To describe the quality of life (QoL) of Brazilian speech therapists and relate it to sociodemographic and professiographic aspects, and to their role in the COVID-19 pandemic.Population-based, cross-sectional epidemiological study. The research involved speech therapists from Brazil, who were invited to answer, online, the WHOQOL-bref form about their health and QoL, in addition to sociodemographic and professional questions.609 speech therapists aged between 21 and 65 years, average age of 34 years, participated in the study. Lower scores in the physical domain of QoL were given by female speech therapists, providing outpatient care, who did not work in private clinics, acted indirectly in the pandemic, were absent from work due to psycho-emotional aspects; in the psychological domain, they were female, without a partner, working in a private clinic or elsewhere and acted directly or indirectly in the pandemic; in the social relations domain, they had no partner, worked in outpatient care, but not in private clinics; and in the environment domain, lower scores were in black and brown race/color, without a partner, attending home care, but not in a private clinic or management/administrative or other.Brazilian speech therapists had the lowest QoL scores in the psychological and environmental domains; their QoL is related to factors such as sex, color/race, presence of a partner, council region, service environments, direct action with COVID-19 patients and COVID-19 diagnosis. Subsequently, on March 11, 2020, the WHO declared this viral infection to be in a pandemic state.On December 31, 2019, China notified the World Health Organization (WHO) of pneumonia cases of unknown etiology in the city of Wuhan and, initially, there were 44 cases. On January 7th and 12th, 2020, respectively, China disclosed the place (Wuhan Seafood Market) where the transmission of the new coronavirus to humans took place and published the genetic sequence of this microorganism. About two weeks later, there were already 282 infected in some Asian countries. It is transmitted from person to person by means of the propagation of droplets , in direct contact with contaminated surfaces or by air in procedures that generate aerosols, such as orotracheal intubation and the like-6.The disease called COVID-19 is caused by the SARS-COV-2 virus, which belongs to a family of coronaviruses similar to SARS-COV and MERS-COV, responsible for respiratory syndromes,6.The symptoms presented after contamination by the new coronavirus range from mild repercussions  to potentially lethal ones . Some infected with SARS-COV-2 are asymptomatic and chronic patients are more susceptible to serious complications of COVID-19. Due to the high rate of transmissibility, the recommendation is to redouble prevention measures, including the use of masks and social distancing.According to the epidemiological bulletin of the Ministry of Health, until October 2020, Brazil registered 5,224,362 cases and 153,675 deaths, corresponding to almost 15% of the number of infected people around the world-8. Treatment is carried out according to risk stratification guiding the therapy.For suspected cases, health professionals are responsible for requesting laboratory tests  and following the other recommendations of the Ministry of Health. In Intensive Care Units, the continuity of speech therapy intervention is essential, especially to manage swallowing disorders. Therefore, after weaning from orotracheal intubation, when there is clinical improvement of the COVID-19 patient, the assessment/conduct of a speech therapist is requested. Therefore, in the hospital context, the Federal Council of Speech Therapists (CFFa) and the Brazilian Intensive Care Medicine Association (AMIB) recommended to speech therapists: suspension of in-person outpatient care (elective procedures/exams), participation in training of the Committee for Control and Hospital Infection (CCHI) and an professional to care exclusively for those patients under investigation of infection or for those infected by the new coronavirus,10.Health professionals, such as speech therapists, have a prominent role in the fight against the pandemic.In Brazil, Ordinance 639/2020 asked the supervisory bodies, including the CFFa, to send the list of registered people with active enrollment and defined the registration/training of health professionals in online courses, since the proper development of their skills is crucial for coping with COVID-19. Considering aspects of mental health, a cross-sectional study recorded that most Chinese health professionals working in hospitals exclusively for COVID-19 reported manifestations such as depression, anxiety, insomnia, anguish, resulting from the fear of getting sick and/or transmitting the disease to those they live with.Given all the adversities that the pandemic inflicted on the population and society in general, it is essential to address the promotion of quality of life (QL), which is conceptualized by the WHO as the way in which human beings see their place in life, culture and values intrinsic to itThus, this research proposed to assess the quality of life of Brazilian speech therapists and relate it to sociodemographic and professiographic aspects, and those related to their role in the COVID-19 pandemic.This is an epidemiological, cross-sectional, descriptive-analytical, quantitative study with information related to the quality of life of speech therapists facing COVID-19, recruited through social media channels . This study was approved by the Research Ethics Committee of the Dr. Alberto Rassi State General Hospital in Goiânia, Brazil, under protocol number 4.094,980., sampling error of 5%, confidence level of 95%. Thus, the calculated sample size was 381 professionals, to which 10% were added to cover possible losses and inconsistencies, totaling 420 speech therapists. Data collection took place between June and October 2020, and ended only after reaching the minimum participation proportional to the number of professionals registered in the Regional Councils of Speech Therapists.The sample calculation was performed considering the population of 45,123 speech therapists in Brazil.Speech therapists of both genders who worked in the Brazilian territory during the pandemic participated in the study. Incomplete forms and those not registered in class councils in the study period were excluded. The sample selected for this study answered the form only after reading and marking the option ‘yes’ by accepting the terms of the Informed Consent Form (Resolution CNS 510/2016)This research used the specific digital questionnaire for speech therapists (Google Forms®), prepared by the research team, addressing questions about their age, gender , race/color , presence of partner , regional council (1st to 9th CFFa), work environment , number of work environments , acting in the fight against the pandemic , diagnosis of COVID-19 , hospitalization due to COVID-19, absence or not from work , reason for absence .. The domain scores were calculated by inverting the response categories for questions 3, 4 and 26 so that (1=5) (2=4) (3=3) (4=2) (5=1); and considering the following syntax:The WHOQOL-bref instrument was also used to assess the QoL. This instrument has 26 questions divided into four domains: physical, psychological, social relationships and environment, abbreviated version of the WHOQOL-100Physical = average *4.Psychological = average *4.Social relationships = average *4.Environment = average *4.The calculation above had results with a range between 4 and 20 points, and was transformed into a scale of 0-100 points with subtraction of each domain by 4 and made the product with a value of 6.25 [(domain-4)*6.25]. For this instrument, the higher the score, the better the QoL for the domain.For quantitative analysis, the data collected by the form were extracted and organized in Microsoft Office Excel® spreadsheets . Descriptive analysis was performed, which for categorical variables is presented in absolute (n) and relative (%) frequencies.For continuous variables, median and interquartile range (IQR - p25-p75) were used. Shapiro Wilk test was performed to verify the normality of the data and from this, non-parametric statistics were applied to compare continuous variables, specifically the Mann-Whitney test (2 groups) and Kruskal-Wallis test (more than two groups). For significant variables, Dunn's test was used for differentiation, which is presented in lowercase letters flanked by their medians in the tables.Also, the Spearman's correlation test was performed with an estimate of the rho coefficient (ρ) which was classified as direct correlation when positive and inverse when negative; and still in very strong correlation when equal to or greater than/less than 0.9 for more or less; strong correlation when 0.7 to 0.9 positive or negative; moderate correlation when 0.5 to 0.7 positive or negative; weak correlation when 0.3 to 0.5 positive or negative; and very weak correlation when 0 to 0.3 positive or negative. The significance level used for all tests was 5%. STATA® software version 14.0 was used in this analysis.st region (64-10.51%), 2nd region (133-21.84%), 3rd region (44-7.22%), 4th region (66-10.84%), 5th region (108-17.73%), 6th region (67-11.00%), 7th region (52-8.54%), 8th region (36-5.91%) and 9th region (39-6.40%).The study included 609 speech therapists with a mean age of 33.92 years . Most of the sample was female , who had a partner  and white race/color , followed by brown , black , yellow/indigenous . This research reached the minimum participation foreseen in the sample calculation in all Brazilian states and also in the regions of the Speech Therapy Council: 1The number of those who registered direct or indirect action in fighting the COVID-19 pandemic was 49.26% (n=300). Most professionals were employed in two or more jobs (313-50.97%) and their work environments included: private clinic (292-47.95%), household (242-39.74%), outpatient (166-27.26%), intensive care unit (113-18.56%), rehabilitation center (86-14.12%), infirmary (83-13.63%), palliative care (63-10.34%), another location (51-8.37%) and management/administrative (31-5.09%). About two thirds of the participants were away from work, the main reasons being: institutional decision (234-38.42%), personal choice (96 - 15.75%) and COVID-19 diagnosis (60-9.85%).The median of perceived quality of life of speech therapists was 75 points (IQR=75.00-75.00) and for satisfaction with health it was 75 points (IQR=50.00-75.00). As for the domains, it was found that the median of the physical domain was 67.86 points (IQR=53.57-78.57); psychological score of 58.33 points (IQR=45.83-70.83); social relationships of 66.67 points (IQR=50.00-75.00); and environment 56.25 points (IQR=46.87-65.62) .There was a significant, direct and very weak correlation of age with the psychological and social relationships domains, so that the older the age, the higher the score and, thus, the better the QoL in these domains among these participants  had the best QoL score and the lowest score came from the 9th region . There may be a relationship with socioeconomic inequalities  and with an average difference of 52% in the mortality rate from SARS-COV-2 between the South and North regions of Brazil , during this research.For the environment domain, speech therapists from the 7,22 due to the intense service, the low availability of personal protective