Unfavorable hydroxychloroquine COVID-19 research associated with authors having a history of political party donations.

We explored the degree to which political bias in medicine and study authors could explain the stark variation in Hydroxychloroquine (HCQ)/Chloroquine (CQ) study favorability in the US compared to the rest of the world. COVID-19/SARS-CoV-2 preprint and published papers between January 1, 2020-July 26, 2020 with Hydroxychloroquine and/or Chloroquine; 267 met study criteria, 68 from the US. A control subset was selected. HCQ/CQ study result favorability (favorable, unfavorable, or neutral) was noted. First and last main authors of each US study were entered into FollowTheMoney.org Website, extracting any history of political party donation. Of all US studies (68 total), 39/68 (57.4%) were unfavorable, with only 7/68 (10.3%) of US studies yielding favorable results-compared to 199 non-US studies, 66/199 (33.2%) unfavorable, 69/199 (34.7%) favorable, and 64/199 (32.2%) neutral. Studies with at least one US main author were 20.4% (SE 0.053, P < 0.05) more likely to report unfavorable results than non-US studies. US Studies with at least one main author donating to any political party were 25.6% (SE 0.085, P < 0.01) more likely to have unfavorable results. US studies with at least one author donating to the Democratic party were 20.4% (SE 0.045, P < 0.05) more likely to have unfavorable results. US authors were more likely to publish studies with medically harmful conclusions than non-US authors. Cardiology-specific HCQ/CQ studies were 44.2% more likely to yield harmful conclusions (P < 0.01). Inaccurate propagation of HCQ/CQ cardiac adverse effects with individual scientific author political bias has contributed to unfavorable US HCQ/CQ publication patterns and political polarization of the medications.

Hemorrhagic Complications of Paracentesis: Aberrant Anatomy Versus Aberrant Technique - A Fatal Case of Abdominal Hemoperitoneum.

Large-volume paracentesis carries roughly a 1% risk of overall complications. Hemorrhagic complications are classified as abdominal wall hematomas, pseudoaneurysms, and hemoperitoneum. Severe hemorrhage is rare (<0.2%), with death following this complication seen in <0.02% of cases. We present a fatal case of an ultrasound-guided paracentesis leading to subsequent hemoperitoneum from an aberrant intercostal artery, causing hemorrhagic shock and death. A 47-year-old black male with decompensated alcoholic cirrhosis, model for end-stage liver disease (MELD) score of 22, and Child-Pugh class C presented with a distended abdomen, international normalized ratio (INR) 1.9, and hemoglobin 9.6 g/dL. An ultrasound-guided therapeutic paracentesis was performed in the right lower quadrant with 50 mL intravenous albumin given after 4 L of uncomplicated ascitic fluid removal. The patient became hypotensive, tachycardic, and placed on pressor support medication within 12 hours after the procedure. After a complex hospital course, the patient passed away on hospital day 10 after multisystem organ failure. The patient was found to have an aberrant intercostal artery bleed secondary to the paracentesis procedure causing an abdominal hemoperitoneum.

Jaundice and Elevated Beta-Human Chorionic Gonadotropin in a Female: Duodenal Choriocarcinoma, Not Pregnancy.

A 29-year-old woman with developmental delay presented with 2.5 weeks of jaundice of the skin with accompanying microcytic anemia (hemoglobin 6.8 g/dL, mean corpuscular volume 70.5 fL), elevated liver enzymes (aspartate aminotransferase 77 U/L, alanine aminotransferase 95 U/L, alkaline phosphatase 362 U/L), total bilirubin (9.5 mg/dL; 4.4 mg/dL direct), lipase (325 U/L), and cancer antigen 19-9 (68 U/mL). The patient had no prior gastrointestinal or liver disease. CT of the chest/abdomen/pelvis found a large lobulated non-fully obstructing mass in the second and third part of the duodenum, with endoscopic biopsies yielding an invasive, well-differentiated adenocarcinoma positive for cytoplasmic-stained cells to antibody to beta-human chorionic gonadotropin (hCG) antigen, suggesting a duodenal choriocarcinoma. Treatment included biliary drainage with a percutaneous transhepatic catheter and folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, but a repeat CT scan five months later revealed an increase in tumor size and invasion; the patient died shortly thereafter. Beta-hCG-secreting choriocarcinomas are rare, rapidly growing, highly invasive malignant tumors and are uncommonly present at extragonadal sites.

Multifaceted highly targeted sequential multidrug treatment of early ambulatory high-risk SARS-CoV-2 infection (COVID-19).

