Atypical age distribution and high disease severity in children with RSV infections during two irregular epidemic seasons throughout the COVID-19 pandemic, Germany, 2021 to 2023.

BackgroundNon-pharmaceutical interventions (NPIs) during the COVID-19 pandemic affected respiratory syncytial virus (RSV) circulation worldwide.AimTo describe, for children aged < 5 years, the 2021 and 2022/23 RSV seasons in Germany.MethodsThrough data and 16,754 specimens from outpatient sentinel surveillance, we investigated RSV seasonality, circulating lineages, and affected children's age distributions in 2021 and 2022/23. Available information about disease severity from hospital surveillance was analysed for patients with RSV-specific diagnosis codes (n = 13,104). Differences between RSV seasons were assessed by chi-squared test and age distributions trends by Mann-Kendall test.ResultsRSV seasonality was irregular in 2021 (weeks 35-50) and 2022/23 (weeks 41-3) compared to pre-COVID-19 2011/12-2019/20 seasons (median weeks 51-12). RSV positivity rates (RSV-PR) were higher in 2021 (40% (522/1,291); p < 0.001) and 2022/23 (30% (299/990); p = 0.005) than in prior seasons (26% (1,430/5,511)). Known globally circulating RSV-A (lineages GA2.3.5 and GA2.3.6b) and RSV-B (lineage GB5.0.5a) strains, respectively, dominated in 2021 and 2022/23. In 2021, RSV-PRs were similar in 1 - < 2, 2 - < 3, 3 - < 4, and 4 - < 5-year-olds. RSV hospitalisation incidence in 2021 (1,114/100,000, p < 0.001) and in 2022/23 (1,034/100,000, p < 0.001) was approximately double that of previous seasons' average (2014/15-2019/20: 584/100,000). In 2022/23, proportions of RSV patients admitted to intensive care units rose (8.5% (206/2,413)) relative to pre-COVID-19 seasons (6.8% (551/8,114); p = 0.004), as did those needing ventilator support (6.1% (146/2,413) vs 3.8% (310/8,114); p < 0.001).ConclusionsHigh RSV-infection risk in 2-4-year-olds in 2021 and increased disease severity in 2022/23 possibly result from lower baseline population immunity, after NPIs diminished exposure to RSV.

The Outcome of Laparoscopic Versus Open Appendectomy in Childhood.

BACKGROUND: Appendectomy in children is performed either lapa - roscopically (LA) or by open surgery (OA). We studied whether, and how, the outcome is affected by the technique used and by the intraoperative conversion of LA to OA. METHODS: We analyzed routine data from children and adolescents in three age groups (1-5 years, 6-12 years, and 13-17 years) who were insured by the AOK statutory health insurance carrier in Germany and who underwent appendectomy in the period 2017-2019. General surgical complications and reoperations within 90 days were assessed with relevant indicators. Associations between the surgical technique and these indicators were studied with logistic regression. RESULTS: Of the 21 541 patients included in the study, general surgical complications were observed in 2.1% and reoperations in 1.8% overall. Broken down by age group, the corresponding figures were 5.4% and 4.4% (age 1 to 5), 2.5% and 1.8% (age 6 to 12), and 1.5% and 1.6% (age 13 to 17). The main risk factors for complications and reoperations were acute complicated appendicitis and conversion from LA to OA. Regression analysis revealed similar outcomes with OA compared to LA in the 1-to-5 age group, (odds ratios and 95% confidence intervals: 1.1 [0.6; 2.1] for general surgical complications and 1.5 [0.8; 2.7] for reoperations), but worse outcomes with OA in the other two age groups (age 6 to 12: 1.9 [1.2; 2.9] and 2.1 [1.5; 2.9]; age 13 to 17: 1.7 [1.0; 2.9] and 2.2 [1.4; 3.6]). When conversions were assigned to the LA group, the odds ratio (OA compared to LA) for reoperation across all age groups was 3.5 [2.8; 4.4] in patients with acute uncomplicated appendicitis and 4.2 [3.4; 5.3] in patients with complicated appendicitis. Complicated appendicitis also increased the rate of general surgical complications and the length of stay in hospital. CONCLUSION: Among children in the two older age groups, LA was followed by fewer general surgical complications and reoperations than OA. These differences were less pronounced when conversions were counted as belonging to the LA group. Children aged 1-5 appear to benefit the least from the lapa - roscopic technique.

