The COVID-19 LST Report: Recent Episodes
COVID19LST
The COVID-19 Literature Surveillance Team is a group of physicians, medical students, PhDs and others that are keeping up with the latest research on SARS-CoV-2. We find the newest articles, read them and grade their level of evidence to bring you the bottom line.
Visit COVID19LST.org for full daily report with links to articles. Contact us at: contact@covid19lst.org
Producers: Sarah Taylor Writers: Thamanna Nishath, Sangeetha Thevuthasan Host: Jasmine Rah, Will Smith
© 2020 | COVID19LST.org Support this podcast: https://anchor.fm/covid19lst/support
In today's episode we discuss:
—Climate: Infectious Disease Society of America (IDSA) made 4 strong recommendations for preventing COVID-19 infection in health care personnel. A pulmonologist and interventional cardiologist from the Cleveland Clinic and Emory University critique recently published IDSA guidelines for preventing COVID-19 infection in healthcare workers. They argue the recommendation to use either respirators or surgical masks conflicts with Centers for Disease Control guidance to use respirators, and believe the guidelines are missing recommendations on proper gloving strategies, which are crucial to avoid self-contamination. The authors suggest the IDSA must clarify these points to alleviate confusion for healthcare workers who are inundated with recommendations from multiple organizations.
—Transmission & Prevention: A retrospective observational study conducted by physicians at the Military Instruction Hospital during April 2020 found that among 1,739 crew members aboard a French aircraft carrier in April 2020, 64% tested positive for COVID-19 via real-time polymerase chain reaction (RT-PCR), with there being significant variations in symptomatic presentation and antibody development. This article suggests viral circulation in local outbreaks requires further testing and analysis.
—Management: Remdesivir for adults with COVID-19 may decrease time on mechanical ventilation. A multi-specialty team from Minnesota and Oregon conducted a systematic review of 5 randomized-controlled trials evaluating remdesivir as a treatment for adults with COVID-19. They found that a 10-day course of remdesivir may reduce the proportion of patients receiving mechanical ventilation (RR: 0.71 [CI, 0.56 to 0.90]; 3 RCTs), but was associated with a statistically insignificant decrease in mortality (RR: 0.93 [95% CI, 0.82 to 1.06]; 4 RCTs) compared to control groups. Authors suggest that remdesivir use probably confers little to no mortality benefit, but may improve recovery by reducing time on mechanical ventilation.
—Adjusting Practice During COVID-19: Methodological quality has been lower in some COVID-19 clinical research. As part of a systemic review of COVID-19 research quality, a team of molecular biologists, physicians, and statisticians from the University of Ottawa compared the quality of 686 research articles published during the COVID-19 pandemic to 593 historical controls matched for journal and study design published pre-pandemic. COVID-19 publications had a shorter time to acceptance (13.0 vs. 110 days, p<0.0001) and lower methodological quality scores compared to historical controls. Authors suggest the push for rapid research during the pandemic may result in lower quality research, and highlight the need for higher quality evidence.
—R&D: Diagnosis & Treatments: SARS-CoV-2 lethal infected with K18-hACE2 transgenic mice may offer post-exposure protection. Researchers from the Israel Institute for Biological Research in Ness-Ziona, Israel analyzed the efficacy of monoclonal MD65 antibodies in K18-hACE2 transgenic mice with SARS-CoV-2 infection, finding a greater survival rate compared to mice without MD65 antibodies, in the setting of both prophylactic and post-exposure administration, as well as decreased viral load in lung tissue.
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We are an affiliated group of medical students, PhDs, and physicians keeping up with the latest research on SARS-CoV-2 / COVID-19. We find the newest articles, read them, grade their level of evidence, and bring you the bottom line. Our goal is to empower you to take the best care of yourself and those in your care.
Our Story:
What did University of Washington third-year medical student Jasmine Rah do when her training program was suspended due to COVID-19? She teamed up with her mentor, Dr. Will Smith, an ER Doctor on the front lines of fighting COVID-19 who is also a UW clinical professor and Col. with the US Army Reserves, to launch the daily COVID-19 Literature Surveillance Team.
In just the first five months of 2020, more than ten thousand papers have been published regarding COVID-19. This is more than twice the number of publications on influenza or malaria for the entire year of 2019. Many of these articles were just researchers desperate to share the findings in the hopes of helping others. However, many articles covered the same topic and many were of poor quality, highlighting the need for assistance in parsing through data, especially during the time of crisis in order to develop situational awareness.
The 50+ strong group of physicians, medical students, and other experts review every COVID-19 related study that is published each day, grades its level of evidence (aka scientific integrity) based on the Center for Oxford scheme, and summarizes delivering the BLUF- Bottom Line Up Front (it's a reporters dream come true!).
Their concept is to enable providers to "Stay Informed. Read Less. Do More." This effort is 100% volunteer, free, and open access. With the need to share information quickly to combat COVID-19 many leading medical journals have suspended peer review, which means more people have access to more information more quickly- but it also means there is a lot of noise. The COVID-19 LST cuts through this noise to get doctors and health care workers on the front lines the scientifically-sound information they need, quickly, to save lives.
Though it was initially created to guide clinical decision making, it grew to also guide policymakers, various agencies of Government, researchers, students and laypersons. Through COVID-19 LST, we now understand the very important role of screening/summarizing evidence in an unbiased manner and the critical role of a literature surveillance team. Critical members of COVID-19 LST were then invited to join in founding the non-profit, the Literature Surveillance Team or theLST.org. The next step is now to continue our process for other topics with clinical significance in the future.
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In today's episode we discuss:
—Epidemiology
· What does the literature say about face mask usage against COVID-19? A large international, interdisciplinary group summarize the evidence supporting mask wearing to mitigate the spread of COVID-19. They reviewed direct epidemiological evidence, population-level impacts, transmission characteristics, laboratory-based source control experiments, personal protective equipment efficacy research, sociological considerations, and implementation policies. Authors conclude all evidence indicates mask wearing effectively reduces viral droplet transmission and should be encouraged by officials to help minimize the spread of COVID-19.
—Understanding the Pathology: ABO blood group showed minimal differences in SARS-CoV-2 antibody response but blood group B had higher neutralizing antibody titers. A multicenter prospective cohort study conducted by Johns Hopkins University, Mississippi Valley Regional Blood Center in Springfield, IL, Washington University School of Medicine in St. Louis, MO, Mayo Clinic in Rochester, MN, and National Institute of Health in Baltimore, MD involved 202 individuals who were eligible to donate COVID-19 convalescent plasma at the beginning of the pandemic. They found there was no difference in anti-SARS-CoV-2 spike IgA or IgG between ABO groups, but significantly higher neutralizing antibody (nAb) titers were present in blood group B (44%) compared to blood groups A (25%), O (20%) and AB (0%). These findings suggest blood group B may have higher nAb titers after recovery from COVID-19 infection and thus greater protection against future infection with SARS-CoV-2, however further studies correlating ABO blood groups and disease severity are needed to further support these findings.
—Transmission & Prevention: Further robust research is necessary to deduce the link, if any between COVID-19 vaccination efficacy and obesity. Researchers from Harvard Medical School, Massachusetts General Hospital and ConscienHealth in Pittsburgh refute previous speculations that obesity could be associated with reduced efficacy of the COVID-19 vaccines. Data from Phase 3 vaccine trial results show Pfizer-BioNTech has 95.4% efficacy (CI: 86.0 - 99.1%) in people with obesity compared to 94.8% (CI: 87.4-98.3%) in people without obesity and Moderna efficacy of 91.2% (CI:32.0-98.9%) in people with severe obesity and 94.8% (CI: 89.3-96.8%) overall. Since obesity is one of the most significant risk factors for severe outcomes from COVID-19, these authors suggest that ongoing placebo-controlled vaccine trials designed with necessary power for detecting differences among classes of obesity are important for post-vaccine risk stratification and public health strategy.
· A nanomechanical study found SARS-CoV-2 to survive best on polystyrene compared to other tested inanimate surfaces. A nanomechanical study by researchers in Alberta, Canada and Changsha, Shenzhen, and Guangdong, China tested SARS-CoV-2 survival on four different surfaces and found that the spike protein on the outer surface of the SARS-CoV-2 virion, which is responsible for transmission via fomites, survived the best on polystyrene, then stainless steel, then gold, and then on glass, suggesting that fomite transmission of SARS-CoV-2 is prevalent and that more surfaces need to be tested to get a better understanding for both prevention and tracking transmission of the virus.
The rest of the reports can be found here: https://www.covid19lst.org/reports
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Support this podcast: https://anchor.fm/covid19lst/support
In today's episode we discuss:
—Epidemiology: Seroprevalence of SARS-CoV-2 antibodies in over 6000 healthcare workers show increased occupational risk. Physicians and laboratory scientists from Spain conducted a cross-sectional study of 6,038 healthcare workers (HCW) across 4 regions in Spain to assess the seroprevalence of IgG anti-SARS-CoV-2 antibodies. They found 11% of HCW (n=662) had IgG against SARS-CoV-2, with those with high (OR: 2.06; 95%CI: 1.63-2.62) and moderate (OR: 1.77; 95%CI: 1.32-2.37) risk exposures more likely to have antibodies. Because this rate of seropositivity is slightly higher than in the general Spanish population, authors suggest their data confirm the occupational risk of SARS-CoV-2 infection among HCW with working in a clinical environment.
—Adjusting Practice During COVID-19: There was an effect of the COVID-19 pandemic process on STEMI patients’ timeline? An interdisciplinary group of cardiology researchers from hospitals in Samsun and Sivas, Turkey, performed a combined observational analysis as well as chart review to assess the effects that the COVID-19 pandemic has had on the management of ST elevation myocardial infarction (STEMI) patients. They concluded that there was a delayed time to first medical contact (61 minutes in non-pandemic times versus 190 minutes during the pandemic), as well as a delayed time for patients to leave their house after their onset of symptoms (30 minutes in non-pandemic times versus 165 minutes during the pandemic). While this implies that there may need to be widespread analysis of medical responses to patients experiencing STEMI, the authors do comment on the fact that the COVID-19 burden in areas studied was relatively small when compared to hotspots around the world. Further investigation is required in areas that can represent a patient population more severely burdened by COVID-19, however these results suggest an opportunity for quality improvement changes to more efficiently manage patients with STEMI during the pandemic and improve outcomes.
—R&D: Diagnosis & Treatments: Fluvoxamine when compared to placebo can decrease clinical deterioration in outpatients with symptomatic COVID-19. A double-blind randomized clinical trial, conducted by physicians from Washington University in St. Louis, analyzed the efficacy of fluvoxamine (100 mg 3 times daily for 15 days) against a placebo to decrease clinical deterioration of COVID-19 in non-hospitalized patients with confirmed SARS-CoV-2 infection within 7 days and oxygen saturation 92% or greater. Clinical deterioration (defined as development of both 1) shortness of breath or hospitalization for shortness of breath or pneumonia and 2) oxygen saturation less than 92% on room air or need for supplemental oxygen to achieve oxygen saturation of 92% or greater) occurred in 0 of 80 patients in the fluvoxamine group and in 6 of 72 patients in the placebo group without a significant increase in adverse events.
—Transmission & Prevention: Genomic evidence of points to in-flight transmission of SARS-CoV-2 despite predeparture testing. A study by the New Zealand Ministry of Health looking at the points of infection and transmission of SARS-CoV-2 in 86 people returning to New Zealand through an international flight from Dubai, UAE. Passengers were placed in managed isolation and quarantine and tested for SARS-CoV-2 on their third and twelfth day after their return; 7 passengers subsequently tested positive for COVID-19.
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In today's episode we discuss:
—Epidemiology: Do we need routine COVID-19 testing of Emergency Department staff? A study from the University of Washington uses a mathematical model based on the Diamond Princess cruise ship data to predict detection of SARS-CoV-2 in asymptomatic health care workers (HCWs) in the emergency department in regions with high COVID-19 rates. Results revealed that within six months, weekly testing in asymptomatic HCWs would reduce infection rates by 3 to 5.9% when the transmission constant is 1.219e-4 new infections/person^2, while a transmission constant of 3.660e-4 new infections/person^2 would result in reduction of infections by 11 to 23%. The authors urge more frequent testing in asymptomatic HCWs to help reduce the rate of SARS-CoV-2 infection.
—Understanding the Pathology: Dynamic changes are witnessed in anti-SARS-CoV-2 antibodies during SARS-CoV-2 infection and recovery in a retrospective analysis by bioinformatics and global health specialists in Jiangsu, China where 1,850 hospitalized patients with COVID-19 were analyzed and those with mild or moderate disease were found to develop IgG antibodies one week earlier than patients with severe disease. While spike protein and receptor-binding domain specific IgG levels were 1.5- and 2-fold higher in critically ill hospitalized patients and SARS-CoV-2 RNA-negative recovered patients, respectively, compared to those who are remained RNA-positive. These data suggest earlier development of antibodies may be protective against developing severe disease; however, those who recover from more severe disease may also have higher levels of antibodies and a shorter duration of viral shedding.
—Management: Coronary calcium scoring was found to be a predictor for outcome in COVID-19. A retrospective cohort study conducted at the University of Munich by a team of internal medicine and radiology specialists found the coronary artery calcification (CAC) score to be a significant prognostic indicator based on 109 SARS-CoV-2-infected patients. Authors found the median CAC to be 140 [IQR 1–1165] in patients with critical COVID-19, and 160 [IQR: 88–562] in patients with fatal outcome. Authors note limitations due to retrospective design and small sample size, however, these findings suggest that coronary artery disease is significantly associated with an adverse clinical outcome in COVID-19.
—Adjusting Practice During COVID-19: There is a high prevalence of deep venous thrombosis in non-severe COVID-19 patients hospitalized for a neurovascular disease. This prospective study from Strasbourg University Hospital, France evaluates 13 patients with non-severe COVID-19 and concurrent neurovascular disease for deep venous thrombosis (DVT) via doppler ultrasound scanning (DUS) of the lower limbs. Results showed that despite thromboprophylaxis, the prevalence of asymptomatic DVT was 38.5%. The authors thus advocate for the use of bedside DUS to identify DVT in patients with COVID-19 given that D-dimer, the classic marker of DVT, has been shown to correlate with COVID-19 severity and may be elevated in this population regardless of coagulable state.
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In today's episode we discuss:
—Epidemiology: The authors present a case report of a 29-year-old SARS-CoV-2 positive woman with minimal, mild symptoms who underwent an uncomplicated and successful vaginal delivery to a healthy baby boy at the University of Missouri Women and Children’s Hospital in April 2020. After birth, the patient’s placenta was subsequently analyzed using hematoxylin-and-eosin (H&E) staining, which revealed evidence of general placental vascular malperfusion possibly due to hypertrophic arteriolopathy along with immunohistochemistry (IHC) staining which revealed the presence of SARS-CoV-2 in chorionic villi endothelial cells. Current literature on COVID-19 in pregnant patients is somewhat conflicting regarding morbidity, miscarriage rates, susceptibility, and the possibility of vertical transmission; the authors posit that this case is the first report of placental SARS-CoV-2 in the setting of mild COVID-19 disease, where the patient had only symptoms of mild myalgias.
—R&D: Diagnosis & Treatments: A prospective study conducted at a Malaysian COVID-19 quarantine center of 217 asymptomatic adult males, where 160 tested positive, found a far greater SARS-CoV-2 detection rate using morning salivary samples (93.1%) when compared to nasopharyngeal swabs (52.5%) (p<0.001, 45.6% concordance, 47.5% discordance). These results suggest that the higher accuracy of salivary analysis could play a role in improved diagnostics, decreasing direct healthcare worker-patient interaction and risk of transmission, improving transport preservation, reducing test wait time, and allowing for self-collection.
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In today's episode we discuss:
—Adjusting Practice During COVID-19: A team of cardiologists and pharmacists from hospitals in Shanghai and Wuhan, China assessed the association between mortality in hospitalized COVID-19 patients (n=535) and low molecular weight heparin (LMWH) use between January 26-March 26, 2020. They found overall adjusted odds ratio for mortality was lower in the LMWH-users vs non-users (0.20; 95% CI, 0.09-0.46), specifically in severe (0.08; 95% CI, 0.01–0.62) and critically ill cases (0.32; 95% CI ,0.10–0.996). Authors suggest LMWH appears correlated with a survival benefit in hospitalized COVID-19 patients, especially those severely and critically ill.
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In today's episode we discuss:
—Climate: American physicians from Yale and the University of Maryland argue that the US government should mandate vaccination of migrant detainees against COVID-19. They assert the crowded and inadequate sanitary conditions in these facilities create epicenters for disease proliferation and that without federal mandates, states will fail to vaccinate this vulnerable population. Authors suggest such policy is both sound medical practice and a moral imperative.
—Epidemiology: A team of Spanish physicians conducted a retrospective cohort-study using the SEMI-COVID-19 Registry of 12,170 COVID-19 patients from 150 hospitals in Spain to investigate impact of arterial stiffness on mortality. They found arterial stiffness (pulse pressure greater than or equal to 60 mmHg) and systolic blood pressure (SBP) less than 120 mmHg on admission significantly and independently predicted all-cause in-hospital mortality (ORadj: 1.27, p=.0001; ORadj: 1.48, p=.0001, respectively). Authors concluded SBP and pulse pressure values on admission are independent predictors of mortality in COVID-19 patients.
—Management: A single-center retrospective cohort study of 157 hospitalized COVID-19 patients in Wuhan, China analyzed 43 demographic, clinical, and laboratory parameters and found an association between higher systolic blood pressure (SBP) on admission and increased mortality. They also utilized regression models to predict mortality and survivability based of available data and they suggest utilizing these models for risk stratification and appropriate triaging of patients to improve outcomes.
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In today's episode we discuss:
—Climate: More transparency is needed for emergency use authorizations (EUA), including drugs and vaccines for COVID-19, according to a journalist writing for the Journal of the American Medical Association reporting on a recent US Government Accountability Office (GAO) report. The report calls on the Food and Drug Administration (FDA) to publicly share safety and efficacy data related to EUAs to improve public confidence during this unprecedented time.
—Epidemiology: Persistence of SARS-CoV-2 in a first trimester placenta may have led to transplacental transmission and fetal demise from an asymptomatic mother. An interdisciplinary group of researchers at Model Hospital in Mumbai, India describe a case of hydrops fetalis detected at 13 weeks gestation in an asymptomatic carrier of the SARS-CoV-2 virus. The patient tested posted for COVID-19 at 7.6 weeks of gestation and then was subsequently found to have detectable SARS-CoV2 in the amniotic fluid and placental cells at 13 weeks gestation. These findings suggest possible transplacental SARS-CoV-2 transmission and viral replication within the placenta. While there was evidence of robust placental inflammation, fetal tissue was unavailable for biopsy and therefore infection of the fetus itself is unable to be determined.
—Understanding the Pathology: Immunometabolism may be useful for inflammaging, immunosenescence, and autoimmunity in COVID-19. In this review, an interdisciplinary group of French researchers propose that inflammaging, which is chronic low-grade inflammation that occurs with aging, may be the common factor predisposing individuals with certain comorbidities to more severe COVID-19. They discuss how the underlying mechanisms of immunosenescence and chronic inflammation seen in diseases such as diabetes, hypertension, metabolic syndrome, systemic lupus erythematosus, and rheumatoid arthritis seem to predispose COVID-19 patients to the immune dysfunction and cytokine storm observed in severe disease. Thus, authors propose an immunometabolism-mediated treatment paradigm that includes metformin, rapamycin, and dimethyl fumarate.
—Transmission & Prevention: Intrauterine transmission of SARS-CoV-2 from COVID-19 infected pregnant women is a potential complication according to one review. Members of the Pakistan Health Research Council reviewed 16 articles (498 COVID-19 infected pregnant women) on vertical transmission of SARS-CoV-2 and found vertical transmission occurred in 4.883% of SARs-CoV-2 infected mothers (23/471), and in the 17 cases where outcomes were reported, 4 infants developed COVID-19 pneumonia, 8 required care in the neonatal intensive care unit, 4 received mechanical ventilation, and none died. Authors suggest vertical transmission is possible and that because severe neonatal complications can occur, recommend neonatal screening for infants born to mothers with SARS-CoV-2.
—Management: Do care bundles improve outcomes in patients with COVID-19 or related conditions in intensive care? A systematic review by authors from Ireland and Australia examined the literature on ICU care bundles used in the management of COVID-19 and other acute respiratory pathogens and identified 21 studies encompassing 8 countries, with care bundles most commonly including guidance on ventilator setting, restrictive fluid management, sedation, and prone positioning.
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In today's episode we discuss:
—Climate: A systematic review by an international team of researchers highlights the significant underrepresentation of geriatric patients in published COVID-19 randomized control trials (RCTs). In the 12 RCTs included in the review, patients had mean age of 56.3 years, and were on average 20 years younger than patients from large observational trials. One explanation for this discrepancy is the strict exclusion criteria used for RCTs, which commonly exclude patients with cognitive impairment and multiple comorbidities frequently seen in the elderly population. The authors strongly advocate for future RCTs to include this vulnerable population that has been disproportionately affected by the COVID-19 pandemic.
—Epidemiology: Pediatric ischemic stroke is an infrequent complication of SARS-CoV-2. Physician members of the International Pediatric Stroke Study Group surveyed 61 international sites to assess the prevalence of SARS-CoV-2 infection in pediatric stroke patients. They found 3.6% (6/166) of pediatric arterial ischemic stroke, 0.9% (1/108) of neonatal arterial ischemic stroke, 1.9% (1/54) of pediatric cerebral sinovenous thrombosis, and zero (0/33) neonatal cerebral sinovenous thrombosis patients were positive for SARS-CoV-2. Authors suggest these results indicate that SARS-CoV-2 does not appear to increase the risk of stroke in neonatal and pediatric populations but acknowledge that more robust testing is needed to determine any role the virus has in pediatric stroke.
—Transmission & Prevention: Dry heat incubation and ambient temperature fail to consistently inactivate SARS-CoV-2 on N95 respirators. Internists and microbiologists from University of New Mexico assessed whether dry heat incubation could decontaminate N95 respirators and found SARS-CoV-2 was not inactivated when N95 coupons inoculated with the virus were heated to 60-75 degrees Celsius for either 30 or 60 minutes when placed on parchment paper but was inactivated when placed on tissue culture plates. When intact 3M 1860 N95 respirators were incubated at 70-75 degrees Celsius for 60 minutes, SARS-CoV-2 was not inactivated. Authors suggests that dry heat incubation is not a consistently effective method for deactivating SARS-CoV-2 on N95 respirators.
—R&D: Diagnosis & Treatments: Efficacy of lopinavir/ritonavir in the treatment of COVID-19 was not found to be considerable according to a systematic review. An international research team from Nested Knowledge, Inc conducted a systematic review of 16 studies assessing the effectiveness and safety of lopinavir/ritonavir (LPV/r) in the treatment of COVID-19 and found the majority of included studies showed no significant improvement in clinical outcomes (RT-PCR negativity, chest-CT findings, mortality, adverse events) following LPV/r treatment, though they could not perform meta-analysis due to the high heterogeneity of the comparison groups. Though their review suggests little survival or clinical benefit of LPV/r in COVID-19, authors recommend larger clinical trials are needed to more definitively explore its potential benefits due to the limitations of currently available data.
—Mental Health & Resilience Needs: Experiences of New Zealand registered nurses of Chinese ethnicity during the COVID-19 pandemic are brought to light in one study.
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In today's episode we discuss:
—Climate: The US Centers for Disease Control COVID-19 Response Team used data from three online CARAVAN omnibus surveys (n=858) conducted to assess parental attitudes and concerns about schools reopening during the COVID-19 pandemic and found more white families were in favor of in-person school (62.3%) compared to Hispanic families (50.2%, p=0.014) and Black families (46.0%, p=0.007), while non-white parents were more concerned about schools opening safely (98.8% very or somewhat concerned) than were white families (86.0%, p=0.012). Authors suggest socioeconomic differences and structural inequities may drive these differing attitudes and recommend school districts consider each community's unique needs when devising school reopening plans.
—Epidemiology: In a retrospective cohort study evaluating albumin levels in correlation with disease severity and inflammatory markers (CRP, d-dimer, and IL-6), investigators in Milan, Italy analyzed data from 207 COVID-19 patients admitted to Fatebenefratelli-Sacco Hospital and found 50.7% patients had hypoalbuminemia (serum albumin <30 g/L), and that albumin levels were significantly inversely correlated with increased severity of disease and worse outcomes at day 30, as well as inversely correlated with inflammatory markers. The results suggest hypoalbuminemia and urinary protein wasting may be useful biomarkers on admission to determine disease severity.
—Understanding the Pathology: Microbiologists and infectious disease specialists from Anhui Medical University and the Anhui and Fuyang Centers for Disease Control in China analyzed SARS-CoV-2 IgM and IgG antibody responses using indirect ELISA in serum from 165 patients and found spike protein IgM and IgG was detectable in 12.5% of hospitalized patients on day 1 of infection, IgM peaked at 22-28 days and was undetectable in 30% and 79% of patients at three and seven months, respectively, and IgG peaked at four months and declined rapidly at seven months. Authors suggest their analysis can help guide SARS-CoV-2 diagnosis and vaccine development via an improved understanding of the human humoral response in COVID-19.
—Transmission & Prevention: A review of current data on COVID-19 transmission and vaccine efficacy by otolaryngologists from Harvard Medical School and Johns Hopkins School of Medicine illustrates how COVID-19 mRNA vaccines generate immunogenicity by creating IgG antibodies against the SARS-CoV-2 virus, however IgG antibodies, while preventing patients from clinically getting sick with COVID-19, do not stop the virus from replicating in the upper airway -- as this requires secretory IgA antibodies -- suggesting that transmission precautions should still be widely practiced even after vaccination.
—Management: A multicenter retrospective study conducted by French physicians at the Cochin Hospital utilized demographic data, clinical symptomatology, and results of lab tests from 605 patients with clinical suspicion of COVID-19 to create a pre-test probability score of SARS-CoV-2 infection (the PARIS score) and found that fever, myalgias, lymphopenia, and elevated CRP had the highest positive predictive value, though no clinical variable was individually significant. The high-probability PARIS score had a positive predictive value of 93%, while the low-probability score had a negative predictive value of 98%.
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In today's episode we discuss:
—Understanding the Pathology: SARS-CoV-2 Infection likely triggers an autoimmune response. A case control study from Northern Italy found elevated inflammatory markers and autoantibodies (ANA, ASCA, IgG and anti-Cardiolipin) in 40 hospitalized COVID-19 patients compared to healthy controls. These results add to the growing body of evidence suggesting the association of COVID-19 with autoimmune disease and inflammatory dysfunction. The authors suggest utilizing these antibodies as prognostic indicators, especially when considering treatment with plasma therapy.
—Management: Is there an effect of artificial liver blood purification treatment on the survival of critically ill COVID-19 patients? A prospective study by multiple infectious disease centers in China to investigated the efficacy of liver blood purification treatment on the survival of severe/critical COVID-19 patients with serum inflammatory factors greater than or equal to five times the upper limit. A total of 101 critical COVID-19 patients were enrolled in the study and divided into either the treatment group or the control group. The authors demonstrated that artificial liver therapy clears inflammatory mediators through blocking the cytokine storm thus preventing theses cases from worsening any further and improving the survival rate.
—Mental Health & Resilience Needs: Mental health continues to take a toll approximately 35 days after hospitalization for COVID-19 infection. Investigators from Hackensack Meridian School of Medicine and Hospital in New Jersey conducted a single center prospective cohort study of 183 COVID-19 patients admitted to Hackensack Meridian Hospital in order to identify persistent physical symptoms, psychological health, social relationships, and activities of daily living all pertaining to their self-reported quality of life 35 ± 5 days after hospital discharge. The results revealed 16.9% of participants reported their mental health as poor or fair, impairing their daily living, physical and mental health, and quality of life, suggesting the importance of early intervention for both physical and mental symptoms, along with social support, as an essential part of full recovery from COVID-19.
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In today's episode we discuss:
—Climate: Board members of the International Society of Vaccine (ISV) summarize their organization's recent efforts to provide information and resources about COVID-19 vaccines to members worldwide: they provide links to their recent virtual lecture series on COVID-19 vaccines and suggest their organization is a global leader on vaccine development that can provide balanced information to a variety of stakeholders. The authors encourage new researchers and developers to join the ISV at www.isv-online.org.
Support this podcast: https://anchor.fm/covid19lst/support
In today's episode we discuss:
—Epidemiology: What was the SARS-CoV-2-specific neutralizing antibody response in Norwegian healthcare workers after the first wave of COVID-19 pandemic? A multicenter prospective survey study of 607 healthcare workers (HCW) by a researcher at the Influenza Centre at the University of Bergen in Norway found 5% of participants (32/607) were seropositive for SARS-CoV-2 (spike-specific IgG, IgM, and IgA antibodies), including 21 who were positive at baseline and 11 who seroconverted during follow-up. 77% of the infected HCWs, in high-risk departments were young nurses aged 23-31. Results also showed that HCW were 11.6 times more likely to contact COVID-19 patients when compared to low-risk HCW or community members, while HCW with partial PPE were at a 2.5 fold higher risk. Authors highlight the importance of protecting high-risk frontline HCW and suggest prioritization of this group during vaccine distribution.
—Understanding the Pathology: Could there be an association of salivary content alteration and early ageusia symptoms in COVID-19 infections? Dental specialists in Saudi Arabia reviewed 36 studies on chemical and inflammatory changes that occur in SARS-CoV-2 infected salivary glands and propose a chemosensory mechanism to explain alterations in taste and smell found commonly seen in COVID-19. In patients reporting aguesia, they found changes in salivary hormones, inorganic compounds, pH, enzymes, and salivary flow rate, which are all involved in normal taste perception. Authors suggest with better understanding and characterization of these changes, we may be able to prevent or treat changes in smell or taste seen among COVID-19 patients.
—Transmission & Prevention: Specific occupations and risk of severe COVID-19 are positively correlated. In this large-scale prospective cohort study, authors from various public health institutes in Glasgow, UK, Limerick, Ireland, and Syracuse, NY, analyzed data from the UK Biobank, involving 120,075 participants aged 40-69 registered with the National Health Service (NHS) in England, Wales or Scotland, and grouped them into occupational groups with concomitant serious COVID-19 infection (having to be hospitalized), in order to asses risk of infection across essential occupations.
—Management: There may be a high prevalence of pulmonary sequelae at 3 months after hospital discharge in mechanically ventilated COVID-19 survivors. In this letter to the editor, Dutch researchers share their clinical data from 48 critically-ill COVID-19 patients who underwent follow-up screening three months after discharge that included pulmonary function testing (PFT), high resolution chest CT (HRCT), and 6-minute walk test (6-MWT).
—R&D: Diagnosis & Treatments: There is some data suggesting usage of smartwatch tracking data to detect COVID-19 cases early. An article reviews a study conducted by researchers at Scripps Research Translational Institute who compared the smartwatch data between 333 participants, 54 of which ended up reporting positive for COVID-19, and found that symptom tracking plus smartwatch biometric data collecting yielded more predictive results of COVID-19 positive test probability than symptom tracking alone.This study was conducted earlier this year and used a smartphone/smartwatch app called DETECT.
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In today's episode we discuss:
—Climate: Operations officers from several international biomedical manufacturing companies discuss the ability of manufacturers to reduce distribution of counterfeit vaccines in light of counterfeit SARS-CoV-2 vaccines being found in Russia and Ecuador in 2020. Authors recommend using various tracking methods such as a GS1 2D DataMatrix barcode, QR code and matrix code, or Automatic Identification and Data Capture (AIDC) flow to scan and identify vaccines, trace them from the factory to delivery, and upload that data into an easily accessible system. They suggest such a tracing system is necessary to ensure the delivery of safe and authentic vaccines from factories to the public.
—Epidemiology: A team from Johns Hopkins University and Brown University conducted a systematic review and meta-analysis of 77 studies (38906 hospitalized patients) and found the overall prevalence of death from COVID-19 among hospitalized patients was 23% (19–27%) in the US and Europe versus 11% (7–16%) in China. Risk factors for death included age 60 or older (sRR = 3.6; 95% CI: 3.0–4.4; I^2 77%), male gender (sRR=1.3; 1.2–1.4; I^2 18%), smoking history (sRR=1.3; 1.1–1.6; I^2 68%), COPD (sRR=1.7; 1.4–2.0; I^2 66%), diabetes (sRR=1.5; 1.4–1.7; I^2 58%), heart disease (sRR=2.1; 1.8– 2.4; I^2 69%), CKD (sRR =2.5; 2.1–3.0; I^2 72%). They observed similar risk factors for severe disease (respiratory rate>30, oxygen saturation<93%, and PaO2/FiO2<300 and/or lung infiltrates>50% within 24–48 hours).
—Transmission & Prevention: Researchers from England studying COVID-19 transmission in the education system found that the overall risk of SARS-CoV2 infection among children and school staff was low: there was minimal evidence of transmission from student to student or student to faculty member, and infected children most commonly acquired SARS-CoV-2 from family members at home. Data suggests that the rate of transmission in schools was directly correlated with regional COVID-19 prevalence, suggesting that re-opening schools may not significantly increase infection rates among children or school staff unless this is during a surge or in high prevalence areas.
· Members of the US Centers for Disease Control COVID-19 Response Team summarize their recommended public health strategies for mitigation of community SARS-CoV-2 transmission: they recommend the use of face masks, maintaining physical distancing, prompt case investigation, avoiding crowded situations, increasing protection for persons at highest risk for severe COVID-19, adequately protecting healthcare workers, improved hygiene practices, avoiding unnecessary travel, and widespread use of safe vaccines. Authors suggest following such evidence-based measures will substantially contribute to combating transmission of COVID-19.
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In today's episode we discuss:
—Understanding the Pathology: Researchers from the Department of Health & Exercise Science at Appalachian State University analyze the vascular impact of SARS-CoV-2 on 20 healthy young adults 3-4 weeks post-infection by doppler ultrasound of arterial blood flow in the upper and lower extremities (markers of vascular function) and pulse wave velocity (indicator of arterial stiffness). Results demonstrated that brachial artery flow-mediated dilation (FMD) was 6% lower after COVID-19 infection, which is clinically significant because each 1% decrease in FMD is associated with a 13% higher risk of cardiovascular events, suggesting that systemic vascular dysfunction and arterial stiffness may be a potential mechanism of COVID-19 vasculopathy.
