Case Of Patient Research Articles

Nosocomial SARS-CoV-2 transmission in multi-bedded hospital cubicles over successive pandemic waves: Lower mortality but wider spread with Omicron despite enhanced infection-prevention measures.

BackgroundIncreased transmissibility of severe-acute-respiratory-syndrome-coronavirus-2(SARS-CoV-2) variants, such as the Omicron-variant, presents an infection-control challenge. We contrasted nosocomial transmission amongst hospitalized inpatients across successive pandemic waves attributed to the Delta- and Omicron variants, over a 9-month period in which enhanced-infection-prevention-measures were constantly maintained.MethodsEnhanced-infection-prevention-measures in-place at a large tertiary hospital included universal N95-usage, routine-rostered-testing (RRT) for all inpatient/healthcare-workers (HCWs), rapid-antigen-testing (RAT) for visitors, and outbreak-investigation coupled with enhanced-surveillance (daily-testing) of exposed patients. The study-period lasted from 21st June 2021-21st March 2022. Chi-square test and multivariate-logistic-regression was utilized to identify factors associated with onward transmission and 28d-mortality amongst inpatient cases of hospital-onset COVID-19.ResultsDuring the Delta-wave, hospital-onset cases formed 2.7% (47/1727) of all COVID-19 cases requiring hospitalisation; in contrast, hospital onset-cases formed a greater proportion (17.7%, 265/1483; odds-ratio, OR=7.78, 95%CI=5.65-10.70) during the Omicron-wave, despite universal N95-usage and other enhanced infection-prevention measures that remained unchanged. The odds of 28d-mortality were higher during the Delta-wave compared to the Omicron-wave (27.7%, 13/47, vs. 10.6%, 28/265, adjusted-odds-ratio, aOR=2.78, 95%CI=1.02-7.69). Onward-transmission occurred in 21.2% (66/312) of hospital-onset cases; being on enhanced-surveillance (daily-testing) was independently associated with lower odds of onward-transmission (aOR=0.18, 95%CI=0.09-0.38)ConclusionA surge of hospital-onset COVID-19 cases was encountered during the Omicron-wave, despite continuation of enhanced infection-prevention measures; mortality amongst hospital-onset cases was reduced. The Omicron variant poses an infection-control challenge in contrast to Delta; surveillance is important especially in settings where infrastructural limitations make room-sharing unavoidable, despite the high risk of transmission.

Clinical case of visual axis opacification after primary posterior capsulorhexis

The formation of posterior continuous capsulorhexis during cataract removal has traditionally been used to prevent visual axis opacification. According to the current literature, closure of the posterior capsulorhexis opening in our patient's case should not have developed in a period of 1year, but it did in only one of the two eyes, despite the presence of equal conditions the same surgeon, the same IOL (sharp-edged hydrophilic acrylic with hydrophobic coating), no concomitant eye diseases and somatic pathology. We conducted a literature search to find the cause of the unilateral development of this complication, as well as the optimal treatment method. The difference between two surgeries was in the diameter of the anterior and posterior capsulorhexis on the right eye they were 0.51.0mm larger than on the left eye, and the left eye has developed opacity, which required surgery. An effective and safe way of treating this problem is the capsulotomy using a 25gauge-vitreotome. The clinical case shows the need for further research on this topic, as formation of posterior continuous capsulorhexis has a risk of intra- and postoperative complications, and more data should be considered to ensure that there is no such recurrence of opacity.

A TRACHEAL FIBROEPITHELIAL POLYP

A TRACHEAL FIBROEPITHELIAL POLYP

A CASE OF NEAR-FATAL ASTHMA EXACERBATION

A CASE OF NEAR-FATAL ASTHMA EXACERBATION

CAUGHT IN THE FRAY: NEUROSARCOIDOSIS PRESENTING AS CHRONIC RESPIRATORY FAILURE

CAUGHT IN THE FRAY: NEUROSARCOIDOSIS PRESENTING AS CHRONIC RESPIRATORY FAILURE

S1834 Spontaneous Bacterial Peritonitis in a Postpartum Female Secondary to Necrotizing Pancreatitis

