Characteristics and Risk Factors of Hospitalized and Nonhospitalized COVID-19 Patients, Atlanta, Georgia, USA, March-April 2020

We compared the characteristics of hospitalized and nonhospitalized patients who had coronavirus disease in Atlanta, Georgia, USA. We found that risk for hospitalization increased with a patient’s age and number of concurrent conditions. We also found a potential association between hospitalization and high hemoglobin A1c levels in persons with diabetes.

COVID-19 Clinical Phenotypes: Presentation and Temporal Progression of Disease in a Cohort of Hospitalized Adults in Georgia, United States

BACKGROUND

The epidemiological features and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) have been described; however, the temporal progression and medical complications of disease among hospitalized patients require further study. Detailed descriptions of the natural history of COVID-19 among hospitalized patients are paramount to optimize health care resource utilization, and the detection of different clinical phenotypes may allow tailored clinical management strategies.

METHODS

This was a retrospective cohort study of 305 adult patients hospitalized with COVID-19 in 8 academic and community hospitals. Patient characteristics included demographics, comorbidities, medication use, medical complications, intensive care utilization, and longitudinal vital sign and laboratory test values. We examined laboratory and vital sign trends by mortality status and length of stay. To identify clinical phenotypes, we calculated Gower's dissimilarity matrix between each patient's clinical characteristics and clustered similar patients using the partitioning around medoids algorithm.

RESULTS

One phenotype of 6 identified was characterized by high mortality (49%), older age, male sex, elevated inflammatory markers, high prevalence of cardiovascular disease, and shock. Patients with this severe phenotype had significantly elevated peak C-reactive protein creatinine, D-dimer, and white blood cell count and lower minimum lymphocyte count compared with other phenotypes (P < .01, all comparisons).

CONCLUSIONS

Among a cohort of hospitalized adults, we identified a severe phenotype of COVID-19 based on the characteristics of its clinical course and poor prognosis. These findings need to be validated in other cohorts, as improved understanding of clinical phenotypes and risk factors for their development could help inform prognosis and tailored clinical management for COVID-19.

Predictors at admission of mechanical ventilation and death in an observational cohort of adults hospitalized with COVID-19

Background

Coronavirus disease (COVID-19) can cause severe illness and death. Predictors of poor outcome collected on hospital admission may inform clinical and public health decisions.

Methods

We conducted a retrospective observational cohort investigation of 297 adults admitted to eight academic and community hospitals in Georgia, United States, during March 2020. Using standardized medical record abstraction, we collected data on predictors including admission demographics, underlying medical conditions, outpatient antihypertensive medications, recorded symptoms, vital signs, radiographic findings, and laboratory values. We used random forest models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for predictors of invasive mechanical ventilation (IMV) and death.

Results

Compared with age <45 years, ages 65–74 years and ≥75 years were predictors of IMV (aOR 3.12, CI 1.47–6.60; aOR 2.79, CI 1.23–6.33) and the strongest predictors for death (aOR 12.92, CI 3.26–51.25; aOR 18.06, CI 4.43–73.63). Comorbidities associated with death (aORs from 2.4 to 3.8, p <0.05) included end-stage renal disease, coronary artery disease, and neurologic disorders, but not pulmonary disease, immunocompromise, or hypertension. Pre-hospital use vs. non-use of angiotensin receptor blockers (aOR 2.02, CI 1.03–3.96) and dihydropyridine calcium channel blockers (aOR 1.91, CI 1.03–3.55) were associated with death.

Conclusions

After adjustment for patient and clinical characteristics, older age was the strongest predictor of death, exceeding comorbidities, abnormal vital signs, and laboratory test abnormalities. That coronary artery disease, but not chronic lung disease, was associated with death among hospitalized patients warrants further investigation, as do associations between certain antihypertensive medications and death.

