Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic precipitated fear of contagion and influenced many people to avoid the emergency department (ED). It is unknown if this avoidance effected overall health or disease mortality.ObjectiveWe aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes.MethodsWe retrospectively accessed a multihospital, multistate electronic health records database managed by HCA Healthcare to obtain a case series of all patients presenting to an ED during the early COVID-19 pandemic (March 1–May 31, 2020) and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes.ResultsThe weekly ED volume from 160 facilities dropped 44% from 141,408 patients (week 1, March 1–7, 2020) to a nadir of 79,618 patients (week 7, April 12–18, 2020), before rising back to 105,667 (week 13, May 24–30, 2020). Compared with 2019, this overall decline was statistically significant (p < 0.001). The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses.ConclusionsThe COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.     

Apheresis and COVID-19 in intensive care unit (ICU)

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. The disease has since spread worldwide, and on March 2020 the World Health Organization (WHO) declared it as pandemic, causing a public health crisis. Symptoms of COVID-19 are variable, ranging from mild symptoms like fever, cough, and fatigue to severe illness. Elderly patients and those with comorbidities like cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop severe forms of the disease. Asymptomatic infections have been well documented. Accumulating evidence suggests that the severity of COVID-19 is due to high levels of circulating inflammatory mediators including cytokines and chemokines leading to cytokine storm syndrome (CSS). Patients are admitted in ICU with severe respiratory failure, but can also develop acute renal failure and multi organ failure. Advances in science and technology have permitted the development of more sophisticated therapies such as extracorporeal organ support (ECOS) therapies that includes renal replacement therapies (RRTs), venoarterial (VA) or veno-venous (VV) extracorporeal membrane Oxygenation (ECMO), extracorporeal CO2 removal (ECCO2R), liver support systems, hemoperfusion, and various blood purification devices, for the treatment of ARDS and septic shock.     

Living with liver disease in the era of COVID-19-the impact of the epidemic and the threat to high-risk populations

The cardinal symptoms of severe acute respiratory syndrome coronavirus 2 infection as the pandemic began in 2020 were cough, fever, and dyspnea, thus characterizing the virus as a predominantly pulmonary disease. While it is apparent that many patients presenting acutely to the hospital with coronavirus disease 2019 (COVID-19) infection have complaints of respiratory symptoms, other vital organs and systems are also being affected. In fact, almost half of COVID-19 hospitalized patients were found to have evidence of some degree of liver injury. Incidence and severity of liver injury in patients with underlying liver disease were even greater. According to the Centers of Disease Control and Prevention, from August 1, 2020 to May 31, 2022 there have been a total of 4745738 COVID-19 hospital admissions. Considering the gravity of the COVID-19 pandemic and the incidence of liver injury in COVID-19 patients, it is imperative that we as clinicians understand the effects of the virus on the liver and conversely, the effect of underlying hepatobiliary conditions on the severity of the viral course itself. In this article, we review the spectrum of novel studies regarding COVID-19 induced liver injury, compiling data on the effects of the virus in various age and high-risk groups, especially those with preexisting liver disease, in order to obtain a comprehensive understanding of this disease process. We also provide an update of the impact of the new Omicron variant and the changing nature of COVID-19 pathogenesis.     

The impact of the COVID-19 pandemic on other infections differs by their route of transmission: A retrospective,observational study in Japan

