Showing papers in "Annals of Internal Medicine in 2020"
TL;DR: The results support current proposals for the length of quarantine or active monitoring of persons potentially exposed to SARS-CoV-2, although longer monitoring periods might be justified in extreme cases.
Abstract: Using news reports and press releases from provinces, regions, and countries outside Wuhan, Hubei province, China, this analysis estimates the length of the incubation period of COVID-19 and its pu...
5,215 citations
TL;DR: In this article, the authors reviewed and synthesized the available evidence on asymptomatic SARS-CoV-2 infection and found that infected persons who remain as healthy played a significant role in the ongoing pandemic, but their relative number and effect have been uncertain.
Abstract: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly throughout the world since the first cases of coronavirus disease 2019 (COVID-19) were observed in December 2019 in Wuhan, China. It has been suspected that infected persons who remain asymptomatic play a significant role in the ongoing pandemic, but their relative number and effect have been uncertain. The authors sought to review and synthesize the available evidence on asymptomatic SARS-CoV-2 infection. Asymptomatic persons seem to account for approximately 40% to 45% of SARS-CoV-2 infections, and they can transmit the virus to others for an extended period, perhaps longer than 14 days. Asymptomatic infection may be associated with subclinical lung abnormalities, as detected by computed tomography. Because of the high risk for silent spread by asymptomatic persons, it is imperative that testing programs include those without symptoms. To supplement conventional diagnostic testing, which is constrained by capacity, cost, and its one-off nature, innovative tactics for public health surveillance, such as crowdsourcing digital wearable data and monitoring sewage sludge, might be helpful.
1,813 citations
TL;DR: In this paper, the causes of COVID-19-related deaths were investigated in a single academic medical center in the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of CoV-19 patients.
Abstract: Background The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide However, little is known about the causes of death and the virus's pathologic features Objective To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests Design Prospective cohort study Setting Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19 Patients The first 12 consecutive COVID-19-positive deaths Measurements Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed Clinical data and medical course were evaluated Results Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2) Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively) Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart Limitation Limited sample size Conclusion The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it Primary funding source University Medical Center Hamburg-Eppendorf
1,723 citations
TL;DR: The high incidence of thromboembolic events suggests an important role of COVID-19–induced coagulopathy, as well as possible therapeutic interventions to reduce it, in patients dying with a polymerase chain reaction–confirmed diagnosis of CO VID-19.
Abstract: Little is known of the pathologic changes that lead to death in patients with COVID-19. This study reports the autopsy findings of consecutive patients who died with a diagnosis of COVID-19.
1,285 citations
TL;DR: Care must be taken in interpreting RT-PCR tests for SARS-CoV-2 infection—particularly early in the course of infection—when using these results as a basis for removing precautions intended to prevent onward transmission.
Abstract: Background Tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on reverse transcriptase polymerase chain reaction (RT-PCR) are being used to "rule out" infection among high-risk persons, such as exposed inpatients and health care workers. It is critical to understand how the predictive value of the test varies with time from exposure and symptom onset to avoid being falsely reassured by negative test results. Objective To estimate the false-negative rate by day since infection. Design Literature review and pooled analysis. Setting 7 previously published studies providing data on RT-PCR performance by time since symptom onset or SARS-CoV-2 exposure using samples from the upper respiratory tract (n = 1330). Patients A mix of inpatients and outpatients with SARS-CoV-2 infection. Measurements A Bayesian hierarchical model was fitted to estimate the false-negative rate by day since exposure and symptom onset. Results Over the 4 days of infection before the typical time of symptom onset (day 5), the probability of a false-negative result in an infected person decreases from 100% (95% CI, 100% to 100%) on day 1 to 67% (CI, 27% to 94%) on day 4. On the day of symptom onset, the median false-negative rate was 38% (CI, 18% to 65%). This decreased to 20% (CI, 12% to 30%) on day 8 (3 days after symptom onset) then began to increase again, from 21% (CI, 13% to 31%) on day 9 to 66% (CI, 54% to 77%) on day 21. Limitation Imprecise estimates due to heterogeneity in the design of studies on which results were based. Conclusion Care must be taken in interpreting RT-PCR tests for SARS-CoV-2 infection-particularly early in the course of infection-when using these results as a basis for removing precautions intended to prevent onward transmission. If clinical suspicion is high, infection should not be ruled out on the basis of RT-PCR alone, and the clinical and epidemiologic situation should be carefully considered. Primary funding source National Institute of Allergy and Infectious Diseases, Johns Hopkins Health System, and U.S. Centers for Disease Control and Prevention.
