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Mês: agosto 2020

When Viruses Collide: Flu Season During Pandemic

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The medical community is about to find out how prepared it is for the double whammy of influenza and COVID-19 that has been predicted for the fall of 2020. The complexities of diagnosis, management of vulnerable patients, and overflowing medical centers that have made the COVID-19 crisis so brutal may all be exacerbated by the arrival of seasonal influenza.

Lewis Jay Kaplan, MD, FCCP, a critical care surgeon at the University of Pennsylvania, Philadelphia, has seen his share of critically ill COVID-19 patients in the surgical ICU that he oversees. He’s approaching the upcoming flu season, poised to collide with the ongoing COVID-19 pandemic, ready to listen to each patient’s story to distinguish one from the other and determine treatment.

“The patients that have underlying comorbidities all have a story, and it’s up to you to figure out which chapter you’re in and how far along you happen to be,” he said. “It’s a very interesting approach to care, medical storytelling.”

With flu season closing in, pulmonologists are ruminating about how they’ll distinguish symptoms of COVID-19 and traditional influenza and how they’ll manage the most vulnerable patients, namely those with underlying respiratory disease and children. Influenza kills 12,000-61,000 people a year, according to the Centers for Disease Control, and results in 140,000-810,00 hospitalizations. Having a flu season in the midst of a pandemic of a disease with multiple overlapping symptoms threatens to overwhelm practitioners, hospitals, and the health system.

Dr. Kaplan said each patient’s story can point to the correct clinical approach. “Instead of just sharing data when you are on rounds, you’re really telling someone’s story.” It arises from a series of questions about how the disease has impacted them, specifics of their presentation, how their signs and symptoms differ from the usual, and how they responded to treatment. “It also helps you to then take what you’re doing, which can seem very, very complicated to individuals who are not medically sophisticated, and then help them to understand why you’re doing what you’re doing at this point.”

That can help get through to a patient with respiratory disease who insists he or she has or doesn’t have COVID-19 rather than the flu. “They form a different group that brings with them different fears and concerns, and you have to help them navigate that, too: all of this data and your decision-making around testing and admissions, and what you can omit doing and what you must do help them to navigate their own story,” Dr. Kaplan said.

Benjamin D. Singer, MD, a pulmonologist at Northwestern University, Chicago, authored an editorial in Science Advances that addressed four factors that will determine the scope of flu spread in the upcoming season: rate of transmission; vaccination rates; coinfection rates; and health disparities in minority populations, which are prone to higher rates of flu as well as COVID-19.

Flu Vaccine “Extra Important”

The convergence of COVID-19 and influenza has the potential to overwhelm the health system, said Daniel A. Solomon, MD, of Brigham and Women’s in Boston. He coauthored a JAMA Insights clinical update on flu season during the COVID-19 pandemic that lists distinguishing and overlapping signs and symptoms of the two diseases.

The flu vaccine, he said, is “extra important this year,” especially in patients with existing respiratory disease, but COVID-19 has thrown up barriers to vaccination. Telemedicine has supplanted office visits. “People may miss that easy-touch opportunity to get the flu vaccine, so we have to be creative about making the flu vaccine highly accessible, maybe in nontraditional ways,” Dr. Solomon said. Some ideas he offered are pop-up vaccine fairs at schools and churches.

But just as COVID-19 may hinder flu vaccines, it may also be helping to mitigate flu transmission. “The interesting thing about transmission of the flu is that it’s transmitted the same way COVID is, so if we actually know how to decrease transmission of COVID, which we do – we’ve done it – we can actually decrease transmission of influenza as well,” Dr. Solomon said. Studies out of Hong Kong and Japan have reported a reduction in influenza cases during COVID-19 outbreaks in those places (Lancet Public Health. 2020;5:e279-88JAMA. 2020;323:1969-71).

Risks of Coinfection

About one in four COVID-19 patients have been diagnosed with an additional respiratory infection, including influenza (JAMA. 2020:323:2085-6). Pulmonologists must keep that in mind when managing COVID-19 suspects, said Dr. Singer.

“While it is true that most of the time COVID-19 travels alone, we have numerous examples in the literature and in our own experience that COVID-19 is accompanied by either another virus or another bacterial infection, including influenza,” Dr. Singer said. “The distinction is important. One is just for diagnostic reasons and public reporting reasons, but also because flu and COVID-19 have different requirements for how you care for patients in terms of the health system.”

Clinical suspicion for coinfection should remain high if the community spread of both COVID-19 and influenza is high, said Megan Conroy, MD, chief pulmonary and critical care fellow at Ohio State University, Columbus. “As the coronavirus first took hold in the United States in March 2020, we were at the tail end of influenza season, so it’s hard to predict what the upcoming influenza season will really look like with regards to coinfection.”

Distinguishing COVID-19 From Flu

Multiple signs and symptoms between COVID-19 and the flu overlap. They include fever, chills, headache, myalgia, cough, and fatigue. Nasal congestion and sore throat are characteristic of the flu; shortness of breath and loss of the sense of smell have been widely reported in COVID-19. “While many upper respiratory infections can result in loss of smell, this may be more prevalent in COVID-19,” Dr. Conroy said. Other symptoms unique to COVID-19 are GI symptoms such as diarrhea and skin rashes such as acral ischemia.

Testing, however, is the cornerstone of the differential diagnosis. “You can’t confidently distinguish between them on symptoms alone,” Dr. Conroy added.

“I think the challenge we’ll face as clinicians, is caring for people with nonspecific symptoms of a respiratory viral illness, especially in the early phase of the illness,” said Dr. Solomon.

But even after that, symptoms can be difficult to distinguish.

“Later in the illness, COVID is more associated with a hypercoagulable state,” he said. “It is more associated with viral pneumonia on chest imaging, like the diffuse ground-glass infiltrates that we’ve all gotten used to seeing – but flu can do both of those things as well. So, without a test, it’s impossible to distinguish between the two infections in the clinic.”