—Management: A single-center observational cohort study from Turin, Italy analyzed coagulopathy in 36 hospitalized pediatric patients (ages birth to 21 years) with COVID-19 (n=30) and Multisystem Inflammatory Syndrome in Children (MIS-C) (n=6) and found that D-dimer values were not useful in predicting disease severity. Significant differences between D-dimer and CRP values were observed between COVID-19 and MIS-C patients, however there was no difference in coagulopathy incidence in these groups (as measured by fibrinogen levels). They recommend against universal pharmacologic prophylaxis in pediatric COVID-19 patients except in cases of multiple concurrent pro-thrombotic risk factors such as obesity, active malignancy, and sickle cell disease.
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In today's episode we discuss:
—Climate: What are the COVID-19 vaccine trial ethics once we have efficacious vaccines? An expert opinion penned by bioethicists from the National Institutes of Health and Fogarty International Center in Bethesda, MD explore the ethics of continuing blinded, placebo-controlled trials for COVID-19 vaccines in the wake of a safe and efficacious vaccine being approved for widespread use. Authors argue it is ethical to continue trials if participants consent and the risk-benefit profile of the trial remains acceptable, because continuing trials could lead to the discovery of longer lasting vaccines, better immunity, or greater efficacy in subpopulations. However, the authors emphasize trial participants in blinded, placebo-controlled trials should be informed of the availability of the vaccine and allowed to leave the trial if they desire.
—Understanding the Pathology: The L37F mutation may be critical to asymptomatic COVID-19 infection and transmission. Computer scientists from the University of Illinois analyzed 75,775 SARS-CoV-2 complete genome isolates to explore virological characteristics in asymptomatic COVID-19. They found patients with asymptomatic COVID-19 were significantly more likely to have the SARS-CoV-2 single nucleotide mutation 11083G>T-(L37F) on Non-Structural Protein 6 (NSP 6)(r=0.61, p=5.42×10^-56) and countries with the highest L37F mutation ratio had lower death ratio. Artificial intelligence (AI), topological data analysis (TDA), and network analysis revealed L37F destabilized NSP6's structure in a way that impeded viral assembly and replication. Authors suggest L37F mutation as a possible explanation for asymptomatic COVID-19 and encourage further research on therapies targeting NSP6.
—Transmission & Prevention: Transmissibility of COVID-19 depends on the viral load around onset in adult and symptomatic patients. Infectious disease specialists and microbiologists from the Toyama University Graduate School of Medicine and Pharmaceutical Sciences in Japan conducted a case-control study comparing patients with 14 COVID-19 who did ("index patients") and 14 who did not transmit SARS-CoV-2 to another patient. They found index patients showed higher viral loads at onset compared to non-index patients (6.6 [5.2 to 8.2] log copies/μL vs. 3.1 [1.5 to 4.8]) and that, in general, symptomatic patients had a higher initial viral load (2.8 log copies/μL) than asymptomatic patients (0.9 log copies/μL, p<0.01). Authors suggest elevated nasopharyngeal viral load contributes to secondary transmission of SARS-CoV-2, and that understanding the viral threshold for infectivity can better quarantine and isolation policies.
· Peripheral oxygen saturation does not decrease in older persons wearing nonmedical face masks in community settings. Internists from McMaster University in Canada conducted a crossover study of 25 retirement home residents older than 65 to monitor self-measured peripheral oxygen saturation (SpO2) with use of a three-layer disposable nonmedical face mask. They found pooled mean SpO2 was 96.1%, 96.5%, 96.3% in the hour prior to use, during one hour of use, and one hour after wearing the masks, respectively.Authors suggest despite some public concerns about mask safety, the use of nonmedical face masks is not associated with a decrease in SpO2 in older populations.
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In today's episode we discuss:
—Climate: The editorial team at JAMA explains their decision to publish the Lenze et al study "Fluvoxamine vs placebo and clinical deterioration in outpatients with symptomatic COVID-19: a randomized clinical trial." While it is a preliminary study with limitations, authors argue it warranted publication due to its design as a placebo-controlled, double-blind randomized clinical trial and the authors' methodological adjustments to conduct study activities without physical contact, such as arranging oxygen and medications deliveries for self-quarantining patients and obtaining consent virtually. The team suggests that the Lenze et al pilot study provides an excellent example of pandemic-appropriate research methods and lays the groundwork for research into preventing outpatients with COVID-19 from deteriorating into a more severe disease status.
—Epidemiology: A retrospective cohort study that analyzed pediatric electronic health record data from PEDSnet (n=135,794 patients <25 years) from found 4% of patients were infected with SARS-CoV-2 (n=5,374), while Kawasaki Disease prevalence decreased in 2020 compared to 2018 or 2019*. Risk factors for SARS-CoV-2 infection included preexisting chronic disease and increased age. Additionally, subjects of Hispanic, Black, or Asian race/ethnicity had a higher likelihood of positive test result compared to White race/ethnicity, though they received fewer tests per population. These results provide large-scale data on pediatric risk factors, which authors hope will add to the growing knowledge on SARS-CoV-2 and host biology in pediatric populations.
· Leaders in the United Kingdom's Department of Health conducted a systematic review and narrative synthesis of literature on SARS-CoV-2 infection in children published through March 9, 2020 (24 articles) and found that children under age 10 had similar infection rates to adults, but the observed rate of infection in children was perceived as lower since children often had undetected milder infections, and transmission usually occurred within familial clusters when children were exposed to an infected adult. Authors suggest further data collection is necessary to understand child to child transmission of SARS-CoV-2 and to detail the clinical course of COVID-19 in children.
—Understanding the Pathology: A cohort-control study by pediatric infectious disease specialist in Ankara, Turkey evaluated cytokine and chemokine levels from serum samples of 60 COVID-19 positive patients (30 pediatric, 30 adult) and found that COVID-19 patients had higher levels of IP10 and MIP-3B compared to 30 healthy controls (15 pediatric, 15 adult; p<0.001), while IP-10 was a predictor for disease severity in children and IL-6 a predictor for disease severity in adults. They suggest these findings provide insight into potential treatment targets for COVID-19 and further elucidate potential uses for inflammatory markers as prognostic indicators for pediatric and adult COVID-19 severity.
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—Epidemiology: A systematic review of 39 articles (30 retrospective and 9 prospective) on venous thromboembolic events (VTE) in COVID-19 by a team of cardiologists and molecular biologists from the Central South University in Hunan, China found that D-dimer, fibrinogen, and APTT may be useful in predicting thromboembolic events in patients with severe COVID-19.
—Understanding the Pathology: Physicians at the Icahn School of Medicine used enzyme-linked immunosorbent assay (ELISA) to screen patients (n=72,401) at Mount Sinai Health System for the SARS-CoV-2 spike protein antibody and found that 30,082 patients tested positive (titer 1:80 or higher) with quantitative microneutralization assay demonstrating that spike protein titer level positively correlated to neutralization titer (Spearman r: 0.87, p<0.000). A subgroup (n=121) had titers drawn at multiple timepoints (30, 82, and 148 days after symptom onset), and their ELISA titers still positively correlated with the neutralization titers after 148 days (r: 0.79; p=0.0001), suggesting that patients infected with SARS-CoV-2 form long lasting neutralizing antibodies and that understanding the kinetics of these antibodies could aid in the vaccine development.
—Management: Infectious disease physicians at the Imperial College London reviewed publications about bacterial and fungal coinfection with human coronaviruses and found that in the nine studies, 62/806 patients (8%) experienced coinfections during hospital admission. Because most patients across all studies received broad spectrum antibiotics (1450/2010; 72%), authors suggest the seemingly low occurrence of coinfection may be attributable to empiric antibiotic use and recommend conducting prospective studies to inform antibiotic stewardship during the COVID-19 pandemic.
· Members of the World Association of Perinatal Medicine propose consensus statements regarding SARS-CoV-2 infection in pregnant patients based on their review of the literature. They comment on diagnosis, screening in laboring patients, maternal and fetal complications, vertical transmission, delivery mode, breastfeeding, appropriate setting of care, and use of antiviral medications.
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In today's episode we discuss:
—Climate: No-fault compensation for vaccine injury. Are we looking at the other side of equitable access to Covid-19 vaccines? An opinion piece on COVID-19 vaccination explains that though there are 79 higher-income countries ready to pay for vaccine distribution in 92 lower-income countries, there is not yet an established method for injury compensation if an adverse vaccine event takes place. This suggests the need for an injury compensation plan in these lower-income countries by incorporating existing systems in wealthier countries, some World Health Organization programs, and the COVAX Facility, an international partnership to help support vaccine access in lower-income countries.
—Epidemiology: One study estimated SARS-CoV-2 seroprevalence in the US as of September 2020. This cross-sectional study, conducted primarily by US Centers for Disease Control and Prevention (Atlanta, Georgia), sampled 177,919 residual serum specimens from across all 50 United States, the District of Columbia, and Puerto Rico during 4 collection periods between July and September, 2020. They found that less than 10% of participants in 42 of 49 jurisdictions had detectable SARS-CoV-2 antibodies, with estimates of seropositivity projected in a given jurisdiction to range between fewer than 1% to 23%. This finding suggests a large variation in SARS-CoV-2 seroprevalence across jurisdictions and that most individuals do not exhibit SARS-CoV-2 antibodies from prior infection, highlighting the need for ongoing preventative practices (face masks, social distancing, etc.) and continued nationwide sera testing to inform SARS-CoV-2 epidemiology in the US.
—Understanding the Pathology: SARS-CoV-2 antibody and COVID-19 severity may vary with multisystem inflammatory syndrome in children (MIS-C). A group associated with Perelman School of Medicine at the University of Pennsylvania compared the antibody response to SARS-CoV-2 in 29 children with minimal (n=10) or severe COVID-19 (n=9) to those with MIS-C (n=10). They discovered that children with MIS-C have higher titers of IgG antibody than children with severe COVID-19 that effectively neutralize SARS-CoV-2 and may be due to longer time since onset of infection. This study is one of the first to study this immunological process in children in hopes of identifying pathophysiological pathways to investigate further.
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—Understanding the Pathology: Critical illness is associated with cerebral microbleeds for patients with severe COVID-19. A retrospective cohort study conducted at University Hospitals of Strasbourg, France compared 19 severe COVID-19 patients with MRI evidence of microhemorrhage to 18 COVID-19 patients with normal MRI and found more pronounced respiratory failure, higher D-dimer increases, and more frequent need for dialysis in the microhemorrhage group. The researchers hypothesize that blood-brain barrier dysfunction due to hypoxemia and levels of uremic toxins may be a key mechanism of COVID-19-related cerebral microhemorrhage, which clinicians should consider during severe COVID-19 patient management.
—Transmission & Prevention: A pooled surveillance testing program for asymptomatic SARS-CoV-2 infections was implemented on a college campus. This observational cohort study conducted by an interdisciplinary team at Duke University in North Carolina implemented mandatory masking, social distancing, and entry-and-surveillance SARS-CoV-2 testing with five-to-one pooled quantitative RT-PCR. Large-scale testing of 10,265 students (n=68,913 total tests) yielded 84 positive results (43 asymptomatic). Authors suggest pooled testing allows for high sensitivity and rapid results, while decreasing supply-chain disruptions by using fewer resources, which could be more successful in limiting transmission than testing only symptomatic individuals.
—Adjusting Practice During COVID-19: Decline in SARS-CoV-2 antibodies after mild infection was noted among frontline health care personnel. The CDC COVID-19 Response Team and IVY Network conducted an analysis of 3,284 frontline healthcare personnel, from 13 different hospitals across 12 states and found 194 had SARS-CoV-2 antibodies at initial baseline testing using ELISA assay (96% sensitivity and 99% specificity). About 60 days later, 156 returned for follow up testing, of which 93.6% had a decline in antibody response, and 108 reported COVID-19 symptoms. Additionally, among the cohort who initially tested positive, seroreversion was observed in 19.4% of those that reported symptoms, and 47.9% of those without symptoms. These results suggest antibodies to SARS-CoV-2 decline over time and negative serologic results do not exclude previous infection, highlighting there may be significant differences in interpretation on serological studies regarding COVID-19 epidemiology.
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—Management: A systematic review analyzed a set of 45 studies (n= 4,203 patients) published between November 1, 2019 and March 15, 2020 and found that elevated leukocyte count, alanine aminotransferase (ALT), aspartate transaminase (AST), lactate dehydrogenase (LDH), and procalcitonin levels predicted ICU admission in patients with COVID-19. Acute respiratory distress syndrome (ARDS) was predicted by elevated LDH, while mortality was predicted by increased leukocyte count and elevated LDH. Treatment with lopinavir-ritonavir showed no significant benefit across mortality and ARDS rates, while corticosteroids were associated with a higher rate of ARDS. These findings suggest that elevated levels of LDH, leukocytosis, procalcitonin, AST, and ALT may be important early signs of disease severity, though early antiviral and steroid treatments do not appear to offer much clinical benefit.
· Members of the Department of Geriatrics at Peking University First Hospital in China conducted a systematic review and meta-analysis of 25 articles assessing coagulation parameters in 3952 SARS-CoV-2 positive patients published between December 1, 2019 and May 1, 2020 and found significantly higher D-dimer (standardized mean difference [SMD] 0.83, I^2=56.9%), prothrombin time (SMD 0.39, I^2=79.4%), and fibrinogen (SMD 0.35, I^2=42.4%) in patients with more severe COVID-19 compared to those with less severe disease, suggesting that hypercoagulability is associated with severity of COVID-19 and coagulation parameters should be assessed in these patients to monitor progression.
—Silver Linings: A literature review by investigators at McGill University of vaccine trials for 23 different viral infectious diseases from January 2005 through March 2020 showed that these trials historically have a 10% chance of moving from phase 2 through Food and Drug Administration (FDA) licensure within 10 years, and the average timeline from phase 2 to approval was 4.4 years, suggesting an unparalleled achievement if COVID-19 vaccine is approved within 18 months of the start of the pandemic.
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—Understanding the Pathology: Investigators in South Korea analyzed samples from 6 COVID-19-positive patients at 3 tertiary hospitals who had recovered with negative SARS-CoV-2 rRT-PCR results and then presented again with subsequent positive rRT-PCR results. One of the patients, a 21-year-old female with allergic rhinitis, recovered with resolution of symptoms, then presented 2 additional times with mild symptoms and subsequent positive testing. A whole-genome sequencing from samples taken at her first and her third presentations found two distinct genomic clades between the viral RNA in the 2 samples, suggesting evolutions of the SARS-CoV-2 genome. Their findings suggest that SARS-CoV-2 infection may not confer immunity against subsequent reinfections of different strains, and precaution should continue to be taken even after recovery.
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—Climate: A review by pediatric specialists with The Ruth & Bruce Rappaport Faculty of Medicine in Haifa, Israel discusses the phenomenon known as “vaccine hesitancy” (continued deferment of vaccines despite proven effectiveness and extremely rare adverse effects), and the barrier it could create for eventual adoption of a COVID-19 vaccine, and suggest patient education on vaccine contraindications and lack of evidence supporting adverse reactions or autoimmune disease associations may reduce vaccine hesitancy. Additionally, they suggest thorough vaccine research and multimedia educational campaigning will be needed for the coming COVID-19 vaccines.
—Epidemiology: Physician scientists from Universidad Nacional de Cuyo in Mendoza, Argentina created a Susceptible-Exposed-Infected-Recovered (SEIR) model to explore COVID-19 management policies and found detection and isolation of just 50% of asymptomatic patients infected with SARS-CoV-2 could significantly reduce hospital bed usage and deaths, suggesting that massive screening initiatives including asymptomatic people will facilitate detection and isolation of all SARS-CoV-2 infected people, allowing for pandemic control in lieu of a complete regional shutdown.
· Computer scientists from Greece and Scotland analyzed the ability of Google Trends (COVID-19 related search terms) to predict the trajectory of the COVID-19 outbreak at the state and national level and found a statistically significant correlation between Google Trends data and COVID-19 cases and deaths by Pearson and Kendall correlation analysis, while prediction analysis by quantile regression predicted the early spread of COVID-19 in several regions. The authors suggest Google Trends can aid epidemic forecasting and allow health care systems to prepare for local outbreaks.
—Transmission & Prevention: Italian immunologists review the challenges of SARS-CoV-2 vaccine development in the elderly populations at high risk for COVID-19: elderly populations have relatively poor immune responses due to immunosenescence, comorbidities, and pharmacologic treatments; and increased pro-inflammatory cytokines (IL-6, 8, TNF-alpha) worsen both SARS-CoV-2 prognosis and vaccine efficacy. A systems biology approach considering clinical, socio-economic, immunological factors alongside advanced technologies, adjuvants, and vectors are necessary to develop an effective SARS-CoV-2 vaccine for the elderly.
—Mental Health & Resilience Needs: An international group of psychiatrists summarized guidelines provided by the International Academy of Suicide Research (IASR) on the reported increase in mental health concerns and suicide attempts after pandemics and they hypothesize that the COVID-19 pandemic might also be followed by similar issues due to several factors, with at-risk populations including the elderly, socially isolated individuals, healthcare professionals, and young children. Recommendations include: videoconferencing for suicide risk assessment rather than teleconferencing, careful attention toward elderly patients in isolation, and increased awareness of mental health concerns during and following the COVID-19 pandemic.
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—Epidemiology: Is there SARS-CoV-2 persistence and non-protective immunity in infected haematological patients? Greek infectious disease physicians present a case of 35-year-old with a history of acute lymphoblastic leukemia 14 days status-post chemotherapy with R-hyper-CVAD who presented on April 8, 2020 with pneumonia after positive RT-PCR for SARS-CoV-2 on March 26. The patient eventually recovered after a seven-week hospitalization and developed antibodies suggestive of immunologic memory but was later readmitted on July 22 with severe COVID-19 pneumonia despite serologic testing with continued adequate IgG. Authors suggest defective innate and adaptive immunity in immunocompromised patients may facilitate SARS-CoV-2 infection (i.e. antibodies may be non-neutralizing following chemotherapy) and allow persistence or viral reactivation.
—Understanding the Pathology: There may be postmortem findings of diaphragm pathology related to critically ill patients with COVID-19. Critical care physicians conducted a case-control study using autopsies of 26 deceased critically ill COVID-19 patients from 3 medical centers in the Netherlands to analyze the extent of diaphragm involvement. Findings show increased ACE-2 expression and SARS-CoV-2 viral infiltration in the diaphragm of patients who died of severe COVID-19 compared to control specimens from 8 deceased ICU patients without COVID-19, suggesting that diaphragm fibrosis could be a source of respiratory distress in COVID-19 patients.
—Management: Early short-course corticosteroids have beneficial outcomes in hospitalized patients with COVID-19. A quasi-experimental study, conducted by the Henry Ford COVID-19 Management Task Force at multiple hospitals in Michigan, evaluated the effect of early corticosteroid therapy in 132 hospitalized patients with severe to moderate COVID-19 versus 81 COVID-19 patients on standard care treatment. They found that early corticosteroid group (median time to initiation 2 days, IQR 1-3, range 0-8) had less transfers to the ICU (34.9% vs 54.3%, p=0.005), decreased ARDS occurrences (26.6% vs 38.3%, p=0.04), and spent less days in the hospital (5 vs 8 days, p less than 0.001) compared with the standard of care group. These findings suggest that early methylprednisolone therapy in patients with moderate/severe COVID-19 may help curb the inflammatory response elicited by SARS-CoV-2 and thus lead to better outcomes.
—R&D: Diagnosis & Treatments: What is the role of immunoglobulin G and IgM antibodies against SARS-CoV-2? Investigators from the National Clinical Research Center for Infectious Diseases in Shenzhen, China analyzed 347 serum samples from 41 RT-PCR confirmed COVID-19 patients (15 with mild-moderate symptoms, 16 with severe, and 10 with critical) admitted to The Third People’s Hospital of Shenzhen.Results revealed 39% of COVID-19 patients had seroconversion of IgG antibodies against SARS-CoV-2 nucleocapsid (N) protein and spike (S) glycoprotein in an average of 11 days after onset of symptoms, and 51.2% with seroconversion to IgM antibodies in an average of 14 days. Further, critical patients were found to have a delayed, but more robust IgG and IgM response. This understanding of antibody kinetics against SARS-CoV-2 may assist in clinical diagnosis, specifically in utilizing immunoassays as a testing tool during the pandemic.
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—Epidemiology: There is higher prevalence of pulmonary macrothrombi in SARS-CoV-2 than in influenza A. A comparative analysis by pathologists at University Hospital Zurich in Switzerland assessed pulmonary macrothrombi autopsy findings in 411 patients who died from the Influenza A pandemic in 1918/1919, 12 from Influenza A in 2009-2020, and 75 for COVID-19. They found COVID-19 patients had significantly higher occurrences of grossly visible pulmonary thrombosis despite empiric thrombophylaxis due to in situ clot formation associated with SARS-CoV-2. Authors suggest a specific COVID-19 coagulopathy may be linked to higher mortality rate seen in COVID-19 compared to the seasonal flu.
—Understanding the Pathology: In vivo demonstration of microvascular thrombosis in severe COVID-19 was found in one study where researchers in the Department of Internal Medicine, Ribeirão Preto School of Medicine in Brazil conducted imaging via video capillaroscopy of 13 severe COVID-19 positive patients requiring mechanical ventilation to assess sublingual microcirculation for evidence of microthrombi. They found microthrombi in 11/13 (85%) of patients and acute thromboembolic occlusion in 5/13 (38%) of patients. This evidence suggests that microvascular thrombosis could be considered a hallmark of COVID-19 and that these microvascular thrombotic events occur systemically, affecting many organ systems.
—Management: Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients were explored by investigators in Stockholm, Sweden. They analyzed thromboprophylaxis and 28-day mortality among 156 patients with COVID-19-associated respiratory failure admitted to 2 local ICUs. Dosing was dependent on changes in regional guidelines over time and not patient severity. Results illustrated the following: - 67 patients on low-dose thromboprophylaxis had a mortality rate of 38.8% - 48 patients on medium-dose thromboprophylaxis had a mortality rate of 25% - 37 patients on high-dose thromboprophylaxis had the lowest mortality rate of 13.5% These findings suggest that starting critically ill patients on high-dose thromboprophylaxis maybe a beneficial strategy in reducing thromboembolic events and mortality.
· Point-of-Care Ultrasound (POCUS) can be useful in managing ICU Patients with COVID-19.
—Adjusting Practice During COVID-19: ewer motor vehicle collisions and higher alcohol involvement were seen in COVID-19 Pandemic trauma presentations in one trauma center. Medical students and physicians from the Medical College of Georgia compared trauma activations at their level 1 trauma center between March 1 and June 15, 2020 to trauma activations from the same time frame in the previous 5 years (2015-2019). While there was no difference in the number and distribution of trauma cases, they found fewer motor vehicle collisions (MVCs)(p=0.009704), higher incidence of alcohol involvement in traumas (p=2.26 × 10^-7), and longer average length of hospital stay (3.87 vs 5.39; p=8.488 × 10^-6) in 2020 compared to pre-pandemic years. Authors suggest the decreased number of MVCs is attributable to fewer drivers during pandemic-related lockdowns but recommend further investigation into factors influencing the observed increase in alcohol related trauma and longer hospital stays to better identify areas of potential preventative interventions.
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—Transmission & Prevention: A review by biomedical engineers in Canada discusses the possibility of using animal models including rhesus macaques, hamsters, and ferrets to help guide research on COVID-19 vaccine development. They also describe 8 current vaccine platforms, including 139 vaccine candidates in pre-clinical evaluation and 26 in clinical evaluation, and highlight the importance of introducing an effective COVID-19 vaccine to return to pre-pandemic life.
—Management: Emergency Medicine and Cardiovascular physicians from Mayo Clinic conduct a review reporting an increased risk of cardiac involvement in athletes with COVID-19: they discuss how 10-27.8% of all hospitalized COVID-19 patients have evidence of myocardial injury, of these 78% have arrhythmias, and note that myocarditis accounts for up to 22% of cardiac deaths in young athletes (<35 years old) with increased incidence during exercise. They urge screening for cardiac dysfunction in convalescent COVID-19 patients and recommend providers maintain a high index of suspicion before medical clearance of young athletic patients with COVID-19.
—Mental Health & Resilience Needs: Mental health experts performed a systematic review of 44 studies (54,231 participants across 13 countries) assessing the prevalence of sleep problems during the pandemic and found pooled prevalence of sleep problems was 35.7%, with COVID-19 patients being most affected (74.8%), followed by healthcare workers (36%), and the general public (32.3%), suggesting that sleep problems are common during the pandemic, particularly among COVID-19 patients, and encourage implementing strategies to mitigate adverse effects in these populations.
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—Epidemiology: Body Mass Index is correlated with Risk for Intubation or Death in SARS-CoV-2 Infection according to a retrospective cohort study. The study, conducted at Columbia University Irving Medical Center, investigated the association between body mass index (BMI) and risk for intubation or death, inflammation, cardiac injury, or fibrinolysis from SARS-CoV-2 infection in 2,466 hospitalized COVID-19-positive adults. Compared to overweight patients, patients with class 3 obesity had the highest risk of intubation or death (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]), though these effects were most clear in patients less than 65 years old. BMI was not associated with admission levels of biomarkers for inflammation (C-reactive protein and erythrocyte sedimentation rate), cardiac injury (troponin level), or fibrinolysis (D-dimer level). These results support previous studies showing increased risk of severe complications in overweight individuals, though this study also shows that other clinical correlates may demonstrate this increased risk upon admission.
—Management: Association of SARS-CoV-2 genomic load trends with clinical status in COVID-19 were found in a study of 42 COVID-19 patients with associated pneumonia admitted to NYU Langone Medical Center. Investigators analyzed each patients' genetic load of SARS-CoV-2 Cycle threshold (Ct) by rapid RT-PCR versus their Sequential Organ Failure Assessment (SOFA) score and found a statistically significant inverse correlation between the change in Ct value and change in clinical SOFA score. These findings suggest that a “decrease in viral load over time was associated with clinical improvement," highlighting the potential use of SARS-CoV-2 genomic load as a potential predictive value in disease outcome.
—Adjusting Practice During COVID-19: There may be increased susceptibility to SARS-CoV-2 infection in patients with reduced left ventricular ejection fraction. Cardiovascular and regenerative medicine researchers at the Université de Strasbourg in France followed-up via telephone interviews with 889 acute coronary syndrome patients who received percutaneous coronary intervention. They found that the incidence of COVID-19-associated hospitalization or mortality was significantly greater in patients with reduced left ventricular ejection fraction (LVEF, n=91) versus patients with moderately reduced and preserved LVEF (n=798; 9% versus 1%, P 60; 0.001). Further, they observed that reduced LVEF was an independent predictor of COVID-19 hospitalization or mortality via multivariate logistic regression (OR: 6.91; 95% CI: 2.60-18.35, P 60; 0.001), suggesting that COVID-19 testing and treatment plans should be considered for patients with reduced cardiac function.
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—Understanding the Pathology: Truncation of orf3b in the circulating SARS-CoV-2 strains has been shown in one study. Microbiologists and Infectious Disease researchers from the University of Hong Kong analyze the genome of SAR-CoV-2 with a particular focus on the orf3b gene, which was found to antagonize type-I interferon activation. Using the sequence data from the GISAID depository, they report a steady increase and persistence of the truncated form of the orf3b gene in SARS-CoV-2 strains worldwide, particularly in countries with the highest confirmed number of COVID-19 cases. The authors note that further research on orf3b's truncation in context with COVID-19's transmissibility and infectivity could be beneficial for guiding future therapeutic and diagnostic developments.
—R&D: Diagnosis & Treatments: Convalescent plasma anti-SARS-CoV-2 spike protein ectodomain and receptor-binding domain IgG correlate with virus neutralization. Researchers primarily at Houston Methodist Hospital analyzed samples of plasma from 68 recovered COVID-19 patients, 2,814 asymptomatic patients, and 10 naive human plasma specimens to investigate the relationship between different neutralizing antibodies and possible ways to screen plasma samples for a virus neutralization (VN) titer ≥ 160.
· There is lack of efficacy of standard doses of ivermectin in severe COVID-19 patients according to a retrospective controlled cohort study. Specialists in global health and infectious disease from Hospital Clinic-Universitat de Barcelona, Spain evaluated efficacy of standard doses of ivermectin in 13 patients with severe COVID-19 against 13 controls without ivermectin. They found no significant differences in clinical or microbiological outcomes between the two groups after 8-11 days of treatment (p >0.999). Authors acknowledge the small sample size in this study, but suggest their results warrant further research involving high-dose ivermectin to better evaluate its efficacy in patients with severe COVID-19.
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In today's episode we discuss:
—Epidemiology: A retrospective case series conducted by radiologists from Zucker School of Medicine at Hofstra/Northwell in Manhasset, NY evaluated imaging features of six patients (all >65 years old) who presented to the emergency department with PCR-confirmed moderate-to-severe SARS-CoV-2 infection that was complicated by thromboembolic events. These authors suggest a hyper-inflammatory state secondary to SARS-CoV-2 infection may increase susceptibility to systemic thrombosis and recommend venous thromboembolism (VTE) prophylaxis in severe COVID-19 cases.
—Understanding the Pathology: Australian pulmonologists respond to recently published data by Mo et al, 2020 that showed diffusion capacity of carbon monoxide (DLCO) and carbon monoxide transfer coefficient (KCO) in COVID-19 patients reduced by 50% and 25% after recovery, respectively. They caution against interpreting these findings as attributable only to reduced alveolar volume and instead propose that lung fibrosis in COVID-19 associated acute respiratory distress syndrome (ARDS) may lead to loss of alveolar units and disrupt the alveolar-capillary barrier. Since pulmonary vascular abnormalities (i.e. vascular pruning, reduced blood flow) may alter DLCO, authors recommend further studies using more specific measures (i.e. combined DLCO and DLNO measurements or advanced imaging techniques) to clarify the pathophysiology underlying reduced gas exchange.
—Management: Emergency Medicine and Critical Care physicians in Saudi Arabia conducted a prospective observational analysis using a point-of-care ultrasound (POCUS) with the Riyadh Residual Lung Injury in COVID-19 (RELIC) scale to predict the evolution of lung injury in 171 severe COVID-19 patients and found that the combination of the two modalities were able to predict evolving interstitial lung disease with a sensitivity of 0.82 (95% CI: 0.76–0.89) and specificity of 0.91 (95% CI: 0.94–0.95).
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In today's episode we discuss:
—Epidemiology: Pediatric cardiologists from the Association for European Pediatric and Congenital Cardiology's COVID-19 Rapid Response Team evaluated 286 children with symptoms of multisystem inflammatory syndrome in children (MIS-C) and found 65% had laboratory evidence of current or past COVID-19 infection, 93% had cardiac involvement, and all had elevated inflammatory markers, suggesting pediatric patients with MIS-C should be monitored for cardiovascular complications and rising biomarkers.
· A literature review conducted by an international panel of pediatric dermatologists describes documented skin manifestations of COVID-19 in children including chilblain-like lesions, erythema multiforme, urticaria (10-20% of cutaneous manifestation reports), vesicular exanthema, and Kawasaki disease-like inflammatory syndrome (pediatric inflammatory multisystem syndrome with nonspecific skin symptoms and cardiovascular involvement).
—Understanding the Pathology: A retrospective cohort study by cardiac pathologists from the Mayo Clinic of post-mortem reviews of 15 patients with COVID-19, six patients with influenza, and six patients with no viral pathology found patients with COVID-19 were significantly more likely to have fibrin microthrombi (12/12 [100%] of COVID-19 vs 2/6 [33%] of influenza and control patients; p=0.006) and that these were found in a higher proportion of arterioles (p=0.003). One-third (33%) of COVID-19 patients had evidence of myocarditis and 26.7% evidence of amyloidosis.
· Investigators mainly from the Institute of Physiology in Berlin compared the respective plasma disruption to the lung epithelium between the plasma of 19 patients with severe COVID-19 (requiring intubation), 14 patients with moderate COVID-19 (requiring hospitalization but not intubation), and 15 healthy controls and found that addition of plasma from COVID-19 patients to healthy endothelial monolayers correlated with "significant endothelial gap formation and loss of junctional VE-cadherin". Additionally, when compared to the heathy control plasma, the plasma from COVID-19 patients not only resulted in increased severity of endothelial permeability but also rapid (within 1-2 hours) and long lasting (over 6 hours) effects, suggesting that endothelial-barrier-stabilizing adjunctive therapies administered to patients exhibiting signs of moderate to severe COVID-19 may delay progression to acute respiratory distress syndrome.
—Management: Neurosurgeons at the Laboratory of Experimental Neurosurgery and Cell Therapy in Milan, Italy compared blood samples from 47 healthy patients to samples from 111 SARS-CoV-2 positive patients and found sphingosine-1-phosphate (S1P) and apolipoprotein M (apoM; a carrier of S1P) levels were significantly decreased in COVID-19 patients compared to healthy patients (p<0.0001). COVID-19 patients requiring intensive care unit (ICU) admission had significantly lower levels of apoM, S1P, albumin, and HDL compared to those not requiring ICU care (p<0.0001), suggesting that the SARS-CoV-2 induced cytokine storm and acute phase response lowers levels of these specific biomarkers, and low levels of S1P (<0.6uM) and apoM may be clinical predictors of severe disease and decreased survival.
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In today's episode we discuss:
—Epidemiology: Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection according to one study.Immunologists and infectious disease specialists at St. James’s Hospital in Dublin, Ireland examined prevalence of post-COVID-19 fatigue in 128 patients who had recovered from COVID-19 using the Chalder Fatigue Score (CFQ-11). They found 52.3% (67/128) of participants met the criteria for fatigue at a median of 10 weeks following initial symptoms and fatigue was associated with female gender and preexisting depression/anxiety, but data showed no association between total CFQ-11 score and age, disease course, or laboratory measures of inflammation. These results suggest post-COVID-19 fatigue may be more prevalent than previously understood, and authors advocate for further research among those with previous SARS-CoV-2 infection.
· An Outbreak of COVID-19 on an Aircraft Carrier Spreads Fast. Public Health experts affiliated with the U.S. Navy conducted an epidemiologic investigation of the COVID-19 outbreak on the U.S.S. Theodore Roosevelt. Results showed that of the 26.6% of crew (1271) who tested positive for SARS-CoV-2 via RT-PCR, nearly half were asymptomatic, more than 30% of symptomatic cases initially reported having cough and headache, and among 1331 suspected or confirmed cases, 23 were hospitalized, 4 received intensive care, and 1 died. The authors suggest that the confined and densely populated areas, as well as the relatively high number of asymptomatic cases, may have contributed to the fast spread of the COVID-19 cases on the Aircraft Carrier.
