Survival of Covid-19 Patients with Hypertension

Background: Coronavirus Disease-2019 (COVID-19) is an infectious disease caused by SARS-CoV-2 virus. Severity of this disease influenced by old age, sex, comorbidities, and other factors. Hypertension and type 2 diabetes mellitus are the most common comorbidities in COVID-19 patients that cause high morbidity and mortality. Objective(s): To analyze the survival of COVID-19 patients with hypertension comorbidity and compare it between diabetes mellitus and non-diabetes mellitus group. Method(s): This retrospective, descriptive study included COVID-19 patients with hypertension comorbidity at Internal Medicine ward Dr. Soetomo Hospital Surabaya from May 2020 to December 2021. Data on age, sex, hypertension, diabetes mellitus type 2, symptoms, vital signs, laboratory finding, length of stay, and outcome were taken from medical records and we carried out kaplan-meier method and log rank test by using SPSS. Result(s): This study obtained 698 sample of confirmed COVID-19 patients and after applying exclusion criteria there were 174 patients with hypertension comorbidity. Most patient were female (60.3%) and age 51-60 years (38.5%). The most common symptoms were shortness of breath (62.1%) and cough (50.6%). There were 50 hypertension and 79 non-hypertension patients died and Survival analysis showed a significant statistical difference between both groups (p=0.042). From 50 deceased hypertensive patients, there are 36 and 14 hypertensive patients with and without diabetes mellitus respectively but survival analysis showed a non-significant statistical difference between both groups (p=0.081) Conclusion(s): There is significant statistical difference in survival analysis in patients with hypertension. We should be aware about COVID-19 patients with hypertension.

Non-steroidal anti-inflammatory drugs amid COVID-19 pandemic: An ally or an enemy?

As the current global pandemic of the novel coronavirus diseases 2019 (COVID-19) continues to rage, the scientific and medical worlds are working to establish an effective therapy against the illness. Recently questions regarding non-steroidal anti-inflammatory drugs (NSAIDs) as a potential therapeutic option for COVID-19 have surfaced. While some studies hint towards the possible benefit of NSAIDs against SARS-CoV-2 infection, the current body of evidence also sheds light on the potential risk of using NSAIDs in COVID-19 patients. Thus, the available literature does not provide conclusive evidence for or against the use of NSAIDs for treating COVID-19 patients. Given the limited data available, we suggest cautionary approaches for the public to avoid possible harm until further evidence emerges. NSAIDs should not be used as the first-line agents for COVID-19 unlessunder medical supervision. Moreover, patients with chronic inflammatory conditions should continue the NSAIDs as per their regular prescriptions.

Different reversibility of skeletal muscle mass and strength in elderly Japanese women after the first wave of COVID-19

BackgroundRestrictions on outdoor movements due to the coronavirus disease (COVID-19) pandemic have led to a decreased physical activity;this can lead to sarcopenia and frailty in older adults. Our recent study has demonstrated a significant decrease in the trunk muscle mass immediately after the pandemic's first wave (April–May 2020) among Japanese community-dwelling older women. In the present study, we further examined whether muscle mass recovery or deterioration occurs after 1 year of the pandemic's first wave by comparing physical measurements among the following assessment periods: before the first wave, immediately after the first wave, and at 1-year follow-up thereafter.MethodsThis study included 77 women (78.0 ± 5.7 years) who underwent physical measurements for muscle mass, grip strength, one-leg stand-up ability (3 s), and oral motor skills and answered questionnaires on sociality (social network, participation, and support) in the three assessment periods.ResultsThe frequency of going out and the subjective vitality were significantly decreased immediately after the first wave;these recovered at the 1-year follow-up (P < 0.001). When comparing muscular measures, the trunk muscle mass index preferentially decreased immediately after the first wave but recovered significantly at the 1-year follow-up (P < 0.001). Conversely, the appendicular skeletal muscle mass index (ASMI) and grip strength continued to decrease until the 1-year follow-up (P < 0.001 and P = 0.03, respectively). The ability to perform a one-leg stand-up for 3 s and the oral motor skills did not change significantly across the assessment periods. The prevalence of pre-sarcopenia and sarcopenia tended to increase during these periods (P = 0.068). The reduction and subsequent recovery patterns for sociality were similar to those observed for the trunk muscle mass.ConclusionsOur findings demonstrated differences in the reversibility of skeletal muscle mass and strength at 1 year after the first wave of the COVID-19 pandemic: the trunk muscle mass declined acutely and recovered rapidly, whereas the ASMI and grip strength declined continuously. These differences in the skeletal muscle recovery and deterioration might help formulate short-term or long-term strategies for COVID-19-related sarcopenia prevention in community-dwelling older adults.

