First and second COVID-19 waves in Brazil: A cross-sectional study of patients' characteristics related to hospitalization and in-hospital mortality

Use of machine learning to identify protective factors for death from COVID-19 in the ICU: a retrospective study

Background

Patients in serious condition due to COVID-19 often require special care in intensive care units (ICUs). This disease has affected over 758 million people and resulted in 6.8 million deaths worldwide. Additionally, the progression of the disease may vary from individual to individual, that is, it is essential to identify the clinical parameters that indicate a good prognosis for the patient. Machine learning (ML) algorithms have been used for analyzing complex medical data and identifying prognostic indicators. However, there is still an urgent need for a model to elucidate the predictors related to patient outcomes. Therefore, this research aimed to verify, through ML, the variables involved in the discharge of patients admitted to the ICU due to COVID-19.

Methods

In this study, 126 variables were collected with information on demography, hospital length stay and outcome, chronic diseases and tumors, comorbidities and risk factors, complications and adverse events, health care, and vital indicators of patients admitted to an ICU in southern Brazil. These variables were filtered and then selected by a ML algorithm known as decision trees to identify the optimal set of variables for predicting patient discharge using logistic regression. Finally, a confusion matrix was performed to evaluate the model's performance for the selected variables.

Results

Of the 532 patients evaluated, 180 were discharged: female (16.92%), with a central venous catheter (23.68%), with a bladder catheter (26.13%), and with an average of 8.46- and 23.65-days using bladder catheter and submitted to mechanical ventilation, respectively. In addition, the chances of discharge increase by 14% for each additional day in the hospital, by 136% for female patients, 716% when there is no bladder catheter, and 737% when no central venous catheter is used. However, the chances of discharge decrease by 3% for each additional year of age and by 9% for each other day of mechanical ventilation. The performance of the training data presented a balanced accuracy of 0.81, sensitivity of 0.74, specificity of 0.88, and the kappa value was 0.64. The test performance had a balanced accuracy of 0.85, sensitivity 0.75, specificity 0.95, and kappa value of 0.73. The McNemar test found that there were no significant differences in the error rates in the training and test data, suggesting good classification. This work showed that female, the absence of a central venous catheter and bladder catheter, shorter mechanical ventilation, and bladder catheter duration were associated with a greater chance of hospital discharge. These results may help develop measures that lead to a good prognosis for the patient.

Associations between epidemiological and laboratory parameters and disease severity in hospitalized patients with COVID-19 during first and second epidemic waves in middle south Mato Grosso

BACKGROUND

COVID-19 is a multisystemic disease characterized by respiratory distress. Disease severity is associated with several factors. Here we characterize virological findings and evaluate the association of laboratorial, epidemiological, virological findings and clinical outcomes of 251 patients during the first and second epidemic waves of COVID-19.

METHODS

This transversal study used biological samples and data from patients hospitalized with COVID-19 between May 2020 and August 2021 in the metropolitan region of Cuiabá, Mato Grosso Brazil. Biological samples were subjected to RT-qPCR and MinION sequencing. Univariate and multivariate logistic regression and Odds ratio were used to correlate clinical, laboratorial, epidemiological data.

FINDINGS

Patients were represented by males (61.7%) with mean age of 52.4 years, mild to moderate disease (49,0%), overweight/obese (69.3%), with comorbidities (66.1%) and evolving to death (55.38%). Severe cases showing symptoms for prolonged time, ≥ 25% of ground-glass opacities in the lungs and fatality rate increased significantly in second wave. Fatality was statistically associated to > 61 years of age,>25% ground-glass opacities in the lungs, immune, cardiac, or metabolic comorbidities. Higher viral load (p < 0.01/p = 0.02 in each wave), decreased erythrocyte (p < 0.01), hemoglobin (p < 0.05/p < 0.01), hematocrit (p < 0.01), RDW (p < 0.01), lymphocyte (p < 0.01), increased leucocyte (p < 0.01), neutrophil (p < 0.01) and CRP levels (p < 0.01) showed significant association with fatality in both waves, as did Neutrophil/Platelet (NPR; p < 0.01), Neutrophil/Lymphocyte (NLR; p < 0.01) and Monocyte/Lymphocyte ratio (MLR; p < 0.01). SARS-CoV-2 genomes from lineage B.1.1.33(n = 8) and Gamma/P.1(n = 15) shared 6/7 and 20/23 lineage-defining mutations, respectively.

MAIN CONCLUSIONS

Severity and mortality of COVID-19 associated with a panel of epidemiological and laboratorial findings, being second wave, caused by Gamma variant, more severe in this in-hospital population.

Prevalence, under-reporting, and epidemiological surveillance of COVID-19 in the Araguaína City of Brazil

Asymptomatic and underreported individuals remain a source of coronafig disease 2019 (COVID-19) transmission to others. Data on the prevalence and epidemiological factors influencing transmission are fundamental for establishing control measures, especially in vulnerable regions such as the Amazon. This study aimed to determine the point prevalence and active infection of COVID-19 among the population in Araguaína, a Brazilian city located in the Amazon region, analyzed the socioeconomic and behavioral variables of a statistically representative sample of this population using an epidemiological survey, and identify the viral genomic diversity in the region. During the sixth epidemiological week of 2021 (February 8 to 12), samples of 497 inhabitants of the municipality asymptomatic for respiratory syndromes underwent reverse transcription-quantitative polymerase chain reaction and serological tests (immunoglobulin M and immunoglobulin G). A questionnaire collated data on socioeconomic factors, prevention measures, and health status history. The active infection rate was 6.2%, and the prevalence was 13.5% of the study population. Active infection cases were under-reported; each reported positive case represented 14-28 under-reported cases. Lineages P.2, P.1, and B.1.1 were detected. Working from home was a protective factor against the infection, and clinical signs of fever, dry cough, and loss of taste or smell were associated with testing positive (p <0.05). A descriptive analysis of the indicators revealed that the entire population was susceptible to the disease. Intensified vaccination strategies are required regardless of socioeconomic factors, health conditions, and preventive measures. Implementation of objective, comprehensive, and efficient management tools to minimize the spread of COVID-19 in this municipality can serve as a model for other regions of Brazil.

Managing long COVID symptoms and accessing health services in Brazil: A grounded theory analysis

Background

The worldwide community has shown significant interest in researching the management of Long COVID. However, there is scarce evidence about the daily experiences of people living with Long COVID and their insights into the healthcare services provided to them.

Aims

This study aims to understand the experience of Long COVID sufferers with their symptoms and in accessing health services.

Method

We employed Charmaz's grounded theory methodology, informed by constructivism, and applied the COREQ guidelines for qualitative research. Sixty-six Brazilians living with Long COVID participated in the study. The data was collected using semi-structured telephone interviews and analyzed using a constant comparative process.

Findings

The findings refer firstly to the consequences of persistent Long COVID symptoms. Secondly, they describe how the disease trajectory required Long COVID sufferers to reorganize their routines and develop adaptive strategies. Lastly, they reflect a diverse array of both positive and negative interactions inside the healthcare system conveyed by individuals suffering from Long COVID. These elements converge towards the core category of the study: "The limbo of Long COVID sufferers: between the persistence of symptoms and access to health services".

Conclusions

Long COVID is characterized by its varied nature, including a range of physical and emotional repercussions experienced by individuals. There is a need for enhanced comprehension and discourse about Long COVID across several domains, including the general public, policy-making entities, and healthcare professionals. In this sense, the development of specialized services or the reinforcement of existing services to support long COVID sufferers is imperative.

