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Background. Coronavirus Disease 2019 (COVID-19) is associated with an increased incidence of pulmonary embolism (PE). Both conditions increase hospital complications and mortality, especially when exhibited concurrently. Unfortunately, both conditions may present similarly, and physicians often have a difficult time finding clinical indicators to suggest pursuing further evaluation of a PE during a COVID-19 infection. Methods. Using a multi-center facility database, we conducted a retrospective analysis of 3,675 COVID-19 patients at Methodist Health System from March 2020 to December 2020. COVID-19 infection was determined via molecular PCR testing and PE was determined by computed tomography (CT) scan with angiography. Patient demographics and laboratory values were determined by a manual review of patient charts. Chi-Square test was used to analyze observed variables. Odds ratios were calculated for variables with a statistically significant difference (p < 0.05). Results. Of the 3,675 patients diagnosed with COVID-19, 150 (4.1%) were diagnosed with PE. Elevated D-dimer level had a statistically significant association with increased rate of PE (OR 0.1988, 95% CI 0.0727 - 0.5438, p < 0.001). Factors such as elevated C-reactive protein (p = 0.61), IL-6 (p = 0.26), smoking history (p = 0.70), age over 65 (p=0.54), BMI over 25 (p = 0.42), and history of chronic kidney disease (p = 0.16) did not show a significant association with PE incidence. Of note, patients with PE during admission were seen to have an increased incidence of intubation (OR 0.40, 95% CI 0.2660 - 0.6029, p < 0.001). Conclusion. Our study suggests that COVID-19 patients with elevated D-dimer have higher odds of having a PE. This study also suggests that COVID-19 patients that develop a PE during hospitalization are more likely to require intubation.
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BACKGROUND: Since vaccination is the decisive factor for controlling the COVID-19 pandemic, it is important to understand the process of vaccination success which is not well understood on a global level. The study is the first to judge the now completed "first wave" of the vaccination efforts. The analysis is very relevant for the understanding why and where the vaccination process observed got stuck by the end of 2021. METHODS: Using data from 118 countries globally and weighted least squared and survival analysis, we identify a variety of factors playing crucial roles, including the availability of vaccines, pandemic pressures, economic strength measured by Gross Domestic Product (GDP), educational development, and political regimes. RESULTS: Examining the speed of vaccinations across countries until the Fall of 2021 when the global process got stuck, we find that initially authoritarian countries are slow in the vaccination process, while education is most relevant for scaling up the campaign, and the economic strength of the economies drives them to higher vaccination rates. In comparison to North and Middle America, European and Asian countries vaccinated initially fast for 5% and 10% vaccination rate thresholds, but became rather slow reaching the 30% vaccination level and above. The findings are robust to various applied estimation methods and model specifications. CONCLUSIONS: Democratic countries are much faster than authoritarian countries in their vaccination campaigns when controlling for other factors. This finding suggests that the quality of government and the political environment play a key role in popular support for government policies and programs. However, despite the early success of their vaccination campaigns, the democratic country group has been confronted with strong concerns of vaccine reluctance among their vast populations, indicating the two most potent variables explaining the speed of the COVID-19 vaccination campaign are education and economic conditions.
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Crises trigger both learning and unlearning at both intra-organizational and inter-organizational levels. This article stresses the need to facilitate unlearning for effective crisis management and shows how we could use mindfulness practice to enhance unlearning and transformative learning in a crisis. This study proposes the conceptualization of mindful unlearning in crisis with different mechanisms to foster unlearning in three stages of crisis (pre-crisis, during-crisis, and post-crisis). These mechanisms include mindful awareness of impermanence and sensual processing (pre-crisis stage), mindful awareness of interdependence and right intention (crisis management stage), and mindful awareness of transiency and past experiences (post-crisis stage).
