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Summary Background The efficacy and safety of azithromycin in the treatment of COVID-19 remain uncertain. We assessed whether adding azithromycin to standard of care, which included hydroxychloroquine, would improve clinical outcomes of patients admitted to the hospital with severe COVID-19. Methods We did an open-label, randomised clinical trial at 57 centres in Brazil. We enrolled patients admitted to hospital with suspected or confirmed COVID-19 and at least one additional severity criteria as follows: use of oxygen supplementation of more than 4 L/min flow; use of high-flow nasal cannula; use of non-invasive mechanical ventilation; or use of invasive mechanical ventilation. Patients were randomly assigned (1:1) to azithromycin (500 mg via oral, nasogastric, or intravenous administration once daily for 10 days) plus standard of care or to standard of care without macrolides. All patients received hydroxychloroquine (400 mg twice daily for 10 days) because that was part of standard of care treatment in Brazil for patients with severe COVID-19. The primary outcome, assessed by an independent adjudication committee masked to treatment allocation, was clinical status at day 15 after randomisation, assessed by a six-point ordinal scale, with levels ranging from 1 to 6 and higher scores indicating a worse condition (with odds ratio [OR] greater than 1·00 favouring the control group). The primary outcome was assessed in all patients in the intention-to-treat (ITT) population who had severe acute respiratory syndrome coronavirus 2 infection confirmed by molecular or serological testing before randomisation (ie, modified ITT [mITT] population). Safety was assessed in all patients according to which treatment they received, regardless of original group assignment. This trial was registered at ClinicalTrials.gov, NCT04321278. Findings 447 patients were enrolled from March 28 to May 19, 2020. COVID-19 was confirmed in 397 patients who constituted the mITT population, of whom 214 were assigned to the azithromycin group and 183 to the control group. In the mITT population, the primary endpoint was not significantly different between the azithromycin and control groups (OR 1·36 [95% CI 0·94–1·97], p=0·11). Rates of adverse events, including clinically relevant ventricular arrhythmias, resuscitated cardiac arrest, acute kidney failure, and corrected QT interval prolongation, were not significantly different between groups. Interpretation In patients with severe COVID-19, adding azithromycin to standard of care treatment (which included hydroxychloroquine) did not improve clinical outcomes. Our findings do not support the routine use of azithromycin in combination with hydroxychloroquine in patients with severe COVID-19. Funding COALITION COVID-19 Brazil and EMS.

Context As COVID-19 overwhelms health systems worldwide, palliative care strategies may ensure rational use of resources while safeguarding patient comfort and dignity. Objective To describe palliative care practices in hospitalized middle-aged and older adults in two of the largest COVID-19 treatment centers in Sao Paulo, Brazil. Methods Retrospective cohort. Eligible patients were those aged 50 years or older hospitalized between March and May 2020 with a laboratory confirmation of SARS-CoV-2 infection. Palliative care implementation was defined as present if medical notes indicated a decision to limit escalation of life support measures, or when opioids or sedatives were prescribed for palliative management of symptoms. Results We included 1162 participants (57% male, median 65 years). Overall, 21% were frail and 54% were treated in intensive care units, but only 17% received palliative care. Stepwise logistic regression demonstrated that age ≥80 years, dementia, history of stroke or cancer, frailty, having a PaO2/FiO2

