Mortality due to COVID-19 infection: A comparison of first and second waves.

BACKGROUND: The USA suffered an initial wave of COVID-19 cases from March to July in 2020. Cases again surged in August 2020 as business restrictions were lifted. We aimed to describe demographic, treatment, and mortality differences between both waves. METHODS: We identified all hospitalized patients with COVID-19 infection in one US six-hospital health system between 1 March 2020 and 31 January 2021. We compared data obtained on patient demographics, treatment received, and mortality between first and second waves of the pandemic. RESULTS: A total of 4434 hospitalized COVID patients were identified, including 1313 patients in the first wave and 3121 patients in the second wave. Mortality was significantly higher in the first wave as compared to the second wave (23.2% vs. 12.3%, p < 0.001). Age and sex were similar in each wave. In the first wave, there were significantly more Non-Hispanic Black patients (28.8 vs. 18.1%, p < 0.001) and Hispanic patients (26.6% vs. 14.9%, p < 0.001) as compared to the second wave. There was a higher mortality rate in the first wave as compared to the second, which persisted after multivariable adjustment for sex, age, ethnicity, laboratory results at admission, treatment received, high flow use and mechanical ventilation (OR: 2.66, 95% CI: 1.83-3.87, p < 0.001). CONCLUSION: Mortality in the second wave was lower than the first wave with significantly higher utilization of steroids, remdesivir and convalescent plasma in second wave.

Impostor syndrome in hospitalists- a cross-sectional study.

Impostor syndrome (IS) is a psychological phenomenon in which highly successful people are plagued with self-doubt. Its prevalence in hospitalists and effects of mentoring programs are unknown. We surveyed 71 hospitalists at one hospital for symptoms of IS using the Clance Impostor Phenomenon Scale (CIPS). Mean CIPS score was 53.82 (±17.1). Twenty-four participants (33.8%) had IP scores >60, indicating impostor syndrome. There was no difference in score for men and women (56.70 versus 53.02, p = 0.35). Non-white hospitalists had lower rates of impostor syndrome compared to white hospitalists (25% versus 43%, p = 0.002). Impostors had no difference in years as a hospitalist compared to non-impostors (6.96 versus 6.62 years, p = 0.81). Hospitalists with mentors compared to those without had no difference in rates of impostor syndrome (40% versus 34.1%, p = 0.88). The prevalence of impostor syndrome is similar in hospitalists to other professions. A voluntary mentoring program was not associated with lower prevalence.

Remdesivir improved time to recovery in adults hospitalized with COVID-19 and lower respiratory tract involvement.

SOURCE CITATION: Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of Covid-19-preliminary report. N Engl J Med. 2020. [Epub ahead of print]. 32445440.

Recommendations for caring for patients with severe and nonsevere COVID-19.

SOURCE CITATION: Ye Z, Rochwerg B, Wang Y, et al. Treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence-based guideline. CMAJ. 2020;192:E536-45. 32350002.

Adding NT-proBNP to the Revised Cardiac Risk Index improved prediction of CV events after noncardiac surgery.

SOURCE CITATION: Duceppe E, Patel A, Chan MTV, et al. Preoperative N-terminal pro-B-type natriuretic peptide and cardiovascular events after noncardiac surgery: a cohort study. Ann Intern Med. 2020;172:96-104. 31869834.

It's not what it looks like: atypical rash in cryoglobulinaemic vasculitis.

A 48-year-old man with a history of intravenous drug use and chronic, untreated hepatitis C presented to the emergency room with acute bilateral lower extremity swelling, erythema and maculopapular rash. Serum C4 levels were low, but dermatology felt the rash was due to venous stasis dermatitis. The patient was discharged with compression stockings, but returned to the hospital 5 days later with no improvement in his symptoms. A more extensive laboratory workup revealed hepatitis C viral load of 4 million, elevated serum cryoglobulins, and skin biopsy showing leucocytoclastic vasculitis. He was treated with oral prednisone, with complete resolution of his symptoms after 2 weeks. He was scheduled for follow-up in gastroenterology clinic for treatment of his hepatitis C for definitive cure of his mixed cryoglobulinaemia, but failed to get insurance authorisation to begin treatment with Harvoni. He presented to the hospital 4 months later with diffuse alveolar haemorrhage.

Fatigue: a prevalent symptom in gastroparesis.

