Using resources wisely in the COVID-19 pandemic: an international list of Choosing Wisely recommendations

BACKGROUND: The novel coronavirus (COVID-19) pandemic has brought forth issues of health system resource limitations into urgent matters of public importance. Our objective was to rapidly develop an international Choosing Wisely list of recommendations for clinicians and the public about using resources wisely in the COVID-19 pandemic. METHODS: Choosing Wisely Canada convened a rapid Delphi process to develop an international Choosing Wisely list for COVID-19. Informed by a rapid review of emerging literature, this process engaged a small group of clinicians and public advisors in Canada (n=10) and internationally (n=8) to develop a candidate list of recommendations. A survey with candidate recommendations was sent to Choosing Wisely clinician leaders in Canada and around the world. Based on survey results and input, list recommendations were modified. RESULTS: The survey was sent to 293 potential respondents and received a 56% response rate in 72 hours (n=163). Respondents were asked to score each of the 9 recommendations on a 5-point Likert scale ranging from 1 strongly disagree to 5 strongly agree followed by free text comment. There were 271 total comments across 9 recommendations. Overall, all 9 recommendations had high levels of agreement with 83%-96% of respondents ranking them as strongly agree or agree. INTERPRETATION: This list of recommendations provides evidence-based statements about using resources wisely in the COVID-19 pandemic. The list reflects international consensus on evidence-based recommendations for both clinicians and the public which were achieved through a rapid consensus building process. TRIAL REGISTRATION: n/

Ruptura idiopática de bexiga urinária em duas éguas

Urinary bladder rupture is rarely reported in adult horses and is usually associated with parturition, history of traumaor urethral obstruction. This paper reports two cases in mares free of these predisposing factors, diagnosed throughclinical manifestations, abdominal ultrasound and abdominocentesis, corrected by cystorrhaphy through laparotomy.While recovery was satisfactory in one case, the other case had complications in celiorraphy such as development ofincisional hernia, small colon eventration and intestinal adherences, opting by the euthanasia of the animal. These reportsare important because of the rarity with which they occur in adult mares. The different prognoses may be related to theseverity of each case, according to the location and extension of the wound, which directly or indirectly influence thetechnique and recovery of the animals.A ruptura de bexiga urinária é raramente relatada em equinos adultos, sendo normalmente associada ao parto, antecedentesde trauma ou obstrução de uretra. Este trabalho relata dois casos em éguas livres destes fatores predisponentes,diagnosticados através de manifestações clínicas, ultrassonografia abdominal e abdominocentese, corrigidos por cistorrafiaatravés de laparotomia. Em um dos casos a recuperação ocorreu satisfatoriamente, porém no outro houve complicaçõesna celiorrafia como desenvolvimento de hérnia incisional, eventração de cólon menor e posterior desenvolvimento deaderências intestinais, optando-se pela eutanásia do animal. Estes relatos são importantes pela raridade com que ocorremem éguas adultas. Os diferentes prognósticos podem estar relacionados à gravidade de cada caso, de acordo com o locale extensão da ferida, que direta ou indiretamente influenciam na técnica empregada e recuperação dos animais

