Updates on Infection Control in Alternative Health Care Settings.

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Impact of COVID-19 on Aesthetic Plastic Surgery Practice in the United Kingdom.

BACKGROUND: The COVID-19 pandemic has transformed the delivery of medical and surgical services globally. Subsequently, all elective and aesthetic procedures have been cancelled or deferred in accordance with government-mandated quarantine measures. The Cosmetic Surgery Governance Forum (CSGF) is a network of aesthetic plastic surgery consultants which has enabled a sharing of expertise during challenging times. We conducted a cross-sectional survey to assess the impact of the COVID-19 pandemic on aesthetic plastic surgeons and their practice in the UK. METHODS: On 15 June 2020, 131 respondents from the CSGF and wider aesthetic plastic surgeons in the UK were invited to respond to an online survey. An anonymised questionnaire was created using SmartSurveyTM and distributed at the end of the quarantine period. Questions regarding their current scope of practice, willingness to recommence face-to-face consultations, financial loss and psychological impact were asked. RESULTS: A total of 101 Consultant Plastic surgeons (76%) completed the questionnaire. If strict protocols and adequate personal protective equipment were available, 50-55% of respondents would consider offering non-surgical treatments as soon as the private clinic was open. Furthermore, 51% would consider procedures under general anaesthetic, whilst 89% of respondents would offer local anaesthetic only in the initial phase. Moreover, 66% reported experiencing a psychological impact and 100% of respondents reported a significant financial impact. CONCLUSIONS: This survey aims to give an account of the current state (May-July 2020) of aesthetic plastic surgery in the UK. There is ongoing uncertainty and deliberation regarding the timing and organisational changes required for aesthetic practice to restart.

National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. METHOD: A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. RESULTS: We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. CONCLUSION: Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Pre-existing Disparities and Potential Implications for the Rapid Expansion of Telemedicine in Response to the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Concerns exist regarding exacerbation of existing disparities in health care access with the rapid implementation of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic. However, data on pre-existing disparities in telemedicine utilization is currently lacking. OBJECTIVE: We aimed to study: (1) the prevalence of outpatient telemedicine visits before the COVID-19 pandemic by patient subgroups based on age, comorbidity burden, residence rurality, and median household income; and (2) associated diagnosis categories. RESEARCH DESIGN: This was a retrospective cohort study. SUBJECT: Commercial claims data from the Truven MarketScan database (2014-2018) representing n=846,461,609 outpatient visits. MEASURES: We studied characteristics and utilization of outpatient telemedicine services before the COVID-19 pandemic by patient subgroups based on age, comorbidity burden, residence rurality, and median household income. Disparities were assessed in unadjusted and adjusted (regression) analyses. RESULTS: With overall telemedicine uptake of 0.12% (n=1,018,092/846,461,609 outpatient visits) we found that pre-COVID-19 disparities in telemedicine use became more pronounced over time with lower use in patients who were older, had more comorbidities, were in rural areas, and had lower median household incomes (all trends and effect estimates P<0.001). CONCLUSION: These results contextualize pre-existing disparities in telemedicine use and are crucial in the monitoring of potential disparities in telemedicine access and subsequent outcomes after the rapid expansion of telemedicine during the COVID-19 pandemic.

How Did the Number and Type of Injuries in Patients Presenting to a Regional Level I Trauma Center Change During the COVID-19 Pandemic with a Stay-at-home Order?