· Ultrasound Imaging Findings of Acute Testicular Infection in Patients With COVID-19 were explored by a team from the Department of Ultrasound Imaging at Wuhan University Renmin Hospital. It was a retrospective study of 142 male patients hospitalized with COVID-19 who underwent bedside scrotal ultrasound. They found 32 patients (22.5%) presented with findings of acute testicular inflammation: 10 with acute orchitis, 7 with acute epididymitis, 15 with epididymo-orchitis. There was a higher frequency in men >80 years-old (p=0.003) and in the severe COVID-19 group (p=0.002). Authors suggest SARS-CoV-2 may infect the testicles and/or epididymis and recommend clinicians be aware of these genitourinary manifestations.
—Transmission & Prevention: United Kingdom’s definitions of vitamin D sufficiency and recommended supplement dose are set too low. UK physicians in Infectious Disease, Endocrinology, Respiratory, and Gerontology conclude that the original threshold goal for vitamin D sufficiency, 25nmol/L, is too low and not evidence-based, suggesting that it should instead be set at 50 nmol/L and recommend supplementation with 800 IU per day. They speculate vitamin D deficiency as a risk factor for COVID-19 and advocate for an increase in the recommended Vitamin D supplement dose.
—Silver Linings: What was the impact of non-COVID-19 deaths after social distancing in Norway? American public health experts analyzed the effect of social distancing in Norway on non-COVID-19 deaths during March 16-May 18, 2020 using the Human Mortality Database’s Short-term Mortality Fluctuations data series.
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In today's episode we discuss:
—Climate: The International COVID-19 Parental Attitude Study (COVIPAS) group conducted a cross-sectional survey of 1541 caregivers from six countries and found that 65% of caregivers were willing to vaccinate their child against COVID-19 whenever a vaccine became available, and that 52% of those refusing vaccination reported that the newness of the vaccine was a deciding factor. Authors suggest these findings demonstrate the need for effective public health education efforts regarding the safety, efficacy, and utility of any available COVID-19 vaccine
—Epidemiology: Massive dissemination of a SARS-CoV-2 Spike Y839 variant in Portugal was found. Bioinformatic and surveillance specialists from Portugal reviewed geotemporal spread of SARS-CoV-2 Spike 839Y variant, introduced from Italy to Portugal in February 2020, using 1,516 SARS-CoV-2 genome sequences collected as part of national surveillance. They found relative frequency increased at a rate of 12.1% every three days, and the Spike 839Y variant was associated with 24.8% of confirmed cases by the end of April. This variant has since been detected in 12 other countries, so authors suggest ongoing surveillance of SARS-CoV-2 genetic diversity and epidemiological monitoring of potentially significant variants.
· A retrospective study of 192 COVID-19 patients hospitalized at “Beato Matteo” (Hospital Group San Donato) conducted by internal and emergency medicine specialists in Vigevano, Italy found no significant association between having lupus anticoagulant (95/192, 49.5%) and mortality (47.7% of 130 survivors and 53.2% of 62 non-survivors; p=0.4745) or need for mechanical ventilation. However, worse outcomes were seen in patients with obesity, low oxygen saturation, and high troponin level. Authors suggest lupus anticoagulant is not a strong prognostic marker in COVID-19 patients and it may be a side effect of rather than a cause for thromboembolism.
—Management: What are the SARS-CoV-2 risks in first trimester pregnancy? A cohort study, conducted at Copenhagen University Hospital, examined potential risk caused by SARS-CoV-2 infection for first trimester pregnancies by analyzing double tests, which are blood samples for pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotropin (β-hCG), of 1,019 pregnant women for SARS-CoV-2 antibodies. Results indicated SARS-CoV-2 infection early in pregnancy as 18 (1.8%) of the 1,019 pregnant women were positive for SARS-CoV-2 antibodies in their serum. However, there was not a significant correlation with nuchal translucency thickness nor increased risk of pregnancy loss between the women testing positive versus those testing negative for SARS-CoV-2 antibodies. While these results may be limited by sample size, population type, and severity of COVID-19 infection, this study demonstrates no increased risk of low-severity COVID-19 infections during the first trimester of pregnancy.
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—Adjusting Practice During COVID-19: A prospective survey study of 66 patients who had undergone image-guided corticosteroid injections for pain management by musculoskeletal imaging specialists at Massachusetts General Hospital in Boston found no significant difference in rates of new COVID-19 cases between patients who received corticosteroid injections (n=1/66, 25 year-old male, 19 days following injection) and the general population (p=0.44), suggesting that corticosteroid injections are safe to perform during the COVID-19 pandemic.
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In today's episode we discuss:
—Epidemiology: A retrospective cohort study by physicians in Wuhan, China found no significant difference in levels of testosterone, follicle-stimulating hormone, or luteinizing hormone between 39 male patients with SARS-CoV-2 and 22 control patients without SARS-CoV-2 (p<0.05) nor between cases with severe versus moderate disease severity; however, 20 patients with >50 days of viral shedding had elevated estradiol levels compared to those with shorter shedding duration (p<0.05), suggesting that SARS-CoV-2 is unlikely to cause sterility or hypogonadism.
—Transmission & Prevention: An international group of vaccine development experts from the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) Working Group conducted a review of available literature regarding vaccine-associated enhanced disease and determined that the risk of COVID-19 VAED is similar to the risk associated with any other viral vaccine and acknowledge that the human experience of COVID-19 may differ from animal or in-vitro studies, recommending rigorous surveillance and phase 3 trials to evaluate safety and efficacy of any COVID-19 vaccine.
—Management: A retrospective cohort study by pediatricians in Florence, Italy of central precocious puberty (CPP) in girls presenting to their clinic during and after the Italian COVID-19 lockdown (March-July 2020) compared to the same period in 2015-2019 found more new cases of CPP in 2020 compared to previous years (37 vs. 16-19, p<0.0005) with accelerated progression in girls with previously diagnosed CPP (p<0.0005), more advanced Tanner stage in newly diagnosed CPP (p<0.005), and higher levels of luteinizing hormone (LH) and estradiol (E2) (p<0.005). These changes are attributed to the psychological stresses, increased BMI, and increased electronic device use during lockdown and suggest environmental factors strongly influence pubertal development.
—Adjusting Practice During COVID-19: A letter to the editor by The Netherlands Comprehensive Cancer Organization discusses derailed oncological care due to COVID-19 and subsequent reprioritization of health care services and determined that healthcare changes resulting from COVID-19 contributed to fewer breast and colorectal cancer diagnoses among age groups eligible for cancer screening, with slow return to expected rates following gradual restarts of cancer screenings. More information is needed to determine the long term clinical outcomes of decreased cancer screening and diagnoses, particularly whether these findings may represent decreased "overdiagnosis of particular early-stage cancers," but believe the trend warrants further investigation.
—R&D: Diagnosis & Treatments: Spanish immunologists investigated immunogenicity of cysteine-like protease (Mpro, a non-structural SARS-CoV-2 protein) by comparing samples from 36 COVID-19 patients diagnosed via RT-PCR versus 33 negative controls and, using ELISA (Mpro sensitivity 97% and specificity 100%), found high titers of IgG, IgM, and IgA against Mpro in serum and detected Mpro antibodies in all saliva samples collected from patients with the highest serum antibody titers, suggesting that detection of Mpro antibodies could be used to distinguish infected from non-infected individuals and that saliva tests could be used as a reliable, non-invasive test for seropositivity.
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—Epidemiology: An observation-based modeling study conducted at Columbia University analyzed reproductive numbers of COVID-19 in the United States and found a significant and rapid drop following social distancing and other control measures. Based on changes expected from such control measures in counterfactual models, a substantial number of cases and deaths could have been avoided if control measures were implemented 1 to 2 weeks earlier.
· An optimization model by mathematicians and data scientists using daily travel surveys, census data, and USPS building locations across various states estimated that >94% of Americans would travel to a nearby USPS facility (<7miles for 90% of travelers) for COVID-19 testing, suggesting that while high cost and additional precautions to protect USPS employees need to be considered, the USPS network has potential to provide greater ease of access to COVID-19 testing for a majority of Americans.
—R&D: Diagnosis & Treatments: A systematic review of 22 reports of rapid COVID-19 tests (n=3,198 total samples with 1,755 RT-PCR confirmed positive SARS-CoV-2 samples) published before May 25, 2020 revealed that antigen tests have variable sensitivity (average = 56.2%), while specificity was 99.5%; rapid molecular assays had a sensitivity of 95.2% and a specificity 98.9%; and calculated pooled results for individual tests revealed that Xpert Xpress assay had a summary sensitivity of 99.4% and specificity of 96.8%, while ID NOW assay had a summary sensitivity of 76.8% and a specificity of 99.6%.
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—Transmission & Prevention: Pediatricians published best practices for breastfeeding mothers who were positive for or exposed to COVID-19 in JAMA Pediatrics. The authors express that while the literature is uncertain on risk of COVID-19 transmission through breastmilk, this route of transmission seems unlikely, and protective antibodies are likely to be the only SARS-CoV-2 related material to be transmitted. They believe their proposed practices for breastfeeding while infected with COVID-19 will promote safe breastfeeding, although they note these suggestions may change overtime.
· Is there an association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19? Investigators on the STOP-COVID (Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19) team retrospectively analyzed data of 3,924 COVID-19 patients from 68 US hospitals admitted to the ICU. They compared estimated 30-day mortality rates of patients that received tocilizumab (an IL-6 inhibitor) in the first 2 days of ICU admission verses those who did not. The researchers performed inverse probability weighting to ensure that baseline and severity of illness factors were balanced between the study groups. The results revealed an estimated 30-day mortality of 27.5% in patients treated with tocilizumab, compared to 37.1% in patients without tocilizumab, suggesting the drug's benefit in treatment of critically ill COVID-19 patients. · Investigators affiliated with Yale School of Medicine performed a systematic review of 86 studies worldwide (n=2560 patients) on dermatologic manifestations in COVID-19 patients and found associations with chilblains/pernio like lesions at 51.5%, erythematous maculopapular rashes at 13.3%, and viral exanthem at 7.7%. Average time of skin lesion onset was 7.9 days after upper respiratory infection symptoms in adults and 1.5 days in children. These findings suggest that dermatologic manifestations may be another way to identify COVID-19 and better manage the spread of disease.
—R&D: Diagnosis & Treatments: At what times during infection is SARS-CoV-2 detectable and no longer detectable using RT-PCR-based tests? A systematic review of 32 longitudinal studies examined the accuracy, temporal sensitivity, and optimal sampling sites and strategies for SARS-CoV-2. The authors reported on a total of 1,023 COVID-19 RT-PCR confirmed participants and 1,619 test results for 11 different sampling sites at various times during SARS-CoV-2 infection. They found that the highest rate of virus detection was within 4 days of symptom onset at 89%, which fell to 54% between 10 and 14 days. The authors discuss that the accuracy of RT-PCR is limited, early testing minimizes false negative results, and lower respiratory tract or fecal testing may be preferred sampling sites when testing more than a few days post symptom onset.
· There is clinical impact of monocyte distribution width and neutrophil-to-lymphocyte ratio for distinguishing COVID-19 and influenza from other upper respiratory tract infections according to a cohort study conducted at Taipei Medical University Hospital (Taiwan), that analyzed potential biomarkers of SARS-CoV-2 infection in 174 patients (9 with nasal swab RT-PCR confirmed COVID-19, 24 with influenza confirmed via rapid-test, and 141 determined to have common URIs).
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In today's episode we discuss:
—Epidemiology: How effective are public health measures, such as quarantine, in decreasing viral spread? An extended Susceptible–Infected–Recovered (SIR) model to estimate the case rate mortality (CFR) of COVID-19 in Wuhan and the rates of infection, recovery, and death globally revealed an estimated CFR of 4.4% and an estimated quarantine effect against transmission of 99.3%, highlighting the importance of adherence to public health quarantine policies in decreasing viral spread during the pandemic.
—Understanding the Pathology: What is the duration of SARS-CoV-2 antibodies in plasma after symptom onset? Infectious Disease researchers from China studied the prevalence of anti-SARS-CoV-2 specific antibodies in 52 convalescent COVID-19 patients (159 blood samples) from 1 to 6 months after symptom onset and found a positive rate of IgG (92.3%) and IgM (90.4%) antibodies in the first month, and continuously high IgG but downtrending IgM antibodies throughout the convalescent phase, suggesting retainment of anti-SARS-CoV-2 IgG antibodies up to at least 6 months post-infection.
—Adjusting Practice During COVID-19: Are patients receptive to at-home rehabilitation services? Cardiac rehabilitation specialists in Providence, RI conducted a retrospective study after initiating a transitional home-based cardiac, pulmonary, or vascular rehabilitation treatment plan for 129 patients between April 6, 2020, to May 27, 2020 (the time of temporary closure of in-person rehabilitation services) and found that about 90% of patients were receptive to participating in at-home rehabilitation services and 70% were responsive to follow-up progress tracking by telephone, suggesting that a home-based treatment is a viable option for treatment centers restricting in-person treatments during the COVID-19 pandemic.
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—Understanding the Pathology: Do childhood vaccines help protect against SARS-CoV-2? A team of Egyptian virologists inoculated mice with common childhood vaccines (BCG, Pneumococcal, Rotavirus, Diphtheria, Tetanus, Pertussis, Hepatitis B, Haemophilus influenzae, Meningococcal, Measles, Mumps, and Rubella) and found no evidence of cross-reacting antibodies against SARS-CoV-2 in serum up to seven weeks post-vaccination, suggesting that if childhood vaccines provide protection against SARS-CoV-2, it may not be antibody mediated.
—Transmission & Prevention: How often are discharged patients re-testing positive for SARS-CoV-2? A review of 62 studies evaluating recurrence of SARS-CoV-2 viral RNA in discharged COVID-19 patients found that the proportion of patients with re-positive RT-PCR ranged from 2.4% to 69.2% across studies, occurring from 1-38 days after discharge, which was attributed to false-negative tests prior to discharge, false positive tests following discharge, reinfection, reactivation, and intermittent viral shedding.
—Adjusting Practice During COVID-19: What treatment options should physicians consider for patients with psoriasis? Following a literature review, dermatologists from Tehran, Iran recommend not starting immunosuppressive drugs for psoriatic patients due to an increased risk of acquiring COVID-19 and instead encourage initiating and continuing low-risk immunomodulating drugs as a safer modality.
—R&D: Diagnosis & Treatments: Is there a correlation between vitamin D levels and COVID-19 severity? A retrospective study conducted by various medical institutions in Tehran, Iran investigated 73 subjects with confirmed COVID-19 and found mean serum vitamin D (25[OH]D) concentrations were significantly lower in the deceased compared to discharged patients, and higher 25(OH)D levels were associated with less extensive lung involvement, suggesting a potential correlation between vitamin D status and clinical course, extent of lung involvement, and patient outcome in COVID-19.
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—Understanding the Pathology: Should we be testing for more than SARS-CoV-2 antibodies? Microbiologists, pathologists, and public health experts associated with Mount Sinai Hospital analyzed 3277 blood specimens from recovered COVID-19 patients and found that neutralizing antibody level is the highest 31-35 days post symptom onset, even though general SARS-CoV-2 antibody levels had been high (well above the 160 titer range cutoff) long before this, suggesting the importance of also testing for neutralizing antibodies.
—Transmission & Prevention: How do close contact and aerosol transmission risks compare? Swiss environmental engineers applied a Quantitative Microbial Risk Assessment (QMRA) to evaluate SARS-CoV-2 infection risk via aerosol transmission and close indoor contact using dose-response mice models and infection risk data from meta-analyses and found lower infection transmission risk via aerosol exposure within one hour (10^-6 to 10^-4) compared to close contact (10^-1; 12.8% risk within 1m) in a typically ventilated room (10-400 square-meters) with one infected person. Close contact may pose higher infection risk than aerosol transmission, but suggest real-life circumstances (i.e. prolonged exposure, higher density) could heighten risk of aerosol transmission not accounted for in this analysis.
—R&D: Diagnosis & Treatments: Polyester or foam nasal swabs: which is better? A comparative analysis investigated sensitivity of polyester and foam nasal swabs stored in viral transport media (VTM), saline, or dry tubes from 126 convalescent COVID-19 patients and found polyester and foam swabs had sensitivities of 87.3% versus 94.5% in VTM, 87.5% versus 93.8% in saline, and 75.0% versus 90.6% in dry tubes, respectively. Polyester swabs had higher cycle threshold values and decreased performance compared to foam swabs when viral loads were near detection threshold, but because estimated sensitivity above 87% was deemed sufficient for times of public health emergency, polyester swabs stored in VTM or saline may suffice in settings where swab shortages exist.
—Mental Health & Resilience Needs: How do science literacy and neurological mechanisms contribute to false beliefs? A Behavioral Neurologist from University of California, San Francisco describes that the neural mechanism behind false beliefs in COVID-19 conspiracy theories and science denial in healthy individuals is similar to those that have Lewy body dementia or Fronto-temporal dementia, concluding that “developing frontal circuitry to support the process of reasoning is part of education and science literacy and stands at the core of a healthy democracy.” Establishing this is the responsibility of the medical and scientific community through changes in the education system and working with political officials.
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—Climate: Hospital Volumes during the COVID-19 Pandemic in 2 US Medical Centers, Stanford University Medical Center and New York-Presbyterian/Weill Cornell Medical Center, were explored with the incidence of 5 medical emergencies: acute MI, ischemic stroke, nontraumatic subarachnoid hemorrhage, ectopic pregnancy, and appendicitis. Authors found decreased incidence of acute myocardial infarction, non-traumatic subarachnoid hemorrhage, and ischemic stroke cases in both centers, a decrease in appendicitis cases in New York, and no changes in ectopic pregnancy cases at either center. They implicate that deferring seeking care for acute conditions due to the fear of contracting COVID-19 could be leading to the higher rates of at-home death of patients during the pandemic.
—Transmission & Prevention: Operation Warp Speed's Strategy and Approach are outlined by an affiliated physician scientist. It is a partnership of the Department of Health and Human Services, Department of Defense, and the private sector. Their goal is to advance “development, manufacturing, and distribution of vaccines, therapeutics, and diagnostics” to establish control over the COVID-19 pandemic. The initiative set objectives of delivering ~300 million doses of the SARS-COV-2 vaccine by mid-2021 with strict criteria by which companies have to comply in order to be accepted. Currently there are “eight vaccines in [their] portfolio which include “Moderna and Pfizer/BioNTech (both mRNA), AstraZeneca and Janssen (both replication-defective live-vector), and Novavax and Sanofi/GSK (both recombinant-subunit-adjuvanted protein).
Management: Among 89 COVID -19 ICU Patients at Newark Beth Israel Medical Center one study found 8.9% (n=8) developed nosocomial candidemia over an average ICU stay of 25 days. Compared to the control, they found that COVID-19 ICU patients with higher BMI, prolonged mechanical ventilation, and superimposed bacterial infections were associated with concomitant candidemia, but in-hospital mortality was not significantly changed. Authors suggest that providers be aware of systemic fungal infections as a potential complication in COVID-19 ICU patients.
—R&D: Diagnosis & Treatments: The efficacy and safety of SARS-CoV-2 Neutralizing Antibody LY-CoV555, an antispike neutralizing monoclonal antibody, were analyzed in a randomized, double-blind, controlled trial. The investigators examined the antibody's effect on viral load, symptom scores, and clinical outcome of 452 patients across 41 centers in the United States receiving one of three doses (700 mg, 2800 mg, or 7000 mg) or a placebo. Although the authors acknowledge the need for further studies, the trial so far indicates possible reduction in symptom severity and a reduction in viral load with higher doses of LY-CoV555, suggesting that LY-CoV555 could become a useful treatment for patients with a recent diagnosis of COVID-19.
—Mental Health & Resilience Needs: Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 Pandemic were examined in a survey of 248 adolescents in the urban areas of New South Wales, Australia.
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—Climate: No-Fault Compensation for Vaccine Injury and Equitable Access to Covid-19 Vaccines are explored by Public Health experts associated with Yale University. They discuss the concept of Vaccine Nationalism, the creation of the COVAX facility, and the plight of low- and middle-income countries during the COVID-19 pandemic. To address the concerns regarding the benefits and risks of the COVID-19 vaccine as well as vaccine manufacturers protection and liability, the authors suggest utilizing a no-fault compensation for vaccine injury.
—Epidemiology: A compromised specific humoral immune response against the SARS-CoV-2 receptor-binding domain is related to viral persistence and periodic shedding in the gastrointestinal tract according to a cohort study conducted by various medical institutions in Shenzhen and Guangzhou, China. They found 21/289 Chinese patients with COVID-19 were readmitted due to persistent SARS-CoV-2 positivity. Among them, anal viral detection was positive in 15/21 (71.4%) patients and there was replication in the GI tract in 3/16 (18.7%) patients, with no respiratory tract replication. They hypothesize there is viral rebound due to decreased levels of IgA and IgG antibodies to the viral receptor-binding domain (RBD) and thus, a lack of protective humoral immune response suggesting this leads to persistence of SARS-CoV-2 in the GI tract along with active viral shedding.
—Transmission & Prevention: Climatic influence on the magnitude of COVID-19 outbreak was explored via a stochastic model-based global analysis. Researchers evaluated the effect of climates on COVID-19 transmission in 228 cities across 3 climatic zones. They found that the temperature and humidity may be major contributors to COVID-19 transmission. Average temperatures and relative humidity were the primary contributors in Europe, diurnal temperatures were most important for India, and temperature seasonality was most important for Brazil. These findings highlight the relationship between climates and COVID-19 spread and provide more insight into COVID-19 transmission.
—R&D: Diagnosis & Treatments: Two sample pooling strategies for SARS-CoV-2 RNA detection for efficient screening of COVID-19 were compared. Using 23 pools each containing 1 positive sample and either 5 or 9 negatives, authors demonstrated a similar diagnostic sensitivity to individual tests (p<0.005) but pooling viral transport medium resulted in a false negative while pooling swabs resulted in diagnosis without loss of sensitivity. Authors suggests pooling swabs may facilitate testing in higher quantities at lower costs, which could be used where resources are limited, however this strategy would require collecting double swab samples for individual re-testing should a pool test positive.
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—Epidemiology: An online survey of 1777 pregnant and postpartum women conducted in Japan found high prevalence of prenatal anhedonia, depression, and anxiety (17%; evaluated via Edinburgh Postnatal Depression Scale [EDPS]), which was positively correlated with perceived risk of contracting COVID-19, concerns regarding financial effects of the pandemic, and lack of social support during the COVID-19 pandemic.
—Understanding the Pathology: A prospective observational study conducted at Infanta Leonor University Hospital in Madrid, Spain from analyzed 26 COVID-19 positive patients with pulmonary embolisms (PE) who were screened for deep vein thrombosis (DVT) via compression ultrasound and found just 2 had evidence of DVT on compression ultrasound, one in their left popliteal vein and the other in their left femoral vein.
—Transmission & Prevention: Researchers from Brazil analyzed results of 4,353 RT-PCR SARS-CoV-2 tests and 2,275 SARS-CoV-2 antibody tests of patients with known blood types collected before June 22, 2020 and found an insignificantly higher infection rate in individuals with type A blood compared to type O blood, indicating that ABO blood types may have a less direct effect on rates of SARS-CoV-2 infections than previously predicted and that altered rates of infection may be mediated by other qualities of the population being studied.
—Management: A prospective observational study conducted in Spain examined the complete blood count (CBC) and cell population data (CPD), via XN20 analyser, of 153 COVID-19 patients and 72 bacterial infection patients and found neutrophil-to-lymphocyte ratio (NLR) values helped distinguish COVID-19 and bacterial infections (positive predictive value 74.1%, negative predictive value 97.1%), suggesting that NLR, along with other CBC and CPD values, may assist in accurately differentiating infectious etiologies during the COVID-19 pandemic.
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—Climate: Navigating through health care data showed disruption by the COVID-19 pandemic and was found to be variable and potentially unreliable due to the pandemic's effects on health-seeking, patient triage, and overall outcomes. Authors note that analytic methods for many study designs rely on the assumption that these factors are constant over time. They suggest that researchers should be cognizant of this disruption when planning studies and performing analyses in order to prevent potential confounding biases in future research studies.
—Management: Longitudinal profile of laboratory parameters and their application in the prediction for fatal outcome among 642 hospitalized patients infected with SARS-CoV-2 were evaluated and authors found that abnormal lactate dehydrogenase, urea, lymphocyte count, and procalcitonin levels were predictors of death during the acute phase (days 1-9), in addition to abnormal procalcitonin, lactate dehydrogenase, lymphocyte count, monocyte percentage, and cholinesterase being predictors of death in the critical phase (days 10-15). This study suggests that these labs should be followed as markers for prognosis and aggressive care should be considered should abnormalities in these markers arise.
—Adjusting Practice During COVID-19: Powered air purifying respirator (PAPR) restores the N95 face mask induced cerebral hemodynamic alterations among healthcare workers during the COVID-19 outbreak according to a study evaluating cerebral hemodynamic changes using Transcranial Doppler (TCD) of the middle cerebral artery (MCA) flow among 154 COVID-19 healthcare workers, of whom 123/154 developed de-novo headache due to N95 use (38/154 had preexisting migraine co-morbidity). Wearing an N95 increased Mean Flow Velocity (MFV) and ET-CO2, while Pulsatility Index (PI) decreased (p<0.001), whereas 24 participants donning N95 with a PAPR exhibited values nearer to baseline. These results implicate combined use of N95 with PAPR to potentially maintain cerebral homeostasis, mitigating PPE-induced headaches among healthcare workers, although larger trials may be required.
—Mental Health & Resilience Needs: Mental health disorders may be related to COVID-19-related deaths based on a commentary by psychiatrists. The authors cite the Center for Disease Control and Prevention (CDC) June 2020 survey with 40.9% of participants reporting “at least one adverse mental or behavioral health condition," which is 3-4 times higher than one year ago. Health disparities and a distressed healthcare workforce are additional areas of concern. The authors recommend screening (e.g. trauma, grieving, depression, anxiety) by primary care physicians and mental health professionals as well as broad supportive public health strategies (e.g. online resources for grieving families) in an effort to identify and aid those in need of assistance.
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—Epidemiology: Health policy researchers analyzed the COVID-19 and excess all-cause mortality rates across three periods (since the start of the pandemic, since 10 May 2020, and since 7 June 2020) between the U.S. and 18 nations and found that while the U.S. mortality rate since the start of pandemic is similar to that of other “High mortality” nations, its mortality rates since May 10th and June 7th far exceed that of any other nation.
· Investigators from multiple university hospitals in Denmark performed a retrospective cohort study comparing 473,654 Danish individuals tested for SARS-CoV-2 to 2.2 million non-tested individuals and found that those who tested positive for SARS-CoV-2 were less likely to have type O blood than A, B, or AB (P<0.001), suggesting a significantly reduced risk of COVID-19 infection in those with type O blood.
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—Epidemiology: A 3-patient case series highlights the potential association between COVID-19 and pancreatitis in pediatric patients. The authors report this association based on temporal observations, asserting that clinicians should be aware of COVID-19 as a potential diagnosis in patients with extra-pulmonary presentations such as pancreatitis.
—Understanding the Pathology: A prospective cohort study of PCR-proven or presumed SARS-CoV-2 infected patients at a tertiary care hospital in the Netherlands found that complement factors C3a, C3c and the terminal complement complex (TCC) were elevated in COVID-19 patients sent to the ICU (n=75) compared to non-ICU COVID-19 patients (n=115; p<0.005 for C3a and TCC), and more intense complement activation was present in patients that deceased and in those with thromboembolic events.
—R&D: Diagnosis & Treatments: A randomized controlled trial of patients hospitalized with COVID-19 pneumonia (n=126) conducted across 24 hospitals in Italy compared treatment with tocilizumab versus standard therapy and found 28.3% of patients who received tocilizumab worsened in clinical condition within 14 days compared to 27.0% who received standard of care, 3.3% in the tocilizumab group died versus 1.6% in the standard therapy group, and those who received tocilizumab had a higher incidence of adverse events overall than those who received standard therapy.
· A physician from the Division of Infectious Diseases at University of North Carolina at Chapel Hill examined studies on tocilizumab as a treatment for COVID-19 and found two randomized control trials (RTCs) met predefined efficacy thresholds via reduction of mechanical ventilation or death (EMPACTA, 28 day threshold; CORIMUNO-19, 14 day threshold), suggesting that observational studies have demonstrated a mortality benefit but current RCT data do not adequately support efficacy of tocilizumab in COVID-19 treatment and would recommend against routine use.
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—Epidemiology: Clinical features and outcomes of adults with COVID-19 admitted to the hospital based on a systematic review and pooled analysis of the literature
—Understanding the Pathology: Endotheliopathy is induced by plasma from critically-ill patients and associated with organ failure in severe COVID-19 based on a retrospective cohort study at Lille University Hospital assessing cytotoxicity of plasma from 28 patients (12 ICU and 16 non-ICU) hospitalized with COVID-19. Samples from COVID-19 patients had significantly decreased human pulmonary microvascular endothelial cells (HPMVEC) viability (p<0.01) and increased cytotoxicity compared to plasma from 8 healthy donors. The authors suggest their findings bolster the growing body of evidence indicating SARS-CoV-2 induces endothelial damage that contributes to organ dysfunction, respiratory failure, and thrombosis.
—Transmission & Prevention: Regeneration Processes for Filtering Facepiece Respirators (FFRs) in Terms of the Bacteria Inactivation Efficiency and Influences on Filtration Performance were investigated through the ability of microwave irradiation (MWI), UV irradiation (UVI), MWI + UVI, steam, and ethanol. Authors found ethanol unacceptably reduced filtration efficiency while steam and MWI effectively decontaminated FFRs (100% inactivation in 90 min and 30 min, respectively) without sacrificing filtration, though long exposure to MWI did damage fiber morphology. While UVI successfully inactivated surface bacteria, efficiency decreased from outer to inner layers and authors suggest that a combination of UVI and short-duration MWI can best decontaminate used FFRs while maintaining filtration performance.
—Management: Anti-androgens may protect against severe COVID-19 outcomes based on results from a prospective cohort study of 77 hospitalized men. The authors found patients taking anti-androgens (dutasteride [n=9], finasteride [n=2], spironolactone [n=1]) were significantly less likely to be admitted to the ICU than men not taking anti-androgens (p=0.0002), even after stratifying for age (p=0.018). Given the reduced risk of experiencing severe COVID-19 (RR: 0.14, 95% CI: 0.02-0.94), they suggest anti-androgens could be utilized therapeutically to improve COVID-19 disease course in men.
—Adjusting Practice During COVID-19: Proof-of-concept calculations to determine the health-adjusted life-year trade-off between intravitreal Anti-VEGF Injections and transmission of COVID-19 were constructed by ophthalmologists in New Zealand through statistical model that weighed risks and benefits of performing anti-VEGF intraocular injections in patients with neovascular age-related macular degeneration (nAMD) during the COVID-19 pandemic.
—R&D: Diagnosis & Treatments: Sensitivity of nasopharyngeal, oropharyngeal, and nasal wash specimens for SARS-CoV-2 detection in the setting of sampling device shortage was explored though a cross-sectional study comparing sensitivities of different samples for detection of ORF1 and E-protein genes via RT-PCR in 29 SARS-CoV-2 positive patients.
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—Epidemiology: Sex differential in COVID-19 mortality varies markedly by age according to collated data from the National Institute for Demographic Studies of pooled aggregate rates of infection and mortality of almost 400 million COVID-19 patients in Europe and Korea. Mortality risk ratio was found to be higher in men (overall RR: 1.35, no measure of significance provided). This risk was increased between the ages of 40-79 (RR: 1.87, no measure of significance provided). Authors suggest their findings corroborate prior data reporting equivalent rates of SARS-CoV-2 infection between men and women but higher rates of mortality in men, and hypothesize that both social and genetic factors contribute to this disparity.
—Transmission & Prevention: COVID-19 Precautions Helped Limit Cases Linked to Milwaukee Primary. A Centers for Disease control case report described preventative measures enacted for the primary election in Milwaukee, Wisconsin which suggested that preventative measures such as mail-in ballots (69% of votes), early voting, social distancing, PPE for poll-workers, and frequent disinfection at polling sites (which were crowded due to reduction of polling sites from 181 to 5) resulted in no substantial increase in COVID-19 cases after the event.
—Management: Anaemia is associated with severe illness in COVID-19 according to a retrospective cohort study (n total=222, n anemic=79). Authors found anemic patients developed more severe cases of COVID-19 compared to non-anemic patients (17.7% vs 8.1%, P=0.001; OR 3.77, 95%CI:1.33-10.71, P=0.013), though results were limited by sample size. Anemic patients also had demonstrably elevated inflammatory markers (CRP, ESR, PCT, lymphocyte count), increased incidence of coagulopathies, and greater magnitude of organ damage, though no level of significance was provided for these measures. Based on this, the authors posit anemia as an independent risk factor for progression to the severe form of COVID-19, and urge close attention to hemoglobin levels in confirmed COVID-19 patients.
—Adjusting Practice During COVID-19: Outcomes of COVID-19 in 198 chronic lymphocytic leukemia (CLL) patients with CLL from 43 cancer care centers internationally yielded 90% hospitalized and an overall survival (OS) of 71% and 63% at 14 and 28 days, respectively. OS was not affected by whether patients were receiving CLL directed therapy (hazard ratio [HR], 0.77; 95% CI: 0.47-1.26; p = 0.30) or were on a "watch-and-wait" plan (HR, 0.83; 95% CI, 0.51-1.36; p = 0.47). Rather, age and CIRS score provided the largest impact on OS. Authors suggest that CLL patients are at greater risk for death from COVID-19, but different treatment plans for CLL have no effect on overall survival.
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—Climate: Decreased air pollution reported during the global shutdown due to the COVID-19 pandemic was "a brief respite" from the impacts of climate change, but in light of the global recession, governments and individuals will likely prioritize the economy and their health rather than the environment (decreased use of public transportation, more fossil fuel consumption, increased use of single use plastics), suggesting these behaviors will contribute to even worse air quality moving forward.
—Epidemiology: Italian sports medicine physicians conducted a cohort study of 30 male professional soccer players, all of whom were negative for acute SARS-CoV-2 infection via RT-PCR and reported histories of either no or mild symptoms of COVID-19, however 18 (60%) were positive for SARS-CoV-2 IgG and demonstrated a statistically significant decrease in spirometry parameters (p<0.05). Because no other relevant differences in cardiopulmonary function testing were found, the authors suggest extensive cardiovascular and hematologic screening for male professional athletes who test positive for SARS-CoV-2 IgG is of limited utility.