Generalized anxiety disorder in Brazilian undergraduate dental students during the COVID-19 pandemic: A cross-sectional study

OBJECTIVE

Explore the prevalence of generalized anxiety disorder (GAD) and associated factors in undergraduate dental students during the first wave of the COVID-19 pandemic in Brazil.

MATERIALS AND METHODS

Cross-sectional study. A semi-structured questionnaire addressing the variables of interest was shared with dental students between July 8 and 27 2020. The outcome was determined using the seven-item generalized anxiety disorder (GAD-7) scale. A 'positive' diagnosis was defined as a total of ≥10 points on the scale. Statistical analysis involved descriptive, bivariate and multivariate analyses, with the significance level set at 5%.

RESULTS

Among the 1050 students evaluated, 53.8% had a positive diagnosis for GAD. The multivariate analysis revealed that the prevalence of symptoms was higher among individuals who resided with more than three people, those enrolled at teaching institutions that suspended all clinical and laboratory activities, those who did not have an adequate home situation to maintain distance learning, those who had been diagnosed with COVID-19, those who felt anxious about having to see patients with a suspicion or diagnosis of COVID-19 and those who preferred to interrupt in-person academic activities until the population is vaccinated for the COVID-19 virus.

CONCLUSION

The prevalence of GAD was high. Aspects related to the composition and organization of the home, the suspension of academic activities, a history of COVID-19 contamination, feelings of anxiety in providing dental care to patients with symptoms/suspected of COVID-19 infection and the preference to interrupt in-person academic activities until the population is vaccinated for COVID-19 were factors predisposing the students to anxiety during the first wave of the pandemic.

Impact of social distancing from the COVID-19 pandemic on the immuno-inflammatory response of older adults

BACKGROUND

Older adults, as the population considered at increased risk for severe COVID-19, were the most impacted by social isolation. Thus, this study aimed to assess the salivary immune/inflammatory response of older adults before and during the COVID-19 pandemic.

METHODS

A cohort of 11 older adults (mean age 66.8 ± 6.1) was followed at three different time points: before (S1) and after 6 (S2) and 20 months (S3) of the beginning of the COVID-19 pandemic in Brazil. Unstimulated saliva samples were obtained to assess the levels of antibodies (secretory IgA, IgG and IgM) by ELISA and cytokines (IL-2, IL-5, IL-6, IL-8 and IL-10, TSLP, IFN-γ, TNF-α) by multiplex analysis. Significant differences were evaluated using the Kruskal-Wallis test with Dunn's post-test.

RESULTS

None volunteer presented periodontal disease or caries. All volunteers received at least two doses of the COVID-19 vaccines after S2 and before S3. A tendency to increase salivary levels of SIgA and IgM at S2 and of IgG at S3 were observed compared to the values found at S1 and S2. Significantly decreased levels of IL-2 and IL-5 were found at S2 and S3 (p < 0.001) time points. Lower levels of IFN-γ were found at S2 as compared to the values observed at S1 (p < 0.01). A significant decrease in the IFN-γ/IL-10 ratio was found at S2 (p < 0.01). When assessing the Th1/Th2 ratios, a significant decrease was found in the IFN-γ/TSLP ratio at S2 (p < 0.001) and S3 (p < 0.001) when compared to the values at S1. In addition, a significant increase was observed in the TNF-α/IL-5 ratio at S2 (p < 0.001) and S3 (p < 0.001) in comparison to the values at S1. In a similar way, an increase in the TNF-α/IL-6 ratio (Fig. 5E) was observed at S3 (p < 0.001) when compared to the values at S1.

CONCLUSIONS

Overall, this study provides valuable insights into the impact of COVID-19-induced social isolation on immune/inflammatory responses in the upper airway mucosa, particularly those present in oral cavity, of older adults. It demonstrates that a controlled shift in Th1 and Th2 immune responses, both during infection and post-vaccination, can create favorable conditions to combat viral infections without exacerbating the immune response or worsening the pathology.

Perceived quality of life and associated factors in long COVID syndrome among older Brazilians: A cross-sectional study

AIMS AND OBJECTIVES

This paper aims to: (a) determine the personal, sociodemographic, clinical, behavioural, and social characteristics of older Brazilians with clinical evidence of long COVID; (b) evaluate perceived quality of life and determine its association with personal, sociodemographic, behavioural, clinical and social variables; and (c) assess significant predictors of high perceived QoL.

BACKGROUND

Given the inherent vulnerabilities of the ageing process, the older people are an at-risk group for both contagion of SARS-CoV-2 and the perpetuation of residual symptoms after infection, the so-called long COVID or post-COVID syndrome.

DESIGN

A cross-sectional survey design using the STROBE checklist.

METHODS

Brazilian older people with long COVID syndrome (n = 403) completed a phone survey measuring personal, sociodemographic, behavioural, clinical, and social characteristics, and perceived Quality of Life (QoL). Data were collected from June 2021-March 2022. A multiple linear regression model was performed to identify salient variables associated with high perceived QoL.

RESULTS

The mean age of participants was 67.7 ± 6.6 years old. The results of the multivariate regression model showed that race, home ownership, daily screen time, musculoskeletal and anxiety symptoms, and work situation were the significant predictors of QoL among COVID-19 survivors.

CONCLUSIONS

Knowledge about the persistence of physical, emotional, and social symptoms of COVID-19 can help nurses and other healthcare providers to improve the management of survivors, bringing benefits to the whole society.

RELEVANCE TO CLINICAL PRACTICE

Given the novelty of long-COVID and its heterogeneous trajectory, interventions focusing on the repercussions and requirements unique to more vulnerable older persons should be developed and these aspects should be included in public health recommendations and policymakers' concerns.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was required to design, to outcome measures or undertake this research. Patients/members of the public contributed only to the data collection.

The impact of early anti-SARS-CoV-2 antibody production on the length of hospitalization stay among COVID-19 patients

IMPORTANCE

The study provides valuable insights into the sociodemographic characteristics, clinical outcomes, and humoral immune response of those affected by the virus that has devastated every field of human life since 2019; the COVID-19 patients. Firstly, the association among clinical manifestations, comorbidities, and the production of neutralizing antibodies (Nabs) against SARS-CoV-2 is explored. Secondly, varying levels of Nabs among patients are revealed, and a significant correlation between the presence of Nabs and a shorter duration of hospitalization is identified, which highlights the potential role of Nabs in predicting clinical outcomes. Lastly, a follow-up conducted 7 months later demonstrates the progression and persistence of Nabs production in recovered unvaccinated individuals. The study contributes essential knowledge regarding the characteristics of the study population, the early humoral immune response, and the dynamics of Nabs production over time. These findings have significant implications for understanding the immune response to COVID-19 and informing clinical management approaches.

Risk factors for COVID-19 mortality in hospitalized patients in Bolivia

Objectives

This study aimed to ascertain which factors are associated with higher risk of mortality among hospitalized COVID-19 Bolivian patients.

Methods

This retrospective observational study assessed risk factors associated with mortality in patients (n = 549) hospitalized for SARS-CoV-2 infection in a Bolivian hospital between April 6, 2020, and August 18, 2022.

Results

The results provide evidence of association between male sex (odds ratio [OR] = 1.6, 95% confidence interval [CI] 1.06-2.6), older age, 51-61 years-old (OR = 5.2, 95% CI 2.2-12.6), 62-70 years-old (OR = 8.7, 95% CI 3.7-20.5), >70 years-old (OR = 16.9, 95% CI 7.1-39.9), and blood group A (OR = 1.9, 95% CI: 1.1-3.4) with higher mortality risk. The strong association between mortality and relatively young age, may be due to high frequency of undiagnosed comorbidities. Vaccination was associated with a reduction in mortality only when time period of hospitalization was not adjusted for.

