Analysis of Protein Biomarkers From Hospitalized COVID-19 Patients Reveals Severity-Specific Signatures and Two Distinct Latent Profiles With Differential Responses to Corticosteroids.

OBJECTIVES: To identify and validate novel COVID-19 subphenotypes with potential heterogenous treatment effects (HTEs) using electronic health record (EHR) data and 33 unique biomarkers. DESIGN: Retrospective cohort study of adults presenting for acute care, with analysis of biomarkers from residual blood collected during routine clinical care. Latent profile analysis (LPA) of biomarker and EHR data identified subphenotypes of COVID-19 inpatients, which were validated using a separate cohort of patients. HTE for glucocorticoid use among subphenotypes was evaluated using both an adjusted logistic regression model and propensity matching analysis for in-hospital mortality. SETTING: Emergency departments from four medical centers. PATIENTS: Patients diagnosed with COVID-19 based on International Classification of Diseases , 10th Revision codes and laboratory test results. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Biomarker levels generally paralleled illness severity, with higher levels among more severely ill patients. LPA of 522 COVID-19 inpatients from three sites identified two profiles: profile 1 ( n = 332), with higher levels of albumin and bicarbonate, and profile 2 ( n = 190), with higher inflammatory markers. Profile 2 patients had higher median length of stay (7.4 vs 4.1 d; p < 0.001) and in-hospital mortality compared with profile 1 patients (25.8% vs 4.8%; p < 0.001). These were validated in a separate, single-site cohort ( n = 192), which demonstrated similar outcome differences. HTE was observed ( p = 0.03), with glucocorticoid treatment associated with increased mortality for profile 1 patients (odds ratio = 4.54). CONCLUSIONS: In this multicenter study combining EHR data with research biomarker analysis of patients with COVID-19, we identified novel profiles with divergent clinical outcomes and differential treatment responses.

Risk factors associated with glycated hemoglobin A1c trajectories progressing to type 2 diabetes.

BACKGROUND AND OBJECTIVE: The notion of prediabetes, defined by the ADA as glycated hemoglobin A1c (HbA1c) of 5.7-6.4%, implies increased vascular inflammatory and immunologic processes and higher risk for developing diabetes mellitus and major cardiovascular events. We aimed to determine the risk factors associated with rapid progression of normal and prediabetes patients to type 2 diabetes mellitus (T2DM). METHODS: Retrospective cohort study in a single 8-hospital health system in southeast Michigan, between 2006 and 2020. All patients with HbA1c <6.5% at baseline and at least 2 other HbA1c measurements were clustered in five trajectories encompassing more than 95% of the study population. Multivariate linear regression analysis was performed to examine the association of demographic and comorbidities with HbA1c trajectories progressing to diabetes. RESULTS: A total of 5,347 prediabetic patients were clustered based on their HbA1c progression (C1: 4,853, C2: 253, C66: 102, C12: 85, C68: 54). The largest cluster (C1) had a baseline median HbA1c value of 6.0% and exhibited stable HbA1c levels in prediabetic range across all subsequent years. The smallest cluster (C68) had the lowest median baseline HbA1c value and also remained stable across subsequent years. The proportion of normal HbA1c in each of the pre-diabetic trajectories ranged from 0 to 12.7%, whereas 81.5% of the reference cluster (C68) were normal HbA1c at baseline. The C2 (steady rising) trajectory was significantly associated with BMI (adj OR 1.10, 95%CI 1.03-1.17), and family history of DM (adj OR 2.75, 95%CI 1.32-5.74). With respect to the late rising trajectories, baseline BMI was significantly associated with both C66 and C12 trajectory (adj OR 1.10, 95%CI 1.03-1.18) and (adj OR 1.13, 95%CI 1.05-1.23) respectively, whereas, the C12 trajectory was also significantly associated with age (adj OR 1.62, 95%CI 1.04-2.53) and history of MACE (adj OR 3.20, 95%CI 1.14-8.93). CONCLUSIONS: We suggest that perhaps a more aggressive preventative approach should be considered in patients with a family history of T2DM who have high BMI and year-to-year increase in HbA1c, whether they have normal hemoglobin A1c or they have prediabetes.KEY MESSAGESProgression to diabetes from normal or prediabetic hemoglobin A1c within four years is associated with baseline BMI.A steady rise in HbA1c during a four-year period is associated with age and family history of T2DM, whereas age and personal history of MACE are associated with a rapid rise in HbA1c.A more aggressive preventative approach should be considered in patients with a family history of T2DM who have high BMI and year-to-year increase in HbA1c.