But testing can have its shortcomings when flu season clashes with the COVID-19 pandemic. “Getting the test is not the same as getting the test results,” Dr. Solomon added. “Though a lot of people can get a test, if it takes 7 or 8 days to get the test result back, the result is useless.”

Widespread, rapid testing also depends on having adequate supplies of viral media transport and swabs. “I think that this is what we should be focusing on now: scaling up access to rapid turnaround testing,” he said. Distinguishing between the two is also important to preserve hospital resources. COVID-19 has more rigorous standards than flu for personal protective equipment and isolation of patients within the hospital.

Having chronic lung disease isn’t necessarily a risk factor for contracting COVID-19 or the flu, or both, Dr. Solomon said. “It’s a risk factor for having severe disease.” Again, he noted that flu vaccines are still necessary in these patients, as well as patients of advanced age and underlying medical conditions such as heart disease, diabetes, and obesity.

In managing children, it’s important to keep in mind that they communicate differently about their illnesses than adults, said Dr. Kaplan. “They may not have the words to tell you the same kind of thing that the adult tells you.” That’s where family members can help to flesh out the history. “They may present with an initially much milder form, if you will, where they’re not as critical up front, but then that small proportion of them comes back with the multi-inflammatory syndrome and then they are profoundly ill.”

Younger people make up a larger share of COVID-19 patients now, compared with the initial wave that hit the Northeast in the spring, Dr. Kaplan said. “We don’t know if that’s because the virus is a little different or the people that are getting sick are a little bit different.”

The COVID-19 strain now emerging may be less virulent than the strain that hit in early spring, he said. “That doesn’t mean that there aren’t still profoundly critical ill people with COVID of many different age ranges, that is true, but there are a lot of people that we now see will test positive, but aren’t really as profoundly ill as when it first landed here in the United States.”

That may be somewhat welcome as flu season arrives.

The physicians interviewed have no relevant disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

#Port du masque chez les enfants: les recommandations de l’OMS

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Zurich – Pour l’Organisation Mondiale de la Santé (OMS), les enfants de12 ans et plus doivent porter un masque, à l’instar des adultes, pour aider à enrayer l’épidémie de Covid-19, alors que le port chez les 6/11 ans va dépendre du niveau de risque.

Les 12 ans et plus doivent spécifiquement porter un masque quand une distanciation de 1 mètre n’est pas assurée et que le risque de transmission du virus est présent, a affirmé l’OMS et l’UNICEF (United Nations Children’s Fund) dans un document commun daté du 21 août.

Le fait que les enfants entre 6 et 11 ans portent un masque dépend d’un certain nombre de facteurs, comme l’importance du risque de transmission, la capacité des enfants à utiliser un masque, la disponibilité des masques et la possibilité d’une supervision par un adulte pour assurer un port correct, ont affirmé les 2 organisations.

L’impact potentiel sur l’apprentissage et le développement psycho-social, de même que sur les interactions que peuvent avoir les enfants avec des personnes fortement susceptibles de développer une maladie grave, jouent aussi un rôle.

Les enfants de moins de 5 ans ne devraient pas se voir demander de porter un masque pour des raisons de sécurité et d’intérêt général de l’enfant, disent l’OMS et l’UNICEF.

Les études suggèrent que les enfants plus âgés jouent un rôle plus actif dans la transmission du nouveau coronavirus par rapport aux plus jeunes, disent les organisations, ajoutant que des données supplémentaires sont nécessaires pour mieux comprendre le rôle des enfants et des adolescents dans la transmission du virus, à l’origine du Covid-19.

Les premières recommandations de l’OMS concernant le port du masque pour entraver la propagation de l’épidémie datent du 5 juin, mais aucun conseil n’avait été émis jusqu’à présent concernant plus spécifiquement les enfants.

Plus de 23 millions de personnes ont été infectées par le coronavirus depuis son identification en Chine, et près de 800 000 en sont mortes, selon le décompte établi par Reuters.

Masques et rentrée scolaire

En France, pour la rentrée 2020, l’Éducation nationale a annoncé que le masque serait obligatoire pour les élèves de plus de 11 ans. Le port du masque est imposé pendant les cours, dans les lieux clos et extérieurs, et ce même si la distanciation d’un mètre est respectée. AL

L’article a été publiée initialement sur Medscape.com sous l’intitulé WHO Says Children Aged 12 and Over Should Wear Masks Like Adults. Traduit par Stéphanie Lavaud.

 

 

#A #anorexia nervosa pode retardar o crescimento em meninas adolescentes?

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Menina sofrendo com anorexia nervosa pode sofrer também de retardo no crescimento

Recente estudo realizado em Israel concluiu que enquanto a altura pré-mórbida de pacientes adolescentes do sexo feminino com anorexia nervosa (AN) é normal, o retardo do crescimento linear é uma característica proeminente da doença. O artigo A Prospective Longitudinal Assessment of Linear Growth and Adult Height in Female Adolescents with Anorexia Nervosa foi publicado no Journal of Clinical Endocrinology & Metabolism.

 

Características do estudo

Em estudo observacional prospectivo, foram analisados dados de 255 meninas adolescentes que foram hospitalizadas por AN. Das 225 meninas, 174 tinham diagnóstico de AN do tipo restritiva e 81 do tipo “binge-purge”. A idade média das pacientes era de 15,4 ± 1,75 anos. A altura das meninas foi aferida no momento da admissão hospitalar, no momento da alta e também na idade adulta. As participantes foram acompanhadas em ambulatório após a alta hospitalar com visitas quinzenais nos primeiros dois meses, visitas mensais nos quatro meses seguintes e a cada três meses até que completassem 18 anos de idade. A duração média da doença era de 2 anos.