Conclusion

Among hospitalized patients in Bolivia male sex, older age, and blood group A are associated with higher mortality risk. Mortality risk increased markedly from a relatively young age and decreased in parallel to the uptake of the vaccination program. However, the gradual reduction in mortality can also be due to improved patient management and changes in natural immunity and virulence of circulating strains as the pandemic progressed.

The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities

Background

Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil.

Methods

We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels.

Results

Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region.

Discussion

Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion.

Conclusions

In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.

Big data evidence of the impact of COVID-19 hospitalizations on mortality rates of non-COVID-19 critically ill patients

The COVID-19 virus caused a global pandemic leading to a swift policy response. While this response was designed to prevent the spread of the virus and support those with COVID-19, there is growing evidence regarding measurable impacts on non-COVID-19 patients. The paper uses a large dataset from administrative records of the Brazilian public health system (SUS) to estimate pandemic spillover effects in critically ill health care delivery, i.e. the additional mortality risk that COVID-19 ICU hospitalizations generate on non-COVID-19 patients receiving intensive care. The data contain the universe of ICU hospitalizations in SUS from February 26, 2020 to December 31, 2021. Spillover estimates are obtained from high-dimensional fixed effects regression models that control for a number of unobservable confounders. Our findings indicate that, on average, the pandemic increased the mortality risk of non-COVID-19 ICU patients by 1.296 percentage points, 95% CI 1.145-1.448. The spillover mortality risk is larger for non-COVID patients receiving intensive care due to diseases of the respiratory system, diseases of the skin and subcutaneous tissue, and infectious and parasitic diseases. As of July 2023, the WHO reports more than 6.9 million global deaths due to COVID-19 infection. However, our estimates of spillover effects suggest that the pandemic's total death toll is much higher.

An assessment of the public health surveillance strategy based on molecular testing during three major pandemic waves of COVID-19 in Brazil

A national laboratory-based surveillance system was adapted to monitor the situation of SARS-CoV-2 in Brazil. The objective of the study was to compare the challenges in implementing COVID-19 surveillance strategies based on the Ministry of Health's (MoH) distribution of RT-PCR tests to different types of laboratories. This retrospective study analyzed the MoH's testing policies and distribution of RT-PCR tests to laboratories during the first, second, and third waves. Recipient laboratories were divided into groups: public health laboratories that belonged to the national network of public health laboratories (Group 1); public laboratories granted authorization during the pandemic (Group 2); and High-Capacity Testing Centers (Group 3). We analyzed the timing and duration of COVID-19 testing policies and the allocation of tests to laboratories by group and wave. Using t-tests, we analyzed the difference in the weekly average of tests distributed to labs by group and using Pearson's correlation coefficient, analyzed the test distribution according to infection and death rates. Between epiweek 9, 2020, and epiweek 22, 2022, the MoH distributed an average of 263,004 RT-PCR tests per week. The weekly average of tests distributed was highest in the second wave (310,327 tests), followed by the first (218,005 tests) and third waves (201,226 tests). There was a significant increase in the mean weekly tests distributed in the second wave compared to the first and third waves (p = 0.047; IC 8.29-1110.71). We found a significant difference between the weekly average of tests distributed in the first and second wave (p < 0.001; IC -209.83-76.20) to Group 2. Group 3 received the second-highest number of tests from the MoH overall, with a reduction during the third wave to first-wave levels. The distribution of RT-PCR tests was not correlated with the case and death incidence.

Impact of the COVID-19 pandemic on paediatric renal tumour presentation and management, a SIOP renal tumour study group study

BACKGROUND

The COVID-19 pandemic had global catastrophic effects on the management of non-communicable diseases including paediatric cancers. Restrictions during the start of 2020 complicated timely referrals of patients to specialized centres. We aimed to evaluate the pandemic's impact on the number of new diagnoses, disease characteristics and management delay for paediatric renal tumour patients included in the SIOP-RTSG-UMBRELLA study, as compared with data from a historical SIOP-RTSG trial (2005-2009).

METHODS

The number of intensive care admissions, population mobility rates and national lockdown periods/restrictions were used as proxies of the pandemic's severity and impact on societies. Clinical and tumour data were extracted from the SIOP-RTSG-UMBRELLA study and from historical SIOP-RTSG trials.

RESULTS

During the first lockdown in Europe, the number of newly diagnosed patients decreased following restrictions and population immobilisation. Additionally, there was a higher proportion of advanced disease (37% vs. 17% before and after COVID-9, p < 0.001) and larger median tumour volume (559 cm3 vs. 328 and 434 cm3 before and after, p < 0.0001). Also in Brazil, the proportion of advanced disease was higher during the national decrease in mobilisation and start of restrictions (50% and 24% vs. 11% and 18% before and after, p < 0.01). Tumour volume in Brazil was also higher during the first months of COVID-19 (599 cm3 vs. 459 and 514 cm3 ), although not significant (p = 0.17). We did not observe any delays in referral time nor in time to start treatment, even though COVID-19 restrictions may have caused children to reach care later.

CONCLUSION

The COVID-19 pandemic briefly changed the tumour characteristics of children presenting with renal tumours. The longer-term impact on clinical outcomes will be kept under review.

Ninety-day outcomes in patients diagnosed with COVID-19 in São Paulo, Brazil: a cohort study

OBJECTIVE

COVID-19 has been associated with a significant burden to those who survive the acute phase. We aimed to describe the quality of life and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) at 90 days after hospital discharge of COVID-19 patients.

METHODS

Patients with COVID-19 admitted to a private hospital in the city of São Paulo, Brazil, between April of 2020 and April of 2021 were interviewed by telephone at 30 and 90 days after discharge to assess the quality of life and symptoms of depression, anxiety, and PTSD.

RESULTS

A total of 2,138 patients were included. The mean age was 58.6 ± 15.8 years, and the median length of hospital stay was 9.0 (5.0-15.8) days. Between the two time points, depression increased from 3.1% to 7.2% (p < 0.001), anxiety increased from 3.2% to 6.2% (p < 0.001), and PTSD increased from 2.3% to 5.0% (p < 0.001). At least one physical symptom related to COVID-19 diagnosis persisted in 32% of patients at day 90.

CONCLUSIONS

Persistence of physical symptoms was high even at 90 days after discharge. Although the prevalence of symptoms of anxiety, depression, and PTSD was low, these symptoms persisted for three months, with a significant increase between the time points. This finding indicates the need to identify at-risk patients so that they can be given an appropriate referral at discharge.

Metabolic control of diabetic patients assisted by private and public health care systems during the COVID-19 pandemic: A retrospective cohort study

AIMS

We sought to analyze the impacts of social restriction measures imposed by the pandemic COVID-19 on the control of metabolic parameters in diabetic patients.

METHODS

We accessed the medical records of patients who underwent clinical follow-up in the public and private health systems between July 2019 and June 2021. The sample consisted of 288 patients (111 adults and 177 older individuals). A two-way ANOVA mixed model was used to test the effects of intra- (time: baseline and after 24 months) and inter-subject factors. Linear regression analysis was used to predict the difference in body weight considering age, sex, HbA1c, health care system and insulin use.

RESULTS

Among adults, we observed an increase in body weight and LDL-c levels, especially for insulin users (p ≤ 0.05). Adults assisted by the public health care system showed higher HbA1c levels (p = 0.001). Among older individuals using insulin, blood glucose levels decreased (p = 0.019). Body weight decreased in those assisted by the private system (p = 0.005), while glycemia decreased for patients assisted by both health care systems (p = 0.043). The linear regression model confirmed that the increase in body weight was more pronounced in adults than in older individuals.

