Measuring misclassification of Covid-19 as garbage codes: Results of investigating 1,365 deaths and implications for vital statistics in Brazil

The purpose of this article is to quantify the amount of misclassification of the Coronavirus Disease-2019 (COVID-19) mortality occurring in hospitals and other health facilities in selected cities in Brazil, discuss potential factors contributing to this misclassification, and consider the implications for vital statistics. Hospital deaths assigned to causes classified as garbage code (GC) COVID-related cases (severe acute respiratory syndrome, pneumonia unspecified, sepsis, respiratory failure and ill-defined causes) were selected in three Brazilian state capitals. Data from medical charts and forensic reports were extracted from standard forms and analyzed by study physicians who re-assigned the underlying cause based on standardized criteria. Descriptive statistical analysis was performed and the potential impact in vital statistics in the country was also evaluated. Among 1,365 investigated deaths due to GC-COVID-related causes, COVID-19 was detected in 17.3% in the age group 0–59 years and 25.5% deaths in 60 years and over. These GCs rose substantially in 2020 in the country and were responsible for 211,611 registered deaths. Applying observed proportions by age, location and specific GC-COVID-related cause to national data, there would be an increase of 37,163 cases in the total of COVID-19 deaths, higher in the elderly. In conclusion, important undercount of deaths from COVID-19 among GC-COVID-related causes was detected in three selected capitals of Brazil. After extrapolating the study results for national GC-COVID-related deaths we infer that the burden of COVID-19 disease in Brazil in official vital statistics was probably under estimated by at least 18% in the country in 2020.

The effect of the COVID-19 pandemic on severe asthma care in Europe - will care change for good?

Background The COVID-19 pandemic has put pressure on health-care services forcing the reorganization of traditional care pathways. Aim To investigate;(1) how physicians taking care of severe asthma patients in Europe reorganized care during the COVID-19 pandemic;(2) patient satisfaction with these changes;and (3) impact on future care. Methods In this European-wide cross-sectional study, patient surveys were sent to patients with a physiciandiagnosis of severe asthma, and physician surveys to severe asthma specialists (November 2020 - May 2021). Results 1101 patients and 268 physicians from 16 European countries contributed to the study. Common physicianreported changes in severe asthma care included use of video/phone consultations (46%) and change to home administered biologics (38%), which resulted in high satisfaction levels in most patients (Figure 1). Many physicians expect continued implementation of video/phone consultations (41%) and home administration of biologics (52%). Conclusions Change to video/phone consultations and home administration of biologics was common in severe asthma care during the COVID-19 pandemic, and was associated with high satisfaction levels in most but not all cases. Many physicians expect these changes to continue in future severe asthma care, though satisfaction levels may change after the pandemic. (Figure Presented).

Symptom burden and immune dynamics 6 to 18 months following mild SARS-CoV-2 infection -a case-control study.

BACKGROUND: The burden and duration of persistent symptoms after non-severe COVID-19 remains uncertain. This study aimed to assess post-infection symptom trajectories in home-isolated COVID-19 cases compared to age- and time-period matched seronegative controls, and investigate immunological correlates of long COVID. METHODS: A prospective case-control study conducted between February 28th and April 4th 2020 included home-isolated COVID-19 cases followed for 12 (n = 233) to 18 (n = 149) months, and 189 age-matched SARS-CoV-2 naive controls. We collected clinical data at baseline, 6, 12 and 18 months post-infection, and blood samples at 2, 4, 6 and 12 months for analysis of SARS-CoV-2 specific humoral and cellular responses. RESULTS: Overall, 46% (108/233) had persisting symptoms 12 months after COVID-19. Compared to controls, adult cases had a high risk of fatigue (27% excess risk, gender and comorbidity adjusted odds ratio [aOR] 5.86, 95% confidence interval [CI]3.27-10.5), memory problems (21% excess risk, aOR 7.42, CI 3.51-15.67), concentration problems (20% excess risk, aOR 8.88, CI 3.88-20.35), and dyspnea (10% excess risk, aOR 2.66, CI 1.22-5.79). The prevalence of memory problems increased overall from 6 to 18 months (excess risk 11.5%, CI 1.5, 21.5, p = 0.024) and among women (excess risk 18.7%, CI 4.4, 32.9, p = 0.010). Longitudinal spike IgG was significantly associated with dyspnea at 12 months. The spike-specific clonal CD4 + TCRß depth was significantly associated with both dyspnea and number of symptoms at 12 months. CONCLUSIONS: This study documents a high burden of persisting symptoms after mild COVID-19, and suggest that infection induced SARS-CoV-2 specific immune responses may influence long-term symptoms.

