Impact of the COVID-19 outbreak on acute stroke care

Door to needle time trends after transition to tenecteplase: A Multicenter Texas stroke registry

BACKGROUND

Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase.

METHODS

The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times.

RESULTS

In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002).

CONCLUSION

In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

COVID-19 pandemic impacts on the elderly: the relationship between PPPD and prefrontal alpha rhythm

BACKGROUND

In the COVID-19 epidemic more patients presented with persistent postural-perceptual dizziness (PPPD), but it has received little attention by the doctors in China and many patients reject psychological measurements or scales. Therefore, there is an urgent need for an objective method to diagnose and evaluate PPPD.

OBJECTIVE

To investigate the effect of the COVID-19 epidemic on elderly PPPD patients and define the relationship between prefrontal alpha rhythm asymmetry (FAA) by Electroencephalography (EEG) and PPPD.

METHODS

This case-control study was conducted to discuss the differences of elderly outpatients (>60 years) with PPPD during the peak period of COVID-19 in 2020 and the corresponding period in 2019, and collect the prefrontal FAA value in PPPD during COVID-19 outbreak, which were compared to its FAA in healthy control.

RESULTS

Compared with the same period in 2019, the number of elderly PPPD patients during the epidemic period in 2020 increased significantly (16.4%, p = 0.000, x2 =31.802) . The left alpha wave signal power (F3) was significantly higher than the right alpha wave signal power (F4) (Z= -3.073, p = 0.002). In PPPD patients FAA were significantly lower in patients compared to control group (Z = -11.535, p = 0.000). There was a negative correlation between FAA and HAMA scores (R2 =0.906, p < 0.05) and a negative correlation between FAA and HAMD scores (R2 =0.859, p < 0.05), too.

CONCLUSIONS

The increase in cases of elderly PPPD patients is most likely attributed to the mental health in older adults during the COVID-19 pandemic. Less left frontal brain activity in EEG may be related to elderly PPPD.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

OBJECTIVES

Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.

DESIGN

We conducted a secondary data analysis with a quasi-experimental design.

SETTING

We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.

PARTICIPANTS

We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.

RESULTS

40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).

CONCLUSIONS

A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Manifestations and Outcomes of Intracerebral Hemorrhage During the COVID-19 Pandemic in China: Multicenter, Longitudinal Cohort Study

BACKGROUND

The COVID-19 pandemic has inevitably affected the distribution of medical resources, and epidemic lockdowns have had a significant impact on the nursing and treatment of patients with other acute diseases, including intracerebral hemorrhage (ICH).

OBJECTIVE

This study aimed to investigate how the COVID-19 pandemic affected the manifestations and outcomes of patients with ICH.

METHODS

Patients with acute ICH before (December 1, 2018-November 30, 2019) and during (December 1, 2019-November 30, 2020) the COVID-19 pandemic at 31 centers in China from the Chinese Cerebral Hemorrhage: Mechanism and Intervention (CHEERY) study were entered into the analysis. Demographic information and clinical manifestations and outcomes were collected and compared between the 2 groups.

RESULTS

From December 1, 2018, to November 30, 2020, a total of 3460 patients with ICH from the CHEERY study were enrolled and eventually analyzed. The results showed that during the COVID-19 pandemic, patients with ICH were more likely to be older (P<.001) with a history of ischemic stroke (P=.04), shorter time from onset to admission (P<.001), higher blood pressure (P<.001), higher fasting blood glucose (P=.003), larger hematoma volume (P<.001), and more common deep ICH (P=.01) and intraventricular hemorrhage (P=.02). These patients required more intensive care unit treatment (P<.001) and preferred to go to the hospital directly rather than call an ambulance (P<.001). In addition, the COVID-19 pandemic was associated with an increased risk of pulmonary infection during hospitalization (adjusted risk ratio [RRadjusted] 1.267, 95% CI 1.065-1.509), lower probability of a 3-month good outcome (RRadjusted 0.975, 95% CI 0.956-0.995), and a higher probability of in-hospital (RRadjusted 3.103, 95% CI 2.156-4.465), 1-month (RRadjusted 1.064, 95% CI 1.042-1.087), and 3-month (RRadjusted 1.069, 95% CI 1.045-1.093) mortality.

CONCLUSIONS

Our study indicated that the cloud of COVID-19 has adversely impacted the presentation and outcomes of ICH. Medical workers may pay more attention to patients with ICH, while the public should pay more attention to hypertension control and ICH prevention.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900020872; https://www.chictr.org.cn/showprojEN.html?proj=33817.

The impact of the COVID-19 pandemic on delayed care of cardiovascular diseases in Europe: a systematic review

AIMS

Cardiovascular diseases (CVD) are the leading cause of death worldwide. The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems, causing delays in essential medical services, and potentially impacting CVD treatment. This study aims to estimate the impact of the pandemic on delayed CVD care in Europe by providing a systematic overview of the available evidence.

METHODS AND RESULTS

PubMed, Embase, and Web of Science were searched until mid-September 2022 for studies focused on the impact of delayed CVD care due to the pandemic in Europe among adult patients. Outcomes were changes in hospital admissions, mortality rates, delays in seeking medical help after symptom onset, delays in treatment initiation, and change in the number of treatment procedures. We included 132 studies, of which all were observational retrospective. Results were presented in five disease groups: ischaemic heart diseases (IHD), cerebrovascular accidents (CVA), cardiac arrests (CA), heart failures (HF), and others, including broader CVD groups. There were significant decreases in hospital admissions for IHD, CVA, HF and urgent and elective cardiac procedures, and significant increases for CA. Mortality rates were higher for IHD and CVA.

CONCLUSION

The pandemic led to reduced acute CVD hospital admissions and increased mortality rates. Delays in seeking medical help were observed, while urgent and elective cardiac procedures decreased. Adequate resource allocation, clear guidelines on how to handle care during health crises, reduced delays, and healthy lifestyle promotion should be implemented. The long-term impact of pandemics on delayed CVD care, and the health-economic impact of COVID-19 should be further evaluated.

Clinical outcomes associated with speech, language and swallowing difficulties post-stroke

BACKGROUND

 There is a lack of prospective research in South Africa's speech therapy private sector, specifically, in the acute stroke population. There is a need to understand the quality of speech therapy services and outcomes post-stroke in the private sector.

OBJECTIVES

 This prospective cohort study investigated associations between speech, language, and swallowing conditions (i.e. dysarthria, apraxia of speech, aphasia, dysphagia), and outcomes post-stroke (i.e. length of hospital stay [LOS], degree of physical disability according to the Modified Rankin Scale [mRS], functional level of oral intake according to the Functional Oral Intake Scale [FOIS], dehydration, weight loss, aspiration pneumonia, mortality).

METHOD

 A prospective design was used to determine the incidence of speech, language, and swallowing conditions post-stroke. Convenience sampling was used to select participants (N = 68). Various statistical tests were used and the alpha level was set at Bonferroni correction p  0.01.

RESULTS

 Co-occurring speech, language, and swallowing conditions frequently occurred post-stroke (88%). Participants who were referred to speech therapy later than 24 h post-admission (52.94%) stayed in hospital for a median of 3 days longer than those who were referred within 24 h (p = 0.042). Dysphagia was significantly associated with moderate to severe physical disability (p  0.01). Dysphagia with aspiration was significantly associated with poor functional level of oral intake, at admission and at discharge (p  0.01). At discharge, aspiration pneumonia was significantly associated with severe physical disability (p  0.01, r = 0.70).

CONCLUSION

 In South Africa's private sector, co-occurring speech, language, and swallowing conditions commonly occurred post-stroke, and dysphagia was strongly associated with physical disability and poor functional level of oral intake. Length of hospital stay was increased by delayed speech therapy referrals.Contribution: This article contributes data on speech therapy services, communication and swallowing disorders post-stroke, and outcomes in South Africa's private sector.

A tale of two cities: A retrospective observational cohort study of the impact of COVID-19 on acute stroke presentation, timing, and outcomes

OBJECTIVES

The purpose of this study was to identify the impact of COVID-19-related "shelter in place" restrictions on stroke metrics in two metropolitan Texas cities, Austin and San Antonio.