Introduction: SBP is an infection of the fluid that accumulates in the abdomen caused by translocation of bacteria without an obvious source, such as bowel perforation. Typically, this translocation represents a failure in defensive factors to contain pathogens to the bowel and can lead to seeding other extra-intestinal sites. Our patient is unique in that her SBP was characterized in the setting of a recent pregnancy. Her course was complicated by pre-eclampsia resulting in emergent c-section, further complicated by hypertriglyceridemia-induced pancreatitis. After significant intervention, necrotizing pancreatitis leading to retroperitoneal fat saponification and abscess formation was the likely etiology for SBP. Case Description/Methods: A 27-year-old female presented with diffuse abdominal pain, nausea, vomiting, and diarrhea. Past medical history is significant for recent emergency c-section due to pre-eclampsia complicated by hypertriglyceridemia-induced pancreatitis. On admission, she was hypotensive, tachycardic, tachypneic and febrile, with significant bilious emesis. CT revealed large volume ascites, peri-pancreatic fluid, small volume fluid and gas within the endometrial cavity. Peritoneal fluid analysis presented an SBP picture. Abdominal drains were placed to mitigate peritoneal fluid collection, which settled in the retro-peritoneal space. Cultures resulted in pan-sensitive E.coli growth and the patient was started on appropriate therapy. However, the patient continued to have persistent fevers and severe abdominal pain while on medical management. At this point, exploratory abdominal surgery was indicated revealing significant amounts of retroperitoneal saponified fat secondary to necrotizing pancreatitis, and extensive communicating abscesses which were subsequently drained. Discussion: SBP is an infection of fluid that accumulates within the abdomen, typically seen in patient's with chronic liver disease and can be managed with medical therapy. In our patient's case, there was no know history of liver disease. Our patient presented febrile, with diffuse abdominal pain. Imaging revealed significant ascites and cultures resulted in pan-sensitive E.coli. Multiple differentials were assessed including recurrent pancreatitis, C.difficile infection leading to bowel perforation and/or protein-losing enteropathy, endometritis given recent c-section amongst others. After surgical assessment, our likely diagnosis was necrotizing pancreatitis seeding pancreatic enzymes into the retroperitoneal cavity.

Complete Closed Rupture of the Medial Bundle of the Flexor Hallucis Brevis Tendon Off the Medial Sesamoid Insertion

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: Flexor tendon injuries of the hallux are uncommon overall but when they happen, the flexor hallucis longus (FHL) tendon is the most frequent one affected. The rupture of FHL usually results from open injuries and deep cuts in the sole at the base of the toe;4 complete subcutaneous ruptures are extremely rare.5 There are around 36 cases reported of complete or partial closed ruptures of the FHL tendon along its entire course6 and the majority of the partial ruptures correspond to dancers and athletes.7 As far as FHB, we found a few reports of calcific tendinitis of the medial bundle and cases of calcifying tendinitis.8 To the best of our knowledge, this is the only case report of isolated closed rupture of the FHB tendon. Methods: A 33-year-old man, amateur soccer player, presented with mild swelling, ecchymosis, and increasing pain in the left hallux triggered by movement and palpation, relieved by rest. He sustained a direct axial blow and blunt force trauma with a soccer ball plus hyperextension. Standard bilateral weightbearing feet radiographs were normal. Physical exam revealed the left hallux normally aligned but with limited painful motion of 20° each way and no obvious instability. Palpation of the left first metatarsophalangeal joint was tender but not particularly over the sesamoids. MRI revealed an avulsion of the flexor Hallucis Brevis tendon off the proximal aspect of the medial sesamoid accompanied by fluid and edema, effusion in the first MTP joint and bone contusions in the first metatarsal head and dorsal base of the first proximal phalanx. Treatment with a toe spacer and postop sandal with the toe straight with an extension block was decided. Results: Tendon's blood flow around the sesamoids is limited making it susceptible to degenerative rupture. The most common mechanism of complete tendon rupture is direct open injury. Closed rupture is very rare and complete rupture in closed injury is even more. We did not find reports on third degree type of injuries, neither for any kind of isolated rupture of FHB. In our patient's case, dorsiflexion stretched all plantar soft tissue around the first MTP but he was able to do active movement of the great toe probably due to the FHL and lateral FHB insertion integrity. We found few reports of second-degree strain injury of FHL and FHB in a chronic setting, all treated conservatively with partial immobilization and strapping of the hallux to prevent extension. After conservative treatment at 3 months follow-up, our patient presented with no subjective complains, normal motion, stability and alignment of the hallux. Conclusion: Despite an extensive literature search, we did not find a similar injury, and this is probably the first time it is described. As found in our research, the most common injury related to the flexor tendons of the hallux are in soccer players and involve the FHL or both.23 These findings made us conclude that these injuries are either under-diagnosed or exceptional.

