well as brain damage. The protocol was registered a priori at PROSPERO. The search was conducted in PubMed, Embase and PsycINFO databases, resulting in the inclusion of 22 articles. Interestingly, EE showed a beneficial impact on neurodevelopmental reflexes (SMD= -0.73, CI= [-0.98; -0.47], p< 0.001, I²= 0.0%), motor function (SMD= -0.55, CI= [-0.81; -0.28], p< 0.001, I²= 62.6%), cognitive function (SMD= -0.93, CI= [-1.14; -0.72], p< 0.001, I²= 27.8%) and brain damage (SMD= -0.80, CI= [-1.03; -0.58], p< 0.001, I²= 10.7%). The main factors that potentiate EE positive effects were enhanced study quality, earlier age at injury as well as earlier start and longer duration of EE exposure. Overall, EE was able to counteract the behavioral and histological damage induced by the lesion, being a promising therapeutic strategy for HI.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Chagas disease and SARS-CoV-2 coinfection does not lead to worse in-hospital outcomes

Chagas disease (CD) continues to be a major public health burden in Latina America. Information on the interplay between COVID-19 and CD is lacking. Our aim was to assess clinical characteristics and in-hospital outcomes of patients with CD and COVID-19, and to compare it to non-CD patients. Consecutive patients with confirmed COVID-19 were included from March to September 2020. Genetic matching for sex, age, hypertension, diabetes mellitus and hospital was performed in a 4:1 ratio. Of the 7018 patients who had confirmed COVID-19, 31 patients with CD and 124 matched controls were included (median age 72 (64-80) years-old, 44.5% were male). At baseline, heart failure (25.8% vs. 9.7%) and atrial fibrillation (29.0% vs. 5.6%) were more frequent in CD patients than in the controls (p < 0.05). C-reactive protein levels were lower in CD patients compared with the controls (55.5 [35.7, 85.0] vs. 94.3 [50.7, 167.5] mg/dL). In-hospital management, outcomes and complications were similar between the groups. In this large Brazilian COVID-19 Registry, CD patients had a higher prevalence of atrial fibrillation and chronic heart failure compared with non-CD controls, with no differences in-hospital outcomes. The lower C-reactive protein levels in CD patients require further investigation.

Development and validation of the MMCD score to predict kidney replacement therapy in COVID-19 patients

BACKGROUND

Acute kidney injury (AKI) is frequently associated with COVID-19, and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalised COVID-19 patients, and to assess the incidence of AKI and KRT requirement.

METHODS

This study is part of a multicentre cohort, the Brazilian COVID-19 Registry. A total of 5212 adult COVID-19 patients were included between March/2020 and September/2020. Variable selection was performed using generalised additive models (GAM), and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. Accuracy was assessed using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

The median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalisation. The temporal validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. The geographic validation cohort had similar age and sex; however, this cohort had higher rates of ICU admission, AKI, need for KRT and in-hospital mortality. Four predictors of the need for KRT were identified using GAM: need for mechanical ventilation, male sex, higher creatinine at hospital presentation and diabetes. The MMCD score had excellent discrimination in derivation (AUROC 0.929, 95% CI 0.918-0.939) and validation (temporal AUROC 0.927, 95% CI 0.911-0.941; geographic AUROC 0.819, 95% CI 0.792-0.845) cohorts and good overall performance (Brier score: 0.057, 0.056 and 0.122, respectively). The score is implemented in a freely available online risk calculator ( https://www.mmcdscore.com/ ).

CONCLUSIONS

The use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalised COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation.

COVID-19 outcomes in people living with HIV: Peering through the waves

OBJECTIVE

To evaluate clinical characteristics and outcomes of COVID-19 patients infected with HIV, and to compare with a paired sample without HIV infection.

