Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019.

BACKGROUND & AIMS: The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. METHODS: Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. RESULTS: A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death. CONCLUSIONS: Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.

A Statistically Significant Reduction in Length of Stay and Hospital Costs with Equivalent Quality of Care Metrics for ERCPs Performed During the Weekend Versus Postponed to Weekdays: A 6-Year Study of 533 ERCPs at Four Teaching Hospitals.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic/therapeutic endoscopic procedure for numerous pancreaticobiliary diseases. Data regarding performing ERCP on weekend (WE; Saturday/Sunday) versus postponing ERCP to first two available weekdays (WD; Monday/Tuesday) are scarce. ERCP requires costly resources including specialized nurses, endoscopy room equipped with fluoroscopy, anesthesia services, and highly trained therapeutic endoscopists. Hospitals frequently do not have these resources readily available during WE, leading to postponing ERCPs to WD. AIMS: This study analyzes the effect of performing ERCP on WE versus postponement to WD on hospital efficiency, and on patient safety/outcomes. METHODS: A computerized search of electronic medical records, January 2011-December 2016, at four Beaumont Hospitals retrospectively identified all gastroenterology consults performed on Friday or Saturday before 12:00 noon, which resulted in ERCP performed for any indication on WE versus postponing ERCP to WD. Length of stay (LOS), hospital costs, hospital charges, and hospital reimbursements were compared between both groups, as were quality of care measures. RESULTS: Among 5196 patients undergoing ERCPs, 533 patients were identified, including 315 patients in the WE group and 218 patients in the WD group. Comparing WE versus WD groups, median LOS was shorter (4.5 days vs. 6.9 days, p < 0.0001); median hospital costs were less ($9208 vs. $11,657, p < 0.0001); and median hospital charges were less ($28,026 vs. $37,899, p < 0.0001). Median hospital reimbursements were not significantly different in WE versus WD groups ($10,277 vs. $10,362, p = 0.65). Median hospital charges were lower than median hospital reimbursements (net profit) in WE but not in WD. WE versus WD had no significant differences in morbidity, mortality, ≤ 30-day readmission rates, need for repeat ERCP ≤ 30 days, or post-ERCP complications. LIMITATIONS: This is a retrospective study. CONCLUSIONS: Performing ERCPs during weekends significantly reduced LOS, hospital costs, and hospital charges compared to postponing ERCP to WD and resulted in net hospital profits, without impairing quality of medical care.

Diffusion of nanoparticles in semidilute and entangled polymer solutions.

We studied the diffusion of gold nanoparticles in semidilute and entangled solutions of polystyrene (PS) in toluene using fluctuation correlation spectroscopy (FCS). The polymer concentration was varied from approximately 6c* to 20c*, where c* is the overlap concentration. In our experiments, the particle radius (R approximately 2.5 nm) was much smaller compared to the radius of gyration (Rg approximately 18 nm) of the chain but comparable to the average mesh size (xi) of the fluctuating polymer network. The diffusion coefficient (D) of the particles decreased monotonically with polymer concentration and it can be fitted with a stretched exponential function, D=D0 exp(-microcnu), with the value of the scaling parameter, nu approximately 0.9. At high concentration of the polymer, a clear subdiffusive motion of the particles was observed. The results were compared with the diffusion of free dyes (coumarin 480), which showed normal diffusive behavior for all concentrations.

A prospective mixed-methods study evaluating the integration of an evidence based medicine curriculum into an internal medicine residency program.

INTRODUCTION: Evidence based medicine (EBM) skills are often lacking in the general internal medicine physician population. Our aim is to evaluate the impact of our internal medicine EBM curriculum on the residents' EBM skills and knowledge through mixed methods. METHODS: A prospective study was performed that evaluated the EBM curriculum: quantitatively, with pre/posttests and qualitatively through a focus group that addressed residents' opinion on the educational and clinical impact of each aspect of the curriculum. RESULTS: A total of 60 internal medicine residents were surveyed. Short-term EBM skills: therapy workshops (N=25) median pretest score of 8 (IQR): [6-9]) vs posttest 8 (IQR: [8-9]), (p=0.006); diagnosis (N=16) pretest score of 6 (IQR: [3-6]) vs posttest 7 (IQR: [6-9]), (p=0.006); systematic review (N=13) pretest score of 4 (IQR: [4-6]) vs posttest 7 (IQR: [6-8]), (p=0.002); and harm (N=16) pretest score of 6 (IQR: [5-7]) vs posttest 7 (IQR: [7-8]), (p=0.004). Long-term EBM skills: Fresno test of competence in EBM, pretest median score of 110.5/212 (IQR: 96.0-124.0) and a median posttest score of 115/212 (IQR: 100.0-130.0) (p=0.60). Having previous EBM training, being actively involved in research and being the first author on a publication was associated with higher Fresno test scores. Focus group provided qualitative feedback on the residents' EBM curriculum perception. CONCLUSION: This curriculum adds a significant contribution to the current field of medical education as it fills an important educational gap, through defining ways of effectively delivering EBM concepts which led to improvement in residents' ability to evaluate and apply medical literature. The EBM curriculum was overall well received by the residents.