—Transmission & Prevention: A retrospective cohort study of 2888 residents in a Guangzhou community with RT-PCR and genome sequencing of samples collected from the environment and residents found that working in waste management (RR=13, 95% CI: 2.3-180), failing to change into clean shoes at home (RR=7.4, 95% CIexact: 1.8-34), and coming home and cleaning shoes daily (RR=6.3, 95% CIexact: 1.4-30) were significantly associated with SARS-CoV-2 infection.
—Adjusting Practice During COVID-19: An international consortium of multidisciplinary cancer care experts from the European Society for Medical Oncology presents a set of statements encompassing 28 committee-approved guidelines for cancer care best practices during the SARS-CoV-2 pandemic that encompass 10 categories (patient management and follow-up, infection prevention, use of specific therapies [GC-SF, thromboembolism prophylaxis, targeted TKI, chemotherapy, radiation], immunotherapy utilization, COVID-19 testing, and clinical trial activity) and suggest that their guidelines offer the best strategy for providing high quality care to cancer patients during the COVID-19 pandemic while minimizing potential harm.
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—Epidemiology: Outcomes of COVID-19 in living donor liver transplant (LDLT) recipients are studied by hepatologists and leading liver transplant surgeons from the Institute of Liver Transplantation & Regenerative Medicine in Gurugram, India through a case series of 12 living donor liver transplant patients who tested positive for SARS-CoV-2 via RT-PCR. Most were symptomatic (n=11, 91.7%) with evidence of pneumonia on radiologic imaging (n=9, 75%) and with median duration of detectable virus of 12 days. While the majority (n=10, 83.3%) were on tacrolimus-based immunosuppression, all but one patient (n=11, 91.7%) survived with only supportive care. Because the patient who died had multiple other risk factors for severe COVID-19 (quadruple immunosuppression, hypertension, metabolic syndrome, diabetes), these authors suggest that liver transplant patients as a whole are not at particularly increased risk for mortality from COVID-19.
· Hematological manifestations of SARS-CoV-2 in children are explored in a review of 15 articles meeting study criteria and found children with SARS-CoV-2 were less likely to be lymphopenic compared to adults, with the most common abnormalities being leukopenia in older children and lymphocytosis in infants/neonates. Thrombotic complications and platelets and erythrocytes abnormalities were relatively uncommon and more likely in children with multisystem inflammatory syndrome. Authors suggest these findings, which contrast hematologic changes observed in adults, may be a result of pediatric patients' immature ACE-2 expression and immune systems.
—Understanding the Pathology: Mechanisms by Which SARS-CoV-2 May Impact Male Fertility are discussed in a letter to the editor based on Dutta and Sengupta’s article "SARS-CoV-2 and male infertility: possible multifaceted pathology." They propose viral binding to angiotensin-converting enzyme 2 receptors on spermatogonia, Leydig cells, and Sertoli cells may cause overactivation and negatively impact spermatogenesis. Additionally, they urge further studies on SARS-CoV-2's ability to disrupt sperm formation and function because SARS-CoV-2 seems to disproportionately impact males in some studies.
—R&D: Diagnosis & Treatments: REGN-COV2 antibodies prevent and treat SARS-CoV-2 infection in certain species based on virologists from Regeneron Pharmaceuticals results from an in vivo study of their proprietary therapeutic cocktail REGN-COV2's (human antibodies REGN10933, REGN10987) ability to reduce viral load via SARS-CoV-2 spike protein binding in resus macaques and golden hamsters. They found a 50 mg/kg dose significantly reduced SARS-CoV-2 gRNA (p<0.0001) and sgRNA (P=0.0012) in rhesus macaques on oral swab and that 0.5-50 mg/kg prophylactic doses prevented weight loss and reduced lung findings associated with pneumonia in Golden hamsters (p<0.0001). Authors suggest this REGN-COV2 regimen shows potential for prevention and treatment of SARS-CoV-2 in humans and express optimism regarding ongoing clinical trials.
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—Understanding the Pathology: Findings from models of the change in energy (ΔΔG) of the binding of the SARS-CoV-2 spike (S) protein to the angiotensin converting enzyme-2 (ACE2) receptors from primates, rodents, birds, reptiles, and fish (n=215 vertebrates) suggest that a broad range of mammals are susceptible to SARS-CoV-2, indicating the need for surveillance of animals that are potential reservoirs.
—Adjusting Practice During COVID-19: A review of the major impacts of COVID-19 on specialty fields that treat non-communicable disease including cardiology (e.g alteration to STEMI), nephrology (e.g. dialysis centers complying with CDC recommendations and social distancing guidelines), obstetrics and gynecology (e.g. ACOG recommendations to separate neonates from COVID-19 positive mothers), hematology oncology (e.g. dramatic decreases in blood donations in some areas), as well as other specialties, found that the pandemic will likely result in negative impacts on many patients with non-communicable diseases, and may even lead to the development of de novo sequelae due to impaired healthcare practices.
—Mental Health & Resilience Needs: A opinion piece by a psychiatrist at Massachusetts General Hospital highlights that the rapidly changing nature of COVID-19 research and management has caused “Bayesian fatigue” by making the sum total knowledge a physician has gathered over their career less important than the most recent research, which has caused a negative psychological toll on physicians who long to see mastery and makes it difficult for physicians to counsel friends, family and patients as our knowledge on the COVID-19 pandemic is rapidly evolving.
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—Epidemiology: Computer scientists evaluated Italian, Swiss, and German COVID-19 contact tracing apps based on Google/Apple exposure notification (GAEN) and Bluetooth signals in 108 pairs of handsets and found that Swiss and German app detection rules triggered no exposure notifications, while the Italian app's detection rules triggered notifications at a 50% true positive rate and 50% false positive rate, suggesting that while contact tracing apps are innovative, many limitations exist before they can be used for epidemiological data collection.
· A case report describes a previously healthy 20 year old male with fever and odynophagia who was admitted 2 weeks later for bilateral facial weakness, at which time neurological examination revealed severe neuropathy of the facial nerve bilaterally and discrete signs of active denervation. SARS-CoV-2 and Epstein-Barr virus (EBV) were subsequently detected, which may have contributed to this patient’s clinical presentation (either via immune mediated or direct viral damage).
—Understanding the Pathology: An in vitro study found that 15/15 ex vivo thyroid specimens (removed due to the presence of benign thyroid nodules) expressed abundant levels of mRNA encoding for the ACE-2 receptor in thyroid follicular cells, making them a potential target for SARS-COV-2 entry and suggesting that COVID-19-related subacute thyroiditis may potentially be due to direct viral infection of the thyroid gland.
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—Understanding the Pathology: Physicians from Pisa University Hospital (Italy) remark on Zhao et al's (2020) findings on ABO Blood Group Correlations With COVID-19, stating that their observed association between blood group A and increased risk of COVID-19 may be due to their choice in cohort. In the authors' own study of a group of 7,713 healthy blood donors, there was no significant difference in rate of anti-SARS-CoV-2 nucleocapsid IgG based on blood type and there are other studies with similar findings. While this study does not eliminate the need to examine differential rates of infection and outcomes for COVID-19 patients based on blood type, it does indicate that previous study results may be biased by group selection.
—Transmission & Prevention: Vaccines that present the α-gal epitope produced by glycoengineered bacteria or yeast had increased uptake by antigen presenting cells (APCs) by 10 to 200 fold when given to mice. Since anti-Gal is a natural immunoglobulin G (IgG) in the human serum, authors state that vaccines with the α-gal epitope may increase anti-viral immune response of T cells against the SARS-CoV-2 virus. Authors suggest the development of vaccines with α-gal epitopes have been shown to be safe for use in humans through clinical trials and could offer improved efficacy via maximized immune response to SARS-CoV-2.
—Resources: A data-driven, ontology-based, and natural language processing approach for analyzing COVID-19 clinical trials was developed by a high school student from The Harker School in San Jose, California who data mined ClinicalTrials.gov using Application Programming Interfaces (APIs) to compile relevant data from COVID-19 clinical trials including drug treatments and interventions, outcomes, Medical Subject Heading (MeSH), and Human Phenotype Ontologies (HPO). The results (available at http://covidresearchtrials.com) provide a public compilation of unique reports in each category analyzed, which could offer guidance to the global research community to support the development of future clinical trials, treatments and interventions, and meta-analyses, as well as general insight into the response to COVID-19.
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—Climate: An article in Nature highlights concerns among the scientific community about current COVID-19 vaccine trials being run by AstraZeneca, Pfizer, and Moderna. In light of two reported cases of transverse myelitis in trial participants, some scientists urge for more transparency from the companies leading trials, others are concerned about public opinion of vaccine safety and worry about political pressure on the trials, especially during the U.S. election season, and some question the vaccine trials' goals of reducing cases of symptomatic COVID-19, and instead suggest focusing on reducing incidence of severe disease.
—Epidemiology: Members of the Max Planck Institute for Evolutionary Anthropology in Germany conducted a genetic analysis investigating previous findings of an association between severe COVID-19 disease (hospitalization and respiratory failure) and a six-gene region on chromosome 3 (49.4kb), asserting that the region has been inherited from Neanderthals, following analysis using the 1000 Genomes Project. The anthropologists report this haplotype is seen in 50% of South Asians and 16% of Europeans, which they believe directly contributes to increased susceptibility to severe disease.
—Understanding the Pathology: A review by molecular biologists found a higher prevalence of the G614 variant of SARS-CoV-2 is related to increased prevalence of chemosensory dysfunction due to expression of a spike protein with higher receptor binding domain affinity to h-ACE2 receptors, leading to enhancement of SARS-CoV-2 binding in the olfactory epithelium and increased chemosensory deficits.
—Adjusting Practice During COVID-19: Increased risk of COVID-19 infection among patients with a history of or current gynecologic cancer has led to the development and implementation of an algorithm for less invasive and more cost-effective surveillance with telemedicine-based, risk-stratified surveillance and a shared-decision making program for patient follow-up, suggesting the potential for reconsideration of healthcare delivery for these patients.
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—Understanding the Pathology: Discordance between Serum Neutralizing Antibody (NAbs) Titers and the Recovery from COVID-19 was seen in a cross-sectional study of adult serum samples after recovery from COVID-19 (n=49) conducted at Bezmialem Vakif University Hospital in Turkey. 20.36% of participants had low titers of NAbs, while NAbs increased with the severity of disease (r=0.73, p=0.016, 95%CI 0.18-0.93) and patient age (r=0.29, p=0.04,95%CI 0.01-0.53). Authors suggest COVID-19 recovery may not be dependent on antibody titers alone and the SARS-CoV-2 immune response likely depends on patient age, disease severity, and several other complex factors.
—Management: Treatment of COVID-19 atypical pneumonia by early Tocilizumab administration in "non-critically-ill" patients on hemodialysis was explored in three case reports of hemodialysis (HD) patients with atypical COVID-19 pneumonia and progressively worsening alteration of inflammatory markers, most notably increased interleukin-6 (IL-6). All three patients showed significant symptom improvement and progressive resolution of disease after administration of tocilizumab (an anti-IL-6 monoclonal antibody). These findings show potential for tocilizumab as a treatment option for atypical COVID-19 pneumonia, specifically for patients on HD.
—R&D: Diagnosis & Treatments: Androgen Receptor Genetic Variant Predicts COVID-19 Disease Severity according to a Prospective Longitudinal Study of Hospitalized COVID-19 Male Patients. The study followed 65 hospitalized male COVID-19 patients over 60 days and found that patients with high glutamine (CAG) repeats in the androgen response (AR) gene had longer hospitalizations (mean: 45.7 days) and a high rate of ICU admissions (70.6%) compared to patients with low CAG repeats (mean 25 days, 45.2%). These findings suggest AR CAG length is associated with severe COVID-19 disease in males, which supports current evidence of the importance of androgens in SARS-CoV-2 infection. The authors recommend AR CAG length as a potential biomarker for risk of ICU admission and suggest further study into the use of anti-androgens in treating COVID-19.
· Mass screening of asymptomatic persons (n=1,924) for SARS-CoV-2 using saliva conducted in Japan by researchers affiliated with Hokkaido University Hospital and Hokkaido Graduate School of Medicine found self-collected saliva and nasopharyngeal swabs had equivalent utility with similar specificity and sensitivity as specimens for nucleic acid amplification. Authors suggest the self-collected saliva method may be superior to nasopharyngeal swabs for mass testing in asymptomatic populations as it eliminates close contact between the test subject and provider, allows for parallel sample collection, and minimizes discomfort.
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—Climate: Pediatricians and OBGYNs discusses ethical concerns (e.g. reproductive autonomy) surrounding public health policies on pregnancy avoidance during a public health emergency, suggesting that such policies should only be put in place if the pregnancy-related risks associated are well understood, pose a significant risk, cannot be minimized, and if contraception is readily available. The authors conclude that, at this time, COVID-19 does not meet all of these criteria, emphasizing that more information is needed prior to establishing recommendations.
—Epidemiology: A cohort study found that of 598 pregnant patients hospitalized due to COVID-19, 272 (45.5%) were symptomatic upon admission, with 16.2% requiring ICU admission and 8.5% required invasive mechanical ventilation. Out of 458 completed pregnancies during the COVID-19-associated hospitalization, 10 (2.2%) resulted in a pregnancy loss. This study suggests that pregnant persons might be at increased risk for severe disease, making COVID-19 screening in pregnancy and patient education increasingly important as we have not yet fully understood the long-term ramifications of COVID-19 in pregnant persons and their babies.
—Transmission & Prevention: Mechanical engineers tested 18 commercially available topical products using an in vivo model with a custom-built tribometer to mimic the shear loading force against skin in order to identify a practical lubricating solution for medical workers required to wear facial personal protective equipment (PPE) for a prolonged period of time and found the longest-lasting reduction of friction in talcum powder, a petrolatum-lanolin mixture, and a coconut oil-cocoa butter-beeswax mixture.
—R&D: Diagnosis & Treatments: Individuals with COVID-19 infection detected via routine surveillance using low-frequency high-analytic sensitivity (benchmark PCR) tests are likely outside of the transmissible infectious period by the time the results are received, thus allowing for viral spread before the person is aware they are infected, and suggesting that a shift in testing to a low analytic sensitivity test which has quick point-of-care results, inexpensive mass-production, and the ability to be performed frequently would allow for identification, isolation, and filtration of people who could spread infection.
—Mental Health & Resilience Needs: A cross-sectional study of 288 perinatal patients found higher rates of anxiety (34.4%) and depression (39.2%) compared to pre-COVID-19 scores (3.1% for both conditions combined) as measured by the Patient Health Questionnaire Anxiety and Depression Scale, while postnatal groups scored higher than antenatal groups overall (p<0.0001), suggesting that perinatal patients, postnatal patients in particular, may experience increased mental health challenges as a result of the COVID-19 pandemic.
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—Epidemiology: Age-specific COVID-19 case-fatality rates show no evidence of changes over time. Members of the University Vita-Salute San Raffaele School of Medicine in Milan, Italy looked at national-level COVID-19 surveillance data in Italy and found that case fatality rates were 3% in people younger than 60 years compared to 30% in people over 80 years old. This is consistent with higher rates of chronic comorbidities in older populations. These fatality rates remaining consistent over 4 months of monitoring suggests that COVID-19 mortality has not improved or worsened, and younger age groups tend to have less severe COVID-19 outcomes.
—Adjusting Practice During COVID-19: Ocular findings in COVID-19 patients with severe systemic disease, including conjunctival congestion, epiphora, and chemosis, appeared to be common in a review by an ophthalmologist from the Department of Ophthalmology, John Hopkins University School of Medicine. Citing a study of 276 patients admitted to the hospital with COVID-19 in Hubei, China reporting that their eyeglass usage was lower than the general population, the ophthalmologist hypothesizes the possibility of ocular transmission of SARS-CoV-2 and encourages use of personal protective equipment (face shield, goggles, eyeglasses) to prevent ocular transmission during this pandemic.
—R&D: Diagnosis & Treatments: A web visualization tool using T cell subsets as the predictor to evaluate COVID-19 patient's severity: A study conducted at the Wuhan Pulmonary Hospital analyzing COVID-19 positive patients (n=340) found T-cell subsets analyzed upon initial diagnosis (Total T-cells, Helper T-cells [TH], Suppressor T-cells [TSC], and TH/TSC) differed significantly in patients that were discharged (n=310) compared to death cases (n=30); while age, underlying disease status, Helper T-cell count, and TH/TSC ratio were significant predictors of either death or discharge, but a well-functioning immune system at time of hospitalization indicated a higher chance of recovery. These findings suggest T-cell subset monitoring may be useful to detect changes in condition and predict prognosis of patients with COVID-19. · Targeting the endolysosomal host-SARS-CoV-2 interface by clinically licensed functional inhibitors of acid sphingomyelinase (FIASMA) including the antidepressant fluoxetine showed that fluoxetine successfully inhibits the entry/propagation of SARS-CoV-2 in cell culture without cytotoxic effects. It also exhibits antiviral activity against two subtypes of Influenza A virus via a mechanism that impairs endolysosomal acidification and leads to accumulation of cholesterol in endosomes. Similar effects were also observed with amiodarone and imipramine, two other FIASMA drugs. These findings suggest endolysosomal lipid balance as a potential efficacious FIASMA drug target of the host-virus interface for SARS-CoV-2 and other enveloped viruses.
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—Management: A 31-year-old female kidney transplant recipient on immunosuppressants tested negative twice 18 days after initial positive test for SARS-CoV-2, yet tested positive again for SARS-CoV-2 via RT-PCR on day 20 with recurrence of symptoms. Despite treatment with lopinavir-ritonavir and resolution of symptoms 6 days after treatment, the patient continued to test positive by rectal swab for an additional 21 days and was monitored by serial cycle threshold of viral RNA.
—R&D: Diagnosis & Treatments: An observational study of 242 patients with severe COVID-19 pneumonia and corresponding elevated inflammatory markers (including 61 patients receiving methylprednisolone in week 2 of infection) found 22 patients (9%) died and 31 (12.8%) suffered death or intubation. Hazard ratios for death and death or intubation for the week-2 MP group had lower adjusted risk for both outcomes compared to out-of-week-2 MP (administered Week 1 or Week 3), non-pulse glucocorticoids (<100mg/day), or no glucocorticoids, but these values were only significant in patients with low SpO2/FiO2 (<353).
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—Climate: Although the United States received an overall top Global Health Security (GHS) Index score, the ability to curtail COVID-19 transmission was hindered by low scores on public confidence in the government, access to health care without barriers, and limitations of federal regulations, suggesting a need for greater emphasis on country leadership and public confidence in future GHS indices as well as a national review of the United States' pandemic approach to identify and address other problem areas.
—Adjusting Practice During COVID-19: A review of mask fit testing for N95/FFP2/N99/FFP3s identify inadequate mask fit testing as a risk factor for infection among healthcare workers, arguing that well fitted N95/FFP2/N99/FFP3 masks are essential to protect healthcare workers against respiratory viruses such as COVID19, particularly during aerosol-generating procedures. Additionally, quantitative fit testing has been evidenced to detect facial leaks better than qualitative fit testing protocols.
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—Climate: An expert opinion from individuals affiliated with University of North Carolina and Boston University schools of medicine expose socioeconomic disparities and health inequities in US populations, with higher COVID-19 mortality present among Black, Latinx, and Indigenous populations when compared to Whites. They recommend new policies that include a monthly universal food income to all US households, unemployment insurance reform, and community development investment policies. Such policies may promote improvement of health inequity among Americans.
—Epidemiology: To assess environmental prevalence of SARS-CoV-2, microbiologists collected and analyzed 57 samples from 13 households, 9 public venues, and the wastewater sewage system of Horcajo de los Montes village in Spain (883 inhabitants). They found 12% of samples from clothing, fridge and oven handles, doors knobs, keyboards, and other items were SARS-CoV-2 positive via RT-PCR. Although 6% of villagers had COVID-19, most known cases had resolved prior to sample collection, suggesting there may be a significant incidence and persistence of SARS-CoV-2 in the environment even after recovery within the population.
· Physicians from Brigham and Women's Hospital in Boston, Massachusetts extracted data from the Premier Healthcare Database to explore outcomes and clinical profiles of 3,222 young adults (ages 18-34) hospitalized with COVID-19 and found 21% of patients required intensive care, 10% required mechanical ventilation, and 2.7% died. Also, there was increased risk of adverse outcomes in patients with morbid obesity, hypertension, or diabetes. Authors suggest young adults hospitalized for COVID-19 may experience significant adverse outcomes, emphasizing the importance of prevention among this age group.
—Management: A cohort-control study conducted by pathologists at University Women’s Hospital Basel in Switzerland investigated 5 COVID-19 positive pregnant women (three mildly symptomatic and two asymptomatic) and 10 controls for the potential of vertical transmission of SARS-CoV-2. All 5 mothers and 2/5 fetuses has malperfusion, including 1 fetus having small thrombi. One patient, who was the only one symptomatic at childbirth, had placental pathological findings of lymphohistiocytic villitis and intervillositis, as well as viral RNA present in both the placenta and umbilical cord. The authors concluded that SARS-CoV2 infection displays potential for increased risk of fetal malperfusion through an increased coagulative state and and may result in placental infection.
—Adjusting Practice During COVID-19: A review of studies by surgeons in India assessed the efficacy of chest computed tomography (CT) as a preoperative COVID-19 diagnostic tool for patients undergoing elective surgeries and found early studies indicated chest CT as an effective screening tool, but further evaluation of subsequent studies showed low predictive value and potentially unnecessary surgery delay. Authors suggest chest CT is not practical in settings where RT-PCR is readily available, recommending its use only for symptomatic patients with high post-operative complication risk or pulmonary sequelae after COVID-19.
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—Climate: Authors from the Department of Environmental Health at George Washington University and Harvard University highlight the need for governmental interventions regarding workplace safety, specifically through the Occupational Safety and Health Administration (OSHA), to protect workers reentering the workforce during the COVID-19 pandemic. Businesses are beginning to return to a normal work schedule, and they argue there needs to be an infection control protocol—PPE, symptom screening processes, hand sanitizer stations—to prevent further COVID-19 transmission. The authors ultimately advocate for OSHA to implement an Emergency Temporary Standard (ETS) to facilitate the safe reopening of businesses.
—Understanding the Pathology: Investigators at David Geffen School of Medicine at University California, Los Angeles performed serial measurements on the IgG levels of plasma from 34 mildly symptomatic participants with confirmed or suspected COVID-19. Based on these serial measurements (first measurement: mean 37 days after symptom onset; last measurement: mean 86 days after onset), the estimated mean change of anti-SARS-CoV-2 IgG was −0.0083 log10 ng/mL per day with an estimated half-life of 36 days (95% CI: 26 to 60 days), suggesting a short lifespan of humoral immunity against SARS-CoV-2 in mild cases.
—Transmission & Prevention: A commentary by a multidisciplinary team of vaccine experts discusses the possibility of a second wave of COVID-19 cases near the end of 2020 and warns against the potential for co-occurrence with seasonal influenza. The authors advocate for public health authorities to prioritize influenza vaccination production and usage this year, especially among vulnerable populations (e.g.—pregnant women, the elderly, patients with multiple co-morbidities) and health care providers. The goal is to prevent severe complications caused by contraction of both COVID-19 and the influenza virus.
—Management: A professional opinion piece by physicians at Holbael University Hospital (Denmark) suggest that cases of COVID-19 with acute respiratory distress syndrome (ARDS) resemble the low compliance seen in neonatal respiratory distress syndrome (NRDS). They discuss that SARS-CoV-2 replicates in alveolar type II cells, impacting the production and turnover of surfactant, and causes alveolar inflammation and collapse. The authors propose that severe COVID-19 cases should be evaluated for surfactant levels (for which a point of care test for babies has been developed), and individuals with low surfactant could be given surfactant treatment to possibly improve patient outcomes.
—R&D: Diagnosis & Treatments: A special report by members of the National Institutes of Health (NIH) briefly describes the various COVID-19 diagnostic tests currently available and the new NIH Rapid Acceleration of Diagnostics (RADx) initiative, which is aimed at rapidly increasing COVID-19 diagnostic capabilities in the US. Challenges this program will encounter include: digital connectivity, manufacturing, and distribution. The authors highlight how the RADx initiative will provide diagnostic testing solutions on a larger scale, promote entrepreneurship, and help address inequities in healthcare.
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—Epidemiology: A meta-analysis of 15 peer-reviewed articles found recurrent COVID-19 infections (confirmed via RT-PCR) were reported at a mean of 34 ± 10.5 days after full clinical recovery from an initial infection, but these patients also had persistent positive RT-PCR tests for a mean of 39 ± 9 days following their initial infection. Furthermore, a persistent positive test could be detected in patients without clinical relapse for 54 ± 24 days following initial infection.
—Understanding the Pathology: Investigators describe post-mortem neuropathological findings in 2 patients with COVID-19 and neurological decompensation. Case 1 showed widespread multi-focal cortical infarcts, and case 2 showed brainstem encephalitis. Since viral RNA was not detected in the post mortem brain tissue in either case, these pathologies may not be a direct consequence of viral invasion.
—Transmission & Prevention: Researchers argue that hurricane protection measures, such as evacuation and sheltering, cause people to gather together and is the paramount reason for the 3.7x increase in COVID-19 cases between May 1 and July 24, 2020. They suggest that during hurricanes, 1) people at risk should social distance, 2) officials should provide better communications for guidance on safe evacuation and sheltering, and that 3) we should "learn from each 2020 storm and refine operations."
—Adjusting Practice During COVID-19: Pharmacists and epidemiologists in Denmark conducted a population-based cohort study of 9,236 patients who tested positive for SARS-CoV-2 via PCR and found no significant difference between NSAID users (n=248) and non-NSAID users (n=8,988) regarding 30-day mortality, hospitalization, ICU admission, mechanical ventilation, or renal replacement therapy. Authors suggest NSAID use during COVID-19 infection may have minimal effect on risk of mortality or adverse outcomes.
· A survey of 414 interventional cardiologists and cardiac catheterization laboratory (CCL) directors in the United States found a 55% decrease in percutaneous coronary interventions (PCI) and a 64% decrease in transcatheter aortic valve replacements during March 15 to April 15, 2020 compared to 2019. Additionally, procedure deferral for angiogram/PCI for unstable angina, NSTEMI, and STEMI increased with greater inpatient COVID-19 burden and 40% of CCL directors reported increased cases of late presenting STEMIs. These findings suggest that patient fears due to the pandemic may be influencing their decisions to delay seeking urgent cardiac care.
—R&D: Diagnosis & Treatments: Editors from the New England Journal of Medicine had an audio discussion to discuss guidelines for deployment of a COVID-19 vaccine.
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—Climate: Vaccine experts discuss concerns regarding historical disparities in vaccine/healthcare access in disadvantaged and minority groups. They propose a SARS-CoV-2 vaccine distribution plan with special emphasis on the ethical principles, utilitarianism, and egalitarianism, employing a tier system beginning with healthcare providers/front-line workers, adults > 65, and those with high comorbidities, followed by random chance selection weighted so that disadvantaged areas have higher access to the vaccine.
· Health policy experts argue that the multifaceted impacts that young people are facing as a result of the COVID-19 pandemic are being ignored due to their reduced infection rates and improved outcomes following infection. The authors call for more research on the impact the pandemic is having on young people, involving young people in pandemic policy planning at institutional and governmental levels, more governmental resource allocation to young people, and prioritization of young voices in the media, organizations and government.
—Transmission & Prevention: A retrospective study in Thailand of 211 asymptomatic contacts of COVID-19 patients who later tested positive and 839 asymptomatic contacts of COVID-19 patients who never tested positive evaluated factors that contributed to whether an individual with close contact to a person with COVID-19 contracted the virus. Factors independently associated with a lower likelihood of contracting SARS-CoV-2 included wearing a mask during all contact with the infected individual, maintaining greater than 1 meter of distance from the infected individual, having close contact for less than or equal to 15 minutes with the infected individual, and frequent hand washing.
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—Epidemiology: A multicenter study of 286 patients with lab-confirmed COVID-19 infections, 94.3% of whom were on antiretroviral therapy (88.7% with HIV viral suppression and 80.8% with comorbidities) found that the presence of comorbidities and lower CD4 counts (200 cells/mm-cubed) were significantly correlated with poorer outcomes including higher hospitalization rates, higher ICU admission rates, and reduced overall survival, whereas there was no correlation of outcomes to antiretroviral regimen or lack of viral suppression.
—Adjusting Practice During COVID-19: A retrospective cross-sectional study of emergency physicians (EPs; n=32) at Monash Medical Center in Australia found physician productivity (defined as number of patients examined per hour) decreased by 48.5% during the COVID-19 pandemic compared to historical performances, which authors attribute to increased workload from COVID-19 preparation. Researchers suggest new technical and adaptive challenges during the pandemic calls for strong role modeling and leadership to address complexities encountered by EPs and other healthcare providers.
—R&D: Diagnosis & Treatments: A retrospective propensity score-matched case-control study at Mount Sinai Hospital, New York investigated the effects of convalescent plasma therapy (CPT) in 39 patients with severe or life-threatening COVID-19 infection and found that by day 14 post-transplant, O2 requirements worsened in only 17.9% of CPT recipients when compared to 28.2% of propensity score-matched controls (potentially confounded by therapeutic anticoagulant use in the transplant cohort), in addition to statistically significant improved survival in plasma recipients when compared to controls.
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—Climate: Emergency medicine physicians at Massachusetts General Hospital (U.S.) describe the challenges posed by increasing natural disasters due to climate change in the context of COVID-19, specifically an increased need for hospitals during heat waves and natural disasters, and the need for virus transmission mitigation efforts during evacuations due to fires and hurricanes. The authors propose short-term solutions to these issues, such as the need to modify sheltering in response to natural disasters, and long-term solutions, such as increasing state and national funding for climate mitigation and public health disaster plans.
· Members of global health departments in the US and India call attention to the accelerated timelines of vaccine development for COVID-19 and highlight the critical need for active safety surveillance, especially in low-and-middle income countries, to establish capacity for primary data collection in addition to delineating real adverse reactions to ensure proper understanding and awareness of the benefit-risk profile of an imminent COVID-19 vaccine.
—Transmission & Prevention: The systems director of Laboratory Services at Houston Methodist Healthcare System in Texas presents a description of the effectiveness of an Incident Command System (ICS) implemented in their organization at the very beginning of the COVID-19 outbreak. The author highlights the role of ICS in organizing the staff and patients, in addition to analyzing, planning, and implementing strategies to manage the pandemic and alleviate anxiety through communicating reliable information, indicating the importance of an ICS in organizations for constructive disaster management in the future.
—Management: A single-center retrospective cohort study or 205 patients with confirmed COVID-19 pneumonia with acute hypoxemic respiratory failure (AHRF) and 60 patients treated with corticosteroids at the physician's discretion found that patients treated with corticosteroids exhibited lower risk of ICU transfer, intubation, and death in addition to greater SpO2/FiO2 improvement when compared to controls. These results suggest that usage of corticosteroids for non-intubated patients with COVID-19 pneumonia complicated by AHRF may lead to decreased mortality and complications.
—Adjusting Practice During COVID-19: Physicians, ethicists, and public health experts in San Diego County, California present the systems and protocols they developed for county-wide, population-based crisis management of COVID-19. The team developed healthcare community coalitions, teams to triage scarce resources, systems to transmit information across multiple facilities, virtual tabletop exercises for disaster preparedness, and committees responsible for transparent communication with the public.
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—Epidemiology: Random COVID-19 testing of 200 people in Chelsea, MA using the BioMedomics SARS-CoV-2 combined IgM/IgG LFA to determine seropositivity in a group of asymptomatic patients showed that 24.7% of seropositive participants were asymptomatic, suggesting that better safety precautions such as improved testing, isolation, contact-tracing, and distancing are needed as a high number of individuals can be carrying the virus asymptomatically.
· A systematic review of 97 studies exploring COVID-19 in 230,398 health care workers (HCW) showed COVID-19 prevalence of 11% by RT-PCR (95% CI: 7-15%) and 7% by antibody detection (95% CI: 4-11%) with serious complications seen in 5% (95% CI: 3-8%) and mortality in 0.5% (95% CI: 0.02-1.3%). Overall, those working in nursing or in a non-emergency setting were found to be at highest risk. Because 40% of HCW were asymptomatic at diagnosis, they suggest HCW simultaneously risk spreading and contracting COVID-19 and emphasize the need to screen HCW and implement standard procedures for the use of personal protective equipment.
—Management A multidisciplinary coalition of Brazilian investigators conducted a multi-center, randomized open-label clinical trial (CoDEX) exploring the clinical impact of dexamethasone on COVID-19 patients in 41 ICUs in Brazil (n=299). Adult patients presenting with moderate to severe ARDS who received dexamethasone (n=151) spent fewer days on mechanical ventilation within a 28 day period compared to those receiving standard care (mean 6.6 days [95% CI: 5.0-8.2] vs 4.0 days [95% CI: 2.9-5.4], difference 2.26 days [p=0.04])). This adds to a growing body of research suggesting dexamethasone improves outcomes in moderate to severe COVID-19.
—R&D: Diagnosis & Treatments: Investigators affiliated with International Medical University, Malaysia and the University of Huddersfield, UK performed a systemic review and meta-analysis with a total of 8,121 hospitalized patients with COVID-19 showing significantly lower odds for mortality with metformin use in diabetic, COVID-19 cases (pooled analysis OR: 0.62) than cases without use of metformin. The authors hypothesize that this finding may be due to anti-inflammatory mechanisms of metformin dampening the cytokine storm in COVID-19. However, as this finding was only seen in patients with pre-existing diabetes, further research is needed to provide evidence of the morbidity and mortality benefit in repurposing metformin for COVID-19 patients without concomitant diabetes.
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—Climate: Analysis of a cross-sectional, self-reported survey of 10,624 Internet users revealed that 17% of survey participants used telehealth due to the pandemic with Blacks, Latinos, and those identified with other races having statistically significant higher odds than White participants. The authors urge the need for social change to combat systemic racism, especially in the setting of the COVID-19 pandemic, and call for better access and adaptation to telehealth for all races, ethnicities, and socioeconomic groups.
· Anthropologists from Austria and Pakistan offer multiple reasons why COVID-19 may overwhelm low-income countries, using Pakistan as an example. The authors discuss risk factors such as economic disparities, lack of sanitation facilities, and distrust towards governmental actions, and outline how such factors will hinder the recovery process of struggling countries.
