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      Care for Women With Ectopic Pregnancies During the Coronavirus Disease 2019 (COVID-19) Pandemic

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      , MD, MSPH , , MD, , MD, MPH
      Obstetrics and Gynecology
      Lippincott Williams & Wilkins

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          Abstract

          Women with ectopic pregnancies may be delaying care owing to concerns over coronavirus disease 2019 (COVID-19) exposures and presenting for medical care in more critical condition.

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          The Untold Toll — The Pandemic’s Effects on Patients without Covid-19

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            Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

            We conducted a nationwide retrospective survey on the impact of COVID-19 on the diagnosis and treatment of acute cornary syndrome (ACS) from 2 to 29 March in Austria. Of the 19 public primary percutaneous coronary (PCI) centres contacted, 17 (90%) provided the number of admitted patients. During the study period, we observed a significant decline in the number of patients admitted to hospital due to ACS (Figure 1 ). Comparing the first and last calendar week, there was a relative reduction of 39.4% in admissions for ACS. In detail, from calendar week 10 to calendar week 13, the number of ST-segment elevation myocardial infarction (STEMI) patients admitted to all hospitals was 94, 101, 89, and 70, respectively. The number of non-STEMI patients declined even more markedly from 132 to 110, to 62, and to 67. Figure 1 Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19. The absolute numbers of all ACS (blue bars), STEMI (orange bars), and NSTEMI (grey bars) admissions in Austria from calendar week 10 to calendar week 13 are shown. Abbreviations: STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction. The main finding of our retrospective observational study is an unexpected major decline in hospital admissions and thus treatment for all subtypes of ACS with the beginning of the COVID-19 outbreak in Austria and subsequent large-scale public health measures such as social distancing, self-isolation, and quarantining. Several factors might explain this important observation. The rigorous public health measures, which are undoubtedly critical for controlling the COVID-19 pandemic, may unintentionally affect established integrated care systems. Amongst others, patient-related factors could mean that infarct-related symptoms such as chest discomfort and dyspnoea could be misinterpreted as being related to an acute respiratory infection. Moreover, the strict instructions to stay at home as well as the fear of infection in a medical facility may have further prevented patients with an ACS from going to a hospital. Irrespective of the causes, the lower rate of admitted and therefore treated patients with ACS is worrisome and we are concerned that this might be accompanied by a substantial increase in early and late infarct-related morbidity and mortality. Our study does not provide data on mortality; however, considering the annual incidence of ACS in Austria (200/100 000/year = 17 600/year in 8.8 million habitants) 1 and taking into consideration sudden cardiac deaths and silent infarctions (one-third), there will remain ∼1000 ACS cases a month. The difference between the assumed number of ACS patients and the observed number in our study, i.e. 725 ACS patients in calendar weeks 10–13 is 275. According to these assumptions, 275 patients were not treated in March 2020. Based on data showing that the cardiovascular mortality of untreated ACS patients might be as high as 40% (as it was in the 1950s), 2 we can theoretically estimate 110 ACS deaths during this time frame. The number of deaths associated with this unintentional undersupply of guideline-directed ACS management is very alarming, particularly when considering that the official number of COVID-related deaths in Austria was 86 on 29 March. In conclusion, it seems likely that the COVID-19 outbreak is associated with a significantly lower rate of hospital admissions and thus, albeit unintended, treatment of ACS patients, which is most likely explained by several patient- and system-related factors. Every effort should be undertaken by the cardiology community to minimize the possible cardiac collateral damage caused by COVID-19.
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              Delayed access or provision of care in Italy resulting from fear of COVID-19