BACKGROUND: Fatigue is seen in many medical conditions. Patients with gastroparesis may complain of fatigue. AIM: The aim of this work is to first assess the prevalence and severity of fatigue in patients with gastroparesis, and secondly to correlate fatigue with symptoms, quality of life, and factors that may contribute to fatigue. METHODS: One hundred and fifty-six patients with gastroparesis filled out questionnaires including the fatigue assessment instrument (FAI), patient assessment of upper gastrointestinal symptom severity index, patient assessment of upper gastrointestinal disorders-quality of life and hospital anxiety, and depression scale to evaluate for fatigue, symptoms, quality of life, and depression. Gastric emptying test and laboratory studies for hemoglobin, glycosylated hemoglobin, thyroid function (TSH), and inflammatory markers (CRP and ESR) were obtained. RESULTS: Fatigue was reported by 93 % of patients. The mean total FAI score was 3.71 ± 0.2, with 51 % of patients having a score above 4, indicating severe fatigue. There were moderate correlations between fatigue and many symptoms of gastroparesis: upper abdominal discomfort (r = 0.446), upper abdominal pain (r = 0.422), loss of appetite (r = 0.329), bloating (r = 0.297), and abdominal distention (r = 0.265). Fatigue in patients using metoclopramide (3.5 ± 0.4) was similar to patients using domperidone (3.7 ± 0.5) or neither medicine (3.8 ± 0.3). Fatigue severity correlated with a decreased quality of life (r = -0.694, p < 0.001), increased depression (r = 0.339, p = 0.009), lower anxiety (r = -0.441, p < 0.001), and lower hemoglobin levels (r = -0.258, p = 0.005), but not to glycosylated hemoglobin, ESR, CRP, TSH, or gastric emptying. CONCLUSIONS: Fatigue is an important significant symptom in patients with gastroparesis with a high prevalence and severity. Fatigue is correlated with many symptoms of gastroparesis, low hemoglobin, depression, inflammation, decreased quality of life, but not to severity of delayed gastric emptying or to medication use.

Characteristics of nausea and its effects on quality of life in diabetic and idiopathic gastroparesis.

AIM: Nausea is a common symptom of gastroparesis (GP). The study is to determine the manifestations and impact of nausea in GP and to determine if there are any differences in diabetic (DG) and idiopathic gastroparesis (IG). METHODS: The patients referred for GP symptoms underwent gastric emptying scintigraphy and completed the Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM), Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL), SF-36v2 Health-Related Quality-of-Life survey, and the Nausea Profile (NP). RESULTS: Fifty-nine GP patients (20 diabetic, 39 idiopathic; 52 female; mean age 43 y) with delayed gastric emptying were enrolled. Nausea was an important symptom in these patients as assessed by PAGI-SYM (2.3±0.2) and it correlated with worse quality of life by PAGI-QOL (r=-0.299; P=0.021). The nausea and vomiting scores were similar in DG and IG, but DG had more severe retching (2.6±0.3 vs. 1.4±0.3; P=0.02) and more episodes of vomiting per week (4.4±1.4 vs. 3.5±1.3; P=0.037) compared with IG. Using the NP, total nausea scores in DG (61±3) were found to be greater than IG (49 (3; P=0.03) with somatic distress scores (60±5 vs. 44±4; P=0.03), and the gastrointestinal (GI) distress scores (84±4 vs. 73±4; P=0.05) were found to be greater in DG than IG. Although DG had slower gastric emptying than IG, there was no significant correlation between the NP scores and the degree of gastric retention on gastric emptying scintigraphy. CONCLUSIONS: Nausea and vomiting symptoms correlate with worse quality of life in GP patients. The DG patients experience greater nausea and increased somatic distress than IG. The differential perception of nausea in DG versus IG might be because of distinct pathophysiologic mechanisms.

Wireless capsules for esophageal pH monitoring: are we placing them correctly?

BACKGROUND: Recommended Bravo capsule placement is 6 cm proximal to the squamocolumnar junction. This is because the junction resides 1 cm distal to the lower esophageal sphincter. AIM: To determine the positional accuracy of capsule placement compared with the ideal location in symptomatic patients. METHODS: Retrospective analysis of consecutive symptomatic outpatients undergoing both capsule placement and esophageal manometry on the same day. Error in capsule placement (ECP) was calculated as the actual capsule position (ACP) minus the ideal capsule position (ICP) based on manometry results. An error in positioning < or =3 cm was deemed an accurate placement. RESULTS: Accurate placement of the capsule occurred in 91/147 (62%) patients. In patients with inaccurate placement, 92.9% were placed >3 cm proximal to the ICP. Only longer esophageal length correlated with the severity of proximal misplacement. There was no relationship between severity of ECP and whether the study demonstrated acid reflux. CONCLUSIONS: Our results suggest that endoscopic misplacement of Bravo capsules is common. Capsule misplacement proximally occurred far more frequently than distal misplacement. Capsule misplacement was not associated with pH study results.