Delays in Stroke Onset to Hospital Arrival Time During COVID-19

COVID-19 and stroke in women: impact on clinical, psychosocial and research aspects

Despite the growing interest in gender medicine, the influence of sex and gender on human diseases, including stroke, continues to be underestimated and understudied. The COVID-19 pandemic has overall impacted not only the occurrence and management of stroke but has also exacerbated sex and gender disparities among both patients and healthcare providers. This paper aims to provide an updated overview on the influence of sex and gender in stroke pathophysiology and care during COVID-19 pandemic, through biological, clinical, psychosocial and research perspectives. Gender equity and awareness of the importance of sexual differences are sorely needed, especially in times of health crisis but have not yet been achieved to date. To this purpose, the sudden yet worldwide diffusion of COVID-19 represents a unique learning experience that highlights critical unmet needs also in gender medicine. The failures of this recent past should be kept as food for thought to inspire proper strategies reducing inequalities and to address women's health and wellbeing issues, particularly in case of future pandemics.

Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study

BACKGROUND

Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors.

METHODS

We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay.

RESULTS

In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908).

CONCLUSIONS

Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.

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.

Patient factors associated with treatment time for stroke before and after the onset of COVID-19

OBJECTIVES

Prior to our study, little was known about factors related to time-to-treatment for stroke pre- and post-COVID-19.

DESIGN

This was a retrospective cohort study to evaluate factors associated with delayed door-to-needle time among patients with acute ischemic stroke over two time-periods.

RESULTS

Final sample consisted of 932 charts with mean age of 68.1(±15.6). Significant factors associated with shorter door-to-needle time included ≤ four hours since symptom onset and stroke occurring during post-Covid-19 time-period. Those on anti-coagulants had 72 % higher odds of longer door-to-needle time. As patients got older and stroke symptoms were more severe, less time was spent in door-to-imaging.

CONCLUSION

Results highlight the importance of early recognition of stroke symptoms and rapid transport to the hospital. Faster response times in post-Covid-19 time-period may be attributable to systematic processes put in place to address pandemic-related challenges. Outcomes may depend on research to identify gaps in stroke treatment.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BACKGROUND

The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics.

OBJECTIVE

This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area.

METHODS

The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions.

RESULTS

The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations.

CONCLUSIONS

Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Rapid outpatient transient ischemic attack clinic and stroke service activity during the SARS-CoV-2 pandemic: a multicenter time series analysis

Background and aim

Rapid outpatient evaluation and treatment of TIA in structured clinics have been shown to reduce stroke recurrence. It is unclear whether short-term downtrends in TIA incidence and admissions have had enduring impact on TIA clinic activity. This study aims to measure the impact of the pandemic on hospitals with rapid TIA clinics.

Methods

Relevant services were identified by literature search and contacted. Three years of monthly data were requested - a baseline pre-COVID period (April 2018 to March 2020) and an intra-COVID period (April 2020 to March 2021). TIA presentations, ischemic stroke presentations, and reperfusion trends inclusive of IV thrombolysis (IVT) and endovascular thrombectomy (EVT) were recorded. Pandemic impact was measured with interrupted time series analysis, a segmented regression approach to test an effect of an intervention on a time-dependent outcome using a defined impact model.

Results

Six centers provided data for a total of 6,231 TIA and 13,191 ischemic stroke presentations from Australia (52.1%), Canada (35.0%), Italy (7.6%), and England (5.4%). TIA clinic volumes remained constant during the pandemic (2.9, 95% CI -1.8 to 7.6, p = 0.24), as did ischemic stroke (2.9, 95% CI -7.8 to 1.9, p = 0.25), IVT (-14.3, 95% CI -36.7, 6.1, p < 0.01), and EVT (0, 95% CI -16.9 to 16.9, p = 0.98) counts. Proportion of ischemic strokes requiring IVT decreased from 13.2 to 11.4% (p < 0.05), but those requiring EVT did not change (16.0 to 16.7%, p = 0.33).

Conclusion

This suggests that the pandemic has not had an enduring effect on TIA clinic or stroke service activity for these centers. Furthermore, the disproportionate decrease in IVT suggests that patients may be presenting outside the IVT window during the pandemic - delays in seeking treatment in this group could be the target for public health intervention.

COVID-19 Pandemic Brings Challenges to the Management of Stroke-The Differences Between Stroke Cases Admitted to a Tertiary Hospital Before and During COVID-19 Pandemic in China

Background

An international public health emergency has resulted from the emergence of the new coronavirus-2. Both direct and indirect influences have been felt on the treatment of acute stroke. However, no conclusive link between COVID-19 and the alleged decline in admissions for stroke-related reasons has been established, and the findings of recent studies are contentious. Most of those researches are not made use of authentic data. Therefore, the goal of this study is to examine how the COVID-19 pandemic has affected hospital admissions for stroke patients, to provide a basis for managing stroke patients in hospitals during COVID-19 pandemic.

Methods

This retrospective study took place at the People's Hospital of Peking University in Beijing, China. For each patient, interventions such as the application of tissue plasminogen activator (tPA) were examined. We recorded each patient's outcomes. The stroke patients' hospital admissions were compared to the average of the prior year. As the time span of interest, we selected the epidemic period (January 2020 to December 2020).

Results

When compared to the previous year in the pre-COVID period, mean monthly stroke hospitalizations decreased during the pandemic by 54.42% (P<0.001); average lengths of stay (ALOS) increased; and non-emergency admissions decreased by 78.8% (P<0.001). The monthly volume of stroke patients exceeding the intravenous thrombolysis (IVT) window decreased by 25% and 59.73%, respectively (P <0.001). There was a 5.3% increase in the percentage of IVT or within IVT time window in male stroke patients (p=0.019; p=0.049). During COVID-19, the proportion of non-local patients among male stroke patients decreased by 10% compared with the previous year (p=0.006).

Conclusion

The COVID-19 epidemic has had a negative impact on stroke management in China, healthcare systems must work to assess and adapt to the new reality.

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.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19

OBJECTIVE

The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19.

DESIGN

This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances.

RESULTS

The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%.

CONCLUSIONS

Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

Stroke metrics during the first year of the COVID-19 pandemic, a tale of two comprehensive stroke centers

Although a decrease in stroke admissions during the SARS-CoV-2 pandemic has been observed, detailed analyses of the evolution of stroke metrics during the pandemic are lacking. We analyzed changes in stroke presentation, in-hospital systems-of-care, and treatment time metrics at two representative Comprehensive Stroke Centers (CSCs) during the first year of Coronavirus disease 2019 pandemic. From January 2018 to May 2021, data from stroke presentations to two CSCs were obtained. The study duration was split into: period 0 (prepandemic), period 1 (Wave 1), period 2 (Lull), and period 3 (Wave 2). Acute stroke therapies rates and workflow times were compared among pandemic and prepandemic periods. Analyses were adjusted for age, sex, comorbidities, and pre-morbid care needs. There was a significant decrease in monthly hospital presentations of stroke during Wave 1. Both centers reported declines in reperfusion therapies during Wave 1, slowly catching up but never to pre pandemic numbers, and dropping again in Wave 2. Both CSCs experienced in-hospital workflow delays during Waves 1 and 2, and even during the Lull period. Our results highlight the need for proactive strategies to reduce barriers to workflow and hospital avoidance for stroke patients during crisis periods.

