Cross-sectional study to assess the impact of the COVID-19 pandemic on healthcare services and clinical admissions using statistical analysis and discovering hotspots in three regions of the Greater Toronto Area

OBJECTIVES

The COVID-19 pandemic disrupted healthcare services, leading to the cancellation of non-urgent tests, screenings and procedures, a shift towards remote consultations, stalled childhood immunisations and clinic closures which had detrimental effects across the healthcare system. This study investigates the impact of the COVID-19 pandemic on clinical admissions and healthcare quality in the Peel, York and Toronto regions within the Greater Toronto Area (GTA).

DESIGN

In a cross-sectional study, the negative impact of the pandemic on various healthcare sectors, including preventive and primary care (PPC), the emergency department (ED), alternative level of care (ALC) and imaging, procedures and surgeries is investigated. Study questions include assessing impairments caused by the COVID-19 pandemic and discovering hotspots and critical subregions that require special attention to recover. The measuring technique involves comparing the number of cases during the COVID-19 pandemic with before that, and determining the difference in percentage. Statistical analyses (Mann-Whitney U test, analysis of variance, Dunn's test) is used to evaluate sector-specific changes and inter-relationships.

SETTING

This work uses primary data which were collected by the Black Creek Community Health Centre. The study population was from three regions of GTA, namely, the city of Toronto, York and Peel. For all health sectors, the sample size was large enough to have a statistical power of 0.95 to capture 1% variation in the number of cases during the COVID-19 pandemic compared with before that.

RESULTS

All sectors experienced a significant decline in patient volume during the pandemic. ALC admissions surged in some areas, while IPS patients faced delays. Surgery waitlists increased by an average of 9.75%, and completed IPS procedures decreased in several subregions.

CONCLUSIONS

The COVID-19 pandemic had a universally negative impact on healthcare sectors across various subregions. Identification of the hardest-hit subregions in each sector can assist health officials in crafting recovery policies.

Knowing the unknown: The underestimation of monkeypox cases. Insights and implications from an integrative review of the literature

Monkeypox is an emerging zoonotic disease caused by the monkeypox virus, which is an infectious agent belonging to the genus Orthopoxvirus. Currently, commencing from the end of April 2022, an outbreak of monkeypox is ongoing, with more than 43,000 cases reported as of 23 August 2022, involving 99 countries and territories across all the six World Health Organization (WHO) regions. On 23 July 2022, the Director-General of the WHO declared monkeypox a global public health emergency of international concern (PHEIC), since the outbreak represents an extraordinary, unusual, and unexpected event that poses a significant risk for international spread, requiring an immediate, coordinated international response. However, the real magnitude of the burden of disease could be masked by failures in ascertainment and under-detection. As such, underestimation affects the efficiency and reliability of surveillance and notification systems and compromises the possibility of making informed and evidence-based policy decisions in terms of the adoption and implementation of ad hoc adequate preventive measures. In this review, synthesizing 53 papers, we summarize the determinants of the underestimation of sexually transmitted diseases, in general, and, in particular, monkeypox, in terms of all their various components and dimensions (under-ascertainment, underreporting, under-detection, under-diagnosis, misdiagnosis/misclassification, and under-notification).

Miscarriage after a normal scan at 12-14 gestational weeks in women at low risk of carrying a fetus with chromosomal anomaly according to nuchal translucency screening

OBJECTIVES

To estimate the risk of second-trimester miscarriage in women with low risk of carrying a fetus with chromosomal abnormality, according to nuchal translucency (NT) screening, and to determine whether NT thickness or other factors affect the risk.

METHODS

The study population comprised 14 278 singleton pregnancies with a risk of Down syndrome < 1:250 at NT scan, and where no fetal karyotyping was performed < 25 weeks. Risk factors for miscarriage were investigated by logistic regression.

