Prevention of COVID-19 in Thoracic Surgery Patients: Lessons Learned during the First Pandemic Wave.

BACKGROUND: The aim of this retrospective study was to investigate the implementation of measures to prevent perioperative COVID-19 in thoracic surgery during the first wave of the COVID-19 pandemic 2020 allowing a continued surgical treatment of patients. METHODS: The implemented preventive measures in patient management of the thoracic surgery department of the Asklepios Lung Clinic Munich-Gauting, Germany were retrospectively analyzed. Postoperative COVID-19 incidence before and after implementation of preventive measures was investigated. Patients admitted for thoracic surgical procedures between March and May 2020 were included in the study. Patient characteristics were analyzed. For the early detection of putative postoperative COVID-19 symptoms, typical post-discharge symptomatology of thoracic surgery patients was compared to non-surgical patients hospitalized for COVID-19. RESULTS: Thirty-five surgical procedures and fifty-seven surgical procedures were performed before and after implementation of the preventive measures, respectively. Three patients undergoing thoracic surgery before implementation of preventive measures developed a COVID-19 pneumonia post-discharge. After implementation of preventive measures, no postoperative COVID-19 cases were identified. Fever, dyspnea, dry cough and diarrhea were significantly more prevalent in COVID-19 patients compared to normally recovering thoracic surgery patients, while anosmia, phlegm, low energy levels, body ache and nausea were similarly frequent in both groups. CONCLUSIONS: Based on the lessons learned during the first pandemic wave, we here provide a blueprint for successful easily implementable preventive measures minimizing SARS-CoV-2 transmission to thoracic surgery patients perioperatively. While symptoms of COVID-19 and the normal postoperative course of thoracic surgery patients substantially overlap, we found dyspnea, fever, cough, and diarrhea significantly more prevalent in COVID-19 patients than in normally recovering thoracic surgery patients. These symptoms should trigger further diagnostic testing for postoperative COVID-19 in thoracic surgery patients.

Development of atopic sensitization in Finnish and Estonian children: A latent class analysis in a multicenter cohort.

BACKGROUND: The prevalence of atopy is associated with a Western lifestyle, as shown by studies comparing neighboring regions with different socioeconomic backgrounds. Atopy might reflect various conditions differing in their susceptibility to environmental factors. OBJECTIVE: We sought to define phenotypes of atopic sensitization in early childhood and examine their association with allergic diseases and hereditary background in Finland and Estonia. METHODS: The analysis included 1603 Finnish and 1657 Estonian children from the DIABIMMUNE multicenter young children cohort. Specific IgE levels were measured at age 3, 4, and 5 years, respectively, and categorized into 3 CAP classes. Latent class analysis was performed with the statistical software package poLCA in R software. RESULTS: Both populations differed in terms of socioeconomic status and environmental determinants, such as pet ownership, farm-related exposure, time spent playing outdoors, and prevalence of allergic diseases (all P < .001). Nevertheless, we found similar latent classes in both populations: an unsensitized class, a food class, 2 inhalant classes differentiating between seasonal and perennial aeroallergens, and a severe atopy class. The latter was characterized by high total and specific IgE levels and strongly associated with wheeze (odds ratio [OR], 5.64 [95% CI, 3.07-10.52] and 4.56 [95% CI, 2.35-8.52]), allergic rhinitis (OR, 22.4 [95% CI, 11.67-44.54] and 13.97 [95% CI, 7.33-26.4]), and atopic eczema (OR, 9.39 [95% CI, 4.9-19.3] and 9.5 [95% CI, 5.2-17.5] for Finland and Estonia, respectively). Environmental differences were reflected in the larger seasonal inhalant atopy class in Finland, although composition of classes was comparable between countries. CONCLUSION: Despite profound differences in environmental exposures, there might exist genuine patterns of atopic sensitization. The distribution of these patterns might determine the contribution of atopic sensitization to disease onset.

[Overview of the Organization of the Emergency Medical Service in Germany: What is the Basis for the Hospital Restructuring Act and the Supply Enhancement Act?] / Übersicht über die Organisation des vertragsärztlichen Bereitschaftsdienstes in Deutschland: Auf welche Basis bauen Krankenhausstrukturgesetz und Versorgungsstärkungsgesetz auf?

