Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. noninvasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19

Health-related quality of life in patients with type 1 diabetes mellitus in the different geographical regions of Brazil : data from the Brazilian Type 1 Diabetes Study Group

Background: In type 1 diabetes mellitus (T1DM) management, enhancing health-related quality of life (HRQoL) is as important as good metabolic control and prevention of secondary complications. This study aims to evaluate possible regional differences in HRQoL, demographic features and clinical characteristics of patients with T1DM in Brazil, a country of continental proportions, as well as investigate which variables could influence the HRQoL of these individuals and contribute to these regional disparities. Methods: This was a retrospective, cross-sectional, multicenter study performed by the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG), by analyzing EuroQol scores from 3005 participants with T1DM, in 28 public clinics, among all geographical regions of Brazil. Data on demography, economic status, chronic complications, glycemic control and lipid profile were also collected. Results: We have found that the North-Northeast region presents a higher index in the assessment of the overall health status (EQ-VAS) compared to the Southeast (74.6 ± 30 and 70.4 ± 19, respectively; p < 0.05). In addition, North- Northeast presented a lower frequency of self-reported anxiety-depression compared to all regions of the country (North-Northeast: 1.53 ± 0.6; Southeast: 1.65 ± 0.7; South: 1.72 ± 0.7; Midwest: 1.67 ± 0.7; p < 0.05). These findings could not be entirely explained by the HbA1c levels or the other variables examined. Conclusions: Our study points to the existence of additional factors not yet evaluated that could be determinant in the HRQoL of people with T1DM and contribute to these regional disparities

Panoramic snapshot of serum soluble mediator interplay in pregnant women with convalescent COVID-19: an exploratory study

IntroductionSARS-CoV-2 infection during pregnancy can induce changes in the maternal immune response, with effects on pregnancy outcome and offspring. This is a cross-sectional observational study designed to characterize the immunological status of pregnant women with convalescent COVID-19 at distinct pregnancy trimesters. The study focused on providing a clear snapshot of the interplay among serum soluble mediators.MethodsA sample of 141 pregnant women from all prenatal periods (1st, 2nd and 3rd trimesters) comprised patients with convalescent SARS-CoV-2 infection at 3-20 weeks after symptoms onset (COVID, n=89) and a control group of pre-pandemic non-infected pregnant women (HC, n=52). Chemokine, pro-inflammatory/regulatory cytokine and growth factor levels were quantified by a high-throughput microbeads array.ResultsIn the HC group, most serum soluble mediators progressively decreased towards the 2nd and 3rd trimesters of pregnancy, while higher chemokine, cytokine and growth factor levels were observed in the COVID patient group. Serum soluble mediator signatures and heatmap analysis pointed out that the major increase observed in the COVID group related to pro-inflammatory cytokines (IL-6, TNF-α, IL-12, IFN-γ and IL-17). A larger set of biomarkers displayed an increased COVID/HC ratio towards the 2nd (3x increase) and the 3rd (3x to 15x increase) trimesters. Integrative network analysis demonstrated that HC pregnancy evolves with decreasing connectivity between pairs of serum soluble mediators towards the 3rd trimester. Although the COVID group exhibited a similar profile, the number of connections was remarkably lower throughout the pregnancy. Meanwhile, IL-1Ra, IL-10 and GM-CSF presented a preserved number of correlations (≥5 strong correlations in HC and COVID), IL-17, FGF-basic and VEGF lost connectivity throughout the pregnancy. IL-6 and CXCL8 were included in a set of acquired attributes, named COVID-selective (≥5 strong correlations in COVID and &lt;5 in HC) observed at the 3rd pregnancy trimester.Discussion and conclusionFrom an overall perspective, a pronounced increase in serum levels of soluble mediators with decreased network interplay between them demonstrated an imbalanced immune response in convalescent COVID-19 infection during pregnancy that may contribute to the management of, or indeed recovery from, late complications in the post-symptomatic phase of the SARS-CoV-2 infection in pregnant women

Influence of a weaning protocol with the systematic use of the noninvasive ventilation in the length of the mechanical ventilation

