Difference Between COVID-19 Alpha Variant B.1.1.7 and the Original Virus in Gastrointestinal Symptoms and Mortality: Does a Negative Correlation Exist?

BACKGROUND: Up to half the patients diagnosed with acute coronavirus disease 2019 (COVID-19) presented with gastrointestinal symptoms. Gastric mucosal cells, enterocytes, and colonocytes express the viral entry receptor angiotensin-converting enzyme 2 (ACE2) and coreceptor transmembrane protease serine 2 (TMPRSS2) and are prone to infection. Direct infection of gastrointestinal epithelial cells has been demonstrated. COVID-19 disease was first diagnosed in Israel at the end of February 2020 with 842,536 confirmed cases and 6428 deaths by the end of June 2021. In our multicenter, retrospective cohort study, we looked for gastrointestinal signs and symptoms in two periods and correlated them with mortality. Period 1 included the first and second waves and the original virus. Period 2 represented the third wave and the alpha variant. OBJECTIVES: To reveal gastrointestinal signs and symptoms in two periods and correlate them with mortality. METHODS: From 22,302 patients hospitalized in general medical centers, we randomly selected 3582 from Period 1 and 1106 from Period 2. The study was performed before vaccinations were available. RESULTS: Gastrointestinal signs and symptoms, diarrhea, vomiting, abdominal pain, and taste/smell loss were significantly more prevalent during Period 1. Thirty-day mortality and in-hospital mortality were significantly higher in Period 2 than in Period 1, 25.20% vs. 13.68%, and 21.17% vs. 12.87%, respectively (P < 0.001). CONCLUSIONS: Thirty-day mortality and in-hospital mortality rates were 1.84 and 1.64 times higher from 6 November 2020 to 15 January 2021, the alpha variant, and in negative correlation with gastrointestinal symptoms.

Comparing Coronavirus Disease 2019 (COVID-19) Pandemic Waves in Hospitalized Patients: A Retrospective, Multicenter, Cohort Study.

BACKGROUND: Coronavirus disease 2019 was first diagnosed in Israel at the end of February 2020. By the end of June 2021, there were 842 536 confirmed cases and 6428 deaths. Our aim in this multicenter, retrospective, cohort study is to describe the demographic and clinical characteristics of hospitalized patients and compare the pandemic waves before immunization. METHODS: Of 22 302 patients hospitalized in general medical centers, we randomly selected 6329 for the study. Of these, 3582 and 1106 were eligible for the study in the first period (first and second waves) and in the second period (third wave), respectively. RESULTS: Thirty-day mortality was higher in the second period than in the first period, 25.20% vs 13.68% (P < .001). Invasive mechanical ventilation supported 9.19% and 14.21% of patients in the first period and second period, respectively. Extracorporeal membrane oxygenation (ECMO) was used more than twice as often in the second period. CONCLUSIONS: Invasive ventilation, use of ECMO, and mortality rate were 1.5 to 2 times higher in the second period than in the first period. In the second period, patients had a more severe presentation and higher mortality than those in the first period.

COVID-19 and Renal Failure - Adding Insult to Injury? Israel's Experience Based on Nationwide Retrospective Cohort Study.

INTRODUCTION: Renal failure (RF) is a risk factor for mortality among hospitalized patients. However, its role in COVID-19-related morbidity and mortality is inconclusive. The aim of the study was to determine whether RF is a significant predictor of clinical outcomes in COVID-19 hospitalized patients based on a retrospective, nationwide, cohort study. METHODS: The study sample consisted of patients hospitalized in Israel for COVID-19 in two periods. A random sample of these admissions was selected, and experienced nurses extracted the data from the electronic files. The group with RF on admission was compared to the group of patients without RF. The association of RF with 30-day mortality was investigated using a logistic regression model. RESULTS: During the two periods, 19,308 and 2994 patients were admitted, from which a random sample of 4688 patients was extracted. The 30-day mortality rate for patients with RF was 30% (95% confidence interval (CI): 27-33%) compared to 8% (95% CI: 7-9%) among patients without RF. The estimated OR for 30-day mortality among RF versus other patients was 4.3 (95% CI: 3.7-5.1) and after adjustment for confounders was 2.2 (95% CI: 1.8-2.6). Furthermore, RF patients received treatment by vasopressors and invasive mechanical ventilation (IMV) more frequently than those without RF (vasopressors: 17% versus 6%, OR = 2.8, p<0.0001; IMV: 17% versus 7%, OR = 2.6, p<0.0001). DISCUSSION: RF is an independent risk factor for mortality, IMV, and the need for vasopressors among patients hospitalized for COVID-19 infection. Therefore, this condition requires special attention when considering preventive tools, monitoring, and treatment.