MATERIALS AND METHODS

Data was derived from stroke quality metric registries and compared between two treatment periods: (1) during the state's COVID-19 "shelter in place" restriction period, and (2) the corresponding period during the previous year for Austin and San Antonio, Texas. Primary outcomes include the dichotomized process measures of time last known well (TLKW) to arrival, arrival to brain imaging initiation, and arrival to administration of thrombolytic therapy. Secondary outcomes are clinical endpoints: independent ambulation at discharge, discharge to home, and in-hospital mortality.

RESULTS

Austin patients were older and presented with less-severe strokes. San Antonio patients were more likely to be Hispanic, suffer from a large vessel occlusion, and have independent ambulation at discharge (adjusted odds ratio, 2.04; 95% confidence intervals, (1.25-3.37). Within-city analyses revealed a trend toward increased TLKW to arrival in Austin and San Antonio during COVID-19. During COVID, Austin patients had decreased length of stay (LOS) while a higher proportion of San Antonio patients had a favorable outcome (discharged home & independent ambulation).

CONCLUSIONS

Longer TLKW to hospital arrival during COVID did not impact arrival-to-imaging, arrival-to-treatment times nor patient outcomes, even in patients at higher risk for stroke. Future studies should continue to assess the impact of COVID-19 on stroke care and outcomes pre- and post-introduction of the COVID-19 vaccine, and as infectivity rates spike or recede.

The decline in stroke hospitalization due to COVID-19 is unrelated to COVID-19 intensity

BACKGROUND AND PURPOSE

During the coronavirus disease 2019 (COVID-19) pandemic many countries reported a decline in stroke volumes. The aim of this study was to analyze if the decline was related to the intensity of the COVID-19 pandemic.

METHODS

The first pandemic year (1 March 2020 to 28 February 2021) overall and during the three COVID-19 waves were compared with the preceding year. Volumes of acute ischaemic stroke (AIS), subarachnoid hemorrhage, intracerebral hemorrhage and recanalization treatments (intravenous thrombolysis [IVT] and mechanical thrombectomy [MT]) were obtained from the National Register of Reimbursed Health Services. Door-to-needle time, onset-to-door time and National Institutes of Health Stroke Scale at admission were obtained from the Registry of Stroke Care Quality.

RESULTS

During the pandemic year compared to the preceding year there were 26,453 versus 28,771 stroke admissions, representing an 8.8% decline (p < 0.001). The declines (-10%, -11%, -19%) appeared in COVID-19 waves (spring 2020, autumn 2020, winter 2021) except for an increase (2%) during summer 2020. Admissions for AIS declined by 10.2% (p < 0.001), whilst hemorrhagic stroke volumes were minimally decreased. The absolute volumes of IVT and MT decreased by 9.4% (p < 0.001) and 5.7% (p = 0.16), respectively. However, the proportions of ischaemic stroke patients receiving IVT (18% vs. 18%; p = 0.72) and MT (6% vs. 6%; p = 0.28) remained unchanged.

CONCLUSIONS

There was a decline in stroke admissions, but such decline was not related to COVID-19 incidence. The frequency of use of recanalization procedures (IVT, MT) and times (onset-to-door time, door-to-needle time) in AIS were preserved in the Czech Republic during the first year of the pandemic.

Association of the COVID-19 pandemic on stroke admissions and treatment globally: a systematic review

OBJECTIVES

The COVID-19 pandemic has highlighted insufficiencies and gaps within healthcare systems globally. In most countries, including high-income countries, healthcare facilities were over-run and occupied with too few resources beyond capacity. We carried out a systematic review with a primary aim to identify the influence of the COVID-19 pandemic on the presentation and treatment of stroke globally in populations≥65 years of age.

DESIGN

A systematic review was completed. In total, 38 papers were included following full-text screening.

DATA SOURCES

PubMed, MEDLINE and Embase.

ELIGIBILITY CRITERIA

Eligible studies included observational and real-world evidence publications with a population who have experienced stroke treatment during the COVID-19 pandemic. Exclusion criteria included studies comparing the effect of the COVID-19 infection on stroke treatment and outcomes.

DATA EXTRACTION AND SYNTHESIS

Primary outcome measures extracted were the number of admissions, treatment times and patient outcome. Secondary outcomes were severity on admission, population risk factors and destination on discharge. No meta-analysis was performed.

RESULTS

This review demonstrated that 84% of studies reported decreased admissions rates during the COVID-19 pandemic. However, among those admitted, on average, had higher severity of stroke. Additionally, in-hospital stroke treatment pathways were affected by the implementation of COVID-19 protocols, which resulted in increased treatment times in 60% of studies and increased in-hospital mortality in 82% of studies by 100% on average. The prevalence of stroke subtype (ischaemic or haemorrhagic) and primary treatment methods (thrombectomy or thrombolysis) did not vary due to the COVID-19 pandemic.

CONCLUSIONS

During the COVID-19 pandemic, many populations hesitated to seek medical attention, decreasing hospital admissions for less severe strokes and increasing hospitalisation of more severe cases and mortality. The effect of the pandemic on society and healthcare systems needs to be addressed to improve stroke treatment pathways and prepare for potential future epidemics.

PROSPERO REGISTRATION NUMBER

CRD42021248564.

Experiences of postnatal mothers with quality of care including water, sanitation and hygiene amenities during the outbreak of COVID - 19 in Ghana: An institutional cross-sectional study

Objective

To investigate the experiences and perceptions of postnatal mothers with quality of healthcare including WASH amenities among postnatal mothers in Ghana during the COVID-19 outbreak.

Study design

The study was an institutional cross-sectional.

Methods

The survey was conducted in six (6) regions across the northern, middle, and coastal belts of Ghana among postnatal mothers (n = 424). Eligible respondents accessed antenatal care (ANC) in 12 healthcare facilities (primary level and secondary level) during the outbreak of COVID-19 pandemic. Univariate ordered logistic regression analysis was conducted to predict determinants of overall perceived quality of healthcare and experiences with WASH amenities in healthcare facilities visited.

Findings

Privacy and confidentiality (mean score = 3.07) were the most highly rated quality indicator while the least rated indicator was dignity and respect of clients (mean score = 2.13). Approximately 50% of postnatal mothers reported paying out-of-pocket for essential ANC medications. Perceived quality of healthcare was positive among those who accessed care at a district/municipal hospital (Coef. = 1.29; 95%CI 0.45, 2.13, p = 0.003); co-habiting with a partner (Coef. = 1.64; 95%CI 0.64, 2.65, p = 0.001), and resident in an urban location (Coef. = 2.30; 95%CI 0.30, 3.30, p = 0.001). Mothers who accessed care at a district or municipal hospital (Coef. = 1.81; 95%CI 0.83, 2.78, p = 0.001); were co-habiting with a partner (Coef. = 1.92; 95%CI 0.76, 3.07, p = 0.001), and had a private health insurance cover (Coef. = 3.18; 95%CI 0.69, 5.67, p = 0.012) were more likely to rank WASH amenities better than their comparators.

Conclusion

Overall perception of postnatal mothers of healthcare quality including WASH amenities after outbreak of COVID-19 was good, but with significant concerns about dignity and respect accorded them during care and having to pay out-of-pocket for some ANC medications. Relevant managers, service providers and regulatory institutions are encouraged to initiate and sustain policy dialogues and stakeholder consultations on the healthcare quality care gaps established in this study. There is the need for more investments in WASH amenities in the health sector as a quality assurance strategy, especially for maternal and child health services.

Impact of the COVID-19 pandemic lockdown on hospitalizations for cerebrovascular disease and related in-hospital mortality in China: A nationwide observational study

BACKGROUND AND PURPOSE

The aim of this nationwide study was to assess the impact of the COVID-19 pandemic on cerebrovascular disease hospitalization rates, out-of-pocket rates, and in-hospital case fatality rates.

METHODS

All hospitalizations for cerebrovascular disease from 1599 hospitals from 2019 to 2020 were selected using the International Classification of Diseases, 10th revision, in the Hospital Quality Monitoring System (HQMS). We defined 2019 as the pre-pandemic group and 2020 as the post-pandemic group. Multivariate analyses were done to assess the association between the pandemic and patient outcomes and out-of-pocket rate with odds ratios (OR) and 95% CIs presented.