Prognostic Value of SARS-CoV-2 Anti-RBD IgG Antibody Quantitation on Clinical Outcomes in Hospitalized COVID-19 Patients.

Background: Antibody levels against SARS-CoV-2 can be used as an indicator of recent or past vaccination or infection. However, the prognostic value of antibodies targeting the receptor binding protein (anti-RBD) in hospitalized patients is not widely reported. Purpose: Determine prognostic impact of SARS-CoV-2 antibody quantification at the time of admission on clinical outcomes in hospitalized COVID-19 patients. Methods: We conducted a pilot observational study on patients hospitalized with SARS-CoV-2 infection to determine the prognostic impact of antibody quantitation within the first two days of admission. Anti-nucleocapsid IgG (anti-N) and Anti-RBD levels were measured. Anti-RBD level of 500 AU/mL was used as a cutoff to stratify patients. Spearman's rank Coefficient (rs) was used to demonstrate association. Results: Of the 26 patients included, those who were vaccinated more frequently tested positive for Anti-RBD (100% vs 46.2%, P = 0.005) with higher median titer level (623 vs 0, P = 0.011) compared to unvaccinated patients. Anti-N positivity was more frequently seen in unvaccinated patients (53.9% vs 7.7%, P = 0.03). Anti-RBD levels >500 were associated with lower overall hospital length of stay (LOS)(5 vs 10 days, P = 0.046). The analysis employing a Spearman Rank coefficient demonstrated a strong negative correlation between anti-S titer and LOS (rs=-.515, p = 0.007) and a moderate negative correlation with oxygen needs (rs =-.401, p = 0.042). Conclusion: Anti-RBD IgG levels were associated with lower LOS and oxygen needs during hospitalization. Further studies are needed to determine if levels on admission can be used as a prognostic indicator.

High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19.

Intravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated. This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest. From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439). HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.

Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care.

BACKGROUND: Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes. METHODS: Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed. RESULTS: Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured. CONCLUSIONS: Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.

Social Determinants of Health Correlating with Mechanical Ventilation of COVID-19 Patients: A Multi-Center Observational Study.

IMPORTANCE: Several studies have relayed the disproportionate impact of COVID-19 on marginalized communities; however, few have specifically examined the association between social determinants of health and mechanical ventilation (MV). OBJECTIVE: To determine which demographics impact MV rates among COVID-19 patients. DESIGN: This observational study included COVID-19 patient data from eight hospitals' electronic medical records (EMR) between February 25, 2020, to December 31, 2020. Associations between demographic data and MV rates were evaluated using uni- and multivariate analyses. SETTING: Multicenter (eight hospitals), largest health system in Southeast Michigan. PARTICIPANTS: Inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab. Exclusion criteria were missing demographic data or non-permanent Michigan residents. EXPOSURE: Patients were divided into two groups: MV and non-MV. MAIN OUTCOME AND MEASURES: The primary outcome was MV rate per demographic. A multivariate model then predicted the odds of MV per demographic descriptor. Hypotheses were formulated prior to data collection. RESULTS: Among 11,304 COVID-19 inpatients investigated, 1621 (14.34%) were MV, and 49.96% were male with a mean age of 63.37 years (17.79). Significant social determinants for MV included Black race (40.19% MV vs 31.31% non-MV, p<0.01), poverty (14.60% vs. 13.21%, p<0.01), and disability (12.65% vs 9.14%; p<0.01). Black race (AOR 1.61 (CI 1.41-1.83; p<0.01)), median income (AOR 0.99 (CI 0.99-0.99; p<0.01)), disability (AOR 1.55 (CI 1.26, 1.90; p<0.01)), and non-English-speaking status (AOR 1.26 (CI 1.05, 1.53)) had significantly higher odds of MV. CONCLUSIONS AND RELEVANCE: Black race, low socioeconomic status, disability, and non-English-speaking status were significant risk factors for MV from COVID-19. An urgent need remains for a pandemic response program that strategizes care for marginalized communities.

Prediabetes as a risk factor for major adverse cardiovascular events.

