Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

INTRODUCTION The unnecessary overuse of ED services in the United States leads to an estimated wasteful spending of $38 billion yearly. The burden of these visits is multiplied in pandemics and times of crisis, such as the COVID-19 pandemic, during which ED resources may already be overwhelmed. Post-operative Emergency Department (ED) visits following suboccipital decompression in CM-1 patients are not well described. METHODS A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. Pre-operatively and post-operatively prior to hospital discharge, patients are counselled extensively on activity restrictions after surgery, incision care, expectations of severe headache and neck stiffness for the first few weeks after surgery, the variability in degree and timing of symptom improvement from patient to patient, and the proper intake of analgesics, as prescribed. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS). RESULTS In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%). Concentration disturbance at presentation was the only factor significantly associated with a post-operative ED visit (P = .023). The occurrence of a post-operative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted OR of CCOS≥13 = 0.35, P = .021;adjusted OR of CCOS≥14 = 0.38, P = .016). CONCLUSION Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of post-operative ED visits, which are mostly due to pain-related complaints, despite preoperative and postoperative counselling. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of post-operative ED service utilization are warranted.

[Correlation between early inflammation indicators and the severity of coronavirus disease 2019].

OBJECTIVE: To explore the correlation between early inflammation indicators and the severity of coronavirus disease 2019 (COVID-19). METHODS: A retrospective study was conducted. Patients with COVID-19 admitted to Wenzhou Central Hospital from January 17 to February 14, 2020 were enrolled. The general information, chest CT before admission, the first laboratory parameters and chest CT within 24 hours after admission were collected. Patients were followed up for 30 days after the first onset of dyspnea or pulmonary imaging showed that the lesions progressed more than 50% within 24 to 48 hours (according to the criteria for severe cases) as the study endpoint. According to the endpoint, the patients were divided into two groups: mild type/common type group and severe/critical group, and the differences in general information and inflammation index of the two groups were compared. Logistic regression was used to analyze the inflammation index and the severity of COVID-19. Receiver operating characteristic (ROC) curve was draw to evaluate the predictive value of early inflammation indicators for severe/critical in patients with COVID-19. RESULTS: A total of 140 patients with COVID-19 were included, 74 males and 66 females; the average age was (45±14) years old; 6 cases (4.3%) of mild type, 107 cases (76.4%) of common type, and 22 cases (15.7%) of severe type, 5 cases (3.6%) were critical. There were significantly differences in ages (years old: 43±13 vs. 57±13), the proportion of patients with one chronic disease (17.7% vs. 55.6%), C-reactive protein [CRP (mg/L): 7.3 (2.3, 21.0) vs. 40.1 (18.8, 62.6)], lymphocyte count [LYM (×109/L): 1.3 (1.0, 1.8) vs. 0.8 (0.7, 1.1)], the neutrophil/lymphocyte ratio [NLR: 2.1 (1.6, 3.0) vs. 3.1 (2.2, 8.8)] and multilobularinltration, hypo-lymphocytosis, bacterial coinfection, smoking history, hyper-tension and age [MuLBSTA score: 5.0 (3.0, 5.0) vs. 5.0 (5.0, 7.0)] between mild/common group and severe/critical group (all P < 0.05). Univariate Logistic regression analysis showed that CRP, NLR, MuLBSTA score, age, and whether chronic diseases were associated with the severity of COVID-19 [odds ratio (OR) and 95% confidence interval (95%CI) were 1.037 (1.020-1.055), 1.374 (1.123-1.680), 1.574 (1.296-1.911), 1.082 (1.042-1.125), 6.393 (2.551-16.023), respectively, all P < 0.01]. Further multivariate Logistic regression analysis showed that CRP and MuLBSTA score were risk factors for the development of COVID-19 to severe/critical cases [OR and 95%CI were 1.024 (1.002-1.048) and 1.321 (1.027-1.699) respectively, both P < 0.05]. ROC curve analysis showed that the area under the curve for CRP and MuLBSTA score to predict severe/critical cases were both 0.818, and the best cut-off points were 27.4 mg/L and 6.0 points, respectively. CONCLUSIONS: CRP and MuLBSTA score are related to the severity of COVID-19, and may have good independent predictive ability for the development of severe/critical illness.

Telemedicine in the Coronavirus Disease 2019 Pandemic: A Pediatric Rehabilitation Perspective.

ABSTRACT: In the spring of 2020, coronavirus disease 2019 evolved into a worldwide pandemic, forcing traditional face-to-face healthcare to a standstill. Telemedicine was quickly adopted as a major tool for pediatric rehabilitation services. This article describes the national legislative response of the United States to the coronavirus disease 2019 pandemic and the opportunities and challenges of implementing telemedicine in pediatric rehabilitation outpatient settings, consultations, as well as physician and patient education. The feasibility of performing a remote pediatric musculoskeletal and neurological tele-evaluation is also discussed. Although challenges exist, telemedicine has demonstrated its potential and has proven to be a practical system. Future developments in technology and accessibility, in addition to support from government and third-party payers, have the potential to make telemedicine an effective and vital platform in a coordinated healthcare system.

