Clinical characteristics and outcomes of the first two waves of the COVID-19 pandemic in a community hospital: a retrospective cohort study

•

The COVID-19 pandemic has demonstrated a wave pattern similar to that of previous pandemics

•

Treatment guidelines have changed rapidly, based on clinical studies

•

In our hospital, the use of steroids and noninvasive ventilation increased with time

•

During the second wave, patients had a slower progression to death

Objective

To describe the clinical characteristics and outcomes of two waves of the COVID-19 pandemic.

Methods

A de-identified dataset of patients with COVID-19 admitted to our community hospital in Evanston, Illinois, from March 1, 2020 to February 28, 2021 was retrospectively reviewed. Patients from the first wave were identified as those admitted during the initial peak of admissions observed at our hospital between March 1, 2020 and September 3, 2020. The second wave was defined as those admitted during the second peak of admissions observed between October 1, 2020 and February 28, 2021.

Results

In total, 671 patients were included. Of these, 399 (59.46%) were identified as patients from the first wave and 272 (40.54%) as patients from the second wave. Significantly more patients received steroids (86.4% vs 47.9%, p < 0.001), remdesivir (59.6% vs 9.5%, p < 0.001), humidified high-flow nasal cannula (18% vs 6.5%, p < 0.001), and noninvasive ventilation (11.8% vs 3.3%, p < 0.001) during the second wave. Patients from the first wave had a greater hazard for death compared with patients from the second wave (hazard ratio [HR] 1.62, 95% CI 1.08–2.43; p = 0.019).

Conclusion

Among patients hospitalized with COVID-19 in our community hospital, there was a decrease in case-fatality rate in the second surge of the COVID-19 pandemic compared with the first wave.

Clostridium tertium Bacteremia: A Marker of an Underlying Perforated Colonic Diverticular Disease in a Non-Neutropenic Patient With COVID-19

Clostridium tertium (C. tertium) is an aero-tolerant, gram-positive, endospore-forming, and non-exotoxin-producing bacillus that has colonized the gastrointestinal tract of animals and humans. It is considered a rare pathogen of humans, possibly because of its low virulence. Most C. tertium infections in the reviewed literatures were predominately reported among neutropenic hosts with hematological malignancies. A 66-year-old female patient with a past medical history of type II diabetes mellitus and chronic obstructive pulmonary disease was admitted with coronavirus disease 2019 (COVID-19) that initially required non-invasive ventilation. The patient developed septic shock due to C. tertium bacteremia. Computed tomography of the abdomen depicted free intraperitoneal gas and sigmoid colon perforation. Exploratory laparotomy revealed perforated sigmoid diverticulitis, and Hartmann’s procedure was performed. The patient received a prolonged course of susceptibility-guided antibiotics to clear C. tertium bacteremia. The authors described a rare case of C. tertium bacteremia as a marker of underlying perforated colonic diverticulitis in a non-neutropenic patient with COVID-19 that necessitated operative procedure intervention for primary source control and an extended course of targeted antibiotic therapy to treat the Clostridial infection. Our case reaffirmed the available literature that suggested the presence of C. tertium bacteremia in non-neutropenic patients raises suspicion of an associated gastrointestinal tract pathology that should warrant a diagnostic workup to identify the infection source culprit.

Gender-Related Differences in Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Background

Gender-related differences in phenotypic expression and outcomes have been established in many cardiac conditions; however, the impact of gender in hypertrophic cardiomyopathy (HCM) remains unclear. We conducted a systematic review and meta-analysis to assess the differences in clinical outcomes between female and male HCM patients.

Methods

We searched MEDLINE and EMBASE from inception to October 2020. Included were cohort studies that compared outcomes of interest including all-cause mortality, HCM-related mortality, and worsening heart failure (HF) or HF hospitalization between male and female. Data from each study were combined using the random effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI).

Results

Eleven retrospective cohort studies with a total of 9,427 patients (3,719 females) were included. Female gender was significantly associated with an increased risk of all-cause mortality (pooled OR = 1.63, 95% CI: 1.26-2.10, p ≤ 0.001), HCM-related mortality (pooled OR = 1.47, 95% CI: 1.08-2.01, p = 0.015), and worsening HF or HF hospitalization (pooled OR = 2.05, 95% CI: 1.76-2.39, p ≤ 0.001).