RESULTS

In total, 9 640 788 patients with the cerebrovascular disease were recruited (mean age was 65.7[SE.0.004] years, and 55.7% were male), and data is available for 5145358 patients in 2019 (pre-epidemic) and 4495430 patients in 2020(post-pandemic), indicating a 12.6% decrease. Out-of-pocket rate increase of 9.3% (2020 vs 2019: 34.1%% vs 31.2% [absolute difference, 2.9% {95% CI, 1.3% to 4.5%}, odd ratio {OR}, 1.1{95% CI, 1.0 to 1.1}]. The epidemic has led to an 18.0% increase in in-hospital mortality (2020 vs 2019: 1.1%% vs 0.9% [absolute difference, 0.2% {95% CI, 0.1% to 0.2%}, odd ratio {OR}, 1.1{95% CI, 1.1 to 1.2}]. The epidemic has led to significantly increased in-hospital mortality for patients with stroke but had no significant impact on other cerebrovascular diseases.

CONCLUSIONS

During the COVID-19 pandemic lockdown, patients hospitalized for stroke fell by 12.6%, and there were substantial increases in out-of-pocket rates (9.3%) and in-hospital case fatality rates (18.0%).

Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!

Background:

In acute ischemic stroke, timely treatment is of utmost relevance. Identification of delaying factors and knowledge about challenges concerning hospital structures are crucial for continuous improvement of process times in stroke care.

Objective:

In this study, we report on our experience in optimizing the door-to-needle time (DNT) at our tertiary care center by continuous quality improvement.

Methods:

Five hundred forty patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in two phases. In study phase I, including 292 patients, process times and delaying factors were collected prospectively from May 2015 until September 2017. In study phase II, process times of 248 patients were obtained from January 2019 until February 2021. In each study phase, a new clinical standard operation procedure (SOP) was implemented, considering previously identified delaying factors. Pre- and post-SOP treatment times and delaying factors were analyzed to evaluate the new protocols.

Results:

In study phase I, SOP I reduced the median DNT by 15 min. The probability to receive treatment within 30 min after admission increased by factor 5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of the SOP with implementation of a mobile thrombolysis kit led to a further decrease of DNT by 5 min in median in study phase II. The median DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to undergo IVT within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83) compared with study phase I.

Conclusion:

Continuous process analysis and subsequent development of targeted workflow adjustments led to a substantial improvement of DNT. These results illustrate that with appropriate vigilance, there is constantly an opportunity for improvement in stroke care.

Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France

OBJECTIVE

To assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who had a stroke and ST-segment elevation myocardial infarction (STEMI).

DESIGN

Two cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry.

SETTING

6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region.

PARTICIPANTS

This study involved 9218 patients (6436 patients who had a stroke and 2782 patients who had an STEMI) in the CNV Registry from January 2019 to August 2020.

METHOD

Hospital reorganisations, retrieved in a scoping review, were collected from heads of hospital departments. Other data were from the CNV Registry. Associations between reorganisations, use of care and care management times were analysed using multivariate linear regression mixed models. Interaction terms between use-of-care variables and period (pre-wave, per-wave and post-wave) were introduced.

MAIN OUTCOME MEASURES

STEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time.

RESULTS

Per-wave period management times deteriorated for stroke but were maintained for STEMI. Per-wave changes in use of care did not affect STEMI management. No association was found between reorganisations and stroke management times. In the STEMI cohort, the implementation of systematic testing at admission was associated with a 41% increase in care management time (exp=1.409, 95% CI 1.075 to 1.848, p=0.013). Implementation of plan blanc, which concentrated resources in emergency activities, was associated with a 19% decrease in management time (exp=0.801, 95% CI 0.639 to 1.023, p=0.077).

CONCLUSIONS

The pandemic did not markedly alter the functioning of the emergency network. Although stroke patient management deteriorated, the resilience of the STEMI pathway was linked to its stronger structuring. Transversal reorganisations, aiming at concentrating resources on emergency care, contributed to maintenance of the quality of care.

TRIAL REGISTRATION NUMBER

NCT04979208.

Acute ischemic stroke and COVID-19 pandemic in Brazil: a comparative study of frequency and risk factors before and during SARS-CoV-2 era

Background

COVID-19 pandemic directly impacted the request for hospital care and medical assistance for several diseases worldwide, as occurred with acute ischemic stroke. The present study sought to compare the incidence and severity of acute ischemic stroke (AIS), in addition to sociodemographic, clinical, and radiological characteristics of patients hospitalized in the prepandemic (2018–2019) and pandemic (2020–2021) eras.

Methods

An incidence case–control, observational, and analytical research was carried out in the Stroke Unit of Hospital Governador Celso Ramos, Florianopolis, Santa Catarina, Brazil, including 171 patients admitted with acute ischemic stroke from April 2018 to April 2019 (prepandemic era) and 148 patients between January 2020 and January 2021 (during pandemic).

Results

The mean incidence of AIS hospital admissions was significantly lower in the pandemic period (CI 95%, 0.2 to 5.6; p = 0.04), being lower in the lockdown periods and when the incidence of new COVID-19 cases increased. Besides, referring to AIS severity, the mean areas of AIS were larger during the pandemic period (p < 0.01), especially in August, September, December, and January (p < 0.05). Sociodemographic and clinical variables did not show any difference between the two periods of the study.

Conclusions

Hospital admissions for AIS decreased in the COVID-19 pandemic, mostly during months of higher incidences of new COVID-19 cases. When the incidence of admissions diminished, an increase in the severity of AIS was observed, characterized by larger areas. These findings might contribute to other similar referral centers in managing public policies related to stroke.

Intravenous Thrombolysis for Acute Ischemic Stroke during the COVID-19 Pandemic-Polish Single-Center Retrospective Cohort Study

COVID-19 has affected the entire world and has had a great impact on healthcare, influencing the treatment of patients with acute ischemic stroke (AIS). The aim of this study was to determine the impact of the COVID-19 pandemic on the care of patients with AIS. We performed a retrospective analysis of 1599 patients diagnosed with AIS and hospitalized in the authors' institution from January 2018 to December 2021. The final sample consisted of 265 patients treated with thrombolysis without a diagnosis of COVID-19. The initiation of thrombolytic treatment during the pandemic was delayed (2:42 ± 0:51 vs. 2:25 ± 0:53; p = 0.0006). The delay was mainly related to the pre-hospital phase (1:41 ± 0:48 vs. 1:26 ± 0:49; p = 0.0014), and the door-to-needle time was not affected. There were no differences in stroke severity and patients' outcomes. Patients with AIS were less likely to have previously been diagnosed with atrial fibrillation (16.9% vs. 26.7%; p = 0.0383), ischemic heart disease (25.3% vs. 46.5%; p = 0.0003) and hyperlipidemia (31.2% vs. 46.5%; p = 0.0264). Patients treated during the pandemic had higher glycemia (149.45 ± 54. vs. 143.25 ± 60.71 mg/dL; p= 0.0012), while no significant differences in their lipid profiles were found. Conclusions: The COVID-19 pandemic affected the treatment of AIS patients locally at our stroke center. It caused treatment delay and hindered the recognition of risk factors prior to the occurrence of AIS.

Impact of COVID-19 on emergency department management of stroke and STEMI. A narrative review

The novel coronavirus of 2019 (COVID-19) has resulted in a global pandemic; COVID-19 has resulted in significant challenges in the delivery of healthcare, including emergency management of multiple diagnoses, such as stroke and ST-segment myocardial infarction (STEMI). The aim of this study was to identify the impacts of the COVID-19 pandemic on emergency department care of stroke and STEMI patients. In this study a review of the available literature was performed using pre-defined search terms, inclusion criteria, and exclusion criteria. Our analysis, using a narrative review format, indicates that there was not a significant change in time required for key interventions for stroke and STEMI emergent management, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). Potential future areas of investigation include how emergency department (ED) stroke and STEMI care has adapted in response to different COVID-19 variants and stages of the pandemic, as well as identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic.

How have COVID-19 stringency measures changed scholarly activity?

Government restrictions to the movement of people due to the COVID-19 pandemic have had a wide range of effects on scientific activity. Here, we show that during the pandemic there has been a reduction in the number of registered non-COVID-19 clinical trials. Furthermore, using the Oxford COVID-19 Government Response Tracker Stringency Index (SI) as an indicator of COVID-19-related workplace adjustment (e.g., restrictions on gatherings, workplace closures, and stay-at-home orders), we demonstrate that this drop in clinical trial registration has been greater in countries with a higher SI. This could have significant consequences for the discovery of treatments that are required to reduce the global burden of disease.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background

Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems.

