Validation of the qSOFA and CRB-65 in SARS-CoV-2 infected community-acquired pneumonia

Rationale Prognostic accuracy of the qSOFA and CRB-65 risk scores has not been widely evaluated in SARS-CoV-2 infected compared to SARS-CoV-2 non-infected community-acquired pneumonia (CAP). Objectives The aim was to validate the qSOFA(−65) and CRB-65 scores in a large cohort of SARS-CoV-2 infected and non-infected CAP patients. Methods We included all cases with CAP hospitalized in 2020 from the German nationwide mandatory quality assurance program and compared SARS-CoV-2 infected with non-infected cases. We excluded cases with unclear SARS-CoV-2 infection state, transferred to another hospital or on mechanical ventilation (MV) during admission. Predefined outcomes were hospital mortality and need of MV. Results Among 68 594 SARS-CoV-2 infected patients, hospital mortality (22.7%) and MV (14.9%) was significantly higher when compared to 167.880 SARS-CoV-2 negative patients (15.7% and 9.2%, respectively). All CRB-65 and qSOFA criteria were associated with both outcomes, and age dominated mortality prediction in SARS-CoV-2 (relative risk >9). Scores including the age-criterion had higher AUCs for mortality in SARS-CoV-2 positive (e.g. CRB-65 AUC 0.76) compared to SARS-CoV-2 negative (AUC 0.68) patients, and NPV was highest for qSOFA-65=0 (98.2%). Sensitivity for MV prediction was poor with all scores (AUCs 0.59–0.62), and NPVs were insufficient (qSOFA-65=0 missed 1490/10 198∼ 15% patients with MV). Results were similar when excluding frail and palliative patients. Conclusions Hospital mortality and MV rates were higher in SARS-CoV-2 positive compared to SARS-CoV-2 negative CAP. For SARS-CoV-2 positive CAP, the CRB-65 and qSOFA-65 scores showed adequate prediction of mortality, but not of MV.

[Recommendations for the Utilization of Claims Data During a Pandemic: Lessons Learned from the Project EgePan-Unimed of the Netzwerk Universitätsmedizin (NUM)]. / Potentiale von und Empfehlungen zur Nutzung von GKV Routinedaten in einer pandemischen Versorgungslage ­ Erfahrungen aus dem Projekt egePan-Unimed des Netzwerk Universitätsmedizin (NUM).

For appropriate response to the COVID-19 pandemic, and for obtaining answers to various relevant research questions, empirical data are required. Claims data of health insurances are a valid data source in such a situation. Within the project egePan-Unimed of the Netzwerk Universitätsmedizin (NUM) we investigated five COVID-19-related research questions using German claims data of statutory health insurances. We studied the prevalence and relevance of risk factors for a severe course of COVID-19, the background incidence of cerebral venous sinus thrombosis and myocarditis, the frequency and symptoms of post-COVID as well as the care of people with a psychiatric condition during the COVID-19 pandemic. Based on these cases, context-specific recommendations regarding the use of German claims data for future pandemics or other public health emergencies were derived, namely that the utilization of established and interdisciplinary project teams enables a timely project start and furthermore, meta-analytic methods are a valuable way to pool aggregated results of claims data analyses when data protection regulations do not allow a consolidation of data sets from different statutory health insurances. Under these circumstances, claims data are a readily available and valid data source of empirical evidence base necessary for public health measures during a pandemic.

Development of a risk score to identify patients at high risk for a severe course of COVID-19.

Aim: We aimed to develop a risk score to calculate a person's individual risk for a severe COVID-19 course (POINTED score) to support prioritization of especially vulnerable patients for a (booster) vaccination. Subject and methods: This cohort study was based on German claims data and included 623,363 individuals with a COVID-19 diagnosis in 2020. The outcome was COVID-19 related treatment in an intensive care unit, mechanical ventilation, or death after a COVID-19 infection. Data were split into a training and a test sample. Poisson regression models with robust standard errors including 35 predefined risk factors were calculated. Coefficients were rescaled with a min-max normalization to derive numeric score values between 0 and 20 for each risk factor. The scores' discriminatory ability was evaluated by calculating the area under the curve (AUC). Results: Besides age, down syndrome and hematologic cancer with therapy, immunosuppressive therapy, and other neurological conditions were the risk factors with the highest risk for a severe COVID-19 course. The AUC of the POINTED score was 0.889, indicating very good predictive validity. Conclusion: The POINTED score is a valid tool to calculate a person's risk for a severe COVID-19 course. Supplementary Information: The online version contains supplementary material available at 10.1007/s10389-023-01884-7.

