A Qualitative Analysis of Physician, Staff, and Patient Perspectives During the Discharge Process for Vascular Patients

Objectives: Evidence demonstrates that when hospitals focus on the discharge process patient safety improves and overall costs decline. Hospital discharge requires care coordination of multiple disciplines, often leading to fragmented care, and adverse outcomes after discharge include emergency department visits and hospital readmissions. The Re-Engineered Discharge (RED) process was developed as an evidence-based strategy to improve the hospital discharge. We evaluated perspectives and priorities of physicians, health care workers, and patients involved in the vascular discharge process using RED as a framework. Method(s): A single-center qualitative analysis using a semi-structured focus groups and an interview guide based on the RED process. Focus groups were Zoom platform recorded, transcribed into text files, independently coded, and analyzed with Dedoose qualitative software using a directed content analysis approach. Thematic concepts were created, and comparisons between groups were analyzed by coding frequency. Researchers independently thematically coded each transcript;prior to analysis, all redundancy of codes was resolved;and all team members agreed on text categorization and coding frequency. Result(s): Eight focus groups with 38 participants were performed. Participants included: physicians (n = 13), nursing and ancillary staff (n = 19), and patients/caregivers (n = 6). Transcript analyses revealed facilitators and barriers to discharge. Overarching themes identified from the qualitative analysis frequencies are displayed by stakeholder role (Fig 1). Themes identified with the greatest coding frequencies included helpfulness of discharge instructions, patient health literacy, patient medical complexity, poor interdisciplinary team communication, time constraints during discharge, technology literacy of patients, barriers to obtaining medications for patients, barriers to organizing outpatient services for health care workers, barriers for patients to obtain help after discharge, and the impact of COVID-19. Conclusion(s): These findings identify the need to strengthen efforts to overcome stakeholder barriers to improve patient safety at the interface of the hospital to create a well-organized discharge. Physicians were most concerned with low patient health literacy, patient understanding of discharge instructions, organizing outpatient services, and overall patient medical complexity hindering a smooth discharge. Health care staff identified time constraints, obtaining medications and, and inter-team communication as their greatest obstacles to an organized discharge. Patients found the complexity and amount of discharge instructions, the impact of COVID-19 on support systems, and technology utilization after discharge most challenging. Modifications to address individual stakeholder barriers within the discharge process are needed to develop a national standardized discharge specific for vascular surgery patients to improve patient safety and satisfaction. [Formula presented]Copyright © 2023

The MET Project: Distinguishing Multisystem Inflammatory Syndrome in Children from Typhus Using Artificial Intelligence

Background. Multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection shares features with other inflammatory states, notably Kawasaki Disease. The rickettsial infection murine typhus is also in the differential for MIS-C in endemic areas. As the therapeutic approaches differ, it is essential to distinguish these disorders soon after presentation, well before confirmatory serologic testing results. Our objective was to develop an algorithm to accurately predict MIS-C versus typhus. Methods. Retrospective review extracted demographic, clinical, and laboratory features available within 6 hours of presentation for 133 MIS-C and 87 typhus patients. 33 features were broken into 44 inputs and passed through an attention module to compute importance. Inputs were then entered into machine learning algorithms as MIS-C or typhus. Patients were divided into training and test cohorts respecting proportions in the dataset. An equation was built to calculate the 'MET' (MIS-C versus endemic typhus) score. Results. MIS-C patients were younger (8.4 v 11.2 years, p< 0.0001) and the majority (71%) presented on day 4-6 of fever;most typhus patients (84%) presented with >=6 days (mean 4.9 v 7.3 days, p< 0.0001). Typhus patients were more likely to have rash (86% v 51%, p< 0.0001) and MIS-C patients red eyes (71% v 36%, p< 0.0001), other features were similar. MIS-C patients had higher C-reactive protein levels (17.7 v 9.8 mg/dL), procalcitonin (14.0 v 0.48 ng/mL), fibrinogen (558 v 394 mg/ dL) and neutrophil-to-lymphocyte ratio (12 v 3.5), all p< 0.0001, other parameters were similar. MIS-C patients were also more likely to have elevated troponin (0.48 v 0.01 ng/mL, p< 0.0001) and require intensive care (66% v 6%, p< 0.0001). A long short term memory network outperformed 6 other models (99% accuracy using all 33 elements). The MET score predicted MIS-C versus typhus with 90% accuracy using only 10 features (sensitivity 90%, specificity 90%). Conclusion. The clinical and laboratory similarities between typhus and MIS-C present challenges, but they can be reliably distinguished using artificial intelligence with as little as 10 features. Our ongoing interprofessional collaboration aims to make the MET score readily available to clinicians for use in patient encounters.