Treatment of acute mesenteric ischemia between 2010 and 2020 - a German nation-wide study

BACKGROUND

Aim of this study was to analyze long-term trends of hospitalizations, treatment regimen and in-hospital mortality of in-patients with acute mesenteric ischemia (AMI) over the past decade and effects of the SARS-CoV2-pandemic.

METHODS

We analyzed fully anonymized data from the German Federal Statistical Office of patients with AMI between 2010 and 2020. Besides descriptive analyses of age, gender, in-hospital mortality, comorbidity burden and treatment regimen, multivariable logistic regression analyses were performed to identify independent variables associated with in-hospital mortality and different treatment.

RESULTS

A total of 278,121 hospitalizations (120,667 male [43.4%], mean age 72.1 years) with AMI were included in this study. The total number of hospitalizations increased from 2010 (n = 24,172) to 2019 (n = 26,684) (relative increase 10.4%). In-hospital mortality decreased over the past decade from 36.6% to 2010 to 31.1% in 2019 (rel. decrease 15.2%). Independent risk factors for in-hospital mortality were older age (OR = 1.03 per year), higher comorbidity burden (OR = 1.06 per point in van Walraven score [vWs]), male gender (OR = 1.07), AMI as a secondary diagnosis (OR = 1.44), and the need for surgical (visceral surgery: OR = 1.38, vascular surgery: OR = 3.33) and endovascular treatment (OR = 1.21). We report a decline in hospitalizations during the first wave of infection in spring 2020 (rel. decrease 9.7%).

CONCLUSION

In-hospital mortality rate has declined over the past decade, but remains high at above 30%. Older age, increased comorbidity and male gender are independent factors for in-hospital mortality. Hospitalizations requiring vascular surgery are associated with high in-hospital mortality, followed by visceral surgery and endovascular approaches. The first wave of the SARS-CoV2-pandemic in spring 2020 implied a decrease in hospital admissions.

Impact of Coronavirus Disease 2019 on Hospital Admissions, Health Status, and Behavioral Changes of Patients with COPD

Introduction

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of acquiring severe coronavirus disease 2019 (COVID-19), which is why self-isolation was recommended. However, long periods of social isolation, accompanied by limited access to health care systems, might influence the outcome of patients with severe COPD negatively.

Methods

Data from COPD and pneumonia patients at Charité-Universitätsmedizin Berlin and the volume of endoscopic lung volume reduction (ELVR) surgeries from the German Lung Emphysema Registry (Lungenemphysem Register e.V.) were analyzed from pre-pandemic (2012 to 2019) to the pandemic period (2020 and 2021). In addition, 52 patients with COPD Global initiative for chronic Obstructive Lung Disease (GOLD) stage 4 status included in the lung emphysema registry received questionnaires during lockdowns from June 2020 to April 2021.

Results

Admissions and ventilation therapies administered to COPD patients significantly decreased during the COVID-19 pandemic. Likewise, there was a reduction in ELVR treatments and follow-ups registered in German emphysema centers. Mortality was slightly higher among patients hospitalized with COPD during the pandemic. Increasing proportions of COPD patients with GOLD stage 3 and GOLD stage 4 status reported behavioral changes and subjective feelings of increasing COPD symptoms the longer the lockdown lasted. However, COPD symptom questionnaires revealed stable COPD symptoms over the pandemic time period.

Summary

This study reveals reduced COPD admissions and elective treatment procedures of COPD patients during the pandemic, but a slight increase in mortality among patients hospitalized with COPD, irrespective of COVID-19. Correspondingly, patients with severe COPD reported subjective deterioration of their health status, probably caused by their very strict compliance with lockdown measures.

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration

OBJECTIVES

The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic.

DESIGN

A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria.

RESULTS

The results showed delays in laboratory results, level of care, treatment and interventional procedures, specific aspects of care, radiology treatment, and diagnosis. Causes for delays included poor communication between staff, problems in getting laboratory results, confusion over policy, and misunderstanding of COVID-19-specific rules.

CONCLUSIONS

Healthcare delays can be reduced during a pandemic by proactively standardizing medical processes/procedures when testing for infection, improving staff to staff communication teaching the SBAR (situation, background, assessment, and recommendations) communication model, and using simulation to identify latent safety issues and educating medical personnel on new protocols related to the pandemic. Simulation can be used to test new protocols developed during the pandemic.

Effects of the COVID-19 Pandemic on Prehospital Emergency Care for Adults with Stroke and Transient Ischaemic Attack: A Systematic Review and Meta-Analysis

INTRODUCTION

COVID-19 has challenged global health care systems and resulted in prehospital delays for time-sensitive emergencies, like stroke and transient ischemic attacks (TIA). However, there are conflicting international reports on the level of effect of the pandemic on ambulance response intervals and emergency call volumes for these conditions.

OBJECTIVES

The purpose of this study was to synthesize the international evidence on the effect of COVID-19 on ambulance response intervals and emergency call volume for suspected stroke and TIA.

METHODS

Following a published protocol, we conducted a systematic search of six databases through May 31, 2022. We re-ran this search on April 14, 2023, to check for any new papers. We considered for inclusion peer-reviewed quantitative studies comparing prehospital emergency care for adults with suspected stroke/TIA before and during the COVID-19 pandemic. Two authors screened title/abstract and full text articles. One author carried out data extraction, with a random selection of articles being checked by another author. We calculated overall pooled estimates of ambulance intervals (activation, response, patient care, and total prehospital intervals) and stroke/TIA emergency call volume. Subgroup and sensitivity analyses included location and stroke/TIA diagnosis. Two authors assessed study quality using the appropriate Joanna Briggs Institute tool. We worked with patient and public involvement contributors and clinical and policy stakeholders throughout the review.

RESULTS

Of 4,083 studies identified, 52 unique articles met the inclusion criteria. Mean response interval (-1.29 min [-2.19 to -0.38]) and mean total prehospital interval (-6.42 min [-10.60 to -2.25]) were shorter in the pre-COVID-19 period, compared to the COVID-19 period. Furthermore, there was a higher incidence rate of emergency call volume for suspected stroke/TIA per day pre-COVID-19 compared with the COVID-19 period (log IRR = 0.17 [0.02 to 0.33]). Ambulance response interval definitions and terminology varied between regions and countries.

CONCLUSIONS

Our review indicates that prehospital delays for suspected stroke/TIA increased during the COVID-19 pandemic. Furthermore, emergency call volume for suspected stroke/TIA decreased during this period. In order to minimize delays in future pandemics or other health care emergencies future research may involve understanding the potential reasons for these delays.