Characteristics and outcomes of COVID-19 patients during B.1.1.529 (Omicron) dominance compared to B.1.617.2 (Delta) in 89 German hospitals.

BACKGROUND: The SARS-CoV-2 variant B.1.1.529 (Omicron) was first described in November 2021 and became the dominant variant worldwide. Existing data suggests a reduced disease severity with Omicron infections in comparison to B.1.617.2 (Delta). Differences in characteristics and in-hospital outcomes of COVID-19 patients in Germany during the Omicron period compared to Delta are not thoroughly studied. ICD-10-code-based severe acute respiratory infections (SARI) surveillance represents an integral part of infectious disease control in Germany. METHODS: Administrative data from 89 German Helios hospitals was retrospectively analysed. Laboratory-confirmed SARS-CoV-2 infections were identified by ICD-10-code U07.1 and SARI cases by ICD-10-codes J09-J22. COVID-19 cases were stratified by concomitant SARI. A nine-week observational period between December 6, 2021 and February 6, 2022 was defined and divided into three phases with respect to the dominating virus variant (Delta, Delta to Omicron transition, Omicron). Regression analyses adjusted for age, gender and Elixhauser comorbidities were applied to assess in-hospital patient outcomes. RESULTS: A total cohort of 4,494 inpatients was analysed. Patients in the Omicron dominance period were younger (mean age 47.8 vs. 61.6; p < 0.01), more likely to be female (54.7% vs. 47.5%; p < 0.01) and characterized by a lower comorbidity burden (mean Elixhauser comorbidity index 5.4 vs. 8.2; p < 0.01). Comparing Delta and Omicron periods, patients were at significantly lower risk for intensive care treatment (adjusted odds ratio 0.72 [0.57-0.91]; p = 0.005), mechanical ventilation (adjusted odds ratio 0.42 [0.31-0.57]; p < 0.001), and in-hospital mortality (adjusted odds ratio 0.42 [0.32-0.56]; p < 0.001). This also applied mostly to the separate COVID-SARI group. During the Delta to Omicron transition, case numbers of COVID-19 without SARI exceeded COVID-SARI for the first time in the pandemic's course. CONCLUSION: Patient characteristics and outcomes differ during the Omicron dominance period as compared to Delta suggesting a reduced disease severity with Omicron infections. SARI surveillance might play a crucial role in assessing disease severity of future SARS-CoV-2 variants.

[The different periods of COVID-19 in Germany: a descriptive analysis from January 2020 to February 2021]. / Die verschiedenen Phasen der COVID-19-Pandemie in Deutschland: Eine deskriptive Analyse von Januar 2020 bis Februar 2021.

The first case of coronavirus SARS-CoV­2 infection in Germany was diagnosed on 27 January 2020. To describe the pandemic course in 2020, we regarded four epidemiologically different periods and used data on COVID-19 cases from the mandatory reporting system as well as hospitalized COVID-19 cases with severe acute respiratory infection from the syndromic hospital surveillance.Period 0 covers weeks 5 to 9 of 2020, where mainly sporadic cases of younger age were observed and few regional outbreaks emerged. In total, 167 cases with mostly mild outcomes were reported. Subsequently, the first COVID-19 wave occurred in period 1 (weeks 10 to 20 of 2020) with a total of 175,013 cases throughout Germany. Increasingly, outbreaks in hospitals and nursing homes were registered. Moreover, elderly cases and severe outcomes were observed more frequently. Period 2 (weeks 21 to 39 of 2020) was an interim period with more mild cases, where many cases were younger and often travel-associated. Additionally, larger trans-regional outbreaks in business settings were reported. Among the 111,790 cases, severe outcomes were less frequent than in period 1. In period 3 (week 40 of 2020 to week 8 of 2021), the second COVID-19 wave started and peaked at the end of 2020. With 2,158,013 reported cases and considerably more severe outcomes in all age groups, the second wave was substantially stronger than the first wave.Irrespective of the different periods, more elderly persons and more men were affected by severe outcomes.

Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals.

BACKGROUND: Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents. MATERIALS AND METHODS: Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression. RESULTS: Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66). CONCLUSIONS: PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.

Influenza-associated pneumonia as reference to assess seriousness of coronavirus disease (COVID-19).

Information on severity of coronavirus disease (COVID-19) (transmissibility, disease seriousness, impact) is crucial for preparation of healthcare sectors. We present a simple approach to assess disease seriousness, creating a reference cohort of pneumonia patients from sentinel hospitals. First comparisons exposed a higher rate of COVID-19 patients requiring ventilation. There were more case fatalities among COVID-19 patients without comorbidities than in the reference cohort. Hospitals should prepare for high utilisation of ventilation and intensive care resources.

Risk factors for hospitalized respiratory syncytial virus disease and its severe outcomes.

INTRODUCTION: Respiratory syncytial virus (RSV) is a major cause of hospital admission for acute lower respiratory tract infection in young children. OBJECTIVES: We aimed to identify risk factors for hospitalized RSV disease and its severe outcomes. METHODS: We conducted a retrospective cohort study analyzing data of a ICD-10-code-based hospital surveillance for severe acute respiratory infections (SARI). Using univariable and multivariable logistic regression analysis, we assessed age-group, gender, season, and underlying medical conditions as possible risk factors for RSV and its severe outcomes including ICU admission, application of ventilator support, and death, respectively. RESULTS: Of the 413 552 patients hospitalized with SARI in the database, 8761 were diagnosed with RSV from week 01/2009 to 20/2018 with 97% (8521) aged <5 years. Among children aged <5 years, age-groups 0-5 months (OR: 20.29, 95% CI: 18.37-22.41) and 6 months-1 year (OR: 4.59, 95% CI: 4.16-5.06), and underlying respiratory and cardiovascular disorders specific to the perinatal period (OR: 1.32, 95% CI: 1.11-1.57) were risk factors for being diagnosed with RSV. Age-group 0-5 months (OR: 2.39, 95% CI: 1.45-3.94), low birth weight (OR: 6.77, 95% CI: 1.28-35.71), preterm newborn (OR: 6.71, 95% CI: 2.19-20.61), underlying respiratory and cardiovascular disorders specific to the perinatal period (OR: 4.97, 95% CI: 3.36-7.34), congenital malformation of the heart (OR: 3.65, 95% CI: 1.90-7.02), congenital malformation of the great vessels (OR: 3.50, 95% CI: 1.10-11.18), congenital defect originating in perinatal period (OR: 4.07, 95% CI: 1.71-9.70), cardiovascular disease (OR: 5.19, 95% CI: 2.77-9.72), neurological disorders (OR: 6.48, 95% CI: 3.76-11.18), blood disease (OR: 3.67, 95% CI: 1.98-6.79), and liver disease (OR: 14.99, 95% CI: 1.49-150.82) contributed to ICU admission in RSV cases. CONCLUSIONS: Using ICD-10-based surveillance data allows to identify risk factors for hospitalized RSV disease and its severe outcomes, and quantify the risk in different age-groups.

Evaluation of using ICD-10 code data for respiratory syncytial virus surveillance.

BACKGROUND: Respiratory syncytial virus (RSV) is the most common cause of acute lower respiratory tract infection (ALRI) in young children. ICD-10-based syndromic surveillance can transmit data rapidly in a standardized way. OBJECTIVES: We investigated the use of RSV-specific ICD-10 codes for RSV surveillance. METHODS: We performed a retrospective descriptive data analysis based on existing ICD-10-based surveillance systems for ALRI in primary and secondary care and a linked virological surveillance in Germany. We described RSV epidemiology and compared the epidemiological findings based on ICD-10 and virological data. We calculated sensitivity and specificity of RSV-specific ICD-10 codes and in combination with ICD-10 codes for acute respiratory infections (ARI) for the identification of laboratory-confirmed RSV infections. RESULTS: Based on the ICD-10 and virological data, epidemiology of RSV was described, and common findings were found. The RSV-specific ICD-10 codes had poor sensitivity 6% (95%-CI: 3%-12%) and high specificity 99.8% (95%-CI: 99.6%-99.9%). In children <5 years and in RSV seasons, the sensitivities of RSV-specific ICD-10 codes combined with general ALRI ICD-10 codes J18.-, J20.- and with J12.-, J18.-, J20.-, J21.-, J22 were moderate (44%, 95%-CI: 30%-59%). The specificities of both combinations remained high (91%, 95%-CI: 86%-94%; 90%, 95%-CI: 85%-94%). CONCLUSIONS: The use of RSV-specific ICD-10 codes may be a useful indicator to describe RSV epidemiology. However, RSV-specific ICD-10 codes underestimate the number of actual RSV infections. This can be overcome by combining RSV-specific and general ALRI ICD-10 codes. Further investigations are required to validate this approach in other settings.

