Background: Therapeutic doses of anticoagulation have been administered to patients with coronavirus-19 disease (Covid-19) without thromboembolism, although there is a lack of robust evidence supporting this practice. Study Question: To compare outcomes between patients admitted to the hospital for Covid-19 who received full-dose anticoagulation purely for the indication of Covid-19 and patients who received prophylactic doses of anticoagulation. Study Design: This is a multicenter retrospective cohort study, including 7 community hospitals in Michigan. Patients were >18 years of age, confirmed positive for Covid-19 by polymerase chain reaction, and admitted to the hospital between March 10 and May 3, 2020. Exposed group: Patients receiving therapeutic dose anticoagulation for Covid-19 for any duration excluding clinically evident venous thromboembolism, atrial fibrillation, and myocardial infarction; control group: Patients receiving prophylactic anticoagulation. Propensity score matching was used to adjust for the nonrandomized nature of the study. Measures and Outcomes: The primary endpoint: 30-day in-hospital mortality. Secondary endpoints: intubation, length of hospital stay, and readmissions in survivors. Results: A total of 115 exposed and 115 control patients were analyzed. Rates of 30-day in-hospital mortality were similar (exposed: 33.0% vs. control: 28.7%). Controlling for institution, there was no significant association between treatment and 30-day in-hospital mortality (hazard ratio: 0.63; 95% confidence interval: 0.37–1.06). Survivors had statistically similar length of hospital stay and readmission rates. Conclusions: We found no difference in mortality in patients with Covid-19 without clinically evident venous thromboembolism, atrial fibrillation, and myocardial infarction who received therapeutic versus prophylactic doses of anticoagulation.
Continual feedback to adapt to external regulatory and competitive environment is essential in today's complex healthcare landscape, and hospital leadership needs to transform its strategic planning process to reflect the market dynamic. Digital artifacts such as performance dashboard track operational data and transform these into key performance indicators (KPIs) to set organizational goals and align unit level operations. However, the velocity of change occurring in the marketplace needs a dynamic approach: a real-time aggregation of operational data into KPIs for a daily or weekly review to gain insights and respond quickly to evolving market expectations. This chapter discusses how an rtDashboard (real time dashboard) has evolved to become a key artifact that transformed the way a hospital in SE Michigan engaged in its strategic planning process.
Thyrotoxic Periodic Paralysis (TPP) belongs to a group of muscle diseases called channelopathies, which present with painless generalized muscle weakness without exertion. TPP can be precipitated by a large carbohydrate meal, stress, strenuous exercise, alcohol, a high-salt diet, menstruation, and cold temperatures. Rarely, steroids such as dexamethasone can also precipitate a TPP attack. A 29-year-old Hispanic male, with a history of hyperthyroidism, presented to the emergency department with progressive weakness, predominantly in the lower extremities since morning. Earlier that day, the patient was seen in the same emergency department for difficulty in swallowing. He was diagnosed with uvulitis and received intramuscular dexamethasone and was discharged with amoxicillin for ten days. At home, he started to develop cramps in his lower extremities associated with paresthesias, which progressed to severe weakness to the point where he could not get out of bed. He returned to the hospital and revealed that he had suffered a similar episode following a steroid injection five years ago. He had not sought medical attention as it resolved spontaneously. He denied strenuous exercise, carbohydrate-rich meal, or alcohol ingestion. The patient had been noncompliant with atenolol and methimazole for the past month after losing his medical insurance. On examination, the patient appeared alert and calm. His vitals were significant for tachycardia of 123 beats per minute. Thyromegaly and tenderness were absent on examination of the neck. Muscle strength was 5/5 in the ankle dorsiflexors and ankle plantar flexors bilaterally, but the strength of the iliopsoas, quadriceps, and hamstrings was only 2/5 bilaterally. Deep tendon reflexes were diminished throughout to 1+. Laboratory findings were significant for profound hypokalemia, hypophosphatemia, low thyroid stimulating hormone, and elevated free T3 and T4 levels suggestive of hyperthyroidism. His electrolytes were replaced aggressively and his home medications were restarted. His electrolyte imbalance corrected and his symptoms resolved within a day and he was discharged home. The overwhelming majority of TPP cases reported are male patients, hence this case demonstrates the need to be aware of this complication while treating hyperthyroid male patients with steroids. Hyperthyroidism potentiates catecholamine-mediated Na/K ATPase transport of potassium into the cells. Glucocorticoids are used in the treatment of thyroid storm as it prevents the peripheral conversion of T4 to T3. Moreover, glucocorticoids increase glucose levels stimulating insulin release, which shifts potassium intracellularly accentuating muscle weakness. Although the incidence of glucocorticoids causing TPP is low and not many cases are documented, it is still an important condition to be aware of and can have major clinical implications. Clinicians should be aware of this small subset of hyperthyroidism patients where the use of glucocorticoids can precipitate paralysis.