Ventilação controlada mecânica em cavalos com o emprego de vecurônio

O objetivo do presente estudo foi avaliar os efeitos metabólicos e respiratórios da administração de vecurônio em cavalos submetidos a ventilação controlada e compará-los àqueles que permaneceram em respiração espontânea. Foram empregados vinte animais hígidos alotados em dois grupos experimentais. Todos os animais foram pré-medicados com romifidina (100 mi g/kg IV) sendo a anestesia induzida com a associação de tiletamina-zolazepam (2 mg/kg IV) e a manutenção realizada com halotano. Os animais do grupo I permaneceram em respiração espontânea enquanto os animais do grupo II receberam vecurônio na dose de 0,1 mg/kg IV sendo submetidos a ventilação controlada mecânica. A administração do vecurônio não promoveu qualquer alteração significativa da freqüência ou ritmo cardíaco, pressão venosa central ou pressão arterial. No atinente aos animais que permaneceram em respiração espontânea, não houve qualquer diferença em relação a estes parâmetros quando comparados aos dos animais que permaneceram em respiração espontânea. Os animais que receberam o vecurônio apresentaram valores inferiores de PaCO2 e valores normais de pH em relação aos animais do grupo I. A duração de ação do vecurônio foi de 12,83 ± 1,72 minutos. Após o término da administração do halotano, os animais do grupo II retornaram à ventilação espontânea em 6,09 minutos demonstrando valores de PaCO2 da ordem de 50,78 mmHg. Não houve necessidade de reversão farmacológica do bloqueador e a qualidade da recuperação foi semelhante nos dois grupos. Frente aos resultados obtidos, pode-se concluir que o emprego de ventilação controlada mecânica e vecurônio em eqüinos é factível e isenta de efeitos adversos, sendo portanto indicada nesta espécie.The purpose of this study was to investigate the metabolic and cardiorespiratory effects of the administration of vecuronium under controlled mechanical ventilation versus spontaneous ventilation in horses. Twenty healthy horses scheduled to elective surgery were randomized and assigned in two groups. All animals were pre-medicated with romifidine (100 mu g/kg iv), anesthesia was induced with an association of tiletamine-zolazepam (2 mg/kg iv) and was maintained with halothane. Animals of group I remained in spontaneous ventilation without muscle relaxation while group II received vecuronium (0.1 mg/kg IV) and was submitted to controlled mechanical ventilation. Vecuronium administration did not cause any significant change of heart rate or rhythm, central venous pressure and arterial pressure. With the animals that remained under spontaneous ventilation, no differences were observed in these parameters. The animals that received vecuronium showed lower values of PaCO2 and normal values of pH in relation to the spontaneous ventilation group. Vecuronium duration was 12.83 ± 1.72 minutes. After halothane discontinuation the weaning time in group I I was 6.09 minutes with mean final PaCO2 values of 50.78 mmHg. There was no need of pharmacological reversion of vecuronium effect and recovery from anesthesia was similar in the two groups. In conclusion, the use of mechanical controlled ventilation and vecuronium in horses is easily performed, does not induce further cardiovascular depression and should be employed in equines undergoing major operations

Upper Airways Lesions After endotracheal intubation in equines

A intubação endotraqueal nos eqüinos atualmente é rotina nas salas cirúrgicas das grandes Faculdades, Jockeys Clubes, Hípicas, etc... É um procedimento invasivo, portanto, não deixa de apresentar riscos; porém suas vantagens excedem em muito suas desvantagens. O objetivo desse experimento foi procurar indícios de que a sonda endotraqueal possa causar lesões nas vias aéreas superiores dos eqüinos quando submetidos a intubação endotraqueal e quais suas possíveis conseqüências. Os resultados foram avaliados segundo tempo de execução do ato operatório, idade dos eqüinos, raça dos animais, peso, sexo, número de vezes que foram necessárias para realizar a intubação orotraqueal, diâmetro da sonda endotraqueal e pressão utilizada no “CUFF”. No tocante às lesões em si, avaliamos o tipo e o grau, a saber: sem lesão; lesões leves onde entendemos equimoses que foram classificadas conforme intensidade da lesão em +,++ ou +++; lesões moderadas onde entendemos hematomas, que conforme o grau foram de +,++,+++; lesões como escoriações, que se classificam em leves, moderadas e graves e que, conforme o grau da lesão, correspondem respectivamente a +, leve; ++, moderada e +++, grave; e perfurações. Quanto aos resultados obtidos, não foram observadas diferenças que pudessem correlacionar aparecimento de lesão e os parâmetros analisados segundo metodologia aplicada. Pelos resultados obtidos com a metodologia empregada, concluiu-se que as intubações endotraqueais em eqüinos provocaram lesões nas vias aéreas superiores, entre as quais constatamos: equimose, ulceração, hematomas e escoriação; o local lesado observado com maior freqüência foi a região da traquéia onde se posiciona o “cuff": a lesão encontrada com maior freqüência foi a equimose.Nowadays, endotracheal intubation in equines is a normal routine in surgery rooms of great Universities, Jockey Clubs, and so forth. It is an invasive procedure, so it presents risks, although its advantages exceed a lot its disadvantages. The will of this experiment was to look for indicating that the endotracheal azode could cause lesions in the equine upper airways tract, as well as its possible consequences. The results were evaluated by the time spend in the surgery, age of equines, the animals breed, weight, sex, number of attempts necessary to intubate, tubes diameter and Cuff’s pressure. The lesions were evaluated by their type and grade there were. No lesion, Light lesion, where there were ecchymoses wich were classified by the intensity of the lesions in (+),(++),(+++). Moderate lesions, where we observed hematomas, that by their grade were (+), (++),(+++). Severe lesions, where we catalogued ulcer, which by their grade were shared in (+),(++),(+++). Lesions like lacerations which were classified in light, moderate and severe; and which, by the grade of lesions correspond to light, (++) moderate and (+++) severe. We also had perforations. Evaluating these results, we observed no differences correlating the appearance of the lesion with tract, as well as its possible consequences the evaluated parameters performed by the applied methodology. Overall results showed that endotracheal intubations in equines caused lesions in the upper airways tract; the lesions found were: ecchymoses, hematomas, ulcerations and lacerations; the most frequent lesion site was Cuff’s place in the trachea; the most frequent lesion was the ecchymosis

