Collateral Effects of the COVID-19 Pandemic on Health Services in Argentina

The objective of the work was to characterize the collateral effect that the pandemic has had on health systems in Argentina. Changes in supply and demand in services especially affected and related to non-COVID situations were analyzed. The impact caused by COVID-19 in infectious and non-infectious disease care was evaluated, staff were surveyed regarding resulting problems in adjacent problems, and the vaccination campaigns carried out in the country were addressed. The purpose of this analysis was to alert health services about the collateral effects derived from the COVID-19 pandemic. © TheEditor(s) (ifapplicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021, 2022.

Effects of the COVID-19 pandemic on acute coronary syndromes in Germany during the first wave: the COVID-19 collateral damage study.

BACKGROUND: Reports about the influence of the COVID-19 pandemic on the number of hospital admissions and in-hospital mortality during the first wave between March and May 2020 showed conflicting results and are limited by single-center or limited regional multicenter datasets. Aim of this analysis covering all German federal states was the comprehensive description of hospital admissions and in-hospital mortality during the first wave of the COVID-19 pandemic. METHODS AND RESULTS: We conducted an observational study on hospital routine data (§21 KHEntgG) and included patients with the main diagnosis of acute myocardial infarction (ICD 21 and ICD 22). A total of 159 hospitals included 36,329 patients in the database, with 12,497 patients admitted with ST-elevation myocardial infarction (STEMI) and 23,832 admitted with non-ST-elevation myocardial infarction (NSTEMI). There was a significant reduction in the number of patients admitted with STEMI (3748 in 2020, 4263 in 2019 and 4486 in 2018; p < 0.01) and NSTEMI (6957 in 2020, 8437 in 2019 and 8438 in 2020; p < 0.01). These reductions were different between the Federal states of Germany. Percutaneous coronary intervention was performed more often in 2020 than in 2019 (odds ratio 1.13, 95% confidence interval [CI] 1.06-1.21) and 2018 (odds ratio 1.20, 95% CI 1.12-1.29) in NSTEMI and more often than in 2018 (odds ratio 1.26, 95% CI 1.10-1.43) in STEMI. The in-hospital mortality did not differ between the years for STEMI and NSTEMI, respectively. CONCLUSIONS: In this large representative sample size of hospitals in Germany, we observed significantly fewer admissions for NSTEMI and STEMI during the first COVID-19 wave, while quality of in-hospital care and in-hospital mortality were not affected. Admissions for STEMI and NSTEMI during the months March to May over 3 years and corresponding in-hospital mortality for patients with STEMI and NSTEMI in 159 German hospitals. (p-value for admissions 2020 versus 2019 and 2018: < 0.01; p-value for mortality: n.s.).

Collateral damage in education: implications for the time of COVID-19

The Coronavirus disease of 2019 (COVID-19) has impacted the world immensely in terms of both global health and economy. It has exacerbated the gap between the economically advantaged and disadvantaged groups in terms of access to various resources and opportunities across the world. This situation has been described as ‘collateral damage', which represents unexpected and unintended negative impacts that deprive the poor of certain opportunities and rights. Interestingly, the differences in capability to respond to the issues caused by COVID-19 are observed in developed and developing countries alike. This paper aims to discuss the potential risk factors that encourage students to drop out as collateral damage due to COVID-19, based on the literature on developing South East Asian countries. This commentary argues that collateral damage caused by COVID-19 has revealed a serious limitation in the nature of formal schooling in South East Asia. Although more socio-economically vulnerable groups can participate in formal schooling, there is still not a sufficiently communal climate in these schools that would prevent them from dropping out.

Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction?

Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.

Burdens and psychosocial consequences of the COVID-19 pandemic for Austrian children and adolescents.