METHODS

This is a substudy of a Brazilian multicentric cohort that comprised two periods (2020 and 2021). Data was obtained through the retrospective review of medical records. Primary outcomes were admission to the intensive care unit, invasive mechanical ventilation, and death. Patients with HIV and controls were matched for age, sex, number of comorbidities, and hospital of origin using the technique of propensity score matching (up to 4:1). They were compared using the Chi-Square or Fisher's Exact tests for categorical variables and the Wilcoxon for numerical variables.

RESULTS

Throughout the study, 17,101 COVID-19 patients were hospitalized, and 130 (0.76%) of those were infected with HIV. The median age was 54 (IQR: 43.0;64.0) years in 2020 and 53 (IQR: 46.0;63.5) years in 2021, with a predominance of females in both periods. People Living with HIV (PLHIV) and their controls showed similar prevalence for admission to the ICU and invasive mechanical ventilation requirement in the two periods, with no significant differences. In 2020, in-hospital mortality was higher in the PLHIV compared to the controls (27.9% vs. 17.7%; p = 0.049), but there was no difference in mortality between groups in 2021 (25.0% vs. 25.1%; p > 0.999).

CONCLUSIONS

Our results reiterate that PLHIV were at higher risk of COVID-19 mortality in the early stages of the pandemic, however, this finding did not sustain in 2021, when the mortality rate is similar to the control group.

Assessment of risk scores to predict mortality of COVID-19 patients admitted to the intensive care unit

Objectives

To assess the ABC2-SPH score in predicting COVID-19 in-hospital mortality, during intensive care unit (ICU) admission, and to compare its performance with other scores (SOFA, SAPS-3, NEWS2, 4C Mortality Score, SOARS, CURB-65, modified CHA2DS2-VASc, and a novel severity score).

Materials and methods

Consecutive patients (≥ 18 years) with laboratory-confirmed COVID-19 admitted to ICUs of 25 hospitals, located in 17 Brazilian cities, from October 2020 to March 2022, were included. Overall performance of the scores was evaluated using the Brier score. ABC2-SPH was used as the reference score, and comparisons between ABC2-SPH and the other scores were performed by using the Bonferroni method of correction. The primary outcome was in-hospital mortality.

Results

ABC2-SPH had an area under the curve of 0.716 (95% CI 0.693-0.738), significantly higher than CURB-65, SOFA, NEWS2, SOARS, and modified CHA2DS2-VASc scores. There was no statistically significant difference between ABC2-SPH and SAPS-3, 4C Mortality Score, and the novel severity score.

Conclusion

ABC2-SPH was superior to other risk scores, but it still did not demonstrate an excellent predictive ability for mortality in critically ill COVID-19 patients. Our results indicate the need to develop a new score, for this subset of patients.

Frequency and burden of neurological manifestations upon hospital presentation in COVID-19 patients: Findings from a large Brazilian cohort

BACKGROUND

Scientific data regarding the prevalence of COVID-19 neurological manifestations and prognosis in Latin America countries is still lacking. Therefore, the study aims to understand neurological manifestations of SARS-CoV 2 infection and outcomes in the Brazilian population.

METHODS

This study is part of the Brazilian COVID-19 Registry, a multicentric cohort, including data from 37 hospitals. For the present analysis, patients were grouped according to the presence of reported symptoms (i.e., headache; anosmia and ageusia; syncope and dizziness) vs. clinically-diagnosed neurological manifestations (clinically-defined neurological syndrome: neurological signs or diagnoses captured by clinical evaluation) and matched with patients without neurological manifestations by age, sex, number of comorbidities, hospital of admission, and whether or not patients had underlying neurological disease.

RESULTS

From 6,635 hospitalized patients with COVID-19, 30.8% presented reported neurological manifestations, 10.3% were diagnosed with a neurological syndrome and 60.1% did not show any neurological manifestations. In patients with reported symptoms, the most common ones were headache (20.7%), ageusia (11.1%) and anosmia (8.0%). In patients with neurological syndromes, acute encephalopathy was the most common diagnosis (9.7%). In the matched analysis, patients with neurological syndromes presented more cases of septic shock (17.0 vs. 13.0%, p = 0.045), intensive care unit admission (45.3 vs. 38.9%, p = 0.023), and mortality (38.7 vs. 32.6%, p = 0.026; and 39.2 vs. 30.3%, p < 0.001) when compared to controls.

