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COVID-19 news from Annals of Internal Medicine

Embargoed news from Annals of Internal Medicine

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. Substantial number of overdose deaths found to be misclassified as sudden cardiac death

Findings suggest that national estimates of opioid overdose burden may be grossly underestimated

Abstract: https://www.acpjournals.org/doi/10.7326/M20-0977

URL goes live when the embargo lifts

A 7-year comprehensive study of deaths attributed to out of hospital cardiac arrest (OHCA) in San Francisco found that more than one in six of those deaths were actually from occult overdose. These findings suggest that published national overdose mortality estimates may be substantially underestimated. A brief research report is published in Annals of Internal Medicine.

Researchers from the University of California, San Francisco conducted a case-series analysis of the POST SCD (POstmortem SysTematic Investigation of Sudden Cardiac Death) Study, to compare the characteristics of occult overdose OHCA deaths with all other causes of OHCA deaths and to classify primary intoxicants and whether intoxicants were prescribed for each death investigated. After toxicology and autopsy, the researchers found that more than one in six deaths attributed to OHCA were really due to overdose. Most occult overdose OHCA deaths involved multiple drugs, including opioids, and approximately one-half of intoxicants were prescribed by a physician.

These findings have important implications nationally, as San Francisco's age-adjusted overdose mortality rate is nearly identical to the national median overdose mortality rate. As such, published national mortality estimates based on recognized overdoses may significantly underestimate its true burden because occult overdose deaths masquerading as sudden cardiac deaths are missed without postmortem toxicology analysis. According to the researchers, their findings affirm the need for continued efforts to combat the opioid epidemic and for policymakers to consider naloxone in selected OHCA resuscitations.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. The lead author, Zian H. Tseng, MD, MAS, can be reached through Scott Maier at scott.maier@ucsf.edu .

2. Physicians offer real-world recommendations for overcoming telemedicine challenges with older patients

Abstract: https://www.acpjournals.org/doi/10.7326/M20-1322

URL goes live when the embargo lifts

As routine outpatient physician visits continue to take place via telemedicine, physicians are faced with the challenge of providing quality care to older patients who may have difficulty with technology and often have hearing loss among other impairments. Physicians from Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health developed real-world recommendations to help clinicians effectively connect with patients, regardless of their hearing status, health, or comfort with technology. Their Telemedicine Communication Checklist is published in Annals of Internal Medicine.

The authors offer easy-to-follow steps to take before, during, and after a telemedicine encounter with an older patient. They suggest that before the encounter, clinicians should establish patient preferences regarding format and access to technology. Clinicians should assume that all older patients have some degree of hearing loss and request that they wear a headset. They should also make sure that they are conducting the encounter in good lighting so that the patient can see their face. If possible, captions should be turned on and clinicians should look for cues that the patient is not following the conversation throughout the encounter so that adjustments can be made. After the encounter, the clinician should follow up with a detailed summary of key points and instructions.

According to the authors, the recommendations are timely and relevant due to the sudden prevalence of telemedicine and the constant (and growing) prevalence of hearing loss in older Americans. The steps are simple enough to implement for any provider using telemedicine, regardless of their size or resources, and nearly free.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Carrie L. Nieman, MD, MPH, please contact Molly Sheehan at msheeh19@jhmi.edu.

3. Rituximap may successfully treat chylomicronemia caused by GPIHBP1

Abstract: https://www.acpjournals.org/doi/10.7326/L20-0327

URL goes live when the embargo lifts

Rituximab may successfully treat newly acquired cases of chylomicronemia caused by GPIHBP1 (glycosylphosphatidylinositol-anchored high-density lipoprotein-binding protein 1). Physicians should consider this possibility when patients present with difficult-to-treat chylomicronemia. A case report is published in Annals of Internal Medicine.

Researchers from Central Rhine Hospital Group, Koblenz, Germany and UCLA Department of Medicine describe the case of a 27-year-old woman with unexplained chylomicronemia, which was being investigated for the underlying cause. The patient had a history of antiphospholipid syndrome, Graves disease, and myocarditis. She previously had a cerebral venous sinus thrombosis and had no family history of adiposity, diabetes, autoimmune disease, or hyperlipidemia. Treatment with lipid-lowering drugs, plasma exchanges, and immunoadsorptions were not helpful. Based on approximately 10 other published cases of GPIHBP1, the physicians initiated treatment with rituximab, which is often used to treat autoimmune diseases. The treatment resulted in disappearance of GPIHP1 autoantibodies and normalization of serum levels of GPIHBP1 and serum triglyceride levels.

The clinicians hope that this case will draw attention to the GPIHBP1 autoantibody syndrome for two reasons. First, the syndrome is often not considered in the differential diagnosis of chylomicronemia. And second, the GPIHBP1 autoantibody syndrome carries a high risk for life-threatening pancreatitis, yet it is treatable.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with authors, Jens Lunz, MD or Anne P. Beigneux, PhD, please contact Anne P. Beigneux, PhD, at abeigneux@mednet.ucla.edu.

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