On this page you will find:
For even more information, check out our dynamic COVID Knowledge Bank created by our medical students keeping you up to date on news and journal articles related to the pandemic.
If interested in contributing to literature review, contact Elena Diller at firstname.lastname@example.org
Disclaimer: The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for informational purposes only.
April 27-May 1
1. President Trump announced that federal social distancing guidelines expiring on Thursday 4/30 would not be extended. The President stated that the White House's guidelines would be "fading out," citing the notion that governors are including social distancing guidelines in their plans. This gives states furthur control over their reopening, in contrast to the President's previous statements that he would have "total" authority over when states reopen. Some states including Georgia, Alaska, and Tennessee have already begun loosening social distancing guidelines and stay at home orders, while others like North Carolina and Michigan have extended theirs into the month of May.
2. Georgia governor Brian Kemp announced in an executive order that individuals who hold instructional permits can get a drivers license without a "comprehensive on-the-road driving test." This change will remain in effect until the end of the state's Public Health State of Emergency, which the governor recently extended through May 13th.
3. Identifying people who have been infected with COVID-19 and reaching those they may have infected will require 100,000 additional workers in US cities and states. Battered by budget cuts and job losses since 2008, local and state public health agencies lost about 50,000 jobs. What is begining to happen: Massachusetts is partnering with an NGO to increase contact tracers. Various agencies are developing short, but effective training programs for new hires. Additionally, Apple and Google have announced a cooperation to enable apps for contact tracing.
Promising Results from China: Safety, tolerability, and immunogenicity of a recombinant
adenovirus type-5 vectored COVID-19 vaccine
Journal: The Lancet
P: The population was 108 participants, all of whom were adults in good health, negative for SARS-CoV-2 infection, and between the ages of 18 and 60 years old. The 108 participants were divided into three groups of 36—low dose, middle dose, and high dose groups.
I: As mentioned above, the participants were divided into three groups based on dosage. Each vial of the vaccine contained 5 x 10^10 viral particles per 0.5 mL. The dosages for the three groups are as follows: 5 x 10^10 viral particles per 0.5 mL for the low dose group (one vial), 1 x 10^11 viral particles per mL for the middle dose group (two vials), and 1.5 x 10^11 viral particles per 1.5 mL for the high dose group (three vials). All vaccine doses were administered intramuscularly.
C: No placebo control was present in the trial.
O: The primary outcome was occurrence of adverse reactions within 7 days of vaccination. Secondary outcomes included abnormal changes in lab values 7 days post-vaccination, as well as adverse events within 28 days of vaccination.
Strengths: The “baseline characteristics” across all three dosage groups were similar. Also, thorough measures were taken to exclude participants infected with SARS-CoV-2 and to prevent infection in those participating in the study. Serological screening, nucleic acid testing, and chest CT’s were used to exclude participants who had been exposed to SARS-CoV-2 during recruitment. Those who were included in the study stayed in a “designated hotel” for 14 days in order to prevent SARS-CoV-2 infection.
Limitations: The sample size is small, though the authors acknowledge this. This is also expected given that this is a phase 1 trial. Moreover, the short duration of follow-up and the lack of a randomized control group limits interpretation of the results. Only 16% of the study participants were older than 50 years; in addition, no participants were more than 60 years old. However, phase 2 of the trial will include participants older than 60 years per the authors.
Conclusion: The Ad5 vectored COVID-19 vaccine was found to be tolerable and immunogenic in the population studied. Most adverse reactions were mild to moderate in severity. The few severe adverse reactions were short-lived and self-limiting. No abnormal changes in lab values were seen. “Specific humoral responses” peaked by day 28, while rapid, specific T-cell responses were noted by day 14 after one shot of vaccine. A majority of all three dosage groups had at least a four-fold increase in receptor-binding domain antibodies by day 28. However, four-fold increases in neutralizing antibodies to live SARS-CoV-2 were less prevalent, as this result was found in 50% of the low dose and middle dose groups and 75% of the high dose group by day 28. It is believed that the decreased response of neutralizing antibodies to the vaccine is due to participants with high pre-existing Ad5 neutralizing antibody titers. Regarding T-cell responses, the three dosage groups had a positive result rate of at least 80% by day 14, though this percentage decreased particularly in low dosage participants who had high pre-existing Ad5 neutralizing antibody titers. Despite interference from pre-existing Ad5 neutralizing antibodies, the results support the safety and immunogenicity of the vaccine. As the vaccine proceeds to phase 2, more will be learned about its efficacy.
Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States
P: Four states (Colorado, Minnesota, Ohio, and Virginia) that had at least 7 consecutive days of cumulative hospitalization data for COVID-19 before the stay-at-home order date and at least 17 days following the order date.
I: Stay-at-home order issued by state
C: Each state’s COVID-19 hospitalization data up until the determined effective date of the stay-at-home order was plotted against a best fit exponential growth function. The cumulative hospitalizations after the median effective date were then observed to see if they deviated from the projected exponential growth.
O: Deviation from the best fit exponential growth curve.
Strengths: The deviations from the expected curves for each state are seen at or around the expected median effective date of the stay-at-home orders and these deviations are statistically significant.
Limitations: This analysis assumes that all deviations from the projected hospitalizations are a result of the stay-at-home order. Data was only available for four states.
Conclusions: Prior to enacting stay-at-home orders, each state’s cumulative COVID-19 hospitalization curve favored an exponential function over a linear function. After the median effective date for the orders, the plotted hospitalizations fell out of the 95% prediction bands for the projected exponential growth function -- suggesting that the stay-at-home orders had a significant effect on spread of COVID-19.
Chloroquine or hydroxychloroquine for COVID-19: why might they be hazardous?
JourNal: The Lancet
P: 96,032 COVID-19 patients from an international registry of 671 hospitals across 6 continents.
I: COVID-19 patients received chloroquine (n=1868), hydroxychloroquine (n=3016), chloroquine with a macrolide (n=3783), or hydroxychloroquine with a macrolide (n=6221) within 48 h of COVID-19 diagnosis
C: 81,144 COVID-10 patients who did not receive these drugs served as the control
O: The primary outcome for the study was in-hospital mortality and the occurrence of non-sustained or sustained ventricular tachycardia or ventricular fibrillation
Strengths: The analysis included a Cox proportional hazard model to account for many confounding variables, including age, sex, ethnicity, comorbidities, other medications across the patient population being included in the study. The large size of the population also further strengths the conclusions drawn.
Limitations: The main limitations to the study are those that are commonly inherent to any observational study such as inability to draw causation since there is no randomization along with bias and confounders when analyzing the data.
Conclusions: The results showed a significant increase in the risk of in-hospital mortality with the four treatment regimens compared with the control group. These results indicate a benefit from the absence of 4-aminoquinoline-based treatments in this population and suggest that they could even be harmful. The risk of death associated with 4-aminoquinolines alone or combined with a macrolide was similar, whereas it would be expected that the combination of two QTc-prolonging drugs would increase their proarrhythmic potential. These findings from add to preliminary reports suggesting that regimens of chloroquine or hydroxychloroquine, alone or with azithromycin, are not useful and could be harmful in hospitalized patients with COVID-19.
Hospitalization and Mortality among Black Patients and White Patients with Covid-19
P: Patients that tested positive for COVID-19
I: standard hospital treatment for COVID-19
C: White patients with Covid-19
O: Hospitalization and in-hospital death
Strengths: Large patient population (3481) with a large portion of black patients
Limitations: Study limited to a single center. Retrospective design means that care among participants was not completely standardized.
Conclusions: From the article: “In a large cohort in Louisiana, 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died were black, whereas blacks comprise only 31% of the Ochsner Health population. Black race was not associated with higher in-hospital mortality than white race, after adjustment for differences in sociodemographic and clinical characteristics on admission.”
This study further confirms that Black populations have been disproportionately affected by COVID-19. While it is still not known why this is the case, data in this study indicated that Black patients arrived at the hospital with higher rates of obesity, diabetes, hypertension, and chronic kidney disease.
AIR POLLUTION: Temporary reduction in daily global CO2 emissions during the COVID-19 forced confinement
Journal: nature Climate Change
P: Air quality of 69 countries, including USA and China
I: Social distancing and confinement policies’ impact on CO2 emissions in April 2020
C: CO2 emissions in April 2019
O: On April 7, 2020, global confinement decreased the daily CO2 emissions by 17%. The average of maximum daily decrease per country was 26%, but each country did not have maximum daily