The Effect of Statins on Clinical Outcome Among Hospitalized Patients With COVID-19: A Multi-Centric Cohort Study

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.

Drug effectiveness for COVID-19 inpatients inferred from Japanese medical claim data using propensity score matching

Background

Earlier studies and clinical trials of Coronavirus 2019 (COVID-19) showed that drugs such as antiviral drugs, antibody cocktails, and steroids and anti-inflammatory drugs can prevent severe outcomes and death.

Methods

Observational data in Japan assess drug effectiveness against COVID-19. We applied the average treatment effect model, particularly propensity scoring, which can treat the choice of administered drug as if administration were randomly assigned to inpatients. Data of the Medical Information Analysis Databank, operated by National Hospital Organization in Japan, were used. The outcome was defined as mortality. Subjects were all inpatients, inpatients with oxygen administration, and inpatients using respiratory ventilation, classified by three age classes: all ages, 65 years old or older, and younger than 65 years old. Information about demographic characteristics, underlying disease, administered drug, the proportions of Alpha, Beta and Omicron variant strains, and vaccine coverage were used as explanatory variables for logistic regression.

Results

Estimated results indicated that only one antibody cocktail (sotrovimab, casirivimab and imdevimab) was associated with raising the probability of survival consistently and significantly. By contrast, other drugs, an antiviral drug (remdesivir), a steroid (dexamethasone), and an anti-inflammatory drug (baricitinib and tocilizumab) were related to reduce the probability of survival. However, propensity score matching method might engender biased results because of a lack of data such as detailed information related to intervention and potential confounders. Therefore, the effectiveness of some drugs might not be evaluated properly in this study.

Conclusions

Results indicate high likelihood that antibody cocktails were consistently associated with high probability of survival, although low likelihood was found for other drugs for older patients with mild to severe severity and all age patients with moderate severity. Further study is necessary in light of the lack of available data.

Intervention Effects of Physical Activity on Type 2 Diabetic Patients Potentially Infected with COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has clearly had a great influence on the lifestyles of the population, especially on patients with type 2 diabetes mellitus. During the COVID-19 outbreak, many countries/regions implemented social-isolation measures, leading to an increase in negative behaviors and impairing the capability of diabetic patients to resist COVID-19, ultimately causing severe prognoses. Moreover, as the epidemic progressed, multiple studies emphasized the significance of physical exercise in the management of type 2 diabetic patients infected with COVID-19. In this study, we selected research from 1 December 2019 to 9 August 2023 that focused on COVID-19-infected diabetic patients to investigate the impact of type 2 diabetes on the immune functions, inflammation factor levels, lung injuries, and mental disorders of such patients, as well as to assess the risk of novel coronavirus pneumonia in these patients. Additionally, the effects of high-intensity, moderate-intensity, and low-intensity exercises on novel coronavirus pneumonia infection in type 2 diabetic patients and the mechanisms of the effects of such exercise were considered. We concluded that elderly diabetic patients with COVID-19 should perform low-intensity exercises to facilitate their recoveries. This study offers guidance for a proper understanding of the dangers of diabetes and the use of appropriate measures to reduce the risk of novel coronavirus pneumonia infections in type 2 diabetic patients.

Epidemiological, clinical, therapeutic features and predictors of death among COVID-19 patients hospitalized in Parakou: a cross-sectional study in Northern Benin

BACKGROUND

COVID-19 is an emerging contagious infection with polymorphic clinical manifestations. The purpose of this study was to describe the epidemiological, clinical, therapeutic features and identify the predictors of mortality among COVID-19 hospitalized cases in Parakou.

METHODS

This was a cross-sectional, descriptive and analytic study. Systematic recruitment was used to include all patients hospitalized with COVID-19 from May 8, 2020, to December 31, 2021, whose medical records were available and usable. The variables studied were clinical and paraclinical signs, diagnostic and therapeutic means, evolution under treatment and prognostic factors. This study was approved by the Local Ethical Committee. The data were analyzed using Stata/MP 14.1 software.