A Compassionate Approach to IL Instruction: What We Can Learn from the COVID-19 Pandemic

In early 2020, the COVID-19 pandemic drastically changed the lives of college students across the United States. These students, many of whom had never taken an online class prior to the pandemic, had to quickly adapt to the virtual learning environment and continue their studies during a time of great uncertainty. At the same time, many professors were teaching online for the first time, altering their instructional approaches to meet the needs of students. Both students and faculty faced immense stress caused by the public health crisis, economic distress, political turmoil, and racial injustice plaguing our nation during this time. This article explores the pedagogy of teaching during a pandemic, with an emphasis on compassionate teaching. It identifies the educational barriers that college students faced with the rapid shift to online learning and considers how their experiences might provide insights for librarians. The recommendations for library practice include selecting a small number of essential learning outcomes for each instruction session, supplementing in-person or synchronous online sessions with asynchronous materials, and establishing a sense of community within the classroom. In addition to these suggestions, the author shares a narrative of her experiences incorporating compassionate pedagogy into online library instruction.

Investigating differential effects of socio-emotional and mindfulness-based online interventions on mental health, resilience and social capacities during the COVID-19 pandemic: The study protocol.

BACKGROUND: The SARS-CoV-2 pandemic has led to a mental health crisis on a global scale. Epidemiological studies have reported a drastic increase in mental health problems, such as depression and anxiety, increased loneliness and feelings of disconnectedness from others, while resilience levels have been negatively affected, indicating an urgent need for intervention. The current study is embedded within the larger CovSocial project which sought to evaluate longitudinal changes in vulnerability, resilience and social cohesion during the pandemic. The current second phase will investigate the efficacy of brief online mental training interventions in reducing mental health problems, and enhancing psychological resilience and social capacities. It further provides a unique opportunity for the prediction of intervention effects by individual biopsychosocial characteristics and preceding longitudinal change patterns during the pandemic in 2020/21. METHODS: We will examine the differential effects of a socio-emotional (including 'Affect Dyad') and a mindfulness-based (including 'Breathing Meditation') intervention, delivered through a web- and cellphone application. Participants will undergo 10 weeks of intervention, and will be compared to a retest control group. The effectiveness of the interventions will be evaluated in a community sample (N = 300), which is recruited from the original longitudinal CovSocial sample. The pre- to post-intervention changes, potential underlying mechanisms, and prediction thereof, will be assessed on a wide range of outcomes: levels of stress, loneliness, depression and anxiety, resilience, prosocial behavior, empathy, compassion, and the impact on neuroendocrine, immunological and epigenetic markers. The multi-method nature of the study will incorporate self-report questionnaires, behavioral tasks, ecological momentary assessment (EMA) approaches, and biological, hormonal and epigenetic markers assessed in saliva. DISCUSSION: Results will reveal the differential effectiveness of two brief online interventions in improving mental health outcomes, as well as enhancing social capacities and resilience. The present study will serve as a first step for future application of scalable, low-cost interventions at a broader level to reduce stress and loneliness, improve mental health and build resilience and social capacities in the face of global stressors. TRIAL REGISTRATION: This trial has been registered on May 17, 2020 with the ClinicalTrials.gov NCT04889508 registration number (clinicaltrials.gov/ct2/show/NCT04889508).

Measuring misclassification of Covid-19 as garbage codes: Results of investigating 1,365 deaths and implications for vital statistics in Brazil.

The purpose of this article is to quantify the amount of misclassification of the Coronavirus Disease-2019 (COVID-19) mortality occurring in hospitals and other health facilities in selected cities in Brazil, discuss potential factors contributing to this misclassification, and consider the implications for vital statistics. Hospital deaths assigned to causes classified as garbage code (GC) COVID-related cases (severe acute respiratory syndrome, pneumonia unspecified, sepsis, respiratory failure and ill-defined causes) were selected in three Brazilian state capitals. Data from medical charts and forensic reports were extracted from standard forms and analyzed by study physicians who re-assigned the underlying cause based on standardized criteria. Descriptive statistical analysis was performed and the potential impact in vital statistics in the country was also evaluated. Among 1,365 investigated deaths due to GC-COVID-related causes, COVID-19 was detected in 17.3% in the age group 0-59 years and 25.5% deaths in 60 years and over. These GCs rose substantially in 2020 in the country and were responsible for 211,611 registered deaths. Applying observed proportions by age, location and specific GC-COVID-related cause to national data, there would be an increase of 37,163 cases in the total of COVID-19 deaths, higher in the elderly. In conclusion, important undercount of deaths from COVID-19 among GC-COVID-related causes was detected in three selected capitals of Brazil. After extrapolating the study results for national GC-COVID-related deaths we infer that the burden of COVID-19 disease in Brazil in official vital statistics was probably under estimated by at least 18% in the country in 2020.

Multidomain cognitive dysfunction after minor stroke suggests generalized disruption of cognitive networks.