Bladder urothelial carcinoma extending to rectal mucosa and presenting with rectal bleeding.

An 87-year-old-man with prostate-cancer-stage-T1c-Gleason-6 treated with radiotherapy in 1996, recurrent prostate cancer treated with leuprolide hormonal therapy in 2009, and bladder-urothelial-carcinoma in situ treated with Bacillus-Calmette-Guerin and adriamycin in 2010, presented in 2015 with painless, bright red blood per rectum coating stools daily for 5 mo. Rectal examination revealed bright red blood per rectum; and a hard, fixed, 2.5 cm × 2.5 cm mass at the normal prostate location. The hemoglobin was 7.6 g/dL (iron saturation = 8.4%, indicating iron-deficiency-anemia). Abdominopelvic-CT-angiography revealed focal wall thickening at the bladder neck; a mass containing an air cavity replacing the normal prostate; and adjacent rectal invasion. Colonoscopy demonstrated an ulcerated, oozing, multinodular, friable, 2.5 cm × 2.5 cm mass in anterior rectal wall, at the usual prostate location. Histologic and immunohistochemical analysis of colonoscopic biopsies of the mass revealed poorly-differentiated-carcinoma of urothelial origin. At visceral angiography, the right-superior-rectal-artery was embolized to achieve hemostasis. The patient subsequently developed multiple new metastases and expired 13 mo post-embolization. Comprehensive literature review revealed 16 previously reported cases of rectal involvement from bladder urothelial carcinoma, including 11 cases from direct extension and 5 cases from metastases. Patient age averaged 63.7 ± 9.6 years (all patients male). Rectal involvement was diagnosed on average 13.5 ± 11.8 mo after initial diagnosis of bladder urothelial carcinoma. Symptoms included constipation/gastrointestinal obstruction-6, weight loss-5, diarrhea-3, anorexia-3, pencil thin stools-3, tenesmus-2, anorectal pain-2, and other-5. Rectal examination in 9 patients revealed annular rectal constriction-6, and rectal mass-3. The current patient had the novel presentation of daily bright red blood per rectum coating the stools simulating hemorrhoidal bleeding; the novel mechanism of direct bladder urothelial carcinoma extension into rectal mucosa via the prostate; and the novel aforementioned colonoscopic findings underlying the clinical presentation.

Toxicity after central versus peripheral lung stereotactic body radiation therapy: a propensity score matched-pair analysis.

PURPOSE: To compare toxicity after stereotactic body radiation therapy (SBRT) for "central" tumors-within 2 cm of the proximal bronchial tree or with planning tumor volume (PTV) touching mediastinum-versus noncentral ("peripheral") lung tumors. METHODS AND MATERIALS: From November 2005 to January 2011, 229 tumors (110 central, 119 peripheral; T1-3N0M0 non-small-cell lung cancer and limited lung metastases) in 196 consecutive patients followed prospectively at a single institution received moderate-dose SBRT (48-60 Gy in 4-5 fractions [biologic effective dose=100-132 Gy, α/ß=10]) using 4-dimensional planning, online image-guided radiation therapy, and institutional dose constraints. Clinical adverse events (AEs) were graded prospectively at clinical and radiographic follow-up using Common Terminology Criteria for Adverse Events version 3.0. Pulmonary function test (PFT) decline was graded as 2 (25%-49.9% decline), 3 (50.0%-74.9% decline), or 4 (≥75.0% decline). Central/peripheral location was assessed retrospectively on planning CT scans. Groups were compared after propensity score matching. Characteristics were compared with χ(2) and 2-tailed t tests, adverse events with χ(2) test-for-trend, and cumulative incidence using competing risks analysis (Gray's test). RESULTS: With 79 central and 79 peripheral tumors matched, no differences in AEs were observed after 17 months median follow-up. Two-year cumulative incidences of grade ≥2 pain, musculoskeletal, pulmonary, and skin AEs were 14%, 5%, 6%, and 10% (central) versus 19%, 10%, 10%, and 3% (peripheral), respectively (P=.31, .38, .70, and .09). Grade ≥2 cardiovascular, gastrointestinal, and central nervous system AEs were rare (<1%). Two-year incidences of grade ≥2 clinical AEs (28% vs 25%, P=.79), grade ≥2 PFT decline (36% vs 34%, P=.94), grade ≥3 clinical AEs (3% vs 7%, P=.48), and grade ≥3 PFT decline (0 vs 10%, P=.11) were similar for central versus peripheral tumors, respectively. Pooled 2-year incidences of grades 4 and 5 AEs were <1% and 0%, respectively, in both the prematched and matched groups. CONCLUSION: Moderate-dose SBRT with these techniques yields a similarly safe toxicity profile for both central and peripheral lung tumors.