Characteristics Associated with Hospitalization Among Patients with COVID-19 - Metropolitan Atlanta, Georgia, March-April 2020

The first reported U.S. case of coronavirus disease 2019 (COVID-19) was detected in January 2020 (1). As of June 15, 2020, approximately 2 million cases and 115,000 COVID-19-associated deaths have been reported in the United States.* Reports of U.S. patients hospitalized with SARS-CoV-2 infection (the virus that causes COVID-19) describe high proportions of older, male, and black persons (2-4). Similarly, when comparing hospitalized patients with catchment area populations or nonhospitalized COVID-19 patients, high proportions have underlying conditions, including diabetes mellitus, hypertension, obesity, cardiovascular disease, chronic kidney disease, or chronic respiratory disease (3,4). For this report, data were abstracted from the medical records of 220 hospitalized and 311 nonhospitalized patients aged ≥18 years with laboratory-confirmed COVID-19 from six acute care hospitals and associated outpatient clinics in metropolitan Atlanta, Georgia. Multivariable analyses were performed to identify patient characteristics associated with hospitalization. The following characteristics were independently associated with hospitalization: age ≥65 years (adjusted odds ratio [aOR] = 3.4), black race (aOR = 3.2), having diabetes mellitus (aOR = 3.1), lack of insurance (aOR = 2.8), male sex (aOR = 2.4), smoking (aOR = 2.3), and obesity (aOR = 1.9). Infection with SARS-CoV-2 can lead to severe outcomes, including death, and measures to protect persons from infection, such as staying at home, social distancing (5), and awareness and management of underlying conditions should be emphasized for those at highest risk for hospitalization with COVID-19. Measures that prevent the spread of infection to others, such as wearing cloth face coverings (6), should be used whenever possible to protect groups at high risk. Potential barriers to the ability to adhere to these measures need to be addressed.

A retrospective study of the safety of intramuscular ziprasidone in agitated elderly patients

OBJECTIVE

Authors evaluated the safety of intramuscular ziprasidone for use in acute agitation in an elderly population.

METHOD

Medical records were reviewed retrospectively to identify consecutive patients who were admitted to our neuropsychiatry service with the presenting complaint of dementia (DSM-IV) with agitation and who were given intramuscular ziprasidone and then administered an electrocardiogram (ECG) (N = 23). Some patients also had a baseline ECG (N = 14). QTc intervals were recorded, and significance was defined as a QTc of > or =450 ms or a 10% prolongation from baseline. A paired-samples t test was performed to compare the baseline and postmedication QTc intervals. Confounding factors were examined, and cardiac events (torsades de pointes, cardiac arrest) were recorded.

RESULTS

There was no significant difference in the QTc interval between the baseline and the post-ziprasidone values. One patient had a QTc greater than 500 ms and 25% over baseline, and therefore the medication was discontinued. The mean prolongation of the QTc interval was only 0.5 ms. There were no episodes of torsades de pointes. Other medications that the patients were taking did not appear to affect the QTc interval in an expected manner.

CONCLUSION

Larger studies need to be done to evaluate the safety of intramuscular ziprasidone in agitated elderly patients, a population with an increased risk of QT prolongation and torsades de pointes because of their age, comorbid conditions, and concomitant use of multiple medications.

Schizophrenia, substance use, and brain morphology

The high rate of comorbid substance abuse in schizophrenia and the consistently poor outcome of this comorbidity are well established findings in the research literature. However, the reasons for the high rate of comorbidity are not adequately understood, and the question of why some patients with schizophrenia abuse substances and others do not remains unanswered. There is widespread agreement about the clinical heterogeneity of schizophrenia, and there is some evidence suggesting that the heterogeneous clinical presentation may reflect a parallel underlying heterogeneity of brain morphology. We were interested in examining the possibility that the high rate of substance abuse and the characteristically poor outcome may be associated with the underlying brain morphology. Our hypothesis was that study subjects with schizophrenia and substance abuse would have higher rates of gross brain abnormalities than subjects with only schizophrenia. In an attempt to explore this possibility, we looked at qualitative differences in magnetic resonance imaging scans for a large sample (n = 176) of schizophrenia patients. In the group of patients who abused both alcohol and drugs, we found the rate of gross brain abnormalities to be slightly less than half the rate found among the patients with no history of alcohol or substance abuse (8 vs. 19). Although these results are not statistically significant, they reflect a trend that is compatible with previous findings, suggesting that substance abuse history may be accompanied by less impairment in certain areas, which in turn may be reflected in a better premorbid adjustment. However, our findings are not compatible with previous findings that show substance abuse to be associated with more severe symptoms and a poorer outcome in schizophrenia.