[Quality Assurance Using Administrative/Routine Data for Cholelithiasis - Changes Over Time and Current Status]. / Qualitätssicherung mit Routinedaten bei Cholelithiasis ­ Veränderungen und aktueller Stand.

Quality assurance using administrative/routine data (QSR) is a relatively new measure to assess outcome quality. This approach is methodologically distinct from external quality assurance, as well as from quality assurance based upon registries. Since 2011, QSR for cholelithiasis within AOK patients has been overseen by the Scientific Institute of the AOK (WIdO). Following the introduction of an expert panel in 2013, numerous changes were put into place, whereby the indicator rates for transfusion/bleeding, various complications as well as the overall indicator were reduced. Interestingly, the risk adjusted quality differences between hospitals remained solid.

In-hospital mortality of patients with atrial arrhythmias: insights from the German-wide Helios hospital network of 161 502 patients and 34 025 arrhythmia-related procedures.

Aims: Atrial fibrillation (AFib) and atrial flutter (AFlut) are common arrhythmias with increased use of invasive procedures. A steady re-evaluation of relevant safety endpoints is recommended and both quality management and pay-for-performance programs are evolving. Therefore, the aims of this study were (i) to investigate and report overall in-hospital mortality and mortality of invasive arrhythmia-related procedures and (ii) to identify mortality predictors in a German-wide hospital network. Methods and results: Administrative data provided by 78 Helios hospitals between 2010 and 2017 were examined using International Statistical Classification of Diseases and Related Health Problems- and Operations and Procedures-codes to identify patients with AFib or AFlut as main discharge diagnosis or secondary diagnosis combined with invasive arrhythmia-related interventions. In 161 502 patients, in-hospital mortality was 0.6% with a significant decrease from 0.75% to 0.5% (P < 0.01) during the observational period. In multivariable analysis, age [odds ratio (OR) 2.69, 95% confidence interval (CI) 2.36-3.05; P < 0.01], high centre volume (OR 0.57, 95% CI 0.50-0.65; P < 0.01), emergency hospital admission (OR 1.57, 95% CI 1.38-1.79; P < 0.01), and Charlson Comorbidity Index (CCI, OR 4.95, 95% CI 4.50-5.44; P < 0.01) were found as independent predictors of in-hospital mortality. Mortality rates were 0.05% for left atrial catheter ablation (CA, n = 21 744), 0.3% for right atrial CA (n = 9972), and 0.56% for implantation of a left atrial appendage occluder (n = 2309), respectively. Conclusion: We analysed for the first time in-hospital mortality rates of patients with atrial arrhythmias in a German-wide, multi-centre administrative dataset. This allows feasible, comparable, and up-to-date performance measurement of clinically important endpoints in a real-world setting which may contribute to quality management programs and towards value-based healthcare.

Cardiac tamponade in catheter ablation of atrial fibrillation: German-wide analysis of 21 141 procedures in the Helios atrial fibrillation ablation registry (SAFER).

