The novel coronavirus disease 2019 (COVID-19) is a highly infectious and rapidly spreading disease. There are limited published data on the epidemiology and outcomes of COVID-19 infection among organ transplant recipients. After initial flulike symptoms, progression to an inflammatory phase may occur, characterized by cytokine release rapidly leading to respiratory and multiorgan failure. We report the clinical course and management of a liver transplant recipient on hemodialysis, who presented with COVID-19 pneumonia, and despite completing a 5-day course of hydroxychloroquine, later developed marked inflammatory manifestations with rapid improvement after administration of off-label, single-dose tocilizumab. We also highlight the role of lung ultrasonography in early diagnosis of the inflammatory phase of COVID-19. Future investigation of the effects of immunomodulators among transplant recipients with COVID-19 infection will be important.

Background: As medical infrastructures are strained by SARS-CoV-2, rapid and accurate screening tools are essential. In portions of the world, reverse transcription polymerase chain reaction (RT-PCR) testing remains slow and in limited supply, and computed tomography is expensive, inefficient, and involves exposure to ionizing radiation. Multiple studies evaluating the efficiency of lung point-of-care ultrasound (POCUS) have been published recently, but include relatively small cohorts and often focus on characteristics associated with severe illness rather than screening efficacy. This study utilizes a retrospective cohort to evaluate the test characteristics (sensitivity, specificity, likelihood ratios, predictive values) of lung POCUS in the diagnosis of SARS-CoV-2, and to determine lung score cutoffs that maximize performance for use as a screening tool. Results: Lung POCUS examinations had sensitivity 86%, specificity 71.6%, NPV 81.7%, and PPV 77.7%. The Lung Ultrasound Score had an area under the curve of 0.84 (95% CI 0.78, 0.90). When including only complete examinations visualizing 12 lung fields, lung POCUS had sensitivity 90.9% and specificity 75.6%, with NPV 87.2% and PPV 82.0% and an area under the curve of 0.89 (95% CI 0.83, 0.96). Lung POCUS was less accurate in patients with a history of interstitial lung disease, severe emphysema, and heart failure. Conclusions: When applied in the appropriate patient population, lung POCUS is an inexpensive and reliable tool for rapid screening and diagnosis of SARS-CoV-2 in symptomatic patients with influenza-like illness. Adoption of lung POCUS screening for SARS-CoV-2 may identify patients who do not require additional testing and reduce the need for RT-PCR testing in resource-limited environments and during surge periods.

An elevated gamma gap (>4 g/dL), the difference between serum total protein and albumin, can trigger testing for chronic infections or monoclonal gammopathy, despite a lack of evidence supporting this clinical threshold. Using the National Health and Nutrition Examination Survey (NHANES) 1999–2014, gamma gap was derived in three subpopulations based on availability of testing for human immunodeficiency virus (HIV; N = 25,680), hepatitis C (HCV; N = 45,134), and monoclonal gammopathy of unknown significance (MGUS; N = 6,118). Disease status was confirmed by HIV antibody and Western blot, HCV RNA test, or electrophoresis with immunofixation. Sensitivity, specificity, and likelihood ratios were calculated for different gamma gap thresholds. Area under the curve (AUC) was used to assess performance and cubic splines were used to characterize the relationship between the gamma gap and each disease. Mean gamma gaps of participants with HIV, HCV, or MGUS ranged from 3.4–3.8 g/dL. The AUC was 0.80 (95%CI: 0.75,0.85) for HIV, 0.74 (0.72,0.76) for HCV, and 0.64 (0.60,0.69) for MGUS. An elevated gamma gap of over 4 g/dL corresponded to sensitivities of 39.3%, 19.0%, and 15.4% and specificities of 98.4%, 97.8%, and 95.4% for HIV, HCV, and MGUS, respectively. A higher prevalence of all three diseases was observed at both low and high gamma gaps. An elevated gamma gap of 4 g/dL is insensitive for HIV, HCV, or MGUS, but has a high specificity for HIV and HCV, suggesting that the absence of an elevated gamma gap does not rule out HIV, HCV, or MGUS. Conversely, an elevated gap may justify further testing for HIV and HCV, but does not justify electrophoresis in the absence of additional clinical information.

Morning report is a valuable educational conference but is often a stand-alone classroom-based discussion which misses the opportunity for bedside education. In this report, we describe an innovative morning report structure – the Case Oriented Report and Exam Skills (CORES) – that addresses this pitfall of the traditional case conference format and brings learners to the bedside. The key components of CORES include highlighting concepts of clinical reasoning, emphasizing evidence-based and hypothesis-driven physical exam (HDPE), and integrating emerging bedside technologies such as point-of-care ultrasound (POCUS).

Background: Point‐of‐care ultrasound (POCUS) use continues to expand across multiple clinical subspecialties, and the need for standardization of training and quality assurance has become increasingly important. Despite the need for training, there are currently no widely accepted multispecialty criteria to define an acceptable quality POCUS image for common POCUS applications used by clinicians. Without such criteria, discrepancies in rating POCUS image quality occur, leading to inconsistencies in training and quality assurance, which can ultimately compromise patient care and safety. Methods: To address this gap, the Society of Hospital Medicine (SHM) Point‐of‐care Ultrasound Task Force convened an expert panel of 32 national POCUS experts trained in hospital medicine ( n = 24), critical care ( n = 4), emergency medicine ( n = 3), radiology ( n = 2), and cardiology ( n = 1) and employed a modified‐Delphi approach to develop minimum image quality criteria for five common POCUS applications: heart, lungs, abdomen, lower extremity veins, and skin/soft tissues. Results: After three rounds of voting and group discussion, the panel achieved consensus on a comprehensive list of 215 items to define standard image quality criteria in five different body systems. Conclusions: These POCUS image quality criteria offer a structured, consensus‐based framework for evaluating POCUS images and establish a minimum standard for defining an acceptable quality image. Use of these criteria can improve inter‐rater reliability and advance standardization of POCUS imaging, which affects training, quality assurance, and credentialing/privileging practices.