INTRODUCTION: Type II diabetes mellitus (DM) is a proinflammatory process and a known risk factor for major adverse cardiac events (MACE). The same inflammatory markers may be present in prediabetes (pDM); however, the relationship between pDM by HbA1c and MACE is not well studied. We sought to see if pDM increases one's risk for MACE. METHODS: We retrospectively studied patients at Beaumont Health, Michigan between 2006 and 2020. We divided patients into groups (G1-G5) based on haemoglobin A1c (HbA1c) trends over the study period as follows: G1: pDM patients who remained pDM; G2: pDM who progressed into DM; G3: pDM who normalized their HbA1c; G4: patients who maintained a normal HbA1c; and G5: patients with HbA1c persistently in the DM range. We compared MACE between the groups by univariate and multivariate regression analyses. RESULTS: A total of 119,271 patients were included in the study (G1: N = 13,520, G2: N = 6314, G3: N = 1585, G4: N = 15,018, G5: N = 82,834). Pairwise comparison revealed a statistically significant increase in the odds of MACE in all groups compared to those with normal HbA1c values (G4; p < .001). After adjusting for baseline characteristics, multivariate regression revealed elevated odds of MACE in patients with persistent pDM (G1; aOR = 1.087, p = .002) and diabetes (G2/G5; aOR = 1.25 and aOR = 1.18, p < .001) compared to individuals with normal HbA1c values. CONCLUSION: Prediabetes is a risk factor for MACE. Normalization of HbA1c values appears to decrease the adjusted risk for MACE and should be the goal in patients with pDM.KEY MESSAGESPatients with prediabetes (pDM) are at increased risk for major cardiovascular events.Normalization of HbA1c in pDM patients may have a clinically significant benefit, in terms of lowering the MACE risk.Prediabetes patients who progress into diabetes mellitus may represent a particularly high-risk group.

Congestive Heart Failure 30-Day Readmission: Descriptive Study of Demographics, Co-morbidities, Heart Failure Knowledge, and Self-Care.

Background Congestive heart failure (CHF) readmissions are associated with substantial financial and medical implications. We performed a descriptive study to determine demographic, clinical, and behavioral factors associated with 30-day readmission. Materials and methods Patients hospitalized with CHF at William Beaumont Hospital in Royal Oak, MI, from March 2019-May 2019 were studied. Response to heart failure knowledge and self-care questionnaires along with the patients' demographic and clinical factors were collected. Thirty-day readmission to any of the eight hospitals in the Beaumont Health System was documented. Results One-hundred ninety-six (196) patients were included. The all-cause 30-day readmission rate was 23%. A numerical higher rate of readmissions was observed among males (23.7% vs 22.2%), current smokers (27.3% vs 22.9%), and patients with peripheral vascular disease (PVD; 28.9% vs 21.2%), diabetes mellitus (DM; 26.4% vs 18.9%), hypertension (HTN; 26.4% vs 10%), coronary artery disease (CAD; 24.6% vs 19%), and prior history of cerebrovascular accident (CVA; 28.9% vs 21.2%) (p>0.05). Reduced left ventricular ejection fraction (LVEF) was associated with higher readmissions (24.4% vs 20.5%, p=0.801). Patients with the highest reported questionnaire scores corresponding to better heart failure knowledge and self-care behaviors at home were readmitted at a similar rate compared to those scoring in the lowest interval (25%, p=0.681). Conclusion Though statistically insignificant due to the limitations of sample size, a higher percentage of readmissions was observed in male patients, current smokers, reduced LVEF, and higher comorbidity burden. Better reported patient self-care behavior, medication compliance, and heart failure knowledge did not correlate with reduced readmission rates. While the impact of medical comorbidities on 30-day readmissions is better established, the role of socioeconomic factors remains unclear and might suggest a focus for future work.

The Impact of Disparities in Social Determinants of Health on Hospitalization Rates for Patients with COVID-19 in Michigan (USA).