Aims: Catheter ablation is an established therapy in patients with symptomatic atrial fibrillation (AF) with increasing popularity. Pericardial effusion requiring intervention (PE) is one of the most threatening adverse outcomes. The aim of this study was to examine rates of PE after catheter ablation in a large 'real-world' data set in a German-wide hospital network. Methods and results: Using ICD and OPS codes, administrative data of 85 Helios hospitals from 2010 to 2017 was used to identify AF catheter ablation cases [Helios atrial fibrillation ablation registry (SAFER)]. PE occurred in 0.9% of 21 141 catheter ablation procedures. Patients with PE were significantly older, to a higher percentage female, had more frequently hypertension, mild liver disease, diabetes with chronic complications, and renal disease. Low hospital volume (<50 procedures per year) and radiofrequency ablation (vs. cryoablation) were significantly associated with PE. Using two logistic regression models, age, female gender, hypertension, mild liver disease, diabetes with chronic complications, renal disease, low hospital volume, and radiofrequency ablation remained independent predictors for PE. Conclusion: Overall PE rate was 0.9%. Predictors for PE occurrence involved factors ascribed to the patient (age, gender, comorbidities), the type of catheter ablation (radiofrequency), and the institution (low-volume centres).

[Volume Growth of Inpatient Treatments for Spinal Disease - Analysis of German Nationwide Hospital Discharge Data from 2005 to 2014]. / Mengenentwicklung stationärer Behandlungen bei Erkrankungen der Wirbelsäule ­ Analyse der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2014.

BACKGROUND: Marked volume growth of inpatient treatments for spinal disease has been observed since diagnosis related groups (DRG) were introduced as payment for inpatient services in Germany. This study aims to analyse this increase by population and stratified by types of treatment. MATERIAL AND METHODS: Using German nationwide hospital discharge data (DRG statistics), inpatient treatments for spinal disease with or without surgery were identified. Trends in case numbers were analysed from 2005 to 2014 with consideration of demographic changes, in order to explore which age groups and which types of treatment are affected by volume growth. RESULTS: In 2014 (2005), 289 000 (177 000) inpatient treatments with surgery and 463 000 (287 000) treatments without surgery were identified. After adjusting for demographic factors, treatments with and without surgery exhibited a relative volume growth of + 50%. This increase affected higher age groups and women, in particular. Depending on the type of treatment, very different degrees of volume growth were observed. For example, disc surgeries adjusted for demographic change increased by about + 5%, whereas spinal fusion and vertebral replacement surgeries, kypho-/vertebroplasties and decompression of the spine more than doubled. Within the non-surgically treated cases, local pain therapies of the spine increased after adjustment for demographic changes by about + 142%. The conservatively treated cases showed a demographically adjusted increase of + 22%. CONCLUSION: Apart from demographic changes, this analysis cannot resolve the underlying causes of volume growth in treatments for spinal disease. However, the stratified analysis of various subgroups may help to classify these developments in a more differentiated manner. The results may support a more targeted debate about potential over- or misallocation of inpatient services in this area.

Operative management of cryptorchidism: guidelines and reality--a 10-year observational analysis of 3587 cases.

BACKGROUND: Undescended testis (UDT) is the most common disorder in pediatric surgery and one of the most important risk factors for malignancy and subfertility. In 2009 local guidelines were modified and now recommend treatment to be completed by the age of 1. Aim of this study was to analyze age distribution at the time of orchidopexy, whether the procedure is performed according to guideline recommendations and to assess primary care pediatricians' attitude regarding their treatment approach. METHODS: We retrospectively analyzed 3587 patients with UDT regarding age at orchidopexy between 2003 and 2012 in 13 German hospitals. Furthermore, we conducted an anonymized nation-wide survey among primary care pediatricians regarding their attitude toward management of UDT. RESULTS: Before modification of the guideline 78% (n = 1245) of the boys with UDT were not operated according to guideline recommendations. After the modification that number rose to 95% (n = 1472). 42% of the orchidopexies were performed on patients aged 4 to 17 years. 46% of the primary care pediatricians were not aware of this discrepancy and 38% would only initiate operative management after the first year of life. In hospitals with pediatric surgery departments significantly more patients received orchidopexy in their first year of life (p < .001). CONCLUSION: The guideline for UDT in Germany has not yet been implemented sufficiently. Timing of orchidopexy must be optimized in order to improve long-term prognosis. Both primary care providers and parents should be educated regarding the advantages of early orchidopexy in UDT. Prospective studies are needed to elucidate the high rate of late orchidopexies.