The SARS-CoV-2 virus spreading across the world has led to surges of COVID-19 illness, hospitalizations, and death. The complex and multifaceted pathophysiology of life-threatening COVID-19 illness including viral mediated organ damage, cytokine storm, and thrombosis warrants early interventions to address all components of the devastating illness. In countries where therapeutic nihilism is prevalent, patients endure escalating symptoms and without early treatment can succumb to delayed in-hospital care and death. Prompt early initiation of sequenced multidrug therapy (SMDT) is a widely and currently available solution to stem the tide of hospitalizations and death. A multipronged therapeutic approach includes 1) adjuvant nutraceuticals, 2) combination intracellular anti-infective therapy, 3) inhaled/oral corticosteroids, 4) antiplatelet agents/anticoagulants, 5) supportive care including supplemental oxygen, monitoring, and telemedicine. Randomized trials of individual, novel oral therapies have not delivered tools for physicians to combat the pandemic in practice. No single therapeutic option thus far has been entirely effective and therefore a combination is required at this time. An urgent immediate pivot from single drug to SMDT regimens should be employed as a critical strategy to deal with the large numbers of acute COVID-19 patients with the aim of reducing the intensity and duration of symptoms and avoiding hospitalization and death.

Iliopsoas Mass, Hydroureter, and Back Squats: Using Biomechanics and Diagnostic Persistence to Diagnose a Germ Cell Tumor.

Background: Lesions in the iliopsoas compartment carry a broad differential diagnosis, including infection, tumor, or hematoma, and less commonly, retroperitoneal fibrosis, atrophy secondary to paralysis or muscle disease, foreign body, calcifications secondary to trauma, or rhabdomyolysis. Iliopsoas lesions are oftentimes accompanied by nonspecific symptoms, resulting in a delayed diagnosis. Case Report: We present the case of a 43-year-old male with acute radiating groin pain who was found to have a traumatic iliopsoas hemorrhagic lesion causing ureteral compression and ureteral dilatation, all presumably originating from a new-onset weight-training program. The patient had a drain placed for fluid removal and decompression, with the initial pathologic specimen confirming muscle fibers and an inflammatory process. Further patient symptomology with combined imaging and pathologic persistence yielded a diagnosis of a germ cell tumor. Conclusion: The importance of a plausible differential diagnosis combined with clinical diagnostic persistence must be stressed to all clinicians. Our patient's unrelenting inguinal pain led to a justified repeat psoas mass biopsy, imaging, and laboratory workup that led to a diagnosis of psoas germ cell tumor and immediate chemotherapy plan.

Acute Dysphagia Caused by Sarcomatoid Squamous Cell Carcinoma of the Esophagus.

Sarcomatoid squamous cell carcinoma of the esophagus is a rare etiology of esophageal cancer. Due to its large polypoid character, patients suffering from this disease typically present with progressive dysphagia, weight loss, odynophagia, or chest pain. Risk factors for esophageal cancer include smoking, alcohol use, and chronic gastroesophageal reflux disease. We present a case of an elderly female who presented to our hospital with a one-week history of progressive dysphagia secondary to a large esophageal sarcomatoid squamous cell carcinoma.

Physician Body Mass Index and Bias Toward Obesity Documentation Patterns.

BACKGROUND: Many healthcare professionals consider obese individuals to be unmotivated and to lack the willpower to follow through with weight-loss plans. This attitude may result in less effort put into diagnosing, documenting, and treating obesity. Our aim was to assess documentation patterns of obesity and hypertension overall, by primary care specialty, and in relation to provider body mass index (BMI). METHODS: Twenty-two physicians from one outpatient community practice were included: 10 internal medicine and 12 family practice practitioners. We conducted a retrospective review of medical records from a 1-year period to determine provider documentation of obesity and hypertension. RESULTS: A total of 3,275 obese patients were under the care of 6 physicians with normal BMI, yielding an obesity documentation rate of 23.2%. The 10 overweight physicians had 6,218 obese patients and a documentation rate of 33.5%. The 6 obese physicians had 4,014 patients with obesity and a documentation rate of 21.7%. Obesity documentation rates differed between nonobese physicians (BMI 20-29.9 kg/m2) (30.0%) and obese (BMI ≥30 kg/m2) physicians (21.7%) (P<0.001). We found no difference (P=0.132) between documentation rates of normal-weight BMI physicians and obese physicians. The overall documentation rate of obesity (27.5%) was significantly different than the overall documentation rate of hypertension (83.3%) (P<0.001). CONCLUSION: In our study, nonobese physicians were more likely to document obesity, and documentation of obesity lagged significantly in comparison to hypertension. Addressing weight loss in obese patients starts at the provider level. Steps include documenting obesity on the problem list and providing weight-loss advice during each patient encounter.