Changes in the clinico-functional characteristics of stroke patients in the acute phase during the COVID-19 pandemic

OBJECTIVE

To compare the sociodemographic and clinico-functional characteristics of patients admitted to a stroke unit immediately before and during two different COVID-19 pandemic phases.

METHODS

This exploratory study was conducted in the stroke unit of a public hospital in Brazil. Patients consecutively admitted to a stroke unit for 18 months with primary stroke aged ≥20 years were included and divided into three groups: G1: Pre-pandemic; G2: Early pandemic; and G3: Late pandemic. The sociodemographic and clinico-functional characteristics of the groups were compared (α=0.05).

RESULTS

The study included 383 individuals (G1=124; G2=151; G3=108). The number of risk factors (higher in G2; p≤0.001), smoking (more common in G2; p≤0.01), type of stroke (ischemic more common in G3; p=0.002), stroke severity (more severe in G2; p=0.02), and level of disability (more severe in G2: p≤0.01) were significantly different among the groups.

CONCLUSION

A greater number of serious events and risk factors including smoking and higher level of disability was observed in patients in the beginning of the pandemic than in the late phases. Only the occurrence of ischemic stroke increased in the late phase. Therefore, these individuals may have an increased need for rehabilitation services monitoring and care during their lifespan. Additionally, these results indicate that health promotion and prevention services should be strengthened for future health emergencies.

Exposure-response relationship between COVID-19 incidence rate and incidence and survival of out-of-hospital cardiac arrest (OHCA)

Aim

We aimed to report the epidemiology of OHCA, bystander CPR pattern and other Utstein factors in a region in Hong Kong during the COVID-19 pandemic. In particular, we studied the relationship between COVID-19 incidence, OHCA incidence and survival outcome.

Methods

This was a retrospective cohort study that used data from our registry to compare features of OHCA during pre-pandemic (Jan 2018 to Dec 2019), low-incidence pandemic (Jan 2020 to Dec 2021) and high-incidence pandemic (Jan to Mar 2022). We used multivariable logistic regression to identify survival predictors.

Results

Incidence of OHCA increased dramatically with surging COVID-19 incidence (65.9 vs 74.2 vs 159.2 per 100,000 population per year, p < 0.001). During the pandemic, there were more indoor OHCA (89.3% vs 92.6% vs 97.4%, p < 0.001), fewer witnessed arrest (38.5% vs 38.3% vs 29.6%, p = 0.001), and longer median time to basic life support upon receiving call (9 min vs 10 min vs 14 min, p < 0.001). There was a higher proportion of OHCA cases with bystander-CPR (26.1% vs 31.3% vs 35.3%, p < 0.001). The proportion of cases with survival to admission (STA) (30.8% vs 22.2% vs 15.4%, p < 0.001) and survival to discharge (STD) (2.2% vs 1.0% vs 0.2%, p = 0.001) were lowered. After controlling for confounders, the odds of STA was reduced by 33% and 55% during the low-incidence and high-incidence pandemic respectively.

Conclusion

The increase in COVID-19 incidence had an exposure-response relationship with an increased incidence of OHCA and worsened survival outcomes.

Changes in the care of acute cerebrovascular and cardiovascular conditions during the first year of the covid-19 pandemic in 746 hospitals in the USA: retrospective analysis

Objective

To measure the impact of the covid-19 pandemic on admissions to hospital and interventions for acute ischemic stroke and acute myocardial infarction.

Design

A retrospective analysis.

Setting

746 qualifying hospitals in the USA from the Premier Healthcare Database.

Participants

Patients aged 18 years and older who were admitted to hospital with a primary diagnosis of acute ischemic stroke or acute myocardial infarction between 1 March 2019 and 28 February 2021.

Main outcome measures

Relative changes in volumes were assessed for acute ischemic stroke and acute myocardial infarction hospital admissions as well as intravenous thrombolysis, mechanical thrombectomy, and percutaneous coronary intervention (overall and for acute myocardial infarction only) across the first year of the pandemic versus the prior year. Mortality in hospital and length of stay in hospital were also compared across the first year of the pandemic versus the corresponding period the year prior. These metrics were explored across the different pandemic waves.

Results

Among 746 qualifying hospitals, admissions to hospital were significantly reduced after the covid-19 pandemic compared with before the pandemic for acute ischemic stroke (-13.59% (95% confidence interval-13.77% to -13.41%) and acute myocardial infarction (-17.20% (-17.39% to -17.01%)), as well as intravenous thrombolysis (-9.47% (-9.99% to -9.02%)), any percutaneous coronary intervention (-17.89% (-18.06% to -17.71%)), and percutaneous coronary intervention for acute myocardial infarction (-14.36% (-14.59% to -14.12%)). During the first year of the pandemic versus the previous year, the odds of mortality in hospital for acute ischemic stroke were 9.00% higher (3.51% v 3.16%; ratio of the means 1.09 (95% confidence interval (1.03 to 1.15); P=0.0013) and for acute myocardial infarction were 18.00% higher (4.81% v 4.29%; ratio of the means 1.18 (1.13 to 1.23); P<0.0001).

Conclusions

We observed substantial decreases in admissions to hospital with acute ischemic stroke and acute myocardial infarction, but an increase in mortality in hospital throughout the first year of the pandemic. Public health interventions are needed to prevent these reductions in future pandemics.

Stroke Care Pathway ensures high-quality stroke management in the COVID-19 pandemic

The aim of our study was to assess whether a well-established federal state-wide Stroke Care Pathway delivering high quality stroke care can cope with the COVID-19 pandemic and associated measures to contain the virus spread. The retrospective analysis is based on a prospective, quality-controlled, population-based registry of all stroke patients in the Tyrol, a federal state of Austria and one of the early hot-spots of COVID-19 in Europe. Patient characteristics, pre-hospital management, intra-hospital management and post-hospital were analysed. All residents of the Tyrol suffering ischemic stroke in 2020 (n = 1160) and four pre-COVID-19 years (n = 4321) were evaluated. In 2020, the annual number of stroke patients was the highest in this population-based registry. When local hospitals were overwhelmed with SARS-CoV-2-patients, stroke subjects were temporarily allocated to the comprehensive stroke centre. Stroke severity, quality metrics of stroke management, serious complications, and post-stroke mortality did not differ between 2020 and the four comparator years. Notably, iv. thrombolysis-rate was similar (19.9% versus 17.4%, P = 0.25) and endovascular stroke treatment even better (5.9% versus 3.9%, P = 0.003) but resources for in-patient rehabilitation were limited (25.8% versus 29.8%, P = 0.009). Concluding, a well-established Stroke Care Pathway was able to maintain high-quality acute stroke care even when challenged by a global pandemic.

COVID-19 pandemic experiences among people with epilepsy: Effect on symptoms of co-occurring health conditions and fear of seizure

OBJECTIVE

The Coronavirus disease 2019 (COVID-19) pandemic profoundly affected people worldwide, but little is known about how it impacted people with epilepsy (PWE). We examined the associations between COVID-19 stressors and health outcomes including increases in other health symptoms and fear of seizure among PWE.

