When all computers shut down: the clinical impact of a major cyber-attack on a general hospital.

Importance: Healthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated. Objective: This study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations. Setting: This study was conducted on a public, general, and acute care referral university teaching hospital. Methods: We report the different recovery measures on various hospital clinical activities and their impact on clinical work. Results: The system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial. Conclusions and relevance: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work.

Effects of COVID-19 Lockdowns on the Development of Educational, Social and Emotional Gaps among Children: A Retrospective Chart Review.

BACKGROUND: School closures due to the coronavirus disease 2019 (COVID-19) outbreak affected students physically, socially, and psychologically with an increase in the number of children and adolescent presenting with anxiety, depression, and drug abuse. OBJECTIVES: To examine the impact of COVID-19 and lockdown on the mental health of minors during the pandemic period and to characterize the type and number of referrals to a regional psychiatric outpatient clinic. METHODS: This study included 380 children evaluated in an outpatient child psychiatric clinic. They were divided into two groups: before the lockdowns (BLD) (n=248), from January 2019 to February 2020, and during the lockdowns (LD) (n=132), from March 2020 to April 2021. RESULTS: When comparing the LD to BLD, there was increase in suicide attempts (9.8% vs. 2.8%) and in the use of psychotherapy (81% vs. 56%). There was a decrease in the diagnoses of behavior disorders (29.5% vs. 44.8%) and ADHD (29.5% vs. 50%); as well as a decrease in stimulant usage (22.7% vs. 38%). There was a statistically non-significant increase in the number of children with depression, anxiety, and drug-use disorder. CONCLUSIONS: Many children developed educational, social, emotional, and behavioral gaps during LD, and they lost skills to deal with everyday problems due to social isolation. It is important to follow the long-term impact of the lockdowns and social isolation.

Characteristics of those who fall during orthopedic hospitalization - A retrospective case-control study.

BACKGROUND: The causes of falls are heterogeneous and represent an interaction between patient and environmental factors. This study aimed to explore the characteristics of patients who fell in an in-patient orthopedic department and explore possible reasons for their falls. METHODS: A retrospective case-control study of adults in an orthopedic in-patient setting at a major hospital, who sustained a fall. Sociodemographic and medical characteristics of randomly sampled patients who fell (cases, n = 128) and their controls (n = 128) were compared. RESULTS: Fallers were younger, had less comorbidities, took less medications, and had a shorter length of stay than non-fallers. Moreover, fallers' reasons for hospitalization were not necessarily associated with limited mobility. Fall events occurred most frequently from the patient's bed, in the bathroom and during night shifts. CONCLUSIONS: Our study portrays atypical fallers; that is, patients who had no obvious risk factors for falls and, thus, were not expected to fall. It appears that reduction in falls among high-risk patients may artificially create a population of atypical fallers. The patients may overestimate their abilities and avoid asking for assistance. Our findings suggest that emphasizing the importance of asking for assistance among both low-risk and high-risk patients as well as male and female patients should be an integral part of patient education in orthopedic departments.

Myocarditis following COVID-19 mRNA vaccination.

BACKGROUND: Clinical trials of the BNT162b2 vaccine, revealed efficacy and safety. We report six cases of myocarditis, which occurred shortly after BNT162b2 vaccination. METHODS: Patients were identified upon presentation to the emergency department with symptoms of chest pain/discomfort. In all study patients, we excluded past and current COVID-19. Routine clinical and laboratory investigations for common etiologies of myocarditis were performed. Laboratory tests also included troponin and C-reactive protein levels. The diagnosis of myocarditis was established after cardiac MRI. FINDINGS: Five patients presented after the second and one after the first dose of the vaccine. All patients were males with a median age of 23 years. Myocarditis was diagnosed in all patients, there was no evidence of COVID-19 infection. Laboratory assays excluded concomitant infection; autoimmune disorder was considered unlikely. All patients responded to the BNT162b2 vaccine. The clinical course was mild in all six patients. INTERPRETATION: Our report of myocarditis after BNT162b2 vaccination may be possibly considered as an adverse reaction following immunization. We believe our information should be interpreted with caution and further surveillance is warranted.

Patients Who Leave the Emergency Department Before Treatment Completion: A Retrospective Cohort Study.

BACKGROUND: Patients leaving the emergency department (ED) before treatment completion (LBTC) is a common universal occurrence. We hypothesized that the characteristics of the Israeli health care system, as well as its policy, intended to reduce the burden of nonurgent ED visits, may have an impact on factors associated with LBTC. OBJECTIVES: The purpose of this study was to explore factors associated with LBTC in the Israeli context. METHODS: This was a retrospective cohort study of patients who visited the ED in a major hospital located in northern-central Israel during 2016-2019. Characteristics of 130 randomly sampled LBTC patients and of 130 non-LBTC patients that constituted the control group, were compared. Odds ratios (OR) are presented. RESULTS: A low-acuity triage score (OR 8.18, p < 0.01) and a longer length of stay (OR 1.15, p < 0.01) were found to be risk factors for LBTC, and female gender (OR 0.40, p < 0.01) was found to be a protective factor. In contrast, age and nationality were not found as risk factors. Significant differences were found between the two groups with regard to the main presenting complaint. However, both groups had similar rates of presentations with a psychiatric condition. Approximately half of the LBTC patients presented at times when primary clinics were active. CONCLUSIONS: These findings reflect the strengths of the Israeli health care system. Despite the policy intended to reduce the burden of nonurgent ED visits, there are possible shortcomings in the system that should be addressed.

Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis.

OBJECTIVE: Vestibulitis is currently diagnosed based only on clinical criteria. To achieve histopathological diagnostic criteria, we carried out a computerized image analysis method. METHODS: Vestibular tissues removed from 40 women with severe vestibulitis were immunostained for mast cell count and degranulation by C-kit and mast cell tryptase, respectively. Vestibular nerve cells total area was evaluated after S-100 stain. Controls were 7 women aged 18-48. The images were converted to a digital signal, and analyzed using Image Proplus V4 software. RESULTS: We found a significant increase in inflammatory infiltrate, number of mast cells and degranulated mast cells in vestibulitis compared to normal controls. The inflammatory cells were localized around the superficial minor vestibular glands. The total nerve fiber area was ten times higher in vestibulitis patients than in controls. A significant positive correlation was found between the total nerve fiber area and the number of mast cells in the vestibulitis group of patients. CONCLUSION: We documented two diagnostic histopathological criteria for vestibulitis: (1) the presence of eight or more mast cells per 10 x 10 microscopic field, and (2) the total calculated area of the nerve fibers is ten times higher than expected. These findings re-establish the inflammatory nature of the vestibulitis. It is speculated that the trigger for the local outburst of nerve fibers could be related to the activation of the mast cells by a topical agent.