IntroductionThe Coronavirus disease 2019 (COVID-19) pandemic and people's subsequent behavioral changes have decreased the cases of respiratory infection worldwide. However, research on infectious diseases with other transmission modes is insufficient. The aim was to assess the impact of the COVID-19 pandemic on non-respiratory infectious diseases: infectious enterocolitis, sexually transmitted diseases such as human immunodeficiency virus (HIV) infection and syphilis, and tick-borne diseases.MethodsThis retrospective, cohort study used comprehensive surveillance data from the National Institute of Infectious Diseases in Japan from January 1, 2018, to December 31, 2021. The number of cases of infectious diseases before the COVID-19 pandemic (2018–2019) was compared with that during the COVID-19 pandemic (2020–2021). Reduction rates were calculated as the number of disease cases during the COVID-19 pandemic in 2020 and 2021, respectively, divided by the mean number of disease cases in 2018 and 2019.ResultsThe total numbers of cases of infectious enterocolitis, sexually transmitted diseases, and tick-borne diseases during the study period were 2,507,304 cases, 24,972 cases, and 3012 cases, respectively. The number of cases decreased for infectious enterocolitis and sexually transmitted diseases during the COVID-19 pandemic compared with before the COVID-19 pandemic, with an approximately 40–50% decrease in enterocolitis and 30–55% decreases in sexually transmitted diseases. However, cases of tick-borne diseases changed little, with a 0.2% increase in 2020 and a 6% increase in 2021.ConclusionThe COVID-19 pandemic had a different impact on the number of cases of infectious diseases depending on their mode of transmission.     

Prevention,diagnostic evaluation,management and prognostic implications of liver disease in critically ill patients with COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, broke out in December 2019 in Wuhan city of China and spread rapidly worldwide. Therefore, by March 2020, the World Health Organization declared the disease a global pandemic. Apart from the respiratory system, various other organs of the human body are also seriously affected by the virus. Liver injury in patients with a severe form of COVID-19 is estimated to be 14.8%-53.0%. Elevated levels of total bilirubin, aspartate aminotransferase and alanine aminotransferase and low levels of serum albumin and prealbumin are the main laboratory findings. Patients with pre-existing chronic liver disease and cirrhosis are much more prone to develop severe liver injury. This literature review presented the recent scientific findings regarding the pathophysiological mechanisms responsible for liver injury in critically ill patients with COVID-19, the various interactions between drugs used to treat the disease and the function of the liver and the specific tests providing the possibility of early diagnosis of severe liver injury in these patients. Moreover, it highlighted the burden that COVID-19 put on health systems worldwide and its effect on transplant programs and the care provided to critically ill patients in general and particularly to those with chronic liver disease.     

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.     

Problematics of neurosurgical service during the COVID-19 pandemic in Slovenia

The novel coronavirus disease 2019 (COVID-19) is an ongoing disease caused by severe acute respiratory syndrome coronavirus-2 that still poses an important and urgent threat to global health. In Slovenia, the epidemic was declared on March 12^th, 2020, and since then COVID-19 has had a great impact on our health system. The field of neurosurgery in particular has been experiencing difficulties in both elective and emergency service. In this article, we described epidemiologic protocols and the effect that the COVID-19 pandemic had on the surgical practice and workflow of the Department of Neurosurgery at the University Medical Centre Ljubljana. We analyzed and compared the number of elective and emergency neurosurgical procedures in a 2-year period before and during the pandemic. We recorded a drop in cases mostly on account of elective procedures whilst emergency service remained relatively unaffected.     

新型冠状病毒肺炎相关性急性胰腺炎：证据，挑战与思考

由新型冠状病毒（SARS-CoV-2）感染引起的新型冠状病毒肺炎（COVID-19）自2019年12月发病以来,现已全球大流行。COVID-19除影响呼吸系统外,还可造成全身多系统、多脏器的损害。目前关于COVID-19累及胰腺的证据十分有限,COVID-19患者中急性胰腺炎（AP）的发病率存在不确定性,其临床特征和发病机制也存在诸多疑问。在全球COVID-19流行仍未得到完全控制的背景下,由于目前对COVID-19与AP之间相互作用知之甚少,我们必须警惕他们之间可能存在的联系。临床上诸多治疗程序需要合理化,应采取有效的防护措施,在科学诊治患者的同时有效避免医护人员SARS-CoV-2感染。     

Clinical improvement in a patient with severe coronavirus disease 2019 after administration of hydroxychloroquine and continuous hemodiafiltlation with nafamostat mesylate