I NTRODUÇÃO: O tempo de ventilação mecânica e a necessidade de reintubação foram associados na literatura com um aumento da mortalidade nesse pacientes. Protocolo de desmame foi sugerido para diminuir os dias de ventilação mecânica invasiva e os riscos inerentes a esta. No mesmo período o uso da ventilação não invasiva (VNI) foi proposto em estudos como parte do processo de desmame. Resultados positivos foram observados com esta intervenção em pacientes selecionados. Entretanto, o mesmo não foi observado quando esta era utilizada como tratamento de falência respiratória pós extubação. OBJETIVO: Avaliar a eficácia do protocolo de desmame elaborado o qual incluiu o uso da VNI imediatamente após a extubação em pacientes selecionados. MÉTODOS: Foi realizado um estudo prospectivo com controle histórico em pacientes adultos. Dados consecutivos de pacientes ventilados por um período ³ 48 horas que respeitassem os critérios de inclusão e exclusão do estudo foram coletados. O local do estudo foi uma UTI Médico/Cirúrgica com 22 leitos em um hospital terciário. RESULTADOS: Comparando os pacientes pré- protocolo (74) com os pós- protocolos (74) foi observado que os pacientes eram similares em suas características basais. No grupo protocolo foi evidenciada nos pacientes uma redução nos dias de suporte ventilatório invasivo (7[4; 11,3] vs. 6[4; 9], p=0.04) e uma probabilidade de se manter intubado nos dias de internação na UTI menor nesses pacientes (p=0.02). A taxa de reintubação, em 72 horas após a extubação, se manteve similar entre os grupos. A taxa de mortalidade foi menor (24,3% vs. 10,8, p=0,03) e a sobrevida foi maior no tempo de internação na UTI em dias (p=0,05). O modelo de regressão de Cox, ajustado para a gravidade na admissão da UTI, demonstrou uma relação do protocolo com a sobrevida (RR: 2,77; 95% intervalo de confiança, 1,14- 6,65; p=0,03) e a taxa de reintubação com a mortalidade dos pacientes (RR: 0,27; 95% intervalo de confiança, 0, 11- 0,65; p=0,01). CONCLUSÃO: O protocolo elaborado, o qual incluía o uso da VNI imediatamente após a extubação em pacientes selecionados, reduziu o tempo de suporte ventilatório sem aumentar a taxa de reintubação. O protocolo foi relacionado com a sobrevivência dos pacientes na UTI, sendo que o efeito oposto foi observado com a reintubação.CONTEXT: The length of mechanical ventilation and the need for reintubation were associated on the literature with a mortality increased in these patients. Weaning protocol was a recommendation to reduce the length of invasive ventilation and the risk associated with those. At the same time noninvasive ventilation (NPPV) proposed by studies as part of the weaning technique. Positive results were observes with these interventions in selected patients. However, it was not observes when NPPV was used to treat respiratory failure after extubation. AIM: Evaluate the efficacy of the weaning protocol that was developing with the use of NPPV immediately after extubation in selected patients. DESIGN, SETTINGS AND SUBJECTS: A before- after study was realized with adults patients. Data of consecutive patients mechanically ventilated for ³ 48 hours that respected the inclusion and exclusion criteria was collect. The local of the study was a medical/surgical ICU with 22 beds in a tertiary hospital. RESULTS: Comparing the pre protocol patients (74) with the post protocol patients (74) was observe in both phases the patients had similar baseline characteristics. On the protocol group was observe a reduction on the intubated days of the patients (7[4; 11, 3] vs. 6[4; 9], p=0.04) and a lower probability on these phase to maintained intubated on the length on ICU in days (p=0.02). The reintubation rate was similar on 72 hours after extubation on the groups. The mortality rate was lower (24,3% vs. 10,8, p=0,03) and the survivor was higher on the length on ICU in days (p=0,05). In a Cox model, adjusting on severity at ICU admission, the protocol was relation with the survivor on ICU (RR: 2,77; 95% confidence interval, 1,14- 6,65; p=0,03) and the reintubation rate with the no survivor patients(RR: 0,27; 95% confidence interval, 0, 11- 0,65; p=0,01). CONCLUSION: A weaning protocol, which includes NPPV immediately after extubation for selected patients, reduces the length of invasive ventilation support time without increasing the risk of weaning failure. The protocol was relation with the survivor on ICU and reintubation rate with no survivor