—Epidemiology: A retrospective study in New Jersey compared patients admitted from March 1-14, 2020 (control group) to patients admitted March 18-31, 2020 (COVID-era group) and found that the number of trauma admissions decreased by 44.9% in the COVID-era group, with the length of stay and injury severity scores being significantly reduced in the COVID-era group. The COVID-era group had fewer falls and motor vehicle collision patients, but more self-inflicted injuries suggesting that stay at home orders implemented to reduce the transmission of COVID-19 resulted in less severe and fewer numbers of trauma injuries, but may have increased psychological stress in the population.
· A retrospective cohort study of 496 COVID-19 patients in Singapore found clinical features including anosmia and dysgeusia were more predictive of COVID-19 cases among patients with acute respiratory illness compared to abnormalities in laboratory results and radiographic images.
—Transmission & Prevention: A news article by The Journal of the American Medical Association (JAMA) discusses COVID-19 vaccine development, highlighting advances in mRNA vaccines from SARS-CoV-2 RNA sequencing with benefits including ease of laboratory production without growth in eggs or cell lines, making large scale development and manufacturing more feasible. Authors suggest that a functional COVID-19 mRNA vaccine may be a viable option for commercial production and could aid in advancement of vaccines for other diseases such as human immunodeficiency virus (HIV), herpes simplex virus (HSV), and influenza.
—Adjusting Practice During COVID-19: Retrospective review from the Journal of Knee Surgery evaluated the enhanced recovery after surgery (ERAS) protocol which sought to reduce length of hospital stay and complications for post-operative patients. When comparing cases of knee arthroplasties from the last quarter of 2019 (199 cases) to that of the first quarter in 2020 (76 cases), patients during the COVID-19 outbreak had shorter lengths of inpatient stay without significant changes to the complication or readmission rates.
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—Understanding the Pathology: An observational study of 67 COVID-19 non-ICU patients (45 male, 22 female) admitted to COVID Hospital of Policlinico of Bari, Italy investigating the role of IL-6 levels in loss of taste/smell found a statistically significant correlation between decreased IL-6 and improvement in smell (p<0.05) and taste (p=0.047) (Table 3). The authors believe these results highlight the local inflammatory actions of IL-6 on chemosensory receptors, resulting in taste and smell disorders in COVID-19.
· A neuropathology research group affiliated with Harvard Medical School in Boston report on autopsy and clinical neurologic findings in 18 patients who died within 32 days of COVID-19 symptom onset. All patients had confusion and decreased arousal prior to death, and all brains showed signs of acute hypoxic injury with loss of neurons in cerebral cortex, hippocampus, and cerebellar Purkinje cells, but without thrombi, vasculitis, or viral staining on immunohistochemistry. Authors suggest these findings indicate neuropathological damage associated with COVID-19 cannot be specifically attributed to the virus alone.
—Adjusting Practice During COVID-19: Researchers from the Radiology department at University Hospitals Cleveland Medical Center/Case Western Reserve University conducted a retrospective study to assess imaging utilization in the emergency departments of a multicenter health system. They found a 46% reduction in imaging utilization (p less than 0.0001) with the exception to non-contrast chest CT (increased during this period, p = 0.0053), and non-trauma chest/abdomen/pelvis CT (largely unchanged in imaging use, p = 0.0633). The authors suggest that their findings shed light on how the pandemic has influenced ED imaging utilization, encouraging other institutions to publish data on their imaging practices for a comprehensive picture of the pandemic’s impact.
· Healthcare professionals affiliated with the Universidade Federal de São Paulo in Brazil performed a comparative cohort study at their institution of pregnant women admitted in spontaneous labor (n=41 in 2019; n=40 in 2020). They found that in 2020 there were more deliveries within 3 hours of admission (11/41 or 26.8% in 2019; 16/40 or 40% in 2020), more nulliparous women (9% in 2019; 12.5% in 2020), fewer women with multiple pregnancies (54.5% vs 43.7%), and a lower percentage of newborns weighing less than 2500g (18.1% vs 12.5%). The authors suggest that gravid patients are presenting to the hospital in advanced stages of labor due to decreased public transportation and fear of COVID-19 infection and urge hospitals to encourage these patients to seek care.
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—Epidemiology: Public health experts affiliated with Indiana University estimated the infection fatality ratios (IFR) of SARS-CoV2 based on antibody tests in a random sample of residents aged 12+ in Indiana. The average age of decedents was 76.9 (SD 13.1). 1099 COVID-19 deaths were recorded and the average IFR was 0.26%, but stratified IFR varied by age: >60yo IFR 1.71%, <40yo IFR 0.01%; and by race: whites IFR 0.18% and non-whites IFR 0.59%. These results from the SARS-CoV-2 population prevalence data suggest that risk of death increases with age and varies by race.
· A retrospective single center study (Hospital of the University of Paris, France) of 100 adult patients with confirmed SARS-CoV-2 admitted to the ICU, 81/100 of whom had mortality-associated varying severity of acute kidney injury (AKI), found no statistically significant association between complement activation/inflammatory markers (C3, IL-6, ferritin) and AKI as defined by urinary output and the Kidney Disease Improving Global Outcomes (KDIGO) criteria after adjusting for confounders.
—Understanding the Pathology: Cardiologists at Johns Hopkins University School of Medicine and Harvard Medical School discuss how direct and indirect SARS-CoV-2 triggered endothelial exocytosis could be responsible for widespread thrombosis and hyper-inflammation seen in patients with severe COVID-19, proposing that endothelial exocytosis releases secretory granules containing von Willebrand factor (VWF) and P-selectin thus causing platelet aggregation and leukocyte adherence, resulting in microvascular obstruction and release of pro-inflammatory cytokines. Authors suggest better understanding the role of endothelial exocytosis by SARS-CoV-2 and underlying mechanisms could provide potential therapeutic targets for novel drug development and drug repurposing.
—Transmission & Prevention: A case series conducted by infectious disease experts at Luigi Sacco University Hospital in Milan, Italy found that among 7 patients persistently carrying SARS-CoV-2, treatment with an Atomix Wave kit to wash their nasopharynx with 3% H2O2 solution for 14 days resulted in negative nasopharyngeal SARS-CoV-2 swabs for at least the first 48 hours (one patient tested weakly positive at 72 hours, and four tested weakly positive at day 7) and up to the full 14 days (2 patients). This study indicates that H2O2 washes could be used to disrupt viral shedding, and further studies with more intensive nasopharyngeal washing are required to determine if better viral
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—Epidemiology: Experienced scientists from the Center for Tobacco Control Research and Education at the University of California San Francisco conducted a meta-analysis of 19 peer-reviewed papers involving 11,590 COVID-19 patients. They found a positive association between smoking and severe progression of COVD-19. Authors suggest that while this data clearly shows smoking puts COVID-19 patients at increased risk for disease progression, the actual risk may be even higher due to limitations in the reviewed papers.
—Transmission & Prevention: Infection control experts from West China Hospital of Sichuan University in Chengdu discuss prevention measures implemented to protect healthcare workers (HCW) across China, including mask-wearing for workers, securing and providing personal protective equipment, using fluid resistant protective clothing and respirators, allocating specific hospitals for COVID-19 patients, and enacting strict community lockdown procedures.
—Adjusting Practice During COVID-19: Spanish dermatologists discuss a scabies outbreak in their region during the nationwide lockdown in March-May, 2020, with a three-fold increase in reported cases at a single hospital compared to the same period in the previous five years. Authors suggest that time spent in confinement increased fomite transmission and that individuals were less likely to seek treatment until the scabies lesions became more serious leading to more cases in family clusters, longer infection time due to reinfection, and the need for more aggressive treatment regimens to treat resistant infections.
—R&D: Diagnosis & Treatments: Lab scientists from the Tamil Nadu Veterinary and Animal Sciences University in Chennai, India reviewed the limited existing literature related to antibody-dependent enhancement (ADE) and its potential impact on the effectiveness of immunotherapy and vaccine development for SARS-CoV-2. Citing evidence from research on MERS-CoV and SARS-CoV, authors suggest ADE, which occurs when non-neutralizing or poorly neutralizing antibodies increase viral entry into cells, may intensify coronavirus infection. However, they propose targeting receptor binding motifs as a possible mitigation strategy.
—Mental Health & Resilience Needs: A representative panel survey of adults (n=5,470) conducted across the United States by Australian and American researchers found the mental health impact of COVID-19 disproportionately affected young adults, certain racial/ethnic minorities, essential workers, unpaid adult caregivers, and individuals with pre-existing psychiatric conditions. Authors recommend COVID-19-specific mental health interventions and prevention efforts be implemented to improve care for the at-risk populations identified by this study.
—Silver Linings: Utilizing data from the Epidemiological Surveillance Network from Madrid Autonomous Community, epidemiologists from Madrid, Spain compared the number of cases of reportable communicable diseases in the first quarter of 2020 compared to 2019.
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—Climate: An online survey of gay, bisexual and other men who have sex with men assessed changes in sexual behavior, prophylaxis use, and disease testing during the COVID-19 lockdown. Findings included a mean increase of 2.3 sexual partners during lockdown, HIV and other STI screenings were decreased in about a third of respondents, and lockdown prevented 8.9% of respondents from accessing HIV PrEP. This study suggests the need to help ensure that populations needing these services will have access to them, especially during the pandemic.
—Epidemiology: Post-discharge surveillance of 285 adult patients with COVID-19 in China showed that RT-PCR retested positive (RP) events occurred in 10% of cases within 15 days of discharge and were unlikely due to reinfection. The RP incidence, as well as clinical features and risk factors for RP patients found in this study, can inform COVID-19 post-discharge management in other developing countries.
—Management: Intensivists in Italy describe two COVID-19 patients admitted to the ICU who developed acute liver failure secondary to herpes simplex virus 1 (HSV-1). During their clinical course, both patients received hydroxychloroquine and tocilizumab, required ventilation assistance, developed signs of confusion or delirium, and succumbed to death. Based on these two cases, the authors suggest that "unbalanced use" of immunosuppressive agents in COVID-19 could contribute to secondary infections and argue for research into COVID-19 and its typical therapies in HSV-1 infection or reactivation.
—Adjusting Practice During COVID-19: A survey of 277 neonatal intensive care units (NICUs) globally found that the number of NICUs allowing 24-hour parental presence declined from 83% pre-COVID-19 to 53% during COVID-19 and 43% of NICUs reported a decrease in services for therapy, lactation, and/or social work. The authors warn against limiting parental presence, which can adversely impact the well-being and health of infants and their families.
—R&D: Diagnosis & Treatments: Medical researchers in Thailand conducted a study to explore the viability of saliva pooling as a cost-effective, less invasive alternative SARS-CoV-2 specimen for RT-PCR. The authors analyzed 40 pools of 5 samples and 20 pools of 10 samples. Their findings suggest that saliva pools are able to detect SARS-CoV-2 and, thus, may be an effective testing option in low prevalence areas. The authors note, however, that saliva pooling may be limited by viral RNA breakdown during storage protocol and freeze-thawing, leading to possible false-negative results.
· Investigators affiliated with Mayo Clinic working in collaboration with the United States Food and Drug Administration provide a safety update of the US Convalescent Plasma Expanded Access Program after transfusing 20,000 hospitalized patients with severe or life-threatening COVID-19 with convalescent plasma. Based on the results of these 20,000 patients, the authors suggest that the use of convalescent plasma is safe and carries no excess risk of complications. The authors also share that a future report will describe the efficacy of COVID-19 convalescent plasma therapy.
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—Epidemiology: Systematic review and meta-analysis of 42 studies including 23,353 COVID-19 positive patients estimated random prevalence of olfactory dysfunction to be 38.5%, taste dysfunction 30.4%, and overall chemosensory dysfunction 50.2% among these patients with Caucasians having a 3-6 times higher prevalence of chemosensory deficits (43.2%) than East Asians (15.1%). These results suggest that chemosensory dysfunction is a relatively common effect of COVID, though inter-study variability was high for this analysis.
· A retrospective observational study conducted in Wuhan, China found that among 126 patients with confirmed COVID-19 infection, 3 patients had a re-detected COVID-19 positive result via RT-PCR when tested 11-20 days after being discharged, but remained asymptomatic following discharge. This study suggests that while the reactivation rate is low, the window for COVID-19 viral shedding and virus reactivation may be longer than previously indicated and should be studied more thoroughly in order to guide public health measures.
· A cross-sectional study at Wuhan's Children Hospital of 216 COVID-19-positive pediatric patients (ages 2-12) found that 22.7% of these patients had ocular findings. The most common ocular manifestations included conjunctival discharge (55.1%), eye rubbing (38.8%), and conjunctival congestion (10.2%). Additionally, 9 children had ocular manifestations as their initial presenting symptom, although fever and cough remained the most common COVID-19 manifestations.
—Understanding the Pathology: A group of international interdisciplinary researchers performed real time polymerase chain reaction (RT-PCR) on 461 viral samples of 12 severely ill and 11 mildly ill COVID-19
—Management: Researchers performed a retrospective clinical analysis on 50 critical and 73 non-critical COVID-19-positive and found that lower lymphocyte count, high neutrophil to lymphocyte ratio, high platelet to lymphocyte ratio, elevated IL‐6 and C-reactive peptide, increased chest CT score, need for nutritional support and electrolyte imbalance may be used as prognostic markers of critical COVID-19 positive patients.
—Mental Health & Resilience Needs: Psychologists, pharmacists, and toxicologists in Canada surveyed a group of 320 participants to assess home, work and psychological factors and how they relate to alcohol use to cope with the COVID-19 pandemic. They found that having a child under 18-years-old was associated, higher levels of depression and lower levels of social connectedness showed increased coping tendencies to drink, and loss of income had a positive association with prior 30-day alcohol use, though no association was found between COVID-19 anxiety and drinking to cope.
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—Epidemiology: A study of 47 COVID-19 patients in JiangXi Province, China found that patients whose SARS-CoV-2 oropharyngeal nucleic acid tests turned negative slowly (over more than one week) were significantly more fatigued than patients whose tests turned negative rapidly (within one week), suggesting fatigue may be a clinical sign of persistent active SARS-CoV-2 infection.
· A case series found that out of 3,375 patients with Systemic Lupus Erythematosus (SLE), 3 were infected with COVID-19. All 3 were treated with various immunosuppressive therapies (including hydroxychloroquine) and needed escalating treatment regimens in conjunction with COVID-19 infection treatment. However, the low number of total infections among SLE patients suggests there is not a major burden of COVID-19 infection among the SLE patient population.
—Management: Cardiologists and Infectious Disease physicians analyzed the effect of hydroxychloroquine + moxifloxacin (HCQ + MOX) on corrected QT interval (QTc) in 76 COVID-19 pneumonia patients and found that QTc increased from a mean baseline of 424 ms to 442 ms after 5 days; however, there were no incidences of atrial or ventricular arrhythmia during the short, 5 day study.
· Obstetricians at Johns Hopkins reviewed 20 studies of COVID-19 positive pregnant women in the UK (n=618) and France (n=413) and found that severe COVID-19 is more likely in pregnant women than non-pregnant women and trans-placental infection of SARS-CoV-2 is rare but possible. Overall, however, the effects of fetal SARS-CoV-2 infection are poorly understood at this time and warrant further study.
—R&D: Diagnosis & Treatments: This review conducted by nanophotonic scientists from Spain provides an overview of current COVID-19 diagnostic techniques, while discussing optical biosensors and their potential as new COVID-19 diagnostic tools for intact virus detection, nucleic acid detection, and serological tests. The researchers argue that the application of nanophotonic biosensors for rapid point-of-care diagnosis and large-scale screening could support more efficient patient isolation and control of COVID-19 transmission.
· Italian immunologists conducted an observational longitudinal study of 20 admitted COVID-19-positive patients treated with baricitinib compared to a control group of 56 patients. They found that baricitinib modulates the immune system by inhibiting the over-tuned inflammatory response in COVID-19, including IL-1beta, IL-6, and TNF-alpha. The authors believe this trial of baricitinib exhibits promising results toward dampening the progression of COVID-19 infection to severe disease.
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—Epidemiology: Investigators affiliated with the Laboratorio de Investigacao Medica em Envelhecimento at Universidade de Sao Paulo performed a longitudinal, observational study on 707 COVID-19 patients admitted to a tertiary university hospital in Sao Paulo, Brazil and found that 33% (n=234) of patients had descriptors of delirium (confusional state, disorientation, hallucinations, etc;). Additionally, delirium was independently associated with length of hospital stay, ICU admission, and in-hospital deaths in adults older than the age of 50. Based on these findings, the authors suggest that healthcare workers shouldassess for delirium among COVID-19 patients, which may help monitor the severity and prognosis of these patients.
—Transmission & Prevention: Authors affiliated with several institutions in China performed a cross-sectional study on the daily COVID-19 cases,air quality, and meteorological factors in 33 locations in China. Among their findings, the authors note an association between relative risk of COVID-19 spread and air quality index (AQI) that was greater between 10 degrees Celsius and 20 degrees Celsius and a possibly stronger AQI impact on confirmed COVID-19 cases between the range of 10% to 20% relative humidity, respectively, suggesting that AQI may play a role in COVID-19 transmission in both low temperatures and low humidity, although further investigation is needed.
—Management: A literature review was conducted by pharmacists from Yale, Cleveland Clinic, and University of Pittsburgh regardingalternative drugs for managing analgesia, sedation, and paralysis in COVID-19 patients requiring mechanical ventilation in the event of drug shortages, as detailed in the summary section below. These conservative and alternative management strategies for mechanically ventilated ICU patients can ensure sustainability of optimum critical care in the near future as the COVID-19 pandemic wears on.
—R&D: Diagnosis & Treatments:A case-control validation study including 50 SARS-CoV-2 positive specimens and 300 SARS-CoV-2 negative specimens combined into various sized pooled samples was conducted in South Korea by physicians and infectious disease researchers, and found that less than or equal to 6 specimens was the ideal specimen number for apooled testing strategy to avoid decreasing sensitivity. Limitations of the study were as follows: the cutoff cycle threshold (Ct) number in the PCR kit was Ct value <35 within 40 amplification cycles, in addition to cost effectiveness not being analyzed. These findings help inform the upper limit threshold of number of specimens to process for COVID-19 pooled testing strategies to ensure high sensitivity.
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On today's episode we discuss:
· Smoking Is Associated With COVID-19 Progression: A Meta-analysis: Authors affiliated with University of California, San Francisco and Mahidol University conducted a meta-analysis (n= 19 studies between January 1 and April 28, 2020 from China, U.S., and Korea) of 11,590 total patients with COVID-19 and found that 731 of these patients reported a history of smoking.
· Household Composition May Explain COVID-19 Racial/Ethnic Disparities: A summary of a study by the Agency for Healthcare Research and Quality (U.S.), written by JAMA scientific news writer Rita Rubin, MA, explains that the higher observed death rates from COVID-19 in Black and Hispanic patients compared to White patients may be due to differences in exposure to the virus from work. A simple analysis of risk factors (e.g. age and preexisting conditions) does not explain the ethnic/racial disparities in COVID-19 death rates, but it may be explained by the fact that Black and Hispanic individuals are more frequently employed in a job where in-person essential work is required compared to White individuals.
— Management: Marked factor V activity elevation in severe COVID-19 is associated with venous thromboembolism: Pathologists from the Massachusetts General Hospital conducted a prospective cohort study of 102 patients with severe COVID-19 in March through April 2020, showing elevated Factor V activity at unprecedented levels in the hospital's history (median 150 IU/dL with 16% of values above 200 IU/dL), which was associated with thromboembolitic complications. The authors suggest Factor V levels may serve as an important diagnostic and prognostic marker for COVID-19, and recommend further investigation of increased anticoagulation doses for prophylaxis in patients with severe COVID-19 and markedly elevated Factor V activity.
· Heart Failure In Covid-19 Patients: Prevalence, Incidence And Prognostic Implications: Researchers within the departments of cardiology, clinical analytics, and pharmacy at the Hospital Universitario La Paz, Spain performed a single-center, retrospective study on 3,080 COVID-19-positive patients (with a 30-day or more follow-up) and heart failure. Based on this study's findings (illustrated below), the authors suggest maintaining heart failure guideline directed medical therapy (GDMT) when possible or re-instituting these regimens at discharge.
—Adjusting Practice During COVID-19: A Novel Non-contact Self-Injection-Locked Radar for Vital Sign Sensing and Body Movement Monitoring in COVID-19 Isolation Ward: A case series of two patients with COVID-19 in hospital isolation, conducted at Kaohsiung Medical University Hospital in Taiwan, investigated the accuracy of patient vitals collected by a novel contactless device, a non-contact self-injection-locked radar (Figure 1), compared to a nurse's vital sign testing. Over the course of patient isolation (13 days and 5 days), the patients' temperatures and heart rates were insignificantly different between the device's and nurse's measurements.
—R&D: Diagnosis & Treatments: Hydroxychloroquine for treatment of non-severe COVID-19 patients; systematic review and meta-analysis of controlled clinical trials.
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On today's episode we discuss:
—Climate: Primary care residents at Brigham and Women's Hospital in Boston discuss the importance of community health centers (CHCs) in serving low socioeconomic status, immigrant, rural, and racial/ethnic minority patients during the COVID-19 pandemic. The authors call for Congressional action to ensure adequate funding to CHCs and universal coverage to individuals without employer-sponsored insurance, suggesting that the pandemic may provide an impetus for improving the United States healthcare system so that CHC's could serve patients more effectively.
—Epidemiology: A multicenter cross-sectional study found that among 614 patients with confirmed COVID-19, 278 had elevated troponin levels, which was associated with higher in-hospital mortality. Those with elevated troponin levels were more likely to be older, have atrial fibrillation, heart failure, hypertension, and coronary artery disease. In the hospital, patients with elevated troponins were additionally more likely to have complications including sepsis, pulmonary embolism, delirium, heart failure, acute kidney failure, and major bleeding. This study suggests that running diagnostic tests and identifying patients with elevated troponins may help earlier identify patients requiring more intensive care.
—Understanding the Pathology: A retrospective study of 191 severe COVID-19 patients looked specifically at longitudinal IgM and IgG antibody responses to the nucleocapsid, spike protein, and receptor-binding domain of SARS-CoV-2. There was no significant difference in antibody positive rates between survivors vs non-survivors nor 28-day clinically improved vs non-improved patients. Four weeks after infection, patients who ultimately died had lower spike-IgG titers than survivors, and viral clearance was strongly associated with nucleocapsid-IgG and receptor binding domain-IgG titers, suggesting the possible use of spike-IgG as a predictor of adverse outcomes and the role of IgG as an important factor against SARS-CoV-2 infection.
—Transmission & Prevention: A medical news reporter discussed the herd immunity threshold for COVID-19, stating that determining this threshold is difficult with this virus due to the many uncertainties about the level at which people can act as vectors of disease spread. This author also suggests that even if herd immunity is be achieved, there is no guarantee that it would last.
—R&D: Diagnosis & Treatments: Epidemiologists in Spain examined the avidity of antibodies to SARS-CoV-2 in 76 serum specimens from COVID-19 patients to determine whether antibody avidity corresponded with time since acquisition of the virus. They found that 39 samples tested positive for both IgG and IgM, 37 tested positive for IgG only, and IgG reactivity was lost in 28 samples after urea treatment. Serum that lost reactivity were drawn significantly sooner after onset of symptoms than serum that retained activity suggesting that serum antibody avidity corresponds to the time since onset of symptoms and thus could be useful in predicting the acquisition date of SARS-CoV-2 infection.
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On today's episode we discuss:
—Climate: A group at USC's Keck School of Medicine identified public health concerns of COVID-19 risk in individuals who vape through systematic surveillance on Twitter. They discuss whether this population should be prioritized in COVID-19 screening and whether individuals should stop vaping as a preventive measure. They additionally identified posts sharing unsubstantiated health claims of vaping methods/products used to protect against COVID-19 and discuss the need for additional research in vaping and COVID-19 to combat misinformation.
—Epidemiology: A retrospective single-center study in Wuhan, China including 43 women of child-bearing age (17 pregnant and 26 non-pregnant) with COVID-19 found significantly higher neutrophil%, lymphocyte%, alkaline phosphates, and D-dimer among the pregnant cohort (p<0.001; Table 2), but no significant difference in hospitalization time, time from onset to diagnosis, time of viral shedding, or redirected positive tests. This data suggests no indication that pregnant women are more susceptible to severe adverse outcomes of COVID-19.
—Understanding the Pathology: Researchers in Rome, Italy performed molecular human leukocyte antigen (HLA) typing to compare 99 severe COVID-19 patients to over 1000 previously typed individuals and found a significant association between COVID-19 infection severity and HLA alleles DRB115:01, DQB106:02, and B*27:07. The investigators suggest HLA alleles may be markers of COVID-19 susceptibility but acknowledge a need for larger-scale studies to confirm these findings.
· Cardiologists based in Athens, Greece conducted meta-analyses to explore the relationship of smoking with disease severity and mortality of patients hospitalized with COVID-19 in China and the US. The first meta-analysis of 18 studies (n=6210) found that smoking was associated with a slightly increased risk of severe COVID-19—a difference that is more pronounced in younger patients without diabetes. Additional meta-analyses were inconclusive due to the small sample sizes and the findings are limited by poor-quality data and relatively low study heterogeneity.
—Adjusting Practice During COVID-19: UK researchers report the importance of using electronic self-assessments of patient health status or patient-reported outcomes in COVID-19 diagnosis, tracking, tracing and symptom monitoring citing multiple benefits of electronic self-assessments.
—R&D: Diagnosis & Treatments: A network meta-analysis of 4 randomized clinical studies including 2,049 moderate/severe COVID-19 patients on the effectiveness of remdesivir in COVID-19 treatment found that both 10-day and 5-day regimens of remdesivir corresponded with greater odds of clinical improvement and greater probabilities of clinical recovery as compared to the placebo group. However, the 5-day regimen resulted in greater odds of clinical improvement when compared to the 10-day regimen.
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On today's episode we discuss:
—Epidemiology: A retrospective study of 242 COVID-19 positive inpatients found that 19% had bacterial co-infection and those with bacterial co-infection had an increased risk of mechanical ventilation (44% vs. 17%) and death (50% vs. 15%) independent of demographics and co-morbidities. The authors suggest the concomitant bacterial infection is relatively common in COVID-19 inpatients and may be associated with increased patient mortality.
—Transmission & Prevention: Investigators at Guangzhou Blood Center, China assessed the presence of anti-SARS-CoV-2 antibodies in the blood of 2,199 volunteer blood donors. They found that of 7 total blood donors with positive serum-SARS-CoV-2 antigen reactivity, only 2 possessed antibodies (IgG and IgA) reliably derived from SARS-CoV-2 exposure. Based on these findings, the authors suggest that COVID-19 infection through blood transfusion is a fairly unlikely mode of transmission, although further investigation is needed.
—Management: A comparative cohort study by a French neuroradiology department found that patients with COVID-19 had more severe cases of anterior circulation large vessel occlusion (aLVO) based on lower clot burden scores, lower Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores, and higher infarct core volume. These findings suggest a higher in-hospital mortality risk in aLVO patients with COVID-19, and the authors raise concern that this predicting factor of poor outcome may lead to decreased treatment decisions provided to stroke patients, further worsening the prognosis of aLVO in the setting of COVID-19.
· Gastroenterologists from Madrid, Spain performed a cross-sectional observational study to determine the relationship of incidence, presentation, and severity between patients with inflammatory bowel disease (IBD) and SARS-CoV-2 infection. The researchers found that among the 82 of 805 IBD patients with confirmed or suspected COVID-19, there was no correlation between IBD and COVID-19 infection rates, severity of infection, nor any evidence that COVID-19 induces more frequent IBD episodic flare-ups and suggest that management of IBD can be continued without adjustment due to COVID-19.
—Mental Health & Resilience Needs: Researchers from the Philadelphia Care Foundation in the Netherlands conducted a retrospective, descriptive study on the use of the online support service DigiContact by individuals with intellectual disability and their loved ones during COVID-19 social distancing. They found that DigiContact usage was significantly greater during weeks of the COVID-19 outbreak when compared to the first 20 weeks of 2019 and the first 11 weeks of 2020, indicating that online social services can be important tools in maintaining social support for individuals with intellectual disabilities while adhering to exposure precautions in extenuating circumstances.
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On today's episode we discuss:
—Epidemiology: Australian systematic review and meta-analysis further confirm that patients with chronic disease are at higher risk for worse outcomes with COVID-19. The most common comorbidities were hypertension (22%), diabetes (14%), and cardiovascular diseases (13%). Crude case fatality rate (CFR) was 7% overall but increased significantly with an increasing number of comorbidities.
—Understanding the Pathology: A retrospective cross-sectional study by Chest Diseases specialists in Turkey enrolled 123 adult COVID-19 pneumonia patients with pulmonary infiltrates on CT chest (34 mild, 89 severe), comparing 91 BCG-vaccinated and 32 unvaccinated patients and found increased age (p<0.001) and low income (p<0.001) to be predictors for severe pneumonia, whereas BCG vaccination was not found to be associated with severe COVID-19 pneumonia.
—Management: A prospective study, conducted by fungal experts from the Center of Expertise in Mycology in the Netherlands, of 108 mechanically ventilated COVID-19 patients with ARDS to assess for the prevalence of pulmonary aspergillosis found a 27.7% incidence of COVID-19 associated pulmonary aspergillosis (CAPA), with a 25% lower survival rate among this population than in the non-CAPA patients (19% vs 44%). A correlation between bronchoalveolar lavage (BAL) Galactomannan-index (GM) and odds of death was observed, justified by lower mortality, and reduced GM-index in 11/19 CAPA patients receiving voriconazole and indicated the importance of early identification of clinical and host risk factors for CAPA in critically-ill COVID-19 patients.
—Adjusting Practice During COVID-19: Cardiologists conducted a prospective cohort study at two referral centers (n=1,372 heart failure [HF] patients) in London, England from January 7th, 2020 to June 14th, 2020 and found HF hospitalizations decreased during the COVID-19 pandemic as compared to 2019 (p<0.001) but in-hospital HF mortality significantly increased (p=0.015) and hospitalization for HF in 2020 was independently associated with worse outcomes (hazard ratio: 2.25, p=0.002). Authors suggest patients hospitalized for HF may be at higher risk for adverse outcomes during the COVID-19 pandemic and further investigation of prognosis predictors is needed to inform on management within this population.
—R&D: Diagnosis & Treatments: A retrospective observational study conducted at Third Hospital in Wuhan, China involving 191 COVID-19 patients and 50 healthy controls investigated the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) discrepancies among the infected patients and controls.
—Mental Health & Resilience Needs: A survey study conducted by special education and child development experts from California and Oregon interviewed 77 primarily Hispanic parents of children aged 3-5 who have intellectual and developmental disabilities (IDD) to determine the impact of and challenges that the COVID-19 pandemic has brought upon their families.
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On today's episode we discuss:
—Climate: Physicians affiliated with the Icahn School of Medicine at Mount Sinai, Harvard School of Medicine, and Duke University Medical Center consider the downside of "pressurized research" in the context of previous healthcare crises and reflect on the shortcomings of poor research that have occurred during previous calamities, including the secondary pneumonias that followed trials of immunotherapies during the 1918 influenza epidemic and cases of Guillain–Barre syndrome following swine flu vaccination in 1976. The authors recognize the challenges to meet demands for effective therapies and vaccine development, however, they urge for caution and humility in research during the current pandemic to avoid such shortcomings.
—Epidemiology: Researchers from the Brown University Department of Epidemiology and Department of Medicine examined data from the COVID-19 Data Repository at Johns Hopkins University to determine the relationship between United States state stay-at-home orders and SARS-CoV-2 doubling time in each state and found that stay-at-home mandates correlated with virus doubling times from 2.68 days prior to mitigation efforts to 15 days after. Additionally, states without stay-at-home orders saw an increase in doubling time of 34% whereas states with stay-at-home orders saw a increase of 72%. Although limited by surveillance data, these findings support that present efforts at social distancing help control COVID-19 spread within communities.
A team of global health and computational biology experts from Stanford University discuss how artificial intelligence (AI) has contributed to racial disparities during the COVID-19 pandemic.
—Management: A retrospective cohort study using Electronic Health Record (EHR) data from the Mayo Clinic Health System in Rochester, Minnesota found 246 COVID-19 positive patients had higher plasma fibrinogen levels and lower platelet counts than COVID-19 negative patients (n=13,666) at time of testing but as the infection progressed COVID-19 positive patients showed declining fibrinogen and increased platelet counts, while 31% (n=76/246) developed at least one clot diagnosis . Authors suggest that understanding the evolution and range of COVID-19 associated coagulopathy (CAC) may provide insight for advancement in thrombophylaxis therapy.
—Adjusting Practice During COVID-19: Members of the Neuroscience Section at the University of Milan in Italy propose guidelines for care of patients with neuromuscular disorders (NMD) during the SARS-CoV-2 pandemic recommending outpatient care, minimizing immune-compromising medications and in-person interactions, and maintenance of regular follow-up by utilizing telehealth. Additionally, they suggest providers caring for NMD patients admitted to the hospital with SARS-CoV-2 consider which medications have NMD side effects and consult neurologists for all such patients., suggesting that these measures can optimize outcomes for this group at increased risk for severe disease course.
—R&D: Diagnosis & Treatments: A meta-analysis of 40 studies conducted across 31 provinces in China of severe and critically-ill COVID-19 patients (n=5,872) found severe disease was associated with older age.
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On today's episode we discuss:
—Climate: In this study, investigators from Canada compared mean change in driving from baseline (using Apple Mobility Trends) and COVID-19 mortality rate as of April 30th, 2020 in 36 countries with the highest number of COVID-19 cases globally, excluding those for which driving distance data was not available. They found decreased driving to be associated with lower COVID-19 mortality ( p<0.001), highlighting the importance of social distancing measures to curb the spread and mortality associated with COVID-19.
—Epidemiology: Newborns of COVID-19 mothers: short-term outcomes of colocating and breastfeeding from the pandemic's epicenter: A retrospective cross-sectional study conducted at Elmhurst Hospital Center, New York between March 19 and April 22, 2020 by researchers from Icahn School of Medicine at Mount Sinai found 73.3% of newborns of SARS-CoV-2 positive mothers were roomed-in together (94% also breastfed) and 6.7% overall tested positive for COVID-19, but none required NICU admission for SARS-CoV-2 related illness. Authors suggest that rooming-in and breastfeeding newborns of mothers with COVID-19 may be low risk and could provide educational opportunities regarding isolation, PPE use, and safe breastfeeding to equip mothers to better care for their newborns at home.