IMPORTANCE: The COVID-19 pandemic continues to impact the health-care system in the United States and has brought further light on health disparities within it. However, only a few studies have examined hospitalization risk with regard to social determinants of health. OBJECTIVE: We aimed to identify how health disparities affect hospitalization rates among patients with COVID-19. DESIGN: This observational study included all individuals diagnosed with COVID-19 from February 25, 2020 to December 31, 2020. Uni- and multivariate analyses were utilized to evaluate associations between demographic data and inpatient versus outpatient status for patients with COVID-19. SETTING: Multicenter (8 hospitals), largest size health system in Southeast Michigan, a region highly impacted by the pandemic. PARTICIPANTS: All outpatients and inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab were included. Exclusion criteria included missing demographic data or status as a non-permanent Michigan resident. EXPOSURE: Patients who met inclusion and exclusion criteria were divided in 2 groups: outpatients and inpatients. MAIN OUTCOME AND MEASURES: We described the comparative demographics and known disparities associated with hospitalization status. RESULTS: Of 30,292 individuals who tested positive for SARS-CoV-2, 34.01% were admitted to the hospital. White or Caucasian race was most prevalent (57.49%), and 23.35% were African-American. The most common ethnicity was non-Hispanic or Latino (70.48%). English was the primary language for the majority of patients (91.60%). Private insurance holders made up 71.11% of the sample. Within the hospitalized patients, lower socioeconomic status, African-American race and Hispanic and Latino ethnicity, non-English speaking status, and Medicare and Medicaid were more likely to be admitted to the hospital. CONCLUSIONS AND RELEVANCE: Several health disparities were associated with greater rates of hospitalization due to COVID-19. Addressing these inequalities from an individual to system level may improve health-care outcomes for those with health disparities and COVID-19.

Healthcare Disparities Correlated with In-Hospital Mortality in COVID-19 Patients.

INTRODUCTION: Increasing age, male gender, African American race, and medical comorbidities have been reported as risk factors for COVID-19 mortality. We aimed to identify health-care disparities associated with increased mortality in COVID-19 patients. METHODS: We performed an observational study of all hospitalized patients with SARS-CoV2 infection from within the largest multicenter healthcare system in Southeast Michigan, from February to December, 2020. RESULTS: From 11,304 hospitalized patients, 1295 died, representing an in-hospital mortality rate of 11.5%. The mean age of hospitalized patients was 63.77 years-old, with 49.96% being males. Older age (AOR = 1.05, p < 0.0001), male gender (AOR = 1.43, p < 0.0001), divorced status (AOR = 1.25, p = 0.0256), disabled status (AOR = 1.42, p = 0.0091), and homemakers (AOR = 1.96, p = 0.0216) were significantly associated with in-hospital mortality. CONCLUSION: Older age, male gender, divorced and disabled status and homemakers were significantly associated with in-hospital mortality if they developed COVID-19. Further research should aim to identify the underlying factors driving these disparities in COVID-19 in-hospital mortality.

Effect of Long-Term Proton Pump Inhibitor Use on Glycemic Control in Patients with Type Two Diabetes Mellitus.

There have been conflicting results regarding the effect of proton pump inhibitors (PPIs) as an adjunctive therapy to oral antidiabetic medication (OAM) in those with type 2 diabetes (T2DM). PPIs increase gastrin levels, causing a rise in insulin. No studies have evaluated the duration of PPI therapy and its effect on glycemic control. Medical records across 8 hospitals between 2007 and 2016 were reviewed for 14,602 patients with T2DM (not on insulin therapy) taking PPIs. Values of HbA1c (baseline, follow-up, and the difference between the two) in those prescribed with PPIs and years of therapy were compared to HbA1c values of those who had no record of PPI use. Baseline and follow-up HbA1c for patients on PPIs were 6.8 and 7.0, respectively, compared to 7.1 and 7.2 in their untreated counterparts (p < 0.001 in both comparisons). For both groups, an increase in baseline HbA1c was seen with time. Those on PPI had an increase in HbA1c of 0.16 compared to 0.08 in those not prescribed PPI. Our results show no relationship between the length of PPI therapy and HbA1c reduction.

Treatment of May-Thurner's Syndrome and Associated Complications: A Multicenter Experience.