Background Over 66 million people worldwide have been diagnosed with COVID-19. Therefore, understanding their clinical evolution beyond hospital discharge is essential not only from an individual standpoint, but from a populational level. Objectives Our primary aim was to assess the impact of COVID-19 on health-related quality of life (HRQoL) 3 months after hospital discharge. Additionally, we screened for anxiety and depression and assessed important clinical outcomes. Methods This was a single-centre cohort study performed in Sao Paulo (Brazil), in which participants were contacted by telephone to answer a short survey. EQ-5D-3L was used to assess HRQoL and clinical data from patients’ index admission were retrieved from medical records. Results We contacted 251 participants (59.8% males, mean age 53 years old), 69.7% of which had presented with severe COVID-19. At 3 months of follow-up, 6 patients had died, 51 (20.3%) had visited the emergency department again and 17 (6.8%) had been readmitted to hospital. Seventy patients (27.9%) persisted with increased dyspnoea and 81 had a positive screening for anxiety/depression. Similarly, patients reported an overall worsening of EQ-5D-3L single summary index at 3 months compared to before the onset of COVID-19 symptoms (0.8012 (0.7368 – 1.0) vs. 1.0(0.7368 – 1.0), p

Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p

No Brasil, o primeiro paciente com a doenca do coronavirus 2019 (COVID-19) foi diagnosticado em 26 de fevereiro de 2020. Morava em Sao Paulo (SP) e retornara recentemente de uma viagem da Europa. Ao longo das semanas seguintes, a maioria dos novos casos de COVID-19 tinha um fator de risco epidemiologico identificavel – ter viajado ao exterior ou tido contato com um paciente que sabidamente estava com o coronavirus da sindrome respiratoria aguda grave 2 (SARS-CoV-2). No entanto, como as [...]

Background Online spaced education (OSE) is a method recognized for promoting long-term knowledge retention, changing behaviors and improving outcomes for students and healthcare professionals. However, there is little evidence about its impacts on patient education. Objectives The aim of this research was to compare knowledge retention using educational brochure and OSE on individuals with multiple sclerosis (MS) and to verify the impact of educational methods on fall outcome. Methods Individuals with MS (n = 230) were randomly assigned to two types of patient education—educational brochure (control) and OSE (intervention). During 12 weeks, the intervention group received multiple-choice tests on fall prevention. Knowledge retention, behavior change and fall incidence were assessed before intervention and after 3 and 6 months. The participants’ satisfaction with the education method was also evaluated. Results Knowledge retention was similar between groups, and behavior change was observed in both groups. There was a significant reduction in fall rate in the intervention group, from 0.60 to 0.27 at 6 months (P Conclusion Individuals demonstrated significant improvement in fall rate outcome in both groups with no significant difference. In regard to test scores and satisfaction, results were similar between groups.

INTRODUÇÃO: Dengue é uma doença viral prevalente e potencialmente fatal associada à alteração da permeabilidade capilar e coagulopatia. Entretanto, não há estudos concernentes aos achados tromboelastométricos nesta doença. Realizamos o presente estudo para analisar pacientes com dengue e plaquetopenia por meio de um exame rápido, efetivo e a beira leito comparando com os exames convencionais de coagulação. MÉTODOS: Trata-se de um estudo observacional e transversal conduzido entre os dias 6 de abril a 5 de maio de 2015, em São Paulo, Brasil, durante epidemia de dengue. Foi realizado tromboelastometria ROTEM® em 53 pacientes com dengue e trombocitopenia em associação com exames convencionais de coagulação: tempo de protrombina (TP), international normalized ratio (INR), tempo de tromboplastina parcial ativado (TTPa), tempo de trombina (TT), contagem de plaquetas, fibrinogênio e d-dímero. Um grupo controle de pacientes foi estabelecido para comparação do status tromboelastométrico. RESULTADOS: Um total de 38 pacientes de 53 (71,7%) apresentaram anormalidades no INTEM e 29/53 (57,4%) no EXTEM. Em contrapartida, alterações no FIBTEM foram encontradas apenas em 3/53 (5,7%). Houve significância estatística em pacientes correlacionando alterações tromboelastométricas no EXTEM e INTEM e contagem de plaquetas (p=0,052) e (p=0,005), respectivamente; assim como os valores de fibrinogênio (p=0,006) e (p=0,021), respectivamente. O grupo controle (GC) apresentou status tromboelastométrico normal em 10/10 (100%) na análise do INTEM, EXTEM, FIBTEM. Avaliação do EXTEM demonstrou significância estatística entre o GC e o grupo Dengue: CT (p=0,044); CFT (p

