Effect of Methylprednisolone on Mortality and Clinical Courses in Patients with Severe CoVID-19: A Propensity Score Matching Analysis

Background Whether methylprednisolone therapy can reduce the mortality rate of patients with severe coronavirus disease 2019(COVID-19)remains controversial,and its effects on the length of hospital stay and virus shedding time are also unknown.This retrospective study investigates the previous issues to provide more evidence for methylprednisolone treatment in severe COVID-19.Methods This retrospective study included 563 of 4827 patients with confirmed COVID-19 admitted to Wuhan Huoshenshan Hospital or Wuhan Guanggu Hospital between February 3,2020 and March 30,2020 who met the screening criteria.The participants’epidemiological and demographic data,comorbidities,laboratory test results,treatments,outcomes,and vital clinical time points were extracted from electronic medical records.The primary outcome was in-hospital death,and the secondary outcomes were 2 clinical courses:length from admission to viral clearance and discharge.Univariate and multivariate logistic or linear regression analyses were used to assess the role of methylprednisolone in different outcomes.Propensity score matching was performed to control for confounding factors.Results Of the 563 patients who met the screening criteria and were included in the subsequent analysis,138 were included in the methylprednisolone group and 425 in the nonmethylprednisolone group.The in-hospital death rate between the methylprednisolone and nonmethylprednisolone groups showed a significant difference(23.91%vs.1.65%,P<0.001),which was maintained after propensity score matching(13.98%vs.5.38%,P=0.048).However,univariate logistic analysis in the matched groups showed that methylprednisolone treatment(odds ratio[OR],5.242;95%confidence interval[CI],0.802 to 34.246;P=0.084)was not a risk factor for in-hospital death in severe patients.Further multivariate logistic regression analysis found comorbidities(OR,3.327;95%CI,1.702 to 6.501;P<0.001),lower lymphocyte count(OR,0.076;95%CI,0.012 to 0.461;P=0.005),higher lactate dehydrogenase(LDH)levels(OR,1.008;95%CI,1.003 to 1.013;P=0.002),and anticoagulation therapy(OR,11.187;95%CI,2.459 to 50.900;P=0.002)were associated with in-hospital mortality.Multivariate linear regression analysis in the matched groups showed that methylprednisolone treatment was not a risk factor for a prolonged duration from admission to viral clearance(βValue 0.081;95%CI,−1.012 to 3.657;P=0.265)or discharge(βValue 0.114;95%CI,−0.723 to 6.408;P=0.117).d-dimer(βValue,0.144;95%CI,0.012 to 0.817;P=0.044),LDH(βValue 0.260;95%CI,0.010 to 0.034;P<0.001),and antiviral therapy(βValue 0.220;95%CI,1.373 to 6.263;P=0.002)were associated with a longer length from admission to viral clearance.The lymphocyte count(βValue−0.206;95%CI,−6.248 to−1.197;P=0.004),LDH(βValue 0.231;95%CI,0.012 to 0.048;P=0.001),antiviral therapy(βValue 0.143;95%CI,0.058 to 7.497;P=0.047),and antibacterial therapy(βValue 0.152;95%CI,0.133 to 8.154;P=0.043)were associated with a longer hospitalization duration from admission to discharge.Further stratified analysis revealed that the low daily dose group(≤60 mg/d)and the low total dose group(≤200 mg)had shorter duration from admission to viral clearance(Z=−2.362,P=0.018;Z=−2.010,P=0.044)and a shorter hospital stay(Z=−2.735,P=0.006;Z=−3.858,P<0.001).Conclusions In patients with severe COVID-19,methylprednisolone is safe and does not prolong the duration from admission to viral clearance or discharge.Low-dose,short-term methylprednisolone treatment may be more beneficial in shortening the disease course.

Teaching Research and Effect Observation on the Integration of Clinical Medicine Integrated Course and Ideological and Political Elements from the Perspective of“Sanquan Education”

Purpose:To analyze the application path of the integration of clinical medicine integrated courses with the elements of ideology and politics under the theory of“Sanquan Education,”and to provide references for the promotion of educational reform in medical schools.Methods:60 clinical medicine undergraduates at Jiamusi University in 2018 and 2019 were randomly selected as research subjects.On the basis of the analysis of students’characteristics and pre-study content,the students were divided into the integration group and the traditional group,each with 30 students.Students in the integration group carried out clinical medicine integrated class with the integration of ideological and political elements.Students in the traditional group carried out the traditional clinical medicine integrated class.Classroom evaluation scales,anonymous questionnaires,and interviews were used to conduct research,collect data,and compare and observe the application effects.Results:After carrying out different modes of clinical medicine integrated courses,the undergraduates of the Excellent Physician Class in the integration group were higher than those in the traditional group in terms of teaching satisfaction,comprehensive quality,basic knowledge test,and case analysis scores through questionnaire analysis(P<0.05).In the evaluation of the effect of ideological education,the undergraduates of the Excellent Physician Class of the integration group were higher than the traditional group in terms of the acceptance of doctor-patient communication,the correct rate of mastering the history of the discipline,and the correct rate of mastering the frontiers and policies(P<0.05).Conclusion:Through the integration of clinical medicine integrated course and ideological and political elements,we can help students establish correct values while teaching them professional knowledge,improve the implementation of moral education in medical schools,cultivate excellent medical workers with high morality and firm beliefs for the society,and realize the fundamental educational task of establishing morality and educating people in medical schools in the context of“Sanquan Education.”