Performing Duplex within 72 Hours of Transient Ischemic Attack May Decrease Mortality, the Israeli National Program for Quality Indicators experience.

BACKGROUND: With diagnostic imaging, such as a duplex of the carotid arteries, finding of stenosis and atherosclerotic plaque and consequent end arterectomy may be important for decreasing the danger of developing cerebrovascular accident after transient ischemic attack (TIA). OBJECTIVES: To measure performance rates of duplex of carotid arteries within 72 hours of TIA diagnosis. METHODS: The denominator included all patients who were admitted to emergency departments because of TIA, and the numerator included those who underwent duplex within 72 hours of admission. Inclusion criteria included all patients older than 18 years who were admitted because of TIA according to the ICD9 codes. RESULTS: Measuring this indicator started in 2015 with 5504 patients and a 58% success rate. The figures for the years 2016, 2017, and 2018 were 5309, 5447, and 5278 patients with success rates of 73%, 79%, and 83%, respectively. Six of 26 hospitals (23.0%) reached the target of 80% in 2018. From 2015 to 2018 a total of 21,538 patients were admitted to emergency departments in Israel and diagnosed with TIA. Of these, 15,722 (72.9%) underwent duplex within 72 hours. The mortality rate within 30 days from diagnosis was 0.81% in patients who performed duplex within 72 hours of diagnosis and 2.37% in patients who did not, odds ratio 2.676, 95% confidence interval 2.051-3.492, P < 0.0001. These results indicate a statistically significant decrease of 65.82. CONCLUSIONS: A significant decrease in mortality was noted in patients with a new diagnosis of TIA who underwent duplex within 72 hours of diagnosis.

COVID-19 Inpatient Caseloads in General Hospitals Did Not Affect Quality Indicator Compliance Rates in Israel.

BACKGROUND AND OBJECTIVES: Early in the global COVID-19 pandemic, a concern was raised that potentially high volumes of COVID-19 inpatients in general hospitals might compromise the hospitals' capabilities to maintain high-quality care for routine patients and, thereby, to comply with indicators specifying quality of care. The objective of this study is to evaluate the impact of the surges of COVID-19 inpatients into general hospitals in Israel on the compliance rates for selected quality indicators reported by these hospitals within the Israeli National Program for Quality Indicators (NPQI). METHODS: Compliance rate data were collected from the quality indicators reports made to the NPQI by participating hospitals. COVID-19 inpatient volume data were obtained from the Ministry of Health Digital Technologies and Data Division. Both datasets were analyzed on a week-by-week basis and plotted one alongside the other on a time scale. Association of each quality indicator's compliance rate with the number of COVID-19 inpatients was tested by Pearson's correlation analysis. The study included data from July 1, 2019 through June 30, 2022, spanning the duration of the COVID-19 pandemic in Israel. Five quality indicators included in the study were: Surgical repair of femoral neck fracture within 48 h of admission; Assessment of cerebral ischemic event risk for patients with atrial fibrillation; Duplex carotid ultrasound within 72 h of emergency department admission for patients with suspected transient ischemic attack; Antibiotic prophylaxis for caesarean sections; and Percutaneous coronary intervention within 90 min for patients presenting with ST-elevation myocardial infarction. RESULTS: Compliance rates for five quality indicators, representing different aspects of routine health care, remained steady - even at times with high volumes of COVID-19 inpatients in general hospitals. This lack of effect was prominent throughout the analyzed period, i.e., general hospitals maintained similar compliance rates for all quality indicators both during the surges of COVID-19 patients and between these periods. Statistical analysis showed no correlation between the quality indicators' compliance rates and the number of COVID-19 inpatients. CONCLUSIONS: Our findings indicate that high volumes of COVID-19 inpatients in general hospitals did not affect the hospitals' capability to comply with routine health care quality indicators. The results of our study imply that general hospitals in Israel were able to withstand the challenges associated with the care of COVID-19 inpatients while preserving high quality of care for routine patients.

Quality of care indicator performance was minimally changed in 2020 despite the COVID-19 pandemic.