A comparison of pediatric inflammatory multisystem syndrome temporarily-associated with SARS-CoV-2 and Kawasaki disease.

The connection between Pediatric Inflammatory Multisystem Syndrome (PIMS) and Kawasaki Disease (KD) is not yet fully understood. Using the same national registry, clinical features and outcome of children hospitalized in Germany, and Innsbruck (Austria) were compared. Reported to the registry were 395 PIMS and 69 KD hospitalized patients. Patient age in PIMS cases was higher than in KD cases (median 7 [IQR 4-11] vs. 3 [IQR 1-4] years). A majority of both PIMS and KD patients were male and without comorbidities. PIMS patients more frequently presented with organ dysfunction, with the gastrointestinal (80%), cardiovascular (74%), and respiratory (52%) systems being most commonly affected. By contrast, KD patients more often displayed dermatological (99% vs. 68%) and mucosal changes (94% vs. 64%), plus cervical lymph node swelling (51% vs. 34%). Intensive care admission (48% vs. 19%), pulmonary support (32% vs. 10%), and use of inotropes/vasodilators (28% vs. 3%) were higher among PIMS cases. No patients died. Upon patient discharge, potentially irreversible sequelae-mainly cardiovascular-were reported (7% PIMS vs. 12% KD). Despite differences in age distribution and disease severity, PIMS and KD cases shared many common clinical and prognostic characteristics. This supports the hypothesis that the two entities represent a syndrome continuum.

Mental burden and moral distress among oncologists and oncology nurses in Germany during the third wave of the COVID-19 pandemic: a cross-sectional survey.

PURPOSE: There is evidence for mental burden and moral distress among healthcare workers during the pandemic. However, there is scarcity of analyses regarding possible correlations of mental burden and moral distress in this context. This study provides data to quantify mental burden and possible associations with moral distress among physicians and nurses working in oncology in Germany. METHODS: We conducted a cross-sectional online survey with physicians and nurses working in oncology in Germany between March and July 2021. Next to sociodemographic characteristics and working conditions, mental burden and moral distress were assessed using standardized instruments. Binary multivariate logistic regression using the enter method was performed in order to explore the relationship between mental burden and moral distress. RESULTS: 121 physicians and 125 nurses were included in the study. Prevalence of clinically relevant depressive symptoms, anxiety, somatic symptoms, burnout symptoms and moral distress was 19.2, 14.5, 12.7, 46.0 and 34.7% in physicians and 41.4, 24.0, 46.8, 46.6 and 60.0% in nurses respectively. Mental burden was significantly associated with moral distress, being female/diverse, younger age < 40 and increase in workload. Nurses who felt sufficiently protected from COVID-19 reported significantly less moral distress. CONCLUSION: To improve pandemic resilience, there is a need to ensure safe working environment including psychosocial support. Further evidence on risk and protective factors for moral distress is needed to be able to develop and implement strategies to protect healthcare workers within and beyond the pandemic.

Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany.

BACKGROUND: Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults. METHODS AND FINDINGS: We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias. CONCLUSIONS: In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults. TRIAL REGISTRATION: ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

Extreme obesity is a strong predictor for in-hospital mortality and the prevalence of long-COVID in severe COVID-19 patients with acute respiratory distress syndrome.