Objective

To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic.

Methods

Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel.

Result

There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients.

Conclusions

COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00836-2.

Did the severity of the COVID-19 outbreak affect the quality of acute stroke care? (Data from across the country)

Introduction

The aim of our study was to determine whether the severity of the COVID-19 pandemic affected the quality of acute care of stroke.

Methods

Data from the stroke register at the National Health Information Centre were analysed. Clinical data from two time periods (the first wave: March-April 2020; the second wave: October-November 2020) were compared using an independent sample t-test and the Wilcoxon-Mann-Whitney two sample rank-sum test.

Results

The total number of patients admitted with stroke during the second wave of COVID-19 was 1848, versus 1698 in the first wave. The proportion of patients treated by IVT was similar in both waves (275 (20.7%) vs 333 (22.1%), p = 1, difference in location: -0,0003, 95% CI: -5.0 to 5.95). We found no difference in time from the onset of symptoms to treatment (median = 130 min in both waves, p = 0.52, difference in location: 3.99, 95% CI: -6.0 to 14.0), nor in the door-to-needle time (median = 29 vs 30 min, p = 0.08, difference in location: -2.99, 95% CI: -5.0 to 0.008) between the first and the second waves of the pandemic. We found no difference in NIHSS (median = 3 vs 4, p = 0.51, difference in location: 0.00007, 95% CI: -0.9 to 0.000006) and mRS (median = 3 in both waves, p = 0.60, difference in location: -0.00004, 95% CI: -0.00004 to 0.00003) at discharge from hospital between the two periods.

Conclusion

The severity of the COVID-19 outbreak did not affect the quality of acute stroke care in Slovakia.

The Spill-Over Impact of the Novel Coronavirus-19 Pandemic on Medical Care and Disease Outcomes in Non-communicable Diseases: A Narrative Review

Objectives: The coronavirus-19 (COVID-19) pandemic has claimed more than 5 million lives worldwide by November 2021. Implementation of lockdown measures, reallocation of medical resources, compounded by the reluctance to seek help, makes it exceptionally challenging for people with non-communicable diseases (NCD) to manage their diseases. This review evaluates the spill-over impact of the COVID-19 pandemic on people with NCDs including cardiovascular diseases, cancer, diabetes mellitus, chronic respiratory disease, chronic kidney disease, dementia, mental health disorders, and musculoskeletal disorders.

Methods: Literature published in English was identified from PubMed and medRxiv from January 1, 2019 to November 30, 2020. A total of 119 articles were selected from 6,546 publications found.

Results: The reduction of in-person care, screening procedures, delays in diagnosis, treatment, and social distancing policies have unanimously led to undesirable impacts on both physical and psychological health of NCD patients. This is projected to contribute to more excess deaths in the future.

Conclusion: The spill-over impact of COVID-19 on patients with NCD is just beginning to unravel, extra efforts must be taken for planning the resumption of NCD healthcare services post-pandemic.

Changes in dementia diagnoses in Sweden during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has caused large disruptions to healthcare systems. Refocus on COVID-19 related care might have contributed to indirect effects on other healthcare areas. Care focused on acute conditions have been negatively affected although research into the effects on chronic and care intensive patient groups such as patients with dementia diseases is lacking. In this study we evaluated dementia diagnosis trends in Sweden during 2015–2020 according to International Classification of Disease version 10 coding of common dementia diseases.

Methods

Regional and national statistics in the form of International Classification of Disease version 10 coding, COVID-19 incidence, mortality data, and population census data were collected from the National Institute of Health and Welfare. Logistic regression analysis was performed to identify trends of dementia diagnosis during 2015–2020. Correlation test was performed between COVID-19 incidence, mortality rates, and dementia coding.

Results

Dementia diagnosis incidence has been declining since 2015 and further decline was noted in many regions in Sweden during 2020. As COVID-19 incidence increased, fewer cases of dementia were diagnosed, a decrease that differentially impacted women and those who were advanced in age.

Conclusions

Dementia diagnosis incidence in Sweden has been on a decline since 2015. The COVID-19 pandemic caused a further larger decline in dementia diagnosis incidence during 2020. COVID-19 incidence, but not mortality, was associated with decrease in dementia diagnosis incidence. There might be a large number of undiagnosed patients with dementia and healthcare reforms should be enacted to address this. Women and elderly are particularly vulnerable groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03070-y.

Effect of the COVID-19 Pandemic in the Prehospital Management of Patients with Suspected Acute Stroke: A Retrospective Cohort Study

Acute Ischemic Stroke (AIS) can be successfully handled if it is noticed early in the prehospital setting and immediately diagnosed in the emergency department (ED). The coronavirus pandemic has altered the way health care is delivered and has had a profound impact on healthcare delivery. The effects could include prioritizing the prevention of COVID-19 spread, which could result in the discontinuation or deferral of non-COVID-19 care. We used the National Emergency Medical Service Command Support System, a register of medical interventions performed by emergency medical services (EMS) in Poland, to assess the impact of the COVID-19 epidemic across the Masovian Voivodeship on suspected stroke patients’ baseline characteristics, prehospital vital parameters, clinical and neurological status, emergency procedures performed on the prehospital phase and EMS processing times. Between 1 April 2019 and 30 April 2021, the study population included 18,922 adult suspected stroke patients who were treated by EMS teams, with 18,641 admitted to the emergency departments. The overall number of suspected stroke patients treated by EMS remained unchanged during COVID-19 compared to the pre-COVID-19 period; however, the average time from call to hospital admission increased by 15 min.

Effects of the COVID-19 pandemic on stroke response times: a systematic review and meta-analysis

OBJECTIVES

COVID-19 presents a risk for delays to stroke treatment. We examined how COVID-19 affected stroke response times.

METHODS

A literature search was conducted to identify articles covering stroke during COVID-19 that included time metrics data pre- and post-pandemic. For each outcome, pooled relative change from baseline and 95% CI were calculated using random-effects models. Heterogeneity was explored through subgroup analyses comparing comprehensive stroke centers (CSCs) to non-CSCs.

RESULTS

38 included studies reported on 6109 patients during COVID-19 and 14 637 patients during the pre-COVID period. Pooled increases of 20.9% (95% CI 5.8% to 36.1%) in last-known-well (LKW) to arrival times, 1.2% (-2.9% to 5.3%) in door-to-imaging (DTI), 0.8% (-2.9% to 4.5%) in door-to-needle (DTN), 2.8% (-5.0% to 10.6%) in door-to-groin (DTG), and 19.7% (11.1% to 28.2%) in door-to-reperfusion (DTR) times were observed during COVID-19. At CSCs, LKW increased by 24.0% (-0.3% to 48.2%), DTI increased by 1.6% (-3.0% to 6.1%), DTN increased by 3.6% (1.2% to 6.0%), DTG increased by 4.6% (-5.9% to 15.1%), and DTR increased by 21.2% (12.3% to 30.1%). At non-CSCs, LKW increased by 12.4% (-1.0% to 25.7%), DTI increased by 0.2% (-2.0% to 2.4%), DTN decreased by -4.6% (-11.9% to 2.7%), DTG decreased by -0.6% (-8.3% to 7.1%), and DTR increased by 0.5% (-31.0% to 32.0%). The increases during COVID-19 in LKW (p=0.01) and DTR (p=0.00) were statistically significant, as was the difference in DTN delays between CSCs and non-CSCs (p=0.04).

CONCLUSIONS

Factors during COVID-19 resulted in significantly delayed LKW and DTR, and mild delays in DTI, DTN, and DTG. CSCs experience more pronounced delays than non-CSCs.

Quality of Care and Outcomes for Patients with Acute Ischemic Stroke and Transient Ischemic Attack During the COVID-19 Pandemic

Background and Purpose

Hospitalizations for acute ischemic stroke (AIS) and transient ischemic attack (TIA) decreased during the COVID-19 pandemic. We compared the quality of care and outcomes for patients with AIS/TIA before vs. during the COVID-19 pandemic across the United States Department of Veterans Affairs healthcare system.

