Telemedicine monitoring of high-risk coronavirus disease 2019 (COVID-19) patients by family medicine service after discharge from the emergency department

BACKGROUND:

Up to 25% of the total coronavirus disease 2019 (COVID-19) admissions comprise patients with comorbidities who present to the emergency department (ED) with only mild-to-moderate disease. It is unclear whether as an alternative to hospitalization, telemedicine can be used to monitor these “high-risk” comorbid patients. The aim of our study was to answer this question by comparing the outcome of such patients discharged under a family medicine service (FMS) telemonitoring program and those admitted to hospital.

MATERIALS AND METHODS:

Patients with three or more risk factors for progression to severe COVID-19 disease were designated as “high-risk” in our study. In the absence of acute indication for hospitalization, these high-risk patients with mild-to-moderate disease were discharged home under the supervision of FMS led telemonitoring between October 2020 and February 2021 and were labelled as “Telemedicine group.” They were compared to similar patients who were admitted to hospital between March-August 2020 before the implementation of telemedicine service (TMS) and were taken as “Control group.” Outcome measures included intubation, number of inpatient days, 28-day mortality and cost analysis for the two groups.

RESULTS:

Out of 572 COVID-19 patients who presented to the ED, 70 met the inclusion criteria for the “Telemedicine Group” and 35 were included in the “Control Group”. In the Telemedicine group, 21 (30.0%) patients were brought back to ED for re-evaluation and 16 (22.9%) were eventually admitted to the hospital. There was no difference in terms of oxygen requirements, intubation, and intensive care unit admission (P > 0.74) between the groups, and none of the study patients died. The Family Medicine-led TMS saved 77% inpatient admissions and on average 4.4 hospital days and $3400 per patient (P < . 0001).

CONCLUSION:

Family medicine-led telemonitoring of high-risk COVID-19 patients presenting to the ED with mild-to-moderate disease is a feasible and cost-effective alternative to hospitalization.

Healthcare Workers Emotions, Perceived Stressors and Coping Strategies During a MERS-CoV Outbreak

OBJECTIVE

Healthcare workers (HCWs) are at high risk of contracting Middle East respiratory syndrome coronavirus (MERS-CoV) during an epidemic. We explored the emotions, perceived stressors, and coping strategies of healthcare workers who worked during a MERS-CoV outbreak in our hospital.

DESIGN

A cross-sectional descriptive survey design.

SETTING

A tertiary care hospital.

PARTICIPANTS

HCWs (150) who worked in high risk areas during the April-May 2014 MERS-CoV outbreak that occurred in Jeddah, Saudi Arabia.

METHODS

We developed and administered a "MERS-CoV staff questionnaire" to study participants. The questionnaire consisted of 5 sections with 72 questions. The sections evaluated hospital staffs emotions, perceived stressors, factors that reduced their stress, coping strategies, and motivators to work during future outbreaks. Responses were scored on a scale from 0-3. The varying levels of stress or effectiveness of measures were reported as mean and standard deviation, as appropriate.

RESULTS

Completed questionnaires were returned by 117 (78%) of the participants. The results had many unique elements. HCWs ethical obligation to their profession pushed them to continue with their jobs. The main sentiments centered upon fear of personal safety and well-being of colleagues and family. Positive attitudes in the workplace, clinical improvement of infected colleagues, and stoppage of disease transmission among HCWs after adopting strict protective measures alleviated their fear and drove them through the epidemic. They appreciated recognition of their efforts by hospital management and expected similar acknowledgment, infection control guidance, and equipment would entice them to work during future epidemics.

CONCLUSION

The MERS-CoV outbreak was a distressing time for our staff. Hospitals can enhance HCWs experiences during any future MERS-CoV outbreak by focusing on the above mentioned aspects.

Acute Management and Long-Term Survival Among Subjects With Severe Middle East Respiratory Syndrome Coronavirus Pneumonia and ARDS

BACKGROUND

Data on the management, clinical course, and outcome of critical patients with Middle East Respiratory Syndrome coronavirus are scarce. We report here our experience and long-term outcome of such patients.

METHODS

Subjects intubated for management of ARDS from Middle East Respiratory Syndrome coronavirus pneumonia and ARDS during the April-May 2014 outbreak were included. Their characteristics, ICU course, management, and outcome were evaluated.

RESULTS

Fourteen subjects, including 3 health-care workers, met study criteria. Besides 2 health-care workers, all subjects had comorbidities. Predominant symptoms were fever, cough, and dyspnea. The worst median PaO2 /FIO2 ratio of 118 post-intubation was seen on the third day, and median APACHE II score was 27. All subjects received lung-protective ventilation and 1 mg/kg/d methylprednisolone infusion for ARDS. Eleven subjects received ribavirin and peginterferon α-2a. Subjects had a critical ICU course and required neuromuscular blockade (n = 11; 79%), required rescue therapy for respiratory failure (n = 8; 57%), developed shock (n = 10; 71%), and required renal replacement therapy (n = 8; 57%). Declining C-reactive protein levels correlated with clinical improvement despite continued positive real-time polymerase chain reaction results. Nine subjects died in ICU. Five subjects, including 3 health-care workers, were discharged from hospital and were alive after 1 y.

