Background A local increase in angiotensin 2 after inactivation of angiotensin-converting enzyme 2 by SARS-CoV-2 may induce a redox imbalance in alveolar epithelium cells, causing apoptosis, increased inflammation and, consequently, impaired gas exchange. We hypothesized that N-acetylcysteine (NAC) administration could restore this redox homeostasis and suppress unfavorable evolution in Covid-19 patients. Objective To determine whether NAC in high doses can avoid respiratory failure in patients with Covid-19. Methods It was a double-blind, randomized, placebo-controlled, unicentric trial, conducted at the Emergency Department of Hospital das Clínicas, São Paulo, Brazil. We enrolled 135 patients with severe Covid-19 (confirmed or suspected), with an oxyhemoglobin saturation of less than 94% or respiratory rate higher than 24 breaths/min. Patients were randomized to receive NAC 21 g (approximately 300 mg/kg) for 20 hours, or dextrose 5%. Primary endpoint was the need for mechanical ventilation. Secondary endpoints were time of mechanical ventilation, admission to ICU, time in ICU, and mortality. Results Baseline characteristics were very similar in the two groups, with no significant difference in age, sex, comorbidities, medicines taken, and disease severity. Also, groups were similar in laboratory tests and chest CT scan findings. Sixteen patients (23.9%) in the Placebo group were submitted to endotracheal intubation and mechanical ventilation, compared to 14 patients (20.6%) in the NAC group (p=0.675). No difference was observed in secondary endpoints. Conclusion Administration of NAC in high doses did not affect the evolution of severe Covid-19.

The confirmation of a pandemic by the World Health Organization on March 11, 2020 proved that the SARS-CoV-2 virus would become a worldwide health issue (1). The Brazilian situation was no different from other countries: there was pressure on the health system and health workers. According to an article published by former Brazilian Health Ministry members, the country has been preparing itself for the COVID-19 disease since January 10, 2020 (2), and in many cities and states, isolation protocols have been set up (3). Even so, the number of cases and deaths keep rising in the country, counting 514,849 official cases and 29,314 deaths on June 1, 2020 (4). Many adaptations are being made in the way society works. Medical training had to be adapted in this context. In many schools, the internship was interrupted while other educational activities were adapted to virtual learning environments, with the introduction of web-based activities and new teaching technologies (5,6). These resources, despite being already present in many schools, became the only way of teaching due to isolation protocols demanding many adaptations (7). In Brazil, on the same hand as what was proposed by the Association of American Medical Colleges (8), 1 st to the 4 th years of medical school had their on-site activities suspended. The 5 th and 6 th years, our internship students, are still going to their university-hospitals, as interns work as health-staff in many situations. Their engagement was endorsed by the Federal Government COVID-19 combat strategy (9), which suggests using the internship labor force for the epidemic combat, in similar ways that are proposed by others (10,11). At the same time, a provisory measurement taken by the president allowed medical students to graduate with 75% completion from their internship (12). In the Faculty of Medicine of the University of São Paulo, graduation has been divided in four main educational strategies.

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Introduction Head and neck specialists and otorhinolaryngologists are greatly exposed to coronavirus disease 2019 (COVID-19) transmission in their everyday praxis. Many articles are being published regarding medical staff protection and patient management during the pandemic. Objective To provide an easy access to and a trustful review of the main aspects that have changed in the head and neck surgery and otorhinolaryngology practice due to the COVID-19 pandemic. Data Synthesis The search terms used were: (head and neck or otorhinolaryngology or ORL or thyroid) AND (severe acute respiratory syndrome coronavirus 2 [SARS-COV-2] or COVID-19 or CORONAVIRUS). The results were limited to the year of 2020. Articles were read in English, Portuguese, French, German, and Spanish or translated from Chinese. All included articles were read by at least two authors. Thirty-five articles were included. Most articles suggest postponing elective surgeries, with exception to cancer surgeries, which should be evaluated separately. Twenty-five articles recommended some kind of screening prior to surgery, using polymerase chain reaction (PCR) tests and epidemiological data. Extra precautions, such as use of personal protective equipment (PPE), are suggested for both tracheostomies and endoscopies. Fifteen articles give recommendation on how to use telemedicine. Conclusion The use of PPE (N95 or powered air-purifying respirator [PAPR]) during procedures should be mandatory. Patients should be evaluated about their COVID-19 status before hospital admission. Cancer should be treated. Tracheostomy tube cuff should be inflated inside the tracheal incision. All COVID-19 precautions should be kept until there is a validated antiviral treatment or an available vaccine.

Purpose The aim of this study is to explore which factors of entrepreneurship and innovation influence economic development under the quadruple helix model, contrasting Southern and Northern Europe. Design/methodology/approach In this study, secondary data are collected from the Global Entrepreneurship Monitor databases, Organization for Economic Co-operation and Development and Global Competitiveness Index, for four countries in the North and four Southern European countries, for the period from 2007 to 2015. Data was analyzed with SPSS 22.0 software and subjected to several multivariate statistical tests. Findings The results show a statistically significant difference in the variables of the four quadruple helix model dimensions. This means that Northern European countries (Finland, the Netherlands, Norway and Sweden) display better results on innovation and entrepreneurship than Southern European countries (Spain, Greece, Italy and Portugal). The results also showed that per capita gross domestic expenditure on R&D is positively related to government and university dimensions, with significant differences between Southern and Northern European countries. Originality/value It is hoped that this study will contribute to new evidence on the factors of innovation and entrepreneurship that are decisive for economic development. To the traditional quadruple helix model, control variables were added to meet the endogenous characteristics of the countries.