1,222 citations
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TL;DR: In this paper, the relative risk for serious gastrointestinal complications due to nonaspirin nonsteroidal anti-inflammatory drug (NSAID) exposure among NSAID users as well as in s...
Abstract: ▪Objective:To describe the relative risk for serious gastrointestinal complications due to nonaspirin nonsteroidal anti-inflammatory drug (NSAID) exposure among NSAID users as well as in s...
1,141 citations
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TL;DR: In this article, the prevalence of lupus anticoagulant and anticardiolipin in systemic Lupus erythematosus (SLE) and in non-SLE disorders was determined.
Abstract: Purpose:To determine the prevalence of lupus anticoagulant and anticardiolipin in systemic lupus erythematosus (SLE) and in non-SLE disorders, and to evaluate the clinical significance of ...
991 citations
TL;DR: This national survey explores factors associated with vaccine hesitancy and suggests that multipronged efforts will be needed to increase acceptance of a coronavirus disease 2019 vaccine.
Abstract: Background Coronavirus disease 2019 (COVID-19) has rapidly instigated a global pandemic. Vaccine development is proceeding at an unprecedented pace. Once available, it will be important to maximize vaccine uptake and coverage. Objective To assess intent to be vaccinated against COVID-19 among a representative sample of adults in the United States and identify predictors of and reasons for vaccine hesitancy. Design Cross-sectional survey, fielded from 16 through 20 April 2020. Setting Representative sample of adults residing in the United States. Participants Approximately 1000 adults drawn from the AmeriSpeak probability-based research panel, covering approximately 97% of the U.S. household population. Measurements Intent to be vaccinated against COVID-19 was measured with the question, "When a vaccine for the coronavirus becomes available, will you get vaccinated?" Response options were "yes," "no," and "not sure." Participants who responded "no" or "not sure" were asked to provide a reason. Results A total of 991 AmeriSpeak panel members responded. Overall, 57.6% of participants (n = 571) intended to be vaccinated, 31.6% (n = 313) were not sure, and 10.8% (n = 107) did not intend to be vaccinated. Factors independently associated with vaccine hesitancy (a response of "no" or "not sure") included younger age, Black race, lower educational attainment, and not having received the influenza vaccine in the prior year. Reasons for vaccine hesitancy included vaccine-specific concerns, a need for more information, antivaccine attitudes or beliefs, and a lack of trust. Limitations Participants' intent to be vaccinated was explored before a vaccine was available and when the pandemic was affecting a narrower swath of the United States. Questions about specific information or factors that might increase vaccination acceptance were not included. The survey response rate was 16.1%. Conclusion This national survey, conducted during the coronavirus pandemic, revealed that approximately 3 in 10 adults were not sure they would accept vaccination and 1 in 10 did not intend to be vaccinated against COVID-19. Targeted and multipronged efforts will be needed to increase acceptance of a COVID-19 vaccine when one becomes available. Primary funding source Agency for Healthcare Research and Quality.
895 citations
TL;DR: The psychological distress, depression, anxiety, and stress experienced by health care workers in Singapore in the midst of the COVID-19 pandemic are examined, and these between medically and non–medically trained hospital personnel are compared.
833 citations
Journal Article•
TL;DR: In this paper, a review summarizes trials of clinical decision support systems implemented in clinical settings to aid decision-making at the point-of-care (POC) level, and concludes that the evidence to support widespread use of CDSSs is lacking.
Abstract: Evidence to support widespread use of clinical decision-support systems (CDSSs) is lacking. This review summarizes trials of CDSSs implemented in clinical settings to aid decision making at the poi...
726 citations
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TL;DR: In this article, the authors determine whether very low doses of warfarin are useful in thrombosis prophylaxis in patients with central venous catheters.
Abstract: Objective:To determine whether very low doses of warfarin are useful in thrombosis prophylaxis in patients with central venous catheters. Design:Patients at risk for thrombosis associated ...
Journal Article•
TL;DR: The twofold increase in permeability of patients and their relatives indicates that the intestinal defect in the ability to exclude larger sized molecules is not secondary to clinically recognized intestinal inflammation, but is a primary defect that may be an etiologic factor in this disease.
Abstract: The cause of Crohn's disease is unknown, although alterations in intestinal permeability may play a primary role. Because we were interested in permeability changes that occur before the o...
Journal Article•
TL;DR: In the past, the French-American-British (FAB) Cooperative Group has classified acute myeloid leukemia on the basis of the morphologic features and number of blast cells, the percentage of...