Objectives: The negative psychosocial effects of the COVID-19 pandemic are becoming increasingly apparent. Children and adolescents in particular, were affected and torn away from their daily life routines. The aim of our survey is to evaluate the psychosocial burden and impairments of children and adolescents in Austria during the COVID-19 pandemic by using cross-sectional analysis. Setting: An Austrian-wide online survey was conducted from 21 February to 19 April 2021 for children and adolescents. The questionnaire was distributed widely using the national press agency and public media. Participants: Using an online questionnaire, 5,483 children and adolescents between 6 and 18 years of age were sampled. Outcome measure: Quantitative responses to questions regarding the children's feelings, worries, and needs concerning the COVID-19 pandemic were measured. Furthermore, the children were sampled for subjective risk perception as well as their sleep quality. Results: Most children reported a high degree of fear due to the pandemic, especially female (48.1%) participants being under more emotional strain than their male (35.9%) counterparts. Associated with this, we found a strong overestimation of COVID-19-associated hospitalization likelihood (>100-fold) across all age groups. In addition, an alarming lack of positive perspective during the ongoing pandemic is evident across all age groups, including the youngest participants aged 6-10 years. Feelings of anger and annoyance (58.2%), loneliness (46%), and sadness (42.7%) are reported much more frequently than before the pandemic. On the other hand, only 15.6% reported feeling well (or even better; 2%) since the COVID-19 pandemic. Last but not least, our study shows an alarming 37% of children and adolescents who now report poorer sleep quality than before the pandemic. Conclusion: The results of this survey indicate the high burden and emotional strain for children and adolescents during the pandemic. Personal contact with friends and family is mentioned as the most protective factor for their mental health. The study results underscore the need for immediate action to limit the collateral damage that has already occurred on a psychosocial and developmental level among younger generations worldwide.

Chronic Kidney Disease Patients: Collateral Damage Due to Suspension of Vascular Access Services

This study was conducted at the Department of Vascular Surgery at Combined Military Hospital Lahore from December 2019 to June 2020. The mortality of patients on the waiting list for vascular access in our institution three months after implementing strict policies for elective surgeries (30th March 2020 to 29th June 2020) was compared with the preceding three months. The mortality of patients in the pre-COVID-19 periods on the waiting list for HD was 11 (7.9%) in the pre-COVID-19 period, while this increased to 5 (12.5%) in the post-COVID-19 period. COVID-19 related suspension of vascular access services negatively influences CKD patients waiting for permanent vascular access. © 2022, Army Medical College. All rights reserved.

Collateral Damage: Investigating the Impacts of COVID on STEM Professionals with Caregiving Responsibilities

Numerous reports have showcased the negative impacts of the pandemic on women in the workforce-especially those in STEM and with caregiving responsibilities-and the ways in which COVID-19 has further compounded the challenges they face. We developed a survey to investigate how these individuals have navigated the pandemic, asking them to compare their experiences before and during the pandemic as well as to prospectively consider a future as we begin to recover from the pandemic. We compare self-reported pandemic experiences of these NSF STEM professionals, contrasting by gender and caregiving status. Specifically, we address how the COVID-19 pandemic impacted the professional and personal lives of STEM professionals and whether these effects emerge primarily as gender effects, primarily as caregiver effects, or at the intersection of gender and caregiving roles. Our results highlighted that women, non-binary individuals, and transgender men in STEM have been particularly vulnerable during the pandemic, since they tend to bear the heavier load of caregiving responsibilities. Compared to cismen and non-caregivers, they reported decreased productivity in and satisfaction with their job/work;reduced time spent on research/writing but increased time teaching;an increased toll of societal, political, and personal physical/mental health;and greater blurring of boundaries between work and personal life. To date, the story told about the impact of the pandemic has focused on the acute crisis of COVID-19 on the STEM workforce. It may be too early to tell what the abiding, long-term effects will be for STEM professionals. As we move forward, we must begin to focus on the long-range story of what we do to support individuals in the STEM professions, preventing an “epidemics loss” of caregivers and women, non-binary individuals, and transgender men. © American Society for Engineering Education, 2022.

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis.

BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

Decreased Rate of Presentation, but Worsened Racial-Ethnic Disparity in Acute Gastrointestinal Bleeding During Coronavirus 2019 Shutdown: A Retrospective Cohort Study.