Immunomodulator and Biologic Agent Effects on Sleep Quality in Patients With Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) can disrupt normal sleep physiology and amplify a negative perception about quality of life. Evidence suggests increased circulation of inflammatory cytokines, such as tumor necrosis factor-alpha and interleukin-1, may play a role. METHODS: A total of 56 patients completed the Pittsburgh Sleep Quality Index (PSQI) to measure 7 sleep domains: sleep quality, sleep latency, sleep duration, sleep efficacy, sleep disturbance, sleep medications, and daytime dysfunction. Domain scores were summed to determine the presence or absence of sleep impairment. We compared patients taking immunomodulators or biologic agents to patients not on immunomodulator or biologic agent therapy. Demographics and IBD-related clinical information were collected to adjust for potential confounders that may secondarily affect sleep, such as body mass index, depression/anxiety, and sleep-affecting medications. RESULTS: The majority of patients with IBD (46 [82%]) reported poor sleep quality; 22 (79%) of the patients taking immunomodulators or biologic agents and 24 (86%) of the patients not on these therapies had a global PSQI score ≥5, suggestive of poor sleep quality. However, we found no significant difference between the 2 groups. When we analyzed the 7 PSQI sleep domains individually, we found improved sleep duration in the group taking immunomodulators or biologic agents compared to the group not on therapy, although the difference was not statistically significant. CONCLUSION: The majority of patients with IBD experience some degree of sleep impairment, and treatment with immunomodulators and biologic agents does not appear to improve sleep quality. A multicenter study with a larger sample size is warranted to better assess the diverse population of patients with IBD and the factors that impact their sleep. Routine assessment of sleep quality during IBD clinical encounters is recommended.

Bowel Preparations Administered the Morning of Colonoscopy Provide Similar Efficacy to a Split Dose Regimen: A Meta Analysis.

BACKGROUND: Comparative efficacy of same-day bowel preparations for colonoscopy remains unclear. AIMS: A meta-analysis of randomized controlled trials comparing the efficacy of same-day versus split dose bowel preparations for colonoscopy. METHODS: A systematic search was conducted in MEDLINE, clinicaltrials.gov, Cochrane Registry, EMBASE, SCOPUS, Web of Science and CINAHL. Studies were gathered using keywords: "morning preparation", "morning bowel preparation", "same day bowel preparation", and "colonoscopy." Pooled estimates of bowel preparation quality were analyzed among studies with categorical and continuous outcomes according to relative risk (RR) or mean difference (MD). A random effects model was chosen a priori for all analyses. RESULTS: A total of 1216 studies were retrieved with 15 trials meeting inclusion criteria. The categorical outcome of high quality bowel preparation for any same-day bowel preparation versus any split preparation was no different with a RR 0.95 [0.90;1.00] (P=0.62). Adenoma detection rate (ADR) was not different between groups, RR 0.97 [0.79;1.20] (P=0.81). Willingness to repeat and tolerability did not differ (RR 1.14 [0.96,1.36] (P=0.14) and RR 1.00 [0.96;1.04] (P=0.98), respectively. Adverse events were similar except for bloating, which was less frequent among the same-day preparation group, RR 0.68 [0.40;0.94] (P=0.02). CONCLUSION: No clinically significant differences were noted among recipients of same day or split dose regimens. Adenoma detection rate, willingness to repeat and tolerability were similar, but bloating and interference with sleep favored the same-day preparations. Given lack of clinical differences, patient preference should dictate timing of colonoscopy preparation.

Sigmoid Colonic Polyp as Initial Presentation of Metastatic Papillary Renal Cell Carcinoma.

BACKGROUND: Upon initial presentation, 25%-30% of patients with renal cell carcinoma have metastatic disease. Metastasis to the gastrointestinal tract is rare, but when it occurs, the large bowel is the least common site. CASE REPORT: A 75-year-old white male presented with vague abdominal symptoms and worsening hemoglobin and hematocrit levels. Colonoscopy revealed a polyp in the distal portion of the sigmoid colon. Histologic and immunohistochemical analysis suggested metastatic papillary renal cell carcinoma. CONCLUSION: To the best of our knowledge, this patient had a rare case of metastatic papillary renal cell carcinoma that metastasized to the colon and presented as a colon polyp.

Effects of Immunomodulators and Biologic Agents on Sexual Health in Patients With Inflammatory Bowel Disease.

BACKGROUND: Although much knowledge has been gained regarding the medical and surgical management of inflammatory bowel disease (IBD), a paucity of information is available on the psychosexual issues related to IBD. The aim of this study was to evaluate the sexual health of patients with IBD who were taking immunomodulators and/or biologic agents vs patients with IBD who were not on that medication regimen. METHODS: All study participants completed a validated sexual health questionnaire, the Female Sexual Function Index or the International Index of Erectile Function, to assess their subjective perception of the effect of IBD on the different domains of sexual function during the prior 1-month time period. RESULTS: No statistically significant differences in any baseline demographic variables were found for either sex between the group taking immunomodulators/biologic agents and the nontreatment group. Among females and males, individual question responses, domain scores, and total scores showed no statistically significant differences between the 2 treatment groups. CONCLUSION: Our data suggest that the use of immunomodulators or biologic agents does not affect female or male sexual health. However, treatment of patients with IBD must be individualized based on the aggressive nature of the disease, treatment goals, and the tolerability of various medications.