THE ROLE OF PSYCHOSOCIAL STRESSORS,PERSONALITY AND COPING IN THE MULTIFACTORIAL ORIGIN,INITIATION AND CLINICAL COURSE OF NEOPLASTIC DISEASE AND IN HOST-DEFENSE

Summary: Retrospective and prospective bio-behavioral cancer studies have revealed that psycho social stressors may play a pivotal role in the initiation and progression of malignant neoplasia. In recent research, a pattern has emerged, which in analogy to the coronary prone pattern (type A) has been labelled type C, encompassing suppression of emotional responses, such as anger and hostility, rationality and antiemotionality, as well as high social conformity and a lack of self-assertiveness. There is growing evidence in both infrahuman and human research that specific coping styles (repressive coping) with stress may be associated with specific biologic responses, including neuroendocrine, immunologic and other bodily functions. The application of this model appears to be of importance for further research, as well as for the detection of high risk individuals, but also in regard to therapy, rehabilitation, early detection and possibly also prevention of malignant disease. This concept suggests also new directions and modifications of stress research, as stressors are to be viewed not necessarily as pathological, but in some instances as quite possibly salutary, depending on the nature of the stres-sor, the psychophysiologic state of the individual and his or her ability to cope with adverse life situations. Quite naturally, the development of this concept is still in its initial stages, there remain anumber of open questions, and it needs hardly to be pointed out in this connection that further and painstaking clinical and laboratory work is warranted in order to clarify the role of stressors, life and coping styles and its biological concomitants in neo-plastic disease.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19:A single center experience from Greece

BACKGROUND Coronavirus disease 2019(COVID-19)is still a menacing pandemic,especially in vulnerable patients.Morbidity and mortality from COVID-19 in maintenance hemodialysis(MHD)patients are considered worse than those in the general population,but vary across continents and countries in Europe.AIM To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece.METHODS We correlated clinical,laboratory,and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic.The diagnosis was confirmed by real-time polymerase chain reaction.Outcome was determined as survivors vs non-survivors and“progressors”(those requiring oxygen supplementation because of COVID-19 pneumonia worsening)vs“non-progressors”.RESULTS We studied 32 patients(17 males),with a median age of 75.5(IQR:58.5-82)years old.Of those,12 were diagnosed upon screening and 20 with related symptoms.According to the World Health Organization(WHO)score,the severity on admission was mild disease in 16,moderate in 13,and severe in 3 cases.Chest computed tomography(CT)showed 1-10%infiltrates in 24 patients.Thirteen“progressors”were recorded among included patients.The case fatality rate was 5/32(15.6%).Three deaths occurred among“progressors”and two in“non-progressors”,irrespective of co-morbidities and gender.Predictors of mortality on admission included frailty index,chest CT findings,WHO severity score,and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin.Predictors of becoming a“progressor”included increasing number of neutrophils and neutrophils/lymphocytes ratio.CONCLUSION Patients on MHD seem to be at higher risk of COVID-19 mortality,distinct from the general population.Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.

Clinical Observation and Proposed Classification of Vitiliginous Patches by a Wood’s Lamp

Although vitiligo lesion especially in static state is characterized as sharply demarcated and complete depigmented macule, we encounter patients who have various manners of hypopigmented lesions. We examined the 81 lesions using the newly released Wood’s lamp (Woody®) and investigated whether or not vitiliginous lesions could be uniformly classified under Wood’s lamp illumination and also this classification helped to estimate the tendency of repigmentation after treatment. As result, the vitiliginous lesions were categorized into 4 types on intra- and peri-lesions prior to treatment by using the Wood’s lamp. The inside and border of the lesions were classified as follows: clear white, faint, multi-dot, and perifollicular for the inside, and sharp, blunt, confetti, and trichrome for the border. Suggestive residual pigmentation was detected in 73.6% of patients at the first visit and repigmentation was observed in 67.9% of patients at least 3 months after treatment. Lesions with the “clear white” inside pattern showed significantly lower repigmentation frequency in 38.5% of patients compared to others. The borders with 4 enlarged lesions were composed of 3 of confetti-type and one of sharp-type. This preliminary study demonstrated that detailed observation with a Wood’s lamp could be the basis to classify vitiliginous lesions and might be useful for predicting not only disease progression but also repigmentation prior to treatment.

