Delayed care in myocardial infarction and ischemic stroke patients during the COVID-19 pandemic.

COVID-19 has profound direct health consequences, however secondary effects were much broader as rates of hospital visits steeply declined for non-COVID-19 concerns, including myocardial infarction (MI) and stroke, with patients choosing to wait longer before symptoms convince them to seek medical attention. Thus, patients where ischemia leads to tissue loss should be a major concern. METHODS: The months of March to June 2019 and 2020 were compared to each other at 4 Denver area hospitals. Reduction in overall ED visits and an increase in patient refusal for emergency transport were clear in the data collected. During this period in 2019, 49 MI and 90 stroke patients were admitted. In 2020 this was 40 and 90 respectively. All were matched for age and gender. For MI patients ejection fraction and door to EKG and intervention times were measured. For stroke patients last known well time, time to evaluation, and modified Rankin scores were measured. RESULTS: 254 (8.12%) patients refused emergency services transportation before the pandemic compared to 479 (18.35%) during the pandemic (p-value <0.001, chi square test). In the MI cohort, no significant difference was detected in measured ejection fraction (48% vs 49% p-value = 0.682). Additionally, no significant difference was detected between door to EKG time or door to MI intervention time. During the pandemic 8 (22%) expired with an MI prior to discharge, compared to 2 (4%) before the pandemic. The stroke cohort Door to Evaluation Time, Time since last well known, and modified Rankin scores were all found to have insignificant differences. DISCUSSION: ED volume was significantly lower during the early stages of the pandemic. During this time however only death from cardiac events increased, in spite of similar ejection fractions at discharge. The cause of this remains unclear as ejection fraction similarities make it less attributable to loss of tissue than to other factors. Patient behavior significantly changed during the pandemic, making this a likely source of the increase in mortality seen.

Early detection and treatment of patients with severe sepsis by prehospital personnel.

BACKGROUND: Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel. OBJECTIVE: This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated. METHODS: We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study. RESULTS: Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14-8.88; p = 0.040). CONCLUSIONS: This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality.

Neoadjuvant induction chemotherapy followed by chemoradiation: a phase I trial of gemcitabine, cisplatin, and 5-fluorouracil for advanced pancreatic/gastrointestinal malignancies.

The authors developed a strategy that includes a novel approach of induction full-dose chemotherapy followed by traditional chemoradiation as a neoadjuvant therapy for pancreatic cancer. Here they report the results of a phase I/II trial of gemcitabine, cisplatin, and 5-FU for patients with advanced gastrointestinal malignancies.