We present a case of a 16-year-old male patient with sudden-onset, rash, arthritis and meningitis by Neisseria meningitidis one week after an acute upper respiratory infection. On the 10th day of treatment followed by neurological and arthritis clinical improvement, he presented once again a tender and swollen left knee with a moderate effusion, and active and passive range of motion was severely limited secondary to pain, and when he was submitted to surgical drainage and synovial fluid analysis he showed inflammatory characteristics. A non-steroidal anti-inflammatory drug was taken for five days with complete improvement of symptoms. The case is notable for its combination of features of septic and immune-mediated arthritis, which has rarely been reported in the same patient. Paciente de 16 anos do sexo masculino apresentou-se ao serviço de emergência com quadro de erupção cutânea súbita, artrite e meningite por Neisseria meningitidis, uma semana após apresentar sintomas de infecção de vias aéreas superiores. No décimo dia de tratamento, seguido da melhora clínica neurológica e da artrite, ele volta a apresentar derrame articular moderado com limitação importante da amplitude dos movimentos passivo e ativo secundária à dor. Em seguida, foi submetido à drenagem cirúrgica e a análise do líquido sinovial mostra características inflamatórias. Foi iniciado tratamento com antiinflamatório não esteroidal por cinco dias com melhora completa dos sintomas. Esse caso tem como característica peculiar o fato do indivíduo apresentar tanto as características de artrite séptica pelo meningococo quanto de artrite imunomediada, o que tem sido pouco usual no mesmo paciente.

There are some data suggesting that stressful events, such as soccer games, could affect the incidence and mortality due to cardiovascular disease. However, data on the impact of large-scale international events on the pattern of ICU admissions and outcomes of critically ill patients are limited.

Early on 27 January 2013, 242 people were killed in a nightclub fire in southern Brazil (Santa Maria) after a band’s pyrotechnic show set the establishment ablaze. The survivors were confined inside the nightclub for an unknown period of time. A few hours later, Hospital Israelita Albert Einstein, a level-one hospital in Sao Paulo (Brazil), located 1,247 km (775 miles) from Santa Maria, managed to organize a humanitarian aid and disaster relief mission. A regional telemedicine (TM) hub was installed in the Hospital Universitario de Santa Maria, which is one of the main sites that received injured victims. The miniaturized mobile TM platform TES (Transportable Examination Station; GlobalMed Inc., Scottsdale, AZ, USA) was chosen as a practical and lightweight device (Figures 1 and ​and2).2). This device operated uninterrupted for 2 weeks after the disaster with at least two videoconferences a day (Figure 3). Unfortunately, 242 people died at the scene. Approximately 620 people needed immediate medical attention and were distributed among nearby hospitals. Approximately 80 victims required admission because of respiratory failure, burn injuries, carbon monoxide and cyanide poisoning, and minor trauma. Mechanical ventilation was performed on 42 patients. Figure 1 Miniaturized mobile telemedicine platform TES® (Transportable Examination Station; GlobalMed® Inc., Scottsdale, AZ, USA). Figure 2 Miniaturized mobile telemedicine platform TES® (Transportable Examination Station; GlobalMed® Inc., Scottsdale, AZ, USA). USB, Universal Serial Bus. Figure 3 Health-care providers during videoconferences. Telemedicine inside the Hospital Universitario de Santa Maria the following day after the disaster with people from the Health Ministry, local physicians and staff discussing, through telemedicine, with ... TM allowed emergency staff to discuss these challenging cases with specialists from around the world. Ventilation strategies and bronchoscopy interventions in injured airways were some of the primary issues. Daily ‘toilet bronchoscopy’ was performed during the first 2 days (as suggested during the conferences) to improve the release of smoke with marked improvement. The ceiling foam of the nightclub was composed of polyurethane, which during the fire released cyanide and carbon monoxide that accounted for the majority of the deaths. TM helped to diagnose and manage these patients, and many other supplies were sent after TM sessions. None of the 80 admitted patients died in Santa Maria hospitals. TM encompasses the diagnosis, treatment, monitoring, and education of patients and provides convenient, site-independent access to expert advice and patient information [1-3]. The limitations of TM should be considered, especially when natural disasters severely damage the local infrastructure and networks, thus threatening internet connections. Although TM can provide consultation and decision making, it cannot help in procedural skills [4]. We consider that there is a role for TM in disaster medicine. Mobile health addresses complex issues at the intersection of medicine, public health, and logistics and improves access to external specialists.