Influence of a weaning protocol with the systematic use of the noninvasive ventilation in the length of the mechanical ventilation

I NTRODUÇÃO: O tempo de ventilação mecânica e a necessidade de reintubação foram associados na literatura com um aumento da mortalidade nesse pacientes. Protocolo de desmame foi sugerido para diminuir os dias de ventilação mecânica invasiva e os riscos inerentes a esta. No mesmo período o uso da ventilação não invasiva (VNI) foi proposto em estudos como parte do processo de desmame. Resultados positivos foram observados com esta intervenção em pacientes selecionados. Entretanto, o mesmo não foi observado quando esta era utilizada como tratamento de falência respiratória pós extubação. OBJETIVO: Avaliar a eficácia do protocolo de desmame elaborado o qual incluiu o uso da VNI imediatamente após a extubação em pacientes selecionados. MÉTODOS: Foi realizado um estudo prospectivo com controle histórico em pacientes adultos. Dados consecutivos de pacientes ventilados por um período ³ 48 horas que respeitassem os critérios de inclusão e exclusão do estudo foram coletados. O local do estudo foi uma UTI Médico/Cirúrgica com 22 leitos em um hospital terciário. RESULTADOS: Comparando os pacientes pré- protocolo (74) com os pós- protocolos (74) foi observado que os pacientes eram similares em suas características basais. No grupo protocolo foi evidenciada nos pacientes uma redução nos dias de suporte ventilatório invasivo (7[4; 11,3] vs. 6[4; 9], p=0.04) e uma probabilidade de se manter intubado nos dias de internação na UTI menor nesses pacientes (p=0.02). A taxa de reintubação, em 72 horas após a extubação, se manteve similar entre os grupos. A taxa de mortalidade foi menor (24,3% vs. 10,8, p=0,03) e a sobrevida foi maior no tempo de internação na UTI em dias (p=0,05). O modelo de regressão de Cox, ajustado para a gravidade na admissão da UTI, demonstrou uma relação do protocolo com a sobrevida (RR: 2,77; 95% intervalo de confiança, 1,14- 6,65; p=0,03) e a taxa de reintubação com a mortalidade dos pacientes (RR: 0,27; 95% intervalo de confiança, 0, 11- 0,65; p=0,01). CONCLUSÃO: O protocolo elaborado, o qual incluía o uso da VNI imediatamente após a extubação em pacientes selecionados, reduziu o tempo de suporte ventilatório sem aumentar a taxa de reintubação. O protocolo foi relacionado com a sobrevivência dos pacientes na UTI, sendo que o efeito oposto foi observado com a reintubação.CONTEXT: The length of mechanical ventilation and the need for reintubation were associated on the literature with a mortality increased in these patients. Weaning protocol was a recommendation to reduce the length of invasive ventilation and the risk associated with those. At the same time noninvasive ventilation (NPPV) proposed by studies as part of the weaning technique. Positive results were observes with these interventions in selected patients. However, it was not observes when NPPV was used to treat respiratory failure after extubation. AIM: Evaluate the efficacy of the weaning protocol that was developing with the use of NPPV immediately after extubation in selected patients. DESIGN, SETTINGS AND SUBJECTS: A before- after study was realized with adults patients. Data of consecutive patients mechanically ventilated for ³ 48 hours that respected the inclusion and exclusion criteria was collect. The local of the study was a medical/surgical ICU with 22 beds in a tertiary hospital. RESULTS: Comparing the pre protocol patients (74) with the post protocol patients (74) was observe in both phases the patients had similar baseline characteristics. On the protocol group was observe a reduction on the intubated days of the patients (7[4; 11, 3] vs. 6[4; 9], p=0.04) and a lower probability on these phase to maintained intubated on the length on ICU in days (p=0.02). The reintubation rate was similar on 72 hours after extubation on the groups. The mortality rate was lower (24,3% vs. 10,8, p=0,03) and the survivor was higher on the length on ICU in days (p=0,05). In a Cox model, adjusting on severity at ICU admission, the protocol was relation with the survivor on ICU (RR: 2,77; 95% confidence interval, 1,14- 6,65; p=0,03) and the reintubation rate with the no survivor patients(RR: 0,27; 95% confidence interval, 0, 11- 0,65; p=0,01). CONCLUSION: A weaning protocol, which includes NPPV immediately after extubation for selected patients, reduces the length of invasive ventilation support time without increasing the risk of weaning failure. The protocol was relation with the survivor on ICU and reintubation rate with no survivor