OBJECTIVE: To assess the treatment options and associated complications in patients with May-Thurner's syndrome (MTS). METHODS: We retrospectively reviewed the charts of patients diagnosed with MTS. Thorough review was completed and data relevant to methods of diagnosis, treatment, complications, hospital readmission, and mortality were extracted from patient charts. The patients were followed for two years after diagnosis. RESULTS: Of the 47 patients identified as having "MTS", 32 (70%) were diagnosed formally with either magnetic resonance venography, computed tomography venography, or ultrasound. Two patients were excluded for insufficient availability of follow-up records. Mean age of the population included (N = 30) was 50.24 ±15.33 years and 83% (N = 25) had female gender. The majority (40%) of patients were treated with anticoagulation, thrombolysis, and stent placement, and 13.3% received a combination of anticoagulation, antiplatelet agent, thrombolysis, and stent placement. Overall, we found 28 patients (93%) who underwent endovascular stenting. However, 39.3% (11/28) had stent-related complications that included stent thrombosis, stenosis, and migration. One patient underwent open heart surgery for stent retrieval. Duration of anticoagulation therapy ranged from 6 months to lifelong. Two patients (6.7%) suffered major bleeds requiring transfusion. Fourteen patients (46.6%) developed post-thrombotic syndrome. Seven (23.3%) patients required MTS-related readmission within 30 days. No mortality was noted at two-year follow-up. CONCLUSION: Although our study only included 30 patients, it was evident to us that there is no consensus in the management of MTS. Furthermore, endovascular stenting, which has a major role in the management of MTS, has complication rates that hover close to 40%. Further research is needed to help develop a standardized evidence-based approach in the management of MTS that ensures a decreased risk of immediate and long-term complications.

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy.

GOALS AND BACKGROUND: The utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE. STUDY: Retrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates. RESULTS: Five hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13-23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications. CONCLUSION: Routine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.

Evidence-based medicine curricula and barriers for physicians in training: a scoping review.

OBJECTIVES: To describe the published literature on EBM curricula for physicians in training and barriers during curriculum implementation. METHODS: We performed a systematic search and review of the medical literature on PubMed, Embase, ERIC, Scopus and Web of Science from the earliest available date until September 4, 2019. RESULTS: We screened 9,042 references and included 29 full-text studies and 14 meeting abstracts. Eighteen studies had moderate validity, and 6 had high validity. The EBM curricular structure proved highly variable in between studies. The majority of the EBM curricula was longitudinal with different lengths. Only five studies reported using Kern's six-step approach for curriculum development. Twenty-one articles reported on EBM skills and knowledge, and only 5/29 full-text articles used a validated assessment tool. Time was the main barrier to EBM curriculum implementation. All the included studies and abstracts, independent of the EBM curriculum structure or evaluation method used, found an improvement in the residents' attitudes and/or EBM skills and knowledge. CONCLUSIONS: The current body of literature available to guide educators in EBM curriculum development is enough to constitute a strong scaffold for developing any EBM curriculum. Given the amount of time and resources needed to develop and implement an EBM curriculum, it is very important to follow the curriculum development steps and use validated assessment tools.

Epidemiology, Clinical Characteristics, and Outcomes of a Large Cohort of COVID-19 Outpatients in Michigan.

BACKGROUND: Most outpatients with coronavirus disease 2019 (COVID-19) do not initially demonstrate severe features requiring hospitalization. Understanding this population's epidemiological and clinical characteristics to allow outcome anticipation is crucial in healthcare resource allocation. METHODS: Retrospective, multicenter (8 hospitals) study reporting on 821 patients diagnosed with COVID-19 by real-time reverse transcriptase-polymerase chain reaction assay of nasopharyngeal swabs and discharged home to self-isolate after evaluation in emergency departments (EDs) within Beaumont Health System in March, 2020. Outcomes were collected through April 14, 2020, with a minimum of 12 day follow-up and included subsequent ED visit, admission status, and mortality. RESULTS: Of the 821 patients, mean age was 49.3 years (SD 15.7), 46.8% were male and 55.1% were African-American. Cough was the most frequent symptom in 78.2% of patients with a median duration of 3 days (IQR 2-7), and other symptoms included fever 62.1%, rhinorrhea or nasal congestion 35.1% and dyspnea 31.2%. ACEI/ARBs usage was reported in 28.7% patients and 34.0% had diabetes mellitus. Return to the ED for re-evaluation was reported in 19.2% of patients from whom 54.4% were admitted. The patients eventually admitted to the hospital were older (mean age 54.4 vs 48.7 years, p=0.002), had higher BMI (35.4 kg/m2 vs 31.9 kg/m2, p=0.004), were more likely male (58.1% vs 45.4%, p=0.026), and more likely to have hypertension (52.3% vs 29.4%, p<0.001), diabetes mellitus (74.4% vs 29.3%, p<0.001) or prediabetes (25.6% vs 8.4%, p<0.001), COPD (39.5% vs 5.4%, p<0.001), and OSA (36% vs 19%, p<0.001). The overall mortality rate was 1.3%. CONCLUSION: We found that 80.8% of patients did not return to the ED for re-evaluation. Sending patients with COVID-19 home if they experience mild symptoms is a safe approach for most patients and might mitigate some of the financial and staffing pressures on healthcare systems.