Acute Respiratory Distress Syndrome (ARDS) is common in COVID-19 patients and is associated with high mortality. The aim of this observational study was to describe patients' characteristics and outcome, identifying potential risk factors for in-hospital mortality and for developing Long-COVID symptoms. This retrospective study included all patients with COVID-19 associated ARDS (cARDS) in the period from March 2020 to March 2021 who were invasively ventilated at the intensive care unit (ICU) of the University Hospital Dresden, Germany. Between October 2021 and December 2021 patients discharged alive (at minimum 6 months after hospital discharge-midterm survival) were contacted and interviewed about persistent symptoms possibly associated with COVID-19 as well as the quality of their lives using the EQ-5D-5L-questionnaire. Long-COVID was defined as the occurrence of one of the symptoms at least 6 months after discharge. Risk factors for mortality were assessed with Cox regression models and risk factors for developing Long-COVID symptoms by using relative risk (RR) regression. 184 Patients were included in this study (male: n = 134 (73%), median age 67 (range 25-92). All patients were diagnosed with ARDS according to the Berlin Definition. 89% of patients (n = 164) had severe ARDS (Horovitz-index < 100 mmHg). In 27% (n = 49) extracorporeal membrane oxygenation was necessary to maintain gas exchange. The median length of in-hospital stay was 19 days (range 1-60). ICU mortality was 51%, hospital mortality 59%. Midterm survival (median 11 months) was 83% (n = 55) and 78% (n = 43) of these patients presented Long-COVID symptoms with fatigue as the most common symptom (70%). Extreme obesity (BMI > 40 kg/m2) was the strongest predictor for in-hospital mortality (hazard ratio: 3.147, confidence interval 1.000-9.897) and for developing Long-COVID symptoms (RR 1.61, confidence interval 1.26-2.06). In-hospital mortality in severe cARDS patients was high, but > 80% of patients discharged alive survived the midterm observation period. Nonetheless, most patients developed Long-COVID symptoms. Extreme obesity with BMI > 40 kg/m2 was identified as independent risk factor for in-hospital mortality and for developing Long-COVID symptoms.Trial registration DRKS-ID DRKS00027856.

Effect of clinical peer review on mortality in patients ventilated for more than 24 hours: a cluster randomised controlled trial.

BACKGROUND: Although clinical peer review is a well-established instrument for improving quality of care, clinical effectiveness is unclear. METHODS: In a pragmatic cluster randomised controlled trial, we randomly assigned 60 German Initiative Qualitätsmedizin member hospitals with the highest mortality rates in ventilated patients in 2016 to intervention and control groups. The primary outcome was hospital mortality rate in patients ventilated fore more than 24 hours. Clinical peer review was conducted in intervention group hospitals only. We assessed the impact of clinical peer review on mortality using a difference-in-difference approach by applying weighted least squares (WLS) regression to changes in age-adjusted and sex-adjusted standardised mortality ratios (SMRs) 1 year before and 1 year after treatment. Recommendations for improvement from clinical peer review and hospital survey data were used for impact and process analysis. RESULTS: We analysed 12 058 and 13 016 patients ventilated fore more than 24 hours in the intervention and control hospitals within the 1-year observation period. In-hospital mortality rates and SMRs were 40.6% and 1.23 in intervention group and 41.9% and 1.28 in control group hospitals in the preintervention period, respectively. The groups showed similar hospital (bed size, ownership) and patient (age, sex, mortality, main indications) characteristics. WLS regression did not yield a significant difference between intervention and control groups regarding changes in SMRs (estimate=0.04, 95% CI= -0.05 to 0.13, p=0.38). Mortality remained high in both groups (intervention: 41.8%, control: 42.1%). Impact and process analysis indicated few perceived outcome improvements or implemented process improvements following the introduction of clinical peer review. CONCLUSIONS: This study did not provide evidence for reductions in mortality in patients ventilated for more than 24 hours due to clinical peer review. A stronger focus on identification of structures and care processes related to mortality is required to improve the effectiveness of clinical peer review.

A core outcome set for post-COVID-19 condition in adults for use in clinical practice and research: an international Delphi consensus study.