Severe hemorrhage with necessity of allogeneic blood transfusion is common complication in intensive care unit and is associated with increased morbidity and mortality. Prompt recognition and treatment of bleeding causes becomes essential for the effective control of hemorrhage, rationalizing the use of allogeneic blood components, and in this way, preventing an occurrence of their potential adverse effects. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time present limitations in predicting bleeding and guiding transfusion therapy in critically ill patients. Viscoelastic tests such as thromboelastography and rotational thromboelastometry allow rapid detection of coagulopathy and goal-directed therapy with specific hemostatic drugs. The new era of thromboelastometry relies on its efficacy, practicality, reproducibility and cost-effectiveness to establish itself as the main diagnostic tool and transfusion guide in patients with severe active bleeding.

A 24 year-old patient presented with an adverse reaction to phenytoin therapy associated with drug-induced hypersensitivity syndrome, suggesting a relationship to a reactivation of human herpesvirus 6. The investigation of viral infection was done by antiHHV-6 IgM, IgG serology and PCR. The sequence was analyzed and it was identified as HHV-6 variant B. DOI: http://dx.doi.org/10.17525/vrr.v14i2.32

The number of very old (≥80 years) patients with chronic illness and functional impairment requiring major medical attention is increasing, with great chances of adverse events during hospitalization. Rapid Response Teams (RRT) were implemented to improve the recognition and response to deteriorating ward patients; however, the characteristics and outcomes of very old patients assisted by RRT during hospitalization are not well described.

The utilization of isolation precautions has increased in tertiary care hospitals due to the increase in colonization with multidrug-resistant organisms over time. We assessed the frequency of multidrug-resistant microorganisms responsible for implementation of contact precautions in the ICU of a tertiary care hospital over a 12-year period.

Introduction Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening disease. AFLP is characterized by liver failure with different degrees of coagulopathy. Outcome and survival can be dramatically improved with prompt recognition and treatment. Thromboelastometry has been considered a point of care for the management of bleeding patients. It could, therefore, be an alternative tool to treat the complex cases of AFLP involving liver failure and coagulopathy. Through this study, we present our successful experience of an AFLP case that was submitted to an emergency cesarean section in which blood transfusion was guided by thromboelastometry. Case presentation We report the case of a previously healthy 28-year-old woman, Afro-Brazilian, in her first pregnancy with no medical records until the 36th pregnancy week. She presented to our emergency department with an acute onset of abdominal pain, jaundice, nausea and vomiting. The laboratory examinations revealed metabolic acidosis, acute kidney injury (serum creatinine 3.4mg/dL), platelets 97 × 103/mm3, serum fibrinogen 98mg/dL and increased international nationalized ratio (INR 6.9) without acute bleeding. An emergency cesarean section was indicated. Based on the results of the thromboelastometric tests EXTEM and FIBTEM, prothrombin complex concentrate and fibrinogen concentrate were administered at the beginning of the cesarean section, which succeeded with no major bleeding and without need of further transfusion. Conclusions Thromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in obstetric patients with acute fatty liver of pregnancy, with the potential advantage of helping avoid unnecessary transfusion in such patients.