Planejamento na incerteza: Variáveis para estimar custos médicos direitos de paciente suspeito ou confirmado para COVID-19

In March 2020 the World Health Organization declared a pandemic state for the new coronavirus. Traditional clinical and economic management planning states that the means and ends are known, focusing on the processes that address these conditions of certainty and hiding uncertainties. Therefore, to analyze health costs it is necessary to identify, quantify and value the resources used in health. Thus, the objectives of this study were: to describe the clinical management protocols of the suspected and confirmed patient for COVID-19, from the State of Rio Grande do Sul, from January 30 to May 20, 2020, and to identify variables for the calculation of direct medical costs in the care of these patients. This is a descriptive study. It was noticed how uncertain and dynamic are the characterizations of the suspected patient, the collection criteria and the type of test to be performed. From the categorization of direct medical costs, it is possible to create an instrument to estimate the costs, for the Unified Health System, of the patient with suspected or confirmed infection by COVID-19.En marzo de 2020, la Organización Mundial de la Salud declaró un estado pandémico para el nuevo coronavirus. La planificación del manejo clínico y económico tradicional asume que los medios y fines son conocidos, enfocándose en los procesos que abordan estas condiciones de certeza y ocultan incertidumbres. Para analizar los costos en salud, es necesario identificar, cuantificar y valorar los recursos utilizados en salud. Así, los objetivos de este estudio fueron: describir los protocolos de manejo clínico de pacientes sospechosos y confirmados por COVID-19, en el Estado de Rio Grande do Sul, Brasil, del 30 de enero al 20 de mayo de 2020, e identificar variables para el cálculo de los costos médicos directos en la atención de estos pacientes. Se observó cuán inciertas y dinámicas son las caracterizaciones del paciente sospechoso, los criterios de recolección y el tipo de examen a realizar. A partir de la categorización de los costos médicos directos, es posible crear un instrumento para estimar los costos para el Sistema Único de Salud del paciente con sospecha o confirmación de infección por COVID-19.Em março de 2020, a Organização Mundial de Saúde decretou estado de pandemia pelo novo coronavírus. O planejamento tradicional de manejo clínico e econômico pressupõe que os meios e os fins sejam conhecidos, direcionando-se para os processos que abordam essas condições de certeza e ocultando as incertezas. Para analisar os custos em saúde é necessário identificar, quantificar e valorar os recursos empregados em saúde. Dessa forma, os objetivos deste estudo foram: descrever os protocolos de manejo clínico de pacientes suspeitos e confirmados para COVID-19 no Estado do Rio Grande do Sul, no período de 30 de janeiro a 20 de maio de 2020, e identificar variáveis para o cálculo dos custos médicos diretos no atendimento desses pacientes. Foi observado o quão incertas e dinâmicas são as caracterizações do paciente suspeito, do critério de coleta e do tipo de teste a ser realizado. A partir da categorização dos custos médicos diretos, é possível criar um instrumento para estimar os custos para o Sistema Único de Saúde do paciente com suspeita ou confirmado por infecção da COVID-19

EFEITOS DO TREINAMENTO COMBINADO SOBRE OS SINTOMAS DEPRESSIVOS E A APTIDÃO FÍSICA DE DETENTOS DEPENDENTES QUÍMICOS: UM ENSAIO CLÍNICO CONTROLADO RANDOMIZADO

The objective was to analyze the effect of combined training on depressive symptoms and physical fitness of drug addicts. Twenty-nine male drug addicts (34.24±7.76 years) were randomly allocated into the combined training group (CTG) and control group (CG). Both groups performed physical fitness tests before and after 12 weeks of intervention. The CTG performed combined training (strength and aerobic) in three weekly sessions, with duration progressing from 30 to 48 minutes and the CG maintained usual activities. The CTG showed an increase in the number of repetitions in the abdominal resistance tests (p<0.001), elbow flexion (p<0.001), sitting and standing up (0.014) and improved aerobic capacity (p=0.015) after the intervention. As for depressive symptoms, the CTG showed lower values ​​than the CG (p=0.015) in the post-intervention period. It is concluded that combined training improves physical fitness and can help reduce depressive symptoms in drug addicts deprived of liberty.El objetivo fue analizar el efecto del entrenamiento combinado sobre los síntomas depresivos y la condición física de los drogodependientes. Veintinueve drogadictos masculinos (34,24 ± 7,76 años) fueron asignados aleatoriamente al grupo de entrenamiento combinado (GTC) y al grupo de control (GC). Ambos grupos realizaron pruebas de aptitud física antes y después de 12 semanas de intervención. El GTC realizó entrenamiento combinado (fuerza y ​​aeróbico) en tres sesiones semanales, con duración progresiva de 30 a 48 minutos y el GC mantuvo las actividades habituales. El GTC mostró un aumento en el número de repeticiones en las pruebas de resistencia abdominal (p<0,001), flexión de codo (p<0,001), sentado y de pie (0,014) y mejora de la capacidad aeróbica (p=0,015) después de la intervención. En cuanto a los síntomas depresivos, el GTC mostró valores más bajos que el GC (p=0,015) en el período posterior a la intervención. Se concluye que el entrenamiento combinado mejora la condición física y puede ayudar a reducir los síntomas depresivos en drogodependientes privados de libertad.Objetivou-se analisar o efeito do treinamento combinado nos sintomas depressivos e aptidão física de detentos dependentes químicos. Vinte e nove homens detentos dependentes químicos (34,24±7,76 anos) foram alocados aleatoriamente no grupo de treinamento combinado (GTC) e grupo controle (GC). Ambos os grupos realizaram testes de aptidão física antes e após 12 semanas de intervenção. O GTC realizou treinamento combinado (força e aeróbico) em três sessões semanais, com duração progredindo de 30 a 48 minutos e o GC manteve atividades habituais. O GTC apresentou aumento do número de repetições nos testes de resistência abdominal (p<0,001), flexão de cotovelos (p<0,001), de sentar e levantar (0,014) e melhorou a capacidade aeróbica (p=0,015) após a intervenção. Quanto aos sintomas depressivos, o GTC apresentou valores menores que o GC (p=0,015) no pós-intervenção. Conclui-se que o treinamento combinado melhora a aptidão física e pode auxiliar na redução de sintomas depressivos de dependentes químicos privados de liberdade

