Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates.

BACKGROUND: This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19. METHODS: A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]). RESULTS: Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately. CONCLUSION: Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

The Persistent Effects of the COVID-19 Pandemic on Total Joint Arthroplasty Changes in Practice Patterns in the United States From 2020 to 2021.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has dramatically disrupted orthopaedic surgery practice patterns. This study aimed to examine differences between patients who underwent total joint arthroplasty (TJA) before the pandemic compared to 2020 and 2021. METHODS: A retrospective cohort study was performed on all patients who underwent elective inpatient TJA from January 2017 to December 2021 using a national large database. Descriptive statistics were utilized to trend length of stay (LOS) and patient age. Patient demographics, discharge destinations, and rates of medical comorbidities were assessed for patients undergoing TJA in 2020 and 2021 compared to patients from prepandemic years (2017 to 2019). Overall, 1,173,366 TJAs were identified (2017 to 2019: 810,268 TJAs, average 270,089 cases/year; 2020: 175,185 TJAs; 2021: 187,627 TJAs). There was a 35.3% and 30.5% decrease in 2020 and 2021, respectively, when compared to the prepandemic annual average. RESULTS: Average LOS decreased from 1.6 days in January 2020 to 0.9 days by December 2021. Same-day discharges increased from 6.2% of cases in 2019 to 30.5% in 2021. Discharge to skilled nursing facilities (SNF) reduced from 11.3% in 2017 to 2019 to 4.3% and 4.5% in 2020 and 2021, respectively. Patients ≥70 years old undergoing elective TJA decreased from 39.6% in 2017 to 2019 to 29.2% in April 2020. CONCLUSION: In response to the COVID-19 pandemic, same-day discharges following primary elective TJA increased markedly, the average LOS decreased, discharges to SNFs decreased, and a preferential shift toward younger patients was observed. LEVEL OF EVIDENCE: Therapeutic Level III.

Rare disease emerging as a global public health priority

The genomics revolution over the past three decades has led to great strides in rare disease (RD) research, which presents a major shift in global policy landscape. While RDs are individually rare, there are common challenges and unmet medical and social needs experienced by the RD population globally. The various disabilities arising from RDs as well as diagnostic and treatment uncertainty were demonstrated to have detrimental influence on the health, psychosocial, and economic aspects of RD families. Despite the collective large number of patients and families affected by RDs internationally, the general lack of public awareness and expertise constraints have neglected and marginalized the RD population in health systems and in health- and social-care policies. The current Coronavirus Disease of 2019 (COVID-19) pandemic has exposed the long-standing and fundamental challenges of the RD population, and has reminded us of the critical need of addressing the systemic inequalities and widespread disparities across populations and jurisdictions. Owing to the commonality in goals between RD movements and universal health coverage targets, the United Nations (UN) has highlighted the importance of recognizing RDs in policies, and has recently adopted the UN Resolution to promote greater integration of RDs in the UN agenda, advancing UN's commitment in achieving the 2030 Sustainable Development Goals of “leav[ing] no one behind.” Governments have also started to launch Genome Projects in their respective jurisdictions, aiming to integrate genomic medicine into mainstream healthcare. In this paper, we review the challenges experienced by the RD population, the establishment and adoption of RD policies, and the state of evidence in addressing these challenges from a global perspective. The Hong Kong Genome Project was illustrated as a case study to highlight the role of Genome Projects in enhancing clinical application of genomic medicine for personalized medicine and in improving equity of access and return in global genomics. Through reviewing what has been achieved to date, this paper will provide future directions as RD emerges as a global public health priority, in hopes of moving a step toward a more equitable and inclusive community for the RD population in times of pandemics and beyond.

The Use of Telesurgery Mentoring and Augmented Reality to Teach Arthroscopy.

Surgical teaching methods may be enhanced with telesurgery mentoring technology through virtual, visual, and audio interactions in the operating room, irrespective of geographic restrictions. The use of telesurgery mentoring carries the potential for accelerated learning in arthroscopic and surgical education. A telesurgery platform enables the establishment of a global network of surgeons with the goal of bridging gaps in surgical training via an accessible, cost-effective communication pathway. Specifically, such a platform allows a local surgeon to deliver real-time and live virtual assistance to a remote surgeon over a standard internet connection and removes the geographic barriers that prevent the practice of high-quality surgical care, thereby expanding virtual surgical collaboration. The purpose of our study is to describe our technique of telesurgery mentoring using a telesurgery internet platform (SurgTime; www.surgtime.com) and its applicability to teaching arthroscopic surgery skills both within the United States and in developing countries across the globe.

Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic.

BACKGROUND: Despite known surgical volume reductions in 2020 during the height of the COVID-19 pandemic, no study has fully quantified the impact of the pandemic on the number of elective inpatient total hip (THA) and total knee arthroplasty (TKA) cases. The purpose of the present study was to analyze THA and TKA case volumes in the United States during the COVID-19 pandemic. METHODS: The Premier Healthcare Database was utilized to identify adults undergoing primary elective THA or TKA from January 2017 to December 2020. The National Inpatient Sample was cross-referenced to provide nationwide representative sampling weights. Patients undergoing revision total joint arthroplasty (TJA) or non-elective surgery were excluded. Two quantitative models were created from both databases to estimate TJA case volume in 2020. Descriptive statistics were utilized to report monthly changes in elective TJA utilization throughout 2020. Univariate analyses were performed to compare differences between subgroups. RESULTS: From 2017 to 2019, it was estimated that 1,006,000 elective inpatient TJAs (64.2% TKA and 35.8% THA) were performed annually. In 2020, an estimated 526,000 to 538,000 cases (62.0% TKA and 38.0% THA) were performed, representing a 46.5% to 47.7% decrease in nationwide volume from the prior 3-year average. Moreover, the elective TJA case volume for April 2020 was 1.9% of the average for that month from 2017 through 2019. Subsequently, case volumes for May and June increased compared with the volumes for those months from 2017 through 2019. There was then a decrease in cases for July, corresponding with the "second wave" of COVID-19, followed by an additional steady monthly decline through December, corresponding with the "third wave." Finally, the elective TJA cases for December 2020 represented only 41.0% of the average case volume for that month from 2017 through 2019. CONCLUSIONS: In the midst of the 2020 COVID-19 pandemic, approximately 526,000 to 538,000 elective inpatient TJA cases were performed, representing a 46.5% to 47.7% decrease compared with the 3 previous years. The effects of the COVID-19 pandemic persisted through the end of that year, with decreased case volume through December 2020.

Hospital mortality in patients with rare diseases during pandemics: lessons learnt from the COVID-19 and SARS pandemics.

BACKGROUND: The threat and experience of pandemics occur differently for different groups. The rare disease population is at particular risk of being further marginalised during pandemics. In this study, our objective was to assess the hospital mortality patterns in the rare disease and the general populations during the coronavirus disease of 2019 (COVID-19) and severe acute respiratory syndrome (SARS) pandemics in Hong Kong. METHODS: All admission records during the COVID-19 pandemic (January 23-August 23, 2020) and SARS pandemic (March 11-June 30, 2003) were extracted from the local public healthcare database. Patients with rare diseases were identified using one or more of the 1084 10th version International Classification of Diseases and Related Health Problems (ICD-10) codes cross-referenced with 467 ORPHAcodes. Hospital mortality patterns were compared in patients with and without COVID-19/SARS infection. Admission records during the same period in 2019 and 2002 were retrieved for comparison. RESULTS: During the COVID-19 pandemic, 407,219 patients were admitted to one or more of the 43 public hospitals in Hong Kong, of which, 13,894 were patients with rare diseases (3.4%). A total of 4381 and 77 patients from the general and rare disease populations were infected with COVID-19. Rare disease patients had an adjusted 3.4 times odds of COVID-19-related hospital mortality compared with that of the general population (95% C.I. 1.24-9.41). COVID-19-related mortality was almost exclusively seen in patients ≥ 60 years. While age-related increase in mortality was also observed for the general population during the SARS pandemic, the pattern observed in the rare disease population was significantly different, with a 12.5 times higher SARS-related mortality observed in rare disease patients ≤ 18 years than those in the general population (12.5% vs 1.0%). Patients admitted during the same pandemic periods without coronavirus infection had a significantly higher hospital mortality compared with those admitted one year before the pandemic (p < 0.001). CONCLUSION: This population-based study demonstrated the differential impacts of the COVID-19 and SARS pandemics on the rare disease population. In the era of budget and resource scarcity, this study warrants cautious healthcare planning, with consideration of the rare disease population in healthcare prioritisation.