Conclusions

Female gender was associated with a worse prognosis in HCM. These findings suggest the need for improved care in women including early identification of disease and more possible aggressive management. Moreover, gender-based strategy may benefit in HCM patients.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Development of cavitary lung disease as a long-term complication of coronavirus disease 2019 in a young previously healthy patient: a case report

BACKGROUND

Cavities are frequent manifestations of a wide variety of pathological processes involving the lung. There has been a growing body of evidence of coronavirus disease 2019 leading to a cavitary pulmonary disease.

CASE PRESENTATION

A healthy 29-year-old Filipino male presented to the hospital a couple of months after convalescence from coronavirus disease 2019 with severe pleuritic chest pain, fever, chills, and shortness of breath, and was found to have a cavitary lung lesion on chest computed tomography. While conservative management alone failed to improve the patient's condition, he ultimately underwent left lung video-assisted thoracoscopic surgery decortication. Even though the surgical pathology revealed only necrosis with dense acute inflammation and granulation tissue with no microorganisms, he gradually improved with medical therapy adjunct with surgical therapy.

CONCLUSION

Documented cases of cavitary lung disease secondary to coronavirus disease 2019 have been mostly reported in the acute or subacute phase of the infection. However, clinicians should recognize this entity as a late complication of coronavirus disease 2019, even in previously healthy individuals.

Performance of the quick COVID-19 severity index and the Brescia-COVID respiratory severity scale in hospitalized patients with COVID-19 in a community hospital setting

OBJECTIVE

To evaluate the performance of the Quick COVID-19 Severity Index (qCSI) and the Brescia-COVID Respiratory Severity Scale (BCRSS) in predicting intensive care unit (ICU) admissions and in-hospital mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia.

METHODS

This was a retrospective cohort study of 313 consecutive hospitalized adult patients (18 years or older) with confirmed COVID-19. The area under the receiver operating characteristic curve (AUC) was used to assess the discriminatory power of the qCSI score and BCRSS prediction rule compared to the CURB-65 score for predicting mortality and intensive care unit admission.

RESULTS

The overall in-hospital fatality rate was 32.3%, and the ICU admission rate was 31.3%. The CURB-65 score had the highest numerical AUC to predict in-hospital mortality (AUC 0.781) compared to the qCSI score (AUC 0.711) and the BCRSS prediction rule (AUC 0.663). For ICU admission, the qCSI score had the highest numerical AUC (AUC 0.761) compared to the BCRSS prediction rule (AUC 0.735) and the CURB-65 score (AUC 0.629).

CONCLUSIONS

The CURB-65 and qCSI scoring systems showed a good performance for predicting in-hospital mortality. The qCSI score and the BCRSS prediction rule showed a good performance for predicting ICU admission.

Type 2 diabetes is associated with increased risk of critical respiratory illness in patients COVID-19 in a community hospital

Background

Type 2 diabetes (T2D) is the leading non-communicable disease worldwide and is associated with several microvascular and macrovascular complications. Individuals with T2D are more prone to acquiring selected types of infections and are more susceptible to complications due to these infections. This study aimed to evaluate the relationship between T2D and COVID-19 in the community setting.

Methods

This was a single-center retrospective analysis that included 147 adult patients with laboratory-confirmed COVID-19 admitted to a community hospital. Demographics, medical history, symptoms and signs, laboratory findings, complications during the hospital course, and treatments were collected and analyzed. The Kaplan-Meier method was used to describe the probability of intubation in patients with T2D as compared with patients without T2D. The hazard ratio for intubation in the survival analysis was estimated using a bivariable Cox proportional-hazards model.

Results

Of 147 patients, 73 (49.7%) had a history of T2D. Patients with T2D had higher requirement of ICU admission (31.5% vs 12.2%; p = .004), higher incidence of ARDS (35.6% vs 16.2%, p = .007), higher rates of intubation (32.9% vs 12.2%, p = .003), and higher use neuromuscular blocking agents (23.3% vs 9.5%, p = .02). In the survival analysis at 28 days of follow-up, patients with T2D showed an increased hazard for intubation (HR 3.00; 95% CI, 1.39 to 6.46).

Conclusion

In our patient population, patients with COVID-19 and T2D showed significantly higher ARDS incidence and intubation rates. The survival analysis also showed that after 28 days of follow-up, patients with T2D presented an increased risk for shorter time to intubation.

A Retrospective Study of Coinfection of SARS-CoV-2 and Streptococcus pneumoniae in 11 Hospitalized Patients with Severe COVID-19 Pneumonia at a Single Center

Background

A lethal synergism between the influenza virus and Streptococcus pneumoniae has been identified. However, bacterial coinfection is considered relatively infrequent in hospitalized patients with COVID-19, and the co-prevalence of Streptococcus pneumoniae is low.