Abstract: Excerpt In the past, the French-American-British (FAB) Cooperative Group has classified acute myeloid leukemia on the basis of the morphologic features and number of blast cells, the percentage of ...
TL;DR: COVID-19 predominantly involves the lungs, causing DAD and leading to acute respiratory insufficiency and death may be caused by the thrombosis observed in segmental and subsegmental pulmonary arterial vessels despite the use of prophylactic anticoagulation.
Abstract: The clinicopathological basis for morbidity and mortality with SARS-CoV-2 infection is not well understood. This study reports the clinical and autopsy findings of patients who died of COVID-19.
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TL;DR: Prostacyclin produces substantial and sustained hemodynamic and symptomatic responses in severe primary pulmonary hypertension and may be useful in the management of some patients with this disease.
Abstract: Study Objective:To determine the efficacy of continuous intravenous infusion of prostacyclin (epoprostenol) in primary pulmonary hypertension. Design:Randomized trial with 8-week treatment...
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TL;DR: Risk of clinically overt coronary heart disease in 190 persons with "definite" and 264 with "possible" electrocardiographic left ventricular hypertrophy (ECG-LVH) was compared with that of the general population.
Abstract: Risk of clinically overt coronary heart disease in 190 persons with "definite" and 264 with "possible" electrocardiographic left ventricular hypertrophy (ECG-LVH) was compared with that of...
TL;DR: The risks of the collision of the COVID-19 and addiction epidemics are described, which could put at risk those who have opioid use disorder and methamphetamine use disorder.
Abstract: People with substance use disorder may be especially susceptible to COVID-19, and compromised lung function from COVID-19 could also put at risk those who have opioid use disorder and methamphetamine use disorder. This commentary describes the risks of the collision of the COVID-19 and addiction epidemics.
Journal Article•
TL;DR: In this article, the authors reported that between 1 January 1981 and 1 December 1984, 34 of 396 patients with the acquired immunodeficiency syndrome (AIDS) developed cryptococcal infections.
Abstract: Between 1 January 1981 and 1 December 1984, 34 of 396 patients with the acquired immunodeficiency syndrome (AIDS) developed cryptococcal infections. Twenty-six cases are reviewed. Twenty-t...
TL;DR: Author(s): Tison, Geoffrey H; Avram, Robert; Kuhar, Peter; Abreau, Sean; Marcus, Greg M; Pletcher, Mark J; Olgin, Jeffrey E.
Abstract: Author(s): Tison, Geoffrey H; Avram, Robert; Kuhar, Peter; Abreau, Sean; Marcus, Greg M; Pletcher, Mark J; Olgin, Jeffrey E
TL;DR: The authors review the current array of tests for SARS–CoV-2, highlight gaps in current diagnostic capacity, and propose potential solutions.
Abstract: Diagnostic testing to identify persons infected with severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) infection is central to control the global pandemic of COVID-19 that began in late 2019. In a few countries, the use of diagnostic testing on a massive scale has been a cornerstone of successful containment strategies. In contrast, the United States, hampered by limited testing capacity, has prioritized testing for specific groups of persons. Real-time reverse transcriptase polymerase chain reaction-based assays performed in a laboratory on respiratory specimens are the reference standard for COVID-19 diagnostics. However, point-of-care technologies and serologic immunoassays are rapidly emerging. Although excellent tools exist for the diagnosis of symptomatic patients in well-equipped laboratories, important gaps remain in screening asymptomatic persons in the incubation phase, as well as in the accurate determination of live viral shedding during convalescence to inform decisions to end isolation. Many affluent countries have encountered challenges in test delivery and specimen collection that have inhibited rapid increases in testing capacity. These challenges may be even greater in low-resource settings. Urgent clinical and public health needs currently drive an unprecedented global effort to increase testing capacity for SARS-CoV-2 infection. Here, the authors review the current array of tests for SARS-CoV-2, highlight gaps in current diagnostic capacity, and propose potential solutions.
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TL;DR: In this article, the efficacy of fish-oil dietary supplements in active rheumatoid arthritis and their effect on neutrophil leukotriene levels was evaluated using a nonrandomized, double-blocked setting.
Abstract: Study Objective: To determine the efficacy of fish-oil dietary supplements in active rheumatoid arthritis and their effect on neutrophil leukotriene levels. Design:Nonrandomized, double-bl...
TL;DR: The strongest evidence on risk factors was on PPE use and decreased infection risk and the association was most consistent for masks but was also observed for gloves, gowns, eye protection, and handwashing; evidence suggested a dose-response relationship.
