The Challenge and Value of Dashboard Development during the COVID-19 Pandemic

Decision makers in crisis situations need relevant, accurate and complete information. Today, technologies provide a plethora of options for generating, accumulating and processing information. Technologies also enable that information to be managed and presented through dashboards. Recent emergencies have precipitated a surge in the use of dashboards, a prime example of these developments. In particular, for the duration of the crisis, the availability of large quantities of information and the demand for a more holistic approach to emergency responses incentivized the development of(digital) dashboards. However, the design of such dashboards requires costly investments, especially during when resources are scarce during crises. In this paper, we examine the development of dashboards as part of the response to COVID19 in the Netherlands. We explore the motivation for developing different dashboards and the added value that accrues to emergency services in times of crisis. © 2022 IEEE.

Myasthenic Crisis

Myasthenia gravis (MG) is an acquired autoimmune disorder of the neuromuscular junction, caused by antibodies that target the post-synaptic membrane. These antibodies most commonly bind to the nicotinic acetylcholine receptor (AChR), but in a smaller proportion of cases, antibodies to muscle specific tyrosine kinase (MuSK)(1-10%) or to lipoprotein receptor-related protein 4 (Lrp-4)(1-3%) can be present instead. These antibodies act on the receptors, prevent neuromuscular transmission and induce weakness of skeletal muscles. In 10-15% of MG patients, no antibodies are detected and these patients are designated as seronegative. Weakness can be generalized or localized, is usually more proximal than distal, and nearly always includes eye muscles, causing diplopia and/or ptosis. The pattern of involvement is usually symmetric, except for the eye involvement, which is mostly markedly asymmetric. The muscle weakness typically increases with exercise and repetitive muscle use (fatigue) and varies over the course of a day and from day to day. Patients commonly present first with ocular manifestations, however, the majority develop generalized muscle weakness, involving the facial and bulbar muscles (dysarthria, dysphagia), the limbs, the neck and axial muscles (dropped head, bent spine), and in severe cases the diaphragmatic and intercostal muscles. MuSK-MG predominantly appears in women, who show weakness in mostly cranial and bulbar muscles, commonly with an acute onset and a tendency to rapid progression in comparison to AchRMG. Myasthenic crisis (MC), the severe end of the disease spectrum, can occur at any age and is potentially life-threatening. This is a clinical emergency that requires management in an intensive care setting. MC is mostly provoked by infections or inadequate treatment. In 15-40% of the reported patients with COVID-19 infection a MC occurred. MC appears in around 15-20% of MG patients in the first 2 years after diagnosis. MC can be the first manifestation of MG. Up to a half of MuSK-MG patients develop a MC in their disease course and it is also common in patients with thymoma-associated disease, or AChR-positive late-onset disease;after surgery (including thymectomy);during or after childbirth;in patients taking a contraindicated medication;at the start of corticosteroid treatment or during the tapering of immunosuppression. In approximately 20% the cause of an exacerbation remains unknown. Characteristic symptoms for the impending MC include rapidly progressive muscle weakness, 'inverse aspiration', dysphagia with choking, and dyspnoea associated with orthopnoea and/or tachypnoea which can result in respiratory insufficiency. The clinical management of MC with mechanical ventilation, extended intensive care management and intravenous immunoglobulins (IVIg) or plasmapheresis (PLEX) or in case of persistent MC escalation with rituximab has led to a significant decline in mortality from around 40% in the early 1960s to 5-22% in recent studies with negative prognostic factors including older age at onset, prolonged intubation, and associated comorbidities. At present IVIg and PLEX are considered the gold standard treating MC. However, it may be conceiv- able that newly developed monoclonal antibody therapy (eculizumab, efgartigimod), could be used as rescue therapy to achieve a significant and rapid clinical improvement.

Disrupted sexual health care during the coronavirus pandemic in 2020: The impact on STI positivity among sexual health clinic attendees

Background Dutch Sexual Health Clinics (SHCs) had to downscale services during the first coronavirus wave, but continued to provide essential STI/PrEP care including testing for persons at highest risk for (symptomatic) gonorrhoea, infectious syphilis (syphilis) and HIV. We describe STI positivity among SHC attendees between 2011-2020. Methods National SHC surveillance data contained information on demographics, sexual behaviour, STI testing and diagnoses. We split 2020 into periods: 1 January-12 March (prelockdown), 13 March-31 May (lockdown) and 1 June-31 August (post-lockdown). Chlamydia, gonorrhoea, syphilis and HIV positivity (n positive/N tested) trends were explored by gender and sexual contact. Results In 2020, weekly numbers of consultations varied between 2,803 and 3,515 pre-lockdown, 564 and 1,298 during lockdown and 1,084 and 1,976 post-lockdown. Relatively more MSM, PrEP users and clients notified for or with symptoms of STI were seen during- and post-lockdown compared to pre-lockdown. Chlamydia positivity was around 18% among heterosexual men and 15% among women from 2016-2019, and increased to 21.1% and 16.6% respectively in 2020. Positivity increased during lockdown, up to 32% among heterosexual men, followed by decreases post-lockdown to pre-lockdown levels. Among MSM, the increase during lockdown was smaller, only slightly affecting overall positivity in 2020. Gonorrhoea positivity also increased during lockdown, causing further increasing trends among heterosexuals from 1.8% in 2011 to 2.2% in 2020 and among MSM from 9.0% to 12.1%. Syphilis positivity among MSM fluctuated between 2.0% and 2.9% in 2011-2020. Positivity peaked (6.7%) during lockdown, while the number of diagnoses was similar to pre-lockdown. In contrast, HIV positivity continued to decrease from 2,0% to 0,3% among MSM in 2011-2020. Conclusion Prioritising persons at highest risk caused decreases in diagnoses, especially chlamydia and gonorrhoea, but increases in positivity. More information is needed to understand transmission dynamics, including testing at GPs, self-testing and sexual behaviour during coronavirus pandemic..