Characteristics and Correlates of Metabolic Syndrome in Adolescents with Unipolar and Bipolar Depression: Results from a Cross-National Inpatient Case-Control Study.

<b>Abstract</b> <b><i>Objectives:</i></b> To assess characteristics and correlates of metabolic syndrome (MetS) in adolescents with major depressive disorder (MDD) or bipolar disorder-depressive episode (BP-d). <b><i>Methods:</i></b> Case-control study, using national inpatient sample data, including adolescents (age, 12-18 years) with a primary diagnosis of MDD or BP-d. Using propensity score matching (based on age, sex, and race/ethnicity), we extracted cases with MetS (≥3 of the following conditions: obesity, diabetes, hypercholesterolemia, and hypertension) and controls without MetS. We used a multivariable logistic regression model calculating adjusted odds ratios (aORs) for potential correlates of MetS, focusing on primary mood disorders and psychiatric comorbidities. <b><i>Results:</i></b> In 607 age-/sex-/race/ethnicity-matched adolescents (MDD = 83.5%, BP-d = 16.5%), comparing those with (<i>N</i> = 332) versus without MetS (<i>N</i> = 275), MetS was most prevalent in later-age adolescents (mean age 16.3 years), females (58.1%), Whites (40.3%), and Blacks (31.5%). MetS was characterized by obesity (84.9% vs. 3.6%), hypertension (81% vs. 1.8%), diabetes (72.8% vs. 9.1%), and hypercholesterolemia (67.2% vs. 3.6%) (all <i>p</i> &lt; 0.001). MetS was associated with a primary diagnosis of BP-d versus MDD (aOR 2.42, 95% confidence interval [CI] 1.47-3.97) and comorbid disruptive behavior disorders (DBD) (aOR 4.45, 95% CI 1.55-12.78), while comorbid substance use disorder reduced MetS risk (aOR 0.31, 95% CI 0.19-0.50). <b><i>Conclusion:</i></b> In adolescents with MDD or BP-d, MetS was associated with a primary BP-d diagnosis, and comorbid DBD. MetS-related parameters should be screened for early in adolescents with depression-spectrum disorders aiming to prevent the development or effects of MetS.

Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes.

Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery. The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval. A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery. Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.

알코올 사용 장애 환자의 진전섬망 예측을 위한 의사 결정 모델 개발

Objectives: To identify predictive factors associated with the onset of delirium tremens (DT) and produce a ‘decision tree’ that clinicians could utilize when deciding which patient undergoing alcohol withdrawal symptoms is more likely to develop DT.&#x0D; Methods: Consultation answer notes, demographic, and laboratory data of 243 inpatient consultation cases regarding alcohol withdrawal symptoms were collected. Receiver operating characteristic analysis (ROC) was performed to identify predictors of DT development.&#x0D; Results: DT was developed in 26.75% of consulted cases. ROC revealed that delirium history was the most significant predictor of DT development (κ=0.342; χ2=29.415, p&lt;0.001). Subjects with a delirium history had a conversion rate of 59.5%. Those without such history had a conversion rate of 19.0%. The second most significant factor was body mass index (BMI), with a cutoff point of 23.8 kg/m2 (κ=0.224; χ2=9.043, p&lt;0.01). Among subjects without delirium history, those with BMI ≥23.8 kg/m2 had a conversion rate of 28.6% and those with BMI &lt;23.8 kg/m2 had a conversion rate of 9.0%.&#x0D; Conclusion: Assessing delirium history and BMI of non-psychiatric inpatient ward alcoholic patients can be useful for risk evaluation of DT development. For patients who have a high risk of DT, close monitoring of vital signs and alcohol withdrawal symptoms are needed with prompt administration of benzodiazepine drugs.

Psychiatric Signs Revealing Cerebral Thrombophlebitis: A Case Report

Cerebral thrombophlebitis (CT) corresponds to an obstruction of a cerebral vein by a clot. It is a less frequent pathology than cerebrovascular accidents (CVA) but is certainly not rare. Its diagnosis is more radiological (brain MRI being the reference examination) than clinical, given the heterogeneity of the symptoms. In most frequent cases, CVT is revealed by headaches, papilledema, epileptic seizures, or isolated intracranial hypertension. In other cases, the clinical signs are less obvious and can be presented by psychiatric signs, as in our patient's case. The treatment was primarily based on anticoagulant therapy and the evolution was marked by an improvement of all the symptoms.