BACKGROUND: During a pandemic, it is paramount to understand volume changes in Level I trauma so that with appropriate planning and reallocation of resources, these facilities can maintain and even improve life-saving capabilities. Evaluating nonaccidental and accidental trauma can highlight potential areas of improvement in societal behavior and hospital preparedness. These critical questions were proposed to better understand how healthcare leaders might adjust surgeon and team coverage of trauma services as well as prepare from a system standpoint what resources will be needed during a pandemic or similar crisis to maintain services. QUESTIONS/PURPOSES: (1) How did the total observed number of trauma activations, defined as patients who meet mechanism of injury requirements which trigger the notification and aggregation of the trauma team upon entering the emergency department, change during a pandemic and stay-at-home order? (2) How did the proportion of major mechanisms of traumatic injury change during this time period? (3) How did the proportion and absolute numbers of accidental versus nonaccidental traumatic injury in children and adults change during this time period? METHODS: This was a retrospective study of trauma activations at a Level I trauma center in New Orleans, LA, USA, using trauma registry data of all patients presenting to the trauma center from 2017 to 2020. The number of trauma activations during a government mandated coronavirus 2019 (COVID-19) stay-at-home order (from March 20, 2020 to May 14, 2020) was compared with the expected number of activations for the same time period from 2017 to 2019, called "predicted period". The expected number (predicted period) was assumed based on the linear trend of trauma activations seen in the prior 3 years (2017 to 2019) for the same date range (March 20, 2020 to May 14, 2020). To define the total number of traumatic injuries, account for proportion changes, and evaluate fluctuation in accidental verses nonaccidental trauma, variables including type of traumatic injury (blunt, penetrating, and thermal), and mechanism of injury (gunshot wound, fall, knife wound, motor vehicle collision, assault, burns) were collected for each patient. RESULTS: There were fewer total trauma activations during the stay-at-home period than during the predicted period (372 versus 532 [95% CI 77 to 122]; p = 0.016). The proportion of penetrating trauma among total activations was greater during the stay-at-home period than during the predicted period (35% [129 of 372] versus 26% [141 of 532]; p = 0.01), while the proportion of blunt trauma was lower during the stay-at-home period than during the predicted period (63 % [236 of 372] versus 71% [376 of 532]; p = 0.02). The proportion of gunshot wounds in relation to total activations was greater during the stay-at-home period than expected (26% [97 of 372] versus 18% [96 of 532]; p = 0.004). There were fewer motor vehicle collisions in relation to total activations during the stay-at-home period than expected (42% [156 of 372] versus 49% [263 of 532]; p = 0.03). Among total trauma activations, the stay-at-home period had a lower proportion of accidental injuries than the predicted period (55% [203 of 372] versus 61% [326 of 532]; p = 0.05), and there was a greater proportion of nonaccidental injuries than the predicted period (37% [137 of 372] versus 27% [143 of 532]; p < 0.001). In adults, the stay-at-home period had a greater proportion of nonaccidental injuries than the predicted period (38% [123 of 328] versus 26% [123 of 466]; p < 0.001). There was no difference between the stay-at-home period and predicted period in nonaccidental and accidental injuries among children. CONCLUSION: Data from the trauma registry at our region's only Level I trauma center indicate that a stay-at-home order during the COVID-19 pandemic was associated with a 70% reduction in the number of traumatic injuries, and the types of injuries shifted from more accidental blunt trauma to more nonaccidental penetrating trauma. Non-accidental trauma, including gunshot wounds, increased during this period, which suggest community awareness, crisis de-escalation strategies, and programs need to be created to address violence in the community. Understanding these changes allows for adjustments in staffing schedules. Surgeons and trauma teams could allow for longer shifts between changeover, decreasing viral exposure because the volume of work would be lower. Understanding the shift in injury could also lead to a change in specialists covering call. With the often limited availability of orthopaedic trauma-trained surgeons who can perform life-saving pelvis and acetabular surgery, this data may be used to mitigate exposure of these surgeons during pandemic situations. LEVEL OF EVIDENCE: Level III, therapeutic study.

Superposition of COVID-19 waves, anticipating a sustained wave, and lessons for the future.

The 2019 coronavirus (COVID-19), also known as SARS-CoV-2, is highly pathogenic and virulent, and it spreads very quickly through human-to-human contact. In response to the growing number of cases, governments across the spectrum of affected countries have adopted different strategies in implementing control measures, in a hope to reduce the number of new cases. However, 5 months after the first confirmed case, countries like the United States of America (US) seems to be heading towards a trajectory that indicates a health care crisis. This is in stark contrast to the downward trajectory in Europe, China, and elsewhere in Asia, where the number of new cases has seen a decline ahead of an anticipated second wave. A data-driven approach reveals three key strategies in tackling COVID-19. Our work here has definitively evaluated these strategies and serves as a warning to the US, and more importantly, a guide for tackling future pandemics. Also see the video abstract here https://youtu.be/gPkCi2_7tWo.