Singapore: Technocracy and transition

This chapter describes Singapore’s response to the Covid-19 pandemic. The government’s strategy revolved around the two poles of technocratic and expedient governance on the one hand and social solidarity, targeted at vulnerable or weaker segments of society, on the other. A crucial factor in implementing this dual strategy is Singapore’s smallness, in spatial and demographic terms, meaning that there are natural limits to emulation by others. At the same time, Singapore’s approach was not flawless. In particular, the wildfire-like spread of the virus in migrant workers’ dormitories emerged as an embarrassing blind spot. Other serious Covid-19-related challenges remain. The most significant of these are managing the narrative to preserve high levels of government trust and a further reckoning with the stark socio-economic disparity exacerbated by the crisis. The latter in particular may be a harbinger of wider socio-political change in Singapore which will continue to unfold long after the immediate health emergency has passed. © the several contributors 2021.

Emergency medical services evaluations for chest pain during first COVID-19 lockdown in Hollands-Midden, the Netherlands.

OBJECTIVE: To assess whether the COVID-19 lockdown in 2020 had negative indirect health effects, as people seem to have been reluctant to seek medical care. METHODS: All emergency medical services (EMS) transports for chest pain or out-of-hospital cardiac arrest (OHCA) in the Dutch region Hollands-Midden (population served > 800,000) were evaluated during the initial 6 weeks of the COVID-19 lockdown and during the same time period in 2019. The primary endpoint was the number of evaluated chest pain patients in both cohorts. In addition, the number of EMS evaluations of ST-elevation myocardial infarction (STEMI) and OHCA were assessed. RESULTS: During the COVID-19 lockdown period, the EMS evaluated 927 chest pain patients (49% male, age 62 ± 17 years) compared with 1041 patients (51% male, 63 ± 17 years) in the same period in 2019, which corresponded with a significant relative risk (RR) reduction of 0.88 (95% confidence interval (CI) 0.81-0.96). Similarly, there was a significant reduction in the number of STEMI patients (RR 0.52, 95% CI 0.32-0.85), the incidence of OHCA remained unchanged (RR 1.23, 95% CI 0.83-1.83). CONCLUSION: During the first COVID-19 lockdown, there was a significant reduction in the number of patients with chest pain or STEMI evaluated by the EMS, while the incidence of OHCA remained similar. Although the reason for the decrease in chest pain and STEMI consultations is not entirely clear, more attention should be paid to the importance of contacting the EMS in case of suspected cardiac symptoms in possible future lockdowns.

Impact of the COVID-19 outbreak on acute stroke care.

BACKGROUND AND PURPOSE: There are concerns that the coronavirus disease 2019 (COVID-19) outbreak negatively affects the quality of care for acute cardiovascular conditions. We assessed the impact of the COVID-19 outbreak on trends in hospital admissions and workflow parameters of acute stroke care in Amsterdam, The Netherlands. METHODS: We used data from the three hospitals that provide acute stroke care for the Amsterdam region. We compared two 7-week periods: one during the peak of the COVID-19 outbreak (March 16th-May 3th 2020) and one prior to the outbreak (October 21st-December 8th 2019). We included consecutive patients who presented to the emergency departments with a suspected stroke and assessed the change in number of patients as an incidence-rate ratio (IRR) using a Poisson regression analysis. Other outcomes were the IRR for stroke subtypes, change in use of reperfusion therapy, treatment times, and in-hospital complications. RESULTS: During the COVID-19 period, 309 patients presented with a suspected stroke compared to 407 patients in the pre-COVID-19 period (IRR 0.76 95%CI 0.65-0.88). The proportion of men was higher during the COVID-19 period (59% vs. 47%, p < 0.001). There was no change in the proportion of stroke patients treated with intravenous thrombolysis (28% vs. 30%, p = 0.58) or endovascular thrombectomy (11% vs 12%, p = 0.82) or associated treatment times. Seven patients (all ischemic strokes) were diagnosed with COVID-19. CONCLUSION: We observed a 24% decrease in suspected stroke presentations during the COVID-19 outbreak, but no evidence for a decrease in quality of acute stroke care.