O índice de massa corporal (IMC) médio das meninas no momento da admissão era de 15,7±1,8 kg/m². Já o alvo parental de altura foi baseado em uma média das alturas dos pais e subtraindo 6,5 cm. Os pesquisadores observaram que, embora o escore de desvio padrão da altura pré-mórbida na população do estudo fosse semelhante ao de adolescentes normais, as medições do escore na admissão hospitalar, alta e na idade adulta foram significativamente menores do que o esperado: -0,36, -0,34 e -0,29, respectivamente. O principal resultado da altura adulta foi significativamente menor do que o esperado (p = 0,006). Embora as alturas dos pacientes tenham aumentado significativamente durante a hospitalização, de 158 cm para 159 cm (p < 0,001), a mudança nos escores de desvio padrão não foi significativa e esse escore na alta permaneceu significativamente menor quando comparado a uma população normal.

Os preditores independentes de melhora da altura desde a admissão hospitalar até a idade adulta foram:

  • A idade do paciente (mais velha) e a idade óssea (mais jovem) no momento da admissão hospitalar;
  • O crescimento linear e a mudança no hormônio luteinizante (LH) durante a hospitalização.

 

Limitações

O estudo possui limitações: foi utilizada uma população de estudo de pacientes internados, o que pode restringir a generalização para pacientes com doença menos grave, além de haver dados incompletos sobre os níveis de LH (indetectáveis em 49 pacientes – 19% da amostra).

 

Resultados

A AN é um transtorno psiquiátrico grave, com prevalência de 1,7% a 3,6%. Como ocorre principalmente em adolescentes, pode ter um efeito deletério no crescimento e na altura adulta. Os pesquisadores destacaram que os resultados desse estudo suportam a necessidade de intervenção precoce em pacientes com anorexia nervosa e a necessidade de ganho ponderal em longo prazo para alcançar recuperação no crescimento. Além disso, esses resultados também podem ser aplicados no manejo da desnutrição em adolescentes com doenças crônicas como, por exemplo, doença inflamatória intestinal e fibrose cística, almejando o alcance da altura adulta ideal e de saúde óssea nessas populações vulneráveis.

Autor(a):

Roberta Esteves Vieira de Castro

Graduada em Medicina pela Faculdade de Medicina de Valença. Residência médica em Pediatria pelo Hospital Federal Cardoso Fontes. Residência médica em Medicina Intensiva Pediátrica pelo Hospital dos Servidores do Estado do Rio de Janeiro. Mestra em Saúde Materno-Infantil pela Universidade Federal Fluminense (Linha de Pesquisa: Saúde da Criança e do Adolescente). Doutora em Medicina pela Universidade do Estado do Rio de Janeiro (UERJ). Pós-graduanda em neurointensivismo pelo Instituto D’Or de Pesquisa e Ensino (IDOR). Médica da Unidade de Terapia Intensiva Pediátrica (UTIP) do Hospital Universitário Pedro Ernesto (HUPE) da UERJ. Membro da Rede Brasileira de Pesquisa em Pediatria do IDOR no Rio de Janeiro. Acompanhou as UTI Pediátrica e Cardíaca do Hospital for Sick Children (Sick Kids) em Toronto, Canadá, supervisionada pelo Dr. Peter Cox. Membro da Sociedade Brasileira de Pediatria (SBP) e da Associação de Medicina Intensiva Brasileira (AMIB). Membro do comitê de sedação, analgesia e delirium da AMIB. Membro do comitê de filiação da American Delirium Society (ADS). Coordenadora e cofundadora do Latin American Delirium Special Interest Group (LADIG). Membro de apoio da Society for Pediatric Sedation (SPS).

Referências bibliográficas:

  • Modan-Moses D, Yaroslavsky A, Pinhas-Hamiel O, et al. A Prospective Longitudinal Assessment of Linear Growth and Adult Height in Female Adolescents with Anorexia Nervosa [published online ahead of print, 2020 Aug 20]. J Clin Endocrinol Metab. 2020;dgaa510. doi:10.1210/clinem/dgaa510

#Infecção prévia por #zika pode estar relacionado ao risco de #dengue grave?

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mosquito aedes aegytpi pousado em dedo de pessoa, causador da dengue e zika

dengue e a zika são doenças causadas por flavivírus, que são transmitidos pelo mesmo mosquito, o Aedes Aegypti, e possuem capacidades epidêmicas. O vírus da zika (ZIKV) trouxe diversas consequências graves quando se espalhou pelo Pacífico e pelas Américas de 2013 a 2017, como a microcefalia congênita e a síndrome de Guillain-Barré em adultos.

A relação entre os sorotipos do vírus da dengue (DENV 1 a 4) e o vírus da zika ainda é incerta. Porém, estudos de coorte prospectivos concluíram que a infecção prévia da dengue foi protetora contra o zika não complicado e associada a respostas de células T mais fortes em pessoas com ZIKV.

Para entender a relação inversa, um novo estudo foi realizado na Nicarágua, país que sofreu epidemias sequenciais de dengue dos tipos 1 a 3 (2004-2015), depois zika (2016-2017) e depois dengue do tipo 2 (2018-2020). Os resultados foram publicados na Science hoje, dia 28.

 

Zika vírus e dengue

Os pesquisadores avaliaram coortes prospectivas pediátricas da Nicarágua. Todas as crianças com suspeita de dengue, doença febril e, depois de 2016, com erupção cutânea afebril foram testados para DENV, ZIKV e CHIKV por RT-PCR e por sorologia.

A partir de 2004, os participantes forneceram amostras anuais de soro e/ou plasma que foram testados para anticorpos específicos de DENV por ELISA (n = 8.399 crianças, 57.963 amostras testadas). Desde 2016, as amostras também eram testadas para zika usando o ZIKV ELISA e os ensaios de bloqueio de ligação ZIKV NS1 (n = 14.159 e 14.247 medições, respectivamente).

Durante a epidemia de DENV2, entre 2019 e 2020, os pesquisadores estimaram a probabilidade dos pacientes da coorte desenvolverem uma infecção sintomática pela dengue com base nas histórias de infecção. Foram usados modelos lineares generalizados log-binomial (GLMs) ajustados para idade e sexo.