Health consequences that persist beyond the acute infection phase of COVID-19, termed post-COVID-19 condition (also commonly known as long COVID), vary widely and represent a growing global health challenge. Research on post-COVID-19 condition is expanding but, at present, no agreement exists on the health outcomes that should be measured in people living with the condition. To address this gap, we conducted an international consensus study, which included a comprehensive literature review and classification of outcomes for post-COVID-19 condition that informed a two-round online modified Delphi process followed by an online consensus meeting to finalise the core outcome set (COS). 1535 participants from 71 countries were involved, with 1148 individuals participating in both Delphi rounds. Eleven outcomes achieved consensus for inclusion in the final COS: fatigue; pain; post-exertion symptoms; work or occupational and study changes; survival; and functioning, symptoms, and conditions for each of cardiovascular, respiratory, nervous system, cognitive, mental health, and physical outcomes. Recovery was included a priori because it was a relevant outcome that was part of a previously published COS on COVID-19. The next step in this COS development exercise will be to establish the instruments that are most appropriate to measure these core outcomes. This international consensus-based COS should provide a framework for standardised assessment of adults with post-COVID-19 condition, aimed at facilitating clinical care and research worldwide.

Characteristics and outcomes of sepsis patients with and without COVID-19.

BACKGROUND: The aim of this study was to describe and compare clinical characteristics and outcomes in critically ill septic patients with and without COVID-19. METHODS: From February 2020 to March 2021, patients from surgical and medical ICUs at the University Hospital Dresden were screened for sepsis. Patient characteristics and outcomes were assessed descriptively. Patient survival was analyzed using the Kaplan-Meier estimator. Associations between in-hospital mortality and risk factors were modeled using robust Poisson regression, which facilitates derivation of adjusted relative risks. RESULTS: In 177 ICU patients treated for sepsis, COVID-19 was diagnosed and compared to 191 septic ICU patients without COVID-19. Age and sex did not differ significantly between sepsis patients with and without COVID-19, but SOFA score at ICU admission was significantly higher in septic COVID-19 patients. In-hospital mortality was significantly higher in COVID-19 patients with 59% compared to 29% in Non-COVID patients. Statistical analysis resulted in an adjusted relative risk for in-hospital mortality of 1.74 (95%-CI=1.35-2-24) in the presence of COVID-19 compared to other septic patients. Age, procalcitonin maximum value over 2 ng/ml, need for renal replacement therapy, need for invasive ventilation and septic shock were identified as additional risk factors for in-hospital mortality. CONCLUSION: COVID-19 was identified as independent risk factor for higher in-hospital mortality in sepsis patients. The need for invasive ventilation and renal replacement therapy as well as the presence of septic shock and higher PCT should be considered to identify high-risk patients.

Studying the post-COVID-19 condition: research challenges, strategies, and importance of Core Outcome Set development.

BACKGROUND: A substantial portion of people with COVID-19 subsequently experience lasting symptoms including fatigue, shortness of breath, and neurological complaints such as cognitive dysfunction many months after acute infection. Emerging evidence suggests that this condition, commonly referred to as long COVID but also known as post-acute sequelae of SARS-CoV-2 infection (PASC) or post-COVID-19 condition, could become a significant global health burden. MAIN TEXT: While the number of studies investigating the post-COVID-19 condition is increasing, there is no agreement on how this new disease should be defined and diagnosed in clinical practice and what relevant outcomes to measure. There is an urgent need to optimise and standardise outcome measures for this important patient group both for clinical services and for research and to allow comparing and pooling of data. CONCLUSIONS: A Core Outcome Set for post-COVID-19 condition should be developed in the shortest time frame possible, for improvement in data quality, harmonisation, and comparability between different geographical locations. We call for a global initiative, involving all relevant partners, including, but not limited to, healthcare professionals, researchers, methodologists, patients, and caregivers. We urge coordinated actions aiming to develop a Core Outcome Set (COS) for post-COVID-19 condition in both the adult and paediatric populations.

Perception of the coronavirus pandemic by patients with atopic dermatitis - Results from the TREATgermany registry.

BACKGROUND: TREATgermany, a registry for patients with moderate to severe atopic dermatitis (AD), established an additional questionnaire in spring 2020 to investigate the effects of the coronavirus pandemic on the daily life of patients with AD. MATERIAL AND METHODS: A questionnaire was used to analyze general information regarding a patient's experience of the coronavirus pandemic and, using the Inventory of Life-Changing Events, the resulting personal burden. To analyze possible associations between disease severity (EASI score, oSCORAD, IGA, PGA, POEM), quality of life (DLQI) and personal burden, t-tests, analyses of variance and correlations were evaluated, controlled for sex and age. RESULTS: 58 % (n = 233) of the included 400 registry patients reported high burden scores caused by the coronavirus pandemic, regardless of an actual infection. Men showed significantly higher burden scores than women, and younger than older respondents (both P = 0.03). There were no differences in burden scores related to the physician's assessment of disease severity. However, patients with higher quality of life impairments and higher disease severity perceived the burden of the coronavirus pandemic as less severe (DLQI P = 0.019, PGA P = 0.044). CONCLUSIONS: Our data show that registry patients considered the coronavirus pandemic as a life-changing event and perceived the burden differently. This should be taken into account in the treatment of patients with moderate to severe AD as well as in further studies.