METHODS

This cross-sectional study used data from an online survey that asked about demographic characteristics, health conditions, and potential life stressors during COVID-19. Data were collected from October 30 to December 8, 2020. COVID-19 stressors were anger, anxiety, stress, healthcare access, fear of seeking healthcare, social isolation, sense of control over their lives, and alcohol consumption. A binary variable was created for each of these measures to indicate whether PWEs experienced a negative change versus a neutral or positive change. We used multivariable logistic regression to assess the associations of COVID-19 stressors with primary outcomes: exacerbated co-occurring health conditions and increasing fear of seizure during the pandemic.

RESULTS

Of the 260 PWE included in the study, 165 (63.5%) were women; the average age was 38.7 years. During the survey administration period, 79 (30.3%) of the respondents reported exacerbated co-occurring health conditions, and 94 (36.2%) reported an increased fear of seizures. Regression results indicated that the fear of seeking healthcare during COVID-19 was associated with both exacerbated co-occurring health conditions (aOR 1.12; 95%CI 1.01-1.26) and increasing fear of seizure (aOR 2.31; 95%CI 1.14-4.68). Social isolation was associated with exacerbated co-occurring health conditions during COVID-19 (aOR 1.14; 95%CI 1.01-1.29). Reduced access to physical healthcare was associated with increasing fear of seizure (aOR 2.58; 95%CI 1.15-5.78).

CONCLUSION

A considerable number of PWE experienced more symptoms of existing health conditions and fear of seizure during the initial year of the pandemic (2020). Fear of seeking healthcare services was associated with both negative outcomes. Assuring access to health care and reducing social isolation could potentially reduce negative outcomes for PWE. It is necessary to provide adequate support for PWE to reduce risks as COVID-19 continues to be a health concern.

Recombinant tissue plasminogen activator (rTPA) management for first onset acute ischemic stroke with covid -19 and non-covid -19 patients

OBJECTIVES

Cerebrovascular stroke (CVS) is one of the well-known complications of coronavirus-2019 (Covid-19), but less is known about the outcome and safety of thrombolytic therapy in these patients. In this study we compare the efficacy and safety of Tissue plasminogen activator (rTPA) in acute ischemic stroke (AIS) patients with or without Covid-19 infection.

MATERIALS AND METHODS

A comparative prospective study in which all patients who presented with AIS and eligible for rTPA were recruited from the emergency department and classified into 2 groups (AIS with Covid-19 infection and AIS without Covid-19 as controls). Demographic data, symptoms of Covid-19, clinical examination, neuroimaging, and laboratory investigations were obtained in each patient. National Institute of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (mRS) were assessed before, immediately after rTPA, and 3 months later.

RESULTS

There were 22 patients in the COVID-19 group and 25 control patients. Those with COVID-19 were more likely to have a history of smoking and Diabetes Mellitus than controls. On admission, motor symptoms were more severe in patients with COVID-19. COVID-19 patients were more likely to have symptomatic intra-cerebral hemorrhage and radiological hemorrhagic transformation than controls. Onset to door time (ODT) and onset to successful reperfusion time were significantly longer in Covid-19 patients than controls. Clinical improvement and frequency of re-occlusion and recurrent ischemic stroke at 3 months follow-up did not differ between groups, although there was higher number of deaths (27.3%) in the Covid-19 group than controls (16%).

CONCLUSIONS

Using rTPA is safe and effective in patients with AIS with or without COVID-19 infection despite the high frequency of hemorrhagic transformation and high number of deaths.

Impact of the COVID-19 pandemic on emergent stroke care in Beijing, China

The coronavirus disease 2019 (COVID-19) pandemic has caused an unprecedented disruption to health care systems around the globe. Stroke is still an ongoing issue during the pandemic. We investigated the impact of the COVID-19 outbreak on emergent stroke care in Beijing, China. This is a retrospective analysis of two groups of patients with acute ischaemic stroke (AIS) registered in the Beijing Emergency Care Database between January 1, 2019, and December 31, 2020. Based on a database including 77 stroke centres, the quantity and quality of emergency care for stroke were compared. Subgroup analyses based on hospitals in different areas (high-risk and low/medium-risk areas) were carried out. A total of 6440 and 8699 admissions with suspected stroke were recorded in 2020 and 2019, respectively. There were no significant differences in the mean age and sex distribution for the patients between the two observational periods. The number of AIS admissions decreased by approximately 23.9% during the COVID-19 pandemic compared to that during the prepandemic period. The proportions of intravenous thrombolysis and endovascular treatment were 76.4% and 13.1%, respectively, in 2020, which were higher than those in 2019 (71.7% and 9.3%, respectively). There was no statistically significant difference in the time from stroke onset to arrival at the hospital (97.97 ± 23.09 min vs. 99.40 ± 20.76 min, p = 0.832) between the two periods. The door-to-needle time for thrombolysis (44.92 ± 9.20 min vs. 42.37 ± 9.06 min, p < 0.001) and door-to-thrombectomy time (138.56 ± 32.45 min vs. 120.55 ± 32.68 min, p < 0.001) were increased significantly in the pandemic period compared to those in the prepandemic period, especially in hospitals in high-risk areas. The decline in the number of patients with AIS and delay in treatment started after the launch of the level-1 public health emergency response and returned to stability after the release of professional protocols and consensus statements. Disruptions to medical services during the COVID-19 pandemic have substantially impacted AIS patients, with a clear drop in admission and a decline in the quality of emergent AIS care, especially in hospitals in high-risk areas and at the time of the initial outbreak of COVID-19. Health care systems need to maintain rapid adaptation to possible outbreaks of COVID-19 or similar crises in the future.

Impact of the COVID-19 pandemic on acute stroke care: An analysis of the 24-month data from a comprehensive stroke center in Shanghai, China

INTRODUCTION

Whether the coronavirus disease-2019 (COVID-19) pandemic is associated with a long-term negative impact on acute stroke care remains uncertain. This study aims to compare the timing of key aspects of stroke codes between patients before and after the COVID-19 pandemic.

METHODS

This retrospective cohort study was conducted at an academic hospital in Shanghai, China and included all adult patients with acute ischemic stroke hospitalized via the emergency department (ED) stroke pathway during the 24 months since the COVID-19 outbreak (COVID-19: January 1, 2020-December 31, 2021). The comparison cohort included patients with ED stroke pathway visits and hospitalizations during the same period (pre-COVID-19: January 1, 2018-December 31, 2019). We compared critical time points of prehospital and intrahospital acute stroke care between patients during the COVID-19 era and patients during the pre-COVID-19 era using t test, χ² , and Mann-Whitney U test where appropriate.

