POCUS in Internal Medicine Curriculum: Quest for the Holy-Grail of Modern Medicine.

Point of care ultrasound (POCUS) is an essential component of emergency medicine training that has not taken hold in internal medicine training programs. Internal medicine residents can use POCUS to perform focused examinations and aid complicated procedures. However, while there is widespread interest in learning POCUS, training is not standardized amongst residency curriculums. Therefore, more strides are necessary to correctly implement POCUS training during residency training.

A narrative review of chronic alcohol-induced atrial fibrillation.

Alcohol use disorder (AUD) is highly prevalent and can lead to many cardiovascular complications, including arrhythmias. Chronic alcohol use has a dose-dependent relationship with incidence of atrial fibrillation (AF), where higher alcohol intake (>3 drinks a day) is associated with higher risk of AF. Meanwhile, low levels of chronic alcohol intake (<1 drink a day) is not associated with increased risk of AF. Mechanistically, chronic alcohol intake alters the structural, functional and electrical integrity of the atria, predisposing to AF. Increased screening can help identify AUD patients early on and provide the opportunity to educate on chronic alcohol use related risks, such as AF. The ideal treatment to reduce risk of incident or recurrent AF in AUD populations is abstinence.

Lay abstract Alcohol use disorder (AUD) affects many people and can lead to many cardiovascular consequences, including arrhythmias. Higher alcohol intake (>3 drinks a day) is associated with higher risk of atrial fibrillation (AF). Meanwhile, low levels of chronic alcohol intake (<1 drink a day) is not associated with increased risk of AF. Mechanistically, chronic alcohol intake alters the integrity of the atria, predisposing to AF. Increased screening can help identify AUD patients early on and provide the opportunity to educate on chronic alcohol use related risks, such as AF. The ideal treatment to reduce risk of AF in AUD populations is abstinence.

Congestive heart failure clinics and telemedicine: The key to reducing hospital readmissions in the United States.

The United States healthcare system currently faces an economic challenge related to frequent hospital readmission rates. As such, hospitals have begun implementing strategies to reduce readmission rates for specific medical conditions such as congestive heart failure, which had a 30-day readmission rate of 23.2% in 2014. Patient education and frequent monitoring of symptoms have since allowed patients to work together with doctors and nurses to take charge of their healthcare management. Due to heart failure clinics and the rise of telemedicine and telemonitoring, heart failure readmission rates have since decreased.

Current Management Guidelines on Hyperlipidemia: The Silent Killer.

Given the high incidence of cardiovascular events in the United States, strict control of modifiable risk factors is important. Pharmacotherapy is helpful in maintaining control of modifiable risk factors such as elevated lipids or hypercholesterolemia. Hypercholesterolemia can lead to atherosclerotic disease which may increase the risk of acute coronary events. Statin therapy has long been a mainstay in the treatment of hypercholesterolemia, but while highly regarded, statin therapy also has side effects that may lead to patient noncompliance. Therefore, various medicines are being developed to manage hypercholesterolemia. This paper will discuss the role that lipids play in the pathophysiology of atherosclerotic disease, review the current lipid management guidelines, and discuss new treatment options that are alternatives to statin therapy.

Gastrointestinal Manifestations of COVID-19: A Review of What We Know.

Background: The coronavirus disease 2019 (COVID-19) is not just a disease of the respiratory system. The virus can affect the gastrointestinal (GI) tract as well. Recognizing the various manifestations in every organ system is important because these manifestations can contribute to community-based transmission. Methods: We outline the evidence of the pathophysiology of COVID-19 in the GI tract, the effects of the virus on the gut and liver, the presence of the virus in stool samples, and the potential for fecal-oral transmission of COVID-19. Most of the literature sources used in this paper are case studies from China following the surge of COVID-19 infection. Results: In patients with COVID-19, GI symptoms such as anorexia, nausea, vomiting, diarrhea, and abdominal pain have presented in conjunction with respiratory symptoms such as fever, shortness of breath, and cough. Evidence also shows acute hepatocellular injury, indicated by elevated liver enzymes such as alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. Fecal-oral transmission of COVID-19 is suspected because of the presence of COVID-19 RNA in stool samples of COVID-19-positive patients. Conclusion: Even without the presence of respiratory symptoms, several GI symptoms are associated with COVID-19 infection, as well as possible fecal-oral transmission. Therefore, COVID-19 infection should be considered for patients presenting with primarily GI symptoms.