Physicians’ preference towards the non-evidence based hydroxychloroquine treatment for COVID-19: the pandemic effect

OBJECTIVE: To evaluate whether there is a "pandemic effect" promoting irrational medical reasoning. METHODS: Cross-sectional study. Setting state medical councils were asked to send all registered physicians two sequential email invitations to complete a Google Form questionnaire. Between April 15 and May 3, 2020, 370 doctors answered our questionnaire with questions about the prescription of hydroxychloroquine for COVID-19 and vitamin C for sepsis. The questionnaire had a five-point Likert scale (greater number, greater support) on the degree of propensity to prescribe the medication and a binary question (yes or no) to express the doctor's final decision to prescribe. These two questions, in the same order, were asked for scenarios of mild, moderate and severe cases. RESULTS: The propensity to prescribe hydroxychloroquine for COVID-19 increased with the severity of the clinical presentation: for mild cases, 37% (95% CI 32%-42%) of the physicians chose "yes", increasing to 68% (95% CI 63%-72%) and 89% (95% CI 85%-92%) for moderate or severe cases, respectively (Cochran's Q test: P<0.001). The medians and interquartile ranges of the Likert scales for hydroxychloroquine were 2 (1-4), 4 (2-4), 4 (4-5) in mild, moderate and severe cases of COVID-19 (Friedman test: P<0.001). CONCLUSIONS: The propensity of the Brazilian physician to prescribe hydroxychloroquine for COVID-19 is high and, according to the severity of the disease, ranged from 37 to 89%. On the contrary, the propensity to prescribe vitamin C for sepsis, a non-pandemic situation, was lower and not associated with clinical severity. Our data suggest a "pandemic effect" promoting irrationality in medical reasoning

Redução significante dos valores de hematócrito em equinos saudáveis durante anestesia