Late-life psychosis: making the diagnosis and controlling symptoms

Psychosis is best considered as a state of brain dysfunction characterized by delusions, hallucinations, and formal thought disorder. The greatest risk factor for the development of late-life psychosis is the presence of a progressive dementia. Management of the psychotic patient incorporates nonpharmacologic and pharmacologic interventions. Neuroleptics are the most common treatment for psychosis; they generally have very similar efficacy, and thus the choice of agent generally depends on the side effect profile. The newer atypical neuroleptics have relatively fewer anticholinergic and extrapyramidal effects and therefore are often good choices for the older population.

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.

A survey of telepsychiatry in the USA

Active telepsychiatry services in the United States were surveyed. Telepsychiatry was being used in four broad areas: educational, administrative, research, and clinical. Of the five telepsychiatry sites with accurate patient contact data, there was a mean of 1.35 patient contacts per week. The majority of telepsychiatry usage involved direct physician-patient contact. No adverse outcomes to patients were reported.

White matter hyperintensity signals associated with vascular risk factors in schizophrenia

1. A sample of 165 schizophrenic subjects was compared to a normal control group in order to evaluate associations between white matter hyperintensity signals and vascular risk factors. 2. A comprehensive medical chart review was completed on all subjects evaluating potential vascular risk factors. Brain MRI acquisition was performed with 0.5 and 1.5 Telsa Philips scanners. 3. Prevalence rates of WMH signals in schizophrenic subjects and normal controls were 4.8% and 4.9%, respectively. 4. A significant association was found for schizophrenics with WHM signals to schizophrenics without signals for hypertension and history of CVA's. 5. This finding is consistent with an etiology of WMH signals in schizophrenia being related to vascular disease.

Paddling permanent white water: managing within the paradigm shifts in military medicine

The challenges of managing military medicine over the last three decades have been complicated by rapidly changing priorities and redirections. Inspired by Kuhn's theory of "paradigm shifts," we can identify five distinct paradigms and four paradigm shifts that have dominated military medicine over the last 25 years. These shifts began in the early 1970s when military medicine was forced to make a transition from a focus on combat casualty care to the problems of becoming an all-volunteer force. These paradigm shifts continue in the form of the current challenges of simultaneously embracing new cost-conscious forms of health care delivery while downsizing the force. Each of the shifts has been characterized by a lack of anticipation and the onset of crisis. The present challenges faced by military medical leadership are not necessarily unprecedented; prescience in regard to inevitable future shifts could reduce turmoil and enhance adaptation.

The comorbidity of DSM-III-R personality disorders in somatization disorder

In order to understand psychiatric factors that complicate the medical management of somatizing patients, 94 subjects with known somatization disorder (SD) were evaluated for 13 personality disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. Referred from multiple primary care settings, the patient sample was predominantly female (85%), married (67%), high school graduates (64%), and had a mean age of 43. Structured interviews documented that 23.4% of SD patients had one personality disorder, and 37.2% had two or more disorders. The four most frequently identified personality disorders were avoidance 26.7%, paranoia 21.3%, self-defeating 19.1%, and obsessive-compulsive 17.1%. Interestingly histrionic personality disorder was identified in only 12.8% of the sample and antisocial personality disorder in 7.4%. In making the diagnosis of SD, health care providers need to avoid the common clinical impression that histrionic behavior often accompanies the disorder. Further research with SD patients is needed to examine the relationship of co-occurring personality disorders to symptom recurrence, health care utilization, and readiness for psychiatric referral.

