American journal of hospital medicine, volume 5, issue 3 (2021 July-September)
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Item “Who? What? Is that a test?” African Americans in non-metropolitan Midwest U.S. identify knowledge gaps and opportunities for PrEP for HIV prevention(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-07) Teti, Michelle; Robinson, Erin L.; Pichon, Latrice C.; Myroniuk, Tyler; David, IfeoluA substantive gap exists in understanding the knowledge and perception of Pre-exposure prophylaxis (PrEP) among African Americans overall and especially those in non-urban areas. Thus, this analysis explores these issues among heterosexual African Americans, who face high risks for acquiring HIV, in a non-metropolitan setting in the U.S. Midwest, to inform health care practitioners about increasing awareness and availability of PrEP. We used a qualitative design to explore awareness of and perspectives about PrEP in depth. After listening to a description of PrEP, participants reactions could be summarized in four themes: amazement, suspicion, disapproval, and in need of information. Three of our themes weaved together around African American's mistrust of the medical system. Recent prevention suggestions to highlight PrEP's importance for a range of people versus a strategy for particular groups only may lead to improved PrEP access if we know how to reach diverse and varied groups of people.Item Transcutaneous carbon dioxide monitoring could reduce physical contact with COVID-19 patients(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-07) Carrington, James; Maduke, Tinashe; Steenson, Sarah; Khatun, Nurjahan; Whitacre, Troy; Alnijoumi, Mohammed; Regunath, HariharanBackground: Transcutaneous carbon di-oxide (TcCO2) monitoring can be valuable to allow non-invasive monitoring of plasma carbon dioxide (PaCO2) levels in patients with acute respiratory failure including those with novel coronavirus disease 2019 (COVID-19). Methods: A pilot retrospective chart review was performed on critically-ill, adult patients admitted to the medical intensive care unit to assess correlation between TcCO2 and PaCO2 values. Obtained demographics, diagnoses, acute physiology, and chronic health evaluation II score (APACHE II), and Charlson co-morbidity index. TcCO2 values compared with corresponding blood gas PaCO2 values - including patients requiring inotropic agents. Microsoft Excel 2016 and IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) used for statistical analysis. Results: Cohort consisted of 53 patients with acute respiratory failure from a variety of documented overlapping diagnoses. Thirty-one (58.4%) needed invasive mechanical ventilation, 20 (37.7%) required non-invasive ventilation with impending need for intubation and 2 patients (3.8%) who did not require oxygen delivery beyond high flow nasal cannula. Forty patients provided 121 instances of paired measurements of TcCO2 and PaCO2 where values were strongly correlated, r(121)=.90, p[less than]0.001, including 54 instances where patients received one or more inotrope infusions at time of measurement. In the paired measurement cohort, the sum of instances per overlapping diagnosis accounted for 47[38.8%] COVID-19, 20[16.5%] interstitial lung disease, 69[57%] pneumonia, 74[61.2%] septic shock, 23[19%] acute exacerbation of chronic obstructive lung disease, 8[6.6%] pulmonary embolism, 13[10.7%] aspiration pneumonia, 7[5.8%] severe pulmonary hypertension, 10 [8.3%] cardiac arrest, 24[19.8%] congestive heart failure, 1[0.8%] each for neuromuscular respiratory failure and angioedema and 13[10.4%] stroke. Conclusions: Continuous TcCO2 monitoring correlates well with PaCO2 offering opportunities to reduce the need for physical patient contact for frequent arterial punctures and arterial line placement among critically-ill patients with acute respiratory failure. It is a valuable addition to non-invasive monitoring of PaCO2 especially those with COVID-19 and irrespective of shock states.Item Malignant Mesothelioma Manifesting in an Elderly Female without Occupational Asbestos Exposure(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-07) Steenson, Sarah; Patel, Tarang Pankaj; Kalanjeri, Satish; Johnson, Jeremy CarlCase Presentation: A 71-year-old Caucasian female with a history of SARS-CoV-2 pneumonia, chronic obstructive pulmonary disease (COPD) and 50 pack-years smoking presented with dyspnea, cough, fever, anorexia, and 12-pound weight loss over two weeks. She had three recent hospitalizations for COPD exacerbation and pneumonia. She was noted to be hypoxic despite five liters/minute of supplemental oxygen. Laboratory studies revealed leukocytosis, hypernatremia, and elevated brain natriuretic peptide. Urine streptococcal and legionella antigens, and respiratory viral panel were negative. Chest radiograph [Figure 1] revealed lobulated left-sided pleural masses, which were confirmed on computed tomography (CT) scan of the chest [Figure 2]. CT-guided pleural biopsy was performed, and the diagnosis of malignant mesothelioma (MM) was established. Positron emission tomography revealed avidity of the pleural masses [Figure 3]. The patient denied occupational asbestos exposure, however she reported routinely laundering her husband's clothing who worked extensively with asbestos. She elected to pursue hospice care.Item Review of Obesity Paradox(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-07) Assaf, Roxane; Antoun, JumanaIntroduction: Obesity is a risk factor for many health conditions and complications but may be regarded as a prognostic factor in other conditions. This has been described as the "obesity paradox." The debate whether this paradox exists across all health conditions is a hot topic of research, which is why this review aims at systematically analyzing reviews on the obesity paradox to explore where it holds true and help guide further research and clinical implications. Methods: PubMed was searched using the key term "obesity paradox" with a systematic review and meta-analysis filter with no restriction on the date. Results: A total of 40 reviews were included. Most of the reviews included observational cohort studies focusing on various health conditions such as cancer, atrial fibrillation, stroke, heart failure, acute coronary events, dialysis, chronic diseases, surgery, etc. The obesity paradox appeared to exist in all reviewed health conditions except for solid tumors, where there was no obesity paradox regarding mortality or treatment toxicities. The obesity paradox relationship, however, was not homogeneous across the health systems, and the relationships were described as linear, U-shaped, or J-shaped (the latter two being the most common). Conclusions: The relationship between obesity and health outcomes is not straightforward as obesity is sometimes a risk factor for worse outcomes and other times associated with improved mortality. Hence, there is a need for randomized controlled trials to validate why and in which diseases the obesity paradox exists and understand its pathophysiology. Meanwhile, patients with obesity remain a challenge in the clinical context and need special attention to address their obesity and control their risk factors.Item Two encephalopathic patients with COVID-19 and elevated intracranial pressure(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-07) Winton, John; Stola, AmberCOVID-19, the disease caused by infection with SARS-Cov-2, has proven capable of affecting the central nervous system. Encephalopathy is a well-described phenomenon among COVID-19 patients, but there are few cases in the medical literature that include measurement of intracranial pressure in such patients. In this article, we report two adult patients hospitalized with COVID-19 who developed acute encephalopathy; both underwent lumbar puncture and were found to have significantly elevated intracranial pressure. One of the patients experienced complete, sustained recovery from encephalopathy after normalization of intracranial pressure. These cases, in conjunction with our review of similar cases outlined in other articles, led us to conclude that future research incorporating measurement of opening pressure of encephalopathic patients with COVID-19 may provide information about the pathophysiology of the neurologic manifestations of the disease, particularly in patients on hemodialysis.