OBJECTIVE: Although small strokes typically result in "good" functional outcomes, significant cognitive impairment can occur. This longitudinal study examined a cohort of patients with minor stroke to determine the pattern of deficits, evolution over time, and factors associated with outcome. METHODS: Patients admitted to the hospital with their first clinical minor stroke (NIH Stroke Scale [NIHSS] ≤ 10, absence of severe hemiparesis, aphasia, or neglect) were assessed at 1 month post-infarct, and a subset were followed over time (with 6- and 12-month evaluations). Composite scores at each time point were generated for global cognition, verbal memory, spatial memory, motor speed, processing speed, and executive function. Paired t-tests evaluated change in scores over time. Regression models identified factors associated with initial performance and better recovery. RESULTS: Eighty patients were enrolled, evaluated at 1 month, and prospectively followed. The average age of the participants was 62.3 years, and mean education was 13.5 years. The average stroke volume was 6.6 cc; mean NIHSS score was 2.8. At 1 month, cognitive scores were below the normative range and > 1 standard deviation below the patient's peak ("recovery") score for every cognitive domain, strongly suggesting that they were well below patients' prestroke baselines. Forty-eight patients followed up at 6 months, and 39 at 12 months. Nearly all (98%) patients significantly improved in global cognition (averaged across domains) between 1 and 6 months. Between 6 and 12 months, recovery was variable. Higher education, occupational class, and Caucasian race were associated with higher recovery scores for most domains. CONCLUSIONS: Cognitive impairment across multiple domains is common following minor stroke regardless of infarct location, suggesting a global process such as network dysfunction that improves over 6 months. Degree of recovery can be predicted using baseline factors.

The telemedicine experience: using principles of clinical excellence to identify disparities and optimize care.

ABSTRACT: The use of telemedicine has increased significantly during the Corona virus disease 2019 pandemic. This manuscript serves to identify the underlying principles of clinical excellence in telemedicine and to determine whether effective care practices can be generalized as a one-size-fits-all model or must instead be tailored to individual patient populations.A survey assessing care quality and patient satisfaction for patients using telemedicine was created and administered via email to 2 urban cohorts of varying demographics and socioeconomic backgrounds: a population of patients with prior stroke and cerebrovascular disease, and a cohort of patients followed for interstitial lung disease. Results were compared across groups to determine the generalizability of effective practices across populations.Individuals taking part in telemedicine were more likely to be White, more affluent, and woman, regardless of clinical diagnosis compared with a similar cohort of patients seen in-person the year prior. A lower-than-expected number of patients who were Black and of lower socioeconomic status followed up virtually, indicating potential barriers to access. Overall, patients who participated in televisits were satisfied with the experience and felt that the care met their medical needs; however, those who were older were more likely to experience technical difficulties and prefer in-person visits, while those with less education were less likely to feel that their questions were addressed in an understandable way.When thoughtfully designed, telemedicine practices can be an effective model for patient care, though implementation must consider population characteristics including age, education, and socioeconomic status, and strategies such as ease of access versus optimization of communication strategies should be tailored to meet individual patient needs.

Lower antibiotic prescription rates in hospitalized COVID-19 patients than influenza patients, a prospective study.

BACKGROUND: COVID-19 patients are extensively treated with antibiotics despite few bacterial complications. We aimed to study antibiotic use in hospitalized COVID-19 patients compared to influenza patients in two consecutive years. Furthermore, we investigated changes in antibiotic use from the first to second pandemic wave. METHODS: This prospective study included both patients from two referral hospitals in Bergen, Norway, admitted with influenza (n = 215) during the 2018/2019 epidemic and with COVID-19 (n = 82) during spring/summer 2020, and national data on registered Norwegian COVID-19 hospital admissions from March 2020 to January 2021 (n = 2300). Patient characteristics were compared, and logistic regression analysis was used to identify risk factors for antibiotic use. RESULTS: National and local COVID-19 patients received significantly less antibiotics (53% and 49%) than influenza patients (69%, p < .001). Early antibiotics contributed to >90% of antibiotic prescriptions in the two local hospitals, and >70% of prescriptions nationally. When adjusted for age, comorbidities, symptom duration, chest X-ray infiltrates and oxygen treatment, local COVID-19 patients still had significantly lower odds of antibiotic prescription than influenza patients (aOR 0.21, 95%CI 0.09-0.50). At the national level, we observed a significant reduction in antibiotic prescription rates in the second pandemic wave compared to the first (aOR 0.35, 95% CI 0.29-0.43). CONCLUSION: Fewer COVID-19 patients received antibiotics compared to influenza patients admitted to the two local hospitals one year earlier. The antibiotic prescription rate was lower during the second pandemic wave, possibly due to increased clinical experience and published evidence refuting the efficacy of antibiotics in treating COVID-19 pneumonia.

COVID-19 and Vaccination in the Setting of Neurologic Disease: An Emerging Issue in Neurology.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has left many unanswered questions for patients with neurological disorders and the providers caring for them. Elderly and immunocompromised patients are at increased risk for severe symptoms due to COVID-19, and the virus may increase symptoms of underlying neurological illness, particularly for those with significant bulbar and respiratory weakness or other neurologic disability. Emerging SARS-CoV-2 vaccines offer substantial protection from symptomatic infection, but both patients and providers may have concerns regarding theoretical risks of vaccination, including vaccine safety and efficacy in the context of immunotherapy and the potential for precipitating or exacerbating neurological symptoms. In this statement on behalf of the Quality Committee of the AAN we review the current literature, focusing on COVID-19 infection in adults with neurological disease, in order to elucidate risks and benefits of vaccination in these individuals. Based on existing evidence, neurologists should recommend COVID-19 vaccination to their patients. For those patients being treated with immunotherapies, attention should be paid to timing of vaccination with respect to treatment and the potential for an attenuated immune response.