Bringing Clinical Trials to the Point of Care

Tryon Medical Partners, based in Charlotte, North Carolina, is a fairly new practice, which broke off from a nearby hospital system approximately three years ago. Overall, the patient does enjoy the experience and when integrated with primary care and their own PCPs, I think clinical trial retention rates are higher because of the attention from their provider." Grayson also sees that the patients are excited to participate when asked, and spread the word to friends and family. Because of the practice population, and history of underrepresentation, Grayson believes that the clinical research information and understanding for them is enlightening.

Personal historical perspective of HIV: part 11.

All animal life on earth is thought to have a common origin and have common genetic mechanisms. Evolution has enabled differentiation of species. Pathogens likewise have evolved within various species and mostly come to a settled dynamic equilibrium such that co-existence results (pathogens ideally should not kill their hosts). Problems arise when pathogens jump species because the new host had not developed any resistance. These infections from related species are known as zoonoses. COVID-19 is the latest example of a virus entering another species but HIV (and various strains of influenza) were previous examples. HIV entered the human population from monkeys in Africa. These two papers outline the underlying principle of HIV and the differing epidemiologies in Africa, the USA and in Edinburgh. The underlying immunosuppression of HIV in Africa was initially hidden behind common infections and HIV first came to world awareness in focal areas of the USA as a disease seemingly limited to gay males. The epidemic of intravenous drug abuse in Edinburgh was associated with overlapping epidemics of bloodborne viruses like hepatitis B, hepatitis C and HIV.

Joining Forces: The Addition of a Palliative Care Practitioner to a Resident Teaching Service During COVID-19 Pandemic as a Tool to Improve Patient Care and Provider Communication.

The COVID-19 pandemic has presented an array of novel issues for hospitals and their staff, 1 of the most noted being increased patient isolation due to visitation restrictions. This has created new challenges for health care systems and their workers. To leverage the expertise of Palliative Care Practitioners (PCP) as described here to improve patient/provider communication, patient experience, and quality of care during the COVID-19 pandemic. To address these new obstacles to patient care presented by the pandemic, a PCP was incorporated into the physician team caring for COVID-19 patients at the time of admission. Members of the care team were surveyed and interviewed regarding their experiences with this added support. During a period of peak hospital strain from COVID-19, team members consistently reported that daily PCP involvement led to improvement in communication with patients and families, greater provider awareness of psychosocial stressors, and decreased physician burnout. Integration of a PCP into a clinical care team during the COVID-19 pandemic was perceived as a valuable asset to patients, families, and clinicians.

Feasibility and acceptability pilot of video-based direct observed treatment (vDOT) for supporting antitubercular treatment in South India: a cohort study.

