Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill.

Context: The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective: This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods: This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results: Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM. Conclusion: These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.

Effects of the COVID-19 Crisis on Resident Well-Being in a Community Teaching Hospital.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has been an unexpected crisis that continues to challenge the medical community at large. Healthcare environments have been forced to change dramatically, including for medical residents, who are vital members of the innovative emergency response teams. Articles have previously been published on the effects of crises on the well-being of healthcare practitioners; however, there is a paucity of literature targeting medical residents' experiences and general wellness during devastating events. The objective of our study aimed at understanding the emotional impact of the COVID-19 pandemic on residents' stress, academics, and support systems. METHODS: An anonymous, voluntary Likert scale questionnaire was sent via SurveyMonkey to Internal Medicine and Family Medicine residents in July 2020. Questions focused on residents' mood; stress levels; sense of support; and academics before, during, and immediately after the first surge of COVID-19 at our hospital between March 13 and June 15, 2020. RESULTS: Residents felt sad, stressed, and overworked during the first wave, as opposed to feelings of neutrality and happiness before and immediately after. Levels of concern for personal and loved ones' safety were significantly increased during and after our first wave. The impact on educational training was rated as neutral. Residents noted that institutional support could be improved by the provision of wellness activities and sponsored social events. CONCLUSIONS: This study provides insight on resident well-being during the initial months of the pandemic and identifies areas that could be improved. Our results demonstrated that the pandemic affected many aspects of residents' well-being and education, and the lessons learned can help guide healthcare institutions when implementing wellness activities for trainees during subsequent crises.

Prognostic Value of Coronary Artery Calcification Identified by the Semi-quantitative Weston Method in the Emergency Room or Other Hospitalized Patients.

Background: Coronary artery calcification (CAC) may provide insight to the patients' coronary artery disease (CAD) risks and influence early intervention. With increasing use of non-gated CT scans in clinical practice, the visual coronary artery scoring system (Weston Method) could quickly provide clinicians with important information of CAC for patient triage and management. Methods: We retrospectively studied the available CT imaging data and estimated CAC burden using the Weston method in 493 emergency room or other hospitalized patients. The Weston scores were calculated by the sum of the score for each vessel including the left main, left anterior descending, left circumflex artery and right coronary artery (range 0-12). The primary endpoint was a composite of the major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and coronary revascularization. Results: During a median follow-up of 85 months, a total of 25 (5.1%) MACE were recorded and 57 (11.2%) patients died from any causes. Detectable CAC was most common (96%) in the left anterior descending coronary arteries. Multivariable analysis showed that CAC total scores were independent predictors for MACE and all-cause mortality. Receiver operating characteristic analysis showed that CAC total score ≥5 was the optimal cutoff value for predicting MACEs. Conclusions: In the emergency room and hospitalized patients, the semi-quantitation of CAC burden using the Weston score system was related to the long-term cardiovascular outcomes including mortality. Clinicians and radiologists should maximize the value of non-contrast chest CT images by reporting CAC details.

Porphyromonas asaccharolytica as a Rare Causative Agent for Lemierre's Syndrome.

Lemierre's syndrome is a rare disease associated with significant morbidity and mortality. It begins with an oropharyngeal infection, which spreads locally to involve the internal jugular vein causing thrombophlebitis, followed by distant spread and metastatic infections. Affected individuals are commonly young adults. Causative organisms are usually oropharyngeal flora, most commonly being the anaerobe Fusobacterium necrophorum. Porphyromonas asaccharolytica is a rare etiological agent with only three cases being reported in the literature. This case report describes a previously healthy 22-year-old man who initially presented with acute tonsillitis and was later found to have left internal jugular vein thrombophlebitis along with bilateral septic emboli to the lungs. The patient was treated with a five-week course of ampicillin-sulbactam and metronidazole. Subsequent imaging also showed progression of internal jugular vein thrombus, for which warfarin was given for three months for anticoagulation.