Xylazine (XYL) and acepromazine (ACP) are known to decrease the hematocrit (HT) of horses when administered alone. However in routine anesthesia these drugs are administered by associations which ultimate effect in the HT is unknown but may cause false impressions about the hydration status, blood loss and red blood cell indices. The objective of this study was to characterize the values of HT in horses anesthetized with XYL, ACP, ketamine, midazolam, guaiphenesin, isoflurane and ephedrine. Twenty healthy horses were premedicated with either XYL 0.8 mg/kg (XYL group, n=10) or XYL 0.5 mg/kg plus ACP 0.05 mg/kg (XYL+ACP group, n=10). Anesthesia was induced with ketamine, midazolam and guaiphenesin and maintained with isoflurane. Ephedrine was infused for cardiovascular support. HT, vital parameters and blood gas values were evaluated at baseline, between each drug administration, after standing and 24 hours after baseline (24hBL). The HT started to decrease 17 and 40 minutes after premedication in XYL group and XYL+ACP group, respectively (p&lt;0.05). The maximum decrease of 19% in XYL group and 17% in XYL+ACP group was observed after 1 hour of premedication (p&lt;0.05). In both groups HT remained low for longer than 180 minutes and returned to baseline at 24hBL. A significant HT decrease should be considered in anesthetized healthy horses receiving XYL, ACP, ketamine, midazolam, guaiphenesin, isoflurane and ephedrine.A administração isolada de xilazina (XIL) e acepromazina (ACP) pode diminuir o hematócrito (HT) de equinos. Na rotina anestésica, estes fármacos são administrados em associações, cujo efeito final no HT não é conhecido, mas pode causar falsas impressões sobre o grau de hidratação, perda sanguínea e índices hematimétricos. O objetivo deste estudo foi caracterizar os valores de HT de equinos anestesiados com XYL, ACP, cetamina, midazolam, EGG, isofluorano e efedrina. Vinte equinos hígidos foram pré-tratados com XIL 0,8 mg/kg (grupo XIL, n=10) ou XIL 0,5 mg/kg associada à ACP 0,05 mg/kg (grupo XIL+ACP, n=10). A anestesia foi induzida com cetamina, midazolam e EGG e mantida com isofluorano. A efedrina foi utilizada para suporte cardiovascular. O HT, parâmetros vitais e hemogasometria foram avaliados no momento basal, entre administração de cada fármaco, após retorno à posição quadrupedal e 24 horas após momento basal (24hBL). A diminuição do HT iniciou-se 17 e 40 minutos após administração da medicação préanestésica no grupo XIL e grupo XIL+ACP, respectivamente (p&lt;0,05). A queda máxima de 19% no grupo XIL e 17% no grupo XIL+ACP foi observada após 1 hora da administração da medicação pré-anestésica (p&lt;0,05). Em ambos os grupos, o HT permaneceu baixo por mais de 180 minutos e retornou aos valores basais em 24hBL. Deve-se considerar a ocorrência de uma redução significativa do HT em equinos hígidos anestesiados com XYL, ACP, cetamina, midazolam, EGG, isofluorano e efedrina

Estudo experimental para comparar a resposta inflamatória decorrente da distensão líquida ou gasosa em cavalos submetidos à artroscopia

PURPOSE: To assess comparatively the inflammatory response that follows CO2 or Ringer's lactate joint capsular distension of horses submitted to experimental arthroscopy METHODS: Each animal was submitted to a bilateral tarsocrural arthroscopy employing gas distention in one joint and fluid distention in the contralateral joint. Synovial fluid was evaluated at 0, six, 12, 24 and 48 hours post-operative. RESULTS: The use of CO2 for arthroscopy causes an acute and mild synovitis alike to the liquid capsular distension, showing similar synovial fluid increase of leukocytes, TP, and TNF-alpha. Although synovial fluid PGE(2) content was higher in joints submitted to CO2 distension, lower levels of hemoglobin and leukocytes oxidative burst after surgery indicates that CO2 arthroscopy decreased intra-articular bleeding and activation of infiltrating leukocytes. CONCLUSIONS: The use of CO2 for arthroscopic examination causes acute and mild synovitis that is similar to the effects caused by the liquid capsular distension. CO2 also seems to decrease intra-articular bleeding and activation of leukocytes.OBJETIVO: Avaliar comparativamente a resposta inflamatória decorrente da distensão líquida ou gasosa em cavalos submetidos ao exame artroscópico. \ud MÉTODOS: Cada animal foi submetido a uma artroscopia bilateral tarsocrural empregando uma distensão com gás em uma articulação e líquido na articulação contralateral. O líquido sinovial foi avaliado as zero, seis, 12, 24 e 48 horas do pós-operatório. \ud RESULTADOS: A utilização de CO2 para a artroscopia provoca uma sinovite aguda e leve tal como a distensão capsular por líquido, mostrando um aumento similar de leucócitos, TP (proteína total) e TNF-a. Embora no líquido sinovial a quantidade de PGE2 tenha sido maior nas articulações submetidas à distensão por CO2, níveis mais baixos de hemoglobina e explosão oxidativa de leucócitos após a cirurgia indica que a artroscopia com CO2 diminuiu o sangramento intra-articular e ativação de leucócitos. \ud CONCLUSÕES: A utilização de CO2 para exame artroscópico provoca uma sinovite aguda e leve que são semelhantes aos efeitos causados pela distensão capsular por líquido. O CO2 também parece diminuir o sangramento intra-articular e a ativação de leucócitos.FAPESP (Sao Paulo Research Foundation) [04/14930-0