CONCLUSION

The social restriction measures imposed by the pandemic affected the metabolic control of diabetic patients, especially adults assisted by the public health care system.

The first wave of COVID-19 and mental distress of physician residents in Brazil: a comparison between two cohorts

INTRODUCTION

The reorganization of healthcare systems to face the COVID-19 pandemic has led to concerns regarding psychological distress of healthcare workers, and training requirements of physician residents.

OBJECTIVE

To assess the influence of COVID-19 pandemic on depression, anxiety, burnout and training schedules of residents.

METHODS

Two independent cross-sectional studies (the first in November 2019 [control], the second in June 2020, during the first wave of COVID-19 pandemic) enrolling physician residents from Brazil, using online surveys. In each of them, we collected demographic and training program data, and assessed depression, anxiety and burnout through PHQ-2, GAD-2 and MBI (2-item version) scales, respectively. We controlled confounding variables with logistic regression analysis.

RESULTS

The COVID-19 cohort (n = 524) presented a briefer workload and had at least 1 day off per week more frequently, in relation to the control cohort (n = 1 419). The majority of residents (464/524, 89.5%) had a reduction in their duty hours, and believed they would need an extra training period after the end of the pandemic (399/524, 76.2%). The frequency of depression increased (46.0% vs. 58.8%, aOR = 1.64, 95% CI = 1.32-2.05), anxiety did not change (56.5% vs. 56.5%, aOR = 1.24, 95% CI = 0.99-1.55) and burnout decreased (37.0% vs. 26.1%, aOR = 0.77, 95% CI = 0.60-0.99). Sensitivity analysis did not change these results.

CONCLUSION

Mental distress is frequent among residents and associated with both training program and social environments. The consequences of the COVID-19 pandemic on training requirements should be specifically addressed by supervisors and policymakers, in a case-by-case basis. Psychological support must be provided to healthcare workers.

Different cytokine and chemokine profiles in hospitalized patients with COVID-19 during the first and second outbreaks from Argentina show no association with clinical comorbidities

Background

COVID-19 severity has been linked to an increased production of inflammatory mediators called "cytokine storm". Available data is mainly restricted to the first international outbreak and reports highly variable results. This study compares demographic and clinical features of patients with COVID-19 from Córdoba, Argentina, during the first two waves of the pandemic and analyzes association between comorbidities and disease outcome with the "cytokine storm", offering added value to the field.

Methods

We investigated serum concentration of thirteen soluble mediators, including cytokines and chemokines, in hospitalized patients with moderate and severe COVID-19, without previous rheumatic and autoimmune diseases, from the central region of Argentina during the first and second infection waves. Samples from healthy controls were also assayed. Clinical and biochemical parameters were collected.

Results

Comparison between the two first COVID-19 waves in Argentina highlighted that patients recruited during the second wave were younger and showed less concurrent comorbidities than those from the first outbreak. We also recognized particularities in the signatures of systemic cytokines and chemokines in patients from both infection waves. We determined that concurrent pre-existing comorbidities did not have contribution to serum concentration of systemic cytokines and chemokines in COVID-19 patients. We also identified immunological and biochemical parameters associated to inflammation which can be used as prognostic markers. Thus, IL-6 concentration, C reactive protein level and platelet count allowed to discriminate between death and discharge in patients hospitalized with severe COVID-19 only during the first but not the second wave.

Conclusions

Our data provide information that deepens our understanding of COVID-19 pathogenesis linking demographic features of a COVID-19 cohort with cytokines and chemokines systemic concentration, presence of comorbidities and different disease outcomes. Altogether, our findings provide information not only at local level by delineating inflammatory/anti-inflammatory response of patients but also at international level addressing the impact of comorbidities and the infection wave in the variability of cytokine and chemokine production upon SARS-CoV-2 infection.

Distinct systemic immune networks define severe vs. mild COVID-19 in hematologic and solid cancer patients

Introduction

The COVID-19 pandemic, caused by the coronavirus SARS-CoV-2, has impacted health across all sectors of society. A cytokine-release syndrome, combined with an inefficient response of innate immune cells to directly combat the virus, characterizes the severe form of COVID-19. While immune factors involved in the development of severe COVID-19 in the general population are becoming clearer, identification of the immune mechanisms behind severe disease in oncologic patients remains uncertain.

Methods

Here we evaluated the systemic immune response through the analysis of soluble blood immune factors and anti-SARS-CoV-2 antibodies within the early days of a positive SARS-CoV-2 diagnostic in oncologic patients.

Results

Individuals with hematologic malignancies that went on to die from COVID-19 displayed at diagnosis severe leukopenia, low antibody production against SARS-CoV-2 proteins, and elevated production of innate immune cell recruitment and activation factors. These patients also displayed correlation networks in which IL-2, IL-13, TNF-alpha, IFN-gamma, and FGF2 were the focal points. Hematologic cancer patients that showed highly networked and coordinated anti-SARS-CoV-2 antibody production, with central importance of IL-4, IL-5, IL-12A, IL-15, and IL-17A, presented only mild COVID-19. Conversely, solid tumor patients that had elevated levels of inflammatory cytokines IL-6, CXCL8, and lost the coordinate production of anti-virus antibodies developed severe COVID-19 and died. Patients that displayed positive correlation networks between anti-virus antibodies, and a regulatory axis involving IL-10 and inflammatory cytokines recovered from the disease. We also provided evidence that CXCL8 is a strong predictor of death for oncologic patients and could be an indicator of poor prognosis within days of the positive diagnostic of SARS-CoV-2 infection.

Conclusion

Our findings defined distinct systemic immune profiles associated with COVID-19 clinical outcome of patients with cancer and COVID-19. These systemic immune networks shed light on potential immune mechanisms involved in disease outcome, as well as identify potential clinically useful biomarkers.

[Анализ влияния коморбидной сердечно-сосудистой патологии на течение и исходы COVID-19 у госпитализированных пациентов в первую и вторую волну пандемии в Евразийском регионе]

Цель:  Изучение особенностей клинического течения новой коронавирусной инфекции и  влияния сопутствующих заболеваний на исход заболевания у госпитализированных больных с инфекцией SARS-CoV-2 в первую и вторую волны пандемии.Методы и результаты.  Для оценки особенностей течения COVID-19 в Евразийском регионе были созданы международные регистры АКТИВ 1 и во время второй волны пандемии АКТИВ 2. Набор больных в регистр АКТИВ 1 проводили с 29.06.20 по 29.10.20, набрано 5 397 пациентов. Прием пациентов на учет в АКТИВ 2 проводили с 01.11.20 до 30.03.21, набрано 2 665 больных.Результаты. Госпитальная летальность снизилась в  период второй волны пандемии и  составила 4,8 % против 7,6 % в  период первой волны. В  период второй волны пациенты были старше, имели больше сопутствующих заболеваний и поступали в стационар в более тяжелом состоянии, пациенты имели более высокий уровень полиморбидности. В период второй волны пандемии увеличилась заболеваемость бактериальной пневмонией и сепсисом, но реже встречались тромбозы глубоких вен и «цитокиновый шторм». Наиболее неблагоприятными для прогноза смертности, как в первую, так и во вторую волны эпидемии были сочетания сопутствующих заболеваний: артериальная гипертензия (АГ) + хроническая сердечная недостаточность (ХСН) + сахарный диабет (СД) + ожирение, АГ + ишемическая болезнь сердца (ИБС) + ХСН + СД, АГ + ИБС + ХСН + ожирение.Заключение. У пациентов во вторую волну пандемии наблюдалось более обширное поражение ткани легких, чаще возникала фебрильная лихорадка, были выше уровни С-реактивного белка и  тропонина, ниже уровни гемоглобина и лимфоцитов. Это, вероятно, связано с различной тактикой госпитализации пациентов в первую и вторую волны пандемии в странах, принявших участие в формировании регистров АКТИВ 1 и АКТИВ 2.