Material/Methods

We retrospectively analyzed the clinical characteristics and outcomes of patients subsequently admitted to AMITA Health Saint Francis Hospital between March 1 and June 30, 2020, with documented SARS-CoV-2 and S. pneumoniae coinfection.

Results

We identified 11 patients with S. pneumoniae coinfection. The median age was 77 years (interquartile range [IQR], 74–82 years), 45.5% (5/11) were males, 54.5% (6/11) were white, and 90.9% (10/11) were long-term care facility (LTCF) residents. The median length of stay was 7 days (IQR, 6–8 days). Among 11 patients, 4 were discharged in stable condition and 7 had died, resulting in an inpatient mortality rate of 64%.

Conclusions

At our center, 11 patients with COVID-19 pneumonia who had confirmed infection with SARS-CoV-2 were diagnosed with Streptococcus pneumoniae infection while in hospital. All patients had pneumonia confirmed on imaging and a nonspecific increase in markers of inflammation. The in-hospital mortality rate of 64% (7 patients) was higher in this group than in previous reports. This study highlights the importance of monitoring bacterial coinfection in patients with viral lung infection due to SARS-CoV-2.

Clinical Characteristics and Risk Factors for Death of Hospitalized Patients With COVID-19 in a Community Hospital: A Retrospective Cohort Study

Objective

To describe the clinical characteristics, outcomes, and risk factors for death of patients with coronavirus disease 2019 (COVID-19) in a community hospital setting.

Patients and Methods

This single-center retrospective cohort study included 313 adult patients with laboratory-confirmed COVID-19 admitted to a community hospital in Cook County, Illinois, from March 1, 2020, to May 25, 2020. Demographics, medical history, underlying comorbidities, symptoms, signs, laboratory findings, imaging studies, management, and progression to discharge or death data were collected and analyzed.

Results

Of 313 patients, the median age was 68 years (interquartile range, 59.0-78.5 years; range, 19-98 years), 182 (58.1%) were male, 119 (38%) were white, and 194 (62%) were admitted from a long-term care facility (LTCF). As of May 25, 2020, there were 212 (67.7%) survivors identified, whereas 101 (32.3%) nonsurvivors were identified. Multivariable Cox regression analysis showed increasing hazards of inpatient death associated with older age (hazard ratio [HR] 1.02; 95% CI, 1.01-1.04), LTCF residence (HR, 3.23; 95% CI, 1.68-6.20), and quick Sequential Organ Failure Assessment scores (HR, 2.59; 95% CI, 1.78-3.76).

Conclusion

In this single-center retrospective cohort study of 313 adult patients hospitalized with COVID-19 illness in a community hospital in Cook County, Illinois, older patients, LTCF residents, and patients with high quick Sequential Organ Failure Assessment scores were found to have worse clinical outcomes and increased risk of death.

Neurolitigation: a perspective on the elements of expert testimony for extending the Daubert challenge

Scientific expert witness testimony has the potential for affecting most court decisions in civil and criminal proceedings. Since experts were first utilized in English courts beginning in the 14th century, most contemporary courts struggle with seeking a balance between plaintiff and defense counsel allowing each party its day in court while taking into account the work which other courts have done previously in determining the admissibility of expert witness testimony. When these challenges present themselves in the courtroom, often other courts have approached these identical issues, many in proceedings involving the same expert(s). Confronted with these challenges, trial judges want to understand whether a new Daubert hearing must be held, deal with the issue from a clean slate approach or whether they must reinvent the proverbial wheel. Given these dilemmas, this exposition is based within a heuristic approach that will focus on the consideration of comprehensive data inclusion from an evidentiary foundation as it applies to expert witness testimony admissibility in neurolitigation. While the evidential force of FRE 702 specifically applies to admissibility of scientific evidence, it makes sense that along with scientific, objective data, inclusion of non-medical and other data in forming and admitting expert opinions, have mutual bearing upon the validity of opinions arrived at through neuropsychological assessment. It is these multi-data that should be factored into account when applying the Federal Rule of Evidence 702 scientific admissibility standard. Data from other relevant sources is just as vital as data obtained from objective measures, and co-exists with objective data. Without the integration of this information into resulting diagnostic data and opinions, one's methodology is open to scrutiny and can willfully be characterized as engaging in "junk science". Specific, pragmatic issues are discussed in order to avoid the plausible "junk science" question and to ultimately arrive at a factual and evidenced-based admissibility and reliability determination for the courts. Given the current standard, this article proposes an inclusionary method in neurolitigation as it would necessarily apply to Federal Rule of Evidence 702 which would extend to the integration of data outside medical and scientific information bases to establish accurate opinions for the trier of fact. In so doing, neuropsychological test data, non-medical data and expert testimony would be strengthened through inter-data consistency.