Evolving Impact of COVID-19 on Transplant Center Practices and Policies in the United States.

In our first survey of transplant centers in March 2020, >75% of kidney and liver programs were either suspended or operating under restrictions. To safely resume transplantation, we must understand the evolving impact of COVID-19 on transplant recipients and center-level practices. We therefore conducted a six-week follow-up survey May 7-15, 2020, and linked responses to the COVID-19 incidence map, with a response rate of 84%. Suspension of live donor transplantation decreased from 72% in March to 30% in May for kidneys and from 68% to 52% for livers. Restrictions/suspension of deceased donor transplantation decreased from 84% to 58% for kidneys and from 73% to 42% for livers. Resuming transplantation at normal capacity was envisioned by 83% of programs by August 2020. Exclusively using local recovery teams for deceased donor procurement was reported by 28%. Respondents reported caring for a total of 1166 COVID-19-positive transplant recipients; 25% were critically ill. Telemedicine challenges were reported by 81%. There was a lack of consensus regarding management of potential living donors or candidates with SARS-CoV-2. Our findings demonstrate persistent heterogeneity in center-level response to COVID-19 even as transplant activity resumes, making ongoing national data collection and real-time analysis critical to inform best practices.

Evaluation of endoscopy requests in the resumption of activity during the SARS-CoV-2 pandemic: denial of nonindicated requests and prioritization of accepted requests.

INTRODUCTION: the global SARS-CoV-2 pandemic forced the closure of endoscopy units. Before resuming endoscopic activity, we designed a protocol to evaluate gastroscopies and colonoscopies cancelled during the pandemic, denying inappropriate requests and prioritizing appropriate ones. METHODS: two types of inappropriate request were established: a) COVID-19 context, people aged ≤ 50 years without alarm symptoms and a low probability of relevant endoscopic findings; and b) inappropriate context, requests not in line with clinical guidelines or protocols. Denials were filed in the medical record. Appropriate requests were classified into priority, conventional and follow-up. Requests denied by specialty were compared and the findings of priority requests were evaluated. RESULTS: between March 16th and June 30th 2020, 1,658 requests (44 % gastroscopies and 56 % colonoscopies) were evaluated, of which 1,164 (70 %) were considered as appropriate (priority 8.5 %, conventional 48 %, follow-up 43 % and non-evaluable 0.5 %) and 494 (30 %) as inappropriate (20 % COVID-19 context, 80 % inappropriate context). The reasons for denial of gastroscopy were follow-up of lesions (33 %), insufficiently studied symptoms (20 %) and relapsing symptoms after a previous gastroscopy (18 %). The reasons for denial of colonoscopies were post-polypectomy surveillance (25 %), colorectal cancer after surgery (21 %) and a family history of cancer (13 %). There were significant differences in denied requests according to specialty: General Surgery (52 %), Hematology (37 %) and Primary Care (29 %); 31 % of priority cases showed relevant findings. CONCLUSIONS: according to our study, 24 % of endoscopies were discordant with scientific recommendations. Therefore, their denial and the prioritization of appropriate ones optimize the use of resources.

The impact of coronavirus disease 2019 on the practice of thoracic oncology surgery: a survey of members of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: There is widespread acknowledgement that coronavirus disease 2019 (COVID-19) has disrupted surgical services. The European Society of Thoracic Surgeons (ESTS) sent out a survey to assess what impact the COVID-19 pandemic has had on the practice of thoracic oncology surgery. METHODS: All ESTS members were invited (13-20 April 2020) to complete an online questionnaire of 26 questions, designed by the ESTS learning affairs committee. RESULTS: The response rate was 23.0% and the completeness rate was 91.2%. The number of treated COVID-positive cases per hospital varied from fewer than 20 cases (30.6%) to more than 200 cases (22.7%) per hospital. Most hospitals (89.1%) postponed surgical procedures. All hospitals performed patient screening with a nasopharyngeal swab, but only 6.7% routinely tested health care workers. A total of 20% of respondents reported that multidisciplinary meetings were completely cancelled and 66%, that multidisciplinary decisions were not different from normal practice. Trends were recognized in prioritizing surgical patients based on age (younger than 70), type of surgery (lobectomy or less), size of tumour (T1-2) and lymph node involvement (N1). Sixty-three percent of respondents reported that surgeons were involved in daily care of COVID-19-positive patients. Fifty-three percent mentioned that full personal protective equipment was available to them when treating a COVID-19-positive patient. CONCLUSIONS: The COVID-19 pandemic has created issues for the safety of health care workers, and surgeons have been forced to change their routine practice. However, there was no consensus about surgical priorities in lung cancer patients, demonstrating the need for the production of specific guidelines.