Vestibular neuritis caused by severe acute respiratory syndrome coronavirus 2 infection diagnosed by serology: Case report.

Vestibular neuritis is a disorder selectively affecting the vestibular portion of the eighth cranial nerve generally considered to be inflammatory in nature. There have been no reports of severe acute respiratory syndrome coronavirus 2 causing vestibular neuritis. We present the case of a 42-year-old Caucasian male physician, providing care to COVID-19 patients, with no significant past medical history, who developed acute vestibular neuritis, 2 weeks following a mild respiratory illness, later diagnosed as COVID-19. Physicians should keep severe acute respiratory syndrome coronavirus 2 high on the list as a possible etiology when suspecting vestibular neuritis, given the extent and implications of the current pandemic and the high contagiousness potential.

Machine learning methods to predict mechanical ventilation and mortality in patients with COVID-19.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has affected millions of people across the globe. It is associated with a high mortality rate and has created a global crisis by straining medical resources worldwide. OBJECTIVES: To develop and validate machine-learning models for prediction of mechanical ventilation (MV) for patients presenting to emergency room and for prediction of in-hospital mortality once a patient is admitted. METHODS: Two cohorts were used for the two different aims. 1980 COVID-19 patients were enrolled for the aim of prediction ofMV. 1036 patients' data, including demographics, past smoking and drinking history, past medical history and vital signs at emergency room (ER), laboratory values, and treatments were collected for training and 674 patients were enrolled for validation using XGBoost algorithm. For the second aim to predict in-hospital mortality, 3491 hospitalized patients via ER were enrolled. CatBoost, a new gradient-boosting algorithm was applied for training and validation of the cohort. RESULTS: Older age, higher temperature, increased respiratory rate (RR) and a lower oxygen saturation (SpO2) from the first set of vital signs were associated with an increased risk of MV amongst the 1980 patients in the ER. The model had a high accuracy of 86.2% and a negative predictive value (NPV) of 87.8%. While, patients who required MV, had a higher RR, Body mass index (BMI) and longer length of stay in the hospital were the major features associated with in-hospital mortality. The second model had a high accuracy of 80% with NPV of 81.6%. CONCLUSION: Machine learning models using XGBoost and catBoost algorithms can predict need for mechanical ventilation and mortality with a very high accuracy in COVID-19 patients.

In-hospital outcomes of patients with chronic kidney disease undergoing percutaneous coronary intervention for chronic total occlusion: a systematic review and meta-analysis.

BACKGROUND: The relative safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in patients with chronic kidney disease (CKD) have not been well defined. We performed a systematic review and meta-analysis of observational studies to assess in-hospital outcomes in this population. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to April 2020 for all clinical trials and observational studies. Five observational studies with a total of 6769 patients met our inclusion criteria. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR <60 ml/min/1.73m2 in CKD group and ≥ 60 ml/min/1.73m2 in non-CKD group). The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury, coronary injury (perforation, dissection or tamponade), stroke and procedural success. Mantel-Haenszel random-effects model was used to calculate the odds ratio (OR) and 95% confidence intervals (CI). RESULTS: In-hospital mortality was significantly higher among patients with CKD undergoing PCI for CTO (OR: 5.16, 95% CI: 2.60-10.26, P < 0.00001). Acute kidney injury (OR: 2.54, 95% CI: 1.89-3.40, P < 0.00001) and major bleeding (OR: 2.58, 95% CI: 1.20-5.54, P < 0.01) were also more common in the CKD group. No significant difference was observed in the occurrence of stroke (OR: 2.36, 95% CI: 0.74-7.54, P < 0.15) or coronary injury (OR: 1.38, 95% CI: 0.98-1.93, P < 0.06) between the two groups. Non-CKD patients had a higher likelihood of procedural success compared to CKD patients (OR: 0.66, 95% CI: 0.57-0.77, P < 0.00001). CONCLUSION: Patients with CKD undergoing PCI for CTO have a significantly higher risk of in-hospital mortality, acute kidney injury and major bleeding when compared to non-CKD patients. They also have a lower procedural success rate.