Clinical Course of Lung Cancer Patients with Subcutaneously Implanted Central Venous Access Device Ports from the Time of Receiving Chemotherapy to the Endpoint of Cancer

Background: As the prognosis of lung cancer (LC) patients improves, subcutaneously implanted central venous access device ports (CV-ports) have frequently been used for continuing chemotherapy (CC) or palliative care (PC). In this study, we examined the clinical course of LC patients with subcutaneously implanted CV-ports from the time of receiving chemotherapy to the endpoint of cancer. Materials and Methods: We retrospectively reviewed the clinical data and treatment history of LC patients with subcutaneously implanted CV-ports between June 2008 and November 2013 using clinical records and a pharmacy database. Results: Of the 132 LC patients with subcutaneously implanted CV-ports, 79 (59.8%) had CV-ports for CC (the CC group) and 53 (40.2%) had CV-ports for PC (the PC group). After CV-port implantation, LC patients in the CC group received a median of two regimens with a median of 6 cycles. The median survival time of patients in the CC and PC groups was 457 and 44 days, respectively. In the CC group, the median survival time of small cell and non-small cell LC patients was 342 (95% confidence interval, 235 - 627) and 563 (95% confidence interval, 368 - 728) days, respectively. Nine patients (6.8%) had their CV-ports removed due to complications. Forty (30.3%) of the 132 enrolled patients were referred for at-home PC. The at-home death rate observed among these 40 patients was 30.0% (N = 12). Conclusion: CV-ports may contribute to seamless oncological care.

Clinical Characteristics and Treatment for Patients with Occult Chronic Hepatitis B

Objective To observe the clinical manifestations and assess direct antiviral effect for patients with occult hepatitis B in China.Methods The study includes 15 patients with occult hepatitis B and their medical history,family history,firstdiagnosis time,confirmed-diagnosis time,laboratory report,anti-viral therapy and outcomes were analyzed.Results The average age of the patients is 38.67-year old(6 males and 9 females),2 with acute hepatitis B(2/15,13.3%),13 with no hepatitis history(13/15,86.6%),8 with family history(8/15,53.3%),6 with no family history(6/15,40%),1 with unknown family history(1/15,6.6%).Eight patients were treated with entecavir(0.5 mg/day,taken orally),with effective results and steady conditions;3 patients were treated with lamivudine(0.1 g/day,taken orally),2 of them were prescribed to take adefovir dipivoxil additionally due to drug-resistance,the other one was treated with lamivudine continuously without drug-resistance;4 cases refused anti-viral therapy.One patient’s condition remained steady,1 patient died of cirrhosis with portal hypertension and liver failure 5 years after firstdiagnosis,1 patient progressed to hepatocellular carcinoma and accepted surgery operation treatment 5 years after first-diagnosis,the other 1 patient progressed to compensatory cirrhosis 2 years after first-diagnosis and is steady from then,which indicates that occult chronic hepatitis B can progress to cirrhosis and hepatocellular carcinoma without therapy in time.Conclusions The clinical characteristics of 15 cases with occult chronic hepatitis B showed that these patients with short latency,younger age when being-struck,and light damage to liver function.The efficacy and drugresistance of nucleos(t)ide-analogue(entecavir,lamivudine,adefovir dipivoxil)in treatment of patients with occult chronic hepatitis B are similar to chronic hepatitis B.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease

BACKGROUND Acute severe lower gastrointestinal bleeding(LGIB)is an uncommon but challenging complication of Crohn’s disease(CD).AIM To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODS A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center,a tertiary university hospital in Korea.Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB.A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.RESULTS Multivariable Cox regression analysis revealed that early use of thiopurines[hazard ratio(HR):0.23,95%confidence interval(CI):0.12-0.48;P<0.001]and female sex(HR:0.51,95%CI:0.27-0.94;P=0.031)were significantly associated with a lower risk of acute severe LGIB.The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups(P=0.139 and P=0.769,respectively).The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group(22.1/100 vs 13.2/100 patient-years;P=0.012).However,if hospitalizations due to bleeding episodes were excluded from the analysis,the hospitalization rate was not significantly different between the bleeding group and the matched nonbleeding group(14.5/100 vs 13.2/100 patient-years;P=0.631).CONCLUSION Early use of thiopurines may reduce the risk of acute severe LGIB.History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Enlarged pancreas: not always a cancer

Pancreatic fat accumulation has been described with various terms including pancreatic lipomatosis, pancreatic steatosis, fatty replacement, fatty infiltration, fatty pancreas, lipomatous pseudohypertrophy and nonalcoholic fatty pancreas disease. It has been reported to be associated with type 2 diabetes mellitus, acute pancreatitis, pancreatic cancer and the formation of pancreatic fistula. The real incidence of this condition is still unknown. We report a case of pancreatic steatosis in a non-obese female patient initially diagnosed with a mass in the head of the pancreas. Magnetic resonance imaging（MRI） was carried out to define the characteristics of the pancreatic mass. MRI confirmed the diagnosis of fat pancreas. Enlarged pancreas is not always a cancer, but pancreatic steatosis is characterized by pancreatic enlargement. MRI could give a definite diagnosis of pancreatic steatosis or cancer.