Purpose: In spring 2020, Coronavirus Disease 2019 (COVID-19) "stay-at-home" orders may have led to later, more acute disease presentations of emergent conditions such as gastrointestinal bleeding (GIB). In this retrospective cohort study, we compared incidence and severity of GIB during the strictest COVID shutdown to pre-COVID periods. Patients and methods: We compared weekly counts of emergency department (ED) visits for GIB between March 27 and May 7, 2020 (COVID period) and pre-COVID periods in 2019 and 2020 in a US statewide network of hospitals. We compared the severity of GIB presentations using incident rate ratios (IRR) of "severe" GIB (requiring ≥4 units of blood, endoscopic therapy, interventional radiology or surgical procedure), intensive care (ICU) admission and shock. We also looked for effect modification of demographic covariates on associations between year and GIB outcomes. Results: Fewer patients presented to ED for GIB during COVID than during the same dates in 2019 (534 versus 904; IRR 0.59, 95% CI 0.53-0.66). A greater proportion of COVID-period ED visits required inpatient admission (73.6% vs 67.8%, p = 0.02) and had severe GIB (19.3% vs 14.9%, p = 0.03). Proportion of patients requiring transfusion (p < 0.001), with shock (p < 0.01), or with critical hemoglobin (p = 0.003) or lactate (p = 0.02) were worse during COVID. Non-white patients experienced disproportionately worse outcomes during COVID than in 2019, with greater absolute counts of shock (65 vs 62, p = 0.01 for interaction) or ICU admission (40 vs 35, p = 0.01 for interaction). Conclusion: Fewer acute GIB presented during the pandemic period compared to the year prior. The severity of pandemic presentations was greater, driven by disproportionately worse outcomes in minorities.

Impact of COVID-19 on elective, emergency and oncological surgery during the first and the second wave in a tertiary university hospital : Have we learned the lessons?

BACKGROUND: The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased. METHODS: Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital. RESULTS: Despite a higher 7­day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p < 0.0001). Elective surgical interventions decreased by 88.63% during the first wave compared to 1.79% during the second wave (p < 0.0001). Emergency and oncological interventions decreased by 35.17% during the first wave compared to 5.15% during the second wave (p : 0.0007) and 47.59% compared to 3.89% (p < 0.0001), respectively. Surgical activity reduction in our institution was less pronounced despite higher occupancy of ICU beds during the second COVID-19 wave in fall/winter 2020/2021. CONCLUSION: Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement.

The Collateral Damage of the Pandemic on Non-COVID Related Pneumothorax Patients: A Retrospective Cohort Study.

BACKGROUND: Since the onset of the COVID-19 pandemic, there have been many reported cases showing the consequences-or the collateral damages-of COVID-19 on patients with non-COVID-related diseases. This study aimed to compare the clinical manifestations and treatment results of non-COVID-related pneumothorax patients before and during the pandemic. METHODS: We retrospectively reviewed non-COVID-related pneumothorax patients who visited our hospital before the onset of the pandemic and during the pandemic. The primary outcome was the difference in the amount of pneumothorax between the two periods, and the secondary outcome was the difference in the treatment results between them. Multivariable logistic regression was conducted to find risk factors related to massive pneumothorax. RESULTS: There were 122 and 88 patients in the pre-pandemic and pandemic groups, respectively. There was no significant difference between the two groups with respect to the preoperative demographic variables. However, the median amount of pneumothorax was significantly higher in the pandemic group (pre-pandemic: 34.75% [interquartile range (IQR) 18.30-62.95] vs. pandemic: 53.55% [IQR 33.58-88.80], p < 0.0001) and massive pneumothorax were more frequent in the pandemic group (52.3% vs. 30.3%, p = 0.002). Furthermore, more patients experienced re-expansion pulmonary edema after treatments during the pandemic (p = 0.0366). In multivariable analysis, the pandemic (OR: 2.70 [95% CI 1.49-4.90], p = 0.0011) was related to the occurrence of massive pneumothorax. CONCLUSION: During the pandemic, patients presented with a larger size of pneumothorax and had more re-expansion pulmonary edema, even in a country that handled the COVID-19 pandemic relatively well.

["Now You're Talking!"] / "Jetzt Sprichst Du!": Belastungen und psychosoziale Folgen der Coronapandemie für österreichische Kinder und Jugendliche.

The survey "Jetzt Sprichst Du!" ("Now you're talking!") impressively demonstrates the psychosocial burden and impairments of children and adolescents in Austria during the ongoing COVID-19 pandemic. As part of an online questionnaire, 5483 children and adolescents between 6 and 18 years of age were asked about their feelings, fears, worries, and assessments regarding the coronavirus pandemic. As can be seen, children and adolescents are worried about the situation, and girls are more burdened by this across all age groups. The study also clearly shows that the risk of a COVID-19-associated hospitalization is massively overestimated by children and adolescents, similar to adults. In addition, a great lack of perspective caused by the constantly challenging situation is evident across all age groups. Feelings of fury, anger, loneliness, and sadness are reported much more frequently than previously. Last but not least, our study shows an alarming reduction of sleep quality and a drastic increase in self-reported sleep problem already in this young population. The data from the "Jetzt Sprichst Du!" survey emphasize the need for inevitable and rapid action in order to limit the psychosocial and health-related collateral damage and to reduce the negative impact on young people's psychological development, as far as this is still possible today.

