Outcomes in novel hospital-at-home model for patients with COVID-19: a multicentre retrospective cohort study

BACKGROUND

Hospital-at-home (HaH) care has been proposed as an alternative to inpatient care for patients with coronavirus disease (COVID-19). Previous reports were hospital-led and involved patients triaged at the hospitals. To reduce the burden on hospitals, we constructed a novel HaH care model organized by a team of local primary care clinics.

METHODS

We conducted a multicentre retrospective cohort study of the COVID-19 patients who received our HaH care from 1 January to 31 March 2022. Patients who were not able to be triaged for the need for hospitalization by the Health Center solely responsible for the management of COVID-19 patients in Osaka city were included. The primary outcome was receiving medical care beyond the HaH care defined as a composite outcome of any medical consultation, hospitalization, or death within 30 days from the initial treatment.

RESULTS

Of 382 eligible patients, 34 (9%) were triaged for hospitalization immediately after the initial visit. Of the remaining 348 patients followed up, 37 (11%) developed the primary outcome, while none died. Obesity, fever, and gastrointestinal symptoms at baseline were independently associated with an increased risk of needing medical care beyond the HaH care. A further 129 (37%) patients were managed online alone without home visit, and 170 (50%) required only 1 home visit in addition to online treatment.

CONCLUSIONS

The HaH care model with a team of primary care clinics was able to triage patients with COVID-19 who needed immediate hospitalization without involving hospitals, and treated most of the remaining patients at home.

A 5-year survivor of endarterectomy for sclerosing undifferentiated intimal sarcoma of the pulmonary artery: Importance of clinical suspicion and careful histologic evaluation

We present a diagnostically challenging case of intimal sarcoma of the pulmonary artery (PA) due to the histologic finding of a sclerosing appearance with no appreciable spindle/pleomorphic cell proliferation. Initial endarterectomy specimens were composed of sclerosing extracellular matrix with a few bland cells, some recanalization, and fibrin thrombi, impeding the confirmation of intimal sarcoma as these findings were also consistent with chronic thromboembolic pulmonary hypertension. However, the patient experienced recurrence 5 years later, and the second endarterectomy specimens revealed more firm and solid mass and the proliferation of atypical spindle/pleomorphic cells within a myxomatous matrix in the distal PA, leading to the definitive diagnosis of undifferentiated intimal sarcoma of the PA. The archival specimens from the endarterectomy confirmed intense MDM2 expression by immunohistochemistry, suggesting its role as a potential diagnostic marker for intimal sarcoma. This case highlights that prominent sclerosing extracellular matrix with very few atypical cells should raise the possibility of intimal sarcoma of the PA and that high index of suspicion, generous sampling, and ancillary tests are critical for accurate diagnosis. In this case, the tumor was incidentally removed by endarterectomy, resulting in 5 years of survival.

Inverted Takotsubo cardiomyopathy masking acute myocardial infarction

We report a case of inverted Takotsubo cardiomyopathy masking acute myocardial infarction. In this case, echocardiography on admission showed left ventricular mid and basal akinesis and apical hyperkinesis compatible with an inverted Takotsubo contractile pattern. In the subacute phase, however, he was suspected of having acute myocardial infarction by serial changes of cardiac enzymes. After 8 days of admission, echocardiography showed normalization of the left ventricular contraction, except the inferior wall which was compatible with inferior myocardial infarction. Subsequent myocardial scintigraphy confirmed the diagnosis. It is important to recognize that inverted Takotsubo cardiomyopathy may mask acute myocardial infarction when they occur simultaneously.

Effects of red blood cells on the coagulation of blood in normal and preeclamptic pregnancies

OBJECTIVE

The objective of this study was to determine the cellular effects of whole blood, especially of red blood cells, on the hypercoagulability of blood from patients with preeclampsia.

STUDY DESIGN

The time elapsed between mixing and the onset of coagulation was measured by means of a highly sensitive rheometer for whole blood, platelet-rich plasma (in which red blood cells had been removed from whole blood), and platelet-free plasma from 3 groups of subjects: 25 nonpregnant women, 25 women with normal pregnancies, and 10 patients with preeclampsia.

RESULTS

Time to coagulation for whole blood from patients with preeclampsia was significantly shorter than that for whole blood from women with normal pregnancies. However, there was no significant difference in time to coagulation for platelet-rich plasma between women with preeclampsia and those with normal pregnancies.

