The Value of Medical Registries and Observational Studies Early in Pandemics: The Coronavirus Disease 2019 (COVID-19) Experience.

Whereas randomized clinical trials remain the gold standard for evaluating new therapies for infections, we argue that registries and observational studies early in the coronavirus disease 2019 (COVID-19) pandemic provided invaluable understanding of the natural history and preliminary data on risk factors and possible treatments. We review the data from the current pandemic, the history of registries in general, and their value in public health emergencies. Lessons from these experiences should be incorporated into rigorous planning for the next pandemic.

Severe Sepsis: The Fragile Anatomy of Crude Mortality.

Clinical trials of severe sepsis that target crude mortality are underpowered to detect mortality differences due to intervention. We discuss the importance of including subcomponents of crude mortality in study design; how the proportion of attributable mortality affects sample size requirements; and how minor changes from predicted outcomes affect interpretation.

Human immunodeficiency virus associated thrombotic thrombocytopenic purpura, a clinical conundrum.

HIV complicates the diagnostic and therapeutic approaches to idiopathic thrombotic thrombocytopenic purpura (TTP), prompting debate in the literature regarding the benefit of plasma exchange versus simple plasma infusion. Herein we present a case of HIV-TTP, initially treated conservatively with plasma infusion but because of progressive neurologic decline, required urgent plasma exchange for resolution of hematologic derangements and neurologic sequelae. Based on the available literature, there appears to be a spectrum of HIV-associated TTP disorders. Patients with advanced HIV disease and opportunistic infections who present with thrombotic microangiopathy tend to respond to simple plasma infusion, while patients with less progressive HIV disease tend to behave like those with idiopathic TTP, requiring plasma exchange rather than simple plasma infusion. This article illustrates that in patients with HIV-TTP who do not respond to plasma infusion, early escalation to plasma exchange may help avoid life-threatening complications such as seizures and even death.

Academic I.D. in jeopardy: the erosion of time, professional values, and physician satisfaction.

The American public entrusts academic medicine with a varied portfolio of critical responsibilities: the thoughtful mentoring of future generations of doctors, the engagement of cutting edge discoveries, and the empathic treatment of patients with complicated illnesses. The erosion of time to perform these duties has led to an estrangement of our key professional values and thus a loss of public trust, the inability to recognize new diseases, reduced communication in our ranks, and physician dissatisfaction. Much of this is driven by an unbalanced focus on the business model of medicine, highlighting rapid patient transactions linked to professional income with financial incentives for high-volume care. Reversing the current trends requires a new type of leadership committed to long-held professional values and a recognition of what drives professional excellence. As internists and infectious diseases specialists without procedures in our practice, we are especially vulnerable to these trends.

The efficacy of an alcohol-based nasal antiseptic versus mupirocin or iodophor for preventing surgical site infections: A meta-analysis.

BACKGROUND: Nasal decolonization of Staphylococcus aureus is a proven strategy to reduce surgical site infections (SSI). Recently updated guidelines expanded nasal decolonization beyond traditionally high-risk populations to include the option for alcohol-based antiseptics (ABAs). We assessed the efficacy of a novel ABA for reducing SSI compared to mupirocin and iodophor. METHODS: A literature search in Google Scholar, PubMed, MEDLINE, and Cochrane databases was completed of studies reporting SSI outcomes in hospitals using an ABA. Primary meta-analyses were conducted to analyze ABA clinical efficacy versus no intervention (7 studies); subanalyses compared the ABA to mupirocin (3 studies) or iodophor (2 studies). RESULTS: One hundred forty-seven nasal decolonization titles for SSI prevention were identified, of which 7 were accepted. In the studies selected, 16,212 patients were included: 7,983 (49.24%) control group, and 8,129 (50.14%) intervention group. Significant effect sizes (measured as odds ratios [ORs]) and z-scores were found in all 3 meta-analyses: (OR = 3.178, z = 4.743, P < .001) in ABA clinical efficacy, (OR = 4.110, z = 3.167, P < .01) in ABA versus mupirocin, and (OR = 3.043, z = 3.155, P < .01) in ABA versus iodophor. Funnel plots for each demonstrated a lack of bias. CONCLUSIONS: Statistically significant positive effects were identified in all 3 meta-analyses. An ABA appears to be a viable alternative to mupirocin or iodophors to reduce SSIs.

Home Monitoring for Fever: An Inexpensive Screening Method to Prevent Household Spread of COVID-19.

The COVID-19 pandemic surge has exceeded testing capacities in many parts of the world. We investigated the effectiveness of home temperature monitoring for early identification of COVID-19 patients. Study Design ­: We compared home temperature measurements from a convenience sample of 1180 individuals who reported being test positive for SARS-CoV-2 to an age, sex, and location matched control group of 1249 individuals who had not tested positive. Methods ­: All individuals monitored their temperature at home using an electronic smartphone thermometer that relayed temperature measurements and symptoms to a centralized cloud based, de-identified data bank. Results -: Individuals varied in the number of times they monitored their temperature. When temperature was monitored for over 72 hours fever (≥ 37.6°C or 99.7°F or a change in temperature of ≥ 1°C or 1.8°F) was detected in 73% of test positive individuals, a sensitivity comparable to rapid SARS-CoV-2 antigen tests. When compared to our control group the specificity of fever for COVID-19 was 0.70. However, when fever was combined with complaints of loss of taste and smell, difficulty breathing, fatigue, chills, diarrhea, or stuffy nose the odds ratio of having COVID-19 was sufficiently high as to obviate the need to employ RTPCR or antigen testing to screen for and isolate coronavirus infected cases. Conclusions -: Our findings suggest that home temperature monitoring could serve as an inexpensive convenient screen for the onset of COVID-19, encourage earlier isolation of potentially infected individuals, and more effectively reduce the spread of infection in closed spaces.

Changes in hospitalized coronavirus disease 2019 (COVID-19) patient characteristics and resource use in a system of community hospitals in the United States.

Coronavirus disease 2019 (COVID-19) has migrated to regions that were initially spared, and it is likely that different populations are currently at risk for illness. Herein, we present our observations of the change in characteristics and resource use of COVID-19 patients over time in a national system of community hospitals to help inform those managing surge planning, operational management, and future policy decisions.