The Organic Turn: Coping With Pandemic and Non-pandemic Challenges by Integrating Evidence-, Theory-, Experience-, and Context-Based Knowledge in Advising Health Policy

The COVID-19 pandemic has posed an extraordinary challenge for public health and health policy. Questions have arisen concerning the main strategies to cope with this situation and the lessons to be learned from the pandemic. This conceptual paper aims to clarify these questions via sociological concepts. Regarding coping strategies used during the pandemic, there is a strong tendency for health policymakers to rely on expert knowledge rather than on evidence-based knowledge. This has caused the evidence-based healthcare community to respond to urgent demands for advice by rapidly processing new knowledge. Nonetheless, health policymakers still mainly rely on experts in making policy decisions. Our sociological analysis of this situation identified three lessons for coping with pandemic and non-pandemic health challenges: (1) the phenomenon of accelerating knowledge processing could be interpreted from the organizational innovation perspective as a shift from traditional mechanistic knowledge processing to more organic forms of knowledge processing. This can be described as an “organic turn.” (2) The return of experts is part of this organic turn and shows that experts provide both evidence-based knowledge as well as theoretical, experiential, and contextual knowledge. (3) Experts can use theory to expeditiously provide advice at times when there is limited evidence available and to provide complexity-reducing orientation for decisionmakers at times where knowledge production leads to an overload of knowledge;thus, evidence-based knowledge should be complemented by theory-based knowledge in a structured two-way interaction to obtain the most comprehensive and valid recommendations for health policy.

[The role of university hospitals in regional health care management for coping with the COVID-19 pandemic]. / Die Rolle der Universitätskliniken im regionalen medizinischen Versorgungsmanagement zur Bewältigung der COVID-19 Pandemie.

INTRODUCTION: The complex and dynamic situation in the current pandemic requires a regionally coordinated and interconnected cooperation between the different stakeholders within the health care system, such as the inpatient sector or the public health service. The aim of this study is to analyze health care management during the COVID-19 pandemic in 2020 with a focus on regional networking and communication structures. METHODS: As part of the BMBF-funded project "egePan Unimed", an online questionnaire on pandemic management was sent to the boards of all 35 German university hospitals in November 2020. The questionnaire focused on the core topics of regional networking, crisis management, data exchange, and communication with political stakeholders. The questionnaire consisted of 37 closed and three open-ended questions. After piloting, the invitation to the survey was extended three times by mail and once by telephone. RESULTS: The results (n=25, response 71.4%) show that 68% of the clinics surveyed were connected to representatives from the inpatient sector and 86% to representatives from the public health service. Networking with representatives from the outpatient sector was less common (26%). Of the university hospitals surveyed, 84% had a leadership role in a regional COVID-19 pandemic management effort. Data exchange with regional hospitals in the course of pandemic management took place at 75% of the participating university hospitals and with supra-regional hospitals at 67% of the clinics surveyed. CONCLUSION: To manage regional medical care during the COVID-19 pandemic in 2020, university hospitals often assumed a coordinating role in the complex pandemic care process. There were often structured collaborations with regional clinics and health departments and comparatively few cooperations with the outpatient care sector. However, this cooperation has the potential to prevent overcrowding in hospitals.

Independent Use of a Home-Based Telemonitoring App by Older Patients With Multimorbidity and Mild Cognitive Impairment: Qualitative Study.