RESULTS

The median risk of Down syndrome was 1 : 3138 (range 1 : 9651-1 : 251) and median NT was 1.7 (range 0.4-3.0) mm. The miscarriage rate was 0.5% (77/14 278; 95% CI 0.4-0.6). After having controlled for maternal age, we found the number of previous deliveries and miscarriages to independently predict miscarriage: odds ratio (OR) for each previous delivery 1.48, 95% CI 1.22-1.94, P < 0.0001; OR for each previous miscarriage 1.34, 95% CI 1.07-1.68, P = 0.01. Excluding women with any previous miscarriage and adjusting for parity, we found a U-shaped relationship between maternal age and miscarriage (P = 0.04).

CONCLUSION

In singleton pregnancies with estimated risk of Down syndrome < 1:250 according to NT screening at 12-14 weeks, the spontaneous fetal loss rate before 25 weeks is likely to be around 0.5%. NT thickness up to 3 mm does not seem to affect the risk of miscarriage in such pregnancies. Instead, the risk seems to increase with number of previous miscarriages and deliveries, and possibly the risk is highest in the youngest and oldest women.

By how much does increased nuchal translucency increase the risk of adverse pregnancy outcome in chromosomally normal fetuses? A study of 16,260 fetuses derived from an unselected pregnant population

OBJECTIVE

In this study we aimed to estimate the magnitude of a possible increase in risk of adverse outcome in fetuses with normal karyotype and increased nuchal translucency (NT), and to determine how well NT measurements can distinguish between fetuses with normal and adverse outcome.

METHODS

We studied 16,260 consecutive fetuses with normal karyotype derived from an unselected pregnant population. The following cut-offs for increased risk of adverse outcome were chosen a priori: NT > or = 95th percentile, > or = 3 mm, > or = 3.5 mm, and > or = 4.5 mm. The positive and negative likelihood ratios (+LR, - LR) of the risk cut-offs with regard to fetal malformation, miscarriage, perinatal death, termination of pregnancy and total adverse outcome were calculated, and receiver-operating characteristics (ROC) curves were drawn.

RESULTS

The total rate of adverse outcome was 2.7%. + LR and - LR of NT > or = 3.0 mm were: for lethal or severe malformation, + LR 15.0 (95% CI 7.0-28.6), - LR 0.89 (95% CI 0.81-0.95); for malformation of at least intermediate severity, + LR 8.1 (95% CI 4.3-14.0), - LR 0.95 (95% CI 0.92-0.97); for termination of pregnancy, + LR 41.6 (95% CI 17.1-86.6), - LR 0.67 (95% CI 0.41-0.85); for any adverse outcome, + LR 6.4 (95% CI 3.4-11), - LR 0.96 (95% CI 0.94-0.98). The odds for these adverse outcomes increased with increasing NT. NT > or = 3 mm did not significantly increase the risk of miscarriage or perinatal death. Areas under ROC curves for NT were small, with 95% CI below or only slightly above 0.5.

CONCLUSION

Our likelihood ratios can be used to calculate the individual risk of unfavorable outcome, but NT screening cannot reliably distinguish between normal and adverse outcome in fetuses with normal karyotype.

Routine ultrasound examination at 12 or 18 gestational weeks for prenatal detection of major congenital heart malformations? A randomised controlled trial comprising 36,299 fetuses

OBJECTIVE

To compare the rate of prenatal diagnosis of heart malformations between two policies of screening for heart malformations.

DESIGN

Randomised controlled trial.

SETTING

Six university hospitals, two district general hospitals.

SAMPLE

A total of 39 572 unselected pregnancies randomised to either policy.

METHODS

The 12-week policy implied one routine scan at 12 weeks including measurement of nuchal translucency (NT), and the 18-week policy implied one routine scan at 18 weeks. Fetal anatomy was scrutinised using the same check-list in both groups, and in both groups, indications for fetal echocardiography were ultrasound findings of any fetal anomaly, including abnormal four-chamber view, or other risk factors for heart malformation. In the 12-week scan group, NT >or=3.5 mm was also an indication for fetal echocardiography.

MAIN OUTCOME MEASURE

Prenatal diagnosis of major congenital heart malformation.