Methods

This retrospective cohort study compared AIS/TIA care quality before (March–September 2019) vs. during (March-September 2020) the pandemic. Electronic health record data were used to identify patient characteristics, quality of care and outcomes. The without-fail rate was a composite measure summarizing whether an individual patient received all of the seven processes for which they were eligible. Mixed effects logistic regression modeling was used to assess differences between the two periods.

Results

A decrease in presentations occurred during the pandemic (N = 4360 vs. N = 5636 patients; p = 0.003) and was greater for patients with TIA (-30.4%) than for AIS (-18.7%). The without-fail rate improved during the pandemic (56.2 vs. before 50.1%). The use of high/moderate potency statins increased among AIS patients (OR 1.26 [1.06–1.48]) and remained unchanged among those with TIA (OR 1.04 [0.83,1.29]). Blood pressure measurement within 90-days of discharge was less frequent during the pandemic (57.8 vs. 89.2%, p < 0.001). Hypertension control decreased among patients with AIS (OR 0.73 [0.60–0.90]) and TIA (OR 0.72 [0.54-0.96]). The average systolic and diastolic blood pressure was 1.9/1.4 mmHg higher during the pandemic than before (p < 0.001). Compared to before, during the pandemic fewer AIS patients had a primary care visit (52.5% vs. 79.8%; p = 0.0001) or a neurology visit (27.9 vs. 41.1%; p = 0.085). Both 30- and 90-day unadjusted all-cause mortality rates were higher in 2020 (3.6% and 6.7%) vs. 2019 (2.9, 5.4%; p = 0.041 and p = 0.006); but these differences were not statistically significant after risk adjustment.

Conclusions

Overall quality of care for patients with AIS/TIA did not decline during the COVID-19 pandemic.

A un año de la pandemia en Argentina, características clínicas de pacientes con accidente cerebral agudo en una cohorte hospitalaria y sus implicancias

Introducción

Materiales y métodos

Resultados

Conclusión

Acute Stroke Care during COVID-19: National Data

(1) Background: The pandemic of COVID-19 and subsequent lockdown strategies had a profound impact on many aspects of everyday life. During this time the world faced the unprecedented crisis of healthcare disrupting timely care delivery. This study was designed to evaluate the impact of the pandemic on the acute treatment of stroke in Poland. (2) Methods: The national data on hospitalizations with stroke as a primary diagnosis were obtained from the National Health Fund of Poland. Poisson regression was used to determine the significance of the change in hospital admissions. The differences between proportions were analyzed using the “N-1” Chi-squared test. (3) Results: During the COVID-19 period, the number of hospitalizations dropped by 8.28% with a monthly nadir of 22.02 in April. On a monthly scale during 2020, the greatest decrease was 22.02%. The thrombolysis ratio was also affected, with the highest monthly drop of 15.51% in November. The overall number of in-hospital deaths did not change. (4) Conclusions: The pandemic caused a serious disruption of the acute care of stroke. There is no evidence that the quality of care was seriously compromised.

Impact of the SARS-CoV-2 pandemic on trauma care: a nationwide observational study

Purpose

The SARS-CoV-2 pandemic severely disrupted society and the health care system. In addition to epidemiological changes, little is known about the pandemic’s effects on the trauma care chain. Therefore, in addition to epidemiology and aetiology, this study aims to describe the impact of the SARS-CoV-2 pandemic on prehospital times, resource use and outcome.

Methods

A multicentre observational cohort study based on the Dutch Nationwide Trauma Registry was performed. Characteristics, resource usage, and outcomes of trauma patients treated at all trauma-receiving hospitals during the first (W1, March 12 through May 11) and second waves (W2, May 12 through September 23), as well as the interbellum period in between (INT, September 23 through December 31), were compared with those treated from the same periods in 2018 and 2019.

Results

The trauma caseload was reduced by 20% during the W1 period and 11% during the W2 period. The median length of stay was significantly shortened for hip fracture and major trauma patients (ISS ≥ 16). A 33% and 66% increase in the prevalence of minor self-harm-related injuries was recorded during the W1 and W2 periods, respectively, and a 36% increase in violence-related injuries was recorded during the INT. Mortality was significantly higher in the W1 (2.9% vs. 2.2%) and W2 (3.2% vs. 2.7%) periods.

Conclusion

The imposed restrictions in response to the SARS-CoV-2 pandemic led to diminished numbers of acute trauma admissions in the Netherlands. The long-lasting pressing demand for resources, including ICU services, has negatively affected trauma care. Further caution is warranted regarding the increased incidence of injuries related to violence and self-harm.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01891-5.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study

OBJECTIVE

To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands.

SUMMARY BACKGROUND DATA

Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome.

METHODS

A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period).

RESULTS

During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012).

CONCLUSIONS

The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis

Background and Purpose There are reports of decline in the rates of acute emergency presentations during coronavirus disease 2019 (COVID-19) pandemic including stroke. We performed a meta-analysis of the impact of COVID-19 pandemic on rates of stroke presentations and on rates of reperfusion therapy.Methods Following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, we systematically searched the literature for studies reporting changes in stroke presentations and treatment rates before and during the COVID-19 pandemic. Aggregated data were pooled using meta-analysis with random-effect models.Results We identified 37 observational studies (n=375,657). Pooled analysis showed decline in rates of all strokes (26.0%; 95% confidence interval [CI], 22.4 to 29.7) and its subtypes; ischemic (25.3%; 95% CI, 21.0 to 30.0), hemorrhagic (27.6%; 95% CI, 20.4 to 35.5), transient ischemic attacks (41.9%; 95% CI, 34.8 to 49.3), and stroke mimics (45.6%; 95% CI, 33.5 to 58.0) during months of pandemic compared with the pre-pandemic period. The decline was most evident for mild symptoms (40% mild vs. 25%–29% moderate/severe). Although rates of intravenous thrombolytic (IVT) and endovascular thrombectomy (EVT) decreased during pandemic, the likelihood of being treated with IVT and EVT did not differ between the two periods, both in primary and in comprehensive stroke centers (odds ratio [OR], 1.08; 95% CI, 0.94 to 1.24 and OR, 0.95; 95% CI, 0.83 to 1.09, respectively).Conclusions Rates of all strokes types decreased significantly during pandemic. It is of paramount importance that general population should be educated to seek medical care immediately for stroke-like symptoms during COVID-19 pandemic. Whether delay in initiation of secondary prevention would affect eventual stroke outcomes in the long run needs further study.

Family Caregivers' Experiences and Coping Strategies in Managing Stroke Patients during the COVID-19 Pandemic: A Qualitative Exploration Study

BACKGROUND

Stroke is a chronic disease that requires stroke survivors to be supported long-term by their families. This is especially because of the inaccessibility to post-stroke rehabilitation outside hospitals. The Corona Virus Disease 2019 (COVID-19) crisis and the pandemic restrictions in Malaysia are expected to exponentially increase the demand from family caregivers in supporting stroke survivors. Thus, this study aims to explore the burden, experience, and coping mechanism of the family caregivers supporting stroke survivors during the COVID-19 pandemic.

METHODOLOGY

A phenomenological qualitative study was conducted from November 2020 to June 2021 in Malaysia. A total of 13 respondents were recruited from two public rehabilitation centers in Kota Bharu, Kelantan. In-depth interviews were conducted with the participants. Comprehensive representation of perspectives from the respondents was achieved through purposive sampling. The interviews were conducted in the Kelantanese dialect, recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Three themes on burdens and experiences were identified. They were worsening pre-existing issues, emerging new issues, and fewer burdens and challenges. Two themes on coping strategies were also identified. They were problem-focused engagement and emotion-focused engagement.

CONCLUSIONS

The COVID-19 pandemic has changed the entire system of stroke management. While family caregivers mostly faced the extra burden through different experiences, they also encountered some positive impacts from the pandemic. The integrated healthcare system, especially in the era of digitalization, is an important element to establish the collaborative commitment of multiple stakeholders to compensate burden and sustain the healthcare of stroke survivors during the pandemic.

Impact of the COVID-19 lockdown on the adherence of stroke patients to direct oral anticoagulants: a secondary analysis from the MAAESTRO study

BACKGROUND

The negative impact of the COVID-19 outbreak on stroke care has been reported, but no data exist on the influence of the lockdown on medication adherence to antithrombotic treatment for stroke prevention. We present a comparison of electronic adherence data of stroke patients treated with direct oral anticoagulants (DOAC) prior to and during the COVID-19 lockdown in spring 2020 in Switzerland.