Resultados

  • Ao todo, 8,8% dos participantes da coorte tiveram dengue (n = 302 casos que atendem à definição de caso de dengue, de n = 3434 participantes da coorte com históricos completos de infecção);
  • As crianças com uma infecção anterior por ZIKV tiveram uma probabilidade de 12,1% de ter uma infecção sintomática por DENV2  (IC 9,9 a 14,5%);
  • Apenas 3,5% (IC 2,4 a 4,6%) das crianças que não tinham tido nenhuma infecção tiveram probabilidade de DENV2;
  • 9,2% (IC 4,6 a 14,5%) de crianças com uma infecção prévia por dengue tinham chance de ser infectadas;
  • Crianças com duas infecções anteriores por DENV tiveram probabilidade de 2,5% (IC 0,0 a 9,0%);
  • Crianças com uma infecção prévia por dengue e outra por zika permaneceram com risco elevado, com 9,5% (IC 6,7 a 13,0%);
  • Para crianças com pelo menos duas infecções anteriores de DENV, a probabilidade de dengue foi baixa para aquelas com (2,9%, IC 0,7 a 6,2%) ou sem (0,0%, IC 0,0 a 0,0%) uma infecção subsequente por ZIKV.

 

A probabilidade de ter sinais de alerta ou dengue grave, segundo os critérios critérios da Organização Mundial da Saúde (OMS) de 2009 (n = 144) foi:

  • 5,4% para pessoas com uma infecção prévia de dengue (IC 2,0 a 9,6%),
  • 5,9% para aqueles com uma infecção prévia por zika (IC 4,3 a 7,7%);
  • 4,8% nas crianças que tinham tido infecção por dengue e por zika (IC 2,9 a 7,0%);
  • 0,7% para aquelas que não tinham tido nenhuma infecção por flavivírus (0,7%, IC 0,3 a 1,2%).

O risco de febre hemorrágica da dengue ou síndrome do choque da dengue, de acordo com os critérios da OMS de 1997 (n = 15) foi:

  • 1,1% para crianças com infecção prévia por zika (IC 0,3 para 1,8%);
  • 0,9% para uma infecção anterior de dengue e uma de zika (IC 0 a 3,3%);
  • 0% para crianças sem nenhuma infecção prévia.

Por outro lado, crianças que tiveram várias infecções por dengue tinham menos risco de dengue grave.

Outro estudo

Os pesquisadores também avaliaram as crianças que foram diagnosticadas no Hospital Nacional de Referência Pediátrica da Nicarágua. Desde 2005, o estudo acompanhou 5.832 crianças de seis meses a 14 anos de idade durante e após a apresentação ao hospital por suspeita de infecção por flavivírus.

Em 2018 e 2019, 388 crianças foram inscritas no estudo hospitalar, e todos os casos confirmados virologicamente foram causados ​​por DENV2 (n = 277).

Conclusões

Em conjunto, os estudos mostraram que uma infecção anterior por zika vírus aumenta o risco de desenvolver a dengue e também a doença grave, assim com uma infecção anterior de dengue. Além disso, uma pessoa que teve dengue seguida por zika também tem risco aumentado de gravidade, ao contrário de uma pessoa que já teve infecções sequenciais por DENV.

Os resultados encontrados demonstram também um desafio para o desenvolvimento de vacinas contra dengue e zika.

*Esse artigo foi revisado pela equipe médica da PEBMED

Referência bibliográfica:

#Los #anticoagulantes podrían aumentar la supervivencia de pacientes con #coronavirus

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Un nuevo estudio estadounidense revela que estos fármacos que previenen la coagulación de la sangre reduciría en un 50% la mortalidad por coronavirus

Valentín Fuster en el CNIC.
Valentín Fuster, director del Centro Nacional de Investigaciones Cardiovasculares (CNIC) y del Instituto Mount Sinai Heart de Nueva York.

Los anticoagulantes pueden mejorar la supervivencia de los pacientes hospitalizados con Covid-19 porque previenen posibles infartos o ictus asociados al virus. Este es el principal resultado de un estudio publicado por The Journal of the American College of Cardiology (JACC) que, observando los resultados de las autopsias de 26 pacientes con COVID-19, encontraron que 11 de ellos (un 42%) tenían trombos (pulmonares, cerebrales y / o cardíacos).

El proyecto, dirigido por Valentín Fuster, director del Centro Nacional de Investigaciones Cardiovasculares (CNIC) y del Instituto Mount Sinai Heart de Nueva York, revela que los pacientes que reciben tanto una dosis terapéutica o completa, como una dosis profiláctica o más baja de anticoagulantes, tienen cerca de un 50% más de posibilidad de sobrevivir y, aproximadamente, un 30% menos de intubación que los que no toman anticoagulantes.

En el trabajo, los investigadores analizaron seis regímenes anticoagulantes diferentes. De todos ellos, la heparina de bajo peso molecular terapéutica y profiláctica y el apixaban terapéutico lograban los mejores resultados.

“Este estudio observacional proporciona nueva información sobre el papel de la anticoagulación en el manejo de pacientes ingresados con Covid-19 que confirmaremos con el estudio aleatorizado que hemos comenzado”, ha afirmado Fuster. Además, los datos han servido para diseñar un ensayo clínico aleatorizado internacional a gran escala, coordinado por este equipo que se centra en esos tres regímenes antitrombóticos: heparina oral y subcutánea, y apixaban.

Este trabajo es una extensión de la investigación publicada el pasado mes de mayo y en la que participaron 3.000 pacientes con Covid-19. El análisis descubrió que los enfermos ingresados respondieron mejor al tratamiento con anticoagulantes. La investigación se llevó a cabo ante el hecho de que muchos de los pacientes hospitalizados desarrollaron trombos sanguíneos potencialmente mortales.