RESULTS

In the 12-week scan group, 7 (11%) of 61 major heart malformations were prenatally diagnosed versus 9 (15%) of 60 in the 18-week scan group (P= 0.60). In four (6.6%) women in the 12-week scan group, the routine scan was the starting point for investigations resulting in a prenatal diagnosis versus in 9 (15%) women in the 18-week scan group (P=0.15). The diagnosis was made <or=22 weeks in 5% (3/61) of the cases in the 12-week scan group versus in 15% (9/60) in the 18-week scan group (P=0.08).

CONCLUSIONS

The prenatal detection rate of major heart malformations was low with both policies. The 18-week scan policy seemed to be superior to the 12-week scan policy, although the differences in prenatal detection rates were not statistically significant.

Is measurement of nuchal translucency thickness a useful screening tool for heart defects? A study of 16,383 fetuses

OBJECTIVE

To determine the performance of nuchal translucency thickness (NT) measurement as a screening method for congenital heart defects (CHD) among fetuses with normal karyotype.

METHODS

An NT measurement was made in 16 383 consecutive euploid fetuses derived from an unselected pregnant population. The cut-offs for increased risk of heart defects, chosen a priori and tested prospectively, were: NT >or= 95th centile for crown-rump length, NT >or= 3 mm, and NT >or= 3.5 mm. The sensitivity and false-positive rate (FPR; 1 minus specificity) of the risk cut-offs and their positive and negative likelihood ratios (+LR and -LR) with regard to CHD were calculated.

RESULTS

Among the 16 383 fetuses with an NT measurement there were 127 cases with a diagnosis of heart defect confirmed by cardiac investigations after birth or at autopsy. Of these, 55 defects were defined as major, of which 52 were isolated (no other defects or chromosomal aberrations), corresponding to a prevalence of major heart defects in chromosomally normal fetuses/newborns of 3.3/1000. The sensitivity, FPR, +LR and -LR for NT >or= 95th centile with regard to an isolated major heart defect were: 13.5%, 2.6%, 5.2 and 0.9, respectively. For NT >or= 3.0 mm these values were: 9.6%, 0.8%, 12.0 and 0.9, and for NT >or= 3.5 mm they were: 5.8%, 0.3%, 19.3 and 0.9.

CONCLUSIONS

NT measurement is a poor screening method for isolated major CHD. A method with a much higher detection rate and with a reasonably low FPR is needed. However, increased NT indicates increased risk of fetal heart defect, and women carrying fetuses with increased NT should be offered fetal echocardiography in the second trimester.

Sensory denervation with capsaicin does not influence the critical ischemia time in rat island flaps

Capsaicin causes release and long-term depletion of neuropeptides from sensory neurons. Recently, critical rat pedicle flaps pretreated with capsaicin have shown decreased survival. In the present study, the effect of systemic capsaicin pretreatment on the no-reflow phenomenon was investigated in the rat. Effective depletion of neuropeptides was confirmed with functional tests and immunohistochemistry. Groin island flaps were exposed to 4, 6, 8, 10 or 12 hours of warm ischemia, and flap survival was judged one week postoperatively. In contrast to previously reported negative effects on pedicle flap survival after pretreatment with capsaicin, the present study showed no difference in flap survival between capsaicin-pretreated rats and controls. It is concluded that depletion of neuropeptides from sensory neurons does not have negative effects on the tissue's ability to withstand prolonged complete ischemia. As this contrasts with the findings in critical pedicle flaps, the influence of sensory neuropeptides and the necrosis mechanisms are likely to be different in these two types of ischemic conditions.

Immunological studies on the incorporation of radioactive leucine into sea urchin embryonic proteins: extractability and turn-over of newly synthesized proteins