The roles of experts and litigation support consultants in medical-legal claims

Brain injury claims frequently involve the use of experts to evaluate and document extent of impairment. These experts can cover a wide array of specialities, many of which are delineated in this article. It is pointed out that there are crucial differences between a clinical evaluation and a medical-legal evaluation as the latter is generally more comprehensive and addresses many of the specific issues that arise in a forensic claim. It is suggested that use of a litigation support consultant can provide valuable assistance for the attorney at the outset and over the course of handling a claim such as with selection of experts and preparation for direct and cross examination of experts. Suggestions are also made about criteria for selection of experts such as to ensure that appropriate objectivity, and, consequently, admissibility of conclusions is maintained.

Effects of acute starvation on vitamin A status in rats

Maintenance of vitamin A stores in the body is dependent on a number of basic metabolic processes. These processes, such as protein and carbohydrate metabolism, are disrupted in acute starvation, and, as a result, alterations in vitamin A status may result. We investigated this possibility in 8-week-old Sprague-Dawley male rats. The rats were starved for 24, 48, and 72 hr but had free access to water. At 24 hours of starvation, the plasma retinol concentration was depressed, but not significantly so. After 48 and 72 hours of starvation, however, the plasma retinol concentration decreased to less than half of the control values (61 +/- 4 vs 124 +/- 12 nmol/dl at 72 hours, mean +/- SEM, (p less than 0.005). The hepatic retinoid (retinyl esters + retinol) concentration (nmol/g liver) was increased at 24 and 48 hours of starvation compared to controls (p less than 0.05), and by 72 hours the concentration was 56% greater in starved rats than in fed controls (p less than 0.001). The total hepatic retinoid content (mumol/total liver) was decreased moderately at all periods of starvation compared to controls (p less than 0.05). In both starved and fed animals, the total hepatic content per 100 g body weight, a measure of total vitamin A reserves, was statistically the same. These results demonstrate that acute starvation in rats alters the vitamin A equilibrium between the plasma and hepatic stores without affecting the overall vitamin A reserves.(ABSTRACT TRUNCATED AT 250 WORDS)

Dynorphin: a possible modulatory peptide on morphine or beta-endorphin analgesia in mouse

Dynorphin-(1-13), but not dynorphin-(1-9) has been shown to have significant effects on opiate and beta-endorphin-induced analgesia despite not having any appreciable analgesic activity itself. Dynorphin had no effect on Sandoz FK33824 compound-induced analgesia.

Ethanol-induced analgesia in rats selectively bred for ethanol sensitivity

Two rat lines selectively bred for ethanol-induced depression of locomotor activity were studied for ethanol-induced analgesia. The effects of ethanol on startle amplitude, extent of overt movements and incidence of audible vocalizations in response to intermittent, noncontingent foot shock. All three responses were dose-dependently depressed by ethanol (0.66 to 2.0 g/kg, IP), and to greater extent in the "most affected" line (MA) than in "least affected" (LA) rats. Ethanol-induced response decrements were reinstated at higher shock intensities, indicating a sensory (i.e., analgesic) rather than a motoric or analgesic basis for these effects. Genes which influence ethanol's motoric effects might, in part, influence sensitivity to its sensory effects.

The father's parenting experience in divorce

The author discusses the father-child relationship as it is influenced by divorce. Psychiatrists are often consulted by individuals considering dovorce who are concerned about its probable impact on their children. Data gathered from the treatment of fathers during divorce indicate that there can be positive changes in their parental bonds as a result of increased opportunities to relate to children in a conflict-free atmosphere. In such a setting, the father's nurturing experience provides him with a new perspective on parenting. Psychotherapeutic help can lead to a strengthening of parental bonds, with subsequent benefits to both father and child. The author encourages professionals to support men in improving their fathering during the postdivorce period.