CONCLUSION

COVID-19 in-hospital patients with clinically defined neurological syndromes presented a higher incidence of septic shock, ICU admission and death when compared to controls.

Smart Check - COVID-19 triage system: Evaluation of the impact on the screening time and identification of clinical manifestations of SARS-CoV-2 infection in a public health service

INTRODUCTION

Most patients with COVID-19 have mild or moderate manifestations; however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID-19.

OBJECTIVE

Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and to identify the main initial clinical manifestations in these patients.

METHODOLOGY

We assessed triage times before and after the use of Smart Check in 11 466 patients at Hospital Nossa Senhora da Conceição in Porto Alegre, Brazil, from 1 June to 31 July 2020. In this group, we identified 220 patients for the identification of COVID-19 clinical manifestations in a case-control analysis.

RESULTS

Smart Check was able to decrease the triage time by 33 seconds on average (P < .001), with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID-19 initial manifestations. Those with the highest frequency were dry cough (46.4%), fever (41.3%), dyspnoea (35.8%), and headache (31.8%). Loss of appetite was the manifestation that had a statistically significant association with the SARS-CoV-2 presence (univariate analysis). When analysed together, loss of appetite associated with dyspnoea and/or ageusia and/or fever was related to the diagnosis of COVID-19.

CONCLUSIONS

Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimise triage time for patients with and without COVID-19. In triage centres, a number of initial signs and symptoms should be cause for SARS-CoV-2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations.

Discordance between cytology and biopsy histology of the cervix: what to consider and what to do

OBJECTIVE

Since cytology is the examination utilized for the screening of cervical cancer, it is important to determine its correlation with histologic examination, the gold standard in the diagnosis of cervical disease.

STUDY DESIGN

A retrospective evaluation was made of 431 patients who presented with colposcopic indication for cervical biopsy between 2003 and 2007.

RESULTS

In 90.8% (289/318) of the patients, cytology showing cervical intraepithelial neoplasia (CIN) was confirmed as CIN in the histology of the cervix, while 62.8% (71/113) of patients with normal cytology had a confirmation of a normal histology (κ = 0.558).

CONCLUSION

Cytology demonstrated a sensitivity and specificity of 87.3 and 71.0%, respectively. The agreement between cervical cytology and histology, considering the presence of CIN, was moderate. Correlations between accuracy and errors of cytology are discussed with therapeutic emphasis.

Comparison between Custodiol, del Nido and modified del Nido in the myocardial protection - Cardioplegia Trial: a study protocol for a randomised, double-blind clinical trial

INTRODUCTION

Myocardial protection is essential for successful cardiac surgery, and the search for an ideal cardioplegic solution has continued since its beginning. In this context, Custodiol, del Nido and modified del Nido are single-dose cardioplegic solutions with good safety profiles and great relevance in modern surgical practice. While these solutions have all been evaluated for their impact on patient outcomes independently, limited research exists comparing them directly. Thus, the present study aims to examine the effects of these cardioplegic solutions on myocardial protection and clinical outcomes in adult patients undergoing elective cardiac surgery. The assessment of the increase in myocardial injury biomarkers in patients submitted to all treatment methods may be considered a major strength of our study.

METHODS AND ANALYSIS

This is a clinical trial study protocol that will compare myocardial protection and clinical outcomes among three patient groups based on which cardioplegic solution was used. Patients will be randomised to receive del Nido (n=30), modified del Nido (n=30) or Custodiol (n=30). Myocardial injury biomarkers will be measured at the baseline and 2 hours, 12 hours and 24 hours after the cardiopulmonary bypass. Clinical outcomes will be assessed during the trans operative period and the intensive care unit stay, in addition to other haematological parameters.