The pathogenesis of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is still not fully unraveled. Though preventive vaccines and treatment methods are out on the market, a specific cure for the disease has not been discovered. Recent investigations and research studies primarily focus on the immunopathology of the disease. A healthy immune system responds immediately after viral entry, causing immediate viral annihilation and recovery. However, an impaired immune system causes extensive systemic damage due to an unregulated immune response characterized by the hypersecretion of chemokines and cytokines. The elevated levels of cytokine or hypercytokinemia leads to acute respiratory distress syndrome (ARDS) along with multiple organ damage. Moreover, the immune response against SARS-CoV-2 has been linked with race, gender, and age; hence, this viral infection's outcome differs among the patients. Many therapeutic strategies focusing on immunomodulation have been tested out to assuage the cytokine storm in patients with severe COVID-19. A thorough understanding of the diverse signaling pathways triggered by the SARS-CoV-2 virus is essential before contemplating relief measures. This present review explains the interrelationships of hyperinflammatory response or cytokine storm with organ damage and the disease severity. Furthermore, we have thrown light on the diverse mechanisms and risk factors that influence pathogenesis and the molecular pathways that lead to severe SARS-CoV-2 infection and multiple organ damage. Recognition of altered pathways of a dysregulated immune system can be a loophole to identify potential target markers. Identifying biomarkers in the dysregulated pathway can aid in better clinical management for patients with severe COVID-19 disease. A special focus has also been given to potent inhibitors of proinflammatory cytokines, immunomodulatory and immunotherapeutic options to ameliorate cytokine storm and inflammatory responses in patients affected with COVID-19.
Nitrofurantoin remains the gold standard treatment of uncomplicated cystitis as well as prophylactic treatment of recurrent urinary tract infections. Drug-induced hepatotoxicity presents in acute (3 in 1 000 000) and chronic (1 in 1500) forms. We present a patient with acute liver failure after 5 days of treatment. A 69-year-old man admitted for chronic obstructive pulmonary disease exacerbation 5 days into treatment for cystitis with nitrofurantoin. On admission he was noted to be jaundiced with elevated liver enzymes and normal international normalised ratio. Investigation for infectious, autoimmune and cholestatic causes of hepatotoxicity was negative. The patient improved after discontinuation of the drug and 10 days of methylprednisolone. There are scant data on acute liver failure in the setting of short-term nitrofurantoin administration. The mechanism of toxicity remains unclear, but is hypothesised to be an autoimmune process in which steroids may play a role in treatment. Diagnosis is one of exclusion as the only definitive method of diagnosis is rechallenge.
Since late 2019, the novel coronavirus SARS-CoV-2 has introduced a wide array of health challenges globally. In addition to a complex acute presentation that can affect multiple organ systems, increasing evidence points to long-term sequelae being common and impactful. The worldwide scientific community is forging ahead to characterize a wide range of outcomes associated with SARS-CoV-2 infection; however the underlying assumptions in these studies have varied so widely that the resulting data are difficult to compareFormal definitions are needed in order to design robust and consistent studies of Long COVID that consistently capture variation in long-term outcomes. Even the condition itself goes by three terms, most widely "Long COVID", but also "COVID-19 syndrome (PACS)" or, "post-acute sequelae of SARS-CoV-2 infection (PASC)". In the present study, we investigate the definitions used in the literature published to date and compare them against data available from electronic health records and patient-reported information collected via surveys. Long COVID holds the potential to produce a second public health crisis on the heels of the pandemic itself. Proactive efforts to identify the characteristics of this heterogeneous condition are imperative for a rigorous scientific effort to investigate and mitigate this threat.