This study was undertaken in order to investigate the turn-over of newly synthesized sea urchin embryonic proteins, the distribution of these proteins in the cell and their changes in solubility with time. Refined immunological methods providing unique possibilities for studies of individual proteins were utilized. The proteins were obtained in two soluble fractions: a concentrate of proteins from the cytosol was obtained by homogenization in a hypotonic medium and another fraction constituting membrane-associated proteins was solubilized by detergent treatment of the residual pellet; 75% of the total protein content in early and 60% in later developmental stages was thus solubilized. The proteins solubilized by these mild methods retained their antigenicity and could be analyzed by immunodiffusion methods. The fate of newly synthesized embryonic proteins was studied by incorporation of a radioactive amino acid using two different incubation procedures. The results of these studies indicated that newly synthesized proteins changed their solubility properties with time. Proteins were thus transfered from the soluble to the insoluble fraction. The findings that more proteins became insoluble during development mentioned above also supports such an interpretation. The synthesis of individual proteins was studied by immunodiffusion and autoradiography. Most of the antigens in the two soluble fractions were identical. Experiments with absorbed antisera revealed that only two to four antigens were present exclusively in one of the two soluble fractions. Three groups of antigens differing in regard to their metabolic activities were distinguished. Some antigens were labeled after both procedures without substantially increasing in concentration during development. Thus, their labeling was probably sustained by turn-over. Other antigens were labeled only after one of the two incubation procedures indicating large variations in regard to synthesizing rates of individual proteins.

Phosphatase active antigens in sea urchin eggs and embryos. I. Substrate specificity, pH-optima and inhibitors

Phosphatase activity in sea urchin embryonic antigens was investigated by histochemical staining of immunoprecipitates separated by two-dimensional (crossed) immunoelectrophoresis. Unfertilized eggs were homogenized in a hypotonic medium which solubilized cytoplasmic antigens. Antigens integrated in membranes or enclosed in particles were solubilized by detergent treatment of the residual pellet. Two different phosphatase activities were discerned in the unfertilized eggs, nucleoside diphosphatase (EC 3.6.1.6.) and acid phosphatase (EC 3.1.3.2.). Nucleoside diphosphatase activity was obtained in both the water soluble and detergent extracted protein fractions. This activity was confined to one antigen. Acid phosphatase acitivity on the other hand was almost exclusively obtained in the detergent extracted fraction and about ten distinct antigens displayed this activity. The nucleoside diphosphatase active antigen preferentially hydrolyzed purine nucleoside diphosphates and to a lesser degree triphosphates of these nucleosides. The acid phosphatase active antigens had a broader substrate specificity and hydrolyzed equally well beta-glycerophosphate and nucleotides. Both activities were essentially inactive at neutral or alkaline pH values. The activities were inhibited by p-choloromercuribenzoate and accordingly stimulated by cysteine. Tartrate and sodium fluoride, however, inhibited the acid phosphatase activity while nucleoside diphosphatase activity was either stimulated or not affected at all by these agents.

Phosphatase active antigens in sea urchin eggs and embryos. II. A comparison between the activities in unfertilized eggs and plutei

Phosphatase activities in sea urchin eggs and plutei were investigated by means of histochemical staining of immunoprecipitates. Two protein fractions were obtained by extraction in a hypotonic medium and by detergent treatment of the residual pellet. Three distinctly different phosphatase activities were discerned, nucleoside diphosphatase (EC 3.6.1.6.), acid phosphatase (EC 3.1.3.2.) and alkaline phosphatase (EC 3.1.3.1.). The nucleoside diphosphatase activity, which was confined to one antigen, was present in both water soluble and detergent extracts and at roughly the same concentration in eggs and plutei. By means of a monospecific antiserum the immunological identify of this antigen was established in all instances. The acid phosphatase activity, which was displayed by ten detergent extracted antigens in eggs, was only found in five detergent extracted antigens in plutei. This decrease in number of enzyme active antigens was also reflected by a general decrease in number of enzyme active antigens was also reflected by a general decrease in activity as assessed by quantitative determinations. Furthermore, by means of absorbed antisera it was established that two or three of the acid phosphatase active antigens were "egg specific". Another acid phosphatase active antigen, which was common to both developmental stages, was investigated by a monospecific antiserum. While this antigen was found in both soluble fractions, it was only enzymatically active when extracted with detergent. Alkaline phosphatase active antigens were only found in the detergent extract of plutei. However, immunoprecipitates with this activity appeared both with antiserum against unfertilized eggs and with antiserum against plutei. This suggests that the egg contained the antigens in an enzymatically inactive form.