OBJECTIVES: The objective of this study was to assess the feasibility and acceptability of video-based anti-tuberculosis (TB) treatment adherence support in patients with TB (PwTB) in South India. DESIGN: An exploratory cohort. SETTING: Participants were recruited at the TB treatment centre (direct observed treatment short centre) of a tertiary-level teaching facility in Bangalore, Karnataka, South India. PARTICIPANTS: The study enrolled 25 PwTB, with replacement. Adult PwTB who were on drug-sensitive treatment regimens were included, while those who had drug resistant TB were excluded from the study. INTERVENTION: Participants received scheduled adherence reminders and were trained to videorecord themselves swallowing their medication via a mobile application. The application was automated to submit these videos for evaluation. Participants were followed up monthly till treatment completion or withdrawal. OUTCOME MEASURES: Adherence rate and acceptability of video-based directly observed treatment (vDOT). RESULTS: The mean±SD age of the participants was 33±14 years, majority were females (16, 64%), residing in urban areas (24,96%), married (17, 68%) and had access to smart phones (23,92%). A total of 3193 person days of follow-up was completed; of the videos submitted within the first 6 months of enrollment (2501), 94% (2354/2501) were considered 'acceptable' and 16 (64%) participants were optimally adherent (ie, ≥80%). Participant videos improved in quality and a higher proportion met acceptability criteria over time. Twenty-one (84%) participants stated that they found the application easy to learn; 13 (52%) preferred vDOT over DOT. Mixed model logistic regression showed that those who are married are more likely have daily adherence to anti-TB treatment. CONCLUSION: Video-based mobile phone interventions are acceptable to PwTB and the ease of using the application increases with time. To provide patient-centred care, vDOT is a promising option that can be offered to patients for treatment support and adherence monitoring.

Internal Medicine Year in Review 2022.

A novel coronavirus infection (COVID-19) became a global epidemic just months after the first case of infection was reported in Wuhan, China in December 2019. Its spread has severely affected social systems and people's lives. In the academic world, this led to an increase in the number of papers submitted to this journal. While the number of articles submitted to the journal reached a record high in 2020, the number of articles submitted last year returned to prepandemic levels. In this article, we report on the current submission conditions, including the number of submissions and acceptance rate, as well as the citation trends of highly cited articles and those published by the journal in 2022.

A Rare Case of Viridans Group Streptococci Pyogenic Liver Abscess in a Young Male With No Prior Risk Factors.

Pyogenic liver abscesses (PLAs) secondary to bacterial etiologies are rare in North America and other developed countries. The predominant etiology of PLAs is an infection extending from the hepatobiliary or intestinal system. As such, the most common pathogens isolated from PLA in the United States are Escherichia coli and Klebsiella. Viridans group streptococci (VGS), on the other hand, are a large group of commensal bacteria in the oral flora and are a significantly less common cause of infection. Here, we report a rare case of a complicated isolated VGS PLA in a patient without known comorbidities. The patient was born and raised in the United States without recent travel history. Computed tomography (CT) with contrast showed multiple hypodense multiloculated lesions in the right lobe of the liver, measuring up to 13 cm, with mild wall thickening of the distal ileum and cecum. The abscesses were confirmed later as Streptococcus viridans PLA. The patient was treated with CT-guided drainage and IV antibiotics and, after that, made a quick recovery and was discharged. Our case underlines the significance of considering liver abscess as a differential even in previously healthy individuals with no known prior comorbid conditions, as prompt recognition is imperative in preventing morbidity and mortality.

Symptomatic Ventricular Bigeminy and Trigeminy Associated With COVID-19.

Cardiac manifestations of COVID-19 are well-described in the current literature, although electrocardiogram analyses of COVID-19 patients are limited. The most common arrhythmias experienced by patients with COVID-19 include sinus tachycardia and atrial fibrillation. Ventricular bigeminy associated with COVID-19 is exceedingly rare and requires further studies to determine its incidence and clinical significance. Here, we present the case of a 57-year-old male with no prior cardiac history who was found to have COVID-19 and new-onset, symptomatic premature ventricular contraction bigeminy. This case highlights a rare potential association between COVID-19 and ventricular bigeminy/trigeminy.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022.

It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.