Pre-pandemic support for shared reading buffers adverse parenting impacts: an RCT in Brazil

BACKGROUND

To examine whether (1) a parent-child reading program (Universidade do Bebê [UBB]), conducted in Brazil pre-pandemic can support parenting and parent-child reading 6 months into the pandemic, (2) cognitive stimulation at pandemic onset mediates effects of UBB on these outcomes, and (3) UBB pre-pandemic buffers associations between COVID-19-related distress and parenting/parent-child reading 6 months into the pandemic.

METHODS

400 women, either pregnant or with children 0-24 months, were randomized to UBB (n = 200) or control groups. UBB consisted of monthly parent workshops focusing on parent-child reading and a book-lending library. Assessments pre-pandemic (June-2019) and at pandemic onset (April-2020) included cognitive stimulation. Assessments 6 months into the pandemic (October-2020) included COVID-19 exposure/impact/distress, as well as parenting and parent-child reading.

RESULTS

133 families (n = 69 UBB) contributed data 6 months into the pandemic. Participation in UBB pre-pandemic was associated with parent-child reading but not parenting 6 months into the pandemic. Indirect effects of UBB through cognitive stimulation at pandemic onset were observed for both outcomes. Increased COVID-19-related distress was significantly associated with reduced parenting/parent-child reading 6 months into the pandemic in the control group only.

CONCLUSION

Promotion of cognitive stimulation pre-pandemic may have reduced risk for effects of the pandemic on parenting/parent-child reading.

CLINICAL TRIAL REGISTRATION

The trial has been registered with the Brazilian Clinical Trials Registry RBR-29RZDH on 05/28/2018.

IMPACT

This is the first study showing sustained impacts of a reading aloud intervention beginning in pregnancy and early infancy implemented pre-pandemic. Findings suggest that participation in a reading-aloud intervention buffered associations between COVID-19 distress and parenting/parent-child reading 6 months into the pandemic. Novel empirical evidence suggests that promotion of cognitive stimulation prior to the pandemic may buffer its impacts on parenting and parent-child book reading following onset in low- and middle-income countries. Findings provide important new support for implementation of parent-child reading aloud programs and likely have implications for early childhood development beyond the COVID-19 pandemic for disasters generally.

Profile of coronavirus disease enlightened asthma as a protective factor against death: An epidemiology study from Brazil during the pandemic

INTRODUCTION

The possibility that asthma is not a risk factor for the worst outcomes due to coronavirus disease (COVID-19) is encouraged. The increase in Th2 response dominance can downregulate the late phase of hyperinflammation, which is typically the hallmark of more severe respiratory viral infections, alongside lower angiotensin-converting enzyme receptors in patients with asthma due to chronic inflammation. Few studies associated asthma diagnosis and COVID-19 outcomes. In this context, we aimed to associate the asthma phenotype with the clinical signs, disease progression, and outcomes in patients with COVID-19.

METHODS

We performed an epidemiologic study using patients' characteristics from OpenDataSUS to verify the severity of COVID-19 among Brazilian hospitalized patients with and without the asthma phenotype according to the need for intensive care units, intubation, and deaths. We also evaluated the demographic data (sex, age, place of residence, educational level, and race), the profile of clinical signs, and the comorbidities.

RESULTS

Asthma was present in 43,245/1,129,838 (3.8%) patients. Among the patients with asthma, 74.7% who required invasive ventilatory support evolved to death. In contrast, 78.0% of non-asthmatic patients who required invasive ventilatory support died (OR = 0.83; 95% CI = 0.79-0.88). Also, 20.0% of the patients with asthma that required non-invasive ventilatory support evolved to death, while 23.5% of non-asthmatic patients evolved to death (OR = 0.81; 95% CI = 0.79-0.84). Finally, only 11.2% of the patients with asthma who did not require any ventilatory support evolved to death, while 15.8% of non-asthmatic patients evolved to death (OR = 0.67; 95% CI = 0.62-0.72). In our multivariate analysis, one comorbidity and one clinical characteristic stood out as protective factors against death during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients with asthma were less prone to die than other patients (OR = 0.79; 95% CI = 0.73-0.85), just like puerperal patients (OR = 0.74; 95% CI = 0.56-0.97) compared to other patients.

CONCLUSION

Asthma was a protective factor for death in hospitalized patients with COVID-19 in Brazil. Despite the study's limitations on patients' asthma phenotype information and corticosteroid usage, this study brings to light information regarding a prevalent condition that was considered a risk factor for death in COVID-19, being ultimately protective.

COVID-19 and organisational resilience in Brazil's water sector

The COVID-19 pandemic required a wide range of adaptations to the way that water sector operated globally. This paper looks into the impact of the COVID-19 pandemic on Brazilian water sector and evaluates the water sector's organisational resilience from the lens of water professionals. This study uses British Standard (BS 65000:2014)'s Resilience Maturity Scale method to evaluate organisational resilience in water sector under two defined scenarios of before and during the pandemic. For this purpose, the self-assessment framework developed by Southern Water in the United Kingdom (based on BS 65000:2014), comprising of the core resilience elements of Direction, Awareness, Alignment, Learning, Strengthening, and Assurance, are used for evaluations. A qualitative-quantitative surveying method is used for data collection. A total of 14 responses to the whole questionnaire were received from May 2021 to August 2021, each representing one water company in Brazil (four local companies and ten state-owned ones). The analyses identified COVID-19 as a threat multiplier particularly to already existing financial challenges due to the pre-existing threats in water sector. Bad debt and the COVID-19 emergency measures are recognised as the main challenges by 21 % and 14 % of the survey respondents. The state-owned and local companies scored an almost similar maturity level 3, 35 % and 34 % respectively, while the local companies scored much lower at maturity level 4 i.e., 26 % as opposed to 47 % in state-owned sector. This indicates that COVID-19 has a greater impact on local companies and the needs to increase preparedness. This study replicates an international experience to raise awareness on water sector's resiliency in Brazil and how it can be improved to withstand future external shocks. It sheds light on how and what existing challenges can be exacerbated facing a global shock and proposes opportunities for improvement of resilience maturity in water sector in Brazil.

Mortality in Four Waves of COVID-19 Is Differently Associated with Healthcare Capacities Affected by Economic Disparities

Background: The greatest challenges are imposed on the overall capacity of disease management when the cases reach the maximum in each wave of the pandemic. Methods: The cases and deaths for the four waves of COVID-19 in 119 countries and regions (CRs) were collected. We compared the mortality across CRs where populations experience different economic and healthcare disparities. Findings: Among 119 CRs, 117, 112, 111, and 55 have experienced 1, 2, 3, and 4 waves of COVID-19 disease, respectively. The average mortality rates at the disease turning point were 0.036, 0.019. 0.017, and 0.015 for the waves 1, 2, 3, and 4, respectively. Among 49 potential factors, income level, gross national income (GNI) per capita, and school enrollment are positively correlated with the mortality rates in the first wave, but negatively correlated with the rates of the rest of the waves. Their values for the first wave are 0.253, 0.346 and 0.385, respectively. The r value for waves 2, 3, and 4 are −0.310, −0.293, −0.234; −0.263, −0.284, −0.282; and −0.330, −0.394, −0.048, respectively. In high-income CRs, the mortality rates in waves 2 and 3 were 29% and 28% of that in wave 1; while in upper-middle-income CRs, the rates for waves 2 and 3 were 76% and 79% of that in wave 1. The rates in waves 2 and 3 for lower-middle-income countries were 88% and 89% of that in wave 1, and for low-income countries were 135% and 135%. Furthermore, comparison among the largest case numbers through all waves indicated that the mortalities in upper- and lower-middle-income countries is 65% more than that of the high-income countries. Interpretation: Conclusions from the first wave of the COVID-19 pandemic do not apply to the following waves. The clinical outcomes in developing countries become worse along with the expansion of the pandemic.