Pediatric transplantation in Europe during the COVID-19 pandemic: Early impact on activity and healthcare.

The current pandemic SARS-CoV-2 has required an unusual allocation of resources that can negatively impact chronically ill patients and high-complexity procedures. Across the European Reference Network on Pediatric Transplantation (ERN TransplantChild), we conducted a survey to investigate the impact of the COVID-19 outbreak on pediatric transplant activity and healthcare practices in both solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT). The replies of 30 professionals from 18 centers in Europe were collected. Twelve of 18 centers (67%) showed a reduction in their usual transplant activity. Additionally, outpatient visits have been modified and restricted to selected ones, and the use of telemedicine tools has increased. Additionally, a total of 14 COVID-19 pediatric transplanted patients were identified at the time of the survey, including eight transplant recipients and six candidates for transplantation. Only two moderate-severe cases were reported, both in HSCT setting. These survey results demonstrate the limitations in healthcare resources for pediatric transplantation patients during early stages of this pandemic. COVID-19 disease is a major worldwide challenge for the field of pediatric transplantation, where there will be a need for systematic data collection, encouraging regular discussions to address the long-term consequences for pediatric transplantation candidates, recipients, and their families.

Not just little adults: preparing a children's emergency department for COVID-19.

COVID-19 presented unique challenges in preparing our stand-alone children's emergency department for the pandemic and has demonstrated well the paediatric adage, 'children aren't little adults'.

Current precautions and future directions in lung transplantation during the COVID-19 pandemic - a single center cohort study.

The unprecedented public health emergency caused by the acute viral respiratory coronavirus disease (COVID-19) has drastically changed current practices in solid organ transplantation, markedly so for transplantation of the lungs, the major target of the virus. Although national and state authorities do not recommend postponing transplant procedures, most specialists are reluctant to proceed due to substantial uncertainty and increased risks in the midst of the pandemic. There is an urgent need for evidence-based directions to move forward. Here, we offer our insights as specialists at a high-volume center located in a geographical area with high infection rates.

Robotic surgery during the COVID pandemic: why now and why for the future.

Health care has changed in unprecedented ways since the first reported cases of COVID-19. With global case rates continuing to rise and government restrictions beginning to loosen, many worry that a second wave in our future. In many hospitals around the world, non-emergent surgeries were put on hold as hospitals were transformed into COVID centers. As surgeons and administrators do their best to reinstate non-emergent procedures, guidance is sought from any and all reliable sources. Robotic surgery has many known and demonstrated benefits over open surgery and often over conventional laparoscopy. In this commentary, we aim to highlight some of the advantages robotic surgery may offer during this uniquely challenging time in health care.

CAR T-cell treatment during the COVID-19 pandemic: Management strategies and challenges.

The pandemic of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is spreading rapidly across the world. Currently, the COVID-19 pandemic is affecting the continuity of essential routine healthcare services and procedures, including chimeric antigen receptor T-cell (CAR-T) therapy, a life-saving option for patients with relapsed/refractory (R/R) hematologic malignancies. Due to the rapid disease progression of hematological malignancies, there is an urgent need to manufacture and utilize CAR T-cells. However, CAR-T treatment has become extraordinarily challenging during this COVID-19 pandemic. Thus, many medical and technical factors must now be taken into consideration before, during, and after CAR-T therapy. The purpose of this review is to provide brief suggestions for rational decision-making strategies in evaluating and selecting CAR T-cell treatment and appropriate CAR T-cell products, and protective strategies for medical staff and patients to prevent infection in the midst of the current COVID-19 pandemic.