Cardiac amyloidosis-A review of current literature for the practicing physician.

The amyloidoses are a family of diseases in which misfolded precursor proteins aggregate to form amyloid and deposit in body tissues. A very serious yet underrecognized form of this disease is cardiac amyloidosis, in which amyloid deposits into the extracellular space of the myocardium, resulting in thickening and stiffening of ventricular walls with resultant heart failure and conductive dysfunction. This review provides a discussion of the pathogenesis and clinical presentation of cardiac amyloidosis subtypes, as well as an up-to-date approach to diagnosis and treatment. Significant progress has been made in recent years regarding diagnosis and treatment of this condition, but prognosis remains heavily reliant on early detection of the disease. Two types of precursor protein are responsible for most cardiac amyloidosis cases: transthyretin amyloid, and immunoglobulin-derived light chain amyloid. An early diagnosis of cardiac amyloidosis can allow for novel treatment modalities to be initiated with the potential to improve prognosis.

Papering over the cracks: COVID-19's amplification of the failures of employer-based health insurance coverage.

Background: COVID-19 has altered numerous lives and accounted for significant mortality and morbidity throughout the world and, especially, the USA. During the pandemic, from mid-March to July 2020, around one-fourth of the US population filed for unemployment benefits. Objective: In this article, we discuss the economic ramifications exposed in the American healthcare system's current model by the COVID-19 crisis. Methods: In this review, we analyze 18 articles to look at how access to health insurance has affected how Americans receive medical care during the coronavirus pandemic. Results: The large-scale job losses related to the pandemic translates directly into millions of Americans also losing employer-sponsored health insurance (ESI) coverage. With the pandemic disproportionately affecting minority populations, these communities now bear the additional toll of not receiving appropriate care. Conclusion: Due to the pandemic, it is probable that a significant portion of Americans that are uninsured are less likely to seek medical care for COVID-19 symptoms. While the disease can manifest as a mild respiratory illness in most, others can experience more severe disease and require acute, intensive medical care. The lack of health insurance in this instance can be potentially fatal. Given that COVID-19 has disproportionately affected minority communities across the USA, it is important to highlight the correlation between access to medical care and COVID-19 infection rates. Communities that are of lower socioeconomic status are less likely to have health insurance and follow up with medical care due to out-of-pocket costs, which in turn leads to a higher case fatality rate due to COVID-19.

Cardiology and COVID-19: do we have sufficient information?

COVID-19 caused by severe acute respiratory syndrome coronavirus 2, which originated in Wuhan (China), transformed into a worldwide pandemic. The short span associated with the spread of the virus and its varied manifestations presents a steep learning curve for many clinicians on the front-line of treatment. Cardiology is one such affected area. This paper details the signs and symptoms of cardiovascular disease resulting from COVID-19, including its proposed pathophysiology, signs and symptoms, treatments and outcomes under investigation. The consensus is that COVID-19 patients with cardiovascular injury have a shorter duration from symptom onset to deterioration, higher mortality and higher prevalence in older populations. Diagnosis and intervention for patients with underlying cardiovascular comorbidities is critical.

Approach to critical illness myopathy and polyneuropathy in the older SARS-CoV-2 patients.

One of the major concerns of the health care community and the public surrounding the SARS-CoV-2 pandemic is the availability and use of ventilators. Unprecedented surges of patients presented to intensive care units across the country, with older adults making up a large proportion of the patient population. This paper illustrates contemporary approaches to critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) in older patients, including incidence, risk factors, mechanisms for pathology, diagnosis, contemporary treatment approaches, and outcomes. We hope that the following analysis may help educate clinicians and ultimately decrease the duration of the mechanical ventilation required by these patients, resulting in improved clinical outcomes and an increase in ventilator availability for other patients in need.