Clinical Characteristics and Treatment Overview in Hand-Foot-and-Mouth Disease Using Real-World Evidence Based on Hospital Information System.

Objectives To describe the epidemiological characteristics and medication overview of HFMD in Guangzhou and analyze the factors of length of stay (LOS) based on TCM usage. Method From January 1, 2014, to June 30, 2019, clinical data of HFMD (ICD-10 B08.401) as the initial diagnosis, based on HIS of five medical institutions for outpatient and inpatient cases, was collected. The inpatient cases of the five hospitals in Guangzhou were utilized for hospitalization analysis. Information extracted from the warehouse was standardized. Descriptive analysis was used for baseline characteristics, medication usage, and inpatient characteristics. Potential factors were analyzed by bivariate analysis. COX regression analysis and Kaplan–Meier analysis for calculating HRs and 95% CIs were adopted to determine the predictors of LOS. Stratified COX regression was applied to analyze the relationship between predictors and LOS and to calculate interaction. Results A total of 14172 patients with HFMD were included. It showed that HFMD would occur in males, infants, and summer. Cause and symptoms are the two aspects of conventional Western medicine treatments, while TCM treatment of HFMD took clearing heat and detoxification as the basic principle. Inpatients with HFMD were divided into two groups by the use ratio of TCM. Age, season, and disease severity were possible correlated factors of LOS, extrapolating from their disparity in distribution. By stratified Cox regression, three factors following presented as possible contributions to shortening LOS, including TCM ≥ 0.1 (HR = 1.79, 95% CI (1.67–1.92), P < 0.01), winter (HR = 1.28, 95% CI (1.12–1.47)), P < 0.01), mild HFMD (HR = 1.93, 95% CI (1.69–2.22), P < 0.01). Additive interaction of TCM use and disease severity was significant (RERI = 1.014 (0.493–1.534), P < 0.01). Conclusion Young children and high temperature were the risk factors of HFMD infection, which suggests that increasing surveillance for susceptible particular-age individuals and season is indispensable. Favorable factors to decrease LOS included a higher proportion of TCM use, mild HFMD, and onset in winter. The proportion of TCM use had additive interaction with disease severity, indicating that TCM may have antiviral and other biological effects on HFMD. Increasing the proportion of TCM use was probably beneficial to shortening LOS.

Causes of Dispute for COVID-19 Outpatient and Inpatient Claims at the Muhammadiyah University General Hospital of Malang

Muhammadiyah University General Hospital of Malang is a COVID-19 referral hospital for Malang. Between April 2020 and June 2021, the hospital submitted 62 outpatient and 1364 inpatient cases for COVID-19 claims to the Ministry of Health of the Republic of Indonesia. The percentage of outpatient dispute claims was 25% and of inpatient dispute claims was 39%. These disputed claims disturbed the cash flow of the health facilities. The aim of our study was to describe the causes of outpatient and inpatient COVID-19 dispute claims. Our methodology was descriptive, and the secondary data were taken from claim submission documents. There were ten criteria that caused dispute claims based on KMK Number HK. 01.07/MENKES/4718/2021. This was related to administrative and medical issues. The most common cause of inpatient dispute claims (35%) was that the criteria for discharge from the hospital were not in accordance with the guarantee limit. Additionally, the most common cause of outpatient dispute claims (60%) was the management of isolation that was not related to the guidelines for management and prevention of COVID-19.&#x0D; Keywords: claim dispute criteria, hospital, COVID-19

Minimally Invasive Surgery in the United States, 2022: Understanding Its Value Using New Datasets