Toll-like receptor 1 N248S single-nucleotide polymorphism is associated with leprosy risk and regulates immune activation during mycobacterial infection

Conflicting findings about the association between leprosy and TLR1 variants N248S and I602S have been reported. Here, we performed case-control and family based studies, followed by replication in 2 case-control populations from Brazil, involving 3162 individuals. Results indicated an association between TLR1 248S and leprosy in the case-control study (SS genotype odds ratio [OR], 1.81; P = .004) and the family based study (z = 2.02; P = .05). This association was consistently replicated in other populations (combined OR, 1.51; P < .001), corroborating the finding that 248S is a susceptibility factor for leprosy. Additionally, we demonstrated that peripheral blood mononuclear cells (PBMCs) carrying 248S produce a lower tumor necrosis factor/interleukin-10 ratio when stimulated with Mycobacterium leprae but not with lipopolysaccharide or PAM3cysK4. The same effect was observed after infection of PBMCs with the Moreau strain of bacillus Calmette-Guerin but not after infection with other strains. Finally, molecular dynamics simulations indicated that the Toll-like receptor 1 structure containing 248S amino acid is different from the structure containing 248N. Our results suggest that TLR1 248S is associated with an increased risk for leprosy, consistent with its hypoimmune regulatory function.Fundação Oswaldo Cruz/Programa Estratégico de Apoio à Pesquisa em SaúdeFundação Oswaldo Cruz/Programa Estratégico de Apoio à Pesquisa em SaúdeInstituto Oswaldo Cruz/FIOCRUZ (internal funds)Instituto Oswaldo Cruz/FIOCRUZ (internal funds)Fundação de Amparo a Pesquisa do Estado do Rio de JaneiroFundacao do Amparo a Pesquisa do Estado do Rio de JaneiroFundacao de Amparo a Pesquisa do Estado de Sao PauloFundação de Amparo a Pesquisa do Estado de São PauloConselho Nacional de Pesquisa e Desenvolvimento TecnológicoConselho Nacional de Pesquisa e Desenvolvimento Tecnológic

TNF-308G > A Single Nucleotide Polymorphism Is Associated With Leprosy Among Brazilians: A Genetic Epidemiology Assessment, Meta-Analysis, and Functional Study

Leprosy is an infectious disease caused by Mycobacterium leprae. Tumor necrosis factor (TNF) plays a key role in the host response. Some association studies have implicated the single nucleotide polymorphism TNF -308G > A in leprosy susceptibility, but these results are still controversial. We first conducted 4 association studies (2639 individuals) that showed a protective effect of the -308A allele (odds ratio [OR] = 0.77; P = .005). Next, results of a meta-analysis reinforced this association after inclusion of our new data (OR = 0.74; P = .04). Furthermore, a subgroup analysis including only Brazilian studies suggested that the association is specific to this population (OR = 0.63; P = .005). Finally, functional analyses using whole blood cultures showed that patients carrying the -308A allele produced higher TNF levels after lipopolysaccharide (LPS) (6 hours) and M. leprae (3 hours) stimulation. These results reinforce the association between TNF and leprosy and suggest the -308A allele as a marker of disease resistance, especially among Brazilians.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Repensar las fronteras, la integración regional y el territorio

Parte del acercamiento decolonial, de esta obra colectiva, se refleja tanto en tratar temas “viejos” y “tradicionales” con nuevas miradas, por ejemplo, desde la integración regional, relaciones transfronterizas, Estado, territorio, y abordar tópicos “emergentes” que no han recibido mucha atención de los centros de investigación.Part of the decolonial approach, of this collective work, is reflected both in treating "old" and "traditional" issues with new perspectives, for example, from regional integration, cross-border relations, State, territory, and addressing "emerging" topics that do not they have received a lot of attention from research centers.CLACSOUniversidad Nacional, Costa RicaIDESPOEscuela de Relaciones Internacionale