COVID-19 vs. Influenza: A Chest X-ray Comparison.

Introduction COVID-19 and influenza are primarily respiratory diseases, have similar symptoms with most patients developing mild to moderate illness, and show similar features on chest X-rays. We hypothesize that patients seeking treatments at the emergency department (ED) due to COVID-19 or influenza infection will have similar severity levels of features on chest X-rays, with most of them demonstrating normal to mildly abnormal chest X-ray findings.  Methods Chest X-ray images of 312 COVID-19 patients and 312 influenza patients were obtained from the teaching files of a general diagnostic radiologist. Images from each of these two groups were reviewed and classified. Based on the severity levels of lung abnormalities, each image was categorized into one of four categories: normal, mildly abnormal, moderately abnormal, or severely abnormal. The total number of images in each category within each disease group was counted, and the percentage was calculated compared to the total number of images analyzed in that group. Results from both groups were then compared. Results The severity levels of chest X-ray abnormalities were similar between the COVID-19 group and the COVID-negative influenza group at the time of ED visits, with most images being normal or mildly abnormal. The percentages of the images categorized as normal, mildly abnormal, moderately abnormal, and severely abnormal in the COVID-19 group and the influenza group were 38-39%, 28-29%, 22-21%, and 12-11%, respectively. Conclusion Our findings suggest that in the ED setting, no distinction can be made between COVID-19 and Influenza infections if based just on chest X-rays.

Veterans more likely to start hemodialysis with an arteriovenous fistula.

Hemodialysis via arteriovenous fistulas (AVFs) is associated with reduced morbidity and mortality when compared to alternative vascular accesses, yet few patients in the United States start dialysis with AVFs. Recent studies have demonstrated higher quality of care for many conditions in Veterans Affairs' Medical Centers (VAMC); however, differences in quality of vascular access care are unknown. We used patient-level data (6/05-5/06) from Medicare claims (n = 25,912) to compare the proportions of AVF among incident patients at VAMC-affiliated (n = 20) and unaffiliated dialysis (n = 1631) facilities. Multivariate logistic regression was used to determine whether associations of access type with facility type were independent. Compared to non-VAMC patients, a larger proportion of VAMC patients started dialysis with AVFs (20.9% versus 11.6% in non-VAMC patients; OR 1.99, [95% CI 1.55-2.56]). Although attenuated, this finding persisted in models adjusted for demographics (OR 1.65 [95% CI 1.28-2.13]) and demographics with comorbidities (OR 1.70 [95% CI 1.31-2.20]). However, after accounting for pre end-stage renal disease (ESRD) care, similar proportions of VAMC and non-VAMC patients started hemodialysis with an AVF (OR 1.28 [95% CI 0.98-1.66]). In conclusion, patients receiving care at VAMC-associated facilities were more likely to start hemodialysis with AVFs, perhaps because of better pre-ESRD care. Nonetheless, AVF rates remain suboptimal, indicating a need for ongoing vascular access evaluation and improvement.

Treatment center and geographic variability in pre-ESRD care associate with increased mortality.

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of > 30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of > or = 6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.