CONCLUSION

Hypercoagulability of blood in preeclampsia appears to be strongly related to red blood cell alterations.

An autopsy study of 306 cases of maternal death in Japan

Based on autopsy findings in 306 cases of maternal death from 1964 to 1980, recent trends in maternal death in Japan were discussed. Main topics dealt with were as follows: 1. Although rate of maternal death in Japan is decreasing markedly year by year, approximately 90 per cent of our autopsy cases were direct or indirect maternal deaths. 2. The most common category of the direct maternal death was hemorrhage. Unexpectedly uterine rupture was thought to be a common etiological factor for that. 3. One of the most valuable impression obtained in this study was a high percentage of "sudden death". In our series, 85 of 306 cases (27.8 per cent) were of maternal deaths within 6 hours after their general condition began to deteriorate. The first cause of sudden death was hemorrhage, and the second and the third were ectopic pregnancy and amniotic fluid embolism respectively. 4. Although it was very difficult, 16 cases (5.2 per cent) were judged as the maternal death possibly related to drugs. The most widely suspected and used drugs were hysterotonica such as prostaglandin, oxytocin and Deliverin. In these 16 cases of maternal deaths possibly related to drugs either directly or indirectly, amniotic fluid embolism (in 6 cases), uterine rupture (in 3 cases), and cervical laceration (in 2 cases) were confirmed at autopsy and diagnosed as the direct cause of death. However, in the remaining 5 cases, no acceptable findings could be obtained and an exact cause of death had remained unsolved. 5. Fifteen cases (4.9 per cent) of amniotic fluid embolism were confirmed by autopsy. However, only in 6 out of 15 cases, a clinical diagnosis of amniotic fluid embolism was given. In the remaining 9 cases, clinical diagnoses such as "shock of unknown etiology", "septic or endotoxin shock" and "postpartum collapse" were presumed.

Morphometrical analysis of the peripheral nerve lesions in experimental diabetes rats

Morphometrical analysis of the peripheral nerve lesions in experimental diabetes rats was undertaken to elucidate their relationship to glucose intolerance and nerve conduction velocity. Motor nerve conduction velocity of the rat's tail and nerve fiber density in the cross sectional view of the peroneal nerves significantly reduced in the diabetes rats without insulin treatment. With the teased nerve fiber methods, degenerated nerve fibers frequently appeared and shortening of internodal length was estimated in the diabetes rats by quantification. The slowing of nerve conduction, blood glucose levels on the oral glucose tolerance test and the incidence of degenerated nerve fibers were well correlated with one another. Daily insulin treatment caused a significant decrease in degenerated nerve fibers in the diabetes rats. The reduction of nerve fiber density was also related to glucose intolerance. However, there was neither the relationship between nerve fiber density and incidence of degenerated nerve fibers, nor the relationship between nerve fiber density and nerve conduction velocity.

Peripheral nerve structures of experimental diabetes rats and the effect of insulin treatment

The peripheral nerves of alloxan and streptozotocin diabetes rats six months after the induction of diabetes were morphologically investigated. The effect of insulin treatment was also examined. Prominent segmental demyelination and remyelination were observed in both alloxan and streptozotocin diabetes rats by isolated nerve fiber studies. Axonal degeneration and globular swelling were also recognized in some nerve fibers. Transmission electron microscopic findings were characterized by the figures of destructed myelin sheaths and axons. Reduplication and thickening of basal lamina of vasa nervorum were noted in the diabetes rats. Scanning electron microscopy revealed three dimensional architectures of degenerated nerve fibers and rough surface of Schwann cells in the diabetes rats. Insulin treated diabetes rats showed less structural changes of nerve fibers. It was indicated that the peripheral nerve lesions of experimental diabetes rats were caused by metabolic impairment of both axons and Schwann cells. Insulin treatment seemed to be effective on the experimental diabetic neuropathy.

Immunohistochemical demonstration of somatostatin-containing cells in the human placenta

Present study using immunohistochemical methods clearly demonstrated the presence of somatostatin-containing cells in the human placenta. These cells were located in the cytotrophoblastic layer, while the layer of syncytiotrophoblasts showed no positive reaction. With the progress of gestation, these immunoreactive somatostatin-containing cells disappeared. It was suggested that somatostatin or somatostatin-like substances play an important role in the maintenance of gestation.