White matter hyperintensity signals in psychiatric and nonpsychiatric subjects

OBJECTIVE

As part of an ongoing study investigating the relationship between brain morphology/function and neuropsychological performance in psychopathology, the authors conducted brain magnetic resonance imaging (MRI) studies to investigate the prevalence and psychiatric significance of white matter hyperintensity signals.

METHOD

Brain MRI acquisition was done with 0.5 and 1.5 Tesla Philips scanners. Psychiatric subjects (N = 229) and normal volunteers (N = 154) were recruited by newspaper and local advertising and by physician referral. DSM-III-R criteria were used. White matter hyperintensity signals were rated on a 4-point scale of severity. Prevalence rates and risk ratios were calculated.

RESULTS

Prevalence rates of hyperintensity signals in all psychiatric subjects (mean age = 34 years, SD = 9) and normal volunteers (mean age = 34, SD = 10) were 6.6% and 9.1%, respectively (a nonsignificant difference). When all psychiatric subjects, subjects under age 45, and subjects age 45 and over in a diagnostic category were considered, there were no statistically significant differences between them and normal volunteers in the same age groups in prevalence of schizophrenia, schizoaffective disorder, bipolar disorder, major depression, and obsessive-compulsive disorder. A significant difference existed between the severity of deep white matter hyperintensity signals in subjects with major depression and normal volunteers. Older age was correlated as a risk factor for white matter hyperintensity signals for psychiatric subjects.

CONCLUSIONS

These results do not support previous findings of greater prevalence of hyperintensity signals in bipolar disorder. Significantly higher prevalence rates of hyperintensity signals were seen in subjects with major depression only when severity of the deep white matter hyperintensity signals was considered. Older age is an indirect risk factor for the presence of white matter hypertensity signals, probably as a result of vascular changes associated with concurrent medical illnesses.

Using telemedicine to improve health care in distant areas

Many users consider telemedicine a partial solution to problems of delivering health care to remote areas or areas underserved by clinicians. Current telemedical technology benefits from recent developments such as the decreased cost and improved quality of the coder-decoder (codec) equipment used in interactive digital video systems and the expansion of fiber-optic cable networks. The authors outline some pioneering telemedicine programs of the 1960s and 1970s and describe two recently activated systems in Texas. One network, serving the western two-fifths of the state, links faculty members from four campuses of Texas Tech University Health Sciences Center with almost 40 rural communities. The other connects the state hospital and three other facilities in Austin with four health care sites in the town of Giddings, 65 miles away. Besides serving patients, the systems provide continuing medical education and support to reduce the isolation of rural health care professionals. Primary goals include evaluation and certification of telemedical training and analysis of the cost feasibility of telemedical services.

Screening indexes in DSM-III-R somatization disorder

A sample of 196 general medical patients with multiple unexplained somatic complaints was used to compare the performance (sensitivity and specificity) and positive and negative predictive values for the published screening indexes for somatization disorder. This study shows similar performances for both the DSM-III-R and the Swartz et al. screening indexes for somatization disorder with use of DSM-III-R diagnostic criteria. By use of Receiver Operating Characteristic (ROC) curve analysis, graphs of achievable sensitivity and specificity through the range of possible symptom thresholds allow for a more informed decision to be made concerning which screening index to use at a given symptom threshold. Positive predictive values for screening indexes ranged from 68% to 79%, and negative predictive values ranged from 72% to 81%. Use of a screening index is suggested in medical patients with unexplained complaints and in patients seen in the consultation-liaison (CL) setting.

