Methemoglobinemia in the Era of COVID-19: A Potential Confounder of Glycemic Control.

Glycated hemoglobin A1c (HbA1c) is frequently used as a measure of glycemic control but can be inaccurate in certain clinical scenarios leading to poor estimates of insulin requirements. We present the case of a 76-year-old man with diabetes and COVID infection. HbA1c was measured at 5.7%, though the patient reported home glucose readings of 200 to 300 mg/dL (11.1-16.65 mmol/L). Pulse oximetry on presentation was 50% to 60%, which initially improved to 93% with supplemental oxygen of 15 L via nonrebreather face mask. Treatment with remdesivir and dexamethasone was initiated, but the patient was again found to have low oxygen saturations requiring bilevel positive airway pressure and transfer to the intensive care unit. The patient was started on 1.1 U/kg of insulin daily in a basal-bolus regimen. The patient developed severe hyperglycemia requiring 2.4 U/kg to achieve glycemic control. Co-oximeter analysis of an arterial blood gas sample revealed methemoglobinemia. Exchange transfusion was performed with clinical improvement. Subsequent measurement of fructosamine was 360 umol/L (360 000 µmol/L), correlating with reported home glucose measurements. Methemoglobinemia may impair glycation of hemoglobin or interfere with measurement of HbA1c, thereby compromising the use of this molecule as a marker for glycemic control in patients with this condition.

International cost-effectiveness analysis evaluating endoscopic screening for gastric cancer for populations with low and high risk.

BACKGROUND: Gastric cancer remains one of the 3 most common causes of cancer death worldwide. Understanding the health and economic factors that affect screening cost-effectiveness in different countries will help address when and where it makes most sense to screen for gastric cancer. METHODS: We performed a cost-effectiveness analysis using a Markov model to compare screening and surveillance strategies for gastric cancer in Brazil, France, Japan, Nigeria, and the United States. Primary outcome was the incremental cost-effectiveness ratio. We then performed a sensitivity analysis to determine how each variable affected the overall model. RESULTS: In all countries, the most cost-effective strategies, measured by incremental cost-effectiveness ratio relative to no screening, were screening every 10 years, surveillance of high- and low-risk patients every 5 and 10 years, respectively, and screening every 5 years. Only Japan had at least one cost-effective screening strategy. The most important variables across different screening strategies and countries were starting age of screening, cost of endoscopy, and baseline probability of local gastric cancer at time of diagnosis. CONCLUSIONS: Our model suggests that screening for gastric cancer is cost-effective in countries with higher incidence and lower costs of screening, but screening may still be a viable option in high-risk populations within low incidence countries.

Disease Course and Outcomes of COVID-19 Among Hospitalized Patients With Gastrointestinal Manifestations.

BACKGROUND & AIMS: Our understanding of outcomes and disease time course of COVID-19 in patients with gastrointestinal (GI) symptoms remains limited. In this study we characterize the disease course and severity of COVID-19 among hospitalized patients with gastrointestinal manifestations in a large, diverse cohort from the Unites States. METHODS: This retrospective study evaluated hospitalized individuals with COVID-19 between March 11 and April 28, 2020 at two affiliated hospitals in New York City. We evaluated the association between GI symptoms and death, and also explored disease duration, from symptom onset to death or discharge. RESULTS: Of 2804 patients hospitalized with COVID-19, the 1,084 (38.7%) patients with GI symptoms were younger (aOR for age ≥75, 0.59; 95% CI, 0.45-0.77) and had more co-morbidities (aOR for modified Charlson comorbidity score ≥2, 1.22; 95% CI, 1.01-1.48) compared to those without GI symptoms. Individuals with GI symptoms had better outcomes, with a lower likelihood of intubation (aHR, 0.66; 95% CI, 0.55-0.79) and death (aHR, 0.71; 95% CI, 0.59-0.87), after adjusting for clinical factors. These patients had a longer median disease course from symptom onset to discharge (13.8 vs 10.8 days, log-rank p = .048; among 769 survivors with available symptom onset time), which was driven by longer time from symptom onset to hospitalization (7.4 vs 5.4 days, log-rank P < .01). CONCLUSION: Hospitalized patients with GI manifestations of COVID-19 have a reduced risk of intubation and death, but may have a longer overall disease course driven by duration of symptoms prior to hospitalization.

Evolving Approaches to Tissue Expander Design and Application.

Prosthetic reconstruction utilizing a 2-stage saline tissue expander-to-implant procedure is the most common technique for breast reconstruction in the United States. For nearly the past 50 years, 2-stage breast reconstruction using saline tissue expanders has been the standard of care. However, in December 2016, a carbon dioxide-filled, remote-controlled tissue expander received U.S. Food and Drug Administration clearance. This tissue expander, known as the AeroForm Tissue Expander System (AirXpanders, Inc., Palo Alto, Calif.), is a novel, patient-controlled, needle-free expander operated by a wireless remote control device, which allows patients the comfort and convenience of home expansion, precluding the need for percutaneous saline injections. A multicenter, randomized, prospective clinical trial has revealed statistically significant shorter times to full expansion as well as shorter overall reconstructive times. It is the first tissue expander device designed successfully with an alternative filling medium to saline, namely carbon dioxide. This CO2-filled expander thus provides several potential advantages over previous expander designs, including patient-controlled expansion, obviation of saline injections, and shorter expansion times.

Long-term failure of Amplatzer plugs in the treatment of aortic pathology.

We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.