Internal medicine

The Influenza Outbreak

As set forth elsewhere in this issue, widespread outbreaks of acute respiratory infection have occurred at irregular intervals for many centuries. The general clinical manifestations and the complications have been always practically the same. Owing to conditions that are far from being adequately understood, such infection now and again spreads over the world with great rapidity and in a manner that was altogether mysterious and disconcerting until we learned that it never spreads faster than human travel. It seems as if in the course of evolutionary processes there suddenly is liberated a form of infectious agent against which large numbers of people offer little or no resistance and which is transmitted readily from person to person under the most diverse hygienic and geographic circumstances. That the peculiarly subtile nature of these outbreaks was recognized long before the bacteriologic era is indicated by the introduction of the name influenza, which means, literally, influence. The question as to the real nature of this “influence,” it must be acknowledged, is not settled definitely. The discovery by Pfeiffer in 1890, at the time of the last pandemic, of the influenza bacillus (B. influenzae) in the sputum and respiratory tract of influenza patients seemed, it is true, to have settled the matter. At any rate, Pfeiffer’s claim that he had discovered the cause of influenza secured fairly general acceptance except possibly in France.

april 2020

Internal medicine

Coronavirus Disease 2019 and Influenza 2019-2020

Livingston E, Bucher K, Rekito A. march 2020

Internal medicine

Bisphosphonates for Osteopenia in Postmenopausal Women

To the Editor The JAMA Insights article on bisphosphonates for postmenopausal osteoporosis commented that no clinical trials have assessed benefit of treatment with bisphosphonates in women with osteopenia. I disagree. A double-blind, randomized, placebo-controlled trial of nearly 2000 older women with osteopenia with average bone mineral density (BMD) T scores between −0.91 at the lumbar spine and −1.67 at the femoral neck showed a fracture reduction rate at 6 years of at least 33% from intravenous zoledronate given at 18-month intervals. The reduction in hip fracture rates did not achieve statistical significance; however, the fracture reduction rates outside the hip occurred without the adverse effects of jaw osteonecrosis or atypical hip fractures. The results held true even when data from a subset of 163 women with osteoporosis who were included in the study were later excluded from statistical analysis. The results are remarkable given that 62 of the 954 women (6.4%) in the treatment group received only 1 infusion of zoledronate because of acute phase reactions or iritis and that 115 women (12.2%) in the placebo group vs 33 (3.5%) in the treatment group received bisphophonates outside the study. In addition, the benefits of zoledronate were sustained in women with or without 10-year baseline fracture risks of greater than 3% for hip fractures and 20% for any fracture as determined by the Fracture Risk Assessment Tool (FRAX) calculator proposed by the National Osteoporosis Foundation and in individuals with a history of a nonvertebral fracture after 45 years of age. These data are consistent with the reduction in bone turnover markers, procollagen type 1 N-terminal propeptide and carboxy-terminal collagen crosslinks by 37% to 50% at the end of the study. Similar data have shown bone turnover markers that are suppressed nearly 50% and significant increases in bone mineral density apparent 5 years after a single infusion of zoledronate.

Snyder S. march 2020

Public health medicine

Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China

Importance: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in Wuhan, China, and has subsequently spread worldwide. Risk factors for the clinical outcomes of COVID-19 pneumonia have not yet been well delineated. Objective: To describe the clinical characteristics and outcomes in patients with COVID-19 pneumonia who developed acute respiratory distress syndrome (ARDS) or died. Design, Setting, and Participants: Retrospective cohort study of 201 patients with confirmed COVID-19 pneumonia admitted to Wuhan Jinyintan Hospital in China between December 25, 2019, and January 26, 2020. The final date of follow-up was February 13, 2020. Exposures: Confirmed COVID-19 pneumonia.Main Outcomes and Measures: The development of ARDS and death. Epidemiological, demographic, clinical, laboratory, management, treatment, and outcome data were also collected and analyzed. Results: Of 201 patients, the median age was 51 years (interquartile range, 43-60 years), and 128 (63.7%) patients were men. Eighty-four patients (41.8%) developed ARDS, and of those 84 patients, 44 (52.4%) died. In those who developed ARDS, compared with those who did not, more patients presented with dyspnea (50 of 84 [59.5%] patients and 30 of 117 [25.6%] patients, respectively [difference, 33.9%; 95% CI, 19.7%-48.1%]) and had comorbidities such as hypertension (23 of 84 [27.4%] patients and 16 of 117 [13.7%] patients, respectively [difference, 13.7%; 95% CI, 1.3%-26.1%]) and diabetes (16 of 84 [19.0%] patients and 6 of 117 [5.1%] patients, respectively [difference, 13.9%; 95% CI, 3.6%-24.2%]). In bivariate Cox regression analysis, risk factors associated with the development of ARDS and progression from ARDS to death included older age (hazard ratio [HR], 3.26; 95% CI 2.08-5.11; and HR, 6.17; 95% CI, 3.26-11.67, respectively), neutrophilia (HR, 1.14; 95% CI, 1.09-1.19; and HR, 1.08; 95% CI, 1.01-1.17, respectively), and organ and coagulation dysfunction (eg, higher lactate dehydrogenase [HR, 1.61; 95% CI, 1.44-1.79; and HR, 1.30; 95% CI, 1.11-1.52, respectively] and D-dimer [HR, 1.03; 95% CI, 1.01-1.04; and HR, 1.02; 95% CI, 1.01-1.04, respectively]). High fever (≥39 °C) was associated with higher likelihood of ARDS development (HR, 1.77; 95% CI, 1.11-2.84) and lower likelihood of death (HR, 0.41; 95% CI, 0.21-0.82). Among patients with ARDS, treatment with methylprednisolone decreased the risk of death (HR, 0.38; 95% CI, 0.20-0.72). Conclusions and Relevance: Older age was associated with greater risk of development of ARDS and death likely owing to less rigorous immune response. Although high fever was associated with the development of ARDS, it was also associated with better outcomes among patients with ARDS. Moreover, treatment with methylprednisolone may be beneficial for patients who develop ARDS.

Chaomin Wu, Xiaoyan Chen, Yanping Cai, et al.march 2020