RESULTS

A total of 198 cases of COVID-19 were identified, 117 of whom were men. The mean age was 51.53 ± 19.51 years. The presenting signs were fever 146 (74.11%), cough 157 (79.70%) and dyspnea 118 (53.90%). It was severe COVID-19 in 108 cases (54.55%). Therapeutically, 95 patients (47.98%) had received the combination of Lopinavir/ritonavir and Ribavirin and 95 others (47.98%) received chloroquine. Recovery was noted in 151 (76.26%) patients. Mortality rate was 18.18%. Predictors of death were high blood pressure, presence of signs of severity, high-concentration mask ventilation used, and elevated transaminases.

CONCLUSION

COVID-19 was a reality in Parakou, with a significant number of severe cases requiring hospitalization. Several factors are associated with the prognosis of the disease.

Volatility of the COVID-19 vaccine hesitancy: sentiment analysis conducted in Brazil

Background

Vaccine hesitancy is a phenomenon that can interfere with the expansion of vaccination coverage and is positioned as one of the top 10 global health threats. Previous studies have explored factors that affect vaccine hesitancy, how it behaves in different locations, and the profile of individuals in which it is most present. However, few studies have analyzed the volatility of vaccine hesitancy.

Objective

Identify the volatility of vaccine hesitancy manifested in social media.

Methods

Twitter's academic application programming interface was used to retrieve all tweets in Brazilian Portuguese mentioning the COVID-19 vaccine in 3 months (October 2020, June 2021, and October 2021), retrieving 1,048,576 tweets. A sentiment analysis was performed using the Orange software with the lexicon Multilingual sentiment in Portuguese.

Results

The feelings associated with vaccine hesitancy were volatile within 1 month, as well as throughout the vaccination process, being positioned as a resilient phenomenon. The themes that nurture vaccine hesitancy change dynamically and swiftly and are often associated with other topics that are also affecting society.

Conclusion

People that manifest the vaccine hesitancy present arguments that vary in a short period of time, what demand that government strategies to mitigate vaccine hesitancy effects be agile and counteract the expressed fear, by presenting scientific arguments.

Gastroesophageal reflux in lockdown

Aim

This study examines the changes in gastroesophageal reflux disease (GERD) symptom frequency among patients with GERD throughout the COVID-19 pandemic.

Methods

A structured questionnaire was distributed among 198 GERD patients. The questionnaire consisted of a demographic characteristic assessment, the GerdQ questionnaire, and a reflux symptom index (RSI) questionnaire.

Result & conclusion

A statistically significant increase in GerdQ score was identified among participants during the COVID-19 pandemic (t = 7.055, df = 209, p < 0.001), who had experienced an increase in the frequency of positive predictors of GERD and a decrease in the frequency of negative predictors of GERD. The COVID-19 pandemic and its related lockdown countermeasures may have led to exacerbating and worsening GERD symptoms.

Recent Advancements on Long COVID in China: A Narrative Review

The COVID-19 pandemic is a huge public health crisis in the 21st century. In addition to the acute symptoms, a considerable proportion of patients worldwide have suffered from post-COVID-19 syndrome, commonly known as Long COVID. The impact of Long COVID on individual and public health burden cannot be ignored. According to recent researches, Long COVID has been affecting multiple organ systems throughout the body, with respiratory, mental, nervous and digestive symptoms often seen in Chinese population. Clinical studies have proved that symptoms were alleviated by a variety of treatments, such as physical therapy, rehabilitation training, psychological support, behavioral cognitive therapy, stem cell therapy, etc. Based on the current clinical evidence, it is recommended to strengthen the scientific research on Long COVID and actively carry out early monitoring and intervention in the future, so as to effectively prevent the long-term disease burden and economic pressure.

