A Rare Complication of Cannabinoid Hyperemesis Syndrome.

BACKGROUND Cognitive errors are common in medical practice and can have serious consequences for patients related to misdiagnosis and delays in diagnosis and treatment. We report a case in which cognitive error substantially influenced a patient's diagnosis and treatment. CASE REPORT This report recounts the case of an adolescent girl with symptoms similar to those of her previous episodes of tetrahydrocannabinol-induced hyperemesis, despite a 21-kg weight loss over 6 months. She sought care at multiple facilities until finally being diagnosed with superior mesenteric artery syndrome. Treatment was conservative with intravenous hydration, nasogastric feeding, and gastric decompression until duodenal compression was relieved. The patient's condition had improved at 7-month follow-up, and she declined surgical consultation. CONCLUSIONS This case report seeks to raise awareness of the effects of cognitive errors in clinical practice. This tendency to prematurely attribute symptoms to a known diagnosis and thereby overlook alternative and potentially more accurate explanations can lead to delays in diagnoses and treatments. Awareness of cognitive error is especially important in the context of the increasing prevalence of legalization of tetrahydrocannabinol/marijuana in several states. Superior mesenteric artery syndrome, although rare, is linked to high morbidity and mortality when the diagnosis is delayed; thus, it is crucial to consider it in the differential diagnosis for a patient with weight loss and abdominal pain. By sharing this case, we hope clinicians and patients can become more aware of this rare consequence of tetrahydrocannabinol use to facilitate more comprehensive patient-centered investigations.

Expanding the Role of the Surgical Preoperative Evaluation Clinic: Impact on Risk and Quality Outcome Measures.

Objective: To prove that inpatient-adjusted surgical risk and quality outcome measures can be considerably impacted by interventions to improve documentation in the preoperative evaluation (POE) clinic. Patients and Methods: We designed a quality improvement project with a multidisciplinary team in our POE clinic to more accurately reflect surgical risk and impact expected surgical quality outcomes through improved documentation. Interventions included an improved patient record acquisition process and extensive POE provider education regarding patient comorbidities' documentation. For patients admitted after their planned operations, POE clinic comprehensive evaluation notes were linked to inpatient History and Physical notes. High complexity patients seen from October 1, 2018 to December 31, 2018 were the preintervention cohort, and the patients seen from January 1, 2019 to December 31, 2019 were the postintervention cohort. Results: The primary outcome measures included the total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter. The secondary outcomes included the calculated severity of illness, risk of mortality, case-mix index, and risk-adjustment factor. Postintervention results show statistically significant increases in all primary outcomes with a P<.05. All secondary outcome measures reported positive change. Conclusion: Our interventions confirm that a comprehensive POE and thorough documentation provide a more accurate clinical depiction of the preoperative patient, which in turn impacts quality outcomes in inpatient surgical settings. These results are impactful for direct and indirect patient care and publicly reported hospital and provider level performance data.

Acute Onset of Heart Failure and Renal Failure Due to Pacemaker Syndrome.

Here, we report the outcome of an 87-year-old man with permanent non-valvular atrial fibrillation who initially presented with complete heart block and received a single right ventricle lead pacemaker programmed to ventricular demand pacing (VVIR). Over the next 10 months, the patient was readmitted to the hospital four times with recurrent edema, pleural effusions, and ascites. He was diagnosed with new onset systolic heart failure with mid-range (40-49%) ejection fraction and cardiorenal syndrome requiring dialysis. The underlying cause of his presentation was determined to be pacemaker syndrome mediated by new onset severe tricuspid regurgitation. He was treated with reimplantation of a pacemaker with His bundle pacing with subsequent improvement in his cardiac status and renal function. Implantation of dual-chamber pacing (DDDR) or His bundle pacing to achieve a narrow QRS complex over ventricular demand pacemaker is recommended whenever possible to reduce the incidence of pacemaker syndrome and improve patient outcomes.

Characteristics, Treatment Patterns, and Clinical Outcomes After Heart Failure Hospitalizations During the COVID-19 Pandemic, March to October 2020.