In response to the increased use of emergency rooms, the increasing cost pressure on hospitals and the growing difficulty of filling emergency services in structurally weaker areas, the introduction of central practices (Portalpraxen) has been decided at federal level. Several Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen (KVen)) have already started to transform the medical on-call service before this legislative change and are now at different stages of the reform process. At many hospitals there are already so-called standby duty clinics (BDP). For the assessment of the current reform status as the basis for the Hospital Structure Act and the Nursing Reform Act, the present study aims to provide an overview of the organizational forms of the on-call medical service in the respective districts of the Associations of Statutory Health Insurance Physicians. METHODS: All 17 KV districts were contacted by telephone and/or in writing in order to conduct a semi-structured interview along 3 dimensions: the general organizational structure, the personnel (above all physicians) and the supply mandate. KV Brandenburg, KV Hamburg and KV Nordrhein (subsidiary Gesundheitsmanagementgesellschaft mbH) completed the questionnaire. RESULTS: In the districts of Hesse, Schleswig-Holstein, Thuringia and Westphalia-Lippe, at the time of the 2017 survey, the out-of-hour service was exclusively organised in emergency service practices. Baden-Wuerttemberg, Lower Saxony, North Rhine, Rhineland-Palatinate and Saarland have extensively introduced emergency service practices. However, the traditional service remains present in some regions. There are huge organisational differences between metropolitan and rural areas reflecting various challenges: Bavaria, Brandenburg and Mecklenburg-Western Pomerania only established emergency service practices in major cities due to economic considerations. CONCLUSION: Emergency service practices provide a way to address the challenges of physician shortage and patient control. With their flexibility regarding the organization, they are adaptable to regional differences and are already playing a major role in assuring out-of-hour medical service in Germany.

Predicting the effectiveness of high-flow oxygen therapy in COVID-19 patients: a single-centre observational study.

BACKGROUND: High-flow nasal cannula (HFNC) therapy is a helpful tool in the treatment of hypoxaemic respiratory failure. However, the clinical parameters predicting the effectiveness of HFNC in coronavirus-19 disease (COVID-19) patients remain unclear. METHODS: Sixteen COVID-19 patients undergoing HFNC in the Asklepios Lung Clinic Munich-Gauting, Germany between 16 March and 3 June 2020 were retrospectively included into the study. Seven patients successfully recovered after HFNC (Group 1), while 9 patients required intubation upon HFNC failure (Group 2). Relevant predictors for an effective HFNC therapy were analysed on day 0 and 4 after HFNC initiation via receiver operating characteristics. RESULTS: The groups did not differ significantly in terms of age, sex, body mass index, and comorbidities. Five patients died in Group 2 upon disease progression and HFNC failure. Group 1 required a lower oxygen supplementation (FiO2 0.46 [0.31-0.54] vs. 0.72 [0.54-0.76], P = 0.022) and displayed a higher PaO2/FiO2 ratio (115 [111-201] vs. 93.3 [67.2-145], P = 0.042) on day 0. In Group 2, fever persisted on day 4 (38.5 [38.0-39.4]°C vs. 36.5 [31.1-37.1]°C, P = 0.010). Serum C-reactive protein (CRP) levels > 108 mg L-1 (day 0) and persistent oxygen saturation < 89% and PaO2/FiO2 ratio < 91 (day 4) were identified as significant predictors for HFNC failure (area under curve 0.929, 0.933, and 0.893). CONCLUSIONS: Elevated oxygen saturation, decreased FiO2 and reduced serum CRP on day 4 significantly predict HFNC effectiveness in COVID-19 patients. Based on these parameters, larger prospective studies are necessary to further investigate the effectiveness of HFNC in the treatment of COVID-19-associated hypoxaemic respiratory failure.

Statistical literacy and scientific reasoning & argumentation in physicians.

Objective: Statistical literacy (SL) of physicians, i.e. the ability to use and interpret statistical numbers in the context of science, is an essential prerequisite for risk estimation and communication. Together with scientific reasoning and argumentation (SRA) skills, SL provides the basis for evidence-based practice. Several studies suggest that in medical students both skills are underdeveloped. The aim of the present study was to investigate these skills in practicing physicians and how these skills were acquired. Methods: Data collection in N=71 physicians was conducted online and as paper pencil. SL was assessed with multiple-choice items. SRA skills evidence evaluation and drawing conclusions were measured with a decision scenario. Results: Study results indicated that physicians have medium levels of SL (M=17.58, SD=6.92, max 30 pts.) and SRA (evidence evaluation: M=7.75, SD=1.85, max 10 pts.; drawing conclusions: M=37.20, SD=5.35, max 60 pts.). Skills development via autodidactic learning activities (M=4.78, SD=1.13, range 1-6) was reported significantly more often than development during formal medical education (M=2.31, SD=1.46), t(71)=-9.915, p<.001, or in extracurricular activities (M=3.34, SD=1.87), t(71)=4.673, p<.001. The active involvement in research seemed decisive: The number of publications and time spent in research significantly correlated with SL, r(71)=.355, p=.002; respectively r(71)=.280, p=.018. SRA skills were predicted by the type of MD-thesis, ß=-.380, p=.016, and working in research, ß=3.355, p=.008. Conclusion: Active involvement in research activities seems to be a very important factor for the development of both SL and SRA skills. The implementation of systematic fostering of these skills during formal medical education seems warranted.