Clinical Course and Outcome Patterns of Acute-on-chronic Liver Failure:A Multicenter Retrospective Cohort Study

Background and Aims:Acute-on-chronic liver failure(ACLF)is acute decompensation of liver function in the setting of chronic liver disease,and characterized by high short-term mortality.In this study,we sought to investigate the clinical course of patients at specific time points,and to propose dynamic prognostic criteria.Methods:We assessed the clinical course of 453 patients with ACLF during a 12-week follow-up period in this retrospective multicenter study.The clinical course of patients was defined as disease recovery,improvement,worsening or steady patterns based on the variation tendency in prothrombin activity(PTA)and total bilirubin(TB)at different time points.Results:Resolution of PTA was observed in 231 patients(51%)at 12 weeks after the diagnosis of ACLF.Among the remaining patients,66(14.6%)showed improvement and 156(34.4%)showed a steady or worsening course.In patients with resolved PTA,the clinical course of TB exhibited resolved pattern in 95.2%,improved in 3.9%,and steady or worse in 0.8%.Correspondingly,in patients with improved PTA,these values for TB were 28.8%,27.3%,and 43.9%,respectively.In patients with steady or worsening PTA,these values for TB were 5.7%,32.3%,and 65.6%,respectively.Dynamic prognostic criteria were developed by combining the clinical course of PTA/TB and the clinical outcomes at 4 and 12 weeks after diagnosis in ACLF patients.Conclusions:We propose the following dynamic prognostic criteria:rapid progression,slow progression,rapid recovery,slow recovery,and slow persistence,which lay the foundation for precise prediction of prognosis and the improvement of ACLF therapy.

Comparison of clinical course of patients with severe acute respiratory syndrome among the multiple generations of nosocomial transmission

Background Severe acute respiratory syndrome (SARS) is characterized by both an atypical pneumonia and efficient nosocomial transmissin. However,it remains unknown whether the infectivity and the virulence of the pathogen will change throughout the successive transmission. This study was conducted to compare the clinical features and management regimens of patients with SARS among the multiple generations from nosocomial transmission initiated by a super-spreader. Methods The clinical data of 84 epidemiologically-linked SARS patients from a hospital outbreak were retrospectively studied. All patients,in whom a clear-cut transmission generation could be noted,had a direct or indirect exposure to the index patient and the epidemic successively propagated through the multiple generations of cases within a short period of time. Results There were 66 women and 18 men with mean age of (29.2 ± 10.3) years in this cluster;and 96.4% of whom were health care workers. Detailed contact tracing identified 35 (41.7%) first-generation cases,34 (40.5%) second-generation cases,and 15 (17.8%) third-generation cases. No statistical differences among the multiple generations of transmission were found in terms of age,gender,incubation period and length of hospital stay. With the advanced transmission generations,the initial temperature lowered,the number of cases with dry cough decreased. There were no statistical differences in the peak temperature and duration of fever,other accompanying symptoms,leucopenia;however,the time from initial pulmonary infiltrates to radiographic recovery shortened ( P <0.05). No differences were found in maximum number of lung fields involved,duration from the onset of fever to the occurrence of pulmonary infiltrates and time from the initial pulmonary infiltrate to its peak among the multiple transmission generations ( P >0.05). No statistical differences were found in modes of oxygen therapy and sorts of antibiotics prescribed among the various transmission generations ( P >0.05);however, as with the advanced transmission generations,the number of cases prescribed with methylprednisolone,human γ-globulin,interferon-α,antiviral drugs (oral ribavirin or oseltamivir) increased ( P <0.05) and time from admission to starting these medication shortened ( P <0.05). Conclusions There is no evidence that SARS infection will evolve or transmit within a fashion that permits it to become less powerful throughout the successive transmission within a short time.

Nontumoral Portal Vein Thrombosis:A Challenging Consequence of Liver Cirrhosis

Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dys-function have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable;however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anti-coagulation treatment with vitamin K antagonist or low mo-lecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hyper-tension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anti-coagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anti-coagulation is bleeding, most studies indicate that anticoagu-lation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive ther-apy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evi-dence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.