RESULTS

A total of 1194 acute ischemic stroke cases were enrolled, including 606 patients in COVID-19 and 588 patients in pre-COVID-19. During the COVID-19 pandemic, the median onset-to-hospital time was about 108 min longer compared with the same period of pre-COVID-19 (300 vs 192 min, p = 0.01). Accordingly, the median onset-to-needle time was 169 min in COVID-19 and 113 min in pre-COVID-19 (p = 0.0001), and the proportion of patients with onset-to-hospital time within 4.5 h was lower (292/606 [48.2%] vs 328/558 [58.8%], p = 0.0003) during the pandemic period. Furthermore, the median door-to-inpatient admission and door-to-inpatient rehabilitation times increased from 28 to 37 h and from 3 to 4 days (p = 0.014 and 0.0001).

CONCLUSIONS

During the 24 months of COVID-19, a prolongation of stroke onset to hospital arrival and to intravenous rt-PA administration times were noted. Meanwhile, acute stroke patients needed to stay in the ED for a longer time before hospitalization. Educational system support and process optimization should be pursued in order to acquire timely delivery of stroke care during the pandemic.

Increased stroke severity and mortality in patients with SARS-CoV-2 infection: An analysis from the N3C database

BACKGROUND

Studies from early in the COVID-19 pandemic showed that patients with ischemic stroke and concurrent SARS-CoV-2 infection had increased stroke severity. We aimed to test the hypothesis that this association persisted throughout the first year of the pandemic and that a similar increase in stroke severity was present in patients with hemorrhagic stroke.

METHODS

Using the National Institute of Health National COVID Cohort Collaborative (N3C) database, we identified a cohort of patients with stroke hospitalized in the United States between March 1, 2020 and February 28, 2021. We propensity score matched patients with concurrent stroke and SARS-COV-2 infection and available NIH Stroke Scale (NIHSS) scores to all other patients with stroke in a 1:3 ratio. Nearest neighbor matching with a caliper of 0.25 was used for most factors and exact matching was used for race/ethnicity and site. We modeled stroke severity as measured by admission NIHSS and the outcomes of death and length of stay. We also explored the temporal relationship between time of SARS-COV-2 diagnosis and incidence of stroke.

RESULTS

Our query identified 43,295 patients hospitalized with ischemic stroke (5765 with SARS-COV-2, 37,530 without) and 18,107 patients hospitalized with hemorrhagic stroke (2114 with SARS-COV-2, 15,993 without). Analysis of our propensity matched cohort revealed that stroke patients with concurrent SARS-COV-2 had increased NIHSS (Ischemic stroke: IRR=1.43, 95% CI:1.33-1.52, p<0.001; hemorrhagic stroke: IRR=1.20, 95% CI:1.08-1.33, p<0.001), length of stay (Ischemic stroke: estimate = 1.48, 95% CI: 1.37, 1.61, p<0.001; hemorrhagic stroke: estimate = 1.25, 95% CI: 1.06, 1.47, p=0.007) and higher odds of death (Ischemic stroke: OR 2.19, 95% CI: 1.79-2.68, p<0.001; hemorrhagic stroke: OR 2.19, 95% CI: 1.79-2.68, p<0.001). We observed the highest incidence of stroke diagnosis on the same day as SARS-COV-2 diagnosis with a logarithmic decline in counts.

CONCLUSION

This retrospective observational analysis suggests that stroke severity in patients with concurrent SARS-COV-2 was increased throughout the first year of the pandemic.

[Current approaches in the treatment and rehabilitation of patients with neurological diseases after COVID-19. Resolution of the International Experts Forum]

Despite the significant shift in global attention away from the pandemic, the problem of a new coronavirus infection remains important in the medical community. Almost 3 years after the start of the COVID-19 pandemic the issues of rehabilitation and management of delayed manifestations and sequelae of the disease are especially important. According to numerous available data, the new coronavirus infection is characterized by multiorgan lesions. Respiratory dysfunction, clotting disorders, myocardial dysfunction and various arrhythmias, acute coronary syndrome, acute renal failure, GI disorders, hepatocellular damage, hyperglycemia and ketosis, dermatological complications, ophthalmological symptoms and neurological disorders may be found. Significant prevalence of the latter in the post-coronavirus period necessitated this International Expert Forum to develop unified approaches to the management of patients with neurological complications and sequelae of new coronavirus infection based on practical experience and considering the scientific information available on COVID-19. The expert council developed a resolution formulating the tactics for the management of patients with neurological manifestations of COVID-19.

Impact of free hypertension pharmacy program and social distancing policy on stroke: A longitudinal study

Background

The estimated lifetime risk of stroke was the highest in East Asia worldwide, especially in China. Antihypertensive therapy can significantly reduce stroke mortality. However, blood pressure control is poor. Medication adherence is a barrier as patients' out-of-pocket costs have risen. We aimed to take advantage of a free hypertension pharmacy intervention and quantified the impact on stroke mortality.

Methods

A free pharmaceutical intervention program was implemented in Deqing, Zhejiang province in April 2018. Another non-pharmaceutical intervention, social distancing due to the pandemic of Coronavirus disease 2019 (COVID-19), was also key to affecting stroke mortality. We retrospectively collected the routine surveillance data of stroke deaths from Huzhou Municipal Center for Disease Prevention and Control in 2013-2020 and obtained within-city mobility data from Baidu Migration in 2019-2020, then we quantified the effects of both pharmaceutical intervention and social distancing using Serfling regression model.

Results

Compared to the predicted number, the actual number of stroke deaths was significantly lower by 10% (95% CI, 6-15%; p < 0.001) from April 2018 to December 2020 in Deqing. Specifically, there was a reduction of 19% (95% CI, 10-28%; p < 0.001) in 2018. Moreover, we observed a 5% (95% CI, -4 - 14%; p = 0.28) increase in stroke mortality due to the adverse effect of COVID-19 but it wasn't statistically significant.

Conclusion

Free hypertension pharmacy program has great potential to prevent considerable stroke deaths. In the future, the free supply of low-cost, essential medications that target patients with hypertension at increased risk of stroke could be taken into account in formulating public health policies and guiding allocations of health care resources.

Racial and ethnic variation in emergent surgical care and outcomes during the COVID-19 pandemic: post hoc analysis of an EAST MCT

Objectives

The COVID-19 pandemic highlighted concerns regarding the equity of medical care. We evaluated associations between race/ethnicity, timing of hospital presentation and outcomes of acute appendicitis (AP) and acute cholecystitis (AC) during the initial pandemic peak.

Methods

Analysis was performed on a prospective, observational, multicenter study of adults with AP or AC. Patients were categorized as pre-pandemic (pre-CoV: October 2019–January 2020) or during the first pandemic peak (CoV: April 2020 through 4 months following the end of local pandemic restrictions). Patient demographics, American Association for the Surgery of Trauma (AAST) imaging/pathology grade, duration of symptoms before triage, time from triage to intervention and hospital length of stay were collected.