Mechanical Circulatory Support for Multisystem Inflammatory Syndrome in Children (MIS-C): A Single Center Case Series

Purpose: Multisystem inflammatory syndrome in children (MIS-C) is a rare but life-threatening complication of SARS-CoV-2 that is characterized by a hyperinflammatory state leading to multiorgan dysfunction. With prompt initiation of appropriate medical management, patients fair well with resolution of the hyperinflammatory state and recovery of end-organ function. However, a small subset of patients with MIS-C develop progressive end-organ dysfunction necessitating mechanical circulatory support (MCS). This case series describes a single center experience of MCS for MIS-C. Methods: This is a retrospective case series of patients diagnosed with MIS-C who required MCS between May 2020-February 2022 at Texas Children's Hospital. The study was conducted under institutional review board approval. Results: During the study period, 291 patients were diagnosed with MISC. Of those, 6 required MCS: 4 were placed on VAECMO with 1 patient additionally requiring a left ventricular assist device (LVAD), 1 required solely LVAD support, and 1 required VV-ECMO in the setting of pulmonary hemorrhage. In 5 of the 6 patients, the primary indication for MCS was a hemodynamically significant tachyarrythmia. Echocardiography showed worsening of global longitudinal strain (GLS) prior to cannulation in those patients in which it was measured. 5 of the 6 patients survived to hospital discharge. 2 patients required emergent fasciotomies and subsequent limb amputation. Immunomodulation with anakinra before MCS correlated with shorter intensive care length of stay. Outpatient follow-up was conducted in the MIS-C clinic, ranging from 1 to 15 months since discharge, with notable normalization of cardiac function and no additional adverse events. Conclusion: Overall, the need for MCS in patients diagnosed with MIS-C is uncommon and outcomes seem favorable. The development of tachyarrhythmias and worsening GLS may be risk factors for MCS. These findings need to be validated with larger, multicenter studies. Prospective studies of early therapeutic intervention in MIS-C are also needed.

Performance of the Brighton Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C) among a Large Single Center Cohort

Background. Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare, life-threatening, hyperinflammatory condition presumed to follow SARS-CoV-2 infection. Whether MIS-C can also follow SARS-CoV-2 vaccination is not clear, making MIS-C an adverse event of special interest following immunization. Monitoring for post-vaccine MIS-C is complicated by the clinical overlap of MIS-C with numerous other inflammatory conditions including Kawasaki Disease, toxic shock syndrome, and viral myocarditis. A case definition for MIS-C was recently created with the Brighton Collaboration (BC). We aimed to determine the performance of the BC MIS-C case definition among a large, single-center MIS-C cohort. Methods. Retrospective review was performed for the first 100 MIS-C cases at our institution (May 2020-February 2021). All cases met the Centers for Disease Control and Prevention (CDC) case definition. Data on age, presentation, laboratory results and cardiac studies were collected and used to determine cases that fulfilled the BC case definition for MIS-C (see figure). Case Definition: Definite Case Results. Of 100 children (age < 21 years) diagnosed with MIS-C using the CDC case definition, 93 patients also fulfilled the BC definition. All 100 patients had elevated laboratory markers of inflammation and positive SARS-CoV-2 antibodies. However, 1 patient was excluded for significant respiratory symptoms (pulmonary hemorrhage), 5 were excluded due to only 1 clinical feature, and an additional patient was excluded for having none of the measures of disease activity. Among the 93 patients fulfilling the revised case definition, 88 (95%) met criteria for a definite case. Five of the 93 patients (5%) were considered probable cases, 1 reported only 1 day of fever and 4 had only 1 measure of disease activity. Conclusion. The original case definitions for MIS-C were created rapidly following the first emerging reports of this hyperinflammatory state. Knowledge of the varied clinical presentations of this disorder has grown substantially. Modification of the case definition to include features truly representative of MIS-C will allow for more precise diagnosis in the face of conditions which mimic MIS-C, and for accurate and reliable monitoring for adverse events following immunization.

Prognostic factors in Covid-19

Since the end of 2019, France, like all other the countries in the world, has been facing an unprecedented epidemiological situation: Covid-19. The most vulnerable people, and in particular the elderly, are particularly affected by this epidemic. Although many patients make a full recovery, several factors lead to a poor prognosis. Various studies have proposed as an objective to identify the prognostic factors for mortality and progression to serious illness for patients diagnosed with Covid-19. Some of these prognostic factors can be further used in decision-making for the management of patients with Covid-19. (PsycInfo Database Record (c) 2022 APA, all rights reserved) (French) Depuis la fin de l'annee 2019, la France, de meme que l'ensemble des pays du monde, est confrontee a une situation epidemiologique inedite : la Covid-19. Les personnes les plus vulnerables, et notamment les personnes agees sont particulierement touchees par cette epidemie. Bien que de nombreux patients se retablissent completement, plusieurs facteurs conduisent a un mauvais pronostic. Diverses etudes ont propose comme objectif d'identifier les facteurs pronostiques de mortalite et d'evolution vers une maladie grave pour les patients diagnostiques avec la Covid-19. Certains de ces facteurs pronostiques peuvent etre utilises dans la prise de decision relative a la prise en charge des patients infectes par la Covid-19. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

SARS-COV-2 vaccination is tolerated following multisystem inflammatory syndrome in children (MIS-C)