Inflammasome Genetic Variants Are Associated with Protection to Clinical Severity of COVID-19 among Patients from Rio de Janeiro, Brazil

COVID-19 has a broad spectrum of clinical manifestations, from asymptomatic or mild/moderate symptoms to severe symptoms and death. The mechanisms underlying its clinical evolution are still unclear. Upon SARS-CoV-2 infection, host factors, such as the inflammasome system, are activated by the presence of the virus inside host cells. The search for COVID-19 risk factors is of relevance for clinical management. In this study, we investigated the impact of inflammasome single-nucleotide polymorphisms (SNPs) in SARS-CoV-2-infected individuals with distinct severity profiles at clinical presentation. Patients were divided into two groups according to disease severity at clinical presentation based on the WHO Clinical Progression Scale. Group 1 included patients with mild/moderate disease (WHO < 6; n = 76), and group 2 included patients with severe/critical COVID-19 (WHO ≥ 6; n = 357). Inpatients with moderate to severe/critical profiles were recruited and followed-up at Hospital Center for COVID-19 Pandemic – National Institute of Infectology (INI)/FIOCRUZ, RJ, Brazil, from June 2020 to March 2021. Patients with mild disease were recruited at Oswaldo Cruz Institute (IOC)/FIOCRUZ, RJ, Brazil, in August 2020. Genotyping of 11 inflammasome SNPs was determined by real-time PCR. Protection and risk estimation were performed using unconditional logistic regression models. Significant differences in NLRP3 rs1539019 and CARD8 rs2043211 were observed between the two groups. Protection against disease severity was associated with the A/A genotype (OR_adj = 0.36; P = 0.032), allele A (OR_adj = 0.93; P = 0.010), or carrier-A (OR_adj = 0.45; P = 0.027) in the NLRP3 rs1539019 polymorphism; A/T genotype (OR_adj = 0.5; P = 0.045), allele T (OR_adj = 0.93; P = 0.018), or carrier-T (OR_adj = 0.48; P = 0.029) in the CARD8 rs2043211 polymorphism; and the A-C-G-C-C (OR_adj = 0.11; P = 0.018), A-C-G-C-G (OR_adj = 0.23; P = 0.003), C-C-G-C-C (OR_adj = 0.37; P = 0.021), and C-T-G-A-C (OR_adj = 0.04; P = 0.0473) in NLRP3 genetic haplotype variants. No significant associations were observed for the other polymorphisms. To the best of our knowledge, this is the first study demonstrating an association between CARD8 and NLRP3 inflammasome genetic variants and protection against COVID-19 severity, contributing to the discussion of the impact of inflammasomes on COVID-19 outcomes.

Characterization of demographic data, clinical signs, comorbidities, and outcomes according to the race in hospitalized individuals with COVID-19 in Brazil: An observational study

Background

Brazil is a multiracial country with five major official races: White, Black, individuals with multiracial backgrounds, Asian, and Indigenous. Brazil is also one of the epicentres of the Coronavirus Disease (COVID)-19 pandemic. Thus, we evaluated how the races of the Brazilian population contribute to the outcomes in hospitalized individuals with COVID-19, and we also described the clinical profile of the five official Brazilian races.

Methods

We performed an epidemiological analysis for the first 67 epidemiological weeks of the COVID-19 pandemic in Brazil (from February 22, 2020, to April 04, 2021) using the data available at OpenDataSUS of the Brazilian Ministry of Health, a data set containing data from Brazilian hospitalized individuals. We evaluated more than 30 characteristics, including demographic data, clinical symptoms, comorbidities, need for intensive care unit and mechanical ventilation, and outcomes.

Results

In our data, 585 655 hospitalized individuals with a positive result in SARS-CoV-2 real-time chain reaction (RT-PCR) were included. Of these total, 309 646 (52.9%) identified as White, 31 872 (5.4%) identified as Black, 7108 (1.2%) identified as Asian, 235 108 (40.1%) identified as individuals with multiracial background, and 1921 (0.3%) identified as Indigenous. The multivariate analysis demonstrated that race was significative to predict the death being that Black (OR = 1.43; 95% CI = 1.39-1.48), individuals with multiracial background (OR = 1.36; 95% CI = 1.34-1.38), and Indigenous (OR = 1.91; 95% CI = 1.70-2.15) races were more prone to die compared to the White race. The Asian individuals did not have a higher chance of dying due to SARS-CoV-2 infection compared to White individuals (OR = 0.99; 95% CI = 0.94-1.06). In addition, other characteristics contributed as such as being male (OR = 1.17; 95% CI = 1.16-1.19), age (mainly, +85 years old – OR = 23.02; 95% CI = 20.05-26.42) compared to 1-year-old individuals, living in rural areas (OR = 1.22; 95% CI = 1.18-1.26) or in peri-urban places (OR = 1.25; 95% CI = 1.11-1.40), and the presence of nosocomial infection (OR = 1.91; 95% CI = 1.82-2.01). Among the clinical symptoms, the main predictors were dyspnoea (OR = 1.25; 95% CI = 1.23-1.28), respiratory discomfort (OR = 1.30; 95% CI = 1.28-1.32), oxygen saturation <95% (OR = 1.40; 95% CI = 1.38-1.43). Also, among the comorbidities, the main predictors were the presence of immunosuppressive disorder (OR = 1.44; 95% CI = 1.39-1.49), neurological disorder (OR = 1.21; 95% CI = 1.17-1.25), hepatic disorder (OR = 1.41; 95% CI = 1.34-1.50), diabetes mellitus (OR = 1.40; 95% CI = 1.37-1.42), cardiopathy (OR = 1.13; 95%CI = 1.11-1.14), hematologic disorder (OR = 1.34; 95% CI = 1.24-1.43), Down syndrome (OR = 1.61; 95% CI = 1.43-1.81), renal disease (OR = 1.15; 95% CI = 1.11-1.18), and obesity (OR = 1.18; 95% CI = 1.15-1.21). Individuals on intensive care unit (OR = 2.25; 95% CI = 2.22-2.29) and on invasive (OR = 10.92; 95% CI = 10.66-11.18) or non-invasive (OR = 1.33; 95% CI = 1.30-1.35) mechanical ventilation were more prone to die.

Conclusions

Alongside several clinical symptoms and comorbidities, we associated race with an enhanced risk of death in Black individuals, individuals with multiracial backgrounds, and Indigenous peoples.

