Evolution of prescribing practices and outcomes in the COVID-19 pandemic in metropolitan areas.

Introduction: We wanted to characterize the evolution of the COVID-19 pandemic in a typical metropolitan area. Methods: Data were extracted from the Detroit COVID-19 Consortium database for hospitalized COVID-19 patients treated in Southeast Michigan over the 12-month period from March 2020 to February 2021. Demographic and outcomes data were compared to CDC data. Results: A total of 4,775 patients were enrolled during the study period. We divided the pandemic into three phases: Phase-1 (Spring Surge); Phase-2 (Summer Lull); and Phase-3 (Fall Spike). Changes in hydroxychloroquine, remdesivir, corticosteroid, antibiotic and anticoagulant use closely followed publication of landmark studies. Mortality in critically-ill patients decreased significantly from Phase-1 to Phase-3 (60.3% vs. 47.9%, Chisq p=0.0110). Monthly mortality of all hospitalized patients ranged between 14.8% - 21.5% during Phase-1 and 9.7 to 13.4% during Phase 3 (NS). Discussion: The COVID-19 pandemic presented in three unique phases in Southeast Michigan. Medical systems rapidly modified treatment plans, often preceding CDC and NIH recommendations. Despite improved treatment regimens, intubation rates and mortality for hospitalized patients remained elevated. Conclusion: Preventive measures aimed at reducing hospitalizations for COVID-19 should be emphasized.

Comparison of Resident Self-Evaluation to Standardized Patient Evaluators in a Multi-Institutional Objective Structured Clinical Examination: Objectively Measuring Residents' Communication and Counseling Skills.

BACKGROUND: For the past 30 years, there has been a growing emphasis on communication and self-evaluation skills training in graduate medical education. This is reflected in the Next Accreditation System. The Objective Structured Clinical Examination (OSCE) is widely used in graduate medical education for assessing dimensions of interpersonal communication and counseling skills. The OSCEs may be developed to target challenging clinical scenarios difficult to capture in clinical practice and can be used as a medium for resident self-evaluation. OBJECTIVES: The aims of the study were to evaluate residents' interpersonal, communication, and counseling skills using Kalamazoo Essential Elements Communication Checklist in 4 clinically challenging scenarios and to compare standardized patient (SP) evaluations to residents' self-evaluation by category of medical school. METHODS: South East Michigan Center for Medical Education is a consortium of teaching hospitals. Member residents participate in 4 OSCEs as part of their postgraduate 1 curriculum. The OSCEs were developed to evaluate clinically relevant but difficult to capture scenarios including: (a) error disclosure/counseling an angry patient; (b) delivering bad news/end of life; (c) domestic violence; and (d) counseling a patient with colon cancer requesting alternative treatments. At the conclusion of each OSCE, SPs evaluated and residents self-evaluated their performance. Once evaluations were completed, SPs provided residents with feedback. RESULTS: Six member institutions and 344 residents participated during the 2014, 2015, and 2016 academic years. There were more international medical graduates (59%) than graduates of Liaison Committee for Medical Education-accredited medical schools. There were more males (62.2%) than females. Standardized patients rated residents higher than residents rated themselves in 2014 (<0.001), but not in 2015 or 2016. When combining all years and all residents, there was no correlation of SP and resident scores. Standardized patients rated female residents higher than female residents rated themselves (P < 0.0001). Male residents scored themselves similarly to the SPs, but male residents rated themselves higher than female residents rated themselves (P < 0.001). Standardized patient scores for male and female residents were not significantly different. CONCLUSIONS: Targeted OSCEs provide an objective format to evaluate residents in challenging clinical scenarios. Resident self-evaluations did not correlate with SPs. In addition, female residents rated themselves lower than male residents and lower than SPs. There is need to develop interventions and curricula to improve resident's self-evaluation skills and in particular address lower self-evaluation by female trainees.

High prevalence of obesity in young patients with ST elevation myocardial infarction.

BACKGROUND: There is growing concern about increasing rates of obesity in young people, and increasing ST elevation myocardial infarction (STEMI) at a younger age. There are only a few studies performed to study the risk factors in STEMI among young populations. METHODS: Retrospective chart reviews on all first event STEMI patients between December 2005 and July 2007 were performed. A young population was defined as: men <45 years of age and women <55 years of age. RESULTS: Among 206 patients with STEMI, 36 were young. In young patients with STEMI, 78 % were obese compared with 35 % obese, non-young (p<0.001). Also, among young patients with STEMI, family history of coronary heart disease (CHD) was positive in 39 %, compared with 19 % in non-young patients (p=0.009). This significance for obesity and family history persisted after adjusting for other risk factors using logistic regression (OR 2.96 to 17.75, 95 % CI, p<0.0001 and OR 1.36 to 7.47, 95 % CI, p=0.008, respectively). CONCLUSION: Obesity and family history of CHD were major risk factors with a higher prevalence in young patients with STEMI than non-young patients.

Wrist drop: an atypical presentation of renal cell carcinoma.

Renal cell carcinoma (RCC) causing metastasis to the skeletal muscles is extremely rare. The authors describe a patient with history of RCC treated 5 years ago with radical nephrectomy who presented with left arm swelling after receiving seasonal flu shot. He was initially diagnosed with cellulitis, treated with intravenous antibiotics and discharged home. One month later, he presented with persistent left arm swelling accompanied by wrist drop. Subsequently he developed increased swelling, decreased pulse and wrist drop. He was diagnosed with compartment syndrome, for which fasciotomy was performed, and tissue samples were sent for analysis. Histopathological analysis confirmed metastatic clear cell RCC. The authors described a literature review of previously described cases of metastasis of renal cell cancer to the skeletal muscles. The authors also discussed the rarity of muscle metastasis and unpredictable behavior of RCC after being dormant for long periods.

Endovascular abdominal aortic aneurysm repair by interventional cardiologists--a community-based experience.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively recent technology. In comparison to the conventional open surgical treatment for AAA, endovascular AAA repair (EVAR) combines a less-invasive approach with lower morbidity and mortality. There have been few studies regarding the performance of this procedure in a community-based setting. We report our experience of EVAR performed primarily by interventional cardiologists in a community hospital. METHODS: In our community hospital setting, between September 2005 and November 2007, we included all patients who underwent EVAR by interventional cardiologists, with available on-site vascular surgical support. Clinical and serial computed angiographic imaging outcomes were followed by a retrospective chart review. Data collection tools included demographic and clinical characteristics, anatomical aneurysm features, length of stay, peri- and postprocedural complications, and mortality. RESULTS: A total of 71 consecutive patients had EVAR attempted. The endovascular stent placement was successful in 67 (93%) patients. Thirty-day mortality in this study was 1 of 71 (1.4%). All four procedural failures and the single periprocedural mortality occurred in women. Mean follow-up was 12 months. There were a total of six mortalities and among these four were women (P ≤ 0.001); however, multivariate analysis revealed loss of significant difference in mortality (P = 0.16). Major complications following EVAR were noted in 10 of 71 (14%) patients. CONCLUSION: EVAR can be successfully performed by experienced interventional cardiologists with vascular surgical support in a community-based setting. In our experience, there is acceptable rate of complications and mortality in a carefully selected patient population.

Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review.

PURPOSE: To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis. METHODS: Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2). RESULTS: Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism. CONCLUSION: Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.