equipment and the constant feeling of insecurity experienced by professionals in hospital and/or home care, as well as the suspension of the in-person outpatient service linked to absence from work or teleservice, both with a likely salary impact.Regarding the work environment, the QoL scores of speech therapists in private clinics, rehabilitation centers, management/administrative were higher than those who work in an outpatient clinic, in the household, intensive care unit and palliative care, possibly, as shown by other studiesBased on the data found and the realities experienced by speech therapists during the first period of the pandemic, an increase in the social support network is suggested, reflecting in the cordial and ethical relationship among colleagues, as well as the search for a feeding routine, physical exercise, regular sleep periods, therapies, meditations and relaxation techniques as possibilities in coping with the COVID-19 pandemic.A limitation in this study was the elaboration of more assertive questions regarding professional aspects. Strategies such as request from the council region and comparison with the state of residence were used to restrict answers only to speech therapists, single filling for each participant and obligatoriness in the relevant and complementary questions, in an attempt to reduce uncertainties in the answers.Brazilian speech therapists had lower QoL scores in the psychological and environmental domains in the context of the COVID-19 pandemic. Lower scores in the physical domain of QOL were given by female speech therapists, who provided outpatient care, did not work in private clinics, acted indirectly in the pandemic, who left work and whose reason for leaving were psycho-emotional aspects. As for the psychological domain of QoL, females, the absence of a partner, professionals who worked in a private clinic or elsewhere and who act directly or indirectly in the pandemic had lower scores compared to their peers.Assessing the social relationships domain, the lowest scores were found in professionals who did not have a partner, in those who performed outpatient care but did not work in private clinics. And finally, for the environment domain, lower scores were found in the black and brown race/color, in those without a partner, in those who provided home care, but not in those who attended in private clinics o r who worked in management/administration or another location. Thus, it is concluded that the QoL of speech therapists during the pandemic is related to sociodemographic, professiographic and COVID-19 factors.Brazilian speech therapists work on the front lines to contain the spread of the new coronavirus and take care of sick people, while putting their own lives at risk. Possibly the concern for others overlaps the concern for themselves. Therefore, knowing that their families are safe, and that friends and society value their work is essential for them to be able to face with courage and hope the difficult task in which they are engaged. Studies show that the balanced use of social networks, personal care and empathy are ways to mitigate the impacts on the QoL.Finally, further studies in this area are suggested in order to point out, associate and compare the quality of life of health professionals in the years following the new coronavirus pandemic. . Posteriormente, em 11 de março de 2020, a OMS declarou estado de pandemia à esta infecção viral.Em 31 de dezembro de 2019, a China notificou à Organização Mundial da Saúde (OMS) os casos de pneumonias com etiologia desconhecida na cidade de Wuhan e, inicialmente, eram 44 casos. Nos dias 07 e 12 de janeiro de 2020, respectivamente, a China divulgou o local (mercado de frutos do mar de Wuhan) onde ocorreu a transmissão do novo coronavírus a seres humanos e publicou a sequência genética deste microrganismo. Cerca de duas semanas depois já existiam 282 infectados em alguns países asiáticos. A forma de transmissão é de pessoa para pessoa por meio da propagação de gotículas , no contato direto com superfícies contaminadas ou por via aérea em procedimentos que geram aerossóis, como intubação orotraqueal e similares-6.A doença denominada COVID-19 é causada pelo vírus SARS-COV-2 que pertence a uma família de coronavírus semelhante ao SARS-COV e MERS-COV, responsáveis por causar síndromes respiratórias,6.A sintomatologia apresentada após a contaminação pelo novo coronavírus varia entre repercussões leves  à potencialmente letais . Alguns infectados pelo SARS-COV-2 são assintomáticos e os doentes crônicos têm maior susceptibilidade às complicações graves da COVID-19. Devido ao alto índice de transmissibilidade, a recomendação é redobrar as medidas de prevenção, incluindo o uso de máscaras e distanciamento social.No boletim epidemiológico do Ministério da Saúde, o Brasil registrou até outubro de 2020, o total de 5.224.362 casos e 153.675 óbitos, correspondente a quase 15% do quantitativo de infectados ao redor do mundo-8. O tratamento é feito segundo a estratificação de risco para nortear a terapêutica.Para casos suspeitos, o profissional de saúde é responsável por solicitar exames laboratoriais (imunológico ou de biologia molecular- reverse transcription polymerase chain reaction - RT PCR) e seguir as demais recomendações do Ministério da Saúde. Nas Unidades de Terapia Intensiva a continuidade da intervenção fonoaudiológica é indispensável, especialmente para manejar os distúrbios da deglutição. Portanto, após o desmame da intubação orotraqueal, quando da melhora clínica do usuário com COVID-19, é solicitada a avaliação/conduta de profissional da Fonoaudiologia. Diante disso, no contexto hospitalar, o Conselho Federal de Fonoaudiologia (CFFa) e a Associação de Medicina Intensiva Brasileira (AMIB) recomendaram aos fonoaudiólogos: suspensão da assistência ambulatorial presencial (procedimentos/exames eletivos), participação nos treinamentos da Seção de Comissão de Controle e Infecção Hospitalar (CCIH) e que houvesse um profissional exclusivo para atendimento daqueles pacientes em investigação de infecção ou para aqueles infectados pelo novo coronavírus,10.O profissional de saúde, como o fonoaudiólogo, tem papel de destaque no combate à pandemia.No Brasil, a Portaria 639/2020 solicitou aos órgãos fiscalizadores, entre estes o CFFa, o envio da lista de registrados com inscrição ativa e definiu o cadastro/capacitação dos profissionais de saúde, em cursos à distância, visto que o desenvolvimento adequado de suas competências é crucial para o enfrentamento da COVID-19. Considerando aspectos da saúde mental um estudo transversal registrou que a maioria dos profissionais de saúde chineses lotados em hospitais exclusivos para COVID-19, relataram manifestações como depressão, ansiedade, insônia, angústia, decorrentes do receio de adoecer e/ou transmitir a doença para aqueles de sua convivência.Isto posto e mediante todas as adversidades que a pandemia infligiu à população e sociedade de um modo geral, é indispensável abordar a promoção da qualidade de vida (QV), que é conceituada pela OMS como a maneira pela qual o ser humano enxerga seu lugar na vida, na cultura e nos valores intrínsecos a eleSendo assim, a presente pesquisa propôs avaliar a qualidade de vida do fonoaudiólogo brasileiro e relacionar com os aspectos sociodemográficos, profissiográficos e relativos à atuação na pandemia de COVID-19.WhatsApp®, Instagram®, Facebook®). Esse estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital Estadual Geral de Goiânia Dr. Alberto Rassi, sob o parecer número 4.094.980.Trata-se de um estudo epidemiológico de base populacional, transversal, descritivo-analítico, de caráter quantitativo, com informações relacionados a qualidade de vida do fonoaudiólogo frente a COVID-19, recrutados por meio de canais de mídia social Esta pesquisa utilizou o questionário digital específico para Fonoaudiólogos (via Google Forms®), elaborado pela equipe de pesquisa, abordando questionamentos sobre sua idade, sexo (feminino/masculino), raça/cor , presença de companheiro , regional de atuação (1ª a 9ª CFFa), ambiente de trabalho , número de ambientes de trabalho , atuação no enfrentamento da pandemia , diagnóstico de COVID- 19 , internação devido ao COVID-19, afastamento ou não do local de trabalho , motivo desse afastamento .bref também foi utilizado para avaliar a QV. Esse instrumento conta com 26 questões divididas em quatro domínios: físico, psicológico, relações sociais e meio ambiente, versão abreviada do WHOQOL-100. Os escores dos domínios foram calculados invertendo as categorias de resposta para as questões 3, 4 e 26 de modo que (1=5) (2=4) (3=3) (4=2) (5=1); e considerando a seguinte sintaxe:O instrumento WHOQOL-Físico= média*4.Psicológico= média*4.Relações sociais = média*4.Meio ambiente= média*4.O cálculo acima teve resultados com intervalo entre 4 e 20 pontos, e foi transformado em uma escala de 0-100 pontos com subtração de cada um dos domínios por 4 e feito o produto com o valor de 6,25 . Para esse instrumento, quanto maior o escore, melhor foi a QV para o domínio.Para análise quantitativa, os dados coletados pelo formulário foram extraídos e organizados em planilhas do Microsoft Office Excel ® . Foi realizada análise descritiva que para as variáveis categóricas está apresentada em frequências absolutas (n) e relativas (%).Para as variáveis contínuas, utilizou-se mediana e intervalo interquartil (IIQ - p25-p75). Foi realizada teste de Shapiro Wilk para averiguar a normalidade dos dados e a partir disto, foi aplicada estatística não paramétrica para comparação das variáveis contínuas, especificamente o teste de Mann-Whitney (2 grupos) e Kruskal-Wallis (mais de dois grupos). Para as variáveis significantes foi usado teste de Dunn, para diferenciação que está apresentado em letras minúsculas ladeadas de suas medianas nas tabelas.Foi realizado ainda teste de correlação de Spearman com estimativa do coeficiente rho (ρ) que foi classificado em correlação direta quando positivo e inversa quando negativa; e ainda em correlação muito forte quando igual ou maior/menor que 0,9 para mais ou para menos; correlação forte quando de 0,7 a 0,9 positivo ou negativo; correlação moderada quando de 0,5 a 0,7 positivo ou negativo; correlação fraca quando de 0,3 a 0,5 positivo ou negativo; e correlação muito fraca quando de 0 a 0,3 positivo ou negativo. O nível de significância utilizado para todos os testes foi de 5%. Foi utilizado o software STATA® versão 14.0 nesta análise.Participaram do estudo 609 fonoaudiólogos com média de idade de 33,92 anos . A maioria da amostra foi do sexo feminino , que tinha companheiro  e da raça/cor branca , seguida por parda , preta , amarela/indígena . Esta pesquisa alcançou a participação mínima prevista no cálculo amostral em todos os estados brasileiros e também nas regiões do Conselho de Fonoaudiologia: 1ª região , 2ª região , 3ª região , 4ª região , 5ª região , 6ª região , 7ª região , 8ª região  e 9ª região .O quantitativo dos que registraram atuação direta ou indireta no enfrentamento à pandemia de COVID-19 foi 49,26% (n=300). A maioria dos profissionais tinha ocupação em dois ou mais empregos  e seus ambientes laborais incluíram: clínica particular , domiciliar , ambulatorial , unidade de terapia intensiva , centro de reabilitação , enfermaria , cuidados paliativos , outro local  e gestão/ administrativo . Cerca de 2/3 dos participantes estavam afastados do trabalho, sendo os principais motivos: decisão institucional , escolha