Introduction: Diabetes Mellitus (DM) can slow intestinal transit and delay gastric emptying potentially affecting the quality of bowel preparation (QBP) for colonoscopy. Suboptimal bowel preparation (BP) may lead to missed neoplastic or preneoplastic lesions. This study evaluates glycemic control’s impact on QBP in patients undergoing elective colonoscopy. Methods: A retrospective review of patients who underwent elective colonoscopy with HbA1c levels within one year of the procedure across eight hospitals was conducted. QBP was categorized as optimal or suboptimal based on the Boston Bowel Preparation and Ottawa Bowel Preparation Scales. The association between glycemic control, defined as Hba1c < 5.7 or FBS < 100 mg/dL (Non-diabetic); Hba1c: 5.7-6.4% or FBS: 100-125 mg/dL (Pre-diabetes); Hba1c: 6.5-9.5% or FBS: 126 mg/dL-225 mg/dL (Well-controlled diabetes); Hba1c: >9.5% or FBS >225 mg/dL (Poorly controlled diabetes), and QBP was investigated, along with other patient demographic and clinical characteristics. Socioeconomic status was decided based on the insurance coverage carried by the patient. Significance was assessed at P< 0.05. Results: A total of 1458 patients were included in the analysis (Table 1). QBP was suboptimal in 98 (6.7%) patients. Average days between HbA1c or FBS and colonoscopy were 119.4±89.2. Overall, optimal QBP rates were higher in poorly controlled diabetics (79.5% vs 20.5%, P< 0.001) compared to suboptimal QBP. However, non-diabetics (6.9%), pre-diabetics (4.8%) and well-controlled diabetics (7.7%), had lower rates of suboptimal QBP as compared to poorly controlled diabetics (20.5%). Patients from low socioeconomic status had higher rates of optimal QBP (90.7% vs 9.3%, P< 0.001) but higher rates of suboptimal QBP compared to high socioeconomic status patients (4.7%). Additionally, diabetics on insulin had higher rates of optimal QBP (78.1% vs 21.9%, P< 0.001) but higher rates of suboptimal QBP compared to non-insulin dependent diabetics (5.5%). There were no statistical differences in the QBP rates for age, gender, BMI and patients on GLP-1 agonists. Conclusion: This study shows that poorly controlled and insulin-dependent diabetics have higher rates of suboptimal QBP, leading to missed lesions and increased colon cancer risk. Limited access to healthcare due to low socioeconomic status indirectly contributes to poorly controlled DM and higher rates of suboptimal QBP. Identifying poor preparation risks allows targeted interventions to enhance QBP in high-risk patients. Table 1. - Patient Characteristics and Comparative Analysis of Optimal and Suboptimal Bowel Preparation Groups Patient Characteristics Overall Optimal Bowel Prep Quality Suboptimal Bowel Prep Quality 'P' Value Age (Mean±SD) in years 59.9±9.6 59.96±9.51 58.45±10.25 0.132 Sex Female Male 54.8%45.2% 94.1%92.3% 5.9%7.7% 0.159 Socioeconomic Status Low High 44.2%55.8% 90.7%95.3% 9.3%4.7% < 0.001 BMI (n=1407) Underweight (< 18.5) Healthy Weight (18.5-24.9) Overweight (25-29.9) Obese ( >30) 0.4%15.3%31.9%52.4% 100%94.4%93.3%92.7% 0%5.6%6.7%7.3% 0.736 Glycemic Control Non-diabetic Pre-diabetes Well Controlled Diabetes Poorly Controlled Diabetes 39.5%35.7%22.2%2.7% 93.1%95.2%92.3%79.5% 6.9%4.8%7.7%20.5% < 0.001 Insulin Yes No 7.2%92.8% 78.1%94.5% 21.9%5.5% < 0.001 GLP1 Agonist Yes No 4.5%95.5% 89.2%93.5% 7.1%6.5% 0.198 BMI: Body Mass Index, FBS: Fasting Blood Glucose, GLP-1: Glucagon Like Peptide 1.
Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.
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