Patient Navigator Pilot to Improve Completion of FIT Testing in Primary Care

Introduction: Colorectal cancer (CRC) screening is a critical preventative service and part of routine patient care. CRC is the second leading cause of cancer death in the US, and yet a third of the eligible population does not undergo routine screening. Endoscopy centers have been stretched thin by both COVID-19 and the recent drop in screening initiation age to 45. Fecal immunochemical testing (FIT), a sensitive and specific CRC screening modality, may be used to reach and risk-stratify more patients to increase the yield for detecting advanced neoplasia and cancer, reducing pressure on colonoscopy centers. Unfortunately, FIT is often suboptimal as patients inconsistently complete and return the test for analysis. Method(s): We performed a retrospective analysis of 5211 individuals at a single internal medicine clinic who had FIT ordered as part of USPSTF recommended care from 01/2017 through 12/2021. Starting in 01/2021 we instituted a dedicated patient navigator to support patients in completing FIT. Chi-square, Fisher exact test, and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to compare FIT kit drop off rates pre- and post-intervention, with the model adjusted by age, gender, race, ethnicity, language, and insurance status. Analysis was performed in SAS version 9.4. (Table) Results: The post-intervention period included 1181 (22.7%) patients. The predominant reasons cited for failure to complete testing were forgot (25%), too busy (13%), and lost kit (11%). Our intervention improved drop off rates from 46.4% to 51.3% at 2 weeks (OR 1.19, 95%CI 1.01-1.41), 56.7% to 73.7% at 1 month (2.14 [1.78-2.58]), 64.7% to 89.7% at 3 months (4.73 [3.66-6.12]), and 78.9% to 98.2% at 1 year (14.39 [8.25-25.12]). Overall, our intervention improved FIT kit drop off rates by 53.4% (1.53 [1.30-1.81]). FIT was positive in 4.9% (p=0.0529). (Figure) Conclusion(s): FIT can increase CRC screening rates, particularly in resource-limited settings, and may decrease the burden on endoscopy centers nationwide by improving the efficiency of colonoscopy in the average risk screening population. The addition of a dedicated patient navigator is a simple intervention that, by providing culturally competent care and personalized attention, improves completion rates and return time, allowing FIT to be a reliable method of screening. The ability to increase screening rates and prioritize patients for diagnostic colonoscopies will ultimately lead to earlier detection and treatment of CRC.

Barriers to Barrett's Esophagus Screening Within Veterans Affair Patient Population

Introduction: Barrett's esophagus (BE) is a metaplastic change in the distal esophagus in which squamous epithelium is replaced by columnar epithelium with goblet cells. Chronic gastroesophageal reflux disease (GERD) is strongly linked to the development of BE, which is a known precursor lesion to esophageal adenocarcinoma (EAC). There is no universal guideline for BE screening, however AJG suggest a single screening endoscopy in patients with chronic GERD symptoms and 3 or more addition risk factors, such as male sex, age > 50 years, white race, tobacco smoking, obesity and family history of BE or EAC. Within the Veteran's Affair (VA) hospital in Northport, New York, many veterans possess multiple risk factors for BE. Residents in VA primary care clinic are diligent in colorectal cancer screening, yet there is concern for limited offerings for BE screening. Our project aims to study the barriers to BE screening within a high-risk veteran population. Method(s): This is a survey-based study. A total of 36 internal medicine residents working in VA primary care clinic were asked to fill out a survey regarding their perspective towards BE screening. The results of the survey are compiled in Table. Result(s): 36 residents within the clinic completed the survey. As shown in Table, 35 out of 36 residents expressed that the primary care clinic does not screen for BE adequately. 30 residents expressed uncertainty regarding referral criteria for BE screening, 24 residents revealed having never referred patients for BE screening. When asked about barriers regarding BE screening, consensus polling showed that there is a lack of resident education surrounding indications for screening. Other common barriers include lack of transportation for veterans to appointments, the COVID 19 pandemic, and lack of health literacy within the veteran population. Conclusion(s): Although there is no established guideline for BE screening, per AJG there is recommendation for a one-time screening endoscopy in susceptible population. VA patients pose a high-risk population that appears to have low screening rates. Patients appear to be placed on long term PPIs without re-assessment and endoscopic screening despite possessing multiple risk factors for BE. Our survey shows that within our resident cohort there is concern for lack of awareness regarding screening criteria for BE. With the initiation of this project, we hope to increase awareness of BE screening within the resident group and improve health outcomes within veteran population. (Table Presented).