The number of people infected with severe acute respiratory syndrome coronavirus 2 is increasing globally, and some patients have a fatal clinical course. In light of this situation, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020. While clinical studies and basic research on a treatment for COVID-19 are ongoing around the world, no treatment has yet been proven to be effective. Several clinical studies have demonstrated the efficacy of chloroquine phosphate and nafamostat mesylate with COVID-19. Here, we report the case of a Japanese patient with COVID-19 with severe respiratory failure who improved following the administration of hydroxychloroquine and continuous hemodiafiltlation with nafamostat mesylate. Hence, hydroxychloroquine with nafamostat mesylate might be a treatment option for severe COVID-19.     

COVID-19 Related Mortality During Management of a Hepatic Abscess

The coronavirus disease (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in the capital city of the Hubei Province, Wuhan, China, in late 2019. Declared a pandemic by the World Health Organization on March 11th, 2020, COVID-19 has challenged healthcare systems to limit the spread of community and hospital-acquired disease. This article uses a patient case to highlight the importance of infection control during the height of the SARS-CoV-2 surge at a Level I affiliated community hospital in Western New York.     

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.     

COVID-19 Telemedicine and Vaccination at an Urban Safety Net HIV Medicine Clinic

In response to the emerging coronavirus disease 2019 (COVID-19) pandemic in March 2020, the Owen Clinic at UC San Diego Health scaled up telemedicine to ensure the continuity of human immunodeficiency virus primary care. A group of nurse practitioners, physicians, and a physician assistant developed a dedicated COVID-19 telemedicine clinic to provide virtual health care services to patients with or at risk for severe acute respiratory syndrome coronavirus 2 infection. This effort contributed to successful health outcomes for the clinic’s 476 patients diagnosed with COVID-19. The Owen Clinic was also the first ambulatory clinic within UC San Diego Health to implement on-site COVID-19 vaccines. Nurse practitioners and a physician assistant spearheaded these 2 clinical initiatives.     

Manifestations and risk factors of COVID-19 and mucormycosis: A mini-review

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has become a pandemic disease. It also increases the risk of co-infections. Mucormycosis is a severe fungal infectious disease and its causative agent, mucormycetes, belongs to an opportunist fungus Mucoraceae family. Mucormycosis in COVID-19 patients with mucormycosis presents an additional challenge worldwide. Mucormycosis shares certain risk factors and signs and symptoms with COVID-19. In this review, we summarize manifestations and risk factors of mucormycosis and COVID-19.     

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large,urban, academic hospital system

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic.MethodsWe conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions.ResultsWhile outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020.ConclusionsOverall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.     

The impact of blood campaigns using mobile blood collection drives on blood supply management during the COVID-19 pandemic

Background and objectivesBlood transfusion is a lifesaving procedure for transfusion-dependent patients. Therefore, maintaining blood supply is extremely crucial. The coronavirus disease 2019 (COVID-19) pandemic has negatively affected blood supply by affecting donor attendance. This study aimed to investigate blood supply and demand during the pandemic and demonstrate the positive impact of blood donation campaigns through mobile blood drives.Materials and methodsA cross-sectional study was conducted based on data of the blood bank at Prince Muhammad bin Nasser Hospital (PMBNH) in southwestern Saudi Arabia. Data on the attendance of blood donors at PMBNH were retrieved and retrospectively reviewed to assess the impact of mobile blood drives during the COVID-19 pandemic.ResultsBlood supply and donor attendance during the COVID-19 pandemic dropped by 17.32 %. However, blood supply increased between March and May 2020 due to national blood donation campaigns conducted through mobile blood drives. The drop in blood supply after 3 months of mobile blood drives significantly decreased to 0.17 % (P < 0.01). This means the blood supply was increased as follows; (March 2020 = 32.67 %, April 2020 = 45.54 %, and May 2020 = 19.47 %). On the other hand, blood demand decreased by 12.83 %.ConclusionThis study demonstrated the significant impact of establishing blood donation campaigns through mobile blood drives. Our results showed that the strategy can contribute to sufficient blood units to patients during pandemics and emergencies.     