—Understanding the Pathology: A literature review by interdisciplinary researchers in Iran examined bacterial co-infection and secondary infection in patients with COVID-19 and discuss numerous possible microbiologic mechanisms including elevated bacterial adhesion, impaired mucociliary clearance or chemotaxis, reduction of surfactant levels, and enhanced susceptibility via immune cell dysfunction. The authors hope these findings will promote understanding of pathophysiological mechanisms, which can assist in developing novel management and control strategies in COVID-19 patients with bacterial co-infection.
Transmission & Prevention: Among these 29 seropositive individuals (59% of whom did not self-isolate), 15 had anosmia, which was the only positive predictor for seropositivity (OR 18.2, p<0.001), while 10/29 were completely asymptomatic, indicating the need for frequent testing for staff in maternity units (and beyond) to minimize risk of transmission. A cross-sectional study of 200 healthcare professionals conducted in the UK from 2 tertiary-level maternity units from May 11, 2020 - June 5, 2020 investigated prevalence of IgG anti-SARS-CoV-2 immune seroconversion among the healthcare professionals. They found that 5/40 anesthetists, 7/52 obstetricians, and 17/108 midwives were seropositive (total 29/200, 14.5%).
—Management: A cross sectional study conducted in Wuhan, China from January 1 to February 8, 2020 by Zhongnan Hospital of Wuhan University followed 108 patients with mild COVID-19 treated with oseltamivir and found that the majority self-reported nearly full adherence to a 14-day home isolation protocol, though fewer patients maintained separate toilets and daily exercise (22.2% and 47.2% vs. 70% for other measures). Nearly half (45.37% [n=49]) of patients had negative SARS-CoV-2 PCR at 14 days, and authors suggest that home isolation along with regular contact between patients and doctors could be an effective strategy for saving medical and social resources.
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On today's episode we discuss:
—Climate: An author affiliated with the Department of Health & Human Performance at the University of Tennessee presents the 2018 Social Vulnerabilities for the American Indian and Alaska Native people (AIAN) by tribal geographic areas and calls attention to the high risk of contracting COVID-19 and its associated complications among the AIAN people. The author highlights the potential value of utilizing these resources in order to understand the COVID-19 impact on AIAN communities and their ability to recover from the pandemic.
—Understanding the Pathology: A group of pharmacists and toxicologists in Spain discuss neurological invasion by SARS-CoV-2 and the therapeutic potential of high dose melatonin in limiting the neurological impact of the virus namely in its ability to reduce the permeability of the blood-brain barrier and counteract neuroinflammation.
—Management: A prospective study of 386 hospitalized patients admitted for COVID-19 in Iran found that the development of cardiac injuries was associated with a four-fold increase in-hospital mortality rate and that preexisting cardiovascular disease, malignancy, hypoxia, leukocytosis and lymphopenia upon presentation were independently associated with an increased risk of developing cardiac injuries.
· Endocrinologists at the University of Michigan observed that severe hyperglycemia and insulin resistance were associated with increased inflammatory markers among two diabetic COVID-19 patients at their facility. The authors share their guidelines and protocols for insulin regimens and monitoring inflammatory markers, suggesting that their protocol may improve glycemic control and, thus, patient outcomes in this population.
—Adjusting Practice During COVID-19: A survey conducted by the University of Illinois-Chicago Cancer Center among 609 patients with breast cancer found 45% of patients reported cancer treatment delays during the COVID-19 pandemic. Younger patients self-reported greater delays than older patients, with no significant differences found based on race, insurance, site of care, or cancer stage. These delays in cancer treatment for younger patients indicates potential for increased rates of disease progression, mortality, and pain due to delay, highlighting the need for protective processes and managing strategies for this vulnerable population during the pandemic.
· A study compared 30-day complication rates, readmission, and mortality among 183 hip fracture patients at a tertiary care center in Argentina prior to and during the COVID-19 pandemic. Results showed increased time waiting for surgery during the lockdown time period, as well as higher rate of thromboembolic events and a higher mortality rate during the pandemic.
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On today's episode we discuss:
— Epidemiology: A comparison of outcomes among COVID-19 patients with (n=21) and without (n=236) chronic hepatitis B virus (HBV) infection found that a similar proportion of patients in both groups progressed to severe disease and exhibited at least one transaminase elevation, suggesting that chronic HBV infection does not appear to affect COVID-19 outcomes.
· A systematic review and meta-analysis including 5829 COVID-19 pediatric patients found that in general, nonspecific symptoms such as fever and cough were very common in these patients as were normal white blood cell counts. Additionally, among children younger than 1 year, there was a relatively high incidence of vomiting (33%) as well as critical illness (14%).
— Understanding the Pathology: A genomic analysis using samples from 18 COVID-19 patients with no comorbidities (10 mild, 8 severe) found genome deletions near the Spike S1 and S2 cleavage sites in all of the mild cases and half of the severe cases. The authors propose that these deletions may result in free S1 protein which could compete with viral particles or act as a decoy to weaken the disease and modulate the virus’s virulence.
— Management: Seven critically ill patients diagnosed with COVID-19 underwent successful treatment consisting of early noninvasive-invasive sequential ventilation, prone positioning, and pharmacotherapy consisting of antivirals, anti-inflammatory drugs, immune-enhancing medications, and complication prophylaxis agents. All 7 patients were extubated following a median ICU stay of 12.9 days and discharged home, suggesting that this protocol may contribute to successful outcomes in critically ill patients with COVID-19.
— Adjusting Practice During COVID-19: The Irish College of General Practitioners discuss a remote care model they developed to facilitate patient access to opioid agonist treatment in Ireland during the pandemic and enable continued care for this vulnerable population while mitigating exposure and transmission of the virus.
— R&D: Diagnosis & Treatments: A case-control study at Johns Hopkins evaluated the clinical validity of serum antibodies to SARS-CoV-2 in 11,066 patients by using IgG/IgA assays. 60 patients tested positive for COVID-19 and shortly after an infection developed IgG that was sustained for up to 58 days. Furthermore, for every 2-fold increase in IgG, there was a 62% increase in the predicted odds of developing acute respiratory distress syndrome.
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Epidemiology
· A case report of a 29-year-old SARS-CoV-2 positive woman with minimal, mild symptoms who underwent an uncomplicated and successful vaginal delivery revealed the following in the placenta: 1. Evidence of general placental vascular malperfusion possibly due to hypertrophic arteriolopathy; notably, there were no signs of fetal malperfusion or micro-thrombi and 2. Presence of SARS-CoV-2 in chorionic villi endothelial cells. The authors posit that this case is the first report of placental SARS-CoV-2 in the setting of mild COVID-19 disease, where the patient had only symptoms of mild myalgias.
· In comparing hematological features in COVID-19 positive (n=30) and negative (n=40) children presenting to the emergency department in City Hospital Ankara, Turkey with symptoms of fever, cough, rhinorrhea, and sore throat, COVID-19 positive patients demonstrated neutrophils with lobulation abnormalities, vacuolated monocytes and lowered neutrophil and leukocyte counts (p=0.02). The lack of thrombocytopenia in children with COVID-19 may be responsible for the improved outcomes observed in children.
Understanding the Pathology
· Findings from an in-vitro study by authors affiliated with the University of Hong Kong and Hainan Medical University investigating the viral protein expression, replication kinetics, and host response in monocyte-derived dendritic cells (moDCs) and monocyte-derived macrophages (MDMs) upon infection by SARS-CoV-2 suggest that SARS-CoV-2-infected moDCs and MDMs in the lungs of COVID-19 patients may be a source of pro-inflammatory cytokine production, exacerbating the COVID-19 manifestation.
R&D: Diagnosis & Treatments
· A prospective study conducted at a Malaysian COVID-19 quarantine center of 217 asymptomatic adult males, where 160 tested positive, found a far greater SARS-CoV-2 detection rate using morning salivary samples (93.1%) when compared to nasopharyngeal swabs (52.5%) (p<0.001, 45.6% concordance, 47.5% discordance), suggesting that the higher accuracy of salivary analysis could play a role in improved diagnostics, decreasing direct healthcare worker-patient interaction and risk of transmission, improving transport preservation, reducing test wait time, and allowing for self-collection.
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Climate
· Dr. Melina R. Kibbe from UNC Chapel Hill in the Department of Surgery argues that the COVID-19 pandemic has disproportionately affected female parents working in academic and/or clinical environments with reduction in female manuscript authorship, citing drops in female-first authors (4%), female-last authors (6%), and female-corresponding authors (7%) from 2019 to 2020 in terms of published JAMA Surgery articles. She suggests that protocols should be put in place to alleviate this disparity, such as extending grant end-dates, incorporating offsetting work shifts, and increasing allowances for part-time work.
Transmission & Prevention
· Canadian researchers investigated the effectiveness of performing asymptomatic SARS-CoV-2 testing of hospitalized patients in Hamilton, Ontario during April 2020 when incidence of new daily cases in the community was 1.9 per 100,000 people. Of the 125 hospitalized adults who were tested, only a single patient tested positive (0.8%) and this patient had reported two weeks of fevers and cough, suggesting asymptomatic testing has “minimal utility” in populations with low prevalence of COVID-19.
Management
· A retrospective collaborative study by multiple specialties at First People's Hospital of Tianmen and Fudan University of 183 COVID-19-positive patients found that increased time from symptom onset to admission (HR=0.829), use of corticosteroids (HR=0.496; Figure 2), and use of oseltamivir (HR=0.416) were associated with a longer duration for viral shedding, while use of arbidol (HR=2.605) was associated with a shorter period of shedding. These findings suggest need for early admission and therapy, cautious use of corticosteroids and oseltamivir, and clinical studies on the efficacy of arbidol.
· A case report from the Department of Cardiology, Hospital Universitario de La Princesa in Madrid, Spain examined a 66-year-old male recently diagnosed with COVID-19 pneumonia who presented with acute inferolateral ST segment elevation due to coronary vasospasm (CV) that was detected via optical coherence tomography and invasive vasospasm (ergonovine provocation) test and reversed after intracoronary nitroglycerin administration. Authors suggest COVID-19 induced inflammation may result in CV and myocardial damage, which could also be a viable mechanism in patients with normal coronary arteries on angiogram.
R&D: Diagnosis & Treatments
· Biomedical engineers and medical researchers from the University of California have pioneered a 3D-printable portable imaging platform, TinyArray imager, for rapid use in reading coronavirus antigen microarrays (CoVAMs). It achieved results equivalent to the commercial microarray reader ArrayCAM 400-S in probing and imaging of coronavirus microarrays with COVID-19-positive and -negative sera, suggesting that the TinyArray imager will help to increase serosurveillance in tandem with containment and therapeutic developments.
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Epidemiology
· A recent case report describes an 18-year old male patient diagnosed with COVID-19 after presenting with fever, anorexia, and headache at a clinic on Reunion Island in the Indian Ocean. He later returned with fever, rash, dyspnea, and arthromyalgias and was discovered to be positive for dengue as well highlighting the importance to test for both conditions when clinically indicated.
Understanding the Pathology
· Single cell RNA sequencing of human kidney cells revealed that the expression of angiotensin converting enzyme 2 was highest in the proximal convoluted tubule cells and glomerular parietal cells providing cellular evidence of the means and location by which SARS-CoV-2 can cause direct kidney injury.
Management
· A literature review studied the clinical outcomes of 221 COVID-19 positive kidney transplant patients recipients and found that symptoms were predominantly respiratory with accompanying fever, lymphopenia and elevated CRP were each present in roughly 80% of patients, and 20% of patients died.
· A study conducted in Spain details the effects of an on-site medicalization program at 4 nursing homes with COVID-19 outbreaks in Spain. After implementation, COVID-19 mortality was decreased by 10-15% in the facilities that implemented the programs when compared to other outbreaks in long-term care facilities. These data suggest that medicalization programs such as this can greatly reduce the impact of COVID-19 on long term care facilities.
Adjusting Practice During COVID-19
· A cross-sectional study of adult emergency department visits across 7 medical centers in the United States found that the onset of the pandemic was associated with a decrease in ED visits of roughly 25% as well as reductions in diagnosis of cardiac, surgical, neurological, orthopedic, gastrointestinal, and chronic respiratory emergencies. These data add to the large amount of existing evidence that individuals may be avoiding care, even emergency care, during the pandemic.
R&D: Diagnosis and Treatment
· A group of clinicians from the University of Utah discuss the conflicting data that has emerged regarding corticosteroid use in treatment of COVID-19, citing studies that showed either mortality reduction of COVID-19 when treated with steroids, harm caused by steroid use, or no association between steroid use and mortality. They caution against use of steroids for COVID-19 until randomized clinical trials can be performed to clarify their impact on COVID-19.
· A study conducted in China found several differences in peripheral blood parameters between people infected with COVID-19, influenza, and a healthy control group. Among the differences, monocyte count and percentage of basophils were the key differences between COVID-19 and influenza, indicating their utility in differentiating between COVID-19 and influenza.
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Epidemiology
· Investigators at the CDC performed an analysis of COVID-19 cases from early in the pandemic and found that among the first case reported in each of 99 countries, 60% were in individuals with a history of travel to China, Italy, or Iran.
Understanding the Pathology
· A retrospective study conducted in Spain found that a cohort of 134 COVID-19 patients had significantly elevated levels of uroporphyrin I, coproporphyrin I, and coproporphyrin III when compared to patients with COVID-19 negative pneumonia. These findings provide evidence to suggest that the accumulation of these markers may exacerbate heme shortages while also promoting oxidative damage and mitochondrial dysfunction in patients with COVID-19.
Transmission and Prevention
· A literature review by authors at John Hopkins and the University of California argues that wearing masks reduces disease severity by reducing the viral inoculum exposure of the wearer. The authors cite several countries, including South Korea, Singapore, Hong Kong, Taiwan, Japan, that have practiced population-level mask wearing and have low case fatality rates, suggesting the dual benefit of mask-wearing in allowing generation of herd immunity while preventing severe disease.
Management
· Investigators used data from 17 COVID-19 patients to assess differences in pulse oximetry (SpO2) and arterial oxygen saturation (SaO2) levels and found that SpO2 underestimated the SaO2 value by an average of 5.3%, which could cause overestimation of hypoxia in COVID-19 patients and administration of a higher inspired oxygen fraction than necessary.
Adjusting Practice during COVID-19
· A group of otolaryngologists reviewed 15 international recommendations to compile guidelines for sinus and anterior skull base surgery during the pandemic which include postponing elective surgeries, postoperative COVID-19 testing, and designating COVID-19 operating rooms.
R&D: Diagnosis and Treatments
· Researchers in Germany developed a novel in-cell enzyme-linked immunosorbent assay (ELISA) that can effectively quantify de novo synthesis of SARS-CoV-2 spike protein in fixed and permeabilized cells to offer a rapid and quantifiable detection method of the virus for use in future research.
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CLIMATE:
· An article by Talha Burki in The Lancet argues that the COVID-19 pandemic has had a more negative impact on women compared to men across the globe. She suggests this is in large part due to the indirect effects of the pandemic on women's health, such as an increase in economic, social, and political disparities between men and women, increased domestic violence against women, and decreased access to care for pregnant women. In short, despite COVID-19 causing a disproportionately higher number of deaths in men, there is mounting evidence that the indirect effects the pandemic has on women may even be worse.
· In the article titled, “Should Pediatric Patients Be Prioritized When Rationing Life-Saving Treatments During the COVID-19 Pandemic”, ethicists discuss whether age should guide rationing of scarce life-saving resources after a pediatric hospital sought to establish guidelines for the use of extracorporeal membrane oxygenation (ECMO) devices based on age. The authors recommend a multi-pronged approach in allocating resources by prioritizing the "worst off" and maximizing benefits based off of prognosis, saving the most lives, extending life-years, an individual's instrumental value in society, and treating people equally with dignity.
MANAGEMENT:
· Physicians in Seattle, WA describe characteristics and basic outcomes of a retrospective cohort of 83 adults hospitalized with COVID-19 between March 16, 2020 and April 17, 2020, 42 of whom received the IL-6 antagonist tocilizumab with 41 matched controls. They found overall mortality was similar in both groups, but patients with severe illness treated with tocilizumab had lower mortality by day 7 compared to controls (14.2% vs. 28.6%) and critically ill patients (14.2% vs 28.5%). The authors imply tocilizumab may improve outcomes for select patients and suggest randomized controlled trials are warranted to better understand its potential benefits.
ADJUSTING PRACTICE DURING THE COVID-19 PANDEMIC:
· A review by the American Heart Association discusses several ways healthcare workers can provide critical care for COVID-19 patients that have sustained concurrent cardiopulmonary complications including ARDS, MI, and pulmonary circulatory disease. The article additionally outlines proper use of PPE, limiting exposure to COVID-19, and following pre-planned procedures to deal with these diseases as means to help promote safety for the patients and the providers.
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CLIMATE:
· This review, composed of a literature review and anecdotes from the authors' students, highlights that the fact that a greater percentage of African Americans have succumbed to COVID-19 than other racial and ethnic groups, and discusses economic and social challenges faced by the Black community during the pandemic. The authors advocate for further analysis now and post-pandemic to determine the impact of structural racism and identify strategies to mitigate these disparities (including access to care, improving the education system, and voting rights).
EPIDEMIOLOGY:
· A case report and case series of COVID-19 patients who had concomitant co-infection with Dengue and Tuberculosis highlight the need to avoid both availability bias and premature closure when diagnosing respiratory disease during the pandemic. This will be especially crucial as cold/flu season approaches.
ADJUSTING PRACTICE:
· A group of pulmonologists discuss the effects of COVID-19 on patient care and propose recommendations to restructure clinical practices and workflow in order to avoid delays in patient care and decrease transmission during the pandemic. They recommend the following structural changes before, during, and after clinic visits:
o Before the visit - Implement systems for telephone screening for COVID symptoms and triaging by acuity. - Allow “high-risk” staff to work virtually. - Asymptomatic testing for all patients prior to any potentially aerosolizing procedure.
o During the visit: - Ensure staff have adequate PPE. - Stagger clinic appointments to avoid crowding of lobby and waiting room. - Disinfect all rooms and equipment between patients.
o After the visit: - Transition to virtual appointments if possible.
- Develop a robust system for follow-up and continuity of care
R&D DIAGNOSIS AND TREATMENT:
· Emergency physicians from multiple California medical centers present a framework for point-of-care ultrasound (POCUS) integration into the clinical management of COVID-19 patients. These include utilizing POCUS to improve diagnosis, prognosis, and evaluation of cardiopulmonary complications. The authors stress the need for more research studies on COVID-19 that "progress beyond diagnostic accuracy" and begin to incorporate more patient-centered outcomes. Examples include performing serial POCUS exams to monitor clinical progression of cardiac dysfunction, the development of pulmonary edema, and distinguishing between the H-type (high elastance, low compliance) phenotype seen earlier in disease and the L-type (low elastance, high compliance) form of ARDS seen later in the disease.
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CLIMATE:
· Recent United States healthcare policy updates related to COVID-19 include: - The Supreme Court will be hearing California versus Texas to determine if the Affordable Care Act (ACA) is invalid due to the potential unconstitutionality of its “individual mandate” that implements a fine for citizens that do not have health insurance and opt out of coverage; this is a move that Democrats say poses extra risk during COVID-19 due to the potential for individuals to lose healthcare coverage - The House passed the Health and Economic Recovery Omnibus Emergency Solutions Act, which includes a special enrollment period for both ACA coverage and Medicare, broader vaccine coverage, and increased federal Medicaid matching - The House passed the Patient Protection and Affordable Care Enhancement Act, which will make ACA and marketplace subsidies more generous and expand Medicaid coverage for pediatric and postpartum care
MANAGEMENT:
· An opinion piece by the School of Nursing and Midwifery at Western Sydney University argues that health practitioners and policy makers should learn from the mistakes during the HIV epidemic, making a case for COVID-19 infected mothers to breastfeed their newborns (Figure 2) as opposed to bottle feeding during the COVID-19 pandemic. The authors believe infants will be more likely to thrive if COVID-19 infected mother and her child are allowed more skin-to-skin contact and close proximity (Figure 1), despite current SARS-CoV-2 status, suggesting practitioners and policy makers should support breastfeeding in new mothers.
ADJUSTING PRACTICE DURING COVID-19:
· The authors report a simple way to create a cover for the patient’s mouth during esophagogastroduodenoscopy by using a piece of non-woven fabric that can be attached to a patient's mouthpiece with a band around the head (Figure 1, Video in primary article). This covering should help to reduce the spread of coarse respiratory droplets during esophagogastroduodenoscopy and similar procedures to minimize the transmission of COVID-19.
R&D: DIAGNOSIS AND TREATMENT:
· A cohort study of COVID-19 patients (confirmed n=129, suspected n=20) conducted at Tianjin Haihe Hospital, China found sensitivity and specificity of lateral flow immunochromatographic assay (LFIA) and magnetic chemiluminescence enzyme immunoassay (MCLIA) to IgM and IgG were >90% with no significant difference when compared to real-time reverse transcription polymerase chain reaction (RT-PCR; p>0.05), while blood lymphocyte subset measurements revealed significant lymphocytopenia in. Authors suggest strong antibody (IgM/IgM) response but weak T-cell response in those with COVID-19 may cause difficulty managing inflammation, but LFIA and MCLIA could be useful in early COVID-19 detection and risk assessment regarding vaccine immunization and reinfection.
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On today's episode we discuss:
— Epidemiology:
Researchers from Thailand reviewed epidemiological data on universal Bacillus Calmette-Guérin (BCG) vaccination and found that countries without universal BCG vaccination have the highest number of COVID-19 deaths. They attribute this to the theory that the BCG vaccine enhances both adaptive and innate immune response for viral clearance though acknowledge that the supporting evidence is limited.
· A retrospective study including 442 patients with COVID-19 found that male sex was the factor most associated with greater illness severity. Additionally, older age, African American race, obesity, and pre-existing conditions such as hypertension and diabetes mellitus were associated with higher illness severity while individuals chronically using ACE inhibitors had less severe illness.
— Understanding the Pathology
· A case series from the Netherlands describes 4 young, previously healthy, male patients in their 20s (2 pairs of brothers from unrelated families) with severe COVID-19 who required mechanical ventilation in the ICU. Genetic sequencing of these patients found two different loss of function variants of TLR-7, resulting in diminished type I and II interferon activity when compared to healthy controls. These findings point to potential genetic predispositions that increase the risk of developing severe COVID-19.
Transmission and Prevention
· A study conducted at the National Biodefense Analysis and Countermeasures Center in Maryland, United States found that SARS-CoV-2 decays rapidly in simulated sunlight though the rate was dependent on the aerosol suspension matrix as well as the intensity of simulated sunlight, whereas the relative humidity did not significantly affect the decay rate.
Management
· A systematic review and meta-analysis of 14 studies, including 10,127 patients, explored the relationship between angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and the morbidity and mortality of COVID-19. Results revealed no increase in morbidity or mortality in COVID-19 patients taking ACEIs/ARBs and provides continued support for their safety amid the pandemic.
Adjusting Practice During COVID-19
· Surgical oncologists from Massachusetts General Hospital created a risk stratification scoring system for breast cancer patients whose surgeries were delayed due to COVID-19. The score considers patient and tumor characteristics, length of delay, and tumor response to neoadjuvant chemotherapy and was found to agree with experienced surgeons' judgement when validated. The authors offer this score as a tool to prioritize higher risk patients as surgeries resume.
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On today's episode we discuss:
— Climate: The Immunization Action Coalition and the Vanderbilt School of Medicine discuss the progress of developing a COVID-19 vaccine, detailing the 11 vaccines in phase 1/2 clinical trials and the inclusion of multiple countries in the development of a Target Product Profile, a tool for quantifying critical vaccine characteristics. The authors emphasize the need for well-established infrastructure and logistical planning in order to distribute a potential COVID-19 vaccine safely and effectively to the world in a timely manner.
— Epidemiology: Researchers in the United States and United Kingdom used Twitter data to predict human mobility in and out of China and estimate global spread of COVID-19 and found a high correlation between country-level Twitter user visits and reported COVID-19 cases. These findings highlight the utility of geolocated platforms for public health authorities to develop response protocols and assess impending risks of COVID-19.
— Transmission and Prevention: Based on literature of prostaglandins in SARS-CoV-1 and MERS-CoV, a group from the University of Edinburgh cite the potential roles of multiple prostaglandins (including PGD2, PGE2, PGI2) in the pathogenesis of COVID-19 and consider the possible benefits of NSAID usage in COVID-19 patients.
— Management: A study found that among 59 patients with symptoms consistent with COVID-19, fibrinogen levels were markedly higher in patients who ultimately tested positive on RT-PCR compared to those who tested negative. Additionally, the neutrophil-to-lymphocyte ratio was increased in critically ill COVID-19 patients. These results suggest that fibrinogen may have value as a diagnostic marker in patients with suspected COVID-19 and that neutrophil to lymphocyte ratio may be useful as a prognostic marker indicative of COVID-19 disease severity.
— Adjusting Practice: A cross sectional study of 26 heart failure patients found a 16.2% decrease in daily step count on wearable accelerometers during the first 3 weeks of quarantine compared to regular activity suggesting that widespread COVID-19 quarantine mandates were detrimental to physical activity habits in these patients. These findings highlight the importance of physical activity during the pandemic in reducing deterioration in cardiovascular health.
— R&D Diagnosis and Treatment: Investigators in China measured SARS-CoV-2-specific antibodies among moderate and severe COVID-19 patients as well as non-COVID-19 patients and found that IgA and IgG were higher among severe patients compared to moderate patients whereas no difference was observed between the groups in IgM. Based on their findings, the authors suggest that IgA-IgG serological diagnosis of COVID-19 may be more effective than the traditional detection of IgM-IgG combined antibodies.
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On today's episode we discuss:
— Climate: A cross-sectional study surveying 128 researchers, clinicians, and academic personnel showed that 63.3% found social media to be the most important source of information while 67.2% found it to be misinformation. A majority of the respondents supported mandatory peer review and organization of a trustworthy COVID-19 database to combat potentially deadly misinformation.
A systematic review and meta-analysis evaluating 14 qualifying studies claims to have found that COVID-19 patients with a BMI exceeding 25 kg/m^2 had worse prognosis in all age groups, especially the elderly population, suggesting that this population should be "given special attention to reduce morbidity and mortality associated with COVID-19 infection" to limit their moderate-to-high complication risk.
A survey study conducted in London, England by Imperial College London found among 167 St. Mary's Hospital healthcare workers, 44% attested to self-quarantining during the past 4 months due to symptoms consistent with COVID-19 and 54% of symptomatic workers tested RT-PCR positive. Since previous infection and positive antibody tests do not necessarily indicate immunity, this study suggests a possible massive shortage of healthcare workers during the anticipated second wave of COVID-19 in November 2020 and calls for the creation of safety guidelines in order to prevent such a shortage.
— Transmission and Prevention:A retrospective study of presumed COVID-19 negative patients (n=103) conducted at four inpatient rehabilitation facilities (IRF) in New Jersey, USA found 6.8% of asymptomatic participants (n=7) tested positive for SARS-CoV-2 on admission (71% [n=5] of this group developed symptoms in 2-5 days), and overall 11.6% (n=12) tested positive within 14 days of admission. Authors suggest SARS-CoV-2 testing on admission to post-acute care settings is worthwhile for appropriate infection control regardless of symptom presence.
— Management:A systematic review of 46 case series and case studies with radiologic findings from 923 symptomatic and asymptomatic pediatric patients diagnosed with COVID-19 by RT-PCR found that:
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Chest CT was the most common imagining modality used
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Chest CT was able to detect radiological evidence of COVID-19 in 19% of asymptomatic patients.
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The most common abnormality seen on scans was ground-glass opacities (39%), and
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The most common location of lesions was the lower lobe of the right lung (40%).
These findings emphasize the need for further investigation of chest CT as a screening tool for COVID-19 in children and for study of other imaging alternatives like lung ultrasound to minimize exposure to radiation.
A case report conducted at the Department of Internal Medicine at Michigan State University highlights the case of a 29-year-old male who died from COVID-19 acute respiratory distress syndrome (CARDS) and ventilator-induced lung injury (VILI), displaying both phenotypes of CARDS, the milder type L form and the more severe type H form (which resembles full-blown ARDS). The patient's cause of death was a tension pneumothorax from VILI associated with type H CARDS. This case suggests the need for a better understanding of CARDS and transition to type H in order to prevent patients' entry to the VILI vortex and potential death from COVID-19.
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On today's episode we discuss:
— Epidemiology: Authors at Hubei Provincial Hospital of Traditional Chinese Medicine in Wuhan, China conducted a retrospective study of 4,254 cases across 6 types of nucleic acid collection sites and found that the highest proportion SARS-CoV-2 positive individuals at hospital wards (24.71%, n=84), close COVID-19 contact sites had the lowest (0.17%, n=1), and the most afflicted age group was middle-aged to elderly, suggesting a need for continued development in prevention education and safety protocols.
Researchers modeled the transmission of COVID-19 across Europe from Google and Vodafone data and found a greater drop in local COVID-19 cases in synchronous simulations (each country following the same intervention) compared to unsynchronized ones (elimination rate 5%). While the researchers acknowledge a population bias in the data, they recommend that countries coordinate lockdown efforts to further improve transmission rates.
— Understanding the Pathology: A literature review examining the neuroinvasive potential of SARS-CoV-2 showed potential mechanisms of central nervous system (CNS) infection include blood-brain barrier (BBB) disruption and infection of peripheral nerves leading to trafficking of virions into the CNS, leading authors to believe a government-regulated registry to routinely track COVID-19 patients with neurological manifestations may be critical to determine long-term health consequences, and note the possibility of neurodegenerative disorders as seen with other neurotropic RNA viruses.
— Transmission and Prevention:Physicians at Massachusetts General Hospital, Boston, review a recent study by Haver et al. (2020) regarding serosurveillance efforts to measure incidence of COVID-19 and suggest that the minimal herd immunity threshold in the United States is unlikely to be met as uncontrolled cases are increasing every day, in addition to evidence suggesting that acquired immunity may be temporary and short-lived. They propose implementation of active surveillance strategies including mass COVID-19 testing to better drive public health initiatives to contain the pandemic.
— Management:A retrospective cohort study of 398 hospitalized COVID-19 patients with cancer (n=45) and without cancer (n=353) at Beth Israel Deaconess Medical Center, investigated the incidences of thrombotic events at day 28 of hospitalization, and though acknowledging the study’s limitation in power, reported no significant differences between active cancer cohort, 14.2% (95% CI, 4.7%-28.7%), and non-cancer cohort, 18.2% (95% CI, 10.2%-27.9%). The researchers believe the overall elevated thrombo-inflammatory state of COVID-19 outcompetes a more moderate hypercoagulable state of cancer.
— Adjusting Practice: A review from authors in India of articles making recommendations on the management of solid tumors, hematologic cancers, and radiation/chemotherapy treatment during the pandemic found highly variable recommendations revealing the importance of examining new literature with scrutiny and also highlighting the need for sharing information to collect high quality and coherent data on COVID-19.
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On today's episode we discuss:
— Epidemiology: A meta-analysis of 2,765 patients in 6 studies conducted by authors at Lanzhou University in China found thattuberculosis (TB) was neither associated with increased mortality risk in COVID-19 patients (odds ratio [OR]=1.40, 95% CI: 0.10-18.93, p=0.80, I^2=31%) nor associated with an increased risk of developing severe COVID-19 (odds ratio [OR]=2.10, 95% CI: 0.61-7.18, p=0.24, I^2=36%), suggesting TB may not predispose individuals to COVID-19 related mortality, but based on having previous lung disease those with TB might have a higher chance of serious COVID-19.
— Understanding the Pathology: A cross-sectional study from 23 March to 12 May 2020 found that a majority of serologic testing samples across 10 US states (n=16,025) were negative for SARS-CoV-2 antibodies, with positive results ranging from 1.0% in San Francisco Bay to 6.9% in New York City, but the number of infections was still much greater than number of reported cases at all testing sites. Authors suggest those with asymptomatic or mild infections may not seek healthcare and are often unaware of SARS-CoV-2 infection, so the general public should continue taking preventive measures (i.e. wearing cloth face coverings, social distancing, washing hands, and staying home when sick) to reduce COVID-19 transmission.
— Transmission and Prevention: The Infectious Disease Surveillance Center and National Institute of Infectious Disease in Japan investigated the Diamond Princess cruise ship COVID-19 outbreak between January and February 2020 and 58 of 601 environmental surface samples from cabins with COVID-19 patients remained positive for SARS-CoV-2 RNA for up to 17 days after the cabin was vacated with no statistical difference between symptomatic and asymptomatic individuals. However, there was no evidence of viable transmission through air or wastewater samples, and no viral isolates were obtained from any sample suggesting proper disinfection and hygiene precautions are important in preventing direct and surface transmission during COVID-19 outbreaks.
— Management: Guidelines and recommendations for management of COVID-19 patients include a clinical algorithm for determining appropriate therapeutic strategies for concomitant atrial fibrillation
— Adjusting Practice During COVID-19: Guidelines and recommendations for adjusting practice during the pandemic include a set of triage algorithms and symptomatic management guidelines for geriatric patients diagnosed with or suspicious for COVID-19 infection.
Researchers from Spain assessed data on COVID-19 outcomes in an ongoing randomized controlled trial comparingthe use of ramipril to standard care following transcatheter aortic valve replacement and found that of 102 participants (50 ramipril, 52 control), 11 developed COVID-19 (5 ramipril, 6 control), yielding a hazard ratio of 1.150 (95% CI 0.351 - 3.768) for COVID-19 development with ramipril and found no difference in mortality between groups. Since ramipril did not result in higher COVID-19 incidence or mortality, the authors conclude that discontinuation of ACE-inhibitors as a precautionary measure may actually result in increased cardiovascular mortality.
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On today's episode we discuss:
— Epidemiology: A sharp peak in rates of intestinal obstruction (IO) during the lockdown period in Kerela, India (referred to as "lockdown belly") leads authors to propose four common risk factors, 75% are modifiable with diet and physical activity. These include: 60 years of age or older, prior abdominal surgery, strict adherence to lockdown restrictions, and poor quality diet.
— Understanding the Pathology: A cross sectional study from Columbia University that analyzed kidney biopsies of SARS-CoV-2 infected patients (n=17), revealed a spectrum of glomerular and tubular injuries, acute kidney injury (88%), and lack of SARS-CoV-2 detection in kidney cells as evidence against direct viral injury as a pathophysiologic mechanism of disease. Authors conclude that the principle nephrogenicity of SARS-CoV-2 likely results from ischemic damage and a dysregulated immune response.