pessoal  e diagnóstico de COVID-19 .A mediana de percepção da qualidade de vida dos fonoaudiólogos foi de 75 pontos  e para satisfação com a saúde foi de 75 pontos . Quanto aos domínios verificou-se que a mediana do domínio físico foi de 67,86 pontos ; psicológico de 58,33 pontos ; relações sociais de 66,67 pontos ; e de meio ambiente 56,25 pontos  .Verificou-se que houve uma correlação significativa, direta e muito fraca da idade com os domínios psicológico e de relações sociais, de modo que quanto maior a idade, maior o escore e, assim, melhor a QV nesses domínios desses participantes , no período de realização desta pesquisa.Para o domínio meio ambiente, fonoaudiólogos da 7ª região do Conselho de Fonoaudiologia (Rio Grande do Sul) apresentaram melhor escore de QV e a menor pontuação adveio da 9ª região , podendo haver relação com as desigualdades socioeconômicas ,22 devido ao serviço intenso, a baixa disponibilidade dos equipamentos de proteção individual e a constante sensação de insegurança experimentada pelos profissionais no atendimento hospitalar e/ou domiciliar, como também a suspensão do serviço ambulatorial presencial vinculado ao afastamento do trabalho ou ao teleatendimento, ambos com provável impacto salarial.Concernente ao ambiente de trabalho, os escores de QV dos fonoaudiólogos em clínica particular, centro de reabilitação, gestão/ administrativo mostraram-se superiores ao dos que atuam em ambulatório, domicílio, unidade de terapia intensiva e cuidado paliativo, possivelmente, conforme apontam outros estudosMediante os dados encontrados e as realidades vividas, por nós fonoaudiólogos durante o primeiro período da pandemia, sugere-se aumento da rede de apoio social refletindo no relacionamento cordial e ético entre os colegas bem como a busca por uma rotina de alimentação, prática de exercícios físicos, períodos regulares de sono, terapias, meditações e técnicas de relaxamento como possibilidades no enfrentamento da pandemia COVID-19.Este estudo apresentou como limitação a elaboração de perguntas mais assertivas quanto aos aspectos profissiográficos. Foram utilizadas estratégias como solicitação da região do conselho e comparação com o estado de residência para restringir as respostas apenas aos fonoaudiólogos, preenchimento único por cada participante e obrigatoriedade nas questões relevantes e complementares, na tentativa de reduzir incertezas às respostas enviadas.O fonoaudiólogo brasileiro apresentou mais baixos escores de QV nos domínios psicológico e meio ambiente no contexto de pandemia da COVID-19. Menores pontuações no domínio físico da QV foram dadas por fonoaudiólogos do sexo feminino, que faziam atendimento ambulatorial, não trabalhavam em clínica particular, atuavam de forma indireta na pandemia, que se afastaram do trabalho e cujo motivo de afastamento foram aspectos psicoemocionais. Já para o domínio psicológico da QV o sexo feminino, a ausência de companheiro, os profissionais que trabalhavam em clínica particular ou em outro local e que aturam de forma direta ou indireta na pandemia apresentaram menores escores em relação aos seus pares.Na avaliação do domínio relações sociais, os menores escores foram encontrados nos profissionais que não tinham companheiro, naqueles que realizavam atendimento ambulatorial, mas não trabalhavam em clínicas particulares. E por fim, para o domínio meio ambiente, menores escores foram achados na raça/cor preta e parda, nos com ausência de companheiro, nos que faziam atendimento domiciliar, mas não nos que atendiam em clínica particular ou que atuavam na gestão/administrativo ou outro local. Dessa forma, conclui-se que a QV de fonoaudiólogos durante a pandemia está relacionada a fatores sociodemográficos, profissiográficos e relativos à COVID-19.O fonoaudiólogo brasileiro trabalha na linha de frente para conter a propagação do novo coronavírus e cuidar das pessoas doentes, enquanto coloca a própria vida em risco. Possivelmente a preocupação com o outro sobreponha àquela dispensada a si mesmo, por isso, saber que a família está segura, os amigos e a sociedade valorizam seu trabalho é fundamental para que consigam enfrentar com coragem e esperança a difícil tarefa em que estão empenhados. Estudos apontam que o uso equilibrado das redes sociais, o cuidado pessoal e a empatia são meios de amenizar os impactos na qualidade de vida.Finalmente, sugere-se mais estudos na área a fim de apontar, associar e comparar a qualidade de vida dos profissionais da saúde nos anos subsequentes à pandemia do novo coronavírus.


The Invention of Disaster. It provides some refined perspectives on how to capture the diversity and complexity of the world that we draw from the philosophy of Martinican poet and novelist Edouard Glissant. Glissant’s philosophy of creolisation and relation offers critical pathways towards pluralistic approaches to understanding what we call disaster in a world that is marked by hybridity and relationships rather than essentialism and nativism. A Tout-Monde, in Glissant’s terms, that is the combined additions of different and hybrid interpretations of disaster.This essay expands the postcolonial agenda for future disaster studies that we suggested in the conclusion of the book Tout-Monde of disaster studies will constitute a radical and forward-looking postcolonial agenda; radical in the sense that it will challenge many of our scholarly assumptions, popular discourses as well as common-sense policies and practices.Exploring the  The verTheoretical and epistemological debates on whether disasters are the consequence of nature/hazards or society/vulnerability are all bounded by this ontological assumption and only constitute a pendulum shift within a binary understanding of the world; one that is Eurocentric in nature. As such, all existing paradigms that have been put forward to understand people’s experiences of what we call disaster continue to perpetuate the hegemony of Western scholarship and mirror Hegel’s dialectical quest for reason Gaillard . As if tAlthough antithetical and non-sensical, the hegemony of Western discourses on disaster has nonetheless sustained standardised and universal policies and actions for disaster risk reduction all over the world. This prolongs the imperialist agenda of the West, in dealing with what we call disasters and beyond, as brilliantly exposed by Bankoff , 2019. TThe Invention of Disaster, our intention was to unpack the ontological, epistemological and political processes that have made possible and eventually sustained this hegemony of Western discourses on disaster; an endeavour of deconstruction in Derrida’s  Consequently, relative to Western societies, there is a stronger need for a broader contextualization in order to make sense of the world. (…) A concentration on vision as the primary mode of comprehending reality promotes what can be seen over that which is not apparent to the eye; it misses the other levels and the nuances of existence. . Un pays qui se créolise n’est pas un pays qui s’uniformise.[He adds that:L]a créolisation est la mise en contact de plusieurs cultures ou au moins de plusieurs éléments de cultures distinctes, dans un endroit du monde, avec pour résultante une donnée nouvelle, totalement imprévisible par rapport à la somme ou à la simple synthèse de ces éléments.’inizio dell’elaborazione critica è la coscienza di quello che è realmente, cioè un ‘conosci te stesso’ come prodotto del processo storico finora svoltosi che ha lasciato in te stesso un’infinità di tracce accolte senza beneficio d’inventario. Occorre fare inizialmente un tale inventario.y definition the concept ‘cannot capture the absolutely-other’; and, to the extent that it must invoke a form of generality, of language itself. Any conventional form of understanding must appropriate the other, in an act of violence and reduction. (p. 46)ontinue to use them [i.e. the concepts], to repeat them, to repeat them subversively, and to displace them from the contexts in which they have been deployed as instruments of oppressive power.  été cueilli (accueilli) partout, rejoignant sa réalité.e réclame pour tous le droit à l’opacité, qui n’est pas le renfermement. C’est pour réagir par là contre tant de réductions à la fausse clarté de modèles universels. Il ne m’est pas nécessaire de ‘comprendre’ qui que ce soit, individu, communauté, peuple, de le ‘prendre avec moi’ au prix de l’étouffer, de le perdre ainsi dans une totalité assommante que je gérerais, pour accepter de vivre avec lui, de bâtir avec lui, de risquer avec lui.[Accepting opacity is not isolating or alienating. It is an act of solidarity and mutual trust. According to Glissant  himself:J]e puis donc concevoir l’opacité de l’autre pour moi, sans que je lui reproche mon opacité pour lui. Il ne m’est pas nécessaire que je le ‘comprenne’ pour me sentir solidaire de lui, pour bâtir avec lui, pour aimer ce qu’il fait. Il ne m’est pas nécessaire de tenter de devenir l’autre (de devenir autre) ni de le ‘faire’ à mon image.[We thus need to encourage the use of local languages to the detriment of the violent and reductionist act of translation in a foreign tongue.thought of relation. The thought of relation makes the Tout-Monde of disaster studies. It is at its core:Opacity therefore allows rather than obstructs the L]a Relation est ici entendue comme la quantité réalisée de toutes les différences du monde, sans qu’on puisse en excepter une seule. Elle n’est pas d’élévation mais de complétude. Ses propositions seraient alors qu’elle s’élargit jusqu’à quantifier absolument cette totalité des différences, c’est-à-dire qu’elle ne se rehausse ni ne se justifie d’aucune sublimité, mais qu’elle parait et se multiplie en continu et s’achève et se prolonge à même cette totalité absolument.(…) voir le courage d’affronter l’inconnu est la condition de l’imagination et que la capacité d’imaginer un monde autre est un élément essentiel de la démarche scientifique’ and that ‘pour avancer, il faut d’abord renoncer à certaines évidences; ces ‘évidences’ procurent le sentiment confortable que procurent toutes les certitudes mais elles nous empêchent de poser des questions, ce qui est sinon la seule, au moins la plus sûre façon de parvenir à des réponses’.‘[The Invention of Disaster, we believe that there are enough creative and committed scholars in Asia and the Pacific, Africa and Latin America to raise consciousness among their peers, set their own priorities, build upon their local epistemologies and hence drive our agenda forward.This process requires grounding in our own unique interpretations of the world and in our realisation of the unequal and skewed power relations that currently underpin disaster studies and disaster risk reduction. As we suggested in


Scientific Reports 10.1038/s41598-022-15542-7, published online 15 July 2022Correction to: In the original version of this Article Shelly Masi was incorrectly affiliated with ‘World Wide Fund for Nature - Germany, Reinhardstrasse 18, 10117 Berlin, Germany.’ The correct affiliation is listed below.Eco‑Anthropologie (EA), Muséum National d’Histoire Naturelle, CNRS, Université Paris Cité, Musée de l’Homme 17 place du Trocadéro, 75016 Paris, FranceAdditionally, the order of the accompanying Supplementary Video 1, Supplementary Video 2 and Supplementary Video 3 was incorrectly shown as Supplementary Video 2, Supplementary Video 3 and Supplementary Video 1.The original Article and accompanying Supplementary Information files have been corrected.