METHODS

This is a secondary analysis using data from the ongoing MAAESTRO study, in which stroke patients with atrial fibrillation electronically monitor their adherence to DOAC treatment. Eligible patients for this analysis had at least four weeks of adherence data prior to and during the COVID-19 lockdown. Three adherence metrics (taking adherence, timing adherence, drug holidays) were calculated and compared descriptively.

RESULTS

The analysis included eight patients (median age 81.5 years, IQR 74.8-84.5). Five patients had a pre-lockdown taking adherence over 90% (mean 96.8% ± 2.9), with no change during lockdown, high timing adherence in both periods and no drug holidays. The remaining three patients had pre-lockdown taking and timing adherence below 90%. Of those, two patients showed a moderate decline either in taking or timing adherence compared to pre-lockdown. One showed a substantial increase in taking and timing adherence during lockdown (both + 25.8%).

CONCLUSION

Our data suggest that a major disruption of social life (i.e., the imposed COVID-19 lockdown) is unlikely to relevantly affect the medication intake behaviour of patients with high pre-established adherence, but might have an impact in patients with previously suboptimal adherence.

TRIAL REGISTRATION NUMBER

MAAESTRO: electronic Monitoring and improvement of Adherence to direct oral Anticoagulant treatment-a randomized crossover study of an Educational and reminder-based intervention in ischaemic STROke patients under polypharmacy, NCT03344146.

Risk, Clinical Course, and Outcome of Ischemic Stroke in Patients Hospitalized With COVID-19: A Multicenter Cohort Study

BACKGROUND AND PURPOSE

The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19.

METHODS

We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke.

RESULTS

We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%; P=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52-2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13-2.15]) than patients without stroke.

CONCLUSIONS

In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

The impact of COVID-19 on acute stroke care in Belgium

A worldwide decline in stroke hospitalizations during the COVID-19 pandemic has been reported. Information on stroke care during the pandemic in Belgium is lacking. This study aims to analyze the impact of COVID-19 on acute stroke care in eight Belgian stroke centers. This Belgian study is part of an international observational and retrospective study in 70 countries and 457 stroke centers. We compared volumes of COVID-19 and stroke hospitalizations, intravenous thrombolysis and endovascular treatment rates, acute treatment time intervals and functional outcome at 90 days during the first wave of the pandemic to two control intervals (March–May 2019 and December–February 2020). From March 2020 to May 2020, 860 stroke patients were hospitalized. In the same time period, 2850 COVID-19 patients were admitted, of which 37 (1.3%) were diagnosed with a stroke. Compared to the months prior to the pandemic and the same time epoch one year earlier, stroke hospitalizations were reduced (relative difference 15.9% [p = 0.03] and 14.5% [p = 0.05], respectively). Despite a reduction in absolute volumes, there was no difference in the monthly proportion of thrombolysis or endovascular treatment provided to the overall stroke hospitalizations. Acute treatment time metrics did not change between COVID-19 pandemic and control time epochs. We found no difference in 90-day functional outcomes nor in mortality after stroke between patients admitted during the pandemic versus control periods. We found a decline in the volume of stroke hospitalizations during the first wave of the COVID-19 pandemic in Belgium. Stroke care quality parameters remained unchanged.

Impact of the COVID-19 pandemic on emergency department visits: experience of a Brazilian reference center

Objective

To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil.

Methods

A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients’ demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19.

Results

A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits – a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020.

Conclusion

The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.

Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

We systematically evaluated the impact of the coronavirus 2019 (COVID-19) pandemic on stroke care across the world.

METHODS

Observational studies comparing characteristics, acute treatment delivery, or hospitalization outcomes between patients with stroke admitted during the COVID-19 pandemic and those admitted before the pandemic were identified by Medline, Scopus, and Embase databases search. Random-effects meta-analyses were conducted for all outcomes.

RESULTS

We identified 46 studies including 129 491 patients. Patients admitted with stroke during the COVID-19 pandemic were found to be younger (mean difference, -1.19 [95% CI, -2.05 to -0.32]; I²=70%) and more frequently male (odds ratio, 1.11 [95% CI, 1.01-1.22]; I²=54%) compared with patients admitted with stroke in the prepandemic era. Patients admitted with stroke during the COVID-19 pandemic, also, had higher baseline National Institutes of Health Stroke Scale scores (mean difference, 0.55 [95% CI, 0.12-0.98]; I²=90%), higher probability for large vessel occlusion presence (odds ratio, 1.63 [95% CI, 1.07-2.48]; I²=49%) and higher risk for in-hospital mortality (odds ratio, 1.26 [95% CI, 1.05-1.52]; I²=55%). Patients with acute ischemic stroke admitted during the COVID-19 pandemic had higher probability of receiving endovascular thrombectomy treatment (odds ratio, 1.24 [95% CI, 1.05-1.47]; I²=40%). No difference in the rates of intravenous thrombolysis administration or difference in time metrics regarding onset to treatment time for intravenous thrombolysis and onset to groin puncture time for endovascular thrombectomy were detected.

CONCLUSIONS

The present systematic review and meta-analysis indicates an increased prevalence of younger patients, more severe strokes attributed to large vessel occlusion, and higher endovascular treatment rates during the COVID-19 pandemic. Patients admitted with stroke during the COVID-19 pandemic had higher in-hospital mortality. These findings need to be interpreted with caution in view of discrepant reports and heterogeneity being present across studies.

Stroke Hospitalizations Before and During COVID-19 Pandemic Among Medicare Beneficiaries in the United States

Supplemental Digital Content is available in the text.

Background and Purpose:

Emergency department visits and hospitalizations for stroke declined significantly following declaration of coronavirus disease 2019 (COVID-19) as a national emergency on March 13, 2020, in the United States. This study examined trends in hospitalizations for stroke among Medicare fee-for-service beneficiaries aged ≥65 years and compared characteristics of stroke patients during COVID-19 pandemic to comparable weeks in the preceding year (2019).

Methods:

For trend analysis, we examined stroke hospitalizations from week 1 in 2019 through week 44 in 2020. For comparison of patient characteristics, we estimated percent reduction in weekly stroke hospitalizations from 2019 to 2020 during weeks 10 through 23 and during weeks 24 through 44 by age, sex, race/ethnicity, and state.

Results:

Compared to weekly numbers of hospitalizations for stroke reported during 2019, stroke hospitalizations in 2020 decreased sharply during weeks 10 through 15 (March 1–April 11), began increasing during weeks 16 through 23, and remained at a level lower than the same weeks in 2019 from weeks 24 through 44 (June 7–October 31). During weeks 10 through 23, stroke hospitalizations decreased by 22.3% (95% CI, 21.4%–23.1%) in 2020 compared with same period in 2019; during weeks 24 through 44, they decreased by 12.1% (95% CI, 11.2%–12.9%). The magnitude of reduction increased with age but similar between men and women and among different race/ethnicity groups. Reductions in stroke hospitalizations between weeks 10 through 23 varied by state ranging from 0.0% (95% CI, −16.0%–1.7%) in New Hampshire to 36.2% (95% CI, 24.8%–46.7%) in Montana.

Conclusions:

One-in-5 fewer stroke hospitalizations among Medicare fee-for-service beneficiaries occurred during initial weeks of the COVID-19 pandemic (March 1–June 6) and weekly stroke hospitalizations remained at a lower than expected level from June 7 to October 31 in 2020 compared with 2019. Changes in stroke hospitalizations varied substantially by state.

Delayed Comprehensive Stroke Unit Care Attributable to the Evolution of Infection Protection Measures across Two Consecutive Waves of the COVID-19 Pandemic

We aimed to assess how evidence-based stroke care changed over the two waves of the COVID-19 pandemic. We analyzed acute stroke patients admitted to a tertiary care hospital in Germany during the first (2 March 2020–9 June 2020) and second (23 September 2020–31 December 2020, 100 days each) infection waves. Stroke care performance indicators were compared among waves. A 25.2% decline of acute stroke admissions was noted during the second (n = 249) compared with the first (n = 333) wave of the pandemic. Patients were more frequently tested SARS-CoV-2 positive during the second than the first wave (11 (4.4%) vs. 0; p < 0.001). There were no differences in rates of reperfusion therapies (37% vs. 36.5%; p = 1.0) or treatment process times (p > 0.05). However, stroke unit access was more frequently delayed (17 (6.8%) vs. 5 (1.5%); p = 0.001), and hospitalization until inpatient rehabilitation was longer (20 (1, 27) vs. 12 (8, 17) days; p < 0.0001) during the second compared with the first pandemic wave. Clinical severity, stroke etiology, appropriate secondary prevention medication, and discharge disposition were comparable among both waves. Infection control measures may adversely affect access to stroke unit care and extend hospitalization, while performance indicators of hyperacute stroke care seem to be untainted.