Results

A total of 2165 patients (1496 pre-CoV, 669 CoV) were included from 19 centers. Asian and Hispanic patients with AC had a longer duration of symptoms prior to presentation during CoV than pre-CoV (100.6 hours vs 37.5 hours, p<0.01 and 85.7 hours vs 52.5 hours, p<0.05, respectively) and presented later during CoV than Black or White patients (34.3 and 37.9 hours, p<0.01). During CoV, Asian patients presented with higher AAST pathology grade for AP compared with pre-CoV (1.90 vs 1.26, p<0.01). Asian and Hispanic patients presented with higher AAST pathology grade for AC during CoV versus pre-CoV (2.57 vs 1.45, p<0.01, and 1.57 vs 1.20, p<0.05, respectively). Patients with AC and an AAST pathology grade of ≥3 were at higher odds of postoperative complications (OR 4.4, 95% CI 1.0 to 18.4) and AP (OR 2.8, 95% CI 1.3 to 6.0). Asian and Hispanic patients with AC had a higher risk of postoperative complications compared to White patients (Asian: OR 3.9, 95% CI 1.2 to 12.7; Hispanic: OR 3.3, 95% CI 1.2 to 8.9).

Conclusion

Asian and Hispanic patients had a longer duration of symptoms before hospital presentation during the initial COVID-19 peak, had higher odds of postoperative complications and more advanced pathologic disease.

Level of evidence

III, Prognostic/epidemiological.

The impact of COVID-19 pandemic on treatment delay and short-term neurological functional prognosis for acute ischemic stroke during the lockdown period

BACKGROUND

Preventive strategies implemented during the COVID-19 pandemic may negatively influence the management of patients with acute ischemic stroke (AIS). Nowadays, studies have demonstrated that the pandemic has led to a delay in treatment among patients with AIS. Whether this delay contributes to meaningful short-term outcome differences warranted further exploration.

OBJECTIVE

The objective of this study was to evaluate the impacts of the COVID-19 pandemic on treatment delay and short-term outcomes of patients with AIS treated with IVT and MT.

METHODS

Patients admitted before (from 11/1/2019 to 1/31/2020) and during the COVID-19 pandemic (from 2/1/2020 to 3/31/2020) were screened for collecting sociodemographic data, medical history information, and symptom onset status, and comparing the effect of treatment delay. The patients treated with IVT or MT were compared for delay time and neurological outcomes. Multivariable logistic regression was used to estimate the effect of treatment delay on short-term neurological prognosis.

RESULTS

In this study, 358 patients receiving IVT were included. DTN time increased from 50 min (IQR 40-75) before to 65 min (IQR 48-84), p = 0.048. 266 patients receiving MT were included. The DTP was 120 (112-148) min vs. 160 (125-199) min before and during the pandemic, p = 0.002. Patients with stroke during the pandemic had delays in treatment due to the need for additional PPE (p < 0.001), COVID-19 screening processes (p < 0.001), multidisciplinary consultation (p < 0.001), and chest CT scans (p < 0.001). Compared with pre-COVID-19, during the pandemic, patients had a higher likelihood of spontaneous intracranial hemorrhage after IVT (OR: 1.10; 95% CI, 1.03-1.30) and a lower likelihood of mRS scores 0-2 at discharge (OR: 0.90; 95% CI, 0.78-0.99). In logistic regression analysis, high NIHSS score at admission, increasing age, worse pre-admission mRS, large vessel occlusion, admission during the lockdown period, and low mTICI grade after MT were associated with an mRS ≥ 3.

CONCLUSION

The COVID-19 pandemic has had remarkable impacts on the management of AIS. The pandemic might exacerbate certain time delays and play a significant role in early adverse outcomes in patients with AIS.

Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries-A systematic review

Health system resilience has never been more important than with the COVID-19 pandemic. There is need to identify feasible measures of resilience, potential strategies to build resilience and weaknesses of health systems experiencing shocks. The purpose of this systematic review is to examine how the resilience of health systems has been measured across various health system shocks. Following PRISMA guidelines, with double screening at each stage, the review identified 3175 studies of which 68 studies were finally included for analysis. Almost half (46%) were focused on COVID-19, followed by the economic crises, disasters and previous pandemics. Over 80% of studies included quantitative metrics. The most common WHO health system functions studied were resources and service delivery. In relation to the shock cycle, most studies reported metrics related to the management stage (79%) with the fewest addressing recovery and learning (22%). Common metrics related to staff headcount, staff wellbeing, bed number and type, impact on utilisation and quality, public and private health spending, access and coverage, and information systems. Limited progress has been made with developing standardised qualitative metrics particularly around governance. Quantitative metrics need to be analysed in relation to change and the impact of the shock. The review notes problems with measuring preparedness and the fact that few studies have really assessed the legacy or enduring impact of shocks.

Headache Education Adaptation During the COVID-19 Pandemic: Impact on Undergraduate and Graduate Medical Education

Purpose of Review

Our goal was to describe the changes to headache and neurological education that occurred as a result of the COVID-19 pandemic, and the impact this had on medical learners. We also discuss subsequent implications for the future of education in the field of headache medicine.

Recent Findings

Both educators and learners faced many challenges during the pandemic. These include the following: cancellation of in-person educational meetings, limited in-person networking and wellness events, disengagement from virtual didactic curricula, limitations in procedure-based learning, redeployment to inpatient settings with a decrease in outpatient exposures, and blurred boundaries between home and work life due to more virtual collaboration and home computer use. The development of telehealth programs and trainee wellness initiatives, improved collaboration opportunities among geographically distant institutions, and greater access to conferences for learners are among the many improvements forged by these challenging times in medical education.

Summary

Given the high prevalence of headache disorders and the paucity of headache specialists, training new clinicians with competency in headache medicine is essential. There were many educational challenges and opportunities identified in the literature that resulted from the pressures of the pandemic. Educators need to develop assessments that capture any gaps in learning that may have occurred during this tumultuous time and be vigilant of remediation needs in our learners over the coming years. It is imperative to intentionally design curricula for the future by harnessing new pedagogical tools, innovations, and perspectives gleaned from our experience with the COVID-19 pandemic.

COVID-19 and Stroke Trends in A Tertiary Care Center from South India -Our Monsoon Experience

INTRODUCTION

The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases.

METHODOLOGY

A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality.

RESULTS

Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months.

CONCLUSION

Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients.

Hospital Outcomes among COVID-19 Hospitalizations with Acute Ischemic Stroke: Cross-Sectional Study Results from California State Inpatient Database

Coronavirus disease 2019 (COVID-19) could be a risk factor for acute ischemic stroke (AIS) due to the altered coagulation process and hyperinflammation. This study examined the risk factors, clinical profile, and hospital outcomes of COVID-19 hospitalizations with AIS. This study was a retrospective analysis of data from California State Inpatient Database (SID) during 2019 and 2020. COVID-19 hospitalizations with age ≥ 18 years during 2020 and a historical cohort without COVID-19 from 2019 were included in the analysis. The primary outcomes studied were in-hospital mortality and discharge to destinations other than home. There were 91,420 COVID-19 hospitalizations, of which, 1027 (1.1%) had AIS. The historical control cohort included 58,083 AIS hospitalizations without COVID-19. Conditional logistic regression analysis showed that the odds of in-hospital mortality, discharge to destinations other than home, DVT, pulmonary embolism, septic shock, and mechanical ventilation were significantly higher among COVID-19 hospitalizations with AIS, compared to those without AIS. The odds of in-hospital mortality, DVT, pulmonary embolism, septic shock, mechanical ventilation, and respiratory failure were significantly higher among COVID-19 hospitalizations with AIS, compared to AIS hospitalizations without COVID-19. Although the prevalence of AIS was low among COVID-19 hospitalizations, it was associated with higher mortality and greater rates of discharges to destinations other than home.