BACKGROUND: In 2020, the COVID-19 pandemic affected healthcare systems throughout the world, including the management of patients and compliance rates of quality indicators. OBJECTIVE: To measure the impact in Israel of the COVID-19 pandemic on the indicator-relevant caseload and compliance rates of the quality indicators reported by medical services providers within the Israeli National Program for Quality Indicators (NPQI). METHODS: Data was collected from the reports made to the NPQI by participating hospitals and medical service providers. The indicator results for the number of cases and compliance rates for 2019 were compared to those from 2020. We assessed and compared the results of the quality indicators in general hospitals, geriatric hospitals and departments, psychiatric hospitals and departments, emergency medical services (EMS), and Mother and Baby health centers. RESULTS: We found a decrease in measurable cases in 2020 relative to 2019, especially in geriatric hospitals. In most indicators, compliance rates rose in 2020. Few indicators had lower compliance rates associated with COVID-19 pandemic regulations. CONCLUSIONS AND POLICY IMPLICATIONS: Routine medical activity decreased in Israel in 2020 in comparison to 2019, as reflected by a decrease in cases, but compliance rates were better in most indicators. The results of our study imply that the functioning of healthcare quality measurement programs should not be interrupted during a pandemic. This not only allows measuring of the healthcare system's performance during a crisis, but also may assist in maintaining a high level of healthcare quality.

Quality Indicators for Prevention of Infection in the Surgical Site: The Israeli National Program for Quality Indicators Experience.

BACKGROUND AND OBJECTIVES: The Israeli National Program for Quality Indicators (INPQ) sets as its primary goal to promote high-quality health care within selected core areas in the Israeli health system. Surgical site infection is one of the most common types of acquired infections. The INPQ supports 3 distinct indicators concerning suitable antibiotic treatment in colorectal surgery, cesarean sections, and surgery for femoral neck fractures. METHODS: We measured the number of patients who received prophylactic antibiotics, beginning an hour before the first cut and stopping after 24 hours in 1 of the 3 operations, according to the International Classification of Diseases, Ninth Revision (ICD-9) codes. Goals for success have been established annually according to the results of the previous year. Data computed for each operation included socioeconomic status, dates of hospitalization and release, date of death, date of birth, gender, date of operation, time of beginning and end of the operation, and time of beginning and end of anesthesia. RESULTS: Within 3 to 5 years, we achieved a significant increase in appropriate prophylactic antibiotic use from 78% to 85%, 78% to 95%, and 66% to 88% for colorectal surgery (n = 9404), cesarean sections (n = 141 362), and femoral joint operations (n = 30 728), respectively. The mortality rate was lower, 1.85% versus 0.55% in patients who received proper antibiotic therapy (odds ratio [OR] = 3.141; 95% confidence interval [CI], 1.829-5.394, P < .0001), 0.031% versus 0.006% (OR = 6.741; 95% CI, 1.879-21.187; P = .003), and 5.59% versus 4.51% (OR = 1.253; 95% CI, 1.091-1.439; P = .001), respectively. CONCLUSION: Prophylactic antibiotic treatment is strongly recommended by medical guidelines. The experience of the INPQ supports this approach. We demonstrate a significant lower mortality rate in patients who have been properly treated.

Under (less) pressure - Facial pressure ulcer development in ventilated ICU patients: A prospective comparative study comparing two types of endotracheal tube fixations.

INTRODUCTION: The development of medical device-related pressure ulcers (MDR PUs) as a result of an endotracheal tube fixator (ETTF) use affects patients particularly in the intensive care unit (ICU). STUDY DESIGN AND DATA COLLECTION: Prospective comparative study followed two similar groups of ventilated ICU patients: Group A treated with cloth tape ETTF (CT-ETTF) and Group B treated with Anchorfast Hollister-ETTF (AH-ETTF). Data were collected regarding PU development, location, grade, time from intubation and hospitalisation. RESULTS: Significant differences in PU development (p < 0.01), hospital LOS until PU development (p < 0.01), and ventilation days until PU development (p < 0.01) were found between the two groups all in favour of Group B. Linear regression conducted to identify the primary reason for these findings, revealed that the key factor responsible for more than 40% of the difference in ventilation days until ETT MDR PU formation between the groups was the usage of AH-ETTF (R2 = 0.436, p = 0.000). CONCLUSIONS: There was a significant advantage to AH-ETTF over CT-ETTF in pressure ulcer development. This should be taken into consideration when deciding which ETTF type to use.

Carbon monoxide poisoning in a young, healthy patient: A case study of heart failure recovery after Hyperbaric Oxygenation Treatment.