Humero-radioulnar synostosis is a rare deformity of the upper limb. The synostosis of the elbow is a malformation that may happen between any of the bones of this joint. The most common one is radioulnar synostosis. Humero-radioulnar synostosis has been very little reported in the literature. We report the case of a 32 years old man with a condition of phacomolia, consulting in the emergency room, for pain of the left upper limb after a light football trauma. The patient also had craniosynostosis of the lambdoid suture. Left-arm X-ray showed a bifurcating humerus, with ulnar deficiency, and non-displaced radial and ulnar fractures, successfully treated with a cast for 6 weeks. This study reports a rare and unusual case of Humero-radioulnar synostosis, in a patient with no family history of malformations. La synostose huméro-radioulnaire est une déformation rare du membre supérieur. La synostose du coude est une malformation qui peut se produire entre n'importe lequel des os de cette articulation. La plus fréquente est la synostose radio-ulnaire. La synostose huméro-radioulnaire a été très peu rapportée dans la littérature. Nous rapportons le cas d'un homme de 32 ans, avec un état de phacomolie, consultant aux urgences, pour une douleur du membre supérieur gauche après un léger traumatisme de football. Le patient présentait également une craniosynostose de la suture lambdoïde. La radiographie du bras gauche a montré un humérus bifurqué, avec une déficience ulnaire, et des fractures radiales et ulnaires non déplacées, traitées avec succès par un plâtre pendant six semaines. Cette étude rapporte un cas rare et inhabituel de synostose huméro-radioulnaire, chez un patient sans antécédents familiaux de malformations.


Dieser Text gibt Einblicke in die Lebenssituation (junger) Menschen, die als Binnenvertriebene in Camps in und um Kabul leben. Anhand von Interviews mit Helferinnen vor Ort werden insbesondere existentielle Notlagen sowie besondere Gefährdungen für Mädchen und Frauen dargestellt. Die Machtübernahme durch die Taliban veränderte die Lebensbedingungen vieler Menschen in Afghanistan erheblich. Ein Großteil der Bevölkerung ist von massiver Armut betroffen. Besonders Menschen, die im Zuge der Gewalthandlungen ihr Zuhause verlassen mussten und als Binnenvertriebene in provisorischen Camps gelandet sind, leiden existentielle Not. Auch angesichts anderer Krisen und Konfliktherde weltweit, sind wir im Sinne internationaler Solidarität gehalten, diese Menschen in Afghanistan nicht aus dem Auge zu verlieren.Internally Displaced Persons, IDPs) in provisorischen Camps Als Binnenvertriebene verstehen wir Menschen, die innerhalb ihres Herkunftslandes, also ohne Grenzüberschreitung zwangsmigrieren  internationaler Infrastruktur. Menschen aus ganz Afghanistan, die im Zuge von Kriegshandlungen, die der Machtübernahme durch die Taliban vorausgegangen waren, obdachlos geworden sind, hatten sich auf den Weg in die Hauptstadt gemacht, da diese Gerüchten zufolge Sicherheit bieten sollte. Sie ließen sich mit dem, was sie am Leibe hatten, nieder und bauten provisorische Zelte aus Tüchern. Da der Zulauf vieler Menschen in die so entstehenden und größer werdenden informellen Camps bei der Kabuler Bevölkerung nicht unbemerkt blieb, begannen wohlhabende Privatmenschen und lokale Hilfsorganisationen trotz der chaotischen Situation, eigenintiativ Spenden zu sammeln und die Menschen notdürftig zu versorgen. Bis heute fehlt es aber an einer zentralen Organisation und Verwaltung der Camps. Hilfsorganisationen auf nationaler Ebene, die von der alten Regierung gefördert wurden, haben zudem keinerlei Geldmittel zur Verfügung und sind auf das Ausland sowie auf private Spenden angewiesen. Aus diesem Grunde sind auch Gewaltschutzmaßnahmen, z. B. insbesondere der Schutz von Frauen  zunächst informelle Augenzeugenberichte über die Lage in den IDP-Camps. Durch Kontakt zu in Kabul ansässigen Menschenrechtsaktivist_innen, die vor Ort Hilfe in IDP-Camps leisten, war es möglich, einen qualitativen Forschungszugang zur Situation der sich dort befindlichen Menschen zu generieren, wobei ein besonderes Augenmerk auch auf Kinder und Jugendliche gelegt wird.Dieses Projekt entstand in Co-Autor_innenschaft, bei der eine Person Erfahrung mit erziehungswissenschaftlich orientierter qualitativer Sozialforschung einbringt (SL), die andere mit einem Studium der Wirtschaftsingenieurwissenschaft auf diesem Gebiet fachfremd ist, jedoch Sprach- und Kulturkenntnisse sowie Kontakte mitbringt, ohne die das Projekt nicht hätte verwirklicht werden können (SJ). Um einen direkten Einblick in die Situation von Kindern und Jugendlichen in den IDP-Camps in und um Kabul bekommen zu können, der über die mediale Berichterstattung hinaus geht, bot es sich an, onlinebasierte Expert_inneninterviews .Unter der Kategorie K2 „Existential need“ wurden Textstellen zusammengefasst, in denen von existentieller Armut, dem Fehlen von Nahrung, Kleidung, Wärme und Gesundheitsversorgung die Rede war. Als Ankerbeispiel diente uns die Textstelle:Die Interviewten berichten davon, dass Menschen in den IDP-Camps aufgrund von Hunger, extremen Klimabedingungen  und fehlender Gesundheitsversorgung Gefahr von Leib und Leben ausgesetzt sind . Die Menschen mussten bei der kriegsbedingten Flucht aus ihren Heimatdörfern sämtliches Eigentum zurücklassen. In den IDP-Camps haben sie weder die Möglichkeit, zu arbeiten, noch werden sie ausreichend versorgt. Sie leben in provisorischen Zelten.I deeply observed the whole tent with my own eyes. The roof of the tents was covered only in one part with a women’s scarf and a men’s handkerchief, which the rural men spread on their shoulders were used as a carpet on the hard and dusty ground. One or two pairs of the clothes they had brought with themselves were used as pillows (I3 (Interview_Hashemi): 14)Frau Hashemi erzählt vom Zelt einer siebenköpfigen Familie:Besonders herausgestellt wird die fehlende Gesundheitsversorgung, die ebenfalls Menschenleben kostet: „there is no doctor to treat them, no medicine for them, no means of basic life to make them breathe a little with more comfort“ (I3 (Interview_Hashemi), Pos. 24). Als besonders gefährdet werden dabei Kinder und alte Menschen eingeschätzt. Insbesondere unter ihnen sind Todesfälle zu verzeichnen. Zwei der Interviewten berichten davon, dass sie mit eigenen Augen gesehen haben, wie Menschen an Unterernährung und fehlender medizinischen Hilfe verstorben sind.Hedyeh and Marjan, my two daughters, want their mother every moment. They were very used to their mother and I can not calm them down and I do not know how to take care of this newly born baby, because I have nothing for her. There is nothing we have; no milk, no clothes and no pumpers to prevent this newly born baby girl, whom I now call Mohajir (immigrant). I have sorrows to lose my daughters because of extreme poverty. I know that the soul of my wife Tamana is not calm with the situation that Marjan, Hadeyeh and Mohajir goes through, I ask you to be the reflector of our voices to be heard to all people to help us. (I3 (Interview_Hashemi): 20)Frau Hashemi erzählt zudem von einem Mann, dessen schwangere Frau im Camp zu früh niedergekommen sei und die Geburt nicht überlebt habe. Zur Trauer um seine Ehefrau kommt für ihn nun die Sorge, wie er sein neugeborenes Kind und dessen zwei Schwestern ernähren soll, da keine Ersatzmilch und kaum Nahrung zur Verfügung steht. Sie zitiert den verzweifelten Vater:On the other hand, the government is in such a predicament that it has no time at all to put the displaced in the spotlight and if the important tasks of the government are prioritized, I can say with regret and the utmost courage that their last priority will be to address the problems and shortcomings of the IDPs. The lack of attention of the authorities to the poor living conditions and lack of access to health services causes the elderly and children to resist with death and in the end, they can not resist and surrender to death (I3 (Interview_Hashemi), Pos. 27).Neben zahlreichen weiteren Beispielen von Armut, Hunger und Not problematisieren die Interviewten, dass die Situation der Menschen in den IDP-Camps bei der neuen Regierung nur marginale Aufmerksamkeit erfährt und nicht ausreichend priorisiert wird.most terrible thing is the forced marriages of the young girls against theit consent because the families want to secure their daughters at least in a way, therefore they are forcing (…) their daughters to get married. (I2 (Interview_Saidkhili): 27)and besides the mentioned facts, another In Kategorie 6 „threat to sexual self-determination“ sind Textstellen zusammengefasst, die darauf hinweisen, dass IDP-Camps insbesondere für Frauen und Mädchen hochgradig riskante Orte sind, an denen ihre sexuelle Selbstbestimmung gefährdet sind. Das Ankerbeispiel hier war:It is also very important to provide sanitary ware for women, which is not available to most of these women and girls. (…) On the other hand, the life in Afghanistan is such a way that women, especially a young girl, do not dare to talk to a man about their need to have personal belongings and ask for it, and now that they live in a camp, the environment is new to them and they do not know the place and do not have hygenic materials and it is very difficult (I3 (Interview_Hashemi): 39–40)Das Spektrum der in dieser Kategorie genannten Gefährdungen beginnt allerdings schon beim Fehlen von einigermaßen sicheren Räumen zum Schutz der Intimsphäre, etwa für Toilettengänge, zum Waschen, für Hygienemaßnahmen während der Menstruation. Frau Hashemi weist darauf hin, dass diese Dinge insbesondere in der afghanischen Kultur hochsensibel sind und Mädchen und Frauen daher das – in den Camps nicht erfüllte – Bedürfnis nach Sicherheit und Schutz haben:Auch Frau Saidkhili sieht in diesem Aspekt „very serious problem […]“. (I2 (Interview_Saidkhili): 37). Des Weiteren sind Mädchen und Frauen Voyeurismus ausgesetzt. Frau Hashemi schildert ihre Beobachtungen, wie Mädchen und Frauen, die aufgrund von Hitze ihre stickigen Zelte verlassen und sich an der frischen Luft aufhalten, Blicke von Männern auf sich ziehen, die sich ein Vergnügen daraus machen: „all their eyes were on the women and girls who were in these camps to pass thier time and to hunt these poor women and girls by their evil eyes“ (I3 (Interview_Hashemi): 22–23).We made them  go to school with a thousand hardships so that their future would be good. The sufferings we endured that at least our children live peacefully, unfortunately everything got worse, neither the house nor the land and property remained for us and the lives of our children became hell. The hunger of our children, their lack of clothes, their bare feet, the lack of blankets for their sleep, the illnesses of their father who has both sugar and kidney problems and as you see, he is like a dead body, there is no money for his medicine. All these tragedy has resulted that we have to give our 17-year-old daughter Zahra to a 45-year-old man for a small amount of money and accept her marriage to 45 years old Wahab in order to save her father, siblings and younger brothers from certain hunger deaths (I3 (Interview_Hashemi): 15–17)Alle Interviewten thematisieren aber auch, dass junge Mädchen zum Zwecke von Zwangsverheiratungen an Männer verkauft werden. So berichtet etwa Frau Nouri: „(…) and on other days when I went to the camp and wanted to survey the camp, I am witnessed and saw a father selling his two children so that he can earn some money and save other members of his family with this money“ (I1 (Interview_Nouri): 15). Frau Hashemi erzählt davon, wie ein Elternpaar von sich selbst sagt, sie hätten schweren Herzens die älteste Tochter geopfert. Sie zitiert die Mutter:an extremely oppressed and depressed girl, a girl that from her appearance can be sured that she still has her hopes for a life. Her colorless big eyes with full of tears, dry lips, bony and yellow face and thin body very clearly express her pain and sorrow. From her opresssed eyes, one can clearly observe that she hates life so much which seems to be doomed to breathe to her she has lost the way to take the burden of all this suffering to nowhere. (I3 (Interview_Hashemi): 15–17)Das betroffene Mädchen beschreibt Frau Hashemi alsnow my pain is not just the crooked back of my parents and the fear of my siblings loss due to hunger, not going to school and the destruction of my dream of becoming a doctor. Today, my pain is bigger and bigger than this: I have to marry a 45-year-old man and become the lustful toy of a man who has a wife and four children (I3 (Interview_Hashemi): 15–17).Das Mädchen erzählte Frau Hashemi unter Tränen davon, dass sie die elfte Klasse absolviert habe und sich auf ein Universitätsstudium vorbereiten wollte. Die Diabeteserkrankung ihres Vaters habe sie motiviert, ein Medizinstudium anzustreben. Doch nun seien diese Hoffnungen zunichte gemacht:Die dargestellten Interviewausschnitte geben erste Eindrücke davon, dass sich (junge) Menschen in Kabuler IDP-Camps mit Situationen konfrontiert sehen, die massive Risiken für ihre Entwicklung in jeder Hinsicht bedeuten und in manchen Fällen zur Gefahr für Leib und Leben werden können. Hunger sowie die fehlende Versorgung mit Nahrung, medizinischer Hilfe und weiteren Gütern des täglichen Lebens gefährden insbesondere die vulnerabelsten Gruppen wie kleine Kinder, Schwangere und alte oder kranke Menschen. Zusätzlich stellen sich für weiblich gelesene junge Menschen besondere Gefährdungsrisiken im Bereich der sexuellen Selbstbestimmung dar. Diese Ergebnisse sind besonders anschlussfähig an Studien zur Situation von Frauen in Flüchtlingslagern in anderen Ländern (vgl. Krause und Schmidt


The Funding statement is incorrect. The correct Funding statement is as follows: This study was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) grant 2015/02574-0 (LM). This study was also supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) postdoctoral fellowship grant 88887.334462/2019-00 (RMC-C). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The publisher apologizes for the error.