Long-term spill-over impact of COVID-19 on health and healthcare of people with non-communicable diseases: a study protocol for a population-based cohort and health economic study

INTRODUCTION

The COVID-19 pandemic has a significant spill-over effect on people with non-communicable diseases (NCDs) over the long term, beyond the direct effect of COVID-19 infection. Evaluating changes in health outcomes, health service use and costs can provide evidence to optimise care for people with NCDs during and after the pandemic, and to better prepare outbreak responses in the future.

METHODS AND ANALYSIS

This is a population-based cohort study using electronic health records of the Hong Kong Hospital Authority (HA) CMS, economic modelling and serial cross-sectional surveys on health service use. This study includes people aged ≥18 years who have a documented diagnosis of diabetes mellitus, hypertension, cardiovascular disease, cancer, chronic respiratory disease or chronic kidney disease with at least one attendance at the HA hospital or clinic between 1 January 2010 and 31 December 2019, and without COVID-19 infection. Changes in all-cause mortality, disease-specific outcomes, and health services use rates and costs will be assessed between pre-COVID-19 and-post-COVID-19 pandemic or during each wave using an interrupted time series analysis. The long-term health economic impact of healthcare disruptions during the COVID-19 pandemic will be studied using microsimulation modelling. Multivariable Cox proportional hazards regression and Poisson/negative binomial regression will be used to evaluate the effect of different modes of supplementary care on health outcomes.

ETHICS AND DISSEMINATION

The study was approved by the institutional review board of the University of Hong Kong, the HA Hong Kong West Cluster (reference number UW 21-297). The study findings will be disseminated through peer-reviewed publications and international conferences.

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.

A 12-year retrospective review of tetrodotoxin poisoning in Hong Kong

Introduction:

Tetrodotoxin poisoning is typically caused by puffer fish consumption. This study is to review its demographics, clinical presentations and management in Hong Kong.

Method:

Reported cases of tetrodotoxin poisoning to Hong Kong Poison Information Centre from October 2008 to March 2021 were included in the study. Information from electronic database was analysed.

Results:

Forty-two cases were included in this case series. The number of incidents of tetrodotoxin poisoning ranged from 0 to 5 per year, mostly in the winter months. Median ingestion-to-symptom and ingestion-to-door time was 2 and 6.5 h, respectively. 48% of puffer fish meal sharer was symptomatic and attended emergency department. 100% and 48% of all cases had neurological and cardiovascular/gastrointestinal symptoms, respectively. Fukuda and Tani clinical Grade 1 and 2 were the most common presentation. 17% required intensive care while most patients were managed safely in emergency department and/or emergency medicine ward.

Conclusion:

There are recurrent incidents of tetrodotoxin poisoning in Hong Kong. Public education is the key to prevent future outbreaks. Targeted history and enhanced availability of tetrodotoxin test would assist in its diagnoses.

Non-COVID outcomes associated with the coronavirus disease-2019 (COVID-19) pandemic effects study (COPES): A systematic review and meta-analysis

BACKGROUND

As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs.

METHODS

We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology.

RESULTS

Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28-1.50; absolute risk difference: 5% [95% CI: 4-6%], p<0.00001, very low certainty evidence). Twenty-eight studies (17%) reported significant changes in morbidity (where 93% reported increases), while 30 studies (18%) reported no significant change (very low certainty). Thirty-nine studies (23%) reported significant changes in hospitalizations (97% reporting decreases), while 111 studies (66%) reported no significant change (very low certainty). Sixty-two studies (37%) reported significant disruptions in standards-to-care (73% reporting increases), while 62 studies (37%) reported no significant change (very low certainty).

CONCLUSIONS

There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020201256 (Sept 2, 2020).

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.

Changes in nationwide in-hospital stroke care during the first four waves of COVID-19 in Germany

INTRODUCTION

In the early stages of the global COVID-19 pandemic hospital admissions for acute ischemic stroke (AIS) decreased substantially. As health systems have become more experienced in dealing with the pandemic, and as the proportion of the population vaccinated rises, it is of interest to determine whether the prevalence of AIS hospitalization and outcomes from hospitalization have returned to normal.

PATIENTS AND METHODS

In this observational, retrospective cohort study, we compared the prevalence and outcomes of AIS during the first four waves of the pandemic to corresponding pre-pandemic periods in 2019 using administrative data collected from a nationwide network of 76 hospitals that manages 7% of all in-hospital cases in Germany.

RESULTS

We included 25,821 AIS cases in the study period (2020/2021) and used 26,295 AIS cases as controls (2019). Compared to pre-pandemic numbers, mean daily AIS admissions decreased only during wave 1 (from 39.6 to 34.1; p < 0.01) and wave 2 (from 39.9 to 38.3; p = 0.03) and returned to normal levels during waves 3 and 4. AIS case fatality increased in wave 1 only (from 6.0% to 7.6%; p = 0.03). We observed a consistent decrease in the prevalences of arterial hypertension, diabetes, and obesity among AIS cases throughout the pandemic and no changes in rates of systemic thrombolysis, mechanical thrombectomy, or decompressive craniectomy. The rate of transfer to stroke units increased only during waves 2 (by 4.6%; p < 0.01) and 3 (by 3.0%; p < 0.01). The proportion of patients with coinciding SARS-CoV-2 and AIS was low, peaking at 3.4% in wave 2 and subsequently decreasing to 0.4% in wave 4.

CONCLUSION

In Germany, the COVID-19 pandemic seems to have had a larger effect on nationwide in-hospital AIS care during the early pandemic stages, in which AIS case numbers decreased and case fatality rose. This may reflect a nationwide "learning curve" within health care systems in providing AIS care in times of a pandemic.

Long-term evaluation of the COVID-19 pandemic impact on acute stroke management: an analysis of the 21-month data from a medical facility in Tokyo

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis and profoundly impacted acute treatment delivery. This study conducted long-term evaluations of the impact of the pandemic on acute stroke management.

Methods

Data from a university-owned medical facility in Tokyo, Japan, were retrospectively analyzed. The number of hospital admissions for stroke and time metrics in the management of patients with acute ischemic stroke were evaluated. A year-over-year comparison was conducted using data from April 2019 to December 2021 to assess the impact of the pandemic.

Results

The year-over-year comparison demonstrated that the number of admissions of patients with stroke and patients who underwent magnetic resonance imaging (MRI), intravenous recombinant tissue plasminogen activator (rt-PA), and thrombectomy during the pandemic remained comparable to the pre-COVID data. However, we found a decrease in the number of admissions of patients with stroke alerts and stroke when hospital cluster infection occurred at this facility and when the region hosted the Tokyo Olympics games during the surge of infection. The door-to-computed tomography time in 2021 was affected. This is plausibly due to the reorganization of in-hospital stroke care pathways after hospital cluster infection. However, no significant difference was observed in the onset-to-door, door-to-MRI, door-to-needle, or door-to-groin puncture times.