Prevalence of gastro-intestinal symptoms among COVID-19 patients and the association with disease clinical outcomes

Aim

This study examined the various manifestations of COVID-19 in people's gastro-intestinal system and how gastro-intestinal involvement relates to the progression and outcome of the disease.

Methodology

A questionnaire survey was used to collect data from 561 COVID-19 patients between February 6 and 6 April 2022. Laboratory data and clinical outcomes were obtained from the patients' medical records.

Results

39.9% of patients presented gastro-intestinal symptoms, mainly loss of appetite, nausea, vomiting and diarrhea. Gastro-intestinal symptoms were not linked to poorer outcomes such as mortality, ICU admission or length of hospital stays.

Conclusion

gastro-intestinal symptoms were common among patients and may manifest with respiratory symptoms. We recommended clinicians to watch out for gastro-intestinal symptoms as related to COVID-19 infection.

Association of Cardiovascular Medications With Adverse Outcomes in a Matched Analysis of a National Cohort of Patients With COVID-19

Background

The use of statins, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), and anticoagulants may be associated with fewer adverse outcomes in COVID-19 patients.

Methods

Nested within a cohort of 800,913 patients diagnosed with COVID-19 between April 1, 2020 and June 24, 2021 from the Optum COVID-19 database, three case-control studies were conducted. Cases-defined as persons who: (1) were hospitalized within 30 days of COVID-19 diagnosis (n = 88,405); (2) were admitted to the intensive care unit (ICU)/received mechanical ventilation during COVID-19 hospitalization (n = 22,147); and (3) died during COVID-19 hospitalization (n = 2300)-were matched 1:1 using demographic/clinical factors with controls randomly selected from a pool of patients who did not experience the case definition/event. Medication use was based on prescription ≤90 days before COVID-19 diagnosis.

Results

Statin use was associated with decreased risk of hospitalization (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.69, 0.75) and ICU admission/mechanical ventilation (aOR, 0.90; 95% CI, 0.84, 0.97). ACEI/ARB use was associated with decreased risk of hospitalization (aOR, 0.67; 95% CI, 0.65, 0.70), ICU admission/mechanical ventilation (aOR, 0.92; 95% CI, 0.86, 0.99), and death (aOR, 0.60; 95% CI, 0.47, 0.78). Anticoagulant use was associated with decreased risk of hospitalization (aOR, 0.94; 95% CI, 0.89, 0.99) and death (aOR, 0.56; 95% CI, 0.41, 0.77). Interaction effects-in the model predicting hospitalization-were statistically significant for statins and ACEI/ARBs (P < .0001), statins and anticoagulants (P = .003), ACEI/ARBs and anticoagulants (P < .0001). An interaction effect-in the model predicting ventilator use/ICU-was statistically significant for statins and ACEI/ARBs (P = .002).

Conclusions

Statins, ACEI/ARBs, and anticoagulants were associated with decreased risks of the adverse outcomes under study. These findings may provide clinically relevant information regarding potential treatment for patients with COVID-19.

Prior Statin vs In-Hospital Statin Usage in Severe COVID-19: Review and Meta-Analysis

Studies have shown that statins can decrease COVID-19 mortality in hospitalized patients. This paper evaluates these studies and reviews the possible mechanism of how statins modulate COVID-19 severity. Meta-analysis of 31 retrospective studies demonstrated a reduction in mortality rate among statin users (OR 0.69, 95% CI 0.56-0.86, p =0.0008) (HR 0.83, 95% CI 0.72-0.95, p =0.0078). Meta-analysis of 8 randomized control studies demonstrated a nonsignificant reduction in mortality (OR 0.90, 95% CI 0.69-1.18, p =0.461), including four studies with medications other than statins, and four studies with only statins (OR 0.88, 95% CI 95% CI 0.64-1.21, p =0.423). Prolonged statin usage decreases the extracellular localization of ACE2, along with statins' immunomodulating effects and reduction of oxidative stress, decreases COVID-19 mortality. Hospitalized patients with COVID-19 should continue statin treatment if previously prescribed, and patients should not be started on statins, as they do not seem to provide any mortality benefit.