The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions

ObjectiveWe examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January–October 2020, compared to 2019, in a large sample of U.S. EDs.MethodsWe compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11–April 21), and later-pandemic (April 22–October 31) periods.ResultsED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020.ConclusionWe confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.     

Diagnosis,treatment protocols,and outcomes of liver transplant recipients infected with COVID-19

Several cases of fatal pneumonia during November 2019 were linked initially to severe acute respiratory syndrome coronavirus 2, which the World Health Organization later designated as coronavirus disease 2019(COVID-19). The World Health Organization declared COVID-19 as a pandemic on March 11, 2020. In the general population, COVID-19 severity can range from asymptomatic/mild symptoms to seriously ill. Its mortality rate could be as high as 49%. The Centers for Disease Control and Prevention hav...     

Obesity in people with diabetes in COVID-19 times: Important considerations and precautions to be taken

At the end of 2019, a new disease with pandemic potential appeared in China. It was a novel coronavirus called coronavirus disease 2019 (COVID-19). Later, in the first quarter of 2020, the World Health Organization declared the outbreak of this disease a pandemic. Elderly people, people with comorbidities, and health care professionals are more vulnerable to COVID-19. Obesity has been growing exponentially worldwide, affecting several age groups. It is a morbidity that is associated with genetic, epigenetic, environment factors and/or interaction between them. Obesity is associated with the development of several diseases including diabetes mellitus, mainly type 2. Diabetes affects a significant portion of the global population. Obesity and diabetes are among the main risk factors for the development of severe symptoms of COVID-19, and individuals with these conditions constitute a risk group. Based on a literature review on obesity in people with diabetes in the framework of the COVID-19 pandemic, this study presents updated important considerations and care to be taken with this population.     

Post–COVID-19 Syndrome (Long Haul Syndrome): Description of a Multidisciplinary Clinic at Mayo Clinic and Characteristics of the Initial Patient Cohort

ObjectiveTo describe characteristics of a series of patients reporting prolonged symptoms after an infection with coronavirus disease 2019 (COVID-19).Patients and MethodsThis study describes the multidisciplinary COVID-19 Activity Rehabilitation Program, established at Mayo Clinic to evaluate and treat patients with post–COVID syndrome, and reports the clinical characteristics of the first 100 patients receiving evaluation and management during the timeframe of June 1, 2020, and December 31, 2020.ResultsThe cohort consisted of 100 patients (mean age, 45.4±14.2 years; 68% women; mean body mass index, 30.2 kg/m²; presenting a mean of 93 days after infection). Common preexisting conditions were respiratory (23%) and mental health, including depression and/or anxiety (34%). Most (75%) had not been hospitalized for COVID-19. Common presenting symptoms ware fatigue (80%), respiratory complaints (59%), and neurological complaints (59%) followed by subjective cognitive impairment, sleep disturbance, and mental health symptoms. More than one-third of patients (34%) reported difficulties in performing basic activities of daily living. Only 1 in 3 patients had returned to unrestricted work duty at the time of the analysis. For most patients, laboratory and imaging tests showed no abnormalities or were nondiagnostic despite debilitating symptoms. Most patients required physical therapy, occupational therapy, or brain rehabilitation. Face-to-face and virtual care delivery modalities were feasible.ConclusionMost of the patients did not have COVID-19–related symptoms that were severe enough to require hospitalization, were younger than 65 years, and were more likely to be female, and most had no preexisting comorbidities before severe acute respiratory syndrome coronavirus 2 infection. Symptoms including mood disorders, fatigue, and perceived cognitive impairment resulted in severe negative impacts on resumption of functional and occupational activities in patients experiencing prolonged effects.