Abstract: This rapid and living review examines the epidemiology and risk factors for coronavirus infection in health care workers.
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TL;DR: In this paper, the authors examined the comparative effectiveness of patient, provider, systems, and policy interventions to improve medication adherence for chronic conditions and found evidence that reduced out-of-control medication usage.
Abstract: This review examined the comparative effectiveness of patient, provider, systems, and policy interventions to improve medication adherence for chronic conditions. It found evidence that reduced out...
Journal Article•
TL;DR: The objective was to evaluate the effect of agalsidase beta on disease progression by a time-to-event analysis of renal, cerebrovascular, and cardiac events or death in patients with advanced Fabry disease in a placebo-controlled trial.
Abstract: Fabry disease is a rare, X-linked lysosomal storage disorder that can cause early death from renal, cardiac, and cerebrovascular involvement. In this double-blind multicenter trial, 82 adults with ...
Journal Article•
TL;DR: Excerpt In the course of examining over 200 consecutive specimens of synovial fluid with phase contrast and polarized light microscopy, a collection of fluids from seven patients was obtained and it was found that some of the fluids obtained belonged to the central nervous system.
Abstract: Excerpt In the course of examining over 200 consecutive specimens of synovial fluid with phase contrast and polarized light microscopy, a collection of fluids from seven patients was obtained conta...
Journal Article•
TL;DR: Lifethreatening opportunistic cytomegalovirus infection is a complication of the acquired immunodeficiency syndrome (AIDS) that occurs in 7.4% or more of patients with AIDS as discussed by the authors.
Abstract: Life-threatening opportunistic cytomegalovirus infection is a complication of the acquired immunodeficiency syndrome (AIDS) that occurs in 7.4% or more of patients with AIDS. Cytomegalovir...
TL;DR: A study that aims to describe the 6-day postdischarge clinical, financial, and mental health outcomes of patients with COVID-19 using an observational cohort study is offered.
Abstract: Although characteristics and in-hospital outcomes for persons with coronavirus disease 2019 (COVID-19) have been well described, less is known about the longer-term outcomes of hospitalized patients Although characteristics and in-hospital outcomes for persons with COVID-19 have been well described, less is known about the longer-term outcomes of hospitalized patients Here, a study that aims to describe the 6-day postdischarge clinical, financial, and mental health outcomes of patients with COVID-19 using an observational cohort study is offered
Journal Article•
TL;DR: In this article, the authors identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus, and design a case-control study to evaluate the risk factors.
Abstract: ▪Objective:To identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus. ▪Design:Case-control study. ▪Setting:A Veterans Affairs medical center. ▪...
TL;DR: This study examines the association between obesity and death 21 days after diagnosis of COVID-19 among patients who receive care in an integrated health care system, accounting for obesity-related comorbidities and sociodemographic factors.
Abstract: Background Obesity, race/ethnicity, and other correlated characteristics have emerged as high-profile risk factors for adverse coronavirus disease 2019 (COVID-19)-associated outcomes, yet studies have not adequately disentangled their effects. Objective To determine the adjusted effect of body mass index (BMI), associated comorbidities, time, neighborhood-level sociodemographic factors, and other factors on risk for death due to COVID-19. Design Retrospective cohort study. Setting Kaiser Permanente Southern California, a large integrated health care organization. Patients Kaiser Permanente Southern California members diagnosed with COVID-19 from 13 February to 2 May 2020. Measurements Multivariable Poisson regression estimated the adjusted effect of BMI and other factors on risk for death at 21 days; models were also stratified by age and sex. Results Among 6916 patients with COVID-19, there was a J-shaped association between BMI and risk for death, even after adjustment for obesity-related comorbidities. Compared with patients with a BMI of 18.5 to 24 kg/m2, those with BMIs of 40 to 44 kg/m2 and greater than 45 kg/m2 had relative risks of 2.68 (95% CI, 1.43 to 5.04) and 4.18 (CI, 2.12 to 8.26), respectively. This risk was most striking among those aged 60 years or younger and men. Increased risk for death associated with Black or Latino race/ethnicity or other sociodemographic characteristics was not detected. Limitation Deaths occurring outside a health care setting and not captured in membership files may have been missed. Conclusion Obesity plays a profound role in risk for death from COVID-19, particularly in male patients and younger populations. Our capitated system with more equalized health care access may explain the absence of effect of racial/ethnic and socioeconomic disparities on death. Our data highlight the leading role of severe obesity over correlated risk factors, providing a target for early intervention. Primary funding source Roche-Genentech.