La mortalidad se reduce en un un 50%

En el nuevo estudio, los científicos evaluaron el historial clínico de 4.389 pacientes con coronavirus ingresados en cinco diferentes hospitales entre el 1 de marzo y el 30 de abril de 2020. En concreto, analizaron y compararon las tasas de supervivencia y mortalidad de los pacientes que recibieron dosis de anticoagulantes y aquellos que, en cambio, no tuvieron este tratamiento. Para estimar el riesgo de muerte se contemplaron otros aspectos como la edad, el origen étnico o las enfermedades previas.

De los individuos analizados, 900 (20,5%) recibieron una dosis de tratamiento completo de anticoagulantes; 1.959 (44,6%) una dosis más baja de estos, y 1.530 (34,5 %) no tomaron estos fármacos. Los datos mostraron una fuerte asociación entre los anticoagulantes y la reducción de la probabilidad de muerte intrahospitalaria: las dosis terapéuticas y profilácticas de anticoagulantes redujeron la mortalidad en aproximadamente un 50% en comparación con los pacientes sin anticoagulantes.

En general, 467 pacientes (10,6%) requirieron intubación y ventilación mecánica durante su hospitalización. Los que tomaban anticoagulantes terapéuticos tenían un 31% menos de intubaciones que los que no recibían estos fármacos, mientras que los que fueron tratados con anticoagulantes profilácticos tenían un 28% menos de probabilidad de ser intubados. Por tanto, la diferencia entre los dos grupos de anticoagulantes no fue estadísticamente significativa.

Respecto a los posibles efectos secundarios de estos fármacos, los investigadores comprobaron que las tasas de hemorragia, una complicación de los anticoagulantes, se situaban en torno al 3% de media, un dato muy bajo. Eso sí, el porcentaje de hemorragias fue ligeramente superior en el grupo terapéutico que en los grupos profilácticos y sin anticoagulantes. Por esta razón, es importante que los médicos evalúen cada caso para evaluar la relación beneficio-riesgo.

 

#Cáncer de colon: ¿qué ha pasado con los programas de cribado?

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Debido a la pandemia, estas iniciativas, que algunas cuentan con la farmacia, se vieron suspendidas en marzo. Hoy, algunas han comenzado a reanudarse.

Kit para detección precoz del cáncer de colon y recto.
Kit para detección precoz del cáncer de colon y recto.

Los programas de detección precoz de cáncer colon y recto puestos en marcha en las distintas comunidades autónomas tienen como objetivo disminuir la incidencia y mortalidad de esta enfermedad a través de la  detección y tratamiento de lesiones premalignas y malignas en personas de entre 50 y 69 años, mediante un análisis de heces y una posterior prueba de confirmación si procede.

En algunos de ellos, como el de Cataluña, Islas Baleares, Murcia y Ceuta, las farmacias comunitarias participan de forma activa, bien siendo puntos de información y entrega de los kits necesarios para que el usuario recoja la muestra y en otras, además, se encargan de su recepción y envío a los hospitales de referencia.

Con la pandemia por la Covid-19 y la declaración del estado de alarma el pasado mes de marzo, estos programas se tuvieron que suspender para evitar futuros contagios y porque la Sanidad tenía que enfocar todos sus recursos a la atención a los pacientes con coronavirus.

¿Y ahora? ¿Ya se han retomado de nuevo? La realidad es que no todas las comunidades han procedido de la misma forma. Así, según ha confirmado el presidente del COF de CeutaMario de Miguel Zaragoza, en la Ciudad Autónoma todavía no se ha reanudado y, de momento, no les han transmitido una fecha concreta de cuándo lo harán.

En Murcia, en septiembre

En el caso de Murcia el programa volverá a estar activo a partir del 7 de septiembre, según han confirmado a CF desde la Consejería de Salud. En este caso, va dirigido a todas las personas de entre 50 y 69 años y asignadas a médicos de Atención Primaria pertenecientes a las zonas de salud del área I, VI y IX, aunque de forma progresiva se irán incorporando otras zonas y áreas de salud. Este colectivo reciben una invitación en la que se detalla los lugares, días y horas para recoger y entregar los equipos de cribado y en el reverso de la invitación se especifican las oficinas de farmacia colaboradoras a las que pueden acudir presentando la carta de invitación para retirar los equipos de cribado.

Se reanuda ya en Cataluña

En Cataluña, desde el COF de Barcelona informan a este medio de que el programa, suspendido por la pandemia, “ahora se está volviendo a poner en marcha de manera gradual, al menos en Barcelona”. Hay que recordar que este programa está concertado con CatSalut y cuenta con la participación de farmacias de Barcelona y Gerona (Lérida y Tarragona lo hacen a través del CAP). De hecho, la prueba piloto empezó en la ciudad de Barcelona en 2009, por lo que en 2019 cumplió ya diez años. En la experiencia catalana, los usuarios recogen el kit en las boticas de Barcelona y Gerona y a ellas se les devuelve las muestras para ser analizadas.

En Baleares, hasta octubre nada

En las Islas Baleares, la orden de Sanidad fue que “debido a la crisis sanitaria el programa seguirá interrumpido hasta, al menos, octubre“, cuando comenzará el envío masivo de cartas y a darse nuevas citas, según han confirmado desde el COF. A diferencia del de Cataluña, en la iniciativa balear, las farmacias solo proporcionan los kits y los pacientes dejan las muestras en el centro de salud, que se encargan de tramitarlas. “El programa sigue vigente y se iba ampliando a más áreas sanitarias de la comunidad, aunque muy progresivamente”, confirma el colegio. De hecho, empezó por los sectores Tramuntana (Hospital de Inca), Menorca, Eivissa y Formentera. “Con el tiempo se irán incorporando el resto de los sectores hasta alcanzar la totalidad de hombres y mujeres de 50 a 69 años de las Islas Baleares”, declara la Consejería de Salud.

 

#Scientists discover COVID-19 symptoms appear in a specific order

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Researchers from the University of Southern California (USC) have found what appears to be the likely order in which COVID-19 symptoms first appear.

nurse taking temperature of patient at home using PPE
Scientists may have identified a specific order for COVID-19 symptoms.