Relação entre a infecção por SARS-CoV-2 e a ocorrência de eventos tromboembólicos / Relation between SARS-CoV-2 infection and the occurrence of thromboembolic events

A COVID-19, doença sistêmica responsável pela pandemia catastrófica iniciada em 2019, cursa com um estado de hipercoagulabilidade que justifica a ocorrência de inúmeras complicações tromboembólicas associadas ao quadro. O objetivo do presente trabalho consiste em promover uma revisão de literatura acerca da relação entre os eventos tromboembólicos e a COVID-19 e de seu impacto sobre a mortalidade da doença. Embora a hospitalização e, principalmente, a internação em UTI sejam, por si só, fatores de maior risco para tromboembolismo, observa-se que os processos de trombogênese nesses pacientes tendem a ser mais prevalentes diante da infecção por Sars-CoV-2, sobretudo devido à tempestade de citocinas promovida pelo vírus, com destaque para a liberação de interleucina 6, fator de necrose tumoral e quimiocinas, os quais favorecem a ativação da cascata de coagulação com estado de hipercoagulabilidade. O tromboembolismo venoso (TEV) é, indiscutivelmente, o evento tromboembólico mais prevalente em pacientes com COVID-19, conquanto complicações tromboembólicas arteriais, como síndrome coronariana aguda e acidente vascular isquêmico, também foram descritas com certa importância. Assim, todos os pacientes hospitalizados com COVID-19 devem receber profilaxia antitrombótica, salvo contraindicações, e as complicações tromboembólicas, quando diagnosticadas, devem ser adequadamente manejadas com tratamento específico

Characterization of mesenchymal stem cells derived from the equine synovial fluid and membrane

Abstract\ud \ud Background\ud Isolation of mesenchymal stem cells (MSCs) in equines, has been reported for different tissues including bone marrow, adipose, umbilical cord, peripheral blood, and yolk sac. In regard to the MSCs derived from synovial fluid (SF) or membrane (SM), there is data available for humans, dogs, pigs, goats and horses. Especially in equines, these cells have being considered promising candidates for articular regeneration. Herein, we established and characterized MSCs obtained from equine SF and SM. Samples were obtained during arthroscopy and cultured using MEM (Minimum Essential Medium). MSCs were characterized by morphology and expression of specific markers for stem cells, pluripotency, inflammation, and cell cycle.\ud \ud \ud Results\ud The medium MEM was more effective (97 % ± 2) to maintain both cultures. The cultures were composed by adherent cells with fibroblast-like shape, which had a growth pattern represented by a sigmoidal curve. After the expansion, the cells were analyzed by flow cytometry for stem cells, inflammatory, and cell cycle markers, and both lineages showed significant expression of CD45, Oct3/4, Nanog, CD105, CD90, CD34, CD117, CD133, TRA-1-81, VEGF, and LY6a. In contrast, there were differences in the cell cycle phases between the lineages, which was not observed in relation to the mitochondrial electrical potential.\ud \ud \ud Conclusion\ud Given the large impact that joint pathology has on the athletic performance horses, our results suggested that the SF and SM are promising sources of stem cells with satisfactory characteristics of growth and gene expression that can be used in equine regenerative medicine.This research was supported by grants from CNPq, FAPESP and NETCEM.\ud The funders had no role in the study design, data collection, analysis and\ud interpretation of data, preparation of the manuscript, and decision to\ud publish. We warmly thank the Veterinary Hospital of the School of Veterinary\ud Medicine and Animal Science at USP to provide the biological samples