Lung Histopathology in Coronavirus Disease 2019 as Compared With Severe Acute Respiratory Sydrome and H1N1 Influenza: A Systematic Review.

BACKGROUND: Patients with severe coronavirus disease 2019 (COVID-19) have respiratory failure with hypoxemia and acute bilateral pulmonary infiltrates, consistent with ARDS. Respiratory failure in COVID-19 might represent a novel pathologic entity. RESEARCH QUESTION: How does the lung histopathology described in COVID-19 compare with the lung histopathology described in SARS and H1N1 influenza? STUDY DESIGN AND METHODS: We conducted a systematic review to characterize the lung histopathologic features of COVID-19 and compare them against findings of other recent viral pandemics, H1N1 influenza and SARS. We systematically searched MEDLINE and PubMed for studies published up to June 24, 2020, using search terms for COVID-19, H1N1 influenza, and SARS with keywords for pathology, biopsy, and autopsy. Using PRISMA-Individual Participant Data guidelines, our systematic review analysis included 26 articles representing 171 COVID-19 patients; 20 articles representing 287 H1N1 patients; and eight articles representing 64 SARS patients. RESULTS: In COVID-19, acute-phase diffuse alveolar damage (DAD) was reported in 88% of patients, which was similar to the proportion of cases with DAD in both H1N1 (90%) and SARS (98%). Pulmonary microthrombi were reported in 57% of COVID-19 and 58% of SARS patients, as compared with 24% of H1N1 influenza patients. INTERPRETATION: DAD, the histologic correlate of ARDS, is the predominant histopathologic pattern identified in lung pathology from patients with COVID-19, H1N1 influenza, and SARS. Microthrombi were reported more frequently in both patients with COVID-19 and SARS as compared with H1N1 influenza. Future work is needed to validate this histopathologic finding and, if confirmed, elucidate the mechanistic underpinnings and characterize any associations with clinically important outcomes.

Delayed Cardiotoxicity From a Massive Nortriptyline Overdose Requiring Prolonged Treatment.

PURPOSE: A case of a nortriptyline overdose complicated by delayed ventricular arrhythmias necessitating prolonged sodium bicarbonate infusion is presented, along with a review of tricyclic antidepressant (TCA) toxicology and key concepts for massive overdose management. SUMMARY: A 61-year-old man presented after an intentional nortriptyline overdose with a possible consumption of up to 2500 mg of nortriptyline. Electrocardiogram on presentation demonstrated QRS widening to 240 milliseconds. Despite treatment with a sodium bicarbonate infusion and further narrowing of his QRS interval, his course was complicated by repeated episodes of wide complex tachycardia. Given these episodes, an elevated quantitative serum nortriptyline level of 468 µg/L on hospital day 6 and persistently positive TCA urine screens, the patient was continued on a sodium bicarbonate infusion until hospital day 14. Based on our patient's quantitative serum nortriptyline levels, we calculated an elimination half-life of 184 hours, 6 days post ingestion as compared to the reported half-life of nortriptyline of 14 to 51 hours. CONCLUSION: This case demonstrates that at toxic levels of ingestion, routine TCA pharmacokinetics may be unreliable due to delayed absorption, enterohepatic recirculation, large volume of distribution, and saturable kinetics. Therefore, in these cases, pharmacokinetic values derived from routine dosing should not be used to make clinical decisions (such as timing of discontinuation of sodium bicarbonate infusion). We found that urine TCA screens provided similar information to quantitative nortriptyline levels and can be used to guide therapy along the QRS duration.

Internal Medicine Residents' Exposure to and Confidence in Managing Hospital Acute Clinical Events.

BACKGROUND: Internal Medicine (IM) residency graduates should be able to manage hospital emergencies, but the rare and critical nature of such events poses an educational challenge. IM residents' exposure to inpatient acute clinical events is currently unknown. OBJECTIVE: We developed an instrument to assess IM residents' exposure to and confidence in managing hospital acute clinical events. METHODS: We administered a survey to all IM residents at our institution assessing their exposure to and confidence in managing 50 inpatient acute clinical events. Exposures assessed included mannequin-based simulation or management of hospital-based events as a part of a team or independently in a leadership role. Confidence was rated on a five-point scale and dichotomized to "confident" versus "not confident." Results were analyzed by multivariable logistic regression to assess the relationship between exposure and confidence accounting for year in training. RESULTS: A total of 140 of 170 IM residents (82%) responded. Postgraduate year 1 (PGY-1) residents had managed 31.3% of acute events independently vs 71.7% of events for PGY-3/4 residents (P < .0001). In multivariable analysis, residents' confidence increased with level of training (PGY-1 residents were confident to manage 24.9% of events vs 72.5% of events for PGY-3/4 residents, P < .0001) and level of exposure, independent of training year (P = .001). Events with the lowest levels of exposure and confidence for graduating residents were identified. CONCLUSIONS: IM residents' confidence in managing inpatient acute events correlated with level of training and clinical exposure. We identified events with low levels of resident exposure and confidence that can serve as targets for future curriculum development.