Portanto, objetivamos avaliar o efeito do uso concomitante de R e T em pacientes com AR.O tratamento médico geralmente compreende uma combinação de medicamentos antianginosos. Dentre eles, a trimetazidina (T) e a ranolazina (R) são uma terapia complementar devido ao seu perfil de eficácia e segurança no tratamento de pacientes com AR.7 confirmada por angiografia e em pacientes não elegíveis para revascularização miocárdica.8 Uma amostragem de conveniência de pacientes que estavam sintomáticos após 3 meses de uso de pelo menos 3 medicamentos antianginosos (incluindo T) foi elegível para receber R. Esta análise fez parte de um estudo aprovado pelo comitê de ética em pesquisa (CAAE:24308213.7.0000.0068). As investigações seguiram a Declaração de Helsinque. Todos os pacientes forneceram consentimento informado por escrito.Analisamos retrospectivamente os prontuários clínicos de pacientes acompanhados em um ambulatório especializado de um hospital universitário terciário com diagnóstico de AR, definida como angina incapacitante com pelo menos 3 meses causada por insuficiência coronariana em quadro de doença arterial coronariana,1; última visita: V4) quanto aos seus sintomas de acordo com a classificação da Canadian Cardiovascular Society (CCS). ECG de repouso e exames laboratoriais foram realizados em V1 e V4. A critério do médico, era possível adicionar R à terapia de base9 se a) QTc < 500 ms; b) taxa de filtração glomerular > 30 mL.kg-1.min-1; e c) ausência de disfunção hepática grave. Foi adotada uma dose padrão de 500 mg duas vezes ao dia.Os pacientes foram reavaliados mensalmente durante 3 meses  e as variáveis categóricas foram expressas como números absolutos. Para comparação entre os pontos temporais, foi utilizado o teste t de Student pareado ou o teste de postos sinalizados de Wilcoxon, conforme apropriado. A significância estatística foi estabelecida como valor p < 0,05.c era de 414 ± 16 ms.Este relato inicial avaliou 10 pacientes (7 homens), 61 ± 7 anos, acompanhados por angina limitante com CCS 3 (n = 3) ou 4 (n = 7), entre 2019 e 2020. A 2, 4 dos 10 pacientes apresentaram hipotensão sintomática levando a uma mudança no tratamento anti-hipertensivo: os anti-hipertensivos tiveram que ser interrompidos em 2 pacientes em uso de anlodipino ou hidroclorotiazida ou reduzidos em um paciente em uso de losartana. Na V4, apenas 1 paciente faltou à consulta e, embora tenha sido contatado por telefone, confirmando que estava clinicamente estável, essa informação não foi incluída na análise.Com a exceção de 1 paciente, todos compareceram às visitas agendadas. Em V1 para V4 . Dois pacientes melhoraram 2 classes de CCS e 3 pacientes melhoraram 1 classe. No entanto, 4 pacientes não apresentaram melhora.A 4 não revelou alterações significativas na frequência cardíaca (61 ± 9 bpm) e QTc (417 ± 19 ms) em relação à linha de base .A análise dos ECGs de repouso obtidos em V+ tardia) com T  para otimizar o tratamento médico em pacientes com AR. Nesta experiência inicial, a combinação foi segura e bem tolerada e resultou em uma melhora da CCS.Até onde sabemos, este é o primeiro relato do uso combinado de R , an extremely debilitating condition, requires specialized medical treatment with often complex therapeutic adjustments in an attempt to improve symptoms and quality of life as much as possible.3 However, in the recent “diamond approach”,4 depicting preferred combinations of different classes of AAD for the treatment of patients with angina, does not consider the concomitant use of T and R a useful strategy due to their related mechanism of action.4 Although no known interaction between both drugs has been described,5 there is no data on the efficacy and safety of the use of R in patients already on T. Therefore, we aimed to evaluate the effect of the concomitant use of R and T in patients with RA.Medical treatment usually comprises a combination of antianginal drugs (AAD). Among them, trimetazidine (T) and ranolazine (R) are an add-on therapy due to their efficacy and safety profile in the treatment of patients with RA.7 confirmed by angiography and in patients not eligible for myocardial revascularization.8 A convenience sampling of patients who were symptomatic after 3 months of at least 3 AAD (including T) were eligible to receive R. This analysis was part of a study approved by the research ethics committee (CAAE:24308213.7.0000.0068). Investigations followed the Declaration of Helsinki. All patients provided written informed consent.We retrospectively analyzed the clinical records of patients followed in a specialized, outpatient clinic of a tertiary university hospital with diagnosis of RA, defined as disabling angina for at least 3 months caused by coronary insufficiency in the setting of coronary artery disease,1; last visit: V4) regarding their symptoms according to the Canadian Cardiovascular Society (CCS). Resting ECG and laboratory tests were performed on V1and V4. At the physician’s discretion, R could be added to the background therapy9 if a) QTc< 500 ms; b) glomerular filtration rate > 30 mL.kg-1.min-1; and c) absence of severe hepatic dysfunction. A standard dose of 500 mg twice daily was adopted.Patients were reassessed monthly for 3 months , and categorical variables were expressed as absolute numbers. For comparison between time points, the paired Student t-test or Wilcoxon signed-rank test were used, as appropriate. Statistical significance was set at a p-value of < 0.05.cwas 414 ± 16 ms.This early report evaluated 10 patients (7 men), 61 ± 7 years old, followed for limiting angina CCS 3 (n = 3) or 4 (n = 7), between 2019 and 2020. 2, 4 of the 10 patients presented symptomatic hypotension leading to a change in antihypertensive treatment: antihypertensive drugs had to be either stopped in 2 patients using amlodipine or hydrochlorothiazide or reduced in one patient using losartan. At V4, a single patient missed his appointment, and, although he was reached by phone, confirming he was clinically stable, this information was not included in the analysis.All but one patient attended the scheduled visits. At V1to V4. Two patients improved 2 CCS classes, and 3 patients improved 1 class. However, 4 patients exhibited no improvement.4disclosed no significant changes in heart rate (61 ± 9 bpm) and QTc(417 ± 19 ms) compared to baseline .Analysis of the resting ECGs obtained at V+current inhibitor) with T  to optimize medical treatment in patients with RA. In this early experience, the combination was safe and well tolerated, and it led to an improvement in CCS.To our knowledge, this is the first report on the combined use of R (a late Na5 Likewise, the serum concentration of levamlodipine can be increased when it is combined with R. In the CARISA trial,9 the incidence of hypotension was around 1%, much lower than that observed in our study. The only reported interaction between R and hydrochlorothiazide is an increased risk or severity of QTcprolongation.Because of the persistence of limiting angina despite the association of at least three AAD, including T, the introduction of R in an attempt to better control symptoms was carefully monitored. The only observed adverse event after R was symptomatic hypotension, although R is presumably devoid of any significant hemodynamic effect. The possible explanation for hypotension comes from the many drug-to-drug interactions ascribed to R. Ranolazine, for instance, may decrease the excretion rate of losartan which could result in a higher serum level.cprolongation or laboratory abnormalities, suggesting that the concomitant use of AAD acting both at the cardiac cell level is safe and offers additional angina relief. The central message of this early experience is that, when facing a medical challenge, the clinician must be cautiously audacious. We believe that new strategies, provided they are safe and based on a logical rationale, must be considered, which the aim of bringing hope to so-called “no-option” patients.Three months after the introduction of R, we observed significant improvement in CCS and no QTThe findings of this study have to be seen in light of some limitations. Our study is a retrospective analysis of the data of a small sample size, of an open trial, evaluating the subjective endpoint of angina symptoms in patients with RA followed during 3 months. Therefore, although our conclusions are not definite, they generate hypotheses for future trials.cprolongation or laboratory abnormalities.Concomitant use of R and T in patients with RA, during 3 months, improved CCS and was safe, with no evidence of QT


A pandemia da COVID-19 tem causado um impacto sobre a mortalidade por várias doenças em todo o mundo, especialmente por doenças cardiovasculares (DCVs). O Brasil é um país de dimensões continentais com diferenças significativas na estrutura de saúde entre seus estados.Analisar a mortalidade hospitalar por DCV no sistema público de saúde durante o primeiro ano da pandemia por COVID-19 (2020) no Brasil.Este é um estudo ecológico analisando o número absoluto de mortes hospitalares e a taxa de mortalidade hospitalar no Brasil, suas macrorregiões, e unidades federativas. Os dados foram obtidos do Sistema de Informações Hospitalares (SIH) do Ministério da Saúde. O P-escore foi usado para analisar o excesso de mortalidade. O escore compara os eventos observados com os eventos esperados para um dado local e período. O escore-P foi corrigido por um modelo de regressão joinpoint, com um intervalo de confiança de 95% e nível de significância de 5%.Houve 93.104 óbitos hospitalares por DCV no Brasil em 2020, o que representa 1495 menos óbitos  que o esperado. A região centro-oeste apresentou um escore-P positivo, com um aumento de 15,1% no número de mortes. Dez estados apresentaram um maior número de óbitos em 2020. Ainda, observou-se um excesso de 13,3% de mortalidade hospitalar no país como um todo, e um excesso de mortalidade hospitalar em todas as macrorregiões.Houve uma diminuição no número absoluto de óbitos hospitalares, bem como um aumento na taxa de mortalidade por DCV no Brasil em 2020, após o início da pandemia por COVID-19. A COVID-19 pode levar à morte, conforme idade, condição imunológica, e doenças crônicas dos pacientes infectados.4Os primeiros casos da Doença por Coronavírus 2019 (COVID-19) foram registrados em dezembro de 2019 na China, e a doença rapidamente se disseminou em todo o mundo. Em março de 2020, a COVID-19 foi anunciada como pandemia pela Organização Mundial da Saúde.5 Em 18 abril de 2021, quase um ano e dois meses após o início da pandemia, o país tinha aproximadamente 13,9 milhões de casos confirmados e aproximadamente 373.000 mortes no Brasil, com uma taxa de casos fatais de 2,7%.6 Além disso, desde o início da pandemia, o país