Peptide inhibitor of morphine- and beta-endorphin-induced analgesia

The synthetic beta-endorphin analogs with the omission of the NH2-terminal [Met]enkephalin segment [beta-endorphin-(6-31) and beta-endorphin-(20-31)] are shown to inhibit morphine- or beta-endorphin-induced analgesia in mice by the tail-flick test, whereas the synthetic NH2-terminal pentadecapeptide beta-endorphin-(1-15) has no inhibitory activity. This study raises the possibility that endogenous inhibiting peptides exist in the brain which play a role in the regulation of endorphin actions.

Effect of alpha-methyl-p-tyrosine on dose-dependent mouse strain differences in locomotor activity after ethanol

Ethanol had biphasic effects on locomotor activity in C57Bl and BALB mice, but at different doses in the two strains. Catecholamine depletion attenuated activity increases in both strains but did not affect decreases.

Special problems of women in psychotherapy

Feminist critics have failed to acknowledge the usefulness of Freud's neutral observations about female sexual development. This paper is an attempt to refute the prejudiced, incorrect view of the modern psychoanalytically oriented psychotherapist as sexist in orientation. Several detailed case examples are utilized to illustrate the interpretive treatment of excessive passivity in women patients with a variety of neurotic difficulties.

Psychotherapy of borderline patients: the influence of theory on technique

Although the treatment of borderline patients has attracted increased attention, there is little agreement on the basic nature of the disorder or the proper techniques for its treatment by analytically oriented psychotherapy. The author states that treatment based on the idea that the borderline patient achieves therapeutic gains by raging against an accepting therapist for a prolonged period of time is not so effective as treatment based on the recognition of specific ego defects as the core pathology. He suggests that the therapist be active in the treatment of borderline patients and not permit gross and unproductive distortions of the therapeutic relationship.

Intraventricular ethanol and ethanol intake: a behavioral and radiographic study

Ethanol (10% w/v) was infused intraventricularly at a rate of 11 mul/hr, delivered over 50 sec every 10 min for 10 days into 5 Sprague-Dawley and 5 Wistar rats. Thereafter, preference testing with ascending concentrations of alcohol solutions vs . water vs. food gave no significant differences between treated and sham-operated controls, in contradiction to previously reported increases in alcohol consumption. Ethanol's rate of elimination from the ventricle and its pattern of diffusion into the brain were determined using radioactive ethanol: elimination from the brain is rapid with a half-like of 24 to 35 sec, and the amount diffused throughtout the brain small, with a maximal concentration in any one section of 0.004% (such a concentration is at least 20 times less than would result from a moderately intoxicating parenteral dose of ethanol). The character of the elimination and the lack of effect on alcohol intake found here indicate that intraventricularly administered ethanol is a technique with no usefulness in elucidating the processes affecting alcohol addiction.

Ethanol-induced mouse strain differences in locomotor activity

C57BL/6J mice showed dose dependent devreases in locomotor activity with increasing IP doses of ethanol (0.0, 0.75, 1.50 and 2.25 g/kg), while BALB/cJ mice showed dose dependent increases in activity; both strains were equally active with saline. Whether this finding represents decreased CNS responsivity in C57BL mice to ethanol's excitatory effect or increased response to its depressant action at sub-hypnotic doses is unclear, since anesthetic doses produce anesthesia of far shorter duration in the C57BL strain than in the BALB strain. It is possible that the biphasic action of alcohol is under the control of separate and distinct mechanisms, rather than a common one, and that these two mechanisms are differentially affected by alcohol. Endogenous as well as ethanol-induced neurochemical differences in biogenic amines may also be correlated with the gentic variation in CNS responsivity towards alcohol.

Physician management of dying patients: an exploration

Although there are increasing numbers of disciplined observations and studies about the dying patient, the question remains as to whether they have been read and put into practice. This paper reports on a current study aimed at exploring how physicians actually work with patients suffering from fatal illnesses. Responding to a questionnaire on their methods of managing dying patients were 59 internists, 76 surgeons, 25 gynecologists, 13 general practitioners and 5 psychiatrists. Sixty-six percent of the physicians said they sometimes inform patients of a malignancy, 25 percent said they always tell the patient, and only 9 percent said they never tell the patient. The fact that very few physicians apparently feel justified in saying they never inform a patient about a fatal diagnosis is in itself a modification of previous practice. However, judging from answers to other questions, it is the author's impression that in actual practice many physicians tend to resist informing their patients of the diagnosis in a direct manner and are inclined to be quite selective in informing only those patients described as self-reliant, independent and able to face reality.