The study findings reveal individuals infected with COVID-19 will likely experience symptoms in the following order:

  1. fever
  2. coughing and muscle pain
  3. nausea, vomiting, or both
  4. diarrhea

The research appears in the journal Frontiers in Public Health. Doctoral candidate Joseph Larsen and his colleagues conducted the study in collaboration with faculty advisers Peter Kuhn and James Hicks, at the USC Michelson Center for Convergent Bioscience’s Convergent Science Institute in Cancer.

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had a catastrophic global impact.

According to current data from Johns Hopkins University, there are now more than 23.9 million confirmed cases of COVID-19 globally and more than 820,000 recorded deaths.

Individuals infected with COVID-19 are highly infectious, demonstrating a rate two to three times more contagious than influenza. Also, as outbreaks of COVID-19 occur in clusters, early identification of the disease may reduce their number and size. However, experts are unable to define the initial symptoms accurately.

Improving treatment strategy for COVID-19

The researchers note that an improved understanding of how COVID-19 symptoms appear helps patients promptly seek care or decide to self-isolate.

This information may also help medical professionals identify patients with the disease, rule out other illnesses, and design appropriate treatments more quickly.

“Given that there are now better approaches to treatments for COVID-19, identifying patients earlier could reduce hospitalization time,” says Prof. Larsen, the study’s lead author, and a USC Dornsife professor.

Timing and symptoms differ for COVID-19

Fever and coughing are frequently associated with an assortment of respiratory illnesses, including influenzaSevere Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS).

To determine the order that COVID-19 symptoms appear, the researchers evaluated the rates of symptom incidence of 55,924 confirmed coronavirus cases in China. The World Health Organization (WHO) collected these cases between February 16 and February 24, 2020.

The researchers expanded their analysis with data from 1,099 cases collected by the China Medical Treatment Expert Group via the National Health Commission of China from December 11 to January 29, 2020.

Furthermore, to compare the order of COVID-19 symptoms to influenza, the team looked at the influenza dataset from 2,470 confirmed cases of mostly unvaccinated patients in Europe, North America, and the Southern Hemisphere that was reported to health authorities from 1994 to 1998.

The results revealed that in the three diseases studied caused by coronaviruses  COVID-19, SARS, and MERS  the most probable initial symptom is fever. By contrast, influenza initiates with coughing.

Additionally, although these diseases’ symptoms overlap with COVID-19, what distinguishes the novel coronavirus from them is the timing and symptoms in the upper and lower gastrointestinal tract.

“The upper GI tract (i.e., nausea/vomiting) seems to be affected before the lower GI tract (i.e., diarrhea) in COVID-19, which is the opposite from MERS and SARS,” the researchers wrote. In all diseases, the scientists observed that fever and coughing occur before nausea, vomiting, or both, and diarrhea.

“This order is especially important to know when we have overlapping cycles of illnesses like the flu that coincide with infections of COVID-19,” emphasizes senior author, Peter Kuhn, Professor of Biological Sciences and Professor of Medicine, Biomedical Engineering, and Aerospace & Mechanical Engineering at USC Dornsife.

“Doctors can determine what steps to take to care for the patient, and they may prevent the patient’s condition from worsening.”

Recommendations to slow the spread of COVID-19

The scientists recommend that personnel should test people for fever before they are allowed entry to facilities.

Furthermore, as public spaces start to reopen after the outbreak of the virus, they suggest physicians and other healthcare professionals should record the order of symptom occurrence in COVID-19 and other diseases as part of good clinical practice.

The researchers call for future studies to investigate different strains of COVID-19 and determine whether the onset of symptoms differs in specific strains.

The team also suggests that future research should determine whether risk factors, such as obesity and environmental factors, such as temperature, can affect symptom order. Prof. Larsen and colleagues conclude:

“To slow the spread of COVID-19, our results support the practice that fever should be tested before allowing entry to facilities and that those with fever should immediately seek medical attention for diagnosis and contact tracing. Such measures as these may help to reduce transmission despite the high contagion of SARS-CoV-2.”

In Medical News Today

#Quais anti-hipertensivos estão associados a menor risco de depressão?

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Remédio anti-hipertensivos podem gerar quadros de depressão, segundo estudo.

Quais anti-hipertensivos estão associados a menor risco de depressão?

 

Algumas condições estão associadas a um risco aumentado de depressão, como hipertensão, doenças cardio e cerebrovasculares, entre outras. Além disso, tanto o transtorno depressivo maior como os sintomas depressivos possuem uma relação de maior mortalidade e morbidade, pior qualidade de vida e maior utilização de serviços de saúde. Esse conjunto gera um aumento dos custos.

Estudos epidemiológicos mostram um risco diferenciado entre as classes de anti-hipertensivos e outros medicamentos usados para doenças cardiovasculares e a depressão. Por isso, um estudo recente, publicado esta semana pelo Hypertension, buscou avaliar se os principais medicamentos usados no tratamento desses pacientes podem ter uma relação de risco com a depressão.

Anti-hipertensivos e risco de depressão

Quatro classes principais usadas ​​atualmente para hipertensão e doenças cardiovasculares e cerebrovasculares foram escolhidas para o estudo: agentes de angiotensina (inibidores da enzima conversora de angiotensina — ECA — e bloqueadores do receptor de angiotensina II – ARBs); antagonistas de cálcio; betabloqueadores; e diuréticos.

Foram usados registros de base populacional dinamarqueses (5,4 milhões de indivíduos em janeiro de 2005), sendo excluídos indivíduos que compraram antidepressivos pelo menos uma vez entre o início do registro médico, em 1995, e o início do estudo, 1º de janeiro de 2005, e pessoas com diagnóstico de depressão antes de entrar no estudo.

Os desfechos avaliados foram: primário sendo o diagnóstico de transtorno depressivo (CID: DF32-DF33.31), conforme Registro Central Psiquiátrico Dinamarquês, e secundário uma combinação de um diagnóstico depressivo como especificado antes ou uso de antidepressivos.

