tized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.
Background The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. Methods This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. Results During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE=0.24, P <0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS<5) ischemic stroke (P<0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; P=0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (P<0.0001). Conclusion In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.
The rise of the novel coronavirus disease 2019 (COVID-19) caused unprecedented public health responses worldwide. To prevent hospitals from oversaturating, nations are restructuring their healthcare systems to prioritize limited resources and care for the treatment of COVID-19-infected patients. The Italian healthcare system, for example, converted numerous hospital services to Intensive Care Units, redeployed physicians to short-staffed centers, and centralized medical services to a small number of hospitals to meet the pandemic’s demands. While this restructuring served the nation’s short-term healthcare needs, it impeded access to care for non-COVID-19 patients suffering from acute or chronic non-communicable diseases, such as strokes. These patients are at increased risk of long-term disability and poorer adherence to management plans and have an increased likelihood of disease recurrence. This commentary discusses the ethical dilemma surrounding the necessary healthcare restructuring and unintended impairment of care to non-infected patients. It also explores the need for national public health officials to reassess strategies employed during the pandemic and their need to focus on creating ethical frameworks for maximizing equitable care.
Since being declared a global pandemic in March 2020, coronavirus disease 2019 (COVID-19) has infected over 18.6 million individuals, claiming the lives of over 700,000 worldwide. 1,2 The world has not experienced a pandemic of this magnitude since the Spanish Flu of 1918. 3 Thus, national leaders are facing unique challenges in establishing efficient preparedness plans. Moreover, the pandemic has resulted in an unprecedented global health crisis that has burdened national healthcare systems.Many nations are overwhelmed by COVID-19, which has resulted in an oversaturation of intensive care units (ICU), personnel, and resources. 4 As a result, healthcare systems have been reorganized to accommodate the dramatically increasing case numbers. 5,6 Normal day-to-day services, such as elective surgeries, medicine wards, and outpatient clinics have been cancelled or limited to increase the number of available ICU beds. [4][5][6] Despite the reallocation of resources, nations such as Italy remain overwhelmed with new cases. The country is facing shortages of life-saving technology such as ventilators, prompting healthcare professionals to make one of the most difficult choices in medicine: choosing who gets to live, and who has to die. 7 The oversaturation of resources has resulted in a situation where not every patient can be admitted into the ICU and receive life-saving management. 7 Naturally, this creates the conflict of deciding who receives these treatments. In an effort to reduce the dilemma that faces Italian healthcare professionals, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has released guidelines on choosing which ICU patients get ventilators. 8 The document begins by recognizing the moral dilemma that lies ahead for healthcare professionals, likening it to those that arise during wartime. 7,8 The guideline highlights the difficult decisions made by wartime physicians in an effort to properly distribute scarce
During cadaveric dissection of an 84-year-old male, a previously undocumented mixed-type (direct/indirect) inguinal hernia was found within the spermatic cord. Unlike typical indirect hernias, it did not originate from the deep inguinal ring. Instead, the hernia penetrated the abdominal wall medial to the inferior epigastric vessels, through the wall of the spermatic cord, and continued distally into the scrotum within the spermatic cord. The hernia consisted of a peritoneal sac containing compressed omental tissue. This sac protruded through a weakening in the abdominal wall and into the spermatic cord, but not beyond the superficial ring. The hernia observed presents with characteristics of both direct and indirect inguinal hernias. Consequently, it cannot be classified in the traditional way. This appears to be the first reported instance of this type of hernia.
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