Introduction: Most children who contract SARS-CoV-2 infection are asymptomatic or mildly symptomatic. However, a subset go on to develop a potentially life-threatening hyperinflammatory condition called multisystem inflammatory syndrome in children (MIS-C) 4-6 weeks after COVID-19. The mechanisms by which MIS-C occurs are not yet clear, resulting in hesitation to vaccinate this subset of children against SARS-CoV-2 due to concerns for a reoccurrence of hyperinflammation. Objectives: To evaluate outcomes following SARS-CoV-2 vaccination in patients who were previously diagnosed with MIS-C after COVID-19. Methods: Medical records of patients who were treated for MIS-C at our institution were retrospectively reviewed. Details for those who were subsequently vaccinated against SARS-CoV-2 were extracted. Results: A total of 164 patients were treated for MIS-C between May 2020 and May 2021. 22 patients were 16 years of age or older and an additional 30 patients were age 12-15 years, resulting in a total of 52 patients eligible for SARS-CoV-2 vaccination. 10 (19%) of these patients were vaccinated using the Pfizer-BioNTech product in our COVID-19 vaccine clinic. The age of the patients ranged from 12 to 17 years. 8 were male, and 8 were from racial/ethnic minority groups. All were generally healthy (3 asthma, 1 repaired congenital heart disease) prior to their MIS-C diagnosis. The patients presented between July 2020 and February 2021 with a febrile illness, and fulfilled the case definition for MIS-C established by the Centers for Disease Control and Prevention, including all 10 having positive SARS-CoV-2 serologic testing and 9 with myocarditis or coronary changes (measured by troponin elevation and/or electrocardiographic or echocardiographic evidence). 8 presented in shock or with hypotension, and 6 were admitted to the intensive care unit (ICU), among which 3 required vasoactive medications and 2 intubation. ICU length of stay ranged from 2-15 days, and total hospital stay from 2-23 days. All 10 patients were treated with corticosteroids, 8 received intravenous immunoglobulin, and 5 anakinra. All patients had normal cardiac function without coronary artery dilation at the time of last cardiology follow-up. The patients were vaccinated an average of 199 days from MIS-C hospitalization discharge (range 83 to 337 days). Thus far, a median of 57 days (range 1 to 117 days) has elapsed since 9 of the 10 patients completed the second vaccine dose. None has developed a recurrence of MIS-C or a hyperinflammatory condition. No significant adverse events have occurred following vaccination. Conclusion: These 10 patients who experienced MIS-C after COVID-19 have tolerated vaccination against SARS-CoV-2 without the subsequent development of a similar hyperinflammatory state providing critical information as the COVID-19 pandemic continues to rage across the globe. As we move toward vaccination for children younger than 12 years, a growing number of prior MIS-C patients (average age 8-9 years) will become eligible for vaccination. Given the risk of re-infection with SARS-CoV-2 and the known additive protection from re-infection provided by vaccinating previously infected individuals, it is imperative that patients with a history of MIS-C be offered vaccination against SARS-CoV-2.

[Urologic cancer care during the first wave of the COVID-19 pandemic : Role of federal cancer registration in Germany]. / Uroonkologische Therapie in der ersten Welle der COVID-19-Pandemie : Was sagen uns die Krebsregister der deutschen Bundesländer?

Urologic cancer care needs to be prioritized despite multiple health care restrictions during the coronavirus disease 2019 (COVID-19) pandemic. However, therapies and procedures may be delayed and complicated. In Germany, analysis of the multiple cancer registries provides insights into the actual numbers of treated patients. We provide a review on the registration of urologic cancer care during the first wave of the COVID-19 pandemic in Germany and on potential surgical complications of urologic interventions. We found that during the year 2020 there were generally fewer registrations of newly diagnosed patients with major urologic neoplasms in a representative federal database. The number of surgical interventions in patients with renal cell carcinoma and urothelial bladder cancer decreased, whereas equal numbers of radical prostatectomies were performed when compared to the year 2019. COVID-19 may increase non-urological postoperative complications following surgical treatment of urologic malignancies; however, available data are still very limited.

Les facteurs pronostiques dans la Covid-19

Résumé Depuis la fin de l’année 2019, la France, de même que l’ensemble des pays du monde, est confrontée à une situation épidémiologique inédite : la Covid-19. Les personnes les plus vulnérables, et notamment les personnes âgées sont particulièrement touchées par cette épidémie. Bien que de nombreux patients se rétablissent complètement, plusieurs facteurs conduisent à un mauvais pronostic. Diverses études ont proposé comme objectif d'identifier les facteurs pronostiques de mortalité et d'évolution vers une maladie grave pour les patients diagnostiqués avec la Covid-19. Certains de ces facteurs pronostiques peuvent être utilisés dans la prise de décision relative à la prise en charge des patients infectés par la Covid-19. Summary Since the end of 2019, France, like all other the countries in the world, has been facing an unprecedented epidemiological situation: Covid-19. The most vulnerable people, and in particular the elderly, are particularly affected by this epidemic. Although many patients make a full recovery, several factors lead to a poor prognosis. Various studies have proposed as an objective to identify the prognostic factors for mortality and progression to serious illness for patients diagnosed with Covid-19. Some of these prognostic factors can be further used in decision-making for the management of patients with Covid-19.