ETHICS AND DISSEMINATION

This protocol and its related documents were approved by the Research Ethics Committee of the Hospital Nossa Senhora da Conceição, Brazil, registered under no. 4.029.545. The findings of this study will be published in a peer-reviewed journal in the related field.

TRIAL REGISTRATION NUMBER

RBR-7g5s66.

Hypothyroidism does not lead to worse prognosis in COVID-19: findings from the Brazilian COVID-19 registry

BACKGROUND

It is not clear whether previous thyroid diseases influence the course and outcomes of COVID-19.

METHODS

The study is a part of a multicentric cohort of patients with confirmed COVID-19 diagnosis from 37 hospitals. Matching for age, sex, number of comorbidities, and hospital was performed for the paired analysis.

RESULTS

Of 7,762 patients with COVID-19, 526 had previously diagnosed hypothyroidism and 526 were matched controls. The median age was 70 years, and 68.3% were females. The prevalence of comorbidities was similar, except for coronary and chronic kidney diseases that were higher in the hypothyroidism group (p=0.015 and p=0.001). D-dimer levels were lower in patients with hypothyroid (p=0.037). In-hospital management was similar, but hospital length-of-stay (p=0.029) and mechanical ventilation requirement (p=0.006) were lower for patients with hypothyroidism. There was a trend of lower in-hospital mortality in patients with hypothyroidism (22.1% vs 27.0%; p=0.062).

CONCLUSION

Patients with hypothyroidism had a lower requirement of mechanical ventilation and showed a trend of lower in-hospital mortality. Therefore, hypothyroidism does not seem to be associated with a worse prognosis.

Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression

Objective: To assess the potential benefits of minimally invasive aortic valve replacement (MIAVR) compared with conventional AVR (CAVR) by examining short-term outcomes. Methods: A systematic search identified randomized trials comparing MIAVR with CAVR. To assess study limitations and quality of evidence, we used the Cochrane Risk of Bias tool and GRADE and performed random-effects meta-analysis. We used meta-regression and sensitivity analysis to explore reasons for diversity. Results: Thirteen studies (1,303 patients) were included. For the comparison of MIAVR and CAVR, the risk of bias was judged low or unclear and the quality of evidence ranged from very low to moderate. No significant difference was observed in mortality, stroke, acute kidney failure, infectious outcomes, cardiac events, intubation time, intensive care unit stay, reoperation for bleeding, and blood transfusions. Blood loss (mean difference [MD] = -130.58 mL, 95% confidence interval [CI] = -216.34 to -44.82, I² = 89%) and hospital stay (MD = -0.93 days, 95% CI = -1.62 to -0.23, I² = 81%) were lower with MIAVR. There were shorter aortic cross-clamp (MD = 5.99 min, 95% CI = 0.99 to 10.98, I² = 93%) and cardiopulmonary bypass (CPB) times (MD = 7.75 min, 95% CI = 0.27 to 15.24, I² = 94%) in the CAVR group. In meta-regression analysis, we found that age was the variable with the greatest influence on heterogeneity. Conclusions: MIAVR seems to be an excellent alternative to CAVR, reducing hospital stay and incidence of hemorrhagic events. Despite significantly greater aortic cross-clamp and CPB times with MIAVR, this did not translate into adverse effects, with no changes in the results found with CAVR.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.