vem enfrentando uma crise política e econômica, o que tem dificultado ainda mais o controle da doença.8No Brasil, o primeiro caso foi confirmado em 26 de fevereiro de 2020, e a primeira morte registrada em 17 de março de 2020.6 Ainda, os pacientes podem apresentar sintomas cardiovasculares, causados ou por um comprometimento cardíaco indireto , ou por ação direta do patógeno no tecido cardíaco.9 Assim, o novo coronavírus pode resultar em lesão miocárdica, arritmia, insuficiência cardíaca, miocardite, e choque, principalmente na presença de doença cardiovascular (DCV) pré-existente.12A COVID-19 pode ser assintomática, ou manifestar um amplo espectro de sintomas, incluindo febre, dispneia, tosse, mialgia, anosmia e dor torácica.15 O comportamento da população também mudou, principalmente devido à preocupação quanto à contaminação pelo novo coronavírus.16Além disso, medidas não farmacológicas visando diminuir a transmissão da COVID-19 na comunidade afetaram a organização dos serviços de saúde, por exemplo, reduzindo o número de consultas presenciais e o horário de funcionamento dos serviços. Tais medidas também incluíram restrições na mobilidade urbana e recomendações para se buscar atendimento médico somente em caso de extrema necessidade.22 No Brasil, um estudo relatou diminuição nas internações hospitalares e aumento na mortalidade por DCV durantes os primeiros meses da pandemia.23 Contudo, não existem estudos com dados oficiais abrangendo o todo o ano de 2020.Vários estudos mostraram uma redução significativa nas internações hospitalares por DCVs, paralelamente a um aumento nas taxas de mortalidade e complicações, em comparação às taxas anteriores à pandemia ou de anos anteriores.Em um país de dimensões continentais como o Brasil, é fundamental compreender a situação em cada região para ajudar na tomada de decisões políticas. Assim, o objetivo deste estudo foi investigar a mortalidade hospitalar por DCV dentro do sistema público de saúde brasileiro durante o primeiro ano da pandemia da COVID-19 (2020).http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/nruf.def). O SIH registra todas as internações hospitalares financiadas pelo SUS.Este é um estudo ecológico analisando o número de óbito hospitalar, taxa de mortalidade hospitalar, e causa de mortes de acordo com o capítulo IX da Classificação Internacional de Doenças (CID-10). Foram consideradas unidades de análise: Brasil, suas macrorregiões, e seus estados (ou unidades federativas). Os dados foram obtidos do Sistema de Informações Hospitalar (SIH) do Ministério da Saúde  e o escore P adaptado  foram usados para análise da mortalidade hospitalar, de acordo com as equações seguintes:Escore P para o número absoluto de óbitos hospitalares:Para o escore P adaptado para a taxa de mortalidade hospitalar:24Nessas equações, o ‘valor esperado’ refere-se à média dos cinco anos anteriores (2015 a 2019).joinpoint com o teste de permutação Monte Carlo (4499 permutações). O modelo permite a classificação das tendências em crescente, descendente ou estacionária, e o cálculo da variação percentual média . Foram adotados intervalo de confiança de 95% e nível de significância de 5%.Uma vez que o cálculo do valor esperado para o ano de 2020 não considera a tendência temporal do fenômeno, ele pode ser superestimado (se o indicador de tendência é descendente) ou subestimado . Por isso, também analisamos a tendência temporal usando o modelo de regressão A APC foi usada para corrigir o número de mortes hospitalares esperadas para 2020, e a taxa de mortalidade hospitalar (%). Nesse processo, foi adotada uma série temporal mensal para o período de cinco anos (2015-2019), totalizando 60 meses. Para obter os valores esperados, foram adotadas as seguintes regras:Para tendência crescente: valor médio de 2015-2019 + APCPara tendência decrescente: valor médio de 2015-2019 - APCPara tendência estacionária: foi usado somente o valor médioEm seguida, o estudo prosseguiu para a análise descritiva (frequência absoluta e relativa) da mortalidade hospitalar e os escores P do país, das macrorregiões e das unidades federativas. Os resultados foram apresentados considerados todo o ano de 2020, e o período de março a dezembro do mesmo ano, considerando que a COVID-19 foi confirmada no Brasil no final de fevereiro, e a doença se espalhou de março em diante.Foram usados o programa Microsoft Office Excel® (©2008 Microsoft Corporation), SPSS v.21 (©IBM corporation) e regressão Joinpoint 4.5.0.1 .O estudo utilizou dados de domínio público, que não permite a identificação dos indivíduos. Por esse motivo, o estudo prescindiu de aprovação do comitê de ética em pesquisa.Em 2020, houve 93 104 mortes hospitalares por DCV no Brasil, menos que o número esperado para aquele ano, dado que a média dos cinco anos anteriores (2015 a 2019) foi de 94 599, indicando suma diferença de 1495 mortes hospitalares . Ao se considerar somente os meses de março a dezembro de 2020, esse declínio foi de 3,85% . Considerando as macrorregiões, somente a região centro-oeste mostrou um escore P positivo, com um aumento de 15,2% no número de mortes de janeiro a dezembro, e de 13,42% de março a dezembro. Houve 999 mais óbitos em todo o ano de 2020, e 666 mais óbitos considerando somente o período da pandemia (março a dezembro) .Dez unidades federativas mostraram um maior número de mortes em 2020 em relação ao esperado: duas na região norte (Amazonas e Roraima), quatro na região nordeste , um na região sul (Paraná), e três na região centro-oeste . Ao considerar o período de março a dezembro, esse número foi reduzido a seis estados  .Ao analisar a taxa de mortalidade hospitalar de janeiro a dezembro de 2020, observou-se um excesso de 13,34% no Brasil em 2020 . Em relação ao período de março a dezembro, a taxa aumentou de 8,12% para 9,64% . A taxa de excesso de mortalidade também foi analisada em todas as macrorregiões. Os escores P mais elevados foram observados na região centro-oeste , seguido da região sul . Ainda, quando todo o ano de 2020 foi analisado, seis unidades federativas apresentaram um p-escore negativo , e ao considerar o período de março a dezembro, três unidades federativas apresentaram um p-escore negativo  .Durante janeiro e fevereiro, os escores P para mortes hospitalares por DCV no Brasil e suas regiões foram positivos. Em janeiro, por exemplo, o escore P no país foi de 4,4; o escore mais alto foi na região centro-oeste  e o mais baixo na região sudeste . Em março, o escore P em todo o país  e nas demais regiões (com exceção da região centro-oeste) ficou negativo. O escore P nacional tornou-se positivo de setembro a novembro de 2020. A região nordeste manteve um escore P negativo em todo os meses do ano. Na região sudeste, o escore P tornou-se positivo em agosto , setembro , e novembro  e, no sul, o escore tornou-se positivo em agosto  e setembro . Na região centro-oeste, observou-se um padrão peculiar, em que o escore tornou-se negativo somente em abril  .Em janeiro de 2020, foram observados escores P negativos para taxa de mortalidade hospitalar em nível nacional , e nas regiões sudeste  e sul . Por outro lado, a região centro-oeste apresentou um escore P mais elevado . Para todos os meses subsequentes (fevereiro a dezembro), houve excesso de mortalidade em todas as cinco macrorregiões do Brasil. Destaca-se que, em março, após a pandemia ter sido estabelecida no Brasil, o escore P nacional foi quase três vezes maior que em fevereiro . Ao analisar os dados por região, observou-se que o excesso de mortalidade foi diferente entre as macrorregiões. Enquanto na região sudeste, o escore P aumentou de 1,5 em fevereiro para 10,2 em março , na região sudeste, o aumento foi de 1,6 para 2,1  na região nordeste, e de 4,4 para 6,1  na região norte. Na região centro-oeste, esse aumento ocorreu mais tarde, somente em maio .Este estudo analisou a mortalidade hospitalar por DCV no sistema público de saúde no Brasil durante o ano de 2020. Observou-se uma diminuição no número absoluto de mortes, além de um aumento na taxa de mortalidade hospitalar em todas as macrorregiões do Brasil e na maioria das unidades federativas no período analisado.13 e a adoção de medidas não farmacológicas para conter a pandemia. Diferentes investigações22 em todo o mundo relataram um número reduzido de internações hospitalares em 2020 em comparação a períodos anteriores à pandemia, como mostrado em nosso estudo.A redução no número absoluto de mortes por DCV no Brasil em 2020 pode ser explicada pelo menor número de pacientes que buscaram os serviços de saúde durante a pandemia,17 Outro estudo observou um declínio acentuado no número de admissões hospitalares por outras causas, tais como apendicite aguda, síndrome coronariana aguda, acidente vascular cerebral, fraturas ósseas, câncer, e nascidos vivos, em uma rede de hospitais em Qatar.25Em um estudo multicêntrico no estado de Massachusetts nos EUA, em março de 2020, observou-se uma redução de 43% nas taxas de internações por DCVs agudas, incluindo insuficiência cardíaca, síndrome coronariana aguda, e acidente vascular cerebral.24 recomendações de distanciamento social,26 e dificuldades de locomoção por meios de transporte público,27 podem haver contribuído para a diminuição nas internações e, consequentemente, ao aumento no número absoluto de mortes por DCV registrado em 2020. Estudos brasileiros indicaram que esse cenário epidemiológico contrasta com o aumento nas mortes por parada cardiorrespiratória registradas fora do âmbito hospitalar,30 como observado na cidade de Belo Horizonte, onde houve um aumento de 33% no primeiro mês da pandemia (março de 2020), em comparação a março do ano anterior.28 Ainda, um estudo conduzido na Itália relatou um aumento de 58% em paradas cardiorrespiratórias fora do hospital, e esse aumento esteve fortemente associado com a incidência cumulativa de COVID-19.31 Portanto, o que se tem observado é a ocorrência de mortes “ocultas”,29 na maioria dos casos, nas casas dos indivíduos que aderiram e respeitaram as recomendações sanitárias.Preocupação quanto a contrair COVID-19 nos hospitais,32 a pandemia não se espalhou uniformemente pelo território. Consequentemente, a pandemia teve um impacto diferente entre as regiões. Em nosso estudo, com exceção da região centro-oeste, houve diminuição no número de mortes hospitalares por DCV em relação ao esperado em todas as regiões. Ao analisar mês a mês, enquanto foi observado um declínio no P-escore nas regiões norte, nordeste, sul e sudeste no mês de março, na região centro-oeste, essa diminuição ocorreu mais tarde, em abril, e o escore P manteve-se negativo somente nesse mês. Esse resultado está de acordo com a evolução da pandemia nessa região; em março, por exemplo, a região registrava apenas 460 casos da doença, em comparação