RESUMO
Amyloidosis is characterized by depositing insoluble fibrillar proteins that misfold into beta-pleated sheets. This phenomenon occurs on a systemic or local level and may interfere with the function of various organs, including the heart, kidneys, and liver. Among those presenting with amyloidosis, hepatic, gastrointestinal, renal, cardiac, vitreous, and immunological involvement may occur. These manifestations are linked to several clinical presentations, varying from abdominal pain and hepatomegaly to restrictive cardiomyopathy and chronic renal failure. The two most common types of amyloid proteins are amyloid light chain (AL) and serum amyloid A (AA) proteins. AL produced by immunoglobulin light chains kappa and lambda (κ, λ) circulate systemically and accumulate in organs. At the same time, serum AA proteins are acute-phase reactants seen in infectious, chronic inflammatory states. In an immune-mediated infection such as COVID-19, serum AA levels may be a predictive factor of disease severity and a valuable biomarker to monitor the clinical course of COVID-19 patients. This report highlights a case in which infection with COVID-19 provoked an effective immune response that may have contributed to the accelerated progression of systemic amyloidosis with hepatic involvement. The study further investigates the involvement of AL and AA proteins in COVID-19 infections, including their role in synergistically exacerbating an already grueling clinical course.
RESUMO
BACKGROUND: The Center for Medicare and Medicaid Services (CMS) has targeted hospital readmissions, which cost $17 billion per year, as one potential solution to reduce rising health care costs. Studies have documented the ability of Transitions of care (TOC) services to reduce readmissions in high risk patients. However, the vast majority of studies have not explored TOC services for all-cause admissions nor TOC clinics led by hospitalists. The goal of this study is to provide preliminary data regarding the potential effectiveness of a hospitalist-led TOC clinic servicing all patients on hospital readmission rates. METHODS: This cross-sectional feasibility study analyzed patients on a tertiary hospital teaching service. All discharged patients from January 2016 to September 2018 were given an appointment at the TOC clinic within 14 days of discharge. The control group consisted of patients assigned to the teaching service from January 2018 to November 2018 that were not offered a TOC appointment. RESULTS: Overall, 1373 patients (n = 1373) were included in this study between January 2016 and September 2018. The control group consisted of 1000 patients who were not offered follow up in the TOC clinic while the TOC group consisted of 373 patients who did attend a follow up appointment in the TOC clinic. The study participants (n = 1373) included patients admitted to the hospital for any diagnosis and were analyzed for all cause readmission rates. The TOC group consisted of 52% African Americans, 52% Medicare patients and 8% Medicaid patients. Demographic information for the control group was not available. The TOC group had a statistically significant 42% decreased risk of being readmitted within 30 days of discharge (RR = 0.58, 95% CI: 0.40-0.83). These data showed a statistically significant difference between the TOC group and control group in relation to the incidence of 30-day readmissions (p-value = 0.002). CONCLUSION: Among Medicare and Medicaid beneficiaries and commercial health insurance patients, this hospitalist-led TOC intervention was associated with a statistically significant reduction in 30-day readmissions following discharge for all-cause hospital admissions.
