Prognostic factors for SARS-CoV-2 nasopharyngeal swab negativity: a multicentric study

The diagnosis of coronavirus disease 2019 (COVID-19) is made by the detection of viral RNA by polymerase chain reaction on nasopharyngeal swabs. In some patients the test is falsely negative, while other biological samples are positive. The aim of the study is to identify characteristics and prognostic factors for swab negativity in COVID-19 patients with deep aspirate bronchus (BA)-confirmed disease. Multicentric retrospective case-control study of patients admitted for COVID-19 between March and November 2020 in two internal medicine units of the AOU Careggi and in the Internal Medicine of the Hospital of Varese. Were enrolled patients aged =18 years hospitalized for COVID-19 with viral RNA isolation on biological specimen, considering as cases the patients negative to swab but positive to BA. For each case, four controls with positive swab at admission were enrolled. The study included 95 patients, 19 cases and 76 controls. The mean time between symptoms onset and swab was 2.65 +/- 1.9 days in cases, with a statistically significant (P=0.003) difference compared to controls (5.53 +/- 3.0 days). Patients with negative swab had a longer mean length of stay and more frequent adverse outcome than controls. Swabbing within a short time of symptoms onset is a predictor for false negative. Patients with repeated negative swabs have a worse clinical picture with longer hospital stay, greater need for non-invasive ventilation and higher frequency of adverse outcome.

Diagnosis of SARS-CoV-2 infection: prognostic factors for nasopharyngeal swab negativity

Background and Aim: The diagnosis of Covid 19 is made by the detection of viral RNA by PCR on nasopharyngeal swabs. In some patients the test is falsely negative, while other biological samples are positive. The aim of the study is to identify characteristics and prognostic factors for swab negativity in COVID-19 patients with BA-confirmed disease. Materials and Methods: Multicentre retrospective case-control study of patients admitted for COVID-19 between March and November 2020 in two internal medicine units of the AOU Careggi and in the Internal Medicine of the Hospital of Varese. Enrolled patients aged ≥18 years hospitalized for Covid with viral RNA isolation on biological specimen, considering as cases the patients negative to swab but positive to BA. For each case, four swab-positive controls at admission. Results: Included 95 patients, 19 cases and 76 controls. Advanced mean age, male predominance. The mean time between symptoms onset and swab was 2.65±1.9 days in cases, with a statistically significant difference compared to controls (5.53±3.0 days). Longer mean length of stay and more frequent adverse outcome in patients with negative swab than in controls. Conclusions: Swabbing within a short time of symptoms onset is a predictor for false negative. Patients with repeated negative swabs have a worse clinical picture with longer hospital stay, greater need for non-invasive ventilation and higher frequency of adverse outcome.

Endocrine disorders in COVID-19: a look from a different perspective

Background: COVID-19 is an infectious disease caused by the SARS-CoV-2 virus, particularly known for its respiratory symptoms. Nevertheless, a wide variety of clinical manifestations has been associated with COVID-19, including Kawasaki disease, Guillain- Barré syndrome and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Clinical Case: A 55-years-old woman, affected by immune thrombocytopenia on prednisone therapy, presented with intense fatigue, hyporexia and vomit. She had no fever, no cough, nor other symptoms. She referred a quick prednisone decalage in previous days. ABG showed metabolic alkalosis, severe hyponatremia and hypokalemia. The patient tested positive for SARS-CoV-2. Further investigation showed euvolemic hyponatremia (102 mEq/L) with normal urine osmolality (275 mOsm/Kg), findings consistent with COVID-19-related SIADH. We set a corticosteroid therapy with Prednisone 37,5 mg/die for 5 days, then 25 mg/die for 2 days. After 7 days of hospitalization, the patient tested negative for SARS-CoV-2. In the meantime, kalemia and natremia were back in range. Conclusions: Despite COVID-19 being identified as severe respiratory viral infection, progressively many relevant endocrine manifestations have been reported greatly contributing to the severity of the clinical presentation. There is the urgent need to collect in international multicentric efforts data on all these aspects of the pituitary involvement in COVID-19 patients.

Arterial catheterization: is a new competence for internist?

Background: Arterial catheterization is frequently used in the management of critically ill patients, but their use in internal medicine is limited by the lack of monitoring systems and fewer nursing staff. The aim of our study is to demonstrate the safety of arterial catheters in the internal medicine ward. Materials and Methods: We conducted a retrospective cohort study between January 2018 and December 2021 at the Department of Internal Medicine 1 of the AOU Careggi. All patients with arterial catheters were enrolled. Patients with SARS-CoV2 infection were excluded. We conducted a univariate analysis on the association between self-removal of the device and complications. Results: We enrolled 488 patients. Mean age was 74.26±14.85 years. The main site of arterial access was radial artery (84.83%), followed by femoral artery (10.45%). The average length of stay of the device was 6.39±5.01 days, and in 3.48% there was an accidental self-removal of the device. The most frequent complication was mild bleeding (1.6%), followed by infection of the insertion site (0.8%) and distal embolization (0.3%). Delirium occurred in 20.3% of patients, and an association was found between delirium and self-removal of the arterial catheter (p <0.001, OR 5.35, CI 2.05-13-94). However, there was no association between delirium and any complications (p=1.000). Conclusions: arterial catheterization is a low-complication procedure;the internist should acquire this competence to deal with the presence of critically ill patients and the development of subintensive therapy units.