OBJECTIVE: To compare clinical characteristics, treatment patterns, and 30-day all-cause readmission and mortality between patients hospitalized for heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic. PATIENTS AND METHODS: The study was conducted at 16 hospitals across 3 geographically dispersed US states. The study included 6769 adults (mean age, 74 years; 56% [5033 of 8989] men) with cumulative 8989 HF hospitalizations: 2341 hospitalizations during the COVID-19 pandemic (March 1 through October 30, 2020) and 6648 in the pre-COVID-19 (October 1, 2018, through February 28, 2020) comparator group. We used Poisson regression, Kaplan-Meier estimates, multivariable logistic, and Cox regression analysis to determine whether prespecified study outcomes varied by time frames. RESULTS: The adjusted 30-day readmission rate decreased from 13.1% (872 of 6648) in the pre-COVID-19 period to 10.0% (234 of 2341) in the COVID-19 pandemic period (relative risk reduction, 23%; hazard ratio, 0.77; 95% CI, 0.66 to 0.89). Conversely, all-cause mortality increased from 9.7% (645 of 6648) in the pre-COVID-19 period to 11.3% (264 of 2341) in the COVID-19 pandemic period (relative risk increase, 16%; number of admissions needed for one additional death, 62.5; hazard ratio, 1.19; 95% CI, 1.02 to 1.39). Despite significant differences in rates of index hospitalization, readmission, and mortality across the study time frames, the disease severity, HF subtypes, and treatment patterns remained unchanged (P>0.05). CONCLUSION: The findings of this large tristate multicenter cohort study of HF hospitalizations suggest lower rates of index hospitalizations and 30-day readmissions but higher incidence of 30-day mortality with broadly similar use of HF medication, surgical interventions, and devices during the COVID-19 pandemic compared with the pre-COVID-19 time frame.

The Dynamics of SARS-CoV-2 (RT-PCR) Testing.

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is estimated to have affected 6.2 million people in the United States and 27.5 million people worldwide as of September 9, 2020. On February 2, 2020, the Secretary of the Department of Health and Human Services (HHS) determined that the public health emergency justified the development and emergency use of "in vitro diagnostics for the detection and/or diagnosis of the virus that causes COVID-19" by activating the Emergency Use Authorization (EUA) authority under section 564 of the Federal Food, Drug, and Cosmetic Act. Unfortunately, effective mitigation efforts were thwarted early in the outbreak resulting in an expansion of the initial EUA on February 29, 2020, to improve accessibility to in vitro diagnostic testing. Expectantly, the development and deployment of SARS-CoV-2 testing including RT-PCR expanded rapidly in the weeks following the EUA expansion. These newly developed and approved SARS-CoV-2 RT-PCR tests boast impressive positive and negative agreement rates nearing 100%. Despite the exceptionally high rates of agreement, caution is advised as the RT-PCR tests approved under the COVID-19 EUA are in vitro analyses developed with samples artificially doped with SARS-CoV-2 RNA. These tests therefore do not have clinically applicable sensitivity and specificity because they lack a "gold standard" for diagnosis. Here we present three challenging cases requiring cautious interpretation of the newest generation of RT-PCR molecular detection assays, highlighting the major challenges faced by providers treating patients potentially infected with SARS-CoV-2.

Case report: use of lenzilumab and tocilizumab for the treatment of coronavirus disease 2019.

Background: Coronavirus disease 2019 (COVID-19) is a novel disease associated with a cytokine-mediated, severe, acute respiratory syndrome. Tocilizumab and lenzilumab are recombinant monoclonal antibodies against IL-6 and granulocyte macrophage colony-stimulating factor, respectively, and have been proposed as a potential treatment for acute, hypoxic respiratory failure associated with COVID-19. Results & methodology: We present the case of a 68-year-old man with COVID-19 who was initially treated with hydroxychloroquine and lenzilumab, but continued to develop hypoxemia, requiring an increase in respiratory support with an associated rise in serum inflammatory markers. He was subsequently treated with tocilizumab with marked clinical improvement and a decrease in acute phase reactants within 48 h. Discussion & conclusion: This case demonstrates the effective use of tocilizumab in the treatment of COVID-19 and suggests the superiority of tocilizumab over lenzilumab in the management of this cytokine-mediated syndrome.