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TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dilated cardiomyopathy is characterized by structural defects leading to impaired ventricular function. The etiology is often elusive. Viruses are some of the most common causes world-wide (1). Here we present a male with non-ischemic cardiomyopathy and heart failure due to Coxsackie B myocarditis. CASE PRESENTATION: A 36 year old male with history of heart failure with reduced ejection fraction (35%), non-ischemic cardiomyopathy, and ventricular tachycardia presented for syncope. He was found to be in cardiogenic shock. Work-up revealed an elevated troponin and NT-proBNP, 0.064 and 5570, acute kidney injury, creatinine 3.28, and congestive hepatopathy. Prior cardiac work-up consisted of a left and right heart catheterization which showed no atherosclerotic disease and elevated filling pressures (Pulmonary Capillary Wedge Pressure 16 and Pulmonary Artery Mean Pressure 33). Cardiac MRI showed global dilation of the cardiac chambers, global hypokinesis, and late gadolinium enhancement of the base and septum. This was suggestive of dilated cardiomyopathy and prior myocarditis. Echocardiogram revealed a severe decline in ejection fraction, < 15%, and EKG showed a widened QRS complex with left bundle branch block. Serologic tests were positive for Coxsackie B antibodies. Inotropic support was initiated. Bridge therapy and heart transplant were indicated. However, due to his uninsured status and COVID-19 restrictions, he was unable to be transferred to a heart transplant center. Cardiac Resynchronization Therapy was pursued instead. He was clinically stabilized, initiated on GDMT, and was discharged with close follow-up. Even though serologic antibodies lack specificity, given the history, cardiac MRI findings, and diagnosis of NICM, his clinical picture was presumed to be due to Coxsackie B. DISCUSSION: Myocarditis is an inflammatory condition of the myocardium. Viral is the most common cause in Western nations but Rheumatic and Chagas remain prevalent in the developing world. Diagnosis is confirmed with endomyocardial biopsy. This makes it difficult to ascertain the true incidence but there are approximately 1.5 million cases every year. COVID-19 has been frequently associated with myocardial injury and clinical myocarditis. In most cases, tissue diagnosis is lacking. Viral myocarditis can lead to dilated cardiomyopathy through a variety of mechanisms. It is hypothesized to be the result of direct toxicity via receptor mediated entry or an autoimmune response against viral fragments that are not cleared (2). CONCLUSIONS: Unfortunately, this case highlights the disparities of our healthcare system and how that can directly impact patient care. Viral myocarditis remains a difficult clinical scenario. Treatment is largely supportive but the sequelae of disease can be severe. Antivirals and interferon therapy are promising but further research is needed to explore more pharmacologic options (3). REFERENCE #1: Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000;342:1077. REFERENCE #2: Kang M, An J. Viral Myocarditis. [Updated 2021 May 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459259/ REFERENCE #3: Coletta AP, Clark AL, Cleland JG. Clinical trials update from the Heart Failure Society of America and the American Heart Association meetings in 2008: SADHART-CHF, COMPARE, MOMENTUM, thyroid hormone analogue study, HF-ACTION, I-PRESERVE, beta-interferon study, BACH, and ATHENA. Eur J Heart Fail 2009;11:214. DISCLOSURES: No relevant relationships by Adhish Singh, source=Web Response No relevant relationships by Michael Vu, source=Web Response
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Objective: On March 17th, ASRM published guidance for REI clinics regarding infertility treatment during the COVID-19 pandemic. The recommendations advised against initiation of new fertility treatment cycles outside of emergent fertility preservation. Our objective was to evaluate what SART-member fertility clinics communicated to the public and their patients via clinic websites during this time period. Design: Cross-sectional study. Materials and Methods: Between 4/20/20 and 4/24/20, SART-member fertility clinic websites were reviewed for REI-specific COVID-19 messages (REI-CM). The REI-CM was evaluated for: type of treatment offered, and to whom;adherence to updated ASRM guidance;and citation of ASRM (or other) guidance. Each website was evaluated by two reviewers and arbitrated by a third in the case of discrepancies. Practice size, type, and location were abstracted from SART. Clinics were classified by whether they were under a shelter in place (SIP) order and the duration of that order. Chi squared analyses were performed to determine associations between clinic demographics and patterns in messaging. Results: 381 SART-member clinics maintained active websites. Of those, 249 (65.3%) had REI-CM. The presence of REI-CM was more common in private than academic practices (73% vs 38%, p<0.001) and with increasing practice volume: 38% of clinics with <200 annual cycles vs 91% of clinics with >1000 cycles (p<0.001). There was a trend toward increased REI-CM use in states with a SIP order for ≥30 days (70% of 212, p=0.064). ASRM guidance was cited in 61% (n=152) of REI-CM;however, only 33% (n=82) outlined treatment practices that reflected ASRM guidance published at the time of the data extraction. Adherence to ASRM guidelines was more common in academic than private practices (54% vs 31%, p=0.02) but was not correlated with size of practice or geographic region. Conversely, 18% (n=44) of practices announced treating patients on a “case-by-case basis” with definitions ranging from specific (“women with AMH <0.7”) to vague (“as determined by our providers alongside our patients”). Additionally, 9% of REI-CM (n=23) announced continued treatment regardless of a patient’s clinical urgency. This messaging was more common in groups doing >1000 cycles a year (18%, p=0.009), with a trend toward practices in the northeast (16%, p=0.113) and in states with SIP orders lasting <30 days (14%, p=0.09). Clinics treating all-comers were less likely to cite ASRM than other clinics (41% vs 62%, p=0.045). However, 75% (n=14) cited COVID-19 guidance from WHO, CDC and state and local governments. Conclusions: While public messaging may not reflect the actual practices of a clinic, this study reveals heterogeneity in how clinics incorporated ASRM recommendations and responded to the early stages of the COVID-19 pandemic. Academic practices were more likely to indicate their adherence to ASRM recommendations. High volume groups were more likely to communicate with their patients about what treatments they offered and to treat patients outside ASRM guidance. Lessons learned may inform optimal response in future waves of COVID-19. References: American Society for Reproductive Medicine. Patient Management and Clinical Recommendations During The Coronavirus (COVID-19) Pandemic. Available at Accessed on May 26, 2020