Internal Medicine, Infection Control, and Occupational Health Services

The Department of Medicine played a seminal role in managing the crisis from the COVID-19 pandemic at Saint Barnabas Hospital (SBH) Health System that started in mid-March and reached its zenith in New York City in mid-late April 2020. Internal medicine, under normal circumstances, deals with a wide range of diseases and disproportionate impact from social determinants of health. The COVID-19 crisis completely upended the very systematic process of caring for this broad range of patients. Within a relatively short period of time - days to weeks - it required an almost complete reconfiguration of staffing, roles, and methods of communication to allow effective care for a large number of very sick patients. This chapter documents how Internal Medicine implemented those changes rapidly and the dynamic modifications that were made throughout the initial surge as the crisis took hold, to ultimately work efficiently and effectively in the fight against COVID-19. Specifically, the number of beds capable of caring for COVID-19 patients dramatically increased and multiple administrative spaces were transformed into clinical wards. The number of hospitalists progressively and rapidly increased leading to two COVID-19 services run by primary care physicians and additional services led by oncology, cardiology, and gastroenterology specialists, alongside a multidisciplinary COVID-19 Treatment Committee that made institutional recommendations about treatments. As many practices were standardized throughout the institution optimizing patient care and likely preventing many patients from requiring mechanical ventilation. © SBH Health System 2022.

Defence Medical Rehabilitation Centre (DMRC) COVID-19 Recovery Service.

Coronavirus disease 2019 (COVID-19) causes significant mortality and morbidity, with an unknown impact in the medium to long term. Evidence from previous coronavirus epidemics indicates that there is likely to be a substantial burden of disease, potentially even in those with a mild acute illness. The clinical and occupational effects of COVID-19 are likely to impact on the operational effectiveness of the Armed Forces. Collaboration between Defence Primary Healthcare, Defence Secondary Healthcare, Defence Rehabilitation and Defence Occupational Medicine resulted in the Defence Medical Rehabilitation Centre COVID-19 Recovery Service (DCRS). This integrated clinical and occupational pathway uses cardiopulmonary assessment as a cornerstone to identify, diagnose and manage post-COVID-19 pathology.

Development of High-Grade Sarcoma After Second Dose of Moderna Vaccine.

Coronavirus disease 2019 (COVID-19) is a disease characterized by predominantly respiratory symptoms, which can progress to respiratory failure. Due to the novelty of the vaccines, it is difficult to assess if there are any associated long-term side effects. Here, we present a case of an elderly female who received the Moderna COVID-19 vaccine and developed a high-grade sarcoma at the site of the injection. A 73-year-old female with a past medical history of hypertension, hyperlipidemia, and renal angiomyolipoma status post resection in 2019 presented with worsening right upper arm swelling for the past two weeks. She noticed the swelling two to four days after receiving her second dose of the Moderna vaccine within 1 cm from the prior injection site. Physical examination was remarkable for a 6 cm, circular, mobile, soft mass present in the right upper arm. MRI with and without contrast revealed a 5.2 cm soft tissue mass overlying the triceps region with irregular features concerning for malignancy. Fine needle aspiration revealed pathologic characteristics indicative of high-grade sarcoma. The patient ultimately had resection of the mass four months after the initial visit and was diagnosed as having grade 3, stage IIIA undifferentiated, pleomorphic high-grade sarcoma. Herein, we present a case demonstrating the development of high-grade sarcoma at the injection site in an elderly female patient within days of receiving the second dose of the Moderna COVID-19 vaccine. Currently, it is unclear whether there is a true association between the vaccines and malignancy or inflammatory response exacerbating underlying malignancy. This case highlights the necessity to investigate and be aware of such rare, adverse complications that may be associated with the novel COVID-19 vaccinations to guide physicians in their differential diagnosis.

Evaluation of Hospitalized Patient Outcomes in COVID-19 Infection for Continued versus Discontinued Use of Preadmission Antiplatelet Regimen.