The effectiveness of hyperbaric oxygen treatment for acute cardiac diseases is unknown. Similarly, the effectiveness of hyperbaric oxygen treatment for carbon monoxide intoxication is also unknown, particularly for cases in which carboxyhemoglobin (COHb) levels return to normal. Our case study revolved around a healthy twenty-year-old male patient, who suffered from carbon monoxide intoxication. The patient presented to the Emergency Department unconscious. Blood workup revealed significant carbon monoxide intoxication and cardiac injury (COHb = 41%, troponin T = 0.38 ng/dl, ST depression). He was intubated and transferred to a specialist Centre for hyperbaric oxygenation treatment, whilst mechanically ventilated. COHb on arrival (5 hours later) was 4.3%. First echocardiography revealed estimated ejection fraction of 30%, moderate-severe left ventricular dysfunction and global hypokinesis. Patient received 3 rounds of HBOT; each round was 2.4 ATA, 100% O2 and 120 minutes long within the following 24 hours. Afterwards, the patient was successfully extubated. Three days later, a second echocardiography showed remarkable improvement with normal left ventricular size and function. The patient discharged the following day without complaints or the need for long-term medication. Hyperbaric treatment for carbon monoxide intoxication with compromised cardiac function should be considered even when carboxyhaemoglobin levels have returned to normal. This is due to mitochondrial impairment caused by carbon monoxide intoxication that eventually can lead to significant cardiac deterioration.

Being a legal guardian - the nursing perspective.

BACKGROUND: Surrogate decision making is common in public healthcare worldwide. In Israel any incompetent adult patient requires a Legal Guardian (LG), appointed by the court, for approval of invasive none-life saving procedures. Usually, the LG is a close family member of the patient. Nurses are the most available healthcare providers to the families and the LG during the process of appointment and afterwards. The patient's family is often anxious or even depressed, and thus the perceptions and behavior of nurses charged with providing support are crucial. In a previous study based on interviews of LGs we found that the most difficult issues for the LGs were decision related issues, family related issues and appointment bureaucracy issues. OBJECTIVE: To qualitatively assess nurses attitudes regarding the difficulties that families and LGs face during and after appointments and to compare the findings to previously accessed LG attitudes. RESEARCH DESIGN: After IRB approval, demographic and semi-structured questionnaires were used to assess the attitudes of a convenience sample of 34 nurses who were participating in a critical care training course (41 % of the respondents were from the ICU, 47 % from medical or surgical wards, and 12 % from other departments at secondary and tertiary hospitals in Israel.) regarding LGs difficulties. After reading and analyzing the responses provided by the nurses, the authors categorized the pertinent topics raised using content analysis. Nurses' perceptions were also compared to those of LGs reported in previous research by the authors. RESULTS: Three main themes emerged: 1. Decision related issues; namely coping with the complexity of end of life decision issues; 2. Family related issues; namely, family dynamics related to the various decisions regarding LG identity and patient care; and 3. Bureaucracy issues; namely, the formal process related to LG appointment and decisions. Regarding the first two themes, the feelings of the nurse respondents were quite similar to those of LG respondents from our earlier research. The third theme - bureaucracy issues - was never mentioned by the nurses, as opposed to LGs who mentioned it frequently. This suggests that the nurses did not consider it to be an important issue. CONCLUSIONS: The difficulties of decision making as well as family support and responsibility of LGs are well known by nurses. The appointment and bureaucracy issues were neglected by nurses, although they are very important to the LGs. Improvement of this parameter of care is needed. Possible directions for improvement include raising awareness of nurses regarding the appointment process and alleviation of bureaucracy. Further research is required to identify appropriate strategies for improving these aspects of care.

Attitudes of legal guardians in the ICU - a qualitative report.

UNLABELLED: Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions. OBJECTIVE: To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives. RESEARCH DESIGN: Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis. RESULTS: Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff. CONCLUSIONS: The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.

The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures.

BACKGROUND: ICU patients frequently undergo non-life-saving invasive procedures. When patient informed consent cannot be obtained, legal guardianship (LG), often from a close relative, may be required by law. The objective of this cohort study was to investigate the attitudes of LGs of ICU patients regarding the process of decision making for invasive non-life-saving procedures. METHODS: The study was conducted from May 2009 until June 2010 in general medical/surgical ICUs in two large Israeli medical centers. All 64 LGs who met the study criteria agreed to participate in the study. Three questionnaires were administered: a demographic data questionnaire, the Family Satisfaction with ICU 34 Questionnaire, and the Attitudes towards the LG Decision Making Process questionnaire, developed by the authors. RESULTS: The sample consisted of 64 LGs. Most participants were married (n = 56, 87.5%), male (n = 33, 51.6%), who had either a high school (n = 24, 37.5%) or college (n = 19, 29.7%) education, and were at a mean age of 49.2 (±11.22). Almost all of the procedures performed were tracheotomies (n = 63, 98.4%). About two-thirds of the LGs preferred decisions to be made by the medical staff after discussing options with them (n = 42, 65.6%) and about three-fifths stated that decisions could be made without the need for the appointment of an LG (n = 37, 57.8%). Attitudes towards ease of obtaining information and honesty of information were more positive compared to those of consistency and understanding of information. CONCLUSIONS: The legal guardianship process requires better communication and more understandable information in order to assist LGs in making decisions for others in at times vague and stressful situations.