Estratégias de vedação na ensilagem de milho e desempenho de ovinos em confinamento

Objetivou-se avaliar os efeitos de diferentes estratégias de vedação sobre a estabilidade aeróbia e o valor alimentício da silagem de milho fornecida para cordeiros em terminação. Os tratamentos foram definidos de acordo com a estratégia de vedação do silo: LP (lona preta de polietileno), LP + Bagaço (lona preta de polietileno + bagaço de cana) e LP + Silostop (lona preta de polietileno + filme de barreira de oxigênio Silostop® Orange). Foram utilizados seis cordeiros por tratamento, totalizando 18 animais, em um período experimental de 63 dias. A silagem do tratamento LP apresentou maior estabilidade aeróbia, porém proporcionou menor coeficiente de digestibilidade da matéria seca. Não foi observada diferença significativa entre os tratamentos para o consumo e desempenho dos cordeiros. Todavia, para o peso corporal final, ganho de peso, ganho médio diário, eficiência alimentar e consumo de matéria seca, os melhores resultados, em valor absoluto, foram encontrados para os cordeiros alimentados com dieta à base da silagem coberta com LP + Bagaço. A silagem vedada exclusivamente com a lona preta de polietileno apresentou maior estabilidade aeróbia. As diferentes estratégias de vedação utilizadas nesse experimento não influenciaram o desempenho de cordeiros Dorper x Santa Inês em terminação. Palavras-chave: carcaça; deterioração aeróbia; digestibilidade; ganho de pes

Martian dust storm impact on atmospheric H₂O and D/H observed by ExoMars Trace Gas Orbiter

Global dust storms on Mars are rare but can affect the Martian atmosphere for several months. They can cause changes in atmospheric dynamics and inflation of the atmosphere, primarily owing to solar heating of the dust. In turn, changes in atmospheric dynamics can affect the distribution of atmospheric water vapour, with potential implications for the atmospheric photochemistry and climate on Mars. Recent observations of the water vapour abundance in the Martian atmosphere during dust storm conditions revealed a high-altitude increase in atmospheric water vapour that was more pronounced at high northern latitudes, as well as a decrease in the water column at low latitudes. Here we present concurrent, high-resolution measurements of dust, water and semiheavy water (HDO) at the onset of a global dust storm, obtained by the NOMAD and ACS instruments onboard the ExoMars Trace Gas Orbiter. We report the vertical distribution of the HDO/H O ratio (D/H) from the planetary boundary layer up to an altitude of 80 kilometres. Our findings suggest that before the onset of the dust storm, HDO abundances were reduced to levels below detectability at altitudes above 40 kilometres. This decrease in HDO coincided with the presence of water-ice clouds. During the storm, an increase in the abundance of H2O and HDO was observed at altitudes between 40 and 80 kilometres. We propose that these increased abundances may be the result of warmer temperatures during the dust storm causing stronger atmospheric circulation and preventing ice cloud formation, which may confine water vapour to lower altitudes through gravitational fall and subsequent sublimation of ice crystals. The observed changes in H2O and HDO abundance occurred within a few days during the development of the dust storm, suggesting a fast impact of dust storms on the Martian atmosphere

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Cent scientifiques répliquent à SEA (Suppression des Expériences sur l’Animal vivant) et dénoncent sa désinformation

La lutte contre la maltraitance animale est sans conteste une cause moralement juste. Mais elle ne justifie en rien la désinformation à laquelle certaines associations qui s’en réclament ont recours pour remettre en question l’usage de l’expérimentation animale en recherche

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century