Differential diagnosis for suspected cases of coronavirus disease 2019: a retrospective study.

BACKGROUND: Since December 2019, the coronavirus disease 2019 (COVID-19) has infected more than 12,322,000 people and killed over 556,000 people worldwide. However, Differential diagnosis remains difficult for suspected cases of COVID-19 and need to be improved to reduce misdiagnosis. METHODS: Sixty-eight cases of suspected COVID-19 treated in Wenzhou Central Hospital from January 21 to February 20, 2020 were divided into confirmed and COVID-19-negative groups based on the results of real-time reverse transcriptase polymerase chain reaction (RT-PCR) nucleic acid testing of the novel coronavirus in throat swab specimens to compare the clinical symptoms and laboratory and imaging results between the groups. RESULTS: Among suspected patients, 17 were confirmed to COVID-19-positive group and 51 were distinguished to COVID-19-negative group. Patients with reduced white blood cell (WBC) count were more common in the COVID-19-positive group than in the COVID-19-negative group (29.4% vs 3.9%, P = 0.003). Subsequently, correlation analysis indicated that there was a significant inverse correlation existed between WBC count and temperature in the COVID-19-positive patients (r = - 0.587, P = 0.003), instead of the COVID-19-negative group. But reduced lymphocyte count was no different between the two groups (47.1% vs 25.5%, P = 0.096). More common chest imaging characteristics of the confirmed COVID-19 cases by high-resolution computed tomography (HRCT) included ground-glass opacities (GGOs), multiple patchy shadows, and consolidation with bilateral involvement than COVID-19-negative group (82.4% vs 31.4%, P = 0.0002; 41.2% vs 17.6% vs P = 0.048; 76.5% vs 43.1%, P = 0.017; respectively). The rate of clustered infection was higher in COVID-19-positive group than COVID-19-negative group (64.7% vs 7.8%, P = 0.001). Through multiplex PCR nucleic acid testing, 2 cases of influenza A, 3 cases of influenza B, 2 cases of adenovirus, 2 cases of Chlamydia pneumonia, and 7 cases of Mycoplasma pneumoniae were diagnosed in the COVID-19-negative group. CONCLUSIONS: WBC count inversely correlated with the severity of fever, GGOs, multiple patchy shadows, and consolidation in chest HRCT and clustered infection are common but not specific features in the confirmed COVID-19 group. Multiplex PCR nucleic acid testing helped differential diagnosis for suspected COVID-19 cases.

COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers.

BACKGROUND: The outbreak of COVID-19 has laid unprecedented threats and challenges to health workers (HWs) in Wuhan, China. We aimed to assess the sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on HWs at Tongji Hospital in Wuhan during COVID-19 outbreak. METHODS: We conducted a single-center, cross-sectional survey of HWs via online questionnaires between February 8th and 10th, 2020. We evaluated stress, depression and anxiety by IES-R, PHQ-9, and GAD-7, respectively. We also designed a questionnaire to assess the perceptions of threat of COVID-19, and the satisfactions of the hospital's support measures. Multivariate logistic regressions were used to identify associated variables of acute stress, depression, and anxiety. FINDINGS: We received 5062 completed questionnaires (response rate, 77.1%). 29.8%, 13.5% and 24.1% HWs reported stress, depression and anxiety symptoms. Women (odds ratio [OR], 1.31; 95% CI, 0.47-0.97; p = 0.032), years of working >10 years (OR, 2.02; 95% CI, 1.47-2.79; p<0.001), concomitant chronic diseases (OR, 1.51; 95% CI, 1.27-1.80; p<0.001), history of mental disorders (OR, 3.27; 95% CI, 1.77-6.05; p<0.001), family members or relatives confirmed or suspected (OR, 1.23; 95% CI, 1.02-1.48; p = 0.03), hospital-based and department-based care (OR, 0.76; 95% CI, 0.60-0.97; p = 0.024) and full coverage of all departments for avoiding nosocomial infection (OR, 0.69; 95% CI, 0.53-0.89; p = 0.004) were associated with stress. INTERPRETATION: Women and those who have more than 10 years of working, concomitant chronic diseases, history of mental disorders, and family members or relatives confirmed or suspected are susceptible to stress, depression and anxiety among HWs during the pandemic. In addition, since HWs often have a greater stigma against mental problems than the general public, it is worthwhile to address the needs of the HWs during this pandemic and to provide appropriate psychological supports for those people at high risk of mental problems.