Characterization of Clinical Features of Hospitalized Patients Due to the SARS-CoV-2 Infection in the Absence of Comorbidities Regarding the Sex: An Epidemiological Study of the First Year of the Pandemic in Brazil

The male sex, due to the presence of genetic, immunological, hormonal, social, and environmental factors, is associated with higher severity and death in Coronavirus Disease (COVID)-19. We conducted an epidemiological study to characterize the COVID-19 clinical profile, severity, and outcome according to sex in patients with the severe acute respiratory syndrome (SARS) due to the fact of this disease. We carried out an epidemiological analysis using epidemiological data made available by the OpenDataSUS, which stores information about SARS in Brazil. We recorded the features of the patients admitted to the hospital for SARS treatment due to the presence of COVID-19 (in the absence of comorbidities) and associated these characteristics with sex and risk of death. The study comprised 336,463 patients, 213,151 of whom were men. Male patients presented a higher number of clinical signs, for example, fever (OR = 1.424; 95%CI = 1.399−1.448), peripheral arterial oxygen saturation (SpO2) < 95% (OR = 1.253; 95%CI = 1.232−1.274), and dyspnea (OR = 1.146; 95%CI = 1.125−1.166) as well as greater need for admission in intensive care unit (ICU, OR = 1.189; 95%CI = 1.168−1.210), and the use of invasive ventilatory support (OR = 1.306; 95%CI = 1.273−1.339) and noninvasive ventilatory support (OR = 1.238; 95%CI = 1.216−1.260) when compared with female patients. Curiously, the male sex was associated only with a small increase in the risk of death when compared with the female sex (OR = 1.041; 95%CI = 1.023−1.060). We did a secondary analysis to identify the main predictors of death. In that sense, the multivariate analysis enabled the prediction of the risk of death, and the male sex was one of the predictors (OR = 1.101; 95%CI = 1.011−1.199); however, with a small effect size. In addition, other factors also contributed to this prediction and presented a great effect size, they are listed below: older age (61−72 years old (OR = 15.778; 95%CI = 1.865−133.492), 73−85 years old (OR = 31.978; 95%CI = 3.779−270.600), and +85 years old (OR = 68.385; 95%CI = 8.164−589.705)); race (Black (OR = 1.247; 95%CI = 1.016−1.531), Pardos (multiracial background; OR = 1.585; 95%CI = 1.450−1.732), and Indigenous (OR = 3.186; 95%CI = 1.927−5.266)); clinical signs (for instance, dyspnea (OR = 1.231; 95%CI = 1.110−1.365) and SpO2 < 95% (OR = 1.367; 95%CI = 1.238−1.508)); need for admission in the ICU (OR = 3.069; 95%CI = 2.789−3.377); and for ventilatory support (invasive (OR = 10.174; 95%CI = 8.803−11.759) and noninvasive (OR = 1.609; 95%CI = 1.438−1.800)). In conclusion, in Brazil, male patients tend to present the phenotype of higher severity in COVID-19, however, with a small effect on the risk of death.

Epidemiologic Profile of Severe Acute Respiratory Infection in Brazil During the COVID-19 Pandemic: An Epidemiological Study

Background

The COVID-19 is a significant public health issue, and monitoring confirmed cases and deaths is an essential epidemiologic tool. We evaluated the features in Brazilian hospitalized patients due to severe acute respiratory infection (SARI) during the COVID-19 pandemic in Brazil. We grouped the patients into the following categories: Influenza virus infection (G1), other respiratory viruses' infection (G2), other known etiologic agents (G3), SARS-CoV-2 infection (patients with COVID-19, G4), and undefined etiological agent (G5).

Methods

We performed an epidemiological study using data from DataSUS (https://opendatasus.saude.gov.br/) from December 2019 to October 2021. The dataset included Brazilian hospitalized patients due to SARI. We considered the clinical evolution of the patients with SARI during the COVID-19 pandemic according to the SARI patient groups as the outcome. We performed the multivariate statistical analysis using logistic regression, and we adopted an Alpha error of 0.05.

Results

A total of 2,740,272 patients were hospitalized due to SARI in Brazil, being the São Paulo state responsible for most of the cases [802,367 (29.3%)]. Most of the patients were male (1,495,416; 54.6%), aged between 25 and 60 years (1,269,398; 46.3%), and were White (1,105,123; 49.8%). A total of 1,577,279 (68.3%) patients recovered from SARI, whereas 701,607 (30.4%) died due to SARI, and 30,551 (1.3%) did not have their deaths related to SARI. A major part of the patients was grouped in G4 (1,817,098; 66.3%) and G5 (896,207; 32.7%). The other groups account for &lt;1% of our sample [G1: 3,474 (0.1%), G2: 16,627 (0.6%), and G3: 6,866 (0.3%)]. The deaths related to SARI were more frequent in G4 (574,887; 34.7%); however, the deaths not related to SARI were more frequent among the patients categorized into the G3 (1,339; 21.3%) and G5 (25,829; 4.1%). In the multivariate analysis, the main predictors to classify the patients in the G5 when compared with G4 or G1-G4 were female sex, younger age, Black race, low educational level, rural place of residence, and the use of antiviral to treat the clinical signs. Furthermore, several features predict the risk of death by SARI, such as older age, race (Black, Indigenous, and multiracial background), low educational level, residence in a flu outbreak region, need for intensive care unit, and need for mechanical ventilatory support.

Conclusions

The possible COVID-19 underreporting (G5) might be associated with an enhanced mortality rate, more evident in distinct social groups. In addition, the patients' features are unequal between the patients' groups and can be used to determine the risk of possible COVID-19 underreporting in our population. Patients with a higher risk of death had a different epidemiological profile when compared with patients who recovered from SARI, like older age, Black, Indigenous, and multiracial background races, low educational level, residence in a flu outbreak region, need for intensive care unit and need for mechanical ventilatory support.

Differences in clinical features and mortality in very old unvaccinated patients (≥ 80 years) hospitalized with COVID-19 during the first and successive waves from the multicenter SEMI-COVID-19 Registry (Spain)

BACKGROUND

Old age is one of the most important risk factors for severe COVID-19. Few studies have analyzed changes in the clinical characteristics and prognosis of COVID-19 among older adults before the availability of vaccines. This work analyzes differences in clinical features and mortality in unvaccinated very old adults during the first and successive COVID-19 waves in Spain.

METHODS

This nationwide, multicenter, retrospective cohort study analyzes unvaccinated patients ≥ 80 years hospitalized for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). Patients were classified according to whether they were admitted in the first wave (March 1-June 30, 2020) or successive waves (July 1-December 31, 2020). The endpoint was all-cause in-hospital mortality, expressed as the case fatality rate (CFR).

RESULTS

Of the 21,461 patients hospitalized with COVID-19, 5,953 (27.7%) were ≥ 80 years (mean age [IQR]: 85.6 [82.3-89.2] years). Of them, 4,545 (76.3%) were admitted during the first wave and 1,408 (23.7%) during successive waves. Patients hospitalized in successive waves were older, had a greater Charlson Comorbidity Index and dependency, less cough and fever, and met fewer severity criteria at admission (qSOFA index, PO2/FiO2 ratio, inflammatory parameters). Significant differences were observed in treatments used in the first (greater use of antimalarials, lopinavir, and macrolides) and successive waves (greater use of corticosteroids, tocilizumab and remdesivir). In-hospital complications, especially acute respiratory distress syndrome and pneumonia, were less frequent in patients hospitalized in successive waves, except for heart failure. The CFR was significantly higher in the first wave (44.1% vs. 33.3%; -10.8%; p < 0.001) and was higher among patients ≥ 95 years (54.4% vs. 38.5%; -15.9%; p < 0.001). After adjustments to the model, the probability of death was 33% lower in successive waves (OR: 0.67; 95% CI: 0.57-0.79).

CONCLUSIONS

Mortality declined significantly between the first and successive waves in very old unvaccinated patients hospitalized with COVID-19 in Spain. This decline could be explained by a greater availability of hospital resources and more effective treatments as the pandemic progressed, although other factors such as changes in SARS-CoV-2 virulence cannot be ruled out.