Avaliação de intervenções de Gestão da Clínica na qualificação do cuidado e na oferta de leitos em um hospital público de grande porte

*** Evaluation of clinical governance interventions on qualification of care and supply of beds in a large public hospital ***AIMS: To describe the results achieved in hospital performance indicators and supply of beds, with the strategy of incorporating clinical management into the care process of the backup unit of the Nossa Senhora da Conceição Hospital.METHODS: The study was carried out in the backup unit of the Nossa Senhora da Conceição Hospital, in Porto Alegre, Rio Grande do Sul, Brazil. The backup unit is an inpatient hospital with beds intended for hospital emergency patients characterized by short stay (less than 10 days of hospitalization) and in the study period it had 27 beds. As clinic management tools we implemented multidisciplinary reference teams and multidisciplinary rounds, established a Kanban system to monitor mean length of stay, and introduced the unique therapeutic project at the hospital entrance (emergency room) and management of beds by the Internal Regulation Center. We monitored the hospital indicators number of hospitalizations, mean length of stay, resolvability, mortality rate and turnover rate over a period of 12 months (2016, after implementation of the strategy) and made comparisons with the same period of the previous year. RESULTS: After the introduction of Clinic Management, there was an increase in the number of hospitalizations from 1395 to 1537/year. There were 1240 discharges to home (an average of 104 a month), showing an increase of 101.9% in relation to the previous period. There was also a decrease in the number of internal transfers (between the back unit and other sectors of the hospital), an increase in the turnover rate from 51.6 to 56.9, decrease in the mean stay time of 7.2 days to 6.6 days and a significant decrease in the mortality rate from 3.5 to 0.7 (p <0.05).CONCLUSIONS: The implementation of clinical management in the context of care work in the hospital's backup bed unit fostered improvements in care processes, as well as ensuring greater supply of beds to users.

Length of Hospitalization and Mortality among Stroke Patients before and after the Implementation of a Specialized Unit: A Retrospective Cohort Study Using Real-World Data from One Reference Hospital in Southern Brazil

Stroke constitutes a significant global cause of mortality and disability. The implementation of stroke units influences hospital quality indicators, guiding care management. We aimed to compare hospital length of stay (LOS), in-hospital mortality, and post-discharge mortality between stroke patients admitted in the pre- and post-implementation periods of a stroke unit in a public hospital in southern Brazil. This retrospective cohort study used real-world data from one reference hospital, focusing on the intervention (stroke unit) and comparing it to the general ward (control). We analyzed the electronic medical records of 674 patients admitted from 2009 to 2012 in the general ward and 766 patients from 2013 to 2018 in the stroke unit. Admission to the stroke unit was associated with a 43% reduction in the likelihood of prolonged hospitalization. However, there was no significant difference in the risk of in-hospital mortality between the groups (Hazard ratio = 0.90; Interquartile range = 0.58 to 1.39). The incidence of death at three, six and twelve months post-discharge did not differ between the groups. Our study results indicate significant improvements in care processes for SU patients, including shorter LOS and better adherence to treatment protocols. However, our observations revealed no significant difference in mortality rates, either during hospitalization or after discharge, between the SU and GW groups. While SU implementation enhances efficiency in stroke care, further research is needed to explore long-term outcomes and optimize management strategies.

Improving the performance of machine learning algorithms for health outcomes predictions in multicentric cohorts

Machine learning algorithms are being increasingly used in healthcare settings but their generalizability between different regions is still unknown. This study aims to identify the strategy that maximizes the predictive performance of identifying the risk of death by COVID-19 in different regions of a large and unequal country. This is a multicenter cohort study with data collected from patients with a positive RT-PCR test for COVID-19 from March to August 2020 (n = 8477) in 18 hospitals, covering all five Brazilian regions. Of all patients with a positive RT-PCR test during the period, 2356 (28%) died. Eight different strategies were used for training and evaluating the performance of three popular machine learning algorithms (extreme gradient boosting, lightGBM, and catboost). The strategies ranged from only using training data from a single hospital, up to aggregating patients by their geographic regions. The predictive performance of the algorithms was evaluated by the area under the ROC curve (AUROC) on the test set of each hospital. We found that the best overall predictive performances were obtained when using training data from the same hospital, which was the winning strategy for 11 (61%) of the 18 participating hospitals. In this study, the use of more patient data from other regions slightly decreased predictive performance. However, models trained in other hospitals still had acceptable performances and could be a solution while data for a specific hospital is being collected.