Patient Perception Regarding the Safety of Elective Joint Arthroplasty Surgery During the COVID-19 Pandemic.

BACKGROUND: Total joint arthroplasty (TJA) practices have been dramatically impacted by the COVID-19 pandemic. To date, no study has assessed trends in patient perceptions regarding the safety of elective TJA. METHODS: A single-institution, prospective cohort study was conducted between May 11th and August 10th, 2020. All patients who underwent elective hip and knee arthroplasty were contacted via telephone or emailed surveys. Two-hundred and thirty-five consecutive patients were screened, and 158 agreed to participate. The average age was 65.9 ± 11.5 years, with 51.0% of patients being female. The percentage of participants who underwent total knee, total hip, and unicompartmental knee arthroplasty was 41.4%, 37.6%, and 21.0%, respectively. Survey components assessed demographic data, level of concern and specific concerns about the pandemic, and factors increasing patient comfort in proceeding with surgery. RESULTS: Older age (P = .029) and female sex (P = .004) independently predicted higher concern on multivariate analysis. Race (P = .343), surgical site (knee vs hip, P = .58), and procedure type (primary vs revision, P = .26) were not significantly related to degree of concern. Most participants (71.5%) disagreed that the pandemic would negatively affect the outcome of their surgery. Patient concern mirrored statewide COVID-19 cases and deaths, rather than local municipal trends. The most cited reassuring factors were preoperative COVID-19 testing, personal protective equipment usage by hospital staff, and surgeon support. CONCLUSIONS: Patient concern regarding the safety of elective TJA may follow broader policy-level events rather than local trends. Surgeons should note that universal preoperative COVID-19 testing, adequate personal protective equipment, and surgeon support were reassuring to patients. LEVEL OF EVIDENCE: Level IV Therapeutic.

Erratum to "Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly Medicare patients" [American Journal of Preventive Cardiology 3C (2020) 100090].

[This corrects the article DOI: 10.1016/j.ajpc.2020.100090.].

A thematic study: impact of COVID-19 pandemic on rare disease organisations and patients across ten jurisdictions in the Asia Pacific region.

BACKGROUND: This study assesses the areas and extent of impact of the Coronavirus Disease of 2019 (COVID-19) pandemic on rare disease (RD) organisations in the Asia Pacific region. There is no existing literature that focuses on such impact on RD organisations in any jurisdictions, nor RD populations across multiple jurisdictions in the Asia Pacific region. A cross-sectional survey was distributed to RD organisations between April and May 2020. Quantitative and qualitative data on the impact of COVID-19 on RD organisations and patients were collected from the organisation representative's perspective. Qualitative data was analysed using thematic analysis. A follow-up focus group meeting was conducted in August 2020 to validate the survey findings and to discuss specific needs, support and recommendations for sustainable healthcare systems during the pandemic. RESULTS: A total of 80 RD organisations from Australia, Hong Kong Special Administrative Region of China, India, Japan, mainland China, Malaysia, New Zealand, the Philippines, Singapore and Taiwan participated in the study. Of all, 89% were concerned about the impact of pandemic on their organisations. Results indicate that 63% of the organisations functioned at a reduced capacity and 42% stated a decrease in funding as their biggest challenge. Overall, 95% believed their patients were impacted, particularly in healthcare access, social lives, physical health, psychological health and financial impact. Specifically, 43% identified the reduced healthcare access as their top impact, followed by 26% about the impact on daily living and social life. Focus group meeting discussed differential impact across jurisdictions and point towards telemedicine and digitalisation as potential solutions. CONCLUSIONS: This serves as the first study to assess the impact of COVID-19 on RD patients and organisations across multiple jurisdictions in the Asia Pacific region, identifying major themes on the impact on both RD patients and organisations. By including 80 organisations from ten jurisdictions, our study presents the most comprehensive assessment of the pandemic's impact to date. It highlights the need for mental health support and sheds light on moving towards telemedicine and digitalisation of organisation operation, which constitutes a sustainable model in times of pandemics and beyond.

Metformin is associated with lower hospitalizations, mortality and severe coronavirus infection among elderly medicare minority patients in 8 states in USA.