Clinical characteristics and comorbidities of COVID-19 in unvaccinated patients with Down syndrome: first year report in Brazil

Patients with Down syndrome (DS) are more affected by the Coronavirus Disease (COVID)-19 pandemic when compared with other populations. Therefore, the primary aim of our study was to report the death (case fatality rate) from SARS-CoV-2 infection in Brazilian hospitalized patients with DS from 03 January 2020 to 04 April 2021. The secondary objectives were (i) to compare the features of patients with DS and positive for COVID-19 (G1) to those with DS and with a severe acute respiratory infection (SARI) from other etiological factors (G2) to tease apart the unique influence of COVID-19, and (ii) to compare the features of patients with DS and positive for COVID-19 to those without DS, but positive for COVID-19 (G3) to tease apart the unique influence of DS. We obtained the markers for demographic profile, clinical symptoms, comorbidities, and the clinical features for SARI evolution during hospitalization in the first year of the COVID-19 pandemic in Brazil from a Brazilian open-access database. The data were compared between (i) G1 [1619 (0.4%) patients] and G2 [1431 (0.4%) patients]; and between (ii) G1 and G3 [222,181 (64.8%) patients]. The case fatality rate was higher in patients with DS and COVID-19 (G1: 39.2%), followed by individuals from G2 (18.1%) and G3 (14.0%). Patients from G1, when compared to G2, were older (≥ 25 years of age), presented more clinical symptoms related to severe illness and comorbidities, needed intensive care unit (ICU) treatment and non-invasive mechanical ventilation (MV) more frequently, and presented a nearly two fold-increased chance of death (OR = 2.92 [95% CI 2.44–3.50]). Patients from G1, when compared to G3, were younger (< 24 years of age), more prone to nosocomial infection, presented an increased chance for clinical symptoms related to a more severe illness; frequently needed ICU treatment, and invasive and non-invasive MV, and raised almost a three fold-increased chance of death (OR = 3.96 [95% CI 3.60–4.41]). The high case fatality rate in G1 was associated with older age (≥ 25 years of age), presence of clinical symptoms, and comorbidities, such as obesity, related to a more severe clinical condition. Unvaccinated patients with DS affected by COVID-19 had a high case fatality rate, and these patients had a different profile for comorbidities, clinical symptoms, and treatment (such as the need for ICU and MV) when compared with other study populations.

COVID-19 pandemic in Southern Brazil: Hospitalizations, intensive care unit admissions, lethality rates, and length of stay between March 2020 and April 2022

Coronavirus disease 2019 (COVID‐19) pandemic spread rapidly with more than 515 million cases and 6.2 million deaths. Epidemiological factors are important for understanding the state of the pandemic. This study aims to evaluate the hospitalizations, intensive care unit (ICU) admissions, and lethality from March 2020 to April 2022. Data were collected from a hospital in Porto Alegre city, southern Brazil. The Mann–Whitney, analysis of variance, and Kruskal–Wallis tests were used to compare quantitative variables. Categorical variables were compared by Pearson's χ² test. p values <0.05 for all tests were considered significant. Were observed 3784 hospitalizations. Males were 51.4% and the age was 60.4± 20.3. Intensive care unit (ICU) patients were 31.2%, the median length of stay (LOS) was 9.0 and lethality was 13.3%. ICU lethality was 34.5% versus 4.6% in other inpatients (p < 0.01). The LOS of ICU patients was 22.0 versus 7.0 in other inpatients (p < 0.01). The first peak (July–Novemebr 2020) showed ICU occupancy of 79.1%. The second peak (December 2020–June 2021) with 91.6% occupancy. The third peak January–March 2022 with 81.0% occupancy (p < 0.01). Lethality rates were 10.3% in 2020, 14.9% in 2021 and 15.4% in 2022 (p < 0.01). In conclusion, the ICU occupancy rate was higher in 2021 and the lethality rates of ICU patients were high during pandemic years (10.3% in 2020, 14.9% in 2021, and 15.2% in 2022). The lethality of these patients ranged from 25.0% in March to 21.8% in December 2020, from 20.9% in January 22.2% in Decemebr 2021, and 35.7% in January 2022 to 21.4% in April 2022. These data demonstrate that COVID‐19 is a critical illness, even in a private hospital setting.

Human Development Index Is Associated with COVID-19 Case Fatality Rate in Brazil: An Ecological Study

The Human Development Index measures a region's development and is a step for development debate beyond the traditional, economic perspective. It can also determine the success of a country's response to the COVID-19 pandemic, mainly affecting the case fatality rate among severe cases of SARS-CoV-2 infection. We aimed to associate the Human Development Index with the case fatality rate due to COVID-19 in each Brazilian state and the Federal District, taking into account comorbidities and the need for invasive mechanical ventilation. We also evaluated the influence of the GINI index, number of intensive care unit beds, and occupied households in subnormal clusters on the case fatality rate. We performed an ecological study including two populations: COVID-19 individuals that did not require the mechanical ventilation protocol; and COVID-19 individuals under invasive mechanical ventilation. We performed a Pearson correlation test and a univariate linear regression analysis on the relationship between Human Development Index, Human Development Index-Education Level, Human Development Index-Life Expectancy, and Human Development Index-Gross National Income per capita and COVID-19 deaths. The same analyses were performed using the other markers. We grouped the patients with COVID-19 according to comorbidities and the need for invasive mechanical ventilation. Alpha = 0.05. We included 848,501 COVID-19 individuals, out of which 153,710 needed invasive mechanical ventilation and 314,164 died, and 280,533 COVID-19 individuals without comorbidity, out of which 33,312 needed invasive mechanical ventilation and 73,723 died. We observed a low negative Pearson correlation between the Human Development Index and death and a moderate negative Pearson correlation between the Human Development Index and deaths of individuals on invasive mechanical ventilation, with or without comorbidity. The univariate linear analysis showed the case fatality rate depends on at least 20-40% of the Human Development Index. In Brazil, regions with a low Human Development Index demonstrated a higher case fatality rate due to COVID-19, mainly in individuals who needed invasive mechanical ventilation, than regions with a higher Human Development Index. Although other indexes studied, such as intensive care unit beds and GINI, were also associated with the COVID-19 case fatality rate, they were not as relevant as the Human Development Index. Brazil is a vast territory comprising cultural, social, and economic diversity, which mirrors the diversity of the Human Development Index. Brazil is a model nation for the study of the Human Development Index's influence on aspects of the COVID-19 pandemic, such as its impact on the case fatality rate.

Ultrasound findings in severe COVID-19: a deeper look through the carotid arteries

Objective

To investigate vascular and perivascular abnormalities in the carotid arteries using ultrasound, as well as to evaluate their association with mortality and clinical variables in hospitalized patients with coronavirus disease 2019 (COVID-19).

Materials and Methods

This was a prospective study in which 53 hospitalized patients with severe COVID-19 were evaluated and underwent carotid ultrasound. We documented the carotid ultrasound findings in these patients. Clinical, demographic, laboratory, and imaging features were analyzed and compared by statistical analysis to detect correlations between them.

Results

Carotid ultrasound demonstrated luminal surface irregularity in 29 patients (55%), carotid plaques in 30 (57%), perivascular infiltration in four (8%), and increased intima-media thickness (IMT) in 31 (58%). Of the 31 patients with increased IMT, 19 (61%) died, and the association between increased IMT and COVID-19-related mortality was significant (p = 0.03). Logistic regression showed that the risk of death was 85% in patients who had increased IMT in combination with acute kidney injury at admission or a history of chronic kidney disease (p < 0.05).

Conclusion

In hospitalized patients with severe COVID-19, carotid ultrasound can show increased IMT, luminal surface irregularity, carotid plaques, and perivascular infiltrates. The combination of increased IMT and kidney damage appears to increase the risk of death in such patients.