              During Italy's national lockdown for coronavirus disease 2019 (COVID-19), official hospital statistics in the period March 1–27, 2020, show substantial decreases—ranging from 73% to 88%—in paediatric emergency department visits compared with the same time period in 2019 and 2018 (figure ). Similarly, family paediatricians widely report a considerable reduction in clinic visits, although this is difficult to measure precisely. Figure Visits to paediatric emergency departments across five hospitals in Italy, March 1–27, 2020, compared with the same period in 2018 and 2019 Data are official hospital statistics (courtesy of the authors). Schools and sports activities have been closed since March 1 in Italy, so it is understandable that the numbers of acute infections and traumas among children are lower than usual. In addition, relatively few cases of COVID-19 among children have been reported. 1 As of April 2, the 1624 cases in the paediatric population ( 39°C) and the other presented with severe anaemia (haemoglobin 4·2 mg/dL) and respiratory distress after emergency department access was delayed. One of these patients died several days after hospital admission. One child presented with long-lasting convulsions after three previous episodes of convulsions had been treated at home without medical assistance; the patient was eventually diagnosed with bacterial pneumonia. A 3-year-old girl was admitted to hospital after 6 days at home with very high fever (>39°C), with a sepsis secondary to a pyelonephritis. A neonate was kept home despite vomiting for several days because of hypertrophic pyloric stenosis and arrived in the emergency department in hypovolaemic shock. Another child, aged 2 years, had been vomiting for several days and unable to eat before presenting with severe hypoglycaemia. One child arriving in the emergency department having been unable to pass faeces for more than a week was diagnosed with an abdominal mass of 15 cm diameter, later diagnosed as Wilm's tumour; the diagnosis by telephone from his paediatrician had been functional constipation. An adolescent with cerebral palsy and severe malnutrition got in touch with the hospital after 10 days of fever at home with increased oxygen needs, and died in the ambulance on the way to the hospital. The precise cause of fever and death was not ascertained but the adolescent was negative for COVID-19 infection. Another child with cerebral palsy, tracheotomy, and enteral nutrition died on route to the hospital after 3 days of bloody stools. A child with Mowat Wilson syndrome, in dialysis for chronic renal insufficiency, arrived at the hospital after 3 days of being “less active than usual” with capillary refill time of 4 s, heart rate of 50 beats per min, oxygen saturation level not detectable, mixed acidosis, and creatine 4 mg/dL; the child died after 4 days in the ICU. Of this small series of 12 cases, half of the children were admitted to an ICU and four died. In all cases, parents reported avoiding accessing hospital because of fear of infection with SARS-CoV-2. Furthermore, in five cases, the family had contacted health services before accessing care, but their health provider was unavailable because of the COVID-19 epidemic, or hospital access was discouraged because of the possible risk of infection. All cases were either negative for SARS-CoV-2 or had a clinical presentation (eg, diabetes) that did not justify a diagnostic test according to the national criteria. Notably, no death occurred in the same hospitals during the same period in 2019, and the total yearly number of paediatric deaths in these hospitals ranges from zero to three. These cases are clearly a small sample compared with the overall number of paediatric visits recorded in the five hospitals during this week (12 [2%] of 502). However, since delay in access to care was not monitored systematically, this small case series might underestimate the problem. We believe that further monitoring of access to routine clinical care is needed during the COVID-19 pandemic. There is a need to prevent delays in accessing hospital care and to increase provision of high-quality coordinated care by health-care providers. Both of these aspects should be considered as part of the overall public health impact of the COVID-19 pandemic, as evident in other epidemics,3, 4 and must be adequately monitored. Both the general population and health-care workers need clear guidance and information. Specifically, parents should be made fully aware that the risks of delayed access to hospital care for emergency conditions can be much higher than those posed by COVID-19. Specific duties and obligations of different types of health-care professionals should be clearly defined, taking into consideration the risk level of the working environment, the health-care worker's specialty, the probable harms and benefits of treatment, and competing obligations deriving from workers' multiple roles.4, 5
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                Author and article information

                Journal
                Obstet Gynecol
                Obstet Gynecol
                ong
                Obstetrics and Gynecology
                Lippincott Williams & Wilkins
                0029-7844
                1873-233X
                June 2021
                04 May 2021
                : 137
                : 6
                : 1041-1042
                Affiliations
                Department of Obstetrics & Gynecology, ChristianaCare, Newark, Delaware.
                Author notes
                Corresponding author: Helen Toma, MD, MSPH, Department of Obstetrics & Gynecology, ChristianaCare, Newark, DE; email: helen.v.toma@ 123456christianacare.org .
                Article
                ONG-21-49 00010
                10.1097/AOG.0000000000004392
                8132559
                33957662
                bc09064c-3ca0-4526-8162-023814b2a8f4
                © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                : 07 January 2021
                : 03 March 2021
                : 11 March 2021
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