Effects on sleep: a double-blind study comparing trimipramine to imipramine in depressed insomniac patients

Trimipramine, a sedating tricyclic antidepressant, and imipramine were compared on polysomnographic parameters during a 4-week double-blind trial in depressed patients with insomnia and anxiety. Trimipramine eliminated objective evidence of sleep disturbance. This was not the case with imipramine, although depression improved similarly in both groups. Subjects' sleep appeared unchanged or more disturbed at the end of the treatment with imipramine. For trimipramine, the major changes in sleep parameters occurred during the first week of drug administration and did not parallel the gradual changes seen in the measures of depression. Additionally, trimipramine did not suppress REM sleep even in a subgroup of six trimipramine patients who had short rapid-eye-movement (REM) sleep latencies during the placebo baseline period, even though their depression was alleviated. The data demonstrate that (a) antidepressants may vary in their effects on sleep, even though they have similar effects on depression; (b) REM sleep suppression does not necessarily accompany improvement in depression; and (c) reports of improved sleep by patients undergoing antidepressant therapy may not reflect improvement on objective measures of sleep. The different sleep effects suggest the possibility of different antidepressant pathways.

Organophosphate intoxication: hidden hazards

The case we have reported underscores the need for careful screening of patients with organophosphate intoxication before transfer to psychiatric facilities. In particular, this patient demonstrated a recently defined clinical syndrome that required emergency medical and psychiatric management. Organophosphate intoxication is a common method of attempted suicide, which may be superimposed on other illness such as alcoholism. Anticipation of the possibility of the "intermediate syndrome" should decrease lethality.

Birth order of patients with DSM-III-R somatization disorder

A sample of 143 patients, 76 meeting strict DSM-III-R criteria for somatization disorder and 67 somatizers, was studied using Slater's index to measure birth order position. The results showed that birth order position was not associated with the diagnosis of somatization disorder and that sibship position in both groups occurred by chance. Thus, although environmental factors may influence the development of somatization disorder, the expression of environmental influence through birth order is unlikely.

Medical success in El Salvador

American medicine is respected worldwide, and our ability to respond with aid is beyond that of any nation. While we cannot administer aid indiscriminately, our ability to provide swift, effective humanitarian aid is one way in which we can demonstrate that we are truly relevant in the Third World. Recent United States experience in El Salvador proves this point. In 1983, when the Army was sending the first medical mobile training team to El Salvador, the mortality rate of wounded Salvadorian soldiers was 45%. As a result of U.S. military medical assistance, over the past four years the mortality rate of the wounded decreased to 5%. Activities of the Army Medical Department in El Salvador are an excellent example of efficient use of military medicine in low intensity conflict.

Organic matter in a coal ball: peat or coal?

Chemical analyses of morphologically preserved organic matter in a Carboniferous coal ball reveal that the material is coalified to a rank approximately equal to that of the surrounding coal. Hence, the plant tissues in the coal ball were chemically altered by coalification processes and were not preserved as peat.

The painful migrated ununited greater trochanter in total hip replacement

The migrated painful ununited trochanter following total hip replacement can provoke a significant degree of functional disability. Although this condition is infrequently observed after total hip replacement, its occurrence causes definite problems for its operative management. A technique employing the trochanteric bolt for reattachment of the migrated painful trochanteric fragment is described. The results of this approach in five patients to date are relief from pain and decreased disability in all five. The factors promoting migration of the osteotomized fragment include the quality of the trochanteric bone, the stresses placed on the osteotomy site by the patient during the postoperative period, and the precise method of reattachment of the trochanter at the time of total hip replacement.

Management of diskogenic pain using epidural and intrathecal steroids

The use of methylprednisolone acetate (Depo-Medrol) injected by the epidural or intrathecal route for the relief of diskogenic back pain with or without radiculopathy is an adjunct to conservative management useful when conservative measures fail and surgical treatment is under consideration. This is especially true when symptoms have been present for only a few months. Corticosteroids injected in the same manner seem to have little effect on patients with symptoms persisting for periods longer than 3 months or in patients treated previously by surgical methods.