Thinking outside the box: students positive about visionary elective curricula in medical school.

Objective: Space for personality development as well as for the development of critical, creative and interdisciplinary thinking is rarely found in medical curricula in Germany. To be prepared for the challenges of modern medicine, future physicians need a visionary mindset. The aim of this study is to determine the need for teaching such content among medical students in the context of visionary elective curricula and to examine these with regard to the desired topics and organizational structure. Methods: This is a cross-sectional study with 236 medical students from all semesters of the Ludwig-Maximilians-University Munich. The survey consists of 50 questions and includes single choice, multiple choice, matrix questions, open-ended questions and Likert scales. Responses were examined using descriptive statistics and compared parametrically in sub-aspects. Results: Three-quarters of respondents would like to see curricular content on interdisciplinary interfaces with other disciplines. A suitable framework for this is seen by 87% of the respondents in a visionary elective curriculum. Students would like to see a broad range of specific content such as global health, politics, business, and computer science. The majority of respondents would like to see 1 unit of instruction per week and would participate in an appropriate program. Such an offering would promote creative (53.6%), critical (63.7%), and interdisciplinary thinking (69.0%) and train to become better physicians (87%). Conclusion: Participants in this study are positive toward the introduction of visionary content in medical school. Faculties should build visionary elective curricula according to the graduate profile requirements of the new NKLM 2.0 to make medical education sustainable.

Tackling the Waves of COVID-19: A Planning Model for Intrahospital Resource Allocation.

Background: The current pandemic requires hospitals to ensure care not only for the growing number of COVID-19 patients but also regular patients. Hospital resources must be allocated accordingly. Objective: To provide hospitals with a planning model to optimally allocate resources to intensive care units given a certain incidence of COVID-19 cases. Methods: The analysis included 334 cases from four adjacent counties south-west of Munich. From length of stay and type of ward [general ward (NOR), intensive care unit (ICU)] probabilities of case numbers within a hospital at a certain time point were derived. The epidemiological situation was simulated by the effective reproduction number R, the infection rates in mid-August 2020 in the counties, and the German hospitalization rate. Simulation results are compared with real data from 2nd and 3rd wave (September 2020-May 2021). Results: With R = 2, a hospitalization rate of 17%, mitigation measures implemented on day 9 (i.e., 7-day incidence surpassing 50/100,000), the peak occupancy was reached on day 22 (155.1 beds) for the normal ward and on day 25 (44.9 beds) for the intensive care unit. A higher R led to higher occupancy rates. Simulated number of infections and intensive care unit occupancy was concordant in validation with real data obtained from the 2nd and 3rd waves in Germany. Conclusion: Hospitals could expect a peak occupancy of normal ward and intensive care unit within ~5-11 days after infections reached their peak and critical resources could be allocated accordingly. This delay (in particular for the peak of intensive care unit occupancy) might give options for timely preparation of additional intensive care unit resources.

Automated quantitative thin slice volumetric low dose CT analysis predicts disease severity in COVID-19 patients.

PURPOSE: This study aimed to identify predictive (bio-)markers for COVID-19 severity derived from automated quantitative thin slice low dose volumetric CT analysis, clinical chemistry and lung function testing. METHODS: Seventy-four COVID-19 patients admitted between March 16th and June 3rd 2020 to the Asklepios Lung Clinic Munich-Gauting, Germany, were included in the study. Patients were categorized in a non-severe group including patients hospitalized on general wards only and in a severe group including patients requiring intensive care treatment. Fully automated quantification of CT scans was performed via IMBIO CT Lung Texture analysis™ software. Predictive biomarkers were assessed with receiver-operator-curve and likelihood analysis. RESULTS: Fifty-five patients (44% female) presented with non-severe COVID-19 and 19 patients (32% female) with severe disease. Five fatalities were reported in the severe group. Accurate automated CT analysis was possible with 61 CTs (82%). Disease severity was linked to lower residual normal lung (72.5% vs 87%, p = 0.003), increased ground glass opacities (GGO) (8% vs 5%, p = 0.031) and increased reticular pattern (8% vs 2%, p = 0.025). Disease severity was associated with advanced age (76 vs 59 years, p = 0.001) and elevated serum C-reactive protein (CRP, 92.2 vs 36.3 mg/L, p < 0.001), lactate dehydrogenase (LDH, 485 vs 268 IU/L, p < 0.001) and oxygen supplementation (p < 0.001) upon admission. Predictive risk factors for the development of severe COVID-19 were oxygen supplementation, LDH >313 IU/L, CRP >71 mg/L, <70% normal lung texture, >12.5% GGO and >4.5% reticular pattern. CONCLUSION: Automated low dose CT analysis upon admission might be a useful tool to predict COVID-19 severity in patients.