Reduction in Acute Stroke Admissions during the COVID-19 Pandemic: Data from a National Stroke Registry

Introduction

The COVID-19 pandemic overwhelmed health-care systems worldwide, and medical care for other acute diseases was negatively impacted. We aimed to investigate the effect of the COVID-19 outbreak on admission rates and in-hospital care for acute stroke and transient ischemic attack (TIA) in Israel, shortly after the start of the pandemic.

Methods

We conducted a retrospective observational study, based on data reported to the Israeli National Stroke Registry from 7 tertiary hospitals. All hospital admissions for acute stroke or TIA that occurred between January 1 and April 30, 2020 were included. Data were stratified into 2 periods according to the timing of COVID-19 restrictions as follows: (1) “pre-pandemic” − January 1 to March 7, 2020 and (2) “pandemic” − March 8 to April 30, 2020. We compared the weekly counts of hospitalizations between the 2 periods. We further investigated changes in demographic characteristics and in some key parameters of stroke care, including the percentage of reperfusion therapies performed, time from hospital arrival to brain imaging and to thrombolysis, length of hospital stay, and in-hospital mortality.

Results

2,260 cases were included: 1,469 in the pre-COVID-19 period and 791 in the COVID-19 period. Hospital admissions significantly declined between the 2 periods, by 48% for TIA (rate ratio [RR] = 0.52; 95% CI 0.43–0.64) and by 29% for stroke (RR = 0.71; 95% CI 0.64–0.78). No significant changes were detected in demographic characteristics and in most parameters of stroke management. While the percentage of reperfusion therapies performed remained unchanged, the absolute number of patients treated with reperfusion therapies seemed to decrease. Higher in-hospital mortality was observed only for hemorrhagic stroke.

Conclusion

The marked decrease in admissions for acute stroke and TIA, occurring at a time of a relatively low burden of COVID-19, is of great concern. Public awareness campaigns are needed as patients reluctant to seek urgent stroke care are deprived of lifesaving procedures and secondary prevention treatments.

COVID-19 and ischemic stroke

Since the onset of the COVID‐19 pandemic, a substantial proportion of COVID‐19 patients had documented thrombotic complications and ischemic stroke. Several mechanisms related to immune‐mediated thrombosis, the renin angiotensin system and the effect of SARS‐CoV‐2 in cardiac and brain tissue may contribute to the pathogenesis of ischemic stroke in patients with COVID‐19. Simultaneously, significant strains on global healthcare delivery, including ischemic stroke management, have made treatment of stroke in the setting of COVID‐19 particularly challenging. In this review, we summarize the current knowledge on epidemiology, clinical manifestation, and pathophysiology of ischemic stroke in patients with COVID‐19 to bridge the gap from bench to bedside and clinical practice during the most challenging global health crisis of the last decades.

Hospital admission and mortality rates for non-covid diseases in Denmark during covid-19 pandemic: nationwide population based cohort study

OBJECTIVE

To determine the incidence of hospital admissions and associated mortality rates for non-covid medical conditions during the covid-19 pandemic.

DESIGN

Nationwide, population based cohort study.

SETTING

Denmark from 13 March 2019 to 27 January 2021.

PARTICIPANTS

All Danish residents >1 year of age.

MAIN OUTCOMES MEASURES

Population based healthcare registries that encompass the entire Danish population were used to compare hospital admission and mortality rates during the covid-19 pandemic (from 11 March 2020 to 27 January 2021) with the prepandemic baseline data (from 13 March 2019 to 10 March 2020). Hospital admissions were categorised as covid-19 when patients were assigned a diagnosis code for covid-19 within five days of admission. All patients were followed until migration, death, or end of follow-up, whichever came first. Rate ratios for hospital admissions were computed using Poisson regression and were directly standardised using the Danish population on 1 January 2019 as reference. 30 day mortality rate ratios were examined by Cox regression, adjusted for age and sex, and covid-19 diagnosis was used as a competing risk.

RESULTS

5 753 179 residents were identified during 567.8 million person weeks of observation, with 1 113 705 hospital admissions among 675 447 people. Compared with the prepandemic baseline period (mean hospital admission rate 204.1 per 100 000/week), the overall hospital admission rate for non-covid-19 conditions decreased to 142.8 per 100 000/week (rate ratio 0.70, 95% confidence interval 0.66 to 0.74) after the first national lockdown, followed by a gradual return to baseline levels until the second national lockdown when it decreased to 158.3 per 100 000/week (0.78, 0.73 to 0.82). This pattern was mirrored for most major diagnosis groups except for non-covid-19 respiratory diseases, nervous system diseases, cancer, heart failure, sepsis, and non-covid-19 respiratory infections, which remained lower throughout the study period. Overall 30 day mortality rates were higher during the first national lockdown (mortality rate ratio 1.28, 95% confidence interval 1.23 to 1.32) and the second national lockdown (1.20, 1.16 to 1.24), and these results were similar across most major diagnosis groups. For non-covid-19 respiratory diseases, cancer, pneumonia, and sepsis, the 30 day mortality rate ratios were also higher between lockdown periods.

CONCLUSIONS

Hospital admissions for all major non-covid-19 disease groups decreased during national lockdowns compared with the prepandemic baseline period. Additionally, mortality rates were higher overall and for patients admitted to hospital with conditions such as respiratory diseases, cancer, pneumonia, and sepsis. Increased attention towards management of serious non-covid-19 medical conditions is warranted.

Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

INTRODUCTION

The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system's bottlenecks from a territorial point of view.

METHODS

Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15-May 2, 2020) and an immediate prepandemic period (January 26-March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days.

RESULTS

Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = -0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05-2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4-0.9], p 0.015) during the pandemic period.

CONCLUSION

During the COVID-19 pandemic, Catalonia's stroke system's weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system's analysis is crucial to allocate resources appropriately.

Stroke Patients' Characteristics and Clinical Outcomes: A Pre-Post COVID-19 Comparison Study

Background and Objectives: The Coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to established medical care systems globally. Thus, this study was aimed to compare the admission and outcome variables such as number of patient and its severity, acute recanalisation therapy given pre-post COVID-19 at a primary stroke centre located in Malaysia. Methods: This cross-sectional hospital-based study included adult ischaemic stroke patients. Variables of the study included the number of ischaemic stroke patients, the proportions of recanalisation therapies, stroke severity during admission based on the National Institutes of Health Stroke Scale, functional outcome at discharge based on the modified Rankin Scale, and relevant workflow metrics. We compared the outcome between two six-month periods, namely the pre-COVID-19 period (March 2019 to September 2019) and the COVID-19 period (March 2020 to September 2020). Results: There were 131 and 156 patients, respectively, from the pre-COVID-19 period and the COVID-19 period. The median door-to-scan time and the median door-to-reperfusion time were both significantly shorter in the COVID-19 period (24.5 min versus 12.0 min, p = 0.047) and (93.5 min versus 60.0 min, p = 0.015), respectively. There were also significantly more patients who received intravenous thrombolysis (7.6% versus 17.3%, p = 0.015) and mechanical thrombectomy (0.8% versus 6.4%, p = 0.013) in the COVID-19 period, respectively. Conclusions: The COVID-19 pandemic may not have caused disruptions of acute stroke care in our primary stroke centre. Our data indicated that the number of ischaemic stroke events remained stable, with a significant increase of recanalisation therapies and better in-hospital workflow metrics during the COVID-19 pandemic period. However, we would like to highlight that the burden of COVID-19 cases in the study area was very low. Therefore, the study may not have captured the true burden (and relevant delays in stroke patient management) during the COVID-19 pandemic. The effect of the pandemic crisis is ongoing and both pre-hospital and in-hospital care systems must continue to provide optimal, highly time-dependent stroke care services.