OBJECTIVE: In SARS-CoV-2 (COVID-19) infection, it is unclear if continuation of preadmission antiplatelet regimens upon hospitalization will improve hypercoagulability outcomes. METHODS: This retrospective cohort study analyzed adult patients hospitalized with confirmed COVID-19 infection for a 6-week period from March 13, 2020, to April 27, 2020. Preadmission antiplatelet regimen continuation for less than 75% of admission was compared to continuation for at least 75% of admission. Pregnancy, either death or withdrawal of care within 24 hours of admission, and admission beyond the studied timeframe were excluded. The primary endpoint was difference in World Health Organization COVID-19 Ordinal Scale for Clinical Improvement values (World Health Organization [WHO] scores) between maximum score during admission to that upon discharge. Secondary endpoints were mechanical ventilation requirement, mortality, radiologically confirmed venous thromboembolism, major bleeding, and length of stay. RESULTS: This study included 171 patients. Patients failing to continue antiplatelet regimens for at least 75% of admission (n = 76) had significantly worse WHO score differences than those who did (n = 95) (median -1 vs 2; P < .05). Mechanical ventilation requirement (57% vs 27%; P < .05) and mortality (58% vs 29%; P < .05) also favored antiplatelet continuation. All other endpoints were not significantly different. CONCLUSION: Significantly improved WHO scores, mechanical ventilation requirement, and mortality occurred in patients continuing preadmission antiplatelet regimens in COVID-19 infection. Future prospective studies of COVID-19 patients with consistently collected baseline hypercoagulability markers (platelets, D-dimer, fibrinogen, and coagulation studies) and similar severe disease risk factors are required to confirm potential benefits of antiplatelet therapy during hospitalization.

Nurse-led virtual interventions in managing chronic diseases: a protocol for a systematic review of randomised controlled trials.

INTRODUCTION: Technological advances are changing nursing practice; however, nurse-led virtual care for chronic disease management has not yet been adequately explored and described. This study will review and analyse the effects of nurse-led virtual services and describe the virtual intervention characteristics relevant to the scope of nursing practice in chronic disease management. METHODS AND ANALYSIS: This study will systematically review randomised controlled trials evaluating the effects of nurse-led virtual care interventions on patients with chronic conditions. Databases including PubMed, Embase, Web of Science, CINAHL, Chinese National Knowledge Infrastructure, Wanfang (Chinese) and VIP Chinese Science and Technology Periodicals will be searched. All studies will be screened and selected using the criteria described in 'population, intervention, comparison, outcome and study design' format. Relevant studies will be searched using the reference lists of eligible studies and review articles. The risk of bias will be assessed using the Joanna Briggs Institute Quality Appraisal Form. Two reviewers will independently extract data from all the included studies using a standardised data extraction form on the Covidence platform. RevMan V.5.3 software will be used to perform the meta-analysis. Data synthesis will be conducted with descriptive synthesis by summarising and tabulating the data and presenting them according to the research questions. ETHICS AND DISSEMINATION: Formal ethical approval is not required as the data used in this systematic review are abstracted from the pre-existing literature. The results of this study will be disseminated through peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022361260.