IntroductionWhile minimally invasive surgery (MIS) has transformed the treatment landscape of surgical care, its utilization is not well understood. The newly released Nationwide Ambulatory Surgery Sample allows for more accurate estimates of MIS volume in the United States—in combination with inpatient datasets. Materials and methodsMultiple nationwide databases from the Healthcare Cost and Utilization Project (HCUP) were used: the Nationwide Ambulatory Surgery Sample and National Inpatient Sample. The volume of MIS and robotic procedures were calculated from 2016 to 2018. An online query system, HCUPNet, was queried for inpatient stays from 1993 to 2014. ResultsIn 2017, 9.8 million inpatient major operating room procedures were analyzed, of which 11.1% were MIS and 2.5% were robotic-assisted, compared with 9.6 million inpatient operating room procedures (11.2% MIS and 2.9% robotic-assisted) in 2018. There were 10.6, 10.6, and 10.7 million ambulatory procedures in 2016, 2017, and 2018, respectively. Ambulatory MIS procedures showed an increasing trend across years, representing 16.9%, 17.4%, and 18%, respectively. HCUPNet data revealed an increase in inpatient MIS cases from 529,811 (8.9%) in 1993 to 1,443,446 (20.7%) in 2014. ConclusionsThis study is the first to estimate national MIS volume across specialties in both inpatient and ambulatory hospital settings. We found a trend toward a higher proportion of MIS and robotic cases from 1997 to 2018. These data may help contribute to a more comprehensive understanding of MIS value within surgery and highlight limitations of current databases, especially when categorizing robotic cases on a national scale.

Mortality burden due to liver cirrhosis and hepatocellular carcinoma in Ghana; prevalence of risk factors and predictors of poor in-hospital survival.

Liver-related diseases, including liver cirrhosis and hepatocellular carcinoma (HCC), are significant causes of mortality globally. Specific causes and predictors of liver-related mortality in low resource settings require assessment to help inform clinical decision making and develop strategies for improved survival. The objectives of this study were to determine the proportion of liver-related deaths associated with liver cirrhosis, HCC, and their known risk factors, and secondly to determine predictors of in-hospital mortality among cirrhosis and HCC patients in Ghana. We first performed a cross-sectional review of death register entries from 11 referral hospitals in Ghana to determine the proportion of liver-related deaths and the proportion of risk factors associated with these deaths. Secondly, we conducted a retrospective cohort review of 172 in-patient liver cirrhosis and HCC cases admitted to a tertiary referral centre and determined predictors of in-hospital mortality using binary logistic regression and Kaplan-Meier survival analysis. In total, 8.8% of deaths in Ghanaian adults were due to liver-related causes. The proportion of liver-related deaths attributed to HBV infection was 48.8% (95% CI: 45.95–51.76), HCV infection was 7.0% (95% CI: 5.58–8.45), HBV-HCV co-infection 0.5% (95% CI: 0.1–0.9) and alcohol was 10.0% (95% CI: 8.30–11.67). Of 172 cases of HCC and liver cirrhosis, the in-patient mortality rate was 54.1%. Predictors of in-patient mortality in cirrhotic patients were increasing WBC (OR = 1.14 95% CI: 1.00–1.30) and the revised model for end-stage liver disease with sodium (MELD-Na) score (OR = 1.24 95% CI: 1.01–1.54). For HCC patients, female sex (OR = 3.74 95% CI: 1.09–12.81) and hepatic encephalopathy (grade 1) were associated with higher mortality (OR = 5.66 95% CI: 1.10–29.2). In conclusion, HBV is linked to a high proportion of HCC-related deaths in Ghana, with high in-hospital mortality rates that require targeted policies to improve survival.

To deprescribe or not to deprescribe, that is the question

To deprescribe or not to deprescribe, that is the question

Tumor cell-specific retention of photosensitizers determines the outcome of photodynamic therapy for head and neck cancer

Pheophorbide-based photosensitizers have demonstrated tumor cell-specific retention. The lead compound 3-[1'-hexyloxyethyl]-2-devinylpyropheophorbide-a (HPPH) in a clinical trial for photodynamic therapy of head and neck cancer lesions indicated a complete response in 80% of patients. The question arises whether the partial response in 20% of patients is due to inefficient retention of photosensitizers by tumor cells and, if so, can the photosensitizer preference of individual cancer cases be identified prior to photodynamic therapy. This study determined the specificity of head and neck cancer cells and tumor tissues for the uptake and retention of diffusible pheophorbides differing in peripheral groups on the macrocycle that contribute to cellular binding. The relationship between photosensitizer level and light-mediated photoreaction was characterized to identify markers for predicting the effectiveness of photodynamic therapy in situ. The experimental models were stromal and epithelial cells isolated from head and neck tumor samples and integrated into monotypic tissue cultures, reconstituted three-dimensional co-cultures, and xenografts. Tumor cell-specific photosensitizer retention patterns were identified, and a procedure was developed to allow the diagnostic evaluation of HPPH binding by tumor cells in individual cancer cases. The findings of this study may assist in designing conditions for photosensitizer application and photodynamic therapy of head and neck cancer lesions optimized for each patient's case.