BACKGROUND: The management of multimorbidity is complex and patients have a high burden of disease. When symptoms of dementia also appear, it becomes even more difficult for patients to cope with their everyday lives and manage their diseases. Home-based telemonitoring may support older patients with multimorbidity and mild cognitive impairment (MCI) in their regular monitoring and self-management. However, to date, there has been no investigation into whether patients with MCI are able to operate a telemonitoring app independently to manage their own diseases. This question has become even more important during the current COVID-19 pandemic to maintain high-quality medical care for this patient group. OBJECTIVE: We examined the following research questions: (1) How do patients with MCI assess the usability of the telemonitoring app? (2) How do patients with MCI assess the range of functions offered by the telemonitoring app? (3) Was there an additional benefit for the patients with MCI in using the telemonitoring app? (4) Were patients with MCI able to use the telemonitoring app independently and without restrictions? (5) To what extent does previous experience with smartphones, tablets, or computers influence the perceived ease of use of the telemonitoring app? METHODS: We performed a formative evaluation of a telemonitoring app. Therefore, we carried out a qualitative study and conducted guided interviews. All interviews were audio-recorded, transcribed verbatim, and analyzed using the Mayring method of structured content analysis. RESULTS: Twelve patients (8 women, 4 men) were interviewed; they had an average age of 78.7 years (SD 5.6) and an average Mini-Mental State Examination score of 24.5 (SD 1.6). The interviews lasted between 17 and 75 minutes (mean 41.8 minutes, SD 19.4). Nine patients reported that the telemonitoring app was easy to use. All respondents assessed the range of functions as good or adequate. Desired functionalities mainly included more innovative and varied educational material, better fit of the telemonitoring app for specific needs of patients with MCI, and a more individually tailored content. Ten of the 12 patients stated that the telemonitoring app had an additional benefit for them. Most frequently reported benefits included increased feeling of security, appreciation of regular monitoring of vital parameters, and increased independence due to telemonitoring. Eight patients were able to operate the app independently. Participants found the app easy to use regardless of whether they had prior experience with smartphones, tablets, or computers. CONCLUSIONS: The majority of examined patients with MCI were capable of operating the telemonitoring app independently. Crucial components in attaining independent use were comprehensive personal support from the start of use and appropriate design features. This study provides initial evidence that patients with MCI could increasingly be considered as a relevant user group of telemonitoring apps.

Different spreading dynamics throughout Germany during the second wave of the COVID-19 pandemic: a time series study based on national surveillance data.

BACKGROUND: The second wave of the COVID-19 pandemic led to substantial differences in incidence rates across Germany. METHODS: Assumption-free k-nearest neighbour clustering from the principal component analysis of weekly incidence rates of German counties groups similar spreading behaviour. Different spreading dynamics was analysed by the derivative plots of the temporal evolution of tuples [x(t),x'(t)] of weekly incidence rates and their derivatives. The effectiveness of the different shutdown measures in Germany during the second wave is assessed by the difference of weekly incidences before and after the respective time periods. FINDINGS: The implementation of non-pharmaceutical interventions of different extents resulted in four distinct time periods of complex, spatially diverse, and age-related spreading patterns during the second wave of the COVID-19 pandemic in Germany. Clustering gave three regions of coincident spreading characteristics. October 2020 showed a nationwide exponential growth of weekly incidence rates with a doubling time of 10 days. A partial shutdown during November 2020 decreased the overall infection rates by 20-40% with a plateau-like behaviour in northern and southwestern Germany. The eastern parts exhibited a further near-linear growth by 30-80%. Allover the incidence rates among people above 60 years still increased by 15-35% during partial shutdown measures. Only an extended shutdown led to a substantial decrease in incidence rates. These measures decreased the numbers among all age groups and in all regions by 15-45%. This decline until January 2021 was about -1•25 times the October 2020 growth rates with a strong correlation of -0•96. INTERPRETATION: Three regional groups with different dynamics and different degrees of effectiveness of the applied measures were identified. The partial shutdown was moderately effective and at most stopped the exponential growth, but the spread remained partly plateau-like and regionally continued to grow in a nearly linear fashion. Only the extended shutdown reversed the linear growth. FUNDING: Institutional support and physical resources were provided by the University Witten/ Herdecke and Kliniken der Stadt Köln, German ministry of education and research 'Netzwerk Universitätsmedizin' (NUM), egePan Unimed (01KX2021).