BACKGROUNDHydroxychloroquine has been widely administered to patients with Covid-19 without robust evidence supporting its use. METHODSWe examined the association between hydroxychloroquine use and intubation or death at a large medical center in New York City. Data were obtained regarding consecutive patients hospitalized with Covid-19, excluding those who were intubated, died, or discharged within 24 hours after presentation to the emergency department (study baseline). The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received hydroxychloroquine with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. RESULTSOf 1446 consecutive patients, 70 patients were intubated, died, or discharged within 24 hours after presentation and were excluded from the analysis. Of the remaining 1376 patients, during a median follow-up of 22.5 days, 811 (58.9%) received hydroxychloroquine (600 mg twice on day 1, then 400 mg daily for a median of 5 days); 45.8% of the patients were treated within 24 hours after presentation to the emergency department, and 85.9% within 48 hours. Hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive hydroxychloroquine (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360). Overall, 346 patients (25.1%) had a primary end-point event (180 patients were intubated, of whom 66 subsequently died, and 166 died without intubation). In the main analysis, there was no significant association between hydroxychloroquine use and intubation or death (hazard ratio, 1.04, 95% confidence interval, 0.82 to 1.32). Results were similar in multiple sensitivity analyses.

Obesity has been associated with COVID-19 and with pneumonia and acute respiratory distress syndrome but is also associated with comorbidities that place patients at higher risk. This study examines whether obesity is associated with intubation or death—as well as biomarkers of inflammation, cardiac injury, or fibrinolysis—in the context of COVID-19 disease independent of obesity-related comorbidities.

In patients with concomitant carotid and coronary disease undergoing combined revascularization, combined CEA+CABG is utilized most frequently, followed by staged CEA+CABG and staged CAS+CABG strategies. The staged CAS+CABG strategy was associated with lower risk of mortality, but higher risk of stroke. Future studies are needed to examine the risks/benefits of different carotid revascularization strategies for high-risk patients requiring concurrent CABG.

BACKGROUND:The surge of coronavirus 2019 hospitalizations in New York City required rapid discharges to maintain hospital capacity. OBJECTIVE: To determine whether lenient provisional discharge guidelines with remote monitoring after discharge resulted in safe discharges home for patients hospitalized with COVID-19 illness. DESIGN: Retrospective case series SETTING: Tertiary care medical center PATIENTS: Consecutive adult patients hospitalized with COVID-19 illness between March 26, 2020, and April 8, 2020, with a subset discharged home INTERVENTIONS: COVID-19 Discharge Care Program consisting of lenient provisional inpatient discharge criteria and option for daily telephone monitoring for up to 14 days after discharge MEASUREMENTS: Fourteen-day emergency department (ED) visits and hospital readmissions RESULTS: Among 812 patients with COVID-19 illness hospitalized during the study time period, 15.5% died prior to discharge, 24.1% remained hospitalized, 10.0% were discharged to another facility, and 50.4% were discharged home. Characteristics of the 409 patients discharged home were mean (SD) age 57.3 (16.6) years; 245 (59.9%) male; 27 (6.6%) with temperature ≥ 100.4°F; and 154 (37.7%) with oxygen saturation < 95% on day of discharge. Over 14 days of follow-up, 45 patients (11.0%) returned to the ED, of whom 31 patients (7.6%) were readmitted. Compared to patients not referred, patients referred for remote monitoring had fewer ED visits (8.3% vs 14.1%; OR 0.60, 95% CI 0.31-1.15, p = 0.12) and readmissions (6.9% vs 8.3%; OR 1.15, 95% CI 0.52-2.52, p = 0.73). LIMITATIONS: Single-center study; assignment to remote monitoring was not randomized. CONCLUSIONS: During the COVID-19 surge in New York City, lenient discharge criteria in conjunction with remote monitoring after discharge were associated with a rate of early readmissions after COVID-related hospitalizations that was comparable to the rate of readmissions after other reasons for hospitalization before the COVID pandemic.

No abstract

tors could help level the playing field for hospitals serving disadvantaged patients. Moreover, policymakers could provide underresourced hospitals with access to quality-improvement assistance or introduce downside risk more slowly for these hospitals. Additionally, creating separate tracks for low-and highvolume hospitals, and hospitals with vastly different clinical capabilities and resources, might persuade lower-volume, less well-resourced, and safety-net hospitals to join future bundled payment programs. 7 Ultimately, if bundled payments are to truly achieve their promise as a broadly viable tool for improving the efficiency of care, then policymakers and health systems leaders must make it easier for a diverse set of acute care hospitals to participate in and excel under bundled payment programs.

Coronary angiography has traditionally been used as the final diagnostic tool in the evaluation of coronary artery disease (CAD). However, conventional angiography identifies anatomically obstructive coronary disease, but it is limited in its ability to identify hemodynamically significant lesions. The emergence of fractional flow reserve (FFR) technology, in conjunction with angiography, offers a functional, as well as anatomic, assessment of epicardial coronary obstructions. Several pivotal studies have demonstrated that FFR-guided coronary revascularization is a safe and effective in patients with single and multivessel CAD. There are emerging data to suggest that FFR may also play an integral role in planning surgical revascularization and in the evaluation of post-coronary artery bypass patients and their graft patency. This review will explore the physiologic underpinnings of FFR methodology, its clinical value and limitations, and its applications in coronary artery bypass grafting (CABG) surgery.

OBJECTIVES: Pulmonary fibrosis is a feared complication of COVID-19. To characterize the risks and outcomes associated with fibrotic-like radiographic abnormalities in patients with COVID-19–related acute respiratory distress syndrome (ARDS) and chronic critical illness. DESIGN: Single-center prospective cohort study. SETTING: We examined chest CT scans performed between ICU discharge and 30 days after hospital discharge using established methods to quantify nonfibrotic and fibrotic-like patterns. PATIENTS: Adults hospitalized with COVID-19–related ARDS and chronic critical illness (> 21 d of mechanical ventilation, tracheostomy, and survival to ICU discharge) between March 2020 and May 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We tested associations of fibrotic-like patterns with clinical characteristics and biomarkers, and with time to mechanical ventilator liberation and 6-month survival, controlling for demographics, comorbidities, and COVID-19 therapies. A total of 141 of 616 adults (23%) with COVID-19–related ARDS developed chronic critical illness, and 64 of 141 (46%) had a chest CT a median (interquartile range) 66 days (42–82 d) after intubation. Fifty-five percent had fibrotic-like patterns characterized by reticulations and/or traction bronchiectasis. In adjusted analyses, interleukin-6 level on the day of intubation was associated with fibrotic-like patterns (odds ratio, 4.40 per quartile change; 95% CI, 1.90–10.1 per quartile change). Other inflammatory biomarkers, Sequential Organ Failure Assessment score, age, tidal volume, driving pressure, and ventilator days were not. Fibrotic-like patterns were not associated with longer time to mechanical ventilator liberation or worse 6-month survival. CONCLUSIONS: Approximately half of adults with COVID-19–associated chronic critical illness have fibrotic-like patterns that are associated with higher interleukin-6 levels at intubation. Fibrotic-like patterns are not associated with longer time to liberation from mechanical ventilation or worse 6-month survival.