CONCLUSIONS

Middle East Respiratory Syndrome coronavirus pneumonia with ARDS has high mortality in subjects with comorbidities. The mainstay of treatment is meticulous ARDS management. Those who survived the acute infection and its complications remained well after 1 y in our study. The role of ribavirin and interferon warrants urgent further evaluation.

Outcomes of patients treated with noninvasive ventilation by a medical emergency team on the wards

BACKGROUND

Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear.

METHODS

We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality.

RESULTS

Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ± 5.1 versus 14.4 ± 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P = .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs. 13.3%) or ICU mortality (3.7% vs 8%).

CONCLUSIONS

In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

End-of-life care in Muslim brain-dead patients: a 10-year experience

BACKGROUND

In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue.

RESULTS

We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained "full code," and rests were "do not attempt resuscitation" with varying usage of "life-sustaining" therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions.

CONCLUSION

In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.

Using spirometry to rule out restriction in patients with concomitant low forced vital capacity and obstructive pattern

Background:

Different formulas have been proposed to exclude restriction based on spirometry, however none of them have specifically tested the patients whose spirometry show both obstruction and a low forced vital capacity (FVC).

Study Objective:

The study was designed to create an algorithm that would better predict the absence of restriction in such patients.

Design:

Retrospective analysis of prospectively collected data.

Methods:

A cohort of consecutive adults that underwent complete pulmonary function testing from 2002-2004 was analyzed. The data was randomly split into two groups to allow for derivation and then validation of a predictive formula. Patients were randomly assigned into either a “derivation” or “validation” group. In the derivation group, stepwise logistic regression was used to determine a formula and optimal cut-off value for the variable with the best discriminative capacity. The formula was applied subsequently to the validation group to test the results and compared to previously published formula.

Results:

The study group contained 766 patients. We determined that the variable with the highest association with TLC was [(FEV₁/FVC) % predicted/FVC % predicted]. A value of ≥1.11 was found to be the maximal cutoff to predict the absence of restriction.

The formula was applied to a validation group (n=397) and performed better than prior published algorithm with a sensitivity, specificity, positive predictive value and negative predictive value of 95%, 44%, 22%, and 98%, respectively.

Conclusion:

Our formula performs superior to the previously published algorithms in patients with concomitant low FVC and obstruction to exclude restriction.

Pericardial tamponade after superior vena cava stent: are nitinol stents safe?

Placement of a single new-generation nitinol stent resulted in acute pericardial tamponade in a 70-year-old man with superior vena cava syndrome.

A welder with pneumosiderosis: a case report

Pneumosiderosis or Welder's lung is an occupational lung disease which is usually seen after chronic exposure to iron dust. We present a case of a 64-year-old welder in whom the diagnosis of pneumosiderosis was made by lung biopsies. We also briefly review the literature regarding the disease, its prognosis and association with development of lung cancer. Avoidance of iron dust exposure and implementing prevention strategies in people at risk are the mainstay of therapy.

Refractory restless legs syndrome likely caused by olanzapine

We report a case of severe restless legs syndrome (RLS) that occurred as a side effect of olanzapine therapy. It was refractory to treatment with 2 mg of clonazepam and 3 mg ropinirole. There was partial relief with propoxyphene, however, it was stopped because of side effects. The symptoms disappeared once olanzapine was switched to another antipsychotic medication. Only two prior published reports associate olanzapine usage with development of RLS. In one report, low-dose benzodiazepines and ropinirole were associated with resolution of RLS symptoms stating dopamine depletion as the likely etiology. In our patient, however, RLS due to olanzapine was refractory to the trial of both high-dose benzodiazepine and ropinirole. This suggests that RLS occurring as a side effect of olanzapine therapy may have additional causative mechanisms beyond simple dopamine depletion as postulated before. High-dose narcotics, if tolerated, may be an alternative in such refractory cases.

A rare case of cardiac paraganglioma presenting as anginal pain: a case report

INTRODUCTION

Primary cardiac paraganglioma is a very rare tumor with less than sixty reported cases in the literature. The clinical presentation is variable, but is most commonly manifested by hypertension and symptoms related to the catecholamine excess.

CASE REPORT

We report a case of a 35 year old man who presented with anginal pain and hypertension. He was found to have a cardiac mass on the computed tomographic scan and echocardiogram. He underwent surgical exploration of the mass which on biopsy was found to be a 'Cardiac Paraganglioma'. Surgical resection of the tumor was successfully done and the patient is doing well five years after the surgery without any evidence of recurrence. His blood pressure, however, failed to normalize and needed single agent antihypertensive therapy.

CONCLUSION

Cardiac paragangliomas have a relatively favorable outcome if diagnosed and resected in time. We briefly review the literature regarding the diagnosis, treatment and prognosis of this rare tumor.

A patient with an uncommon complication from insertion of a central venous catheter: A case report

Background

A 72 year old male was admitted to the medical intensive care unit with septic shock.

Case presentation

A left subclavian central venous catheter was inserted on the day of admission whose tip was pushing against the wall of the vessel lumen. The patient's condition improved with treatment, but three days later had a new episode of acute hypotension. CT scan of the chest showed that the catheter had eroded through the superior vena cava wall.

Conclusion

The catheter was pulled out and patient recovered from the complication with supportive therapy. Care should be taken that the tip of the catheter is in the center of the vessel lumen to avoid this rare, but potentially life threatening, complication.