Segmental Hypokinetic Cardiomyopathy in Churg Strauss Syndrome: A Case Report and Review of a Spectacular Evolution

Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is a necrotizing systemic vasculitis of small vessels, associated with late-onset asthma, blood and tissue hypereosinophilia. Cardiac involvement is a major concern and has been described as the leading cause of mortality. In this context, we report the case of a 48-year-old woman with Churg Strauss syndrome, suffering from late-onset asthma, pansinusitis, hypereosinophilia, and cardiac damage, consisting of segmental hypokinetic cardiomyopathy with an altered ejection fraction and healthy coronary artery, complicated by a flutter treated by electric cardioversion. The combination of bolus corticosteroid therapy with Azathioprine, as well as the reduction of the rhythm disorder, led to an improvement of the contractile function and the ejection fraction in this patient's case. This observation illustrates a particular and exceptional form of myocardial damage due to Churg-Strauss syndrome and its spectacular evolution under background treatment and rhythm control.

Assessment of Healthcare Delivery Systems in Orthopaedic Surgery: A Large Retrospective Cohort Evaluation.

The purpose of this study was to assess how quality and volume of common orthopaedic care varies across private, municipal, and federal healthcare delivery systems (HDSs). Hip and knee arthroplasty, knee and shoulder arthroscopy, and hip fracture repair were audited over a two-year period. Electronic medical records were reviewed for demographics, diagnosis, lengths of stay (LoSs), surgical wait times, inpatient complication, readmission, and revision surgery rates. Multivariate regression controlled for differences in age, sex, diagnosis, and Charlson Comorbidity Index to determine how HDS correlated with surgical wait time, length of stay, complication rates, readmission, and revision surgery. The 5,696 included patients comprise 87.4% private, 8.6% municipal, and 4.0% federal HDSs. Compared with private HDS for arthroplasty, federal surgical wait times were 18 days shorter (95% CI = 9 to 26 days, P < 0.001); federal LoS was 4 days longer (95% CI = 3.6 to 4.3 days, P < 0.001); municipal LoS was 1 day longer (95% CI = 0.8 to 1.4, P < 0.001); municipal 1-year revision surgery odds were increased (odds ratio [OR] = 2.8, 95% CI = 1.3 to 5.4, P = 0.045); and complication odds increased for municipal (OR = 12.2, 95% CI = 5.2 to 27.4, P < 0.001) and federal (OR = 12.0, 95% CI = 4.5 to 30.8, P < 0.001) HDSs. Compared with private HDS for arthroscopy, municipal wait times were 57 days longer (95% CI = 48 to 66 days, P < 0.001) and federal wait times were 34 days longer (95% CI = 21 to 47 days, P < 0.001). Compared with private HDS for fracture repair, municipal wait times were 0.6 days longer (95% CI = 0.2 to 1.0, P = 0.02); federal LoS was 7 days longer (95% CI = 3.6 to 9.4 days, P < 0.001); and municipal LoS was 4 days longer (95% CI = 2.4 to 4.8, P < 0.001). Only private HDS fracture repair patients received bone health consultations. The private HDS provided care for a markedly larger volume of patients seeking orthopaedic care. In addition, private HDS patients experienced reduced surgical wait times, LoSs, and complication odds for inpatient elective cases, with better referral patterns for nonsurgical orthopaedic care after hip fractures within the private HDS. These results may guide improvements for federal and municipal HDSs.

Declines in the utilization of hospital-based care duringCOVID-19 pandemic.

The disruptions of the coronavirus disease 2019 (COVID‐19) pandemic impacted the delivery and utilization of healthcare services with potential long‐term implications for population health and the hospital workforce. Using electronic health record data from over 700 US acute care hospitals, we documented changes in admissions to hospital service areas (inpatient, observation, emergency room [ER], and same‐day surgery) during 2019−2020 and examined whether surges of COVID‐19 hospitalizations corresponded with increased inpatient disease severity and death rate. We found that in 2020, hospitalizations declined by 50% in April, with greatest declines occurring in same‐day surgery (−73%). The youngest patients (0−17) experienced largest declines in ER, observation, and same‐day surgery admissions; inpatient admissions declined the most among the oldest patients (65+). Infectious disease admissions increased by 52%. The monthly measures of inpatient case mix index, length of stay, and non‐COVID death rate were higher in all months in 2020 compared with respective months in 2019.