Impact of the COVID-19 pandemic on a tertiary care public hospital in Singapore: resources and economic costs.

BACKGROUND: The COVID-19 pandemic has prompted hospitals to respond with stringent measures. Accurate estimates of costs and resources used in outbreaks can guide evaluations of responses. We report on the financial expenditure associated with COVID-19, the bed-days used for COVID-19 patients and hospital services displaced due to COVID-19 in a Singapore tertiary hospital. METHODS: We conducted a retrospective cost analysis from January to December 2020 in the largest public hospital in Singapore. Costs were estimated from the hospital perspective. We examined financial expenditures made in direct response to COVID-19; hospital admissions data related to COVID-19 inpatients; and the number of outpatient and emergency department visits, non-emergency surgeries, inpatient days in 2020, compared with preceding years of 2018 and 2019. Bayesian time-series was used to estimate the magnitude of displaced services. RESULTS: USD $41.96 million was incurred in the hospital for COVID-19-related expenses. Facilities set-up and capital assets accounted for 51.6% of the expenditure; patient-care supplies comprised 35.1%. Of the 19,611 inpatients tested for COVID-19 in 2020, 727 (3.7%) had COVID-19. The total inpatient- and intensive care unit (ICU)-days for COVID-19 patients in 2020 were 8009 and 8 days, respectively. A decline in all hospital services was observed from February following a raised disease outbreak alert level; most services quickly resumed when the lockdown was lifted in June. CONCLUSION: COVID-19 led to an increase in healthcare expenses and a displacement in hospital services. Our findings are useful for informing economic evaluations of COVID-19 response and provide some information about the expected costs of future outbreaks.

Increased T cell immunosenescence and accelerated maturation phenotypes in older kidney transplant recipients.

Older kidney transplant recipients experience increased rates of infection and death, and less rejection, compared with younger patients. However, little is known about immune dysfunction in older compared with younger kidney transplant recipients and whether it is associated with infection. We evaluated T cell phenotypes including maturation, immune senescence, and exhaustion in a novel investigation into differences in older compared with younger patients receiving identical immune suppression regimens. We evaluated PBMC from 60 kidney transplant recipients (23 older and 37 matched younger patients) by multiparameter immune phenotyping. Older kidney transplant recipients demonstrated decreased frequency of naïve CD4+ and CD8+ T cells, and increased frequency of terminally differentiated, immune senescent, and NK T cells expressing KLRG1. There was a trend towards increased frequency of T cell immune senescence in patients experiencing infection in the first year after transplantation, which reached statistical significance in a multivariate analysis. This pilot study reveals immune dysfunction in older compared with younger transplant recipients, and suggests a likely mechanism for increased vulnerability to infection. The ability to assess T cell maturation and immune senescence in transplant recipients offers the potential for risk stratification and customization of immune suppression to prevent infection and rejection after transplantation.

A case report of CMV lymphadenitis in an adult kidney transplant recipient.

Cytomegalovirus (CMV) infection following kidney transplantation is associated with increased morbidity and mortality. In this case report we describe a case of a 23-year-old woman with an unusual presentation of diffuse CMV lymphadenitis following kidney transplantation that did not respond to gangiclovir therapy. This case highlights the atypical presentation of CMV disease in a kidney transplant recipient, the importance of CMV hypergammaglobulin in the treatment of CMV infection post kidney transplantation, and the difficulties in transitioning care from pediatric to adult transplant programs.

Induction of macrophage matrix metalloproteinase biosynthesis by surfactant protein D.

Recent studies strongly suggest that surfactant protein D (SP-D) plays important roles in pulmonary host defense and the regulation of immune and inflammatory reactions in the lung. Although SP-D can bind to alveolar macrophages and can elicit their chemotaxis, relatively little is known about the direct cellular consequences of SP-D on the function of these cells. Because matrix metalloproteinases (MMPs) are synthesized in increased amounts in response to various proinflammatory stimuli, we investigated the capacity of SP-D to modulate the production of MMPs by freshly isolated human alveolar macrophages. Unexpectedly we found that recombinant rat SP-D dodecamers selectively induce the biosynthesis of collagenase-1 (MMP-1), stromelysin (MMP-3), and macrophage elastase (MMP-12) without significantly increasing the production of tumor necrosis factor alpha and interleukin-1beta. SP-D did not alter the production of these MMPs by fibroblasts. Phosphatidylinositol, a surfactant-associated ligand that interacts with the carboxyl-terminal neck and carbohydrate recognition domains of SP-D, inhibited the SP-D-dependent increase in MMP biosynthesis. A trimeric, recombinant protein consisting of only the neck and carbohydrate recognition domain did not augment metalloproteinase production, suggesting that the stimulatory effect on MMP production depends on an appropriate spatial presentation of trimeric lectin domains. Although SP-D dodecamers can selectively augment metalloproteinase activity in vitro, this effect may be competitively inhibited by tissue inhibitors of metalloproteinases or surfactant-associated ligands in vivo.

Telemedical education: teaching spirometry on the Internet.

Advances in portable equipment have led to routine spirometry testing outside of formal pulmonary function laboratories. Practitioners ordering these tests are not formally trained in spirometry interpretation. Providing effective off-site training can be challenging. Our objective was to develop a remotely accessible computer-based tutorial for teaching spirometry interpretation to nonpulmonologists. We designed an educational module that was accessible via the Internet and tested by 65 medical trainees at a major university medical center. In addition, the module was posted within the Virtual Hospital on the World Wide Web. Increases in spirometry interpretative skills were assessed using pre- and post-tests submitted electronically. The spirometry module significantly improved spirometry interpretation by nonspecialist trainees. This improvement included a broad increase in knowledge base and was observed independent of training level and prior spirometry reading experience. We conclude that computer-based tutorials can effectively train off-site practitioners in spirometry interpretation. This technology allows for the dissemination of educational material from a central site of expertise and provides a valuable adjunct to limited teaching resources.

Predictors of between-method differences in cardiac output measurement using thoracic electrical bioimpedance and thermodilution.

OBJECTIVES: To evaluate the usefulness of transthoracic electrical bioimpedance in trending changes in cardiac output after cardiac surgery, and to identify predictors of differences between cardiac output measured by thermodilution and transthoracic electrical bioimpedance methods. DESIGN: Prospective repeated-measures study. SETTING: University-affiliated tertiary care center. PATIENTS: Thirty-four adult patients undergoing elective cardiac surgery with routine pulmonary artery catheter placement. INTERVENTIONS: Simultaneous paired cardiac output measurements by transthoracic electrical bioimpedance and thermodilution were made at four time points: within 2 hrs of intensive care unit (ICU) admission; when the patient reached a normothermic temperature; after extubation; and 24 hrs after ICU admission. MEASUREMENTS AND MAIN RESULTS: Mean measurements by each method over time did not differ, except at ICU admission, when compared by repeated-measures analysis of variance. For each time point, bias and precision between methods were calculated. Bias calculations ranged from 0.02 to 0.21 L/min/m2. Precision calculations ranged from 1.06 to 1.52 L/min/m2. Predictors of between-method differences identified by a multiple regression model of hemodynamic variables were: increased systemic vascular resistance index, decreased mean arterial pressure (MAP), and the presence of atrial or ventricular pacing. CONCLUSIONS: While mean postoperative cardiac output measurements did not differ by method over time, agreement between transthoracic electrical bioimpedance and thermodilution methods was poor in the immediate postoperative period, with precision calculations indicative of clinically significant differences. Increased systemic vascular resistance index and decreased MAP were predictive of larger between-method differences.