Impact of COVID-19 pandemic restrictions on ST-elevation myocardial infarction: a cardiac magnetic resonance imaging study.

AIMS: The severity of myocardial tissue damage following ST-elevation myocardial infarction (STEMI) strongly determines short- and long-term prognosis. This study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated public health restrictions on infarct severity. METHODS AND RESULTS: STEMI patients treated with primary percutaneous coronary intervention (PCI) and included in the prospective Magnetic Resonance Imaging in Acute ST-Elevation Myocardial Infarction (MARINA-STEMI) cohort study from 2015- 2020 (n = 474) were categorized according to (i) timeframes with and without major public health restrictions in 2020, and (ii) timeframes of major public health restrictions during 2020 and during the corresponding timeframes between 2015-2019. Myocardial damage was evaluated by cardiac magnetic resonance imaging. During major public health restrictions in 2020 (n = 48), there was an increase in infarct size (22 [IQR 12-29] vs. 14 [IQR 6-23]%, P < 0.01), a higher frequency (77% vs. 52%, P < 0.01) and larger extent of microvascular obstruction (1.5 [IQR 0.1-11.4] vs. 0.2 [IQR 0.0-2.6]%, P < 0.01) and a higher rate of intramyocardial haemorrhage (56% vs. 34%, P = 0.02) as compared to the phases without major restrictions in 2020 (n = 101). These findings were confirmed in adjusted analysis and were consistent when comparing patients admitted in 2020 versus patients admitted in the "pre-pandemic" era (2015-2019). Patient characteristics were comparable between groups, except for a significantly longer total ischemia time (P < 0.01) and higher frequency of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow 0 during times of major restrictions (P = 0.03). CONCLUSION: This study provides novel mechanistic insights demonstrating a significant increase in myocardial damage in STEMI patients admitted during the COVID-19 pandemic with a temporal relation to major public health restrictions.

Student nurses' ethical views on responses to the severe acute respiratory syndrome outbreak.

BACKGROUND: Fifteen years have passed since the outbreak of severe acute respiratory syndrome in Hong Kong. At that time, there were reports of heroic acts among professionals who cared for these patients, whose bravery and professionalism were highly praised. However, there are concerns about changes in new generation of nursing professionals. OBJECTIVE: We aimed to examine the attitude of nursing students, should they be faced with severe acute respiratory syndrome patients during their future work. RESEARCH DESIGN: A questionnaire survey was carried out to examine the attitude among final-year nursing students to three ethical areas, namely, duty of care, resource allocation, and collateral damage. ETHICAL CONSIDERATIONS: This study was carried out in accordance with the requirements and recommendations of the Central Research and Ethics Committee, School of Health Sciences at Caritas Institute of Higher Education. FINDINGS: Complete responses from 102 subjects were analyzed. The overwhelming majority (96.1%) did not agree to participate in the intubation of severe acute respiratory syndrome patients if protective measures, that is, N95 mask and gown, were not available. If there were insufficient N95 masks for all the medical, nursing, and allied health workers in the hospital (resource allocation), 37.3% felt that the distribution of N95 masks should be by casting lot, while the rest disagreed. When asked about collateral damage, more than three-quarters (77.5%) said that severe acute respiratory syndrome patients should be admitted to intensive care unit. There was sex difference in nursing students' attitude toward severe acute respiratory syndrome care during pregnancy and influence of age in understanding intensive care unit care for these patients. Interestingly, 94.1% felt that there should be a separate intensive care unit for severe acute respiratory syndrome patients. CONCLUSION: As infection control practice and isolation facilities improved over the years, relevant knowledge and nursing ethical issues related to infectious diseases should become part of nursing education and training programs, especially in preparation for outbreaks of infectious diseases or distress.

Dementia and COVID-19 Lockdown: More Than a Double Blow for Patients and Caregivers.

In dementia research and in clinical practice, the COVID-19 pandemic represents an important challenge, not only for neurological staff and researchers, but above all for patients and their caregivers. It is important that the medical staff demonstrate flexibility, open-mindedness, and humanity when following patients and caregivers. It seems inevitable that caregivers will pay the highest price during this crisis.