Time Does Matter: Reduced Internal Medicine Clerkship Clinical Experiences Due to COVID-19.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has affected medical education in many ways. The Association of American Medical Colleges (AAMC) temporarily suspended clinical student rotations, calling for a transition to remote learning. Unfortunately, due to the heavy impact of COVID-19 in our South Florida community, medical students were not able to return to in-person activities for a significant time. During this period, students had remote clerkship learning activities, didactic sessions, narrative projects, and small-group learning sessions, which were front-loaded using Zoom technology (Zoom Video Communications, Inc., San Jose, California, United States) and web-based learning tools. Once in-person clinical experiences resumed, the duration of all third-year clerkships for the remainder of the year was reduced to five weeks to allow for timely graduation. The Herbert Wertheim College of Medicine (HWCOM) Internal Medicine (IM) clerkship has traditionally been an eight-week-long rotation. Other clerkships that varied from six to eight weeks were similarly reduced to five weeks. We hypothesized that the shortened duration of the IM clerkship would have negative impacts on National Board of Medical Examiners (NBME) exam performance and clerkship clinical experiences would likely be affected. Methods We compared the NBME subject exam results and end of clerkship evaluations from the Class of 2021 (CO2021) which had the traditional eight weeks of patient care, with the CO2022, which had only five weeks of in-person patient care. A T-test analysis was performed comparing performance on the NBME medicine clinical subject exam between students who completed the usual eight-week rotation versus those who completed a five-week rotation. We also evaluated the IM clerkship course evaluation and analyzed student responses and ratings to assess any areas that were statistically significant when comparing the traditional eight-week IM clerkship to the shortened five-week clerkship. Results There was no statistically significant difference (t=0.68, p<0.4951) in mean NBME subject exam performance between cohorts. Students who completed the shortened five-week IM clerkship indicated there was limited volume and diversity of patients, which consequently affected their ability to complete all the required clinical experiences for the IM clerkship. These results indicated a statistically significant difference between the two cohorts (t =3.33, p<.001). Conclusion Students with shortened IM clerkship clinical care time (five weeks) were found to have no significant statistical differences in NBME subject exam performance compared to the traditional eight-week cohorts. However, students felt there was a decreased volume and diversity of patients, and they reported greater difficulties in completing the required clinical experiences, with diminished clinical confidence. Time does matter, and clinical time is very valuable for a student's undergraduate medical education. If another pandemic were to arise, the duration of different clerkships should be carefully assessed and individualized, and methods to assess and reclaim lost clinical time during the advanced clinical and postgraduate years should be considered.

Analysis of mortality in an Intermediate Respiratory Care Unit (ICRU)

Introduction The development of non-invasive mechanical ventilation (NIMV), its scientific evidence and the need to monitor the most severe cases, has led to the creation of the IRCUs. In our hospital, we apply NIMV to patients with acute respiratory failure (ARF) or exacerbated chronic respiratory failure (ACRF). Material and methods Prospective study of 220 non-Covid patients with ARF or ACRF who require NIMV and admission to the IRCU. General clinical and radiological data were collected and mortality was analyzed, as well as compared with the year 2019, when we did not have an IRCU. Results Mean age 71 years, (56 % men) and a Charlson Index (mean) of 6.4 points. The most frequent respiratory failure was hypercapnic 65 % vs. hypoxemic 34 %. After IRCU, 77 % were referred to the ward, 5 % to the Intensive Care Unit (ICU), and 17 % died or began comfort measures. Mortality in the IRCU is significantly related to the data in the table. There are 12 % of patients who, having been discharged from the IRCU, finally die during the rest of their hospital stay. Of these, 3 % are deaths of those admitted to the ICU, and 9 % to deaths on the ward after discharge from the IRCU. Analyzing mortality, we found significant differences in terms of the service they belong to (Internal Medicine 41 %), hypoxemic failure (58 %), bilateral infiltrates (52 %), age (80 years) and Charlson Index (7.8) (*Tab. 1). Finally, we have compared mortality in the IRCU with that of 2019 when we did not have this Unit, using the hospital mortality data (not mortality in the IRCU as it was not available in 2019). For this, we have amnalyzed a representative saple of 53 % of the most severe cases treated in 2019 with NIMV in the ward, according to Apache II, and which was similar in age and comorbidities to those admitted to the IRCU. **Without IRCU: Age 70.6 years // Charlson 6.4 // ICU admission 15 % // Hospital mortality 38 %. **With IRCU: Age 71 years // Charlson 6.4 // ICU admission 5 % // Hospital mortality 29 % Conclusions Mortality is higher in hypoxemics, related to Charlson Index and infiltrates. The opening of the IRCU has led to a decrease in hospital mortality for severe patients who require NIMV, and a 66 % decrease in ICU admissions.