'— Transmission and Prevention: A group of psychologists found that habit reversal training (HRT) was an effective method of treating repetitive behavior problems, such as face touching, and therefore may be an effective strategy for decreasing transmission of SARS-CoV-2. The principles of HRT are centered on mindfulness and behavior modification, and authors include a practical guide to implementing these practices.
— Management: italian authors describe how the anti-coagulant Defibrotide may be the “drug of choice” for treating the hypercoagulable state associated with severe COVID-19 disease because of its profibrinolytic, antithrombotic, and anti-inflammatory effects. These would theoretically protect from the growing evidence implicating the role of endothelial damage and a hyperinflammatory state in SARS-CoV-2 infection.
'— Transmission and Prevention:describes the effect of T cell imbalance, specifically between Treg and Th17, on uncontrolled systemic inflammation in severe COVID-19 cases in pregnancy found that: - Treg cells decreased and Th17 cells increased, with a consequent decrease in the Treg/Th17 cell ratio. - Treg cells dysregulation in COVID-19 was shown trigger hyperinflammation and tissue damage. - Increased Th17 is associated with fetal allograft rejection at the feto-maternal interface. - COVID-19 infection puts pregnant persons at higher risk for pregnancy complications.
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On today's episode we discuss:
— Epidemiology: A retrospective cohort study from New York found that all 16 patients with confirmed SARS-CoV-2 that received a lower extremity computed tomography angiogram (CTA) over a 3-month time period had at least one blood clot on lower extremity CTA compared to just 69% (n=22/36) in propensity-matched patient control data. Limb amputation was also more frequent in COVID-19 patients versus patient controls with peripheral vascular disease, and those presenting with limb ischemia and respiratory symptoms had higher rates of amputation and mortality (p=0.001). Authors use this study to further highlight the morbidity and mortality associated with COVID-19 coagulopathy.
— Transmission and Prevention: An analysis of contact tracing data from South Korea describes how age and proximity affect SARS-CoV-2 transmission within people living in the same household. They found:
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Household contacts had a higher risk of transmission, with 11.8% of household contacts positive for COVID-19 compared to 1.9% of non-household contacts.
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The highest rate of transmission was from the 10-19 year old age group (18.6%)
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The lowest rate of transmission was from the 0-9 year old age group (5.3%), which was likely a result of stringent social distancing due to the typically high rate of infection transmission in preschool and daycare settings.
— Management: A case report conducted at Changi General Hospital discusses a 45-year-old patient who was diagnosed with Hashimoto's thyroiditis following a COVID-19 infection, indicating a potential link between the hyper-inflammatory state caused by the SARS-CoV-2 virus and the development of autoimmune diseases.
— R&D Diagnosis and Treatment: An analysis of laboratory tests, imaging results, and vaginal swabs of 13 pregnant persons with suspected COVID-19 found that 12 tested positive for SARS-CoV-2 via RT-PCR from respiratory tract samples, but all vaginal swab samples tested negative. These findings add to the growing evidence that sexual or vertical transmission of SARS-CoV-2 is unlikely and may assist in decision-making regarding obstetrical management.
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On today's episode we discuss:
— Climate: Results of pooled data from the Medical Expenditure Panel Survey (MEPS) between 2014-2017 (100,064 person-year observations on adults ≥18 years) suggest differences in exposure via employment between races and ethnicities may lead to COVID-19 risk disparities in minority groups. However, other risk factors (age >65, obesity, tobacco use and comorbidities) also play an important role in severity of illness.
— Epidemiology: A systematic review (n=69 studies) and quantitative review (n=61 studies) of case-control, cohort, and cross-sectional studies demonstrate epidemiological evidence for an association of male gender, older age, and comorbidities with COVID-19 disease severity and prognosis, suggesting awareness of these associates can aid in prevention and individualized treatment but urge further studies exploring COVID-19-related factors.
— Understanding the Pathology: A structural analysis of the SARS-CoV-2 virus performed by the Gene Center at the University of Munich in Germany found the Nsp1 protein shuts down host protein translation by binding to the 40S ribosomal subunit, resulting in immune suppression, suggesting that the Nsp1 protein of SARS-CoV-2 could be the starting point for a structure-based drug design incorporating this Nsp1-ribosome interaction, allowing the host immune system to combat the virus.
— Transmission and Prevention: An evaluation of the effect of the South Korean response system responsible for early detection of COVID-19 in the Gyeongsangnam-do Province reveals that out of 17,400 tested residents and 111 positive cases (25 asymptomatic), only two individuals required mechanical ventilation and there were no reported deaths (January 24 - April 15, 2020). The authors believe that this response system's rapid quarantine protocol for positive cases, in addition to all their possible contacts, is responsible for these encouraging outcomes, giving a potential example for other countries to follow while combating the COVID-19 pandemic.
— Management: A systematic review of 204 kidney transplant recipients (74% men) with COVID-19 through 12 case series conducted in multiple countries from January 1 to June 4, 2020 found a higher mortality rate of 21.2% compared with a 5.8% mortality rate in the general population. Mortality was strongly correlated to advanced age, ICU admission, and intubation and a majority of the patients were treated with immunosuppression and hydroxychloroquine, 34% were admitted to the ICU, and 19.7% were administered mechanical ventilation.
— R&D Diagnosis and Treatment: A longitudinal study found that 21.1% of 217 laboratory confirmed, hospitalized COVID-19 patients had detectable SARS-CoV-2 RNA in anal swabs and that detectable viral RNA in anal swabs is associated with increased risks of disease severity, ICU admission, and development of gastrointestinal symptoms.
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On today's episode we discuss:
— Understanding the Pathology: · Highlights from a literature review conducted by a Japanese cardiologist:
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SARS-CoV-2 uses angiotensin-converting enzyme 2 (ACE2) receptors for cellular invasion.
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Renin-Angiotensin-Aldosterone System (RAAS) inhibitor drugs are not associated with a higher risk of mortality from COVID-19.
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An increased number of ACE receptors found in male and diabetic subjects may contribute to an increased susceptibility to the SARS-CoV-2 virus. In conclusion, the author urges more research on ACE2 and SARS-CoV-2 infectivity and whether medications for cardiovascular disease may affect disease severity and mortality.
— Transmission and Prevention: This survey conducted at 26 Detroit skilled nursing facilities (SNF) found that after two repeated point prevalence surveys (testing all healthcare workers regardless of symptoms), separated by a median time interval of 15 days (IQR=14-17 days), the percentage of positive test results for SARS-CoV-2 decreased from 35% (n=373/1063 residents, 26 SNF) to 18% (n=115/637 residents, 12 SNF). The findings suggest that repeated point prevalence surveys may reduce SARS-CoV-2 transmission rates by initiating infection prevention and control activities and the authors recommend frequent surveys of healthcare workers as testing availability increases.
— Management: · A case series of 5 COVID-19-positive patients in Italy found neurological manifestations (namely polyradiculoneuritis and cranial polyneuritis), clinical neurophysiology indications (conduction block, absence of F waves, etc.), and albuminocytological dissociation (in 3/5 patients) suggestive of Guillain Barré syndrome (GBS). Intravenous immunoglobulin (IVIG) therapy at 0.4 g/kg for 5 days partially resolved neurological symptoms in 4/5 patients. These observations suggest that clinicians should be aware of neurologic signs similar to GBS in COVID-19 patients and may consider the use of clinical neurophysiology and IVIG therapy in the management of these patients
— Adjusting Practice: A narrative review conducted by the Department of Emergency Medicine at Singapore General Hospital discusses how Singapore's largest hospital turned a multi-story car park (MSCP) into a flu screening area (FSA) during the COVID-19 pandemic. The authors label this FSA as a physical component of Singapore General Hospital's surge capability, highlighting its use as a means to confront the recent COVID-19 outbreak. This operation is yet another example of efforts to repurpose facilities to accommodate growing COVID-19 infection rates.
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On today's episode we discuss:
— Climate: A review of health-related workplace absenteeism in the United States during the pandemic found that workplace absenteeism during the pandemic had only increased in certain occupational subgroups: personal care service, healthcare support, and food processing. The authors postulate that this is due to the close interpersonal contact experienced in these occupations which creates a higher risk of COVID-19 transmission.
— Epidemiology: A case report describes an 11-year-old boy who presented with symptoms of Guillain-Barre Syndrome three weeks after COVID-19 infection. The authors discuss that Guillain-Barre is a rare but documented phenomenon in adult COVID-19 patients but believe this to be one of the first descriptions of the condition in a pediatric patient.
— Understanding the Pathology: A study of lab values in COVID-19 positive patients admitted to the ICU at Tongji hospital, Wuhan observed 12 thrombotic events in 9 patients with coagulation abnormalities which included lower natural anticoagulants, elevated Factor VIII, and presence of anti-phospholipid antibodies. In near-terminal patients, Factors V and VII were lower and prothrombin time was prolonged. These results suggest elevated Factor VIII and presence of anti-phospholipid antibodies may be involved in the etiopathology of COVID-19 hypercoagulable status, while lower Factor V and VII and prolonged PT may indicate advancing illness.
— Management: A systematic review and meta-analysis of 22 observational cohort studies on renal complications in COVID-19 found that acute kidney injury was the most widely reported renal complication followed by need for renal replacement therapy, electrolyte disturbances, and acidosis. Meta-regression found a significant association between preexisting chronic kidney disease and COVID-19 associated acute kidney injury suggesting increased risk in these patients.
— R&D Diagnosis and Treatment: American pathologists developed and evaluated immunohistochemical and in situ hybridization assays for tissue identification of SARS-CoV-2. They validated their methods through staining of COVID-19 autopsy samples including 8 lungs, 1 placenta, and 10 kidneys finding their protocols to be sensitive and specific for the virus. They provide protocols and reagent lists so that other pathology labs could easily replicate these techniques to study SARS-CoV-2 distribution across tissue types, allowing for a better understanding of tissue-specific pathogenesis.
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On today's episode we discuss:
— Climate: A group of interdisciplinary health professionals analyzed data on the spread of COVID-19 in 239 affected meat and poultry processing facilities and found that COVID-19 was confirmed in 16,233 workers with 86 related deaths. In the states reporting each figure, 9.1% of all workers had confirmed COVID-19 and 87% of cases occurred among racial and ethnic minority workers highlighting the need for focused preventive measures for these groups to decrease health disparities and occupational risks related to COVID-19.
— Understanding the Pathology:A group of researchers utilized rapid antibody discovery to isolate 389 recombinant SARS-CoV-2-reactive human monoclonal antibodies isolated from 4 SARS-CoV-2-infected patients and 1 healthy donor. They tested antibody binding and neutralizing potency against SARS-CoV-2 and found that those recognizing the viral S glycoprotein effectively neutralized the virus. These findings suggest a target site for vaccine and antibody treatment development and identify monoclonal antibody isolates as potential biologics to prevent or treat SARS-CoV-2 infection.
— Management:A review of several randomized control trials investigating the efficacy of Remdesivir treatment for SARS-CoV-2 infection found that in comparison to a placebo, Remdesivir showed reduced mortality and improved recovery time for hospitalized patients requiring low-flow oxygen but was ineffective for patients requiring high-flow or invasive mechanical ventilation. The authors suggest these results may indicate that Remdesivir could be a key pharmacological therapy for moderately-ill hospitalized patients with COVID-19.
— R&D Diagnosis and Treatment:Tulane University researchers present their CRISPR-based assay to diagnose SARS-CoV-2 infection, proposing that its benefits over traditional RT-PCR include an improved sample-to-answer time of roughly 50 minutes and that it does not require specialized laboratory reagents. They report the limit of detection of their CRISPR-based assays was 2 copies of the target RNA sequence--comparable to that of the gold-standard qPCR of 5 copies per test.
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On today's episode we discuss:
Climate:
— An opinion article by Swiss physicians titled “Is Clinical Effectiveness in the Eye of the Beholder?” warns against the implementation of treatments with unsound and incomplete evidence, arguing they may violate the principle of non-maleficence, or 'do no harm'. Hydroxychloroquine as an example of a drug that was widely adopted based off minimal in-vitro studies and unscientific promotion in the media. There is now a consensus that it does not offer therapeutic benefit and may have caused unnecessary harm through dangerous QT prolongation and diminished supply for patients with autoimmune diseases. The authors suggest that until effective treatments are proven, we should rely on social distancing and ensuring scientific journals and researchers are held to a high standard.
Understanding the Pathology:
— A simulation model estimating the possible effect widespread use of remdesivir in South Africa - where the death rate is estimated at 85%-100% among patients who cannot obtain intensive care due to the lack of available ICU beds – predicted a reduction in COVID-19 mortality by 635 to 6,862 deaths (out of a projected 36,383 to 47,820 ICU patients as estimated by the South African National COVID-19 Epidemiology model (NCEM). These results suggest that remdesivir may reduce mortality indirectly by reducing the duration of illness and freeing up ICU beds
Management:
— A case series of nine COVID-19 patients presenting with neurological symptoms discovered a common MRI finding of microbleeds in an unusual distribution (most notably the corpus callosum) suggesting a mechanism of damage to the endothelium of brain vessels (thrombotic microangiopathy) by SARS-CoV-2.
R&D DIAGNOSIS AND TREATMENT:
An interdisciplinary group from across the United States details the key factors that influence the Positive Predictive Value (PPV) and the Negative Predictive Value (NPV) of diagnostic testing for COVID-19, with the goal of enabling healthcare providers to better understand the implications of a positive or negative COVID-19 test result in the context of an unknown true prevalence of the disease in the population. Three key points include:
o For low disease prevalence, the sensitivity doesn't play a large role in the PPV or NPV; instead, the focus must be on having a very high specificity in order to achieve a clinically usable PPV.
o For high disease prevalence, neither the sensitivity nor the specificity has a major impact on the PPV; however, high sensitivity is needed to obtain a clinically relevant NPV, so the focus here must be identification of a test with very high sensitivity.
o In the situation where prevalence is neither low nor high, the sensitivity tends to influence the PPV and the specificity tends to influence the NPV, so increasing utility of a test in this situation can focus on improving either the sensitivity or specificity, or both.
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On today's episode we discuss:
-The relationship between the BCG tuberculosis vaccine and COVID-19 mortality
-More data on pediatric COVID-19 disease
-And research from the Netherlands begs the question “is social media now the preferred form of public education?
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On today's episode we discuss:
—Climate: A cross-sectional study of 640 adults found that COVID-19-related conspiracy theory (CT) beliefs correlated with pre-existing CT beliefs, lower education levels, and a negative perception of government responses. However, there was no correlation between CT beliefs and emotional stress during the pandemic.
—Epidemiology: A multicenter retrospective cohort study from Wuhan comparing pediatric and adult COVID-19 patients found children were more likely to be asymptomatic, have lymphocytosis (vs lymphopenia in adults) and were less likely to respond to anti-viral treatments.
—Management: A prospective clinical study from the University of Utah suggest that SARS-CoV-2 infection induces activating changes in the transcriptome and proteome of platelets, possibly contributing to the immunothrombosis observed in COVID-19 disease.
—Diagnosis and Treatment: Canadian authors describe policies implemented to reduce spread of infection in a 182-bed psychiatric facility, concluding that rapid identification of cases, aggressive testing for carriers, and swift movement of patients to isolation units are necessary to reduce nosocomial spread of COVID-19.
— Management: Spanish authors describe pulmonary parameters in COVID-19 patients with acute respiratory distress syndrome (ARDS), finding a lack of association between PaO2/FiO2 and static compliance of the respiratory system, and a significant increase in oxygenation with prone position. They propose the underlying hypoxemia in COVID-19 ARDS results from dysfunction in lung perfusion.
— Adjusting Practice: The authors argue that the emergency department is an unideal setting for making medical decisions regarding geriatric patients during the COVID-19 pandemic due to the paucity of critical information and the necessity for quick decisions. The authors suggest implementing diverse triage teams with administrative leadership, informing providers with regards to advanced directives, and delaying intubation until better decision-making can be made to improve patient outcomes and promote patient autonomy and beneficence.
—R&D Diagnosis and Treatment: A meta-analysis of chest CT features in 2,451 COVID-19 pneumonia patients found that vascular enlargement, ground glass opacities, interlobar septal thickening, and subpleural bands are the most common findings.
-An in vivo drug trial of Remdesivir in a rhesus macaque animal model found reduced pulmonary findings on chest radiographs, reduced viral titers on bronchoalveolar lavage (BAL), and reduced lung damage on pathology, suggesting early initiation of Remdesivir may provide clinical benefit in severe COVID-19 respiratory disease.
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On today's episode we discuss:
—Climate: A survey of 426 emergency physicians from seven medical institutions in California, New Jersey, and Louisiana found inadequacy of PPE, inability to quickly and accurately diagnose COVID-19, and fear of infecting family members to be the most salient stressors.
—Epidemiology: A systematic review and meta-analysis, including 148 articles comprised of 24,410 COVID-19 positive adults from 9 countries, found that the most common symptoms at presentation were fever (78%), cough (57%), and fatigue (31%), with prevalence of dyspnea in only 23% of patients. The authors conclude that the most common symptoms are fever and cough, although it is noted that these prevalence findings are about 10% less than previously reported.
—Management: A case series of 7 patients found that postmortem tissue samples from patients who died from COVID-19 pneumonia <7 days after onset of respiratory failure (RF) showed acute diffuse alveolar damage (DAD) while samples from those who died >14 days after onset of RF showed organizing DAD, with SARS-CoV-2 detected in tissues with acute DAD but not in tissues with organizing DAD.
—Diagnosis and Treatment:
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Analysis of three case series with conflicting data on mechanically ventilated COVID-19 patients indicated that: 1) low respiratory system compliance (Crs) may be associated with a higher gradient of arterial partial pressures of oxygen to alveolar partial pressures of oxygen (PaO2-PAO2) in COVID-19 respiratory failure, 2) positive end-expiratory pressure (PEEP) levels should be selected by measuring Crs, and 3) increasing tidal volume can reduce both serial dead space ventilation and parallel dead space ventilation. The authors suggest that clinicians focus on individual patient's needs when operating respirators given the heterogeneity in presentations of COVID-19 respiratory failure.
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A cross-sectional study conducted by Tulane University School of Medicine using 29 nasal swab samples and found that COVID-19 could be diagnosed within 50 minutes via a COVID-19 CRISPR fluorescent detection system (FDS) with 100% sensitivity and 71.4% specificity when compared to results obtained by a state testing laboratory via reverse transcriptase (RT)-PCR of the same samples
—Mental Health and Resilience:
- Authors of the Department of Addictive Behavior and Addictive Medicine in Mannheim, Germany evaluated the effect of social isolation on alcohol consumption during the pandemic through an anonymous online survey of 2,102 participants and found that 34.7% of participants reported drinking more alcohol since the lockdown began, highlighting the need for healthcare providers to stay informed on this increased alcohol consumption during the lockdown and to be aware of its potential long-term effects.
- A systematic review conducted at the Galatea Care Programme for Sick Health Professionals in Barcelona, Spain analyzed 30 studies and found a high prevalence of anxiety (30-70%) and depressive symptoms (20-40%) reported among healthcare professionals (HPs), raising concerns that increased psychological support is needed in these population.
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On today's episode we discuss:
—Climate: A survey of 2,402 adults in the United States found that 79.5% of respondents supported government-issued stay-at-home orders and nonessential business closures and 77.3% reported they were self-isolating at home suggesting that attitudes broadly support COVID-19 public health interventions.
—Epidemiology: A study of data on 1353 COVID-19 positive children found the three most common symptoms in these children were fever (21.7%), cough (15.4%), and abnormal breathing (8.1%) with the most severe manifestations, such as intubation or myocarditis, occurring in less than 0.7% of patients, and 1.9% of patients required ICU care.
—Transmission and Prevention: A report by the Center for Disease Control and Prevention of the COVID-19 outbreak that ocurred on the USS Theodore Roosevelt showed that 60% of respondents exhibited evidence of exposure to SARS-CoV-2 via positive neutralizing antibody assay, ageusia and anosmia were the symptoms most associated with current or previous infection among crew members, and 212 (90.2%) of the 235 respondents that reported a previous positive COVID-19 test via RT-PCR tested positive for neutralizing antibodies.
—Management: Guidelines for managing COVID-19 patients includes: Diagnosis, treatment, and prevention of venous thromboembolic disease and Donor and candidate selection for transplants.
—Diagnosis and Treatment:
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A retrospective study found that patients with diminished ovarian reserve who delayed in vitro fertilization treatment (to 90 -180 days from their first visit) had similar live birth rates transfer than those that did not suggesting that delaying IVF in these patients does not affect live birth rate. This data can facilitate decision-making concerning treatment delays and disruptions in this population during the COVID-19 pandemic.
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A meta-analysis of 22 studies assessing the diagnostic efficiency of anti-SARS-CoV-2 IgG and IgM tests found specificities of 99% in both tests and sentisivities of 85% and 74% for IgG and IgM respectively.
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Analysis of SARS-CoV-2 IgM and total antibody levels in 192 patients with severe or mild COVID-19 found no statistically significant differences between mild and severe COVID-19 cases within 6 days of disease onset; however, after day 6, severe cases exhibited higher IgM and a higher overall positivity rate for total antibody titers than that of mild cases. Further, 12/35 mild cases never exhibited IgM positivity and 5/35 remained negative for total antibody titers highlighting the possible limitations in antibody testing of patients with mild COVID-19
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On today's episode we discuss:
—Climate: A study conducted by the Center for Disease Control and Prevention of 2,402 Americans in May found widespread support of the implementation of public health orders such as stay-at-home orders, use of face coverings, and business closures, in response to the COVID-19 pandemic.
—Epidemiology: A cross-sectional study in Indianapolis found that 3.1% of 2,953 asymptomatic adults tested positive for SARS-CoV-2 by nasopharyngeal swab testing. Of the 81 SARS-CoV-2 positive participants who completed a follow-up interview, 71.6% remained asymptomatic at 14 days while the other 28.4% reported one or more symptoms.
—Management: A group of researchers in Toronto suggest SARS-CoV-2 disruption of the renin angiotensin aldosterone system (RAAS) leads to an endothelial imbalance that leaves the endothelium susceptible to inflammation, vasoconstriction, platelet activation, and thrombosis thus playing a major role in the disease.
—Diagnosis and Treatment: A study of 190 patients found that oropharyngeal/nares swabs and nasopharyngeal swabs had sensitivities of 91.7% and 94.4%, respectively, suggesting that oropharyngeal/nares sampling, which may be more readily available during the COVID-19 pandemic, is an effective alternative to nasopharyngeal swabs in ambulatory settings
—Mental Health and Resilience: Psychiatrists and addiction medicine experts from Germany conducted a survey of 2,102 German citizens and found that 34.7% of respondents have consumed “more or much more” alcohol during the pandemic compared to their baseline, and indicated that increased alcohol consumption during this time is associated with lower educational status and increased stress.
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On today's episode we discuss:
—Climate: An analysis of the economic impact of COVID-19 on older adults highlights that more than 1/3 of adults 65 years or older live in counties with a high cost of living and increased COVID-19 prevalence demonstrating an overlap between "infection rates and economic insecurities" during COVID-19 with nearly 25% of these adults relying on Social Security benefits that may be insufficient to meet financial needs during a pandemic. The authors encourage employment and economic recovery strategies to take into consideration the older population
—Epidemiology: A two-center retrospective study at Wuhan Pulmonary Hospital and Tongji Hospital examining 1,018 COVID-19 patients found that increased interleukin-6 (IL-6) levels (>20 pg/mL; P<0.001) and decreased CD8+ T cell levels (<165 cells/mul; P<0.001) are both independently associated with increased mortality in patients with COVID-19, suggesting that both of these indicators may help clinicians in prognostication and clinical decision making.
—Management: A case series of 63 positive end-expiratory pressure (PEEP) titrations performed in 15 patients with COVID-19-related ARDS using electrical impedance tomography (EIT) found that high PEEP were from personalized PEEP at the level of lowest relative alveolar overdistention and collapse, PEEP set was positively correlated to BMI (p< 0.001), and individualized PEEP titration could result in improved clinical outcomes but further research is needed to confirm whether this personalized PEEP titration approach is safe and effective.
—Diagnosis and Treatment: A retrospective cohort conducted at Daegu Catholic University School of Medicine in Korea found that 31 COVID-19-positive patients treated with lopinavir-ritonavir had significantly shorter times to negative conversion of viral RNA than 34 COVID-19-positive patients treated with hydroxychloroquine (median, 21 days vs. 28 days; Figure 2); however, time until clinical improvement was not found to be different between these groups.
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On today's episode we discuss:
— A cross-sectional study conducted in Indianapolis found that 3.1% of 2,953 adults tested positive for SARS-CoV-2 by nasopharyngeal swab testing. Of the 81 SARS-CoV-2 positive participants who completed a follow-up interview, 71.6% remained asymptomatic at 14 days while the other 28.4% reported one or more symptoms.
— A study of 1,353 COVID-19 positive children found the three most common symptoms in this population were fever (21.7%), cough (15.4%), and abnormal breathing (8.1%) with the most severe manifestations, such as intubation or myocarditis, occurring in less than 0.7% of patients, and only 1.9% of patients requiring ICU care.
— An event-study model utilizing data from 15 states plus Washington, D.C. that had implemented mandatory masks in public revealed a statistically significant decrease in daily county-level growth rates of COVID-19 after implementation of mask wearing mandates, suggesting that transmission rates of COVID-19 may decrease as more states mandate face masks in public.
— Pulmonary specialists describe how utilizing nearby hotels for recovering COVID-19 patients discharged from overwhelmed hospitals may be an effective method to meet surging demands citing this approach’s success in certain Italian hospitals.
— A review of the mental health impact of the COVID-19 pandemic could increase the risk for suicidal behaviors.
— Healthcare reform recommendations are outlined as the current pandemic could be a rare catalyst for major political shifts toward a more efficient and effective system of care, primarily addressing barriers to paying for services and provider reimbursement.
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On today's episode we discuss:
— Molecular structures that may contribute to SARS-CoV-2 pathogenicity.
— More evidence for SARS in the urine
— Dosing medications in COVID-19 patients
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On this episode we discuss
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How COVID-19 are causing delays in care seeking with dire consequences
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More data regarding surrounding the issue of testing via RTPCR
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Factors contributing to moral distress in healthcare workers
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On todays report we discuss:
– Who is at risk for acute pulmonary embolisms?
– What is the state of clinical trials on COVID-19 therapeutics?
– Are some patients regain their sense of smell after recovering from their infection?
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On todays report, we discuss
–How frontline healthcare providers can mitigate sleep deprivation during this pandemic
– The connection between obesity and disease severity
– Whether or not we should be using CTs with the nasal swab together to diagnose COVID 19
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On todays report, we discuss:
–The prognosticating findings of critical covid-19
–The readily available compound that can kill sars-cov2 faster than ethanol
–And what the systematic reviews are saying about convalescent plasma treatment
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On today’s report, we discuss
– The ethics of using age to create public policies
– The signs and symptoms of COVID-19 inflammatory syndrome in children
– Potential biomarkers that may help risk stratify patients with COVID-19.
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And on today’s report, we discuss:
–Long awaited randomized controlled trials on hydroxychloroquine and colchicine
–The predictors of in hospital mortality from COVID-19
–And how we should really be using bayesian inference to decide whether or not to believe a negative RT-PCR.
Link to the full report
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— Climate: High rates of moral injury and loss of social identity among healthcare workers during the pandemic has authors from the University of Hildesheim advocating for improved stress management techniques to promote positive coping skills. Commonly reported stressors include separation from family, unsafe working conditions, inadequate resources, and high death rate despite appropriate patient care.
— Epidemiology: Iranian researchers review the neurologic manifestations of COVID-19 finding that:
- Over 1/3 of patients experienced neurologic symptoms, commonly as the initial or only chief complaint.
- The most common CNS manifestations are Headache, dizziness, altered consciousness, and acute cerebrovascular disease.
- While common Peripheral Manifestations include anosmia, ageusia, and rarely Guillain-Barre syndrome (GBS)
— Understanding the Pathology: A cross-sectional study of 34 adult male COVID-19 patients in Wuhan, China found no evidence of SARS-CoV-2 in semen samples within 31 days of their COVID-19 diagnosis. This contradicts a previous study that found RT-PCR positivity in 6 of 38 patients, prompting the need for further investigation.
— Transmission and Prevention:
-Harvard physicians review the literature on asymptomatic and presymtomatic transmission of COVID-19, finding that:
- Viral load of asymptomatic carriers is comparable to symptomatic pts, and viral shedding is highest before symptom onset. Therefore, they recommend that the current ‘symptom-based’ screening strategies need urgent reassessment and Universal testing, irrespective of symptoms, may be warranted in high exposure groups (such as HCW).
-Washington State public health officials conducted extensive contact tracing on the first patient diagnosed with COVID-19 in the US on Jan 20. They found that none of the 78% of identified contacts who agreed to testing were positive by either RT-PCR or follow-up serology, despite 29% reporting prolonged and unprotected exposure. This lack of secondary transmission may be explained by multiple factors including exposure type, duration, and frequency, as well as the patient’s viral load, disease severity, and timing of exposure throughout the course of disease.
— R&D Diagnosis and Treatment: Authors from Taiwan describe an algorithm for the remote management of chronic wound care and follow up during the pandemic.
— Mental Health:
-Researchers from the Institute of History, Philosophy, and Ethics of Medicine in Ulm, Germany studied the psychosocial responses and coping strategies from past pandemics and plagues throughout history. They found that psychological reactions are often complex, contradictory, and a multi-step process.
-Lessons from Lombardy:
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— Climate: Theories attempting to explain the relatively low case fatality rate (CFR) in Africa (3%) compared to the Americas (6%) and Europe (9%) include:
- Minimal early transmission from Asia and Europe
- Younger population and warm, dry climate
- Underestimation of the CFR due to limited resources and testing
- Authors from the University of Arkansas describe howdelayed presentation for stroke may be prohibiting time-sensitive treatment with tissue plasminogen activator (tPA).
— Epidemiology:
-Data from the Korean Centers for Disease Control and Prevention estimates the burden of disease from the pandemic to be 4.93 Disability-Adjusted Life Years per 100,000 population.
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Belgian authors studying anosmia in COVID-19 found that
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87% of those reporting anosmia for less than 12 days were RT-PCR positive for COVID-19 (vs only 23% testing positive in patients reporting symptoms longer than 12 days).
- However, olfactory performance testing found 25% patients were actually having normal smell despite their self reported symptoms.
— Understanding the Pathology:
-Data from the University of Washington hospital system found <1% of asymptomatic patients without known exposure tested positive for COVID-19, compared to 10% in symptomatic patients.
- A retrospective study of the first 1000 COVID-19 patients at New York-Presbyterian Hospital found a bimodal distribution in time-to-intubation after symptom onset (3-4 days & 9 days), suggesting careful monitoring of patients 5-8 days post-symptom onset to anticipate disease progression.
— Transmission and Prevention:
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Scant evidence of detectable SARS-CoV-2 in semen and breastmilk has researchers calling for more robust research to understand implications of potential sexual and vertical transmission of the disease.
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Serologic and RT-PCR testing of an entire otolaryngology unit staff (with an n=58), in a high-prevalence region of Italy, found a 9% positivity; however, survey results showed that their out-of-hospital COVID-19 exposure was actually associated with a higher risk of contracting the infection.
— Management:
- Authors argue against using two consecutive negative PCR tests as a guide for discontinuation of isolation precautions, highlighting how nearly 1/5 patients test positive after two negatives and the substantial amount of PPE and resources required for these tests.
— R&D Diagnosis and Treatment:
- Brazilian pathologists coorelate lung US findings to histopathology in COVID-19 autopsies.
— Mental Health:
- How COVID-19 trauma can countertransfer to psychotherapists, especially less experienced clinicians earlier in their careers.
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Your daily COVID-19 LST Report:
— Climate: Authors from UC, Irvine warn of increased domestic violence during the pandemic, as was seen in past national disasters such as Hurricane Katrina, and advocates for increased allocation of resources to this disproportionately affected population.
— Epidemiology: Italian dermatologists organize cutaneous manifestations of COVID-19 into 2 groups: 1) Inflammatory exanthems (such as Erythematous, morbilliform, urticarial, and papulovesicular) and 2) Vasculitic lesions - such as chilblain, livedo reticularis, and purpura.
— Transmiission and Prevention: Researchers from India discuss the current limitations to contact tracing in resource limited settings, and suggest individuals should be "encouraged to maintain their own contact list on a daily basis" to aid in public health efforts.
— Management: A large observational study of 2,075 hospitalized patients in Spain found the administration of heparin was associated with lower mortality, suggesting prevention against COVID-19 coagulopathy.
A study of 100 patients in France utilized the Apple Watch ECG feature to effectively monitor QT-intervals in at-risk patients, suggesting that 1-lead ECGs may be effective in quarantined outpatients receiving QT prolonging medications.
— R&D Diagnosis and Treatment: A systematic review and meta-analysis found the accuracy of chest CT for COVID-19 diagnosis to be 94% sensitive and 46% specific, this relatively high sensitivity makes CT a potentially useful adjunct to increase the negative predictive value of current screening methods.
— Mental Health and Resilience: Art therapy to address the mental health challenges surrounding isolation and fear amid the COVID-19 pandemic. Authors from George Fox University describe how art therapy can be used to promote resilience and mindfulness.
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Your daily COVID-19 LST Report:
— Climate: Ethicists, microbiologists, and public health experts discuss strategies for optimizing the pandemic response. Considerations include:
- Increased global surveillance measures
- The ethical implications of quarantine laws and clinical research
- Integrating a comprehensive pandemic preparedness strategy for Latin America
— Epidemiology:
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Canadian scientists conducted a meta-analysis of 22 articles published between January 24 and April 2, 2020 exploring the virulence of SARS-CoV-2 and they found that:
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the basic reproduction number of SARS-CoV-2 is 3.15,
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the average incubation time is 5.08 days,
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the asymptomatic rate of infection rate is 46%, and
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the case fatality rate is 3.34% (however when asymptomatic cases are accounted for in a sensitivity analysis, case fatality rate drops to 1.8%).
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Genetic analysis from 84 COVID-19 patients in New York found “clear evidence of multiple independent SARS-CoV-2 introductions into NYC during the first weeks of March”, with the majority coming from Europe.
— Understanding the Pathology:
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Czech researchers studying the immunologic aspects of COVID-19 conclude:
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Both innate and adaptive immune systems are crucial in mounting a response, but it is unknown whether failure to mobilize the adaptive immune system leads to severe disease
- IgA response is stronger than the other antibodies generated and more persistent
- Interleukin(IL)-6 is elevated in greater than 50% of patients
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"Macrophage Activation Syndrome" may explain the unusual finding of elevated CRP in some COVID-19 patients.