The Early Warning Mechanism of Public Health Emergencies Through Whistleblowing: A Perspective Based on Considering the Uncertainty of Risk Perception

Purpose

During the early warning period of public health emergencies, the information released by whistleblowers on the risk posed by the given event can reduce uncertainty in the public's risk perception and help governments take timely actions to contain the large-scale dissemination of risk. The purpose of this study is to give full play to whistleblowers and draw attention to the risk events, forming a pluralistic model of the risk governance during the early warning period of public health emergencies.

Methods

We construct an evolutionary game model of the early warning of public health emergencies through whistleblowing that involves the government, whistleblowers, and the public, discussing the mechanism of interaction between these subjects under the uncertainty of risk perception. Furthermore, we use numerical simulations to analyze the influence of changes in the relevant parameters on the evolutionary trajectory of the subjects' behaviors.

Results

The results of the research are obtained by numerical simulation of the evolutionary game model. The results show that the public's cooperation with the government encourages the latter to take a positive guidance strategy. Increasing the reward for whistleblowers within an acceptable cost, strengthening the propaganda of the mechanism and the higher level of risk perception of the government and whistleblowers will promote whistleblowers' vocalization actively. When the government's reward for whistleblowers is lower, the whistleblowers choose negative vocalization with the improvement of the public's risk perception. If there is no mandatory guidance from the government at this point, the public is prone to passively cooperating with the government owing to a lack of risk-related information.

Conclusion

Establishing an early warning mechanism through whistleblowing is important for containing risk in the early warning period of public health emergencies. Building the whistleblowing mechanism in daily work can improve the effectiveness of the mechanism and enhance the public's risk perception better when the public health emergencies arise.

Risk of Underlying Diseases and Effectiveness of Drugs on COVID-19 Inpatients Assessed Using Medical Claims in Japan: Retrospective Observational Study

Background

Results of earlier studies have demonstrated underlying diseases such as cancer, diabetes mellitus, immunodeficiency, hypertension and heart failure to be risk factors for severe outcomes and mortality. Furthermore, clinical trials have shown that drugs such as antiviral drugs, antibody cocktails, steroids and anti-inflammatory drugs can be expected to prevent severe COVID-19 outcomes and death.

Methods

This study, using inpatient records from the Medical Information Analysis Databank covering national hospital organizations in Japan, was conducted to evaluate the effects of underlying diseases and/or administered drugs on mortality. Subjects were all inpatients receiving oxygen administration and inpatients using respiratory ventilators, categorized by three age classes: all ages, patients 65 years old or older, and patients younger than 65 years old. We used logistic regression to analyze outcomes for underlying diseases, administered drugs, age, sex, the proportion of the mutated strains, and vaccine coverage.

Results

Patients with hypertension, except for younger inpatients, have a lower risk of mortality (estimated coefficient 0.67 among all inpatients (p < 0.01): 0.77 among inpatients with oxygen therapy (p = 0.02) and 0.57 among inpatients with respiratory ventilation w (p = 0.01)). Except for younger inpatients, antibody cocktail (casirivimab/imdevimab or sotrovimab) administration was associated with a higher probability of survival (estimated coefficient 0.27 among all inpatients (p < 0.01)). It raised the survival probability consistently, although other drugs might have reduced the probability of survival.

Conclusion

These findings suggest that antiviral drugs (remdesivir, estimated coefficient 1.44 (p < 0.01)), steroids (dexamethasone, estimated coefficient 1.85 (p < 0.01)), and anti-inflammatory drugs (baricitinib, estimated coefficient 1.62 (p < 0.01), and tocilizumab, estimated coefficient 2.73 (p < 0.01)) might not contribute to survival. These results have not been reported from earlier studies. More sophisticated estimation procedures, such as treatment effect models, are necessary to obtain conclusive results.