The Economic Implications of COVID-19 in the United States.

The novel coronavirus disease 2019 (COVID-19) first reported in Wuhan, China, in 2019 has evolved into a pandemic and public health emergency, leading to extensive fatalities and halting global economies. Older adults have emerged as a critically vulnerable population as earlier data suggests a disproportionately increased incidence of COVID-19 in this population, as well as worse health outcomes. Disease attenuating behaviors such as social distancing has been encouraged and mandated across different countries leading to downstream economic ramifications. This paper seeks to outline the economic implications of COVID-19 in the U.S. (particularly in terms of vocational, retail, and service industries), highlighting the role of nursing homes in disease dissemination. We also discuss potential costs associated with COVID-19 management focusing on the senior population who rely on Medicare benefits for health insurance.

COVID-19: Catastrophic Cause of Acute Lung Injury.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak that began in 2019 and spread rapidly across the globe has been observed to cause acute lung injury and multiorgan system failure. While common symptoms are flu-like, this population has been observed to decompensate at an alarmingly rapid rate to severe hypoxia. SARS-CoV-2 infects host cells by targeting the angiotensin-converting enzyme 2 (ACE2) receptor, which is present on endothelial cells in the lung, heart, kidney, and gastrointestinal tissue. The pathophysiology of acute respiratory distress syndrome (ARDS) in SARS-CoV-2 infection has a component of lung perfusion dysregulation and is described as a "cytokine storm" that causes increased vascular permeability and disease severity. Older adults and those with comorbid conditions, particularly hypertension, diabetes, and history of ischemic heart disease, are especially vulnerable. These high-risk populations are often on angiotensin-modulating therapies, which are theorized to increase ACE2 expressivity, but current evidence for or against discontinuation is equivocal. The standard for SARS-CoV-2 testing is through reverse transcription polymerase chain reaction, which has presented problems due to low sensitivity and possible co-infection with other pathogens. Treatment for ARDS in the setting of SARS-CoV-2 should follow pre-established goals of care and the wishes of the patient and family members or caregivers and consider the high risk for polypharmacy, cognitive decline, malnutrition, and depression, particularly in older adults. Treatment recommendations have outlined ventilation goals to minimize further lung injury. Compassionate use of pharmacologic therapies such as remdesivir has shown promise, and further clinical trials of anticytokine agents are underway.

COVID-19 and Older Adults: What We Know.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus that causes COVID-19 infection, has recently emerged and caused a deadly pandemic. Studies have shown that this virus causes worse outcomes and a higher mortality rate in older adults and those with comorbidities such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease (CKD). A significant percentage of older American adults have these diseases, putting them at a higher risk of infection. Additionally, many adults with hypertension, diabetes, and CKD are placed on angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers. Studies have shown that these medications upregulate the ACE-2 receptor, the very receptor that the SARS-CoV-2 virus uses to enter host cells. Although it has been hypothesized that this may cause a further increased risk of infection, more studies on the role of these medications in COVID-19 infections are necessary. In this review, we discuss the transmission, symptomatology, and mortality of COVID-19 as they relate to older adults, and possible treatments that are currently under investigation. J Am Geriatr Soc 68:926-929, 2020.

A Comprehensive Review of COVID-19 Associated Neurological Manifestations.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 utilizes the angiotensin-converting enzyme 2 (ACE-2) receptor of cells in order to gain entry and continue infection. Recent literature has focused on acute respiratory distress syndrome (ARDS) and other associated pulmonary complications; however, only a scarce amount of literature exists on neurological complications. Such complications also pose a high morbidity in these patients. The exact pathogenesis of nervous system involvement by COVID-19 still remains poorly understood. The aim of this article is to review the neurological symptoms seen in COVID-19 infection and discuss the probable pathogenesis, management and outcome of associated neurological complications.