Acute intracranial bleed symptoms mimic by lactic acidodis linezolid induced

Introduction: Rarely, lactic acidosis can be a life-threatening medication side effect. Hence, determining the etiology of lactic acidosis early in patients is necessary to choose the correct therapeutic intervention. Although lactic acidosis as an adverse drug reaction of linezolid is a well-recognized and documented clinical entity. Case Report: A 90-years-old woman was hospitalized for Sars- CoV-2 related pneumonia, due to an increase of CRP, WBC count and appearance of new opacities on chest CT, it has been decided to start an atimicrobial therapy with Linezolid, suspecting an MRSA superinfection. After six doses she presented an episode of consciusness alteration, lethargy and allucinations.The head CT any bleeding or mass effect has been demonstrate, but blood gas analysis showed a significant lactic acid increase and an important HOC3- reduction. After the suspencion of Linezolid lactate rapidly decrease. Conclusions: Several publications demonstrate that linezolid induces lactic acidosis by disrupting crucial mitochondrial functions, rarely with a rapid onset.It is important that internist are aware that linezolid can cause lactic acidosis not only after a long threatment period but also after few somministration, and that often it may mimic a common disease like cerebrovascular accident. In conclusion, linezolid should be suspected in the differential diagnosis if lactic acidosis exists with an uncommon clinical picture.

Sleep/wake rhythm modifications in the Italian population during SARS-CoV2 pandemic: a web-based cross-sectional survey.

OBJECTIVE: The study aims to investigate in a representative sample of the Italian population whether the SARS-CoV2 pandemic and the subsequent home isolation had repercussion on the daily sleep/wake cycling and habits. MATERIALS AND METHODS: A web-based cross-sectional survey consisted of various multiple-choice questions concerning demographic characteristics, sleep habits, and sleep-related problems was broadcast through mainstream social-media. Individuals were randomly allowed to participate from April 29th to May 17th, namely 50 days after the lockdown imposition and the day before its abrogation. RESULTS: 58.84% of respondents experienced a change in their sleep habits. 71% of those whose sleep changed showed a delayed sleep pattern. Overall, a two-fold risk of delayed sleep pattern without any change in total sleep time emerged during the investigation period. Females emerged almost 2 times more likely to modify their sleep habits than males. Youths were also more likely to experience modifications than old people, who conversely appeared protected. A significant improvement in daytime sleepiness occurred during the home isolation which additionally correlated with delayed bedtime and less sleep time. CONCLUSIONS: A high rate of change in sleep habits, especially among youths and females, occurred in Italian population during the home isolation to limit the SARS-CoV2 pandemic. Moreover, self-reported daytime sleepiness decreased in severity.

Call me maybe: An intervention to reduce telehealth no-show rates in a geriatric primary care clinic

Background: The COVID-19 pandemic has highlighted the importance of telehealth to maintain access to care. In our geriatric primary care clinic affiliated with an urban safety net hospital, we observed high rates of missed telehealth visits (no-shows). We undertook a quality improvement project to decrease the number of telehealth no-show visits by 25% in three months. Methods: We interviewed stakeholders to understand the process of scheduling telehealth visits and providing appointment reminders. Patients received a reminder phone call a few days before all scheduled appointments, whereas they also received a reminder letter ahead of in-person visits. We called a representative sample of patients who had missed their telehealth visit to understand barriers to attendance and preferred method of visit reminders. One recurring theme was that patients preferred reminder letters. Therefore, for our first Plan-Do-Study Act (PDSA) cycle, we implemented a reminder system that standardized the use of letters for all telehealth visits two weeks prior to scheduled visit time. Results: During the 8 weeks prior to our process change, chart review demonstrated that the practice's telehealth no-show rate was 13.6% (73 per 536 scheduled telehealth visits), compared with our in-person no-show rate of 7.8% (69 per 874 scheduled in-person visits). Post-intervention telehealth no-show rate was 9.1% (47 per 519 scheduled telehealth visits) over 6 weeks. The in-person no-show rate over the same time period was 7.3% (36 per 493 scheduled in-person visits). Our intervention was associated with a 33.1% reduction in telehealth no-show rate whereas the no-show rate for in-person visits decreased by 8% over the same time period. Conclusions: Standardized letter reminders, such as those used for in-person visits, can help improve telehealth show rates in a primary care geriatric clinic. Future PDSA cycles will focus on addressing technological challenges and educating patients on the utility of telehealth visits.