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A review of mechanisms that predispose obese and diabetic patients to increased risk of severe COVID-19 disease, implicates a chronic inflammatory state, impaired T cell function, and dysfunction of the RAS system.
— Transmiission and Prevention:
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A pilot study of a contact tracing strategy in Kentucky reported underwhelming cooperation with contact tracing, finding only 19 of 58 cases provided contact information, with others stating inability or unwillingness to cooperate. This highlights the need for a unique approach to contact tracing in the US.
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A cross-sectional study from Singapore found SARS-CoV-2 RNA present on 56% of the surfaces and in air samples tested from the airborne infection isolation rooms (AIIR) occupied by COVID-19 patients. They also found the highest contamination rates within the first 2 weeks of illness.
— Management: Cardiologists from Tel Aviv conduct echocardiography on 100 COVID-19 patients. Teledermatology.
— Mental Health and Resilience: Surveys from the US suggest the older generation have a higher percieved risk of infection, but lower overall psychosocial stress.
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Your daily COVID-19 LST Report:
— Climate: A research letter published in JAMA that analyzed pharmacy records during the pandemic, found a 1,977% increase in fills for Hydroxychloroquine/Chloroquine. The authors warn that this sharp increase in demand may lead to medication shortages for patients who require these for treatment for their chronic conditions, such a s Systemic Lupus Erythematosus and Rheumatoid Arthritis.
— Epidemiology: In pediatrics, a case series conducted at the Children’s Hospital of Philadelphia found evidence to support Multisystem Inflammatory Syndrome in Children (MIS-C) in six patients with COVID-19. They report two notable findings associated with the condition include the development of neurological symptoms and hyponatremia. They note MIS-C resembles Kawasaki disease in clinical features and response to therapeutics, emphasizing the need for further research to determine if MIS-C is distinct clinical syndrome or an atypical presentation of Kawasaki disease.
— Understanding the Pathology: Molecular docking analysis found an increased affinity (–8.6 kcal/mol) between dithymoquinone (an active ingredient in black seed) and the SARS-CoV-2 S protein: human ACE2 receptor interface. This binding could disrupt host recognition and the S-protein pathway for disease progression, suggesting dithymoquinone as a potential natural antiviral worth further studying.
— Management: Clinicians at New York Presbyterian Hospital describe their protocol to place non-intubated, awake, mobile, and hemodynamically stable COVID-19 patients in the prone position in order to prevent worsening respiratory failure.
—R&D: A prospective cohort study of 1788 patients in an Australian screening clinic found that the presence of either anosmia or ageusia exhibited a positive predictive value (PPV) for COVID-19 positivity of only 9.3%, suggesting that while these are more common in COVID-19 positive patients than negative (39.3% vs 8.9%, p<0.001), these should not be used as a screening tool for COVID-19.
— Mental Health and Resilience: Social scientists in the United Kingdom suggest that social representations of COVID-19, such as social distancing and mask wearing, will be resisted as they lead to identity threats (loss of routine, interpersonal relationship changes, disconnection), indicating the importance of adaptive ways to address this threat.
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Your daily COVID-19 LST Report:
— Climate: Researchers call attention to ways the COVID-19 pandemic is unmasking healthcare disparities in two widely different groups, truck drivers and tuberculosis patients. In the words of London analysts who examined the impact on TB patients, care for these vulnerable populations should not be “sidelined”. On a similar theme, Australian researchers discuss the ethical dilemmas around distributive justice and fair resource allocation.
— Epidemiology: Literature reviews and case reports continue to clarify the diagnostic and prognostic value of dermatologic findings in COVID-19. Patients over 50 with elevated BMI were also associated with mortality, but to a lesser extent. Demonstrating that obesity over age being a stronger predictor of disease outcome
— Understanding the Pathology: A UK Biobank (UKB) to analysis of 322,948 subjects (mean age 68-years-old) found an association between the ApoE e4e4 allele and a positive COVID-19 test. Similar results were obtained after excluding patients with pre-existing conditions linked to COVID-19 severity, suggesting the ApoE e4e4 allele independently increases the risk of severe COVID-19 infection.
— Transmission and Prevention: An assessment of viral load in two COVID-19 patients in Seoul, Korea via nasopharyngeal and oropharyngeal swabs, saliva, sputum, and urine cultures using rRT-PCR found that the viral load was consistently high in saliva and relatively higher than in the oropharynx during the subclinical period which raises concerns for occult transmission.
— Management: The Asian-Pacific Association for the Study of the Liver (APASL) COVID-19 Taskforce published clinical practice guidelines for "management of liver injury, liver transplantation, autoimmune diseases, chronic liver diseases, delivery of elective and emergency services, and conduct of clinical trials" in the Asia-Pacific region during the COVID-19 pandemic
— Adjusting Practice: A retrospective observational study in Beijing found that during the pandemic, acute ischemic stroke patients exhibited on average a 40 minute longer hospital arrival to reperfusion time than before the pandemic, suggesting the need to streamline COVID-19 screening and hospital admission protocols for suspected stroke patients.
—R&D: A double-blind, randomized, placebo-controlled trial found shortened time to recovery in remdesivir treated patients (median 11 days compared to 15 days, P<0.001), supporting the preported therapeutic potential of remdesivir for patients with COVID-19.
— Mental Health and Resilience: Obesity and how perceived weight discrimination affects behavior.
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Your daily COVID-19 LST Report:
— Climate: Investigators from the Harvard Business School, Indiana University School of Public Health, and the University of San Francisco’s Department of Medicine found that 41.2% of 3,512 hospitals and 302 hybrid health records were unable to receive electronic COVID-19 surveillance data, demonstrating a crucial need for IT infrastructure in public health management of COVID-19.
— Epidemiology: In a retrospective study of 72 COVID-19 patients admitted to the Beijing YouAn Hospital between January 21 and February 17, 2020 patients with severe and critical disease showed significantly lower lymphocyte counts and significantly higher leukocyte counts, neutrophil counts, and neutrophil-to-lymphocyte ratio at each time point when compared to patients with milder disease.
— Understanding the Pathology: A case control study conducted at Northwestern University using 16 placental specimens from patients with severe COVID-19 found higher rates of maternal vascular malperfusion (MVM) and arterial arteriopathy, but no significant increase in acute or chronic inflammatory pathology when compared to controls, suggesting the importance of antenatal surveillance for these patients.
— Transmission and Prevention: Researchers from the Chinese CDC outline disinfection techniques for hospital waste and wastewater suggest chlorine-based disinfection for hospital wastewater and incineration of pharmaceutical/chemical waste.
— Management Treatments for immunosuppressed kidney transplant patients. A prospective cohort study observing 5,279 COVID-19 patients in New York found that while age and co-morbidities were predictive of hospital admission, oxygen saturation and markers of inflammation may be predictive of critical illness and mortality
Adjusting Practice: A study in Canada of over 1,000 patients with polypharmacy found that almost 60% were currently prescribed drugs that exhibit adverse drug interactions with hydroxychloroquine suggesting the importance of considering current prescriptions when treating COVID-19
—R&D: A retrospective case-series of 30 pediatric patients found that COVID-19 may appear predominantly as ground-glass opacities in a bilateral, peripheral, and lower-lobe distribution in pediatric patients; however, there was a significant rate of negative CT findings (77%) suggesting minimal utility of CT in children, especially those who are young or with mild symptoms.
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— Climate: COVID-19 brings to light the need for universal health care services and Italian authors demand further government investments in the development of such structures. The COVID-19 pandemic has created dissonance between practicality and the traditional four pillars of medical ethics: autonomy, beneficence, non-maleficence, and justice.
— Epidemiology: Authors speculate that anosmia is a specific symptom that can be used as a cheap and effective screening tool for COVID-19. Coupled with the fact that olfactory mucosa has a high expression of ACE2 transcript, they speculate that anosmia is due to direct damage to neuroepithelial stem cells.
— Understanding the Pathology: An author presents a possible explanation for thromboses in COVID-19 patients. They speculate that the virus could attack erythrocytes directly, resulting in antigen-antibody immune complex formation. This type III hypersensitivity reaction would release proteases that could destroy epithelium, mesothelium, and endothelium basement membrane as well as create antiphospholipid antibodies, which could lead to thrombosis.
— Transmission and Prevention: A bioengineer affiliated with the Imperial College in London questions whether 2 meters (approximately 6.6 feet) is an appropriate distance for preventing droplet transmission of SARS-CoV-2 based on studies demonstrating exhalation behavior and travel of exhaled tobacco smoke (a possible surrogate for droplets) reaching a distance of up to 9 meters.
— Management: Guidelines and recommendations for managing COVID-19 patients include: Post-extubation airway obstruction including laryngospasm, Triaging newborns with mothers who are COVID-19 positive, Pemphigus vulgaris patients, Osteoarthritis patients
— Mental Health and Resilience: Impacts on vulnerable populations and what we can do.
— Silver Lining: French patients with OSA, are now using their CPAP more.
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— Climate: A letter to the editor exploring the ethics of the fast-tracked review process of COVID-19 papers currently being utilized by many scientific journals during the pandemic. The authors argue that faster publication of COVID-19-related data does not outweigh the risks of publishing possibly erroneous and lower quality papers. The authors call for a return to the normal review process to uphold publication ethics.
— Epidemiology:
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The authors report the results of a two-center cross sectional study in Wuhan, China, that revealed high rates of lower extremity deep venous thrombosis (DVT) (41 of n = 48) in critically ill COVID-19-positive ICU patients. Incidence of DVT was not significantly associated with mortality.
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Analysis of over 43 million person-weeks of hospitalization data from the Kaiser Permanente Northern California system found that the weekly rates of hospitalizations for acute myocardial infarction declined by up to 48% during the COVID-19 period when compared to both pre-COVID-19 months in 2020 and the same time period in 2019.
— Understanding the Pathology: The Respiratory Translational Research Group at the University of Tasmania responds to a recent finding that nicotine induces an increase in angiotensin-converting enzyme-2 (ACE2) expression in human bronchial epithelial cells. The authors posit all electronic nicotine-delivery systems may increase the risk of infection, transmission, and progression of COVID-19. They urge the World Health Organization and all countries take action to reduce smoking, vaping and water pipe use until more research is done.
— Management: A 59 y/o female was found unresponsive and brought to the ED where ECG showed ST-elevations and chest CT showed diffuse bilateral infiltrates concerning an infectious etiology. Given unknown COVID-19 status, risk of catheterization laboratory staff exposure, and risk of deferring evaluation of her coronary artery disease to a later time, a CorPath robotic intervention arm was used to perform a percutaneous coronary intervention and minimize potential COVID-19 transmission. The patient was successfully discharged 5 days later.
— Guidelines and Recommendations: End of life comfort care, organ donation, and tracheostomy protocol.
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— Climate: An author at Michigan State University advocates for an interdisciplinary approach to studying and learning from this pandemic. In light of COVID-19’s possible origins from a Chinese seafood market, they call for collaboration of bioethicists with expertise in public health and social scientists with expertise in agriculture and food supply. They also suggest adapting the “One Health” approach, which seeks to coordinate veterinary and medical research and education, to bioethics and social sciences research and thinking.
— Epidemiology: Researchers conduct a two-cohort study to better understand the relationship between COVID-19 and tuberculosis (TB). Overall, they found that death rates were low among TB patients with COVID-19, and the authors suggest TB may not be a significant determinant for mortality in COVID-19.
— A literature review of 2,597 pediatric patients with COVID-19 reported:
- Symptoms: 7.6% asymptomatic, 45.5% mild, 41.5% moderate, 4.4% severe, 0.9% critical, and 0.1% death
- Lung imagining: 43.5% with no obvious abnormalities, and 56.5% with inflammatory lesions
- Laboratory results: Blood: 74.7% normal leukocytes, 8.8% leukocytosis, 21% leukopenia, and 9.8% lymphopenia.
- Inflammatory markers: 40.8% increased procalcitonin, 18.8% increased CPR, 20.4% increased LDH
— Understanding the Pathology: Degree of androgen sensitivity in patients may predict their vulnerability to COVID-19 and may explain increased prevalence in male adults. Authors suggest that anti-androgen medications with benign side effect profiles to be considered as prophylactics.
— Transmission and Prevention: A Cochrane systematic review of studies simulating PPE donning and doffing found that utilizing PPE with better overall coverage (PAPR vs N95, gowns vs aprons, water-repellent vs breathable) can reduce contamination rates at the cost of higher difficulty of application. Contamination rates were also reduced when PPE can be easily removed in one-step, double gloving, and after formal video or in-person donning and doffing training.
— Diagnosis and Treatment: Although the average sensitivity and specificity of our current antibody testing for COVID-19 is 84.80% and 98.63% respectively. Statistical analysis suggests that the positive predictive value of this antibody test can be as low as 30% in areas with lower disease prevalence.
— R&D: A retrospective cohort study of 65 hospitalized patients in Brooklyn, New York showed a higher survival rate and lower intubation rate in patients who received calcium channel blocking medications (Nifedipine or Amlodipine) as part of their COVID-19 treatment.
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— Climate: A social media questionnaire of 270 men and 189 women in China found reduced sexual behaviors during the COVID-19 era.
— Epidemiology: In a meta-analysis of 21 studies examining the incidence of gastrointestinal symptoms and liver injury in patients with COVID-19, researchers found that 9.1% of patients had diarrhea, 5.2% had nausea/vomiting, and 3.5% had abdominal pain. There was no significant difference in diarrhea or nausea/vomiting between severe and non-severe cases of COVID-19, and these symptoms did not have prognostic value.
— Pathology: Researchers present a comprehensive review on SARS-CoV-2 immunopathology, describe putative mechanisms for cell-specific pathogenesis based on current research and studies on SARS-CoV and MERS-CoV. Notable mechanisms in pathogenesis include early interferon production and activation of NK cells as crucial steps to mitigate COVID-19 severity.
— Management: Guidelines and recommendations for:
- Ethical allocation of scarce medications
- Managing seizure episodes
- Changing the delivery method of aerosolized medications
- Managing and treating acute kidney injury
- Coordinating rectal cancer treatment
- In a case series of 24 awake, hospitalized COVID-19 patients without mechanical ventilation, 15 tolerated prone positioning with 6 responding with more than 20% increase in partial pressure of arterial oxygen, leading the authors to recommend further studies to explore its efficacy.
— Adjusting Practice: Guidelines and recommendations for practice during the pandemic:. Dental care, Control of infection in trauma surgery. Diagnosis, treatment, and monitoring of obstructive sleep apnea. Prioritization of surgical services.
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— Climate: Based on a 2018 systematic review of the SARS and MERS literature, authors identified key areas of research for these coronaviruses. They noticed that research was lacking in viral pathogenesis, clinical characterization, infection prevention and candidate therapeutics, and therefore recommend prioritizing research in these fields for the study of SARS-CoV-2.
— Epidemiology: Contact tracing in Korea linked initial COVID-19 cases to several fitness class instructors. 26% of participants in their classes developed infection. Investigators speculate that the environment of a fitness class: a moist, warm atmosphere in a confined area coupled with turbulent airflow generated by intense physical exercise can lead to a higher rate of transmission.
— Understanding the Pathology: Iranian neuroscientists performed a literature review investigating the neuroinvasive potential of coronaviruses, and found four suggested routes of entry into the central nervous system (CNS): 1) Through olfactory neurons in the olfactory epithelium.
2) Via infected monocytes crossing the blood-brain barrier (BBB) to infect glial and neuronal cells. 3) Through interaction of CoV and ACE2 receptors on BBB endothelial cells. 4) Via Peripheral nerves (trans-synaptic transmission)
— Management: Monitoring procalcitonin levels may help identify patients at risk of severe disease - a meta-analysis of 4 studies found that “increased procalcitonin values are associated with a nearly 5-fold higher risk of severe SARS-CoV-2 infection.”
— Guidelines: A meta-analysis investigating outcomes in 51 patients who developed postoperative COVID-19 found a mortality rate of 27% suggesting the importance of preoperative testing of asymptomatic patients.
— R&D: Korean laboratory proposes guidelines for diagnosing COVID-19.
They recommend:
- Test Indications: Testing is appropriate to confirm suspected cases of COVID-19 and make decisions on continuing or discontinuing quarantine.
- Diagnostic Methods: RT PCR is recommended, but the authors call for more studies to identify the optimal target gene for these tests. Repeat testing may be necessary.
- Specimen Selection: For asymptomatic individuals, a combination of nasopharyngeal and oropharyngeal swabs is recommended. For patients with severe systems, lower respiratory tract specifics (sputum, bronchoalveolar lavage, tracheal aspirates) are recommended.
- Biosafety: These recommendations are presented in the full report.
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— climate: After lockdown was initiated, air pollution over northern India reached a 20-year low with New Delhi seeing 50% reduction in air pollution leading investigators to suggest that the COVID-19 pandemic is a good opportunity to learn and understand how lockdown activities can help minimize air pollution in the long term.
— Epidemiology: A critically ill 69 year old male COVID-19 patient was found to have both classic COVID-19 CT findings as well as atypical reversed halo sign, suggestive of fungal infection. Endotracheal aspiration culture grew aspergillosis and despite voriconazole treatment the patient ultimately died, emphasizing the importance of considering complicating infections in COVID-19 patients.
— Pathology: One study found that men and adults, who have each been noted as higher risk for severe COVID-19, had higher soluble angiotensin-converting enzyme-2 than women and children, respectively. Further research is warranted to explore if soluble high angiotensin-converting enzyme-2 level is a risk factor for COVID-19 severity.
—Tramission and Prevention: False negative RT-PCR results are becoming an increasing problem. A case report of a 46 year old female describes how she initially tested positive on nasopharyngeal RT-PCR but was sent home one week later after results for 4 nasopharyngeal swabs and one anal swab were negative. The following week, however, she tested positive again on nasopharyngeal and anal swab RT-PCR and was readmitted to the hospital. Investigators summarize the numerous cases of various PPE-induced dermatoses
— R&D: A human monoclonal antibody was identified to cross-neutralize SARS-CoV and SARS-CoV-2 in cell culture, targeting a common epitope through an unknown mechanism independent of receptor-binding interference. Further study could prove it useful in diagnostic testing, prevention, or treatment of COVID-19.
— Mental Health: An online survey distributed randomly throughout China to over 5,000 adults without pre-existing psychiatric disorders found that prevalence of anxiety and depression has jumped to over 20%, up from the 2019 reported rate of 4%.
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— Researchers found nine SARS-CoV-2 neutralizing humanized llama antibodies that successfully blocked viral S protein and angiotensin-converting-enzyme-2 (ACE2) interaction in vitro. They postulate that combinations of these antibodies in creating a single multi-specific antibody could increase this effect, which should be further studied in hopes of contributing to treatment and diagnosis of infection.
— There is growing concern for the safety of female frontline humanitarian workers, with accounts from the Democratic Republic of Congo and the Phillipines of workers being expelled from their apartments for fear that they are carrying COVID-19, reports of harassment in India, instances of personal protective equipment being prioritized for males workers, statistics from Italy and Spain showing twice as many COVID-19 infections in female health care workers. Standardized organization-specific policies are essential for health and safety of female humanitarian workers on the front line.
— A 72 year old man presented to the ER complaining of chest tightness and dyspnea with ST-elevations on EKG and ultimately died 45 minutes after arrival. He was later found to be SARS-CoV-2 positive leading the authors to recommend the use of PPE even in seemingly non-COVID-19 cases and encourage consideration of cardiac manifestations of the disease.
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— More evidence suggesting the lack of negative predictive value of the nasopharyngeal swab RT-PCR continues to build:
— A case report of an obese 14 year old boy who presented initially with fever, gastrointestinal symptoms, and a negative COVID-19 nasopharyngeal swab subsequently developed severe respiratory and cardiac symptoms and positive SARS-CoV-2 on retest. This case emphasizes obesity as a potential independent risk factor for COVID-19 as well as the poor negative predictive value of nasopharyngeal swabs.
— A case report of a cystic fibrosis patient with ultimately diagnosed with COVID-19 via positive RT-PCR after 2 false negatives and a subsequent positive rhinovirus test highlights that identifying another respiratory pathogen should not exclude the possibility of an additional infection of SARS-CoV-2 in patients with severe respiratory disease and the propensity for false negative SARS-CoV-2 RT-PCR result.
— Clinicians are urged to differentiate between High Altitude Pulmonary Edema (HAPE) and COVID-19 because pulmonary vasodilators routinely used to treat HAPE could critically worsen ventilation-perfusion mismatch or cause hypotension in COVID-19 patients.
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— Careful assessment of N95 respiratory decontamination through ultraviolet germicidal irradiation is urged to ensure adequate fit and continued protection because different models of N95 respirators were highly variable in passing a fit test after this treatment. Some models did not pass the baseline fit test, while others were able to withstand multiple or even twenty repeat treatments.
— Clinicians are reminded to actively work against anchoring bias during the pandemic. A septic 94 year-old male admitted with fever, leukocytosis, tachypnea, tachycardia, hypoxia, and infiltrates on chest X-ray was found to have a gram-negative community acquired pneumonia. However, antibiotics were not started for over 12 hours after admission because staff at all levels were focused on ruling out COVID-19.
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— A case report of a COVID-19 positive presymptomatic individual who attended a full-day meeting in Germany, found that he transmitted the virus to 11 of the 13 other participants indicating the high transmission risk of in-person meetings.
— But clearly, removing physical human contact has been having dramatically negative impact on mental health, the economy and life as we know it. How do we move forward?
— Public health experts describe how in Syria, lack of transparency, the high number displaced persons, and a health care system decimated by a decade of conflict has led to uncertainty of the current burden of COVID-19 in the country. The authors call for ceasefires, protection of health care workers, expansion of humanitarian access, and evacuation of critical cases could help Syria during the pandemic.
— A 38 year old male who presented with COVID-19 developed bilateral blindness on the 5th day of hospitalization. MRI revealed T2-weighted hyperintense lesions as well as vasogenic edema, illustrating a possible symptom of the systemic inflammatory state caused by the virus.
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— A retrospective imaging study of 749 COVID-19 patients found that among the 21% who developed neurological symptoms, 44% exhibited abnormalities on brain MRI such as cortical signal abnormalities, cortical diffusion restriction, and leptomeningeal enhancement.
— A study of nasopharyngeal swabs, sputum, and stool samples in 49 patients with COVID-19 found viral persistence, measured from symptom onset, to range between 15.6 days in mild cases to 49.4 days in severe cases.
— A study of over 1,000 COVID-19 patients found that those who received hydroxychloroquine were more ill at baseline and there was no significant association between hydroxychloroquine administration and respiratory failure.
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— A study of viral load in 13 asymptomatic patients that tested positive for COVID-19, demonstrated that in the 3 patients who developed symptoms, the highest viral load generally occurred 2 days prior to symptom onset indicating a high risk of transmission prior to symptoms.
— A case report of a patient who presented with vomiting and abdominal pain after ingesting 10 ml of ethanol-containing hand disinfectant daily for over three weeks. They thought it would prevent COVID-19 infection emphasizes the major health risks of misinformation and increased access to disinfectants during the COVID-19 pandemic.
— Israeli researchers retrospectively analyzed 14,520 patients that had been screened for COVID-19 and found that Hydroxychloroquine or Colchicine prophylaxis likely had no effect in preventing COVID-19.
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— Based on literature that suggests SARS-CoV-2 spreads more readily in cold, dry climates, researchers propose that air should be humidified to support the efficacy of the mucosal barrier.
— A scoping review of 67 studies found that medical grade masks are superior to improvised masks and N95 respirators may be superior to surgical masks in the inpatient setting but have equal performance in outpatient settings.
— Public health experts propose a “one house one-person” plan where only one person from a household is tested and their infection status is extrapolated to the whole household for use in making isolation recommendations in resource limited places.
— Autopsies of 12 COVID-19 patients revealed deep vein thrombosis (DVTs) in 7--none of whom were suspected to have venous thromboembolism before death, highlighting the important role of COVID-19 induced coagulopathy in the disease process.
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— A systematic review and meta-analysis of 10 studies including over 1300 COVID-19 patients found that olfactory and gustatory dysfunction were present in 53% and 44% of patients, respectively.
— Analysis of the effect of N95 reuse decontamination processes on filtration efficiency found that steam, 75C heat, and ultraviolet germicidal treatments had little effect on filtration efficacy; whereas, ethanol submersion and chlorine spray caused significant reductions in filtration.
— One study of 198 COVID-19 patients found a high risk of venous thromboembolisms with occurrence in 59% of the 75 ICU patients within the first 21 days.
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— An analysis of ultraviolet-C (UVC) decontamination of N95 respirators coated in MRSA or a bacteriophage found high variability of viral or bacterial persistence by different locations on the respirators and reduction levels that did not meet the criteria for decontamination.
— The cellular protease Furin, was found to cleave the SARS-CoV-2 S protein S1/S2 multibasic site, which mediates cell to cell fusion and entry into human lung cells. Thus, Furin is suggested for therapeutic potential.
— In a recent case report, a 47 year old man died from small bowel perforation from acute bowel ischemia secondary to COVID-19. The ischemia was characterized by yellow discoloration, necrosis, with patent mesenteric vasculature, which draws attention to direct tissue injury in the gastrointestinal tract from SARS-CoV-2 and possible microvascular thrombosis.
— Of the 55 imported cases of COVID-19 detected through mandatory testing in Brunei, almost half were asymptomatic upon entry suggesting that symptom-based screening at entry points will likely miss a large proportion of cases.
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— The Seattle Flu Study is a multi-institutional, community-wide surveillance project initially intended to track data from influenza that began testing nasal swabs for COVID-19 in any patient with respiratory symptoms. From January 1-March 9, they found that 1.1% of participants tested positive for COVID-19 in 30% of patients seeking clinical care.
— In a retrospective analysis of over 3,000 COVID-19 patients, researchers found that RNA-based diagnostic testing methods lacked negative predictive value, though they were useful indicators for clinical course, pattern, and prognosis.
— Convalescent plasma transfusion was found to be safe, clinically effective, and beneficial in reducing mortality in five studies of 27 COVID-19 patients.
— Key laboratory tests recommended for COVID-19 patients are:
- CBC with differential
- Acute phase inflammatory biomarkers
- Kidney, liver, and cardiac injury biomarkers
- Indicators of improvement: CRP/procalcitonin
- Prognostic biomarkers like D-dimer values
- Sequential organ failure assessment.
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— A study of COVID-19 cases by borough in New York found that the Bronx, which has the highest proportion of ethnic minorities, the most people living in poverty, and the lowest level of education had higher rates of COVID-19 hospitalization than higher income boroughs such as Manhattan.
— Rapid implementation of and training for powered air-purifying respirators at a hospital in Singapore has helped the intensive care and anesthesiology departments achieve 0 patient to doctor transmissions of SARS-CoV-2.
— New guidelines and recommendations from this weekend include:
- Italian provisional guidelines for autopsy during the pandemic
- Cardiovascular magnetic resonance
- Interventional radiology practice recommendations
- Head and neck mucosal malignancies
- ICU acute bed shortage ethics.
- Management of patients with liver disease
- Management of adults with rheumatic disease.
- Role of cardiologists in care and management
- Blood purification treatment
- Skull base surgery
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— A woman from Wuhan exhibited persistent viral shedding for 36 days after symptom resolution, demonstrating the prolonged potential infectivity of recovered patients.
— A new report of SARS-CoV-2 RT-PCR positivity in urine of an infected patient grows concerns of it’s spread.
— Preliminary data from Portugal found that excess all cause mortality during the pandemic has been 3-5 fold higher than what can be explained by the official COVID-19 death count, highlighting the significant role of undiagnosed COVID-19 and overall reduced access to healthcare during the pandemic.
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— There are a number of case reports highlighting atypical presentations of patients subsequently found to be COVID-19 positive.
— A patient presented complaining of otalgia and tinnitus only was found to have positive COVID-19 RT-PCR as well as lung involvement in CT.
— Adding to the conversation of androgen associations to COVID-19, researchers hypothesize that benign prostatic hyperplasia treatments, specifically 5α-reductase inhibitors, may contribute to the higher mortality observed in men by causing increased lung concentrations of androgens, which can have anti-regenerative effects in damaged lung tissue.
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— A possible theory on why some previously recovered patients are re-testing positive.
— Utility of artificial intelligence and POCUS in diagnosis of COVID-19 pneumonia.
— Hematologic and inflammatory markers that may be useful in predicting severity of disease…
— Growing evidence of the dermatologic manifestations of COVID-19
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— Measurements of aerosolized viral RNA in various locations in two Wuhan hospitals found the highest concentrations to be in patient toileting areas and other poorly ventilated areas.
— Results from a case series led to recommendation that patients should have serial CT scans to document lung lesion resolution before discharge and a follow-up RT-PCR and CT scan after discharge to decrease risk of continued infection.
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— A case series of almost 200 COVID-19 patients found that the frequency of pulmonary embolism in infected patients is 2 times higher than that found during the control period.
— Utmost caution is recommended for cryopreserving sperm, which has been found to have low risk of significant virus shedding but there is suggestion that may not be an acceptable risk.
— A pilot cohort study with Baricitinib therapy for COVID-19 patients found significant improvement of clinical and respiratory parameters within two weeks.
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— Preliminary data suggest COVID-19 disease burden may be lower in countries that routinely vaccinate with the BCG tuberculosis vaccine.
— Analysis of lower respiratory tract sputum samples from 92 patients found that viral load exhibits a direct correlation with disease severity.
— Epidemiologists propose an “inverse quarantine,” where only high risk uninfected individuals are isolated, as an economically viable method of reducing mortality.
— Using COVID-19 immunity serosurveillance has become a trendy way to discuss how to make the decision to initiate return-to-work, yet, several challenges remain.
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— Hoarding household cleaners has it's downsides: an upsurge in accidental poisonings
— A recent Lancet article proposes universal weekly COVID-19 testing to ascertain a more accurate measure of prevalence and incidence so that policy is not based solely on models.
— Increasing evidence support warmer climates inhibiting COVID-19 transmission; Many expect the northern hemisphere to experience reduced incidence while the southern hemisphere sees an increase in disease.
— Based on data from a Chinese study on complications in COVID-19 patients, 45% of the US population meets the criteria for being at increased risk for complications.
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— A literature review of 249 COVID-19 articles published between Dec 1st-Feb 6 for research gaps found that there was a lack of randomized controlled trials, cohort studies, and studies on clinical practice.
— Additionally, they found that most of the guidance/guidelines developed by the WHO, US, CDC, ECDC and several Chinese Institutions did not fulfill the principles of evidence-based practice.
— Using an avian coronavirus as a surrogate, researchers found that steaming N95 masks over boiling water for 5 minutes inactivated the virus and caused no significant loss of filtration.
— Recent guidelines have also been published regarding the preparation and transfusion of COVID-19 convalescent plasma
— Another report outlines the current knowledge and efficacy of several different therapeutic treatment options for COVID-19
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— Climate: Growing evidence suggests COVID-19-like viruses may be circulating among wild animals. Call to action for improving care and awareness of vulnerable populations disproportionately affected during this pandemic, such as those with opioid use disorder and victims of domestic violence,
— Epidemiology: Larger scale studies continue to emerge from Italy with more data on symptomatology, clinical course, and fatality rate.
—Pathophysiology: Ongoing discussion on association between obesity and COVID-19 severity, with theories regarding role of ACE2 receptor and proinflammatory cytokines. Cutaneous manifestations of COVID-19.
—Transmission and Prevention: Could anti-microbial properties of copper nanocomposites be utilized in future medical devices? Successful methods of preventing nosocomial transmission in Singapore. PPE precautions during intubation and transesophageal echocardiography.
—New and Emerging Guidelines: Burn care, telemedicine for family members of critically ill, safe practices in the radiology department, triaging of neurosurgical cases, prevention and control strategies for cancer patients.
— Diagnosis and Treatment: Meta-analysis of the most common CT findings in COVID-19 pneumonia.
—Mental Health and Resilience: Urging governments and the public to increase awareness of family violence during the pandemic. Crisis as and opportunity for change.
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—A meta-analysis of 28 studies found that elevated cardiac injury biomarkers and acute cardiac injury are more common in severe to fatal cases.
—Emerging findings reveal that mutated, distinct clades of SARS-CoV-2 with varying virulence may be an additional factor at play
—An analysis of 30 provincial capital cities in China found that increases in ambient temperature and diurnal temperature range were correlated with a decline in daily case counts, similar to what has been observed with influenza
—American Academy of Otolaryngology recommend that smell dysfunction with or without taste dysfunction be a primary screening symptom for COVID-19
—Data driven models predict that an additional 60 days of lockdown in Italy would achieve a 35% decrease in COVID-19 cases and a 66% increase in those recovered.
— Visit COVID19LST.org for our full report.
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Your daily COVID-19LST Report:
— More than 9000 health care workers tested positive for COVID-19, 27 have died; 55% reported having no other contact with COVID-19 patients except at work
— Projection modeling predicts high incidence of COVID-19 in South Korea expected to continue through June
— More evidence for smell dysfunction in COVID-19 patients and the potential role of androgens in the pathology
— Visit COVID19LST.org for our full report.
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Your daily COVID-19 LST Report:
Our most reliably data heavy report yet!
Multiple systematic meta-analyses describing:
— The early symptoms of COVID-19
— Risks associated with pregnancy
Guidelines:
— Management of acute covid-19 cardiovascular syndrome from Circulation
— Management of difficult airways, tracheostomy and laryngectomy
— Visit COVID19LST.org for our full report.
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Your daily COVID-19 LST Report:
Testing continues to be unreliable: more evidence shows the need for repeated negative tests before release from quarantine. — Mechanistically and theoretically an argument could be made for Remdesivir’s efficacy but much remains uncertain. — Continued concerns for health care workers with their increased risk for mental illness based on studies on health care staff in China and guidelines for promoting "Deliberate Resilience". —Visit COVID19LST.org for our full report.
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Introduction to the COVID-19 Literature Surveillance Team (LST). We are an affiliated group of physicians, medical students, and PhDs keeping up with the latest research on SARS-CoV-2 / COVID-19. We find the newest articles, read them, grade their level of evidence, and bring you the bottom line. Our goal is to empower you to take the best care of yourself and those in your care. Our mission to keep you informed and up to date with the latest developments.
Visit COVID19LST.org for our full daily report with links to the articles.
Reach out to us at: contact@covid19lst.org
Support this podcast: https://anchor.fm/covid19lst/support