O acompanhamento foi feito até dezembro de 2015 ou: data de morte ou data de diagnóstico de transtornos mentais do paciente.

Resultados

  • Durante o período de 2005 a 2015, 3.747.190 pessoas foram expostas a pelo menos um medicamento anti-hipertensivo;
  • As taxas de risco de depressão (desfecho 1) e de risco de depressão ou uso de antidepressivos (desfecho 2), respectivamente, foram significativamente menores em pessoas sem uso de medicamentos anti-hipertensivos em comparação com aqueles medicados;
  • O uso contínuo de medicamentos das classes de agentes de angiotensina, antagonistas de cálcio e betabloqueadores tiveram taxas de risco diminuídas (p < 0,001) em todas as quatro análises;
  • Os diuréticos não tiveram nenhum efeito significante;
  • Dos agentes de angiotensina, enalapril e ramipril foram associadas a taxas reduzidas de depressão;
  • Entre os antagonistas de cálcio, amlodipina, verapamil e combinações do verapemil também demonstraram risco menor de depressão;
  • Entre os betabloqueadores, a redução do risco foi demonstrada no uso de propranolol, atenolol, bisoprolol e carvedilol;
  • Todos os medicamentos citados tiveram valores de p < 0,001, com exceção do verapamil em uma análise (p = 0,004) e combinações do mesmo em duas análises (p = 0,022 e p = 0,020).

Conclusões

Apesar de hipertensão e doenças cardio e cerebrovasculares aumentarem o risco de depressão, o estudo demonstrou que medicamentos das principais classes utilizados no tratamento dessas condições pode reduzir esse risco, com exceção apenas dos diuréticos.

Sendo assim, em pacientes que possuem maior predisposição a desenvolver depressão por outros fatores além das condições citadas, podem se beneficiar mais dos medicamentos que possuem riscos reduzidos, sendo eles: enalapril e ramipril; amlodipina, verapamil e combinações do verapemil; e propranolol, atenolol, bisoprolol e carvedilol.

Entre as limitações do estudo, podemos citar casos não diagnosticados e registrados nos bancos de dados tanto de hipertensão e doenças cardio e cerebrovasculares, como de depressão. Além disso, não foi possível entender a adesão dos medicamentos prescritos para confirmar que todos os participantes analisados estavam fazendo uso correto dos medicamentos.

Mesmo assim, por ser um estudo de base populacional, o grande número de pessoas envolvidas faz com que os resultados sejam significativos.

*Esse artigo foi revisado pela equipe médica da PEBMED

Referências bibliográficas:

#Treatment of Coronavirus Disease 2019 (COVID-19): Investigational Drugs and Other Therapies

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Investigational treatments for COVID-19 | Review article | Pharmaceutical  Journal

 According to Medscape:

 

Overview

Coronavirus disease 2019 (COVID-19) is defined as illness caused by a novel coronavirus now called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly called 2019-nCoV), which was first identified amid an outbreak of respiratory illness cases in Wuhan City, Hubei Province, China. [1It was initially reported to the World Health Organization (WHO) on December 31, 2019. On January 30, 2020, the WHO declared the COVID-19 outbreak a global health emergency. [23On March 11, 2020, the WHO declared COVID-19 a global pandemic, its first such designation since declaring H1N1 influenza a pandemic in 2009. [4

No drugs or biologics have been approved by the FDA for the prevention or treatment of COVID-19. Remdesivir gained emergency use authorization (EUA) from the FDA on May 1, 2020, based on preliminary data showing a faster time to recovery of hospitalized patients with severe disease. [5A new drug application (NDA) for remdesivir was submitted to the FDA in August 2020. An EUA for convalescent plasma was announced on August 23, 2020. [6Numerous other antiviral agents, immunotherapies, and vaccines continue to be investigated and developed as potential therapies. Searching for effective therapies for COVID-19 infection is a complex process. Guidelines and reviews of pharmacotherapy for COVID-19 have been published. [789101112]

The urgent need for treatments during a pandemic can confound the interpretation of resulting outcomes of a therapy if data are not carefully collected and controlled. Andre Kalil, MD, MPH, writes of the detriment of drugs used as a single-group intervention without a concurrent control group that ultimately lead to no definitive conclusion of efficacy or safety. [13]

Rome and Avorn write about unintended consequences of allowing widening access to experimental therapies. First, efficacy is unknown and may be negligible, but, without appropriate studies, physicians will not have evidence on which to base judgement. Existing drugs with well-documented adverse effects (eg, hydroxychloroquine) subject patients to these risks without proof of clinical benefit. Expanded access of unproven drugs may delay implementation of randomized controlled trials. In addition, demand for unproven therapies can cause shortages of medications that are approved and indicated for other diseases, thereby leaving patients who rely on these drugs for chronic conditions without effective therapies. [14]

Drug shortages during the pandemic go beyond off-label prescribing of potential treatments for COVID-19. Drugs that are necessary for ventilated and critically ill patients and widespread use of inhalers used for COPD or asthma are in demand. [1516]

It is difficult to carefully evaluate the onslaught of information that has emerged regarding potential COVID-19 therapies within a few months’ time in early 2020. A brief but detailed approach regarding how to evaluate resulting evidence of a study has been presented by F. Perry Wilson, MD, MSCE. By using the example of a case series of patients given hydroxychloroquine plus azithromycin, he provides clinicians with a quick review of critical analyses. [17]

As an example of the number of compounds being evaluated, Gordon et al identified 332 high-confidence SARS-CoV-2 human protein-protein interactions. Among these, they identified 66 human proteins or host factors targeted by 69 existing FDA-approved drugs, drugs in clinical trials, and/or preclinical compounds. As of March 22, 2020, these researchers are in the process of evaluating the potential efficacy of these drugs in live SARS-CoV-2 infection assays. [18]

