Context Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events. Case decription A 66-years-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She had also a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). 4 weeks after discharge she had no signs of COVID-19 infection and her PCR test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism. Conclusions COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening, therefore we suggest to consider performing early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency.

No abstract

BackgroundEstablishing smoke-free environments is a major component of tobacco control policy. The introduction of a smoke-free policy in medical campuses may serve as a role model for other educational and health institutions but little has been published about their prevalence or impact. In 2012, the Faculty of Medicine at Hebrew University–Hadassah in Jerusalem, Israel launched a smoke-free Medical Campus initiative. This study examined smoking behaviours, cigarette smoke exposure and attitudes towards the smoke-free campus policy among students and employees.MethodsUsing a self-administered questionnaire, data was collected from medical, dental and pharmacy students, as well as employees of the school of pharmacy. We approached the entire target population in 2013 (N = 449), with a response rate of 72.5 % (N = 313).ResultsThe rate of smoking was 8.3 % (95 % CI 5.5–11.9 %). Most participants reported daily exposure or exposure several times a week to cigarette smoke (65.8 %). Overall, 98.0 % had reported seeing people smoke in open campus areas and 27.2 % indoors. Most participants supported the smoking ban inside buildings (94.2 %) but fewer supported (40.8 %) a complete ban of smoking throughout the campus, including outside areas. Only 18.4 % agreed that a policy prohibiting smoking was unfair to smokers. A multivariable analysis showed that support for a complete ban on smoking on campus was higher among non-smokers than for smokers (OR = 9.5, 95 % CI 2.2–31.5, p = 0.02).ConclusionsThe smoke-free policy does not have total compliance, despite the strong support among both students and employees for a smoke-free medical campus. The data collected will assist policy makers move towards a total smoke-free medical campus and will aid tobacco control efforts in Israel and other countries.

Background Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards. Methods This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records. Results A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p <  0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6–59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7–0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9–56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = − 0.5). Conclusion Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

Background The liberal administration of hydroxychloroquine‐sulphate (HCQ) to COVID‐19 patients has raised concern regarding the risk of QTc prolongation and cardiac arrhythmias, particularly when prescribed with azithromycin. We evaluated the incidence of QTc prolongation among moderately and severely ill COVID‐19 patients treated with HCQ and of the existence of concomitant alternative causes. Methods All COVID‐19 patients treated with HCQ (between Mar 1 and Apr 14, 2020) in a tertiary medical centre were included. Clinical characteristics and relevant risk factors were collected from the electronic medical records. Individual patient QTc intervals were determined before and after treatment with HCQ. The primary outcome measure sought was a composite end point comprised of either an increase ≥60 milliseconds (ms) in the QTc interval compared with pre‐treatment QTc, and/or a maximal QTc interval >500 ms Results Ninety patients were included. Median age was 65 years (IQR 55‐75) and 57 (63%) were male. Thirty‐nine patients (43%) were severely or critically ill. Hypertension and obesity were common (n = 23 each, 26%). QTc prolongation evolved in 14 patients (16%). Age >65 years, congestive heart failure, severity of disease, C‐reactive protein level, hypokalaemia and furosemide treatment, were all associated with QTc prolongation. Adjusted analysis showed that QTc prolongation was five times more likely with hypokalaemia [OR 5, (95% CI, 1.3‐20)], and three times more likely with furosemide treatment [OR 3 (95% CI, 1.01‐13.7)]. Conclusion In patients treated with HCQ, QTc prolongation was associated with the presence of traditional risk factors such as hypokalaemia and furosemide treatment.

Background Social distancing was the predominant strategy used to mitigate the spread of coronavirus disease 2019 (COVID‐19) at the start of the COVID‐19 pandemic. Methods Retrospective review of all positive blood cultures from January to July in the years 2017–2020. Aims The object of this research was to study the impact of social distancing on the incidence of bacteraemia. The number of admitted patients with positive blood cultures in April–May 2020 in one tertiary medical centre was compared to the number during the same period in the previous three years (April–May 2017–2019). Results There were fewer cases of Streptococcus bacteraemia as well as coagulase‐negative Staphylococcus bacteraemia and other possible contaminated blood cultures, in April–May 2020. Compared to the previous three years, the incidence of Streptococcus pneumoniae bacteraemia among all bacteraemias was lower in April–May 2020 (5%) than in 2017–19 (12.0%, 95% confidence interval 10.3%–14.1%). In general, fewer cases of bacteraemia caused by oropharynx organisms were observed in April–May 2020; only six cases vs 31(95% confidence interval 10–53) during the same period in 2017–19. Only one case of Streptococcus pneumoniae bacteraemia was observed in April–May 2020, and its percentage among all bacteraemias was lower in April–May 2020 (0.4%) than during the same period in 2017–19 (3.3%). Conclusion The incidences of streptococcal bacteraemia and bacteraemia of organisms transmitted via respiratory secretions were lower when there were social distancing restrictions. Adopting measures of social distancing may decrease the morbidity from bacteraemia caused by oropharynx and respiratory bacteria. This article is protected by copyright. All rights reserved.

Background: The liberal administration of hydroxychloroquine-sulphate (HCQ) to COVID-19 patients has raised concern regarding the risk of QTc prolongation and cardiac arrhythmias, particularly when prescribed with azithromycin. We evaluated the incidence of QTc prolongation among moderately and severely ill COVID-19 patients treated with HCQ and of the existence of concomitant alternative causes. Methods: All COVID-19 patients treated with HCQ (between Mar 1 and Apr 14, 2020) in a tertiary medical center were included. Clinical characteristics and relevant risk factors were collected from the electronic medical records. Individual patient QTc intervals were determined before and after treatment with HCQ. The primary outcome measure sought was a composite endpoint comprised of either an increase [?] 60 milliseconds (ms) in the QTc interval compared with pretreatment QTc, and/or a maximal QTc interval >500 ms. Results: Ninety patients were included. Median age was

Background: Hyperuricemia is associated with several risk factors for mortality and severe coronavirus disease 2019 (COVID-19) manifestations. Objective:The objective of this research was to examine whether hyperuricemia is a risk factor for mortality and other adverse outcomes in patients hospitalized for COVID-19.Design: This is a retrospective review of patients hospitalized for COVID-19 between March 15 and November 30, 2020, with available uric acid (UA) levels.Results: Among 1566 patients who were hospitalized during the study period, 222 patients had an available UA level. The mean age ± standard deviation (SD) was 56.5 ± 19.5 years. The mean ± SD for UA (mg/dL) among the total cohort was 5.65 ± 2.18, and 21.2% of the total study population had hyperuricemia (UA > 7 mg/dL) on admission. The mortality rate was 14.4%, and mortality was associated with higher UA levels on admission (6.9 ± 2.6 mg/dL vs. 5.5 ± 2 mg/dL in patients who survived, P < 0.05). Patients who needed intensive oxygen support (high-flow nasal cannula or mechanical ventilation) and those who required longer-than-average hospitalization (> 7 days) had more hyperuricemia (intensive oxygen support: 30% vs. 18%, P = 0.07; long hospitalization 29% vs. 16.2%, P < 0.05). Conclusion:Our findings show that high UA levels are associated with adverse outcomes in patients hospitalized for COVID-19. We suggest evaluating hyperuricemia as a marker that integrates and reflects both poor prognostic baseline characteristics and acute components such as inflammatory state, hypovolemic state, and renal failure.