The impact and collateral damage of COVID-19 on prostate MRI and guided biopsy operations: Society of Abdominal Radiology Prostate Cancer Disease-Focused Panel survey analysis.

The Coronavirus disease 2019 (COVID-19) pandemic has significantly affected health care systems throughout the world. A Qualtrics survey was targeted for radiologists around the world to study its effect on the operations of prostate MRI studies and biopsies. Descriptive statistics were reported. A total of 60 complete responses from five continents were included in the analysis. 70% of the responses were from academic institutions. Among all participants, the median (range) number of prostate MRI was 20 (0, 135) per week before the COVID-19 pandemic versus 10 (0, 30) during the lockdown period; the median (range) number of prostate biopsies was 4.5 (0, 60) per week before the COVID-19 versus 0 (0, 12) during the lockdown period. Among the 30% who used bowel preparation for their patients prior to MRI routinely, 11% stopped the bowel preparation due to the pandemic. 47% reported that their radiology departments faced staff disruptions, while 68% reported changes in clinic schedules in other clinical departments, particularly urology, genitourinary medical oncology, and radiation oncology. Finally, COVID-19 pandemic was found to disrupt not only the clinical prostate MRI operations but also impacted prostate MRI/biopsy research in up to 50% of institutions. The impact of this collateral damage in delaying diagnosis and treatment of prostate cancer is yet to be explored.

El daño colateral de la atención de la pandemia de COVID-19.

Throughout history, pandemics have had a major impact on humanity. The measures used to combat them cause collateral damage. During the COVID-19 pandemic, the actions taken to reduce the exposure, the number of infections, and the case fatality rate focus on reducing mortality, however, the collapse of the health system can cause an even greater number of deaths. At the same time, both medical personnel and patients are affected by the economic slowdown and the "effect of negativity". In this review article the different tools available for pandemic control, their development in a historical context, and how they may impact risk stratification for vulnerable patients (elderly, patients with chronic degenerative and oncological diseases) were analyzed.

A lo largo de la historia, las pandemias han tenido un gran impacto para la humanidad. Las medidas utilizadas para combatirlas causan daño colateral. En la pandemia por COVID-19, las acciones generadas para disminuir la exposición, el número de contagios y la tasa de letalidad conllevan un enfoque en la reducción de la mortalidad, sin embargo el colapso del sistema de salud puede provocar un número aún mayor de muertos. A su vez, tanto el personal médico como los pacientes se ven afectados por la desaceleración económica y el "efecto de la negatividad". En este artículo de revisión se analizaron las diferentes herramientas para el control de la pandemia, su desarrollo en un contexto histórico y como impactan en la estratificación del riesgo para pacientes vulnerables (ancianos, pacientes con enfermedades crónico degenerativas y oncológicos).

The impact of the COVID-19 pandemic on the care and management of patients with acute cardiovascular disease: a systematic review.

The COVID-19 pandemic has disrupted healthcare services around the world, which may have serious implications for the prognosis of patients with acute cardiovascular disease. We conducted a systematic review to assess the extent to which health services related to the care and management of acute cardiovascular events have been impacted during the COVID-19 pandemic. PubMed, MedRxiv, and Google Scholar were searched for observational studies published up to 12 August 2020 for studies that assessed the impact of the pandemic on the care and management of people with acute cardiovascular disease (CVD). In total, 27 articles were included. Of these, 16 examined the impact on acute coronary syndromes (ACS), eight on strokes, one on ACS and strokes, and two on other types of CVD. When comparing the COVID-19 period to non-COVID-19 periods, 11 studies observed a decrease in ACS admissions ranging between 40% and 50% and 5 studies showed a decrease in stroke admissions of between 12% and 40%. Four studies showed a larger reduction in non-ST-segment elevation myocardial infarctions compared to ST-segment elevation myocardial infarctions. A decrease in the number of reperfusion procedures, a shortening in the lengths of stay at the hospital, and longer symptom-to-door times were also observed. The COVID-19 pandemic has led to a substantial decrease in the rate of admissions for acute CVD, reductions in the number of procedures, shortened lengths of stay at the hospital, and longer delays between the onset of the symptoms and hospital treatment. The impact on patient's prognosis needs to be quantified in future studies.