How these potential COVID-19 treatments will translate to human use and efficacy is not easily or quickly understood. The question of whether some existing drugs that have shown in vitro antiviral activity might achieve adequate plasma pharmacokinetics with current approved doses was examined by Arshad et al. The researchers identified in vitro anti–SARS-CoV-2 activity data from all available publications up to April 13, 2020, and recalculated an EC90 value for each drug. EC90 values were then expressed as a ratio to the achievable maximum plasma concentrations (Cmax) reported for each drug after administration of the approved dose to humans (Cmax/EC90 ratio). The researchers also calculated the unbound drug to tissue partition coefficient to predict lung concentrations that would exceed their reported EC50 levels. [19]

The NIH Accelerating Covid-19 Therapeutics Interventions and Vaccines (ACTIV) trials public-private partnership to develop a coordinated research strategy has several ongoing protocols that are adaptive to the progression of standard care. [20]

Another adaptive platform trial is the I-SPY COVID-19 Trial for treating critically ill patients. The clinical trial is designed to allow numerous investigational agents to be evaluated in the span of 4-6 months, compared with standard of care (supportive care for ARDS, remdesivir backbone therapy). Depending on the time course of COVID-19 infections across the US. As the trial proceeds and a better understanding of the underlying mechanisms of the COVID-19 illness emerges, expanded biomarker and data collection can be added as needed to further elucidate how agents are or are not working. [21]

The WHO has embarked on an ambitious global “megatrial” called SOLIDARITY in which confirmed cases of COVD-19 are randomized to standard care or one of four active treatment arms (remdesivir, chloroquine or hydroxychloroquine, lopinavir/ritonavir, or lopinavir/ritonavir plus interferon beta-1a). As of July 4, 2020, the treatment arms in hospitalized patients that include hydroxychloroquine, chloroquine, or lopinavir/ritonavir have been discontinued owing to the drugs showing little or no reduction in mortality compared with standard of care. [22]

 

  • Author: Scott J Bergman, PharmD, FCCP, FIDSA, BCPS, BCIDP; more…

 

Additional information for investigational drugs and biologics can be obtained from the following resources:

#Can honey relieve cough and cold symptoms?

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A recent review and meta-analysis asks whether honey is an effective treatment for a cough and other symptoms of upper respiratory tract infections. Overall, the authors conclude, honey is “superior to usual care for the improvement of symptoms.” However, because data are sparse, questions remain.

A photo of bees with honeycomb to accompany the news article, "Can honey relieve cough and cold symptoms?"
Honey may improve symptoms of a cold, though supporting data are lacking.

Upper respiratory tract infections (URTIs), including the common cold, are highly prevalent.

According to the scientists behind the recent review, which appears in the journal BMJ Evidence-Based Medicine, URTIs are “the most frequent reason for antibiotic prescription.”

However, the majority of URTIs are viral, and antibiotics, therefore, cannot help. The rhinovirus alone accounts for an estimated 80% of all respiratory infections during peak seasons.

In the era of antibiotic resistance, a lack of effective treatments for URTIs is a pressing concern. The World Health Organization (WHO) consider antibiotic resistance to be “one of the biggest threats to global health, food security, and development today.” For this reason, there is an urgent need for alternative approaches to these and other infections.

The common cold is far from life-threatening, but treating it successfully could hinder the “slow-motion pandemic” of antibiotic resistance.

Could honey be the answer?

While enduring a cough or cold, many people seek solace in honey. Although this treatment is popular, scientific evidence of its effectiveness is largely lacking.

The recent systematic review and meta-analysis attempts to fill this gap in research.

To put honey through its paces, the team delved into existing findings. They selected relevant studies that involved humans of any age and in any setting. All of the included studies compared honey with at least one other intervention: no treatment, usual care, or a placebo.

In their analysis, the authors defined URTIs as “acute infections of the respiratory tract, including acute cough, colds, and influenza-like illness, but excluding bronchitis or other infections of the lower respiratory tract.”

Does honey work?

In all, the search for papers yielded only 14 relevant studies; of the 14, data from just 12 studies could be combined in a meta-analysis. Alongside the scientists’ data analysis, they also assessed each study’s risk of bias.

The results of the meta-analysis were generally positive but by no means conclusive. When attempting to assess the effects of honey versus a placebo, the authors write:

“Two of the three studies comparing honey with placebo indicated a beneficial effect of honey, but overall, we do not have a strong evidence base from comparisons of honey against matched placebo.”

However, when honey was compared with usual care, the results were slightly clearer. According to the authors, “Honey was associated with a significantly greater reduction in combined symptom score, cough frequency, and cough severity.”

The authors also conclude that, although the methods of usual care varied widely among the studies, they were all “similarly ineffective.”

A number of limitations

A range of factors hindered this study’s ability to draw firm conclusions. Overall, the problems did not concern the methods of this research, but the quality of the studies available for the team to analyze.

For instance, when they investigated the included studies’ risk of bias, nine of the 14 were at risk of at least one type of bias; and seven of those were at risk of more than one type of bias.

Aside from this, nine of the studies had only recruited children as participants, so the results might not apply to adults.

Also, a significant number of the included studies did not use pure honey: One used Honitus syrup, which has a honey base but includes herbs; two used Grintuss syrup, which is a cough suppressant that includes honey; two combined honey with coffee; and one combined honey, coffee, and milk.

Designing a placebo intervention also caused some difficulties. Researchers need to ensure that participants cannot tell whether they are receiving a placebo or the experimental intervention, which in this case was honey.

If the physical properties of honey help reduce symptoms, such as a cough, any similar compound might also soothe symptoms, making it a poor placebo.

Overall, the clearest point that this analysis makes is that we need to see more research before we can reach conclusions about honey and URTIs. Although URTIs are, in the global scheme of things, relatively mild, their relationship with antibiotic overprescribing makes honey worthy of further scrutiny.

And because honey is widely available, natural, and safe for most adults and children older than 1, if using it reduces the number of antibiotic prescriptions, it would be an all-around win.

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