Change in practice in gynecologic oncology during the COVID-19 pandemic: a social media survey.

OBJECTIVE: COVID-19 has affected gynecologic cancer management. The goal of this survey was to evaluate changes that occurred in gynecologic oncology practice during the COVID-19 pandemic. METHODS: A anonymous survey consisting of 33 questions (https://sites.google.com/view/gyncacovidfmartinelli) regarding interaction between gynecologic cancers and COVID-19 was distributed online via social media from April 9 to April 30, 2020. Basic descriptive statistics were applied. Analytics of survey-diffusion and generated-interest (visualizations, engagement rates, response rate) were analyzed. RESULTS: The survey received 20 836 visualizations, generating an average engagement rates by reach of 4.7%. The response rate was 30%. A total of 86% of respondents completed the survey, for a total of 187 physicians surveyed across 49 countries. The majority (143/187; 76%) were gynecologic oncologists, and most were ≤50 years old (146/187; 78%). A total of 49.7% (93/187) were facing the early phase of the COVID-19 pandemic, while 26.7% (50/187) and 23.5% (44/187) were in the peak and plateau phases, respectively. For 97.3% (182/187) of respondents COVID-19 affected or changed their respective clinical practice. Between 16% (27/165) (before surgery) and 25% (26/102) (before medical treatment) did not perform any tests to rule out COVID-19 infection among patients. The majority of respondents did not alter indications of treatment if patients were COVID-19-negative, while treatments were generally postponed in COVID-19-positive patients. Treatments were considered priority for: early stage high-risk uterine cancers (85/187; 45%), newly diagnosed epithelial ovarian cancer (76/187; 41%), and locally advanced cervical cancer (76/187; 41%). Treatment of early stage low-grade endometrioid endometrial cancer was deferred according to 49% (91/187) of respondents, with hormonal treatment as the option of therapy (31%; 56/178). A total of 77% (136/177) of respondents reported no changes in (surgical) treatment for early stage cervical cancer in COVID-19-negative patients, while treatment was postponed by 54% (96/177) of respondent, if the patient tested COVID-19-positive. Neoadjuvant chemotherapy for advanced ovarian cancers was considered by over one-third of respondents as well as hypofractionation of radiation treatment for locally advanced cervical cancers. CONCLUSION: COVID-19 affected the treatment of gynecologic cancers patients, both in terms of prioritization and identification of strategies to reduce hospital access and length of stay. Social media is a reliable tool to perform fast-tracking, worldwide surveys.

A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group.

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread globally since being identified as a public health emergency of major international concern and has now been declared a pandemic by the World Health Organization (WHO). In December 2019, an outbreak of atypical pneumonia, known as COVID-19, was identified in Wuhan, China. The newly identified zoonotic coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is characterized by rapid human-to-human transmission. Many cancer patients frequently visit the hospital for treatment and disease surveillance. They may be immunocompromised due to the underlying malignancy or anticancer therapy and are at higher risk of developing infections. Several factors increase the risk of infection, and cancer patients commonly have multiple risk factors. Cancer patients appear to have an estimated twofold increased risk of contracting SARS-CoV-2 than the general population. With the WHO declaring the novel coronavirus outbreak a pandemic, there is an urgent need to address the impact of such a pandemic on cancer patients. This include changes to resource allocation, clinical care, and the consent process during a pandemic. Currently and due to limited data, there are no international guidelines to address the management of cancer patients in any infectious pandemic. In this review, the potential challenges associated with managing cancer patients during the COVID-19 infection pandemic will be addressed, with suggestions of some practical approaches. IMPLICATIONS FOR PRACTICE: The main management strategies for treating cancer patients during the COVID-19 epidemic include clear communication and education about hand hygiene, infection control measures, high-risk exposure, and the signs and symptoms of COVID-19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case-by-case basis. Minimizing outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure. More research is needed to better understand SARS-CoV-2 virology and epidemiology.