Time indices of pre-hospital EMS missions before and during the COVID-19 pandemic: a cross-sectional study in Iran

BACKGROUND

The COVID-19 pandemic resulted in many changes in pre-hospital emergency medical services (EMS), including wearing full-body protective suits and well-fitted face masks, which can influence time indices in the course of service delivery. The present study aimed to compare the time indices of pre-hospital EMS missions before and during the COVID-19 pandemic in Iran.

METHODS

This descriptive cross-sectional study used census sampling to select 17,860 emergency calls that caused patient transfer to medical facilities from March 2018 to March 2021 and then examined the time indices of pre-hospital EMS missions during the COVID-19 pandemic. The data collection tool was a two-part checklist: patients' individual characteristics and pre-hospital EMS mission time indices. The data were further analyzed using the SPSS16 and independent samples t-test.

RESULTS

Out of the patients transferred by the EMS, 11,773 cases (65.9%) were male and 6,087 (34.1%) were female. The most common reason for the emergency calls was accidents (28.0%). Moreover, response time (P < 0.001), on-scene time (P < 0.001), transfer time (P < 0.001), total run time (P < 0.001), and round trip time (P < 0.001) increased significantly during the COVID-19 pandemic.

CONCLUSIONS

We concluded that the EMS time indices elevated following the COVID-19 pandemic. Updating pre-hospital information management systems, ambulances and medical equipment, as well as holding training courses for pre-hospital EMS personnel could effectively enhance the time indices of pre-hospital EMS missions.

Clinical Practice and Effectiveness Analysis of the Management of Corona Virus Disease 2019 Infected at Shanghai Fangcang Shelter Hospital: A Descriptive Study

Background

The Fangcang shelter hospital has gradually become the primary management mode in China's fight against this Corona Virus Disease 2019 (COVID-19) in 2020. In early 2022, the Fangcang shelter hospital management model was successfully applied to the new outbreak of COVID-19 in Shanghai also. Although Fangcang shelter hospitals are no longer the prevailing mode of prevention of COVID-19, the management experience of Shanghai makeshift hospitals is worthy of reference for public health.

Methods

The authors conducted a descriptive statistical analysis of Hall 6-2 of the Shanghai National Convention and Exhibition Center Fangcang shelter hospital. The whole hall of the Fangcang shelter hospital was managed by the one hospital, and the inclusion of third-party management personnel alleviated the shortage of medical personnel human resources. Through practice, a new procedure for treating batch infected people was introduced.

Results

By optimizing ward management, 72 on-duty doctors, 360 on-duty nurses, 3 sense-control administrators, and 15 administrators cured 18,574 infected people in 40 days, and created a record of a doctor managing 700 infected people without compromising the quality of treatment. There have been no deaths and no complaints from the infected people located in Hall 6-2 of the Shanghai National Convention and Exhibition Center Fangcang shelter hospital.

Conclusion

Compared with previous data, the new management mode of Fangcang shelter hospitals provides a reference for the management of the new infectious diseases for public health.

Personalized medicine targeting different ARDS phenotypes: The future of pharmacotherapy for ARDS?

INTRODUCTION

Acute respiratory distress syndrome (ARDS) still represents a major challenge with high mortality rates and altered quality of life. Many well-designed studies have failed to improve ARDS outcomes. Heterogeneity of etiologies, mechanisms of lung damage, different lung mechanics, and different treatment approaches may explain these failures. At the era of personalized medicine, ARDS phenotyping is not only a field of research, but a bedside consideration when implementing therapy. ARDS has moved from being a simple syndrome to a more complex area of subgrouping. Intensivists must understand these phenotypes and therapies associated with a better outcome.

AREAS COVERED

After a brief sum-up of the different type of ARDS phenotypes, we will present some relevant therapy that may be impacted by phenotyping. A focus on pharmacotherapy will be realized before a section on non-pharmaceutical strategies. Eventually, we will highlight the limits of our knowledge of phenotyping and the pitfalls of personalized medicine.

