Background The efficacy and safety of tofacitinib, a Janus kinase inhibitor, in patients who are hospitalized with coronavirus disease 2019 (Covid-19) pneumonia are unclear. Methods We randomly assigned, in a 1:1 ratio, hospitalized adults with Covid-19 pneumonia to receive either tofacitinib at a dose of 10 mg or placebo twice daily for up to 14 days or until hospital discharge. The primary outcome was the occurrence of death or respiratory failure through day 28 as assessed with the use of an eight-level ordinal scale (with scores ranging from 1 to 8 and higher scores indicating a worse condition). All-cause mortality and safety were also assessed. Results A total of 289 patients underwent randomization at 15 sites in Brazil. Overall, 89.3% of the patients received glucocorticoids during hospitalization. The cumulative incidence of death or respiratory failure through day 28 was 18.1% in the tofacitinib group and 29.0% in the placebo group (risk ratio, 0.63; 95% confidence interval [CI], 0.41 to 0.97; P=0.04). Death from any cause through day 28 occurred in 2.8% of the patients in the tofacitinib group and in 5.5% of those in the placebo group (hazard ratio, 0.49; 95% CI, 0.15 to 1.63). The proportional odds of having a worse score on the eight-level ordinal scale with tofacitinib, as compared with placebo, was 0.60 (95% CI, 0.36 to 1.00) at day 14 and 0.54 (95% CI, 0.27 to 1.06) at day 28. Serious adverse events occurred in 20 patients (14.1%) in the tofacitinib group and in 17 (12.0%) in the placebo group. Conclusions Among patients hospitalized with Covid-19 pneumonia, tofacitinib led to a lower risk of death or respiratory failure through day 28 than placebo. (Funded by Pfizer; STOP-COVID ClinicalTrials.gov number, NCT04469114 .)

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

Objective: To understand the profile of patients undergoing hip and knee replacement during two years, and to compare the data obtained with the literature. Methods: A total of 323 medical records were reviewed to analyze the perioperative data of patients submitted to hip and knee replacement. results: Osteoarthritis was the main indication for both procedures and male patients were heavier than females (p < 0.05). Hypertension was the prevalent disease among patients. Blood loss was more frequent in knee surgery than in the hip. conclusions: The profile of patients undergoing total arthroplasty improved substantially over the past decade due to shorter hospital stay, lower risk of thromboembolic events and no infection as compared to previous reports.Keywords: Arthroplasty, replacement, knee/epidemiology; Arthroplasty, replacement, hip/epidemiology; Perioperative care reSUMO Objetivo: Conhecer o perfil dos pacientes submetidos à artroplastia de quadril e joelho em um período de dois anos e comparar os dados com relatos da literatura. Métodos: Foram revisados 323 prontuários para analisar os dados perioperatórios de pacientes submetidos à substituição da articulação do joelho e do quadril. resultados: A osteoartrite foi a principal indicação para ambos os procedimentos, e os homens mostraram-se mais pesados que as mulheres (p < 0,05). A hipertensão arterial foi a doença prevalente entre os pacientes. A perda sanguínea foi mais frequente na cirurgia do joelho do que na do quadril. conclusões: O perfil dos pacientes submetidos à artroplastia melhorou substancialmente nos últimos dez anos, associando a diminuição do período de internação com menor risco de eventos tromboembólicos e ausência de infecção, quando comparados com publicações anteriores.

Disease-modifying antirheumatic biological and non-biological therapies are associated with reduced disease progression and joint destruction. Suggestions have been made that total knee and hip joint arthroplasty indications are decreasing as a beneficial effect of the new forms of therapy for rheumatoid arthritis. We present findings of our institution on the incidence of joint arthroplasty in the past few years in patients with rheumatoid arthritis and the increase in the numbers of procedures not associated with inflammatory arthritis.

A high frequency of growing pains was found in our study population and it shows that in a prospective evaluation of patients with signs and symptoms of unknown etiology we can find a frequency higher than that reported in literature.

Aims To evaluate whether a strategy of double-dose influenza vaccination during hospitalization for an acute coronary syndrome (ACS) compared with standard-dose outpatient vaccination (as recommended by current guidelines) would further reduce the risk of major cardiopulmonary events. Methods and results Vaccination against Influenza to Prevent cardiovascular events after Acute Coronary Syndromes (VIP-ACS) was a pragmatic, randomized, multicentre, active-comparator, open-label trial with blinded outcome adjudication comparing two strategies of influenza vaccination following an ACS: double-dose quadrivalent inactivated vaccine before hospital discharge vs. standard-dose quadrivalent inactivated vaccine administered in the outpatient setting 30 days after randomization. The primary outcome was a hierarchical composite of all-cause death, myocardial infarction, stroke, unstable angina, hospitalization for heart failure, urgent coronary revascularization, and hospitalization for respiratory causes, analysed by the win ratio method. Patients were followed for 12 months. During two influenza seasons, 1801 participants were included at 25 centres in Brazil. The primary outcome was not different between groups, with 12.7% wins in-hospital double-dose vaccine group and 12.3% wins in the standard-dose vaccine group {win ratio: 1.02 [95% confidence interval (CI): 0.79–1.32], P = 0.84}. Results were consistent for the key secondary outcome, a hierarchical composite of cardiovascular death, myocardial infarction and stroke [win ratio: 0.94 (95% CI: 0.66–1.33), P = 0.72]. Time-to-first event analysis for the primary outcome showed results similar to those of the main analysis [hazard ratio 0.97 (95% CI: 0.75–1.24), P = 0.79]. Adverse events were infrequent and did not differ between groups. Conclusion Among patients hospitalized with an ACS, double-dose influenza vaccination before discharge did not reduce cardiopulmonary outcomes compared with standard-dose vaccination in the outpatient setting. Clinical Trial Registration ClinicalTrials.gov number: NCT04001504

Objective: To compare the international normalized ratio (INR) measured by a point-of-care (POC) testing device with that measured by the conventional method in patients undergoing anticoagulation therapy with warfarin sodium. Methods:The INR of 383 warfarin-treated patients (mean age: 56.5 years; 207 female) was measured in capillary blood using the Hemochron Jr. device and compared with that of venous plasma samples determined by the conventional method performed in a Coag-A-Mate analyzer. Results were evaluated globally and for the following subgroups: INR < 2.0, from 2.0 to 3.5, and > 3.5.Results: Using both methods, the comparison between INR values yielded a correlation coefficient (r) of 0.86. However, mean differences in INR in both tests, considering the three subgroups, proved to be statistically significant (p <0.001): 0.14 p value < 0.001 for the three subgroups studied. Conclusion:The use of point-of-care testing for monitoring oral anticoagulation has some limitations. Anticoagulation intensity was underestimated by this method in the three subgroups studied.