Conclusions

We did not observe long-term detrimental effects of the pandemic at this site. Prevention of hospital cluster infections remains critical to provide safe and timely acute stroke management during the pandemic.

Reperfusion Therapies for Acute Ischemic Stroke in COVID-19 Patients: A Nationwide Multi-Center Study

(1) Background: Acute ischemic stroke (AIS) is a possible complication of the coronavirus disease 2019 (COVID-19). Safety and efficacy data on reperfusion therapies (RT)—intravenous thrombolysis and endovascular treatment (EVT)—in stroke patients with COVID-19 is lacking. (2) Methods: We performed a retrospective nationwide multi-center pair-matched analysis of COVID-19 patients with AIS who underwent RT. We included adult COVID-19 patients with AIS who were treated with RT between 16 March 2020 and 30 June 2021. All subjects were paired with non-infected controls, matched for age, sex, stroke arterial vascular territory, and RT modality. The primary outcome measure was a favorable functional outcome defined by the modified Rankin scale (mRS 0–2). (3) Results: Thirty-one subjects and thirty-one matched controls were included. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was higher in the COVID-19 group (16 vs. 12, p = 0.028). Rates of ischemic changes and symptomatic intracerebral hemorrhages did not differ significantly between the two groups at 24 h after RT. The median NIHSS 24 h after reperfusion remained significantly higher in the COVID-19 group (16 vs. 5, p = 0.003). MRS 0–2 at discharge was significantly less common in COVID-19 patients (22.6% vs. 51.8%, p = 0.018). Three-month mortality was 54.8% in the COVID-19 group versus 12.9% in controls (p = 0.001). (4) Conclusion: Reperfusion therapies on AIS in COVID-19 patients appear to be safe; however, functional outcomes are significantly worse, and 3-month mortality is higher.

Utilization of Telestroke Prior to and Following the COVID-19 Pandemic

For over two decades, telestroke has been utilized as a means for improving acute access to a stroke specialist when this expertise is otherwise unavailable. During this time, telestroke use has increased and improvements in care metrics have been widely reported. Several telestroke model variations are utilized; each has different workflow implications. A successful telestroke system should include adequate protocols and training, equipment, documentation system, and tracking of quality metrics. Upfront costs of needed technology and devices, credentialing hurdles, and limited reimbursement are all reported barriers to the utilization of telestroke. Emphasis on safety measures during the COVID-19 pandemic resulted in the dramatic upscaling of telehealth utilization, although overall stroke volumes declined in many areas in the early phases of the pandemic. Going forward, continued reduction in cost of required devices and broadband connections, increased use of automated and advanced analytical software, and a universal licensing and credentialing system are needed to continue the expansion of telestroke use.

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.

The impact of the COVID-19 pandemic on the primary definitive management of ureteric stones

Objective:

To assess the management pathways of ureteric stones within our department and any impact on this as a result of the pandemic.

Patients and methods:

Retrospective data were collected at two different time points defined as ‘pre-COVID-19’, during April and May 2019, and ‘peri-COVID-19’, during April and May 2020 of all patients with ureteric stones.

Results:

Similar patient numbers presented with ureteric stones pre-COVID-19 (63) and during the pandemic (75). Pre-COVID-19, 31 patients were admitted, of which 48% had primary ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL). The average time to theatre was 1.2 days. During the pandemic, there were 34 admissions with 56% of these patients receiving primary URS/PCNL. The average time to theatre was 1.5 days. Of the patients referred to the virtual stone clinic, pre-COVID-19, 38% were listed for urgent-elective surgery which was performed at an average of 62 days. During the pandemic, 49% were listed for surgery, waiting 144 days for their procedure.

Conclusion:

Patients who underwent primary surgery during their first admission had their definitive treatment quicker during the pandemic. However, patients listed for elective procedures waited longer in the peri-COVID-19 period.

Level of evidence:

(Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009)): 2c

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

The Impact of COVID-19 on the Acute Stroke Care Pathway: Looking Beyond the Short Term

Background

Methods

Results

Conclusion

Trends in Hospitalizations for Ambulatory Care-Sensitive Conditions During the COVID-19 Pandemic

IMPORTANCE

The association of the COVID-19 pandemic with the quality of ambulatory care is unknown. Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are a well-studied measure of the quality of ambulatory care; however, they may also be associated with other patient-level and system-level factors.

OBJECTIVE

To describe trends in hospital admissions for ACSCs in the prepandemic period (March 2019 to February 2020) compared with the pandemic period (March 2020 to February 2021).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of adults enrolled in a commercial health maintenance organization in Michigan included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period.

EXPOSURE

COVID-19 pandemic (March 2020 to February 2021).

MAIN OUTCOMES AND MEASURES

Adjusted relative risk (aRR) of ACSC hospitalizations and intensive care unit stays for ACSC hospitalizations and adjusted incidence rate ratio of the length of stay of ACSC hospitalizations in the prepandemic (March 2019 to February 2020) vs pandemic (March 2020 to February 2021) periods, adjusted for patient age, sex, calendar month of admission, and county of residence.

RESULTS

The study population included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period, in which 51.3% of person-months (n = 6 547 231) were for female patients, with a relatively even age distribution between the ages of 24 and 64 years. The relative risk of having any ACSC hospitalization in the pandemic period compared with the prepandemic period was 0.72 (95% CI, 0.69-0.76; P < .001). This decrease in risk was slightly larger in magnitude than the overall reduction in non-ACSC, non-COVID-19 hospitalization rates (aRR, 0.82; 95% CI, 0.81-0.83; P < .001). Large reductions were found in the relative risk of respiratory-related ACSC hospitalizations (aRR, 0.54; 95% CI, 0.50-0.58; P < .001), with non-statistically significant reductions in diabetes-related ACSCs (aRR, 0.91; 95% CI, 0.83-1.00; P = .05) and a statistically significant reduction in all other ACSC hospitalizations (aRR, 0.79; 95% CI, 0.74-0.85; P < .001). Among ACSC hospitalizations, no change was found in the percentage that included an intensive care unit stay (aRR, 0.99; 95% CI, 0.94-1.04; P = .64), and no change was found in the length of stay (adjusted incidence rate ratio, 1.02; 95% CI, 0.98-1.06; P = .33).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of adults enrolled in a large commercial health maintenance organization plan, the COVID-19 pandemic was associated with reductions in both non-ACSC and ACSC hospitalizations, with particularly large reductions seen in respiratory-related ACSCs. These reductions were likely due to many patient-level and health system-level factors associated with hospitalization rates. Further research into the causes and long-term outcomes associated with these reductions in ACSC admissions is needed to understand how the pandemic has affected the delivery of ambulatory and hospital care in the US.