EXPERT OPINION

Biological and morphological ARDS phenotypes are now well studied. The future of ARDS therapy will go through phenotyping that allows a personalized medication for each patient. However, a better assessment of these phenotypes is required, and clinical trials should be conducted with an ad-hoc phenotyping before randomization.

Factors associated with reluctancy to acquire COVID-19 vaccination: A cross-sectional study in Shiraz, Iran, 2022

BACKGROUND

Vaccination is a crucial action that can end the COVID-19 pandemic and reduce its detrimental effect on public health. Despite the availability of various vaccines, this study was conducted to better understand the factors behind individuals refusing to get vaccinated.

METHOD

The current cross-sectional study was conducted with individuals above 18 years of age in Shiraz, Iran, who were eligible but refused to receive the COVID-19 vaccination. Demographic features and factors related to their hesitancy and willingness to participate in the vaccination program were recorded in a questionnaire.

RESULT

Out of 801 participants in the current study, 427 (53.3%) were men, with a mean age of 37.92 years (± 14.16). The findings revealed that 350 (43.7%) participants claimed the side effects of the vaccine outweigh the benefits as one reason for their reluctance toward COVID-19 vaccination, followed by the unknown efficacy of vaccines (40.4%) and a lack of trust in vaccine companies (32.8%). Ensuring the safety of the vaccine (43.7%) and verifying its effectiveness (34.5%) were the most prevalent factors behind participating in the vaccination program. Those who reported their socio-economic status as low were significantly reluctant toward vaccination because of a self-presumption of high immunity (p-value < 0.001), the unclear efficacy of vaccines (p-value < 0.001), the side effects outweighing the benefits of vaccines (p-value < 0.001), distrust of vaccine companies (p-value < 0.001), usage of mask, gloves, and sanitizers (p-value < 0.001), contradictory speech of health authorities regarding vaccines (p-value = 0.041), and the unavailability of trusted vaccines (p-value = 0.002). It should also be noted that participants reported a greater likelihood to obtain information about vaccination reluctance from family and friends (p-value <0.001) and complementary medicine professionals (p-value <0.001).

CONCLUSION

Avoiding vaccination is an undeniable public and individual health concern in Iran, as demonstrated in the current study. Concern about vaccine efficacy and side effects is the most reported cause of vaccination reluctance among individuals, which could be altered by emphasizing mass education and averting an infodemic by forming dedicated multidisciplinary organizations.

An analysis of the causes of exhaustion among physicians working in family physician teams during the COVID-19 pandemic in Lithuania

Background

The COVID-19 pandemic had a severe impact on public life around the world, influencing medicine and health, the economy, employment, science, and education. Health care specialists are key workers who faced extreme challenges posed by the pandemic, including threats to their own lives due to the rapid spread of the virus, a huge increase in workload, and professional burnout syndrome. Analysis of the factors that physicians found most exhausting during the pandemic could lay the groundwork for the effective management of future crises.

Objective

To identify the factors that physicians working in family physician (family and internal medicine) teams found most exhausting during the COVID-19 pandemic in Lithuania and assess their causes.

Methods

An anonymous survey of physicians (n = 191) working in family physician teams was carried out from 21 June 2021 to 17 September 2021. Physicians signed an informed consent form prior to completion of the questionnaire. Mixed data analysis was performed, consisting of statistical analysis using the SPSS 27 software and a qualitative causal analysis.

Results

During the pandemic, physicians were most exhausted by: chaotic vaccination priorities (44.5%); unsatisfied patients (52.4%); constantly changing legislation (71.7%); the large workload (75.9%); and the malfunctioning of online systems (81.2%).

Conclusions

Physicians in family physician teams indicated the following aspects that require improvement: service provision; effective work organization for physicians; and the satisfaction of patients with decisions made during the pandemic.