BACKGROUND AND AIMS: Metformin has antiviral and anti-inflammatory effects and several cohort studies have shown that metformin lower mortality in the COVID population in a majority white population. There is no data documenting the effect of metformin taken as an outpatient on COVID-19 related hospitalizations. Our aim was to evaluate if metformin decreases hospitalization and severe COVID-19 among minority Medicare patients who acquired the SARS-CoV2 virus. METHODS: We conducted a retrospective cohort study including elderly minority Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health records, demographic data, as well as clinical and echocardiographic data. We classified those using metformin as those patients who had a pharmacy claim for metformin and non-metformin users as those who were diabetics and did not use metformin as well as non-diabetic patients. Our primary outcome was hospitalization. Our secondary outcomes were mortality and acute respiratory distress syndrome (ARDS). RESULTS: We identified 1139 COVID-19 positive patients of whom 392 were metformin users. Metformin users had a higher comorbidity score than non-metformin users (p < 0.01). The adjusted relative hazard (RH) of those hospitalized for metformin users was 0.71; 95% CI 0.52-0.86. The RH of death for metformin users was 0.34; 95% CI 0.19-0.59. The RH of ARDS for metformin users was 0.32; 95% CI 0.22-0.45. Metformin users on 1000 mg daily had lower mortality, but similar hospitalization and ARDS rates when compared to those on 500-850 mg of metformin daily. CONCLUSIONS: Metformin is associated with lower hospitalization, mortality and ARDS among a minority COVID-19 population. Future randomized trials should confirm this finding and evaluate for a causative effect of the drug preventing disease.

Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly medicare patients.

BACKGROUND: The COVID-19 pandemic has disproportionally impacted the elderly. In the United States and Europe the mortality rate of elderly patients with COVID-19 is greater than 30%. Our aim is to determine predictors of COVID-19 related hospitalization and severity of disease among elderly Medicare patients in the United States. METHODS: We conducted a retrospective cohort study including elderly Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health record, demographic, clinical and echocardiographic predictors. Our primary outcomes were hospitalization and adult respiratory distress syndrome (ARDS). Our secondary outcome was mortality. RESULTS: We identified 400 COVID-19 positive patients (incidence 5.2; (95% CI 4.7-5.7) per 1000 patients). The mean age of our patients was 72 â€‹± â€‹8, 60% were female, 82% were minorities and had a mean Charlson score of 2.9 â€‹± â€‹1.4. Two-hundred and forty-four patients were hospitalized due to COVID-19 (63%) and the mortality rate was 18%; 95% CI 14-22 with 1 patient still in the hospital. Age, socioeconomic status, Charlson score, systolic blood pressure, body mass index, grade 2 or 3 diastolic dysfunction, moderate or severe left ventricular hypertrophy were significant predictors of hospitalization and ARDS (p â€‹< â€‹0.05). CONCLUSIONS: Our study reports a lower incidence on a COVID-19 cohort than previously reported. Predictors of poor outcomes included socio-economic, cardiovascular risk and echocardiographic measures. High touch care with early cardiovascular risk factor modification could explain the low risk of events in our population.

Impact of COVID-19 pandemic on patients with rare disease in Hong Kong.

The COVID-19 pandemic has had significant health, social, and economic consequences internationally. While the pandemic has direct implications on infected patients and families, there is a need to examine the pandemic's effect on patients with non-COVID-19-related diseases. This study examines the impact of the COVID-19 pandemic on 272 rare disease patients with 89 distinct rare diseases in Hong Kong using a cross-sectional online survey between April 10 and April 29, 2020 from the patient and caregiver perspective. The pandemic has impacted patient's health status in 46%, service use patterns in 71%, mental health in 79%, daily living in 82%, social life in 92%, and financial status in 81% of patients. Patient's health status, medical and rehabilitation, and mental health were more impacted by the COVID-19 pandemic in the group of patients with any level of dependency according to the Barthel Index for Activities of Daily Living compared with that in the group of patients who are fully independent (p < 0.0001; p < 0.0001; p = 0.0420). This study is the first study to examine the impact of COVID-19 pandemic on the rare disease population in Hong Kong, and demonstrates the pandemic's effect on service and resource utilization, and patient's physical and mental well-being.