a 3400 casos registrados na região sudeste.32No Brasil, um país de dimensões continentais, caracterizado por polarização demográfica e epidemiológica,33 Tal fato pode ter adiado o aumento no número de casos de COVID-19 e consequentemente o impacto sobre os serviços de saúde em comparação a outras regiões.34Dois fatores devem ser considerados em relação à região centro-oeste. É possível que o avanço mais lento da COVID-19 nessa região esteja associado a um menor fluxo migratório de pessoas em comparação a outras regiões como nordeste e sudeste.33 Ainda, existem características locais relacionadas ao sistema de saúde, incluindo a alta disponibilidade de leitos nas unidades de terapia intensiva – 4,5 por 10 000 habitantes , 1,6/10 000 habitantes no serviço público, e 11,6/10 000 no setor privado.35 A alta disponibilidade de leitos no Distrito Federal também eleva a região centro-oeste à segunda posição em disponibilidade de leitos por macrorregião brasileira .35 Discrepâncias entre unidades federativas em relação à capacidade operacional dos serviços de saúde locais para enfrentar a COVID-19 têm sido um motivo de críticas.36 De fato, um estudo conduzido em seis capitais brasileiras mostrou excesso de mortalidade por DCV em cidades menos desenvolvidas durante a pandemia, possivelmente associado ao colapso do sistema de saúde nessas regiões.37Além disso, a região centro-oeste pode ter sido influenciada pelo Distrito Federal, onde o escore P de óbitos foi 81,5, ou seja, bem maior que o esperado. Apesar de não haver uma explicação clara para o alto escore no Distrito Federal, é possível que o fato esteja relacionado a singularidades de seu papel político no país, uma vez que se trata da capital federal do Brasil.23 É pouco provável que esse aumento na mortalidade hospitalar esteja somente relacionado aos efeitos da COVID-19 sobre o sistema cardiovascular. Na Áustria, por exemplo, somente 6,2% dos pacientes admitidos em caráter de urgência por DCV testaram positivo para COVID-19, o que não explicaria o aumento na mortalidade hospitalar em 65% observado nos hospitais daquele país.18Se, por um lado, conforme discutido anteriormente, houve uma redução no número absoluto das mortes hospitalares, por outro lado, observou-se um excesso na mortalidade hospitalar no país como um todo e em todas as macrorregiões. Esse dado está de acordo com o encontrado em estudos anteriores22 Equipes de saúde têm sido redirecionadas para atender pacientes com COVID-19, e cirurgias eletivas e atendimentos ambulatoriais têm sido interrompidos.23 Assim, a demora em se buscar atendimento médico,40 combinada aos efeitos prejudiciais do SARS-CoV-2 no sistema cardiovascular12 podem haver contribuído para o aumento de descompensação clínica e mortalidade hospitalar durante a pandemia.23 Um estudo realizado no estado brasileiro de Pernambuco mostrou que a existência de DCV prévia acelerou a mortalidade por COVID-19 em aproximadamente quatro dias.41Além disso, o aumento na mortalidade hospitalar pode ser um resultado de múltiplos fatores, tais como mudanças no sistema de saúde durante a pandemia. Na Alemanha, um estudo mostrou uma redução nas internações acompanhada por um aumento significativo na mortalidade por infarto agudo do miocárdio durante a pandemia. Os autores também observaram um atraso em se buscar assistência médica desde o início dos sintomas, e pior condição clínica na admissão.42 Ainda, a população idosa apresenta a maior prevalência de DCV.44Em relação às macrorregiões brasileiras, o excesso de mortalidade hospitalar mais elevado  foi encontrado na região sul, o que pode ser explicado pelas características demográficas e epidemiológicas da população. Em 2020, 16,4% da população da região tinha idade igual ou superior a 60 anos, e o índice de envelhecimento era de 86% , o maior do país.Mesmo considerando a rigidez metodológica adotada, o estudo possui algumas limitações. A primeira diz respeito ao uso de dados secundários do SIH. A qualidade desses dados depende dos registros inseridos no sistema. A qualidade do escore P depende diretamente da acurácia dos dados disponíveis, que pode ser afetada por um atraso entre a ocorrência e o registro do óbito. A falta de dados sobre mortalidade global por doenças cardiovasculares no Brasil, além da avaliação da mortalidade hospitalar restrita aos serviços de saúde pública, são importantes limitações que merecem ser mencionadas.O presente estudo mostrou uma diminuição no número absoluto de mortes hospitalares, bem como um aumento na mortalidade hospitalar por DCV no Brasil em 2020, após o início da pandemia por COVID-19, com diferenças entre as macrorregiões e os estados. O efeito da pandemia da COVID-19 tem sido vasto, incluindo um forte impacto sobre os serviços de saúde e doenças existentes. O fortalecimento do sistema de saúde público brasileiro parece ser a medida mais importante para enfrentar a pandemia e suas consequências no país. 2 Transmission may be person-to-person or due to contact with contaminated surfaces, thus favoring the rapid spread of the virus. COVID-19 can potentially lead to death, according to age, immune status, and pre-existing chronic diseases of infected patients.4The first cases of coronavirus disease 2019 (COVID-19) were registered in December 2019 in China, and the disease quickly spread throughout the world. In March 2020, COVID-19 was declared a pandemic by the World Health Organization.5 On 18 April 2021, almost one year and two months after the start of the pandemic, there were 13.9 million confirmed cases and approximately 373,000 deaths in Brazil, with a case-fatality rate of 2.7%.6 Besides, since the onset of the pandemic, the country has been facing an economic and political crisis, which has made it even more difficult for the country to handle the disease.8In Brazil, the first case was confirmed on 26 February 2020, and the first death was registered on 17 March 2020.6 In addition, patients may also present cardiovascular symptoms, either due to indirect cardiac involvement  or direct action of the pathogen in cardiac tissue.9 Thus, the novel coronavirus can result in myocardial injury, arrhythmia, heart failure, myocarditis, and shock, especially in the presence of pre-existing cardiovascular disease (CVD).12COVID-19 may be asymptomatic, or manifest a wide spectrum of symptoms, including fever, dyspnea, cough, myalgia, anosmia, and chest pain.15 Population’s behavior has also changed, primarily due to concerns regarding contamination by the novel coronavirus.16Furthermore, non-pharmacological measures aimed at reducing COVID-19 transmission at the community level have affected the organization of healthcare services, for instance, by reducing the number of face-to-face consultations and hours of operation of the services. Non-pharmacological measures also included restricted urban mobility and recommendations to seek medical attention only when strictly necessary.22 In Brazil, a study reported reduced hospital admissions and increased in-hospital mortality from CVD during the first months of the pandemic.23 However, there are no studies with official data from the entire year of 2020.Several studies worldwide have demonstrated a significant reduction in hospital admissions due to CVD, in parallel to increased mortality and complication rates, in comparison with rates before the pandemic or previous years.Moreover, in a continent-sized country like Brazil, it is crucial to understand the situation in each region to help policy decision-making. Therefore, the objective of this study was to investigate in-hospital mortality from CVD within the realm of the Brazilian public health system during the first year of the COVID-19 pandemic (2020).http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/nruf.def). The SIH registers all hospital admissions financed by the SUS.This is an ecological study analyzing the number of in-hospital deaths, rate of in-hospital mortality, and cause of deaths according to chapter IX of the International Classification of Diseases (ICD-10). The following were considered as units of analysis: Brazil, its macro-regions, and its federative units. Data were obtained from the Hospital Information System  of the Brazilian Ministry of Health  and the adapted P-score  were used for analysis of in-hospital mortality, as per the following equations:P-score of the absolute number of in-hospital deaths:For the adapted P score of in-hospital mortality rate:24In these equations, the ‘expected value’ refers to the average from the previous five years (2015 to 2019).Since the calculation of the expected value for the year 2020 does not consider the time trend of the phenomenon, it can be overestimated (if the trend indicator is descending) or underestimated (if the time trend is increasing). For this reason, we also analyzed the period trend by theho joinpoint regression model with Monte Carlo permutation test . The model allows the classification of trends as increasing, decreasing or stationary and the calculation of the average percent change (APC). A confidence interval of 95% and a significance level of 5% were adopted.The APC was used to correct the number of in-hospital deaths expected for 2020, as well as the in-hospital mortality rate (%). In this process, a monthly time series of the five years (2015-2019) was adopted, totaling 60 months. To obtain the expected values, the following rules were adopted:If increasing trend: mean value of 2015-2019 + APCIf decreasing trend: mean value of 2015-2019 - APCIf stationary trend: only the mean value was used.Subsequently, the study proceeded to descriptive analysis (absolute and relative frequency) of in-hospital mortality and the P scores for the country, its macro-regions, and federative units. The results were presented considering the whole year of 2020 and the period from March to December of the same year, considering that COVID-19 was confirmed in Brazil at the end of February and the disease spread from March onwards.The software Microsoft Office Excel® (©2008 Microsoft Corporation), SPSS statistics v.21 (©IBM corporation) e Joinpoint Regression 4.5.0.1  were used.This study used public domain data, which do not allow for identification of individuals. For this reason, approval by the Research Ethics Committee was waived.In 2020, there were 93,104 in-hospital deaths due to CVD in Brazil, which is less than that expected for that year, given that the average from the previous 5 years (2015 to 2019) was 94,599, expressing a difference of 1,495 in-hospital deaths (P score: -1.58). When considering only the months from March to December 2020, there was a decrease of 3.85% . Regarding the macro-regions, only the Central-West Region showed a positive P score, with a 15.12% increase