The COVID rehabilitation paradox: why we need to protect and develop geriatric rehabilitation services in the face of the pandemic

Older multi-morbid persons often fall seriously ill due to COVID-19. To be able to participate in a social life again, they often need special rehabilitation measures. Geriatric rehabilitation is a multi-professional service geared to these needs. Paradoxically, however, capacities in geriatric rehabilitation are currently being reduced despite increasing demand. The reasons are manifold and are not only due to the current situation. This article highlights the current situation leading to the COVID rehabilitation paradox and shows ways to learn from it for the future.

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BACKGROUND

COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers.

METHODS

in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups.

RESULTS

of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015).

CONCLUSION

a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for stroke and related 30-day mortality in France: A nationwide observational study

BACKGROUND AND PURPOSE

The aim of this nationwide study was to assess the impact of the COVID-19 pandemic on stroke hospitalization rates, patient characteristics and 30-day case fatality rates.

METHODS

All hospitalizations for stroke from January to June of each year from 2017 to 2020 were selected using International Classification of Diseases, 10th revision, codes I60 to I64 in the national hospital discharge database. Patient characteristics and management were described according to three time periods: pre-lockdown, lockdown, and post-lockdown. Weekly incidence rate ratios (IRRs) were computed to compare time trends in the rates of patients hospitalized for stroke as well as in-hospital and 30-day case fatality rates between the years 2017-2019 and 2020.

RESULTS

In 2020, between weeks 1 and 24, 55,308 patients were hospitalized for stroke in France. IRRs decreased by up to 30% for all age groups, sex, and stroke types during the lockdown compared to the period 2017-2019. Patients hospitalized during the second and third weeks of the lockdown had higher in-hospital case fatality rates compared to 2017-2019. In-hospital case fatality rates increased by almost 60% in patients aged under 65 years. Out-of-hospital 30-day case fatality rates increased between weeks 11 and 15 among patients who returned home after their hospitalization. Important changes in care management were found, including fewer stroke patients admitted to resuscitation units, more admitted to stroke care units, and a shorter mean length of hospitalization.

CONCLUSIONS

During the first weeks of the lockdown, rates of patients hospitalized for stroke fell by 30% and there were substantial increases of both in-hospital and out-of-hospital 30-day case fatality rates.

A Comprehensive Overview of the COVID-19 Literature: Machine Learning-Based Bibliometric Analysis

BACKGROUND

Shortly after the emergence of COVID-19, researchers rapidly mobilized to study numerous aspects of the disease such as its evolution, clinical manifestations, effects, treatments, and vaccinations. This led to a rapid increase in the number of COVID-19-related publications. Identifying trends and areas of interest using traditional review methods (eg, scoping and systematic reviews) for such a large domain area is challenging.

OBJECTIVE

We aimed to conduct an extensive bibliometric analysis to provide a comprehensive overview of the COVID-19 literature.

METHODS

We used the COVID-19 Open Research Dataset (CORD-19) that consists of a large number of research articles related to all coronaviruses. We used a machine learning-based method to analyze the most relevant COVID-19-related articles and extracted the most prominent topics. Specifically, we used a clustering algorithm to group published articles based on the similarity of their abstracts to identify research hotspots and current research directions. We have made our software accessible to the community via GitHub.

RESULTS

Of the 196,630 publications retrieved from the database, we included 28,904 in our analysis. The mean number of weekly publications was 990 (SD 789.3). The country that published the highest number of COVID-19-related articles was China (2950/17,270, 17.08%). The highest number of articles were published in bioRxiv. Lei Liu affiliated with the Southern University of Science and Technology in China published the highest number of articles (n=46). Based on titles and abstracts alone, we were able to identify 1515 surveys, 733 systematic reviews, 512 cohort studies, 480 meta-analyses, and 362 randomized control trials. We identified 19 different topics covered among the publications reviewed. The most dominant topic was public health response, followed by clinical care practices during the COVID-19 pandemic, clinical characteristics and risk factors, and epidemic models for its spread.

CONCLUSIONS

We provide an overview of the COVID-19 literature and have identified current hotspots and research directions. Our findings can be useful for the research community to help prioritize research needs and recognize leading COVID-19 researchers, institutes, countries, and publishers. Our study shows that an AI-based bibliometric analysis has the potential to rapidly explore a large corpus of academic publications during a public health crisis. We believe that this work can be used to analyze other eHealth-related literature to help clinicians, administrators, and policy makers to obtain a holistic view of the literature and be able to categorize different topics of the existing research for further analyses. It can be further scaled (for instance, in time) to clinical summary documentation. Publishers should avoid noise in the data by developing a way to trace the evolution of individual publications and unique authors.

Stroke management during the coronavirus disease 2019 (COVID-19) pandemic: experience from three regions of the north east of Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige)

BACKGROUND

Efficiency of care chain response and hospital reactivity were and are challenged for stroke acute care management during the pandemic period of coronavirus disease 2019 (COVID-19) in North-Eastern Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige), counting 7,193,880 inhabitants (ISTAT), with consequences in acute treatment for patients with ischemic stroke.

METHODS

We conducted a retrospective data collection of patients admitted to stroke units eventually treated with thrombolysis and thrombectomy, ranging from January to May 2020 from the beginning to the end of the main first pandemic period of COVID-19 in Italy. The primary endpoint was the number of patients arriving to these stroke units, and secondary endpoints were the number of thrombolysis and/or thrombectomy. Chi-square analysis was used on all patients; furthermore, patients were divided into two cohorts (pre-lockdown and lockdown periods) and the Kruskal-Wallis test was used to test differences on admission and reperfusive therapies.

RESULTS

In total, 2536 patients were included in 22 centers. There was a significant decrease of admissions in April compared to January. Furthermore, we observed a significant decrease of thrombectomy during the lockdown period, while thrombolysis rate was unaffected in the same interval across all centers.

CONCLUSIONS

Our study confirmed a decrease in admission rate of stroke patients in a large area of northern Italy during the lockdown period, especially during the first dramatic phase. Overall, there was no decrease in thrombolysis rate, confirming an effect of emergency care system for stroke patients. Instead, the significant decrease in thrombectomy rate during lockdown addresses some considerations of local and regional stroke networks during COVID-19 pandemic evolution.

Hospital admissions of acute cerebrovascular diseases during and after the first wave of the COVID-19 pandemic: a state-wide experience from Austria

We investigated hospital admission rates for the entire spectrum of acute cerebrovascular diseases and of recanalization treatments for ischaemic stroke (IS) in the Austrian federal state of Styria during and also after the first coronavirus disease 2019 (COVID-19) wave. We retrospectively identified all patients with transient ischaemic attack (TIA), IS and non-traumatic intracranial haemorrhage (ICH; including intracerebral, subdural and subarachnoid bleeding types) admitted to one of the 11 public hospitals in Styria (covering > 95% of inhospital cerebrovascular events in this region). Information was extracted from the electronic medical documentation network connecting all public Styrian hospitals. We analysed two periods of interest: (1) three peak months of the first COVID-19 wave (March-May 2020), and (2) three recovery months thereafter (June-August 2020), compared to respective periods 4 years prior (2016-2019) using Poisson regression. In the three peak months of the first COVID-19 wave, there was an overall decline in hospital admissions for acute cerebrovascular diseases (RR = 0.83, 95% CI 0.78-0.89, p < 0.001), which was significant for TIA (RR = 0.61, 95% CI 0.52-0.72, p < 0.001) and ICH (0.78, 95% CI 0.67-0.91, p = 0.02), but not for IS (RR = 0.93, 95% CI 0.85-1, p = 0.08). Thrombolysis and thrombectomy numbers were not different compared to respective months 4 years prior. In the recovery period after the first COVID-19 wave, TIA (RR = 0.82, 95% CI 0.71-0.96, p = 0.011) and ICH (RR = 0.86, 95% CI 0.74-0.99, p = 0.045) hospitalizations remained lower, while the frequency of IS and recanalization treatments was unchanged. In this state-wide analysis covering all types of acute cerebrovascular diseases, hospital admissions for TIA and ICH were reduced during and also after the first wave of the COVID-19 pandemic, but hospitalizations and recanalization treatments for IS were not affected in these two periods.

COVID-19 Pandemic Impact on Care for Stroke in Australia: Emerging Evidence From the Australian Stroke Clinical Registry

We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.