in the number of deaths from January to December, and 13.42% from March to December. There were 999 more deaths considering the whole year of 2020, 666 more considering only the pandemic period (March-December) .Ten federative units showed a higher number of deaths in 2020 in relation to what was expected, as follows: two in the north region (Amazonas and Roraima), four in the northeast , one in the south (Paraná), and three in the central-west . When considering the March-December period, this number was reduced to six  .When analyzing the in-hospital mortality rate from January to December 2020, an excess of 13.34% was observed in Brazil in 2020 . Regarding the period from March to December, the rate increased from 8.12% to 9.64% (P Score 18.76). Excess in-hospital mortality was also observed in all macro-regions. The highest P-scores were observed in the central-west region (24.10% from January to December and 28.78% from March to December), followed by the south region (15.23% from January to December and 20.92% from March to December). In addition, six federative units showed negative P-score when analyzing the entire year of 2020  and three when considering the March-December period  .During January and February, the P-scores for in-hospital deaths due to CVD in Brazil and its regions were positive. In January, for example, the nationwide P-score was 4.4; the highest score was in the central-west region (17.0) and the lowest in the southeast (1.5). In March, the nationwide P-score (-1.7) and regional  P-scores became negative. At the nationwide level, the P-score was observed to become positive from September to November 2020. The northeast region maintained a negative P-score for every month of the year. In the southeast region, the P score became positive in August (1.5), September (0.4), and November (10.7), and, in the South, it became positive in the months of August (1.2) and September (4.7). In the central-west, a peculiar pattern was observed, where the score became negative only in April (-3.7) .In January 2020, negative P-scores for in-hospital mortality rate were observed on the nationwide level (-0.1) and in the southeast (-2.9) and south (-2.5) regions. On the other hand, the central-west showed a higher P-score (12.7). For all the following months (February to December), there was excess mortality in all five macro-regions of Brazil. It is noteworthy that, in March, after the pandemic was established in Brazil, the national P-score was almost three times higher (from 2.9 to 8.9) than in February. When analyzing the data by region, it was observed that excess mortality differed between macro-regions. While the P-score increased from 1.5 in February to 10.2 in March (6.6 times greater) in the southeast, it increased from 1.6 to 2.1 (1.3 times greater) in the northeast and from 4.4 to 6.1 (1.4 times greater) in the north. In the central-west, this increase occurred later, only in May .This study analyzed in-hospital mortality from CVD in public health in Brazil during the year of 2020. A decrease was observed in the absolute number of in-hospital deaths, in addition to an increase in the in-hospital mortality rate in all Brazilian macro-regions and in most federative units during the period analyzed.13 Different investigations22 throughout the world have reported reduced numbers of hospital admissions in 2020, when compared to periods before the pandemic, as was shown in our study.The decrease in the absolute number of deaths due to CVD in Brazil in 2020 may be explained by the lower number of patients seeking health services during the pandemic, and adoption of non-pharmacological measures to contain the pandemic.17Another study observed a sharp decline in the number of hospital admissions due to other causes, such as acute appendicitis, acute coronary syndrome, stroke, bone fractures, cancer, and live births, in a network of hospitals in Qatar.25In a multicenter study in the state of Massachusetts, USA, in March 2020, a 43% reduction was observed in hospitalization rates due to acute CVDs, including heart failure, acute coronary syndrome, and stroke.24 social-distancing recommendations,26 and difficulties in locomotion by means of public transportation,27 may have contributed to the decrease in hospital admissions and, consequently, to the decrease in the absolute number of deaths due to CVD registered in 2020. Brazilian studies have indicated that this epidemiological scenario is in contrast with the increase in out-of-hospital deaths due to cardiorespiratory arrest,30 as observed in the city of Belo Horizonte, where there was a 33% increase in the first month of the pandemic (March 2020), in comparison to March of the previous year.28 Furthermore, a study conducted in Italy reported a 58% increase in out-of-hospital cardiac arrest, which was strongly associated with the cumulative incidence of COVID-19.31 Therefore, what has been observed is the occurrence of hidden mortality,29 mostly at the homes of individuals who adhered to and respected sanitary recommendations.Concerns about contracting COVID-19 in hospital centers,32 the pandemic has not spread homogenously throughout the territory. Consequently, the pandemic has had a different impact across regions. In our study, except for the central-west, there was a decrease in the number of in-hospital deaths due to CVD in relation to what was expected in all the regions. When analyzing by month, while a decline in P-score was seen in the north, northeast, south, and southeast regions in March, in the central-west, this decrease was observed later, in April, and it remained negative only during this month. This result is in line with the course of the pandemic in this region; in March, for instance, the region registered only 460 cases of the disease, in contrast with 3,400 cases registered in the southeast.32In Brazil, a continent-sized country, characterized by demographic and epidemiological polarization,33 This fact may have led to a delayed increase in the number of cases of COVID-19, and consequently a delayed impact on health services in comparison to other regions.34Two factors should be considered with respect to the central-west region. It is likely that the slower advance of COVID-19 in this region is associated with the lower migratory flow of people, as compared with other regions like the northeast and the southeast.33 Also, there are local characteristics related to the health system, including the high availability of intensive care unit beds – 4.5 per 10,000 inhabitants , 1.6/10,000 in the public sector, and 11.6/10,000 in the private one.35 This high availability of beds in the Federal District also moves the central-west region to second place in availability of beds by Brazilian macro-region .35 Discrepancies between federative units regarding the operational capacity of their local health services to handle COVID-19 have been a point of criticism.36 In line with this, a study conducted in six Brazilian capitals, showed a higher excess mortality from CVD in less developed cities during the pandemic, possibly associated with the collapse of the health system in these regions.37In addition to this, the central-west may have been influenced by the Federal District, where P-score of deaths was 81.5, much higher than the expected. Even though it is not possible to give a clear explanation about this high score in the Federal District, it may be related to the singularities regarding its political role in the country, given that it is the national capital of Brazil.23 It is unlikely that this increase in in-hospital mortality is merely related to the effects of COVID-19 on the cardiovascular system. In Austria, for instance, only 6.2% of patients urgently admitted due to cardiovascular conditions tested positive for COVID-19, which would not explain the 65% increase in in-hospital mortality observed in hospitals in that country.18If, on one hand, as previously discussed, there was a reduction in the absolute number of in-hospital deaths, on the other hand, an excess was observed in the in-hospital mortality rate at the country level and in all macro-regions, which is in agreement with what has been observed in previous studies22 Health teams have been redirected to provide care for patients with COVID-19, and elective surgeries and outpatient care have been interrupted.23 Therefore, the delay in seeking medical assistance40 and the harmful effects of SARS-CoV-2 on the cardiovascular system12 may have contributed to increased clinical decompensation and in-hospital mortality during the pandemic.23 A study conducted in the Brazilian state of Pernambuco showed that prior existence of CVD accelerated mortality from COVID-19 by approximately four days.41Also, the increase in in-hospital mortality may be the result of multiple factors, such as changes in the health system during the pandemic. In Germany, a study showed a reduction in hospital admissions accompanied by a significant increase in mortality due to acute myocardial infarction during the pandemic. They also observed a greater delay in seeking medical assistance from the onset of symptoms and worse clinical condition upon admission.42 Furthermore, the elderly population has the highest prevalence of CVD.44Regarding Brazilian macro-regions, the highest excess in-hospital mortality (P-score 18.2) was found in the south, which may be explained by demographic and epidemiological characteristics of the population. In 2020, 16.4% of the region’s population was 60 years or older, and the aging index was 86% , which is the highest in the country.Even considering the methodological robustness of this study, it has some limitations. The first concerns the use of secondary data from the SIH. The quality of these data depends on records inserted into the system. The quality of the P-score depends directly on the accuracy of available data, which means that a delay between occurrence and registration of death can affect its accuracy. The lack of data on overall mortality from cardiovascular diseases in Brazil, in addition to the assessment of in-hospital mortality restricted to the public health network are important limitations that deserve to be mentioned.This study has demonstrated a decrease in the absolute number of in-hospital deaths, as well as an increase in in-hospital mortality due to CVD in Brazil in 2020, after the onset of the COVID-19 pandemic, with differences between macro-regions and federative units. The impact of the COVID-19 pandemic has been vast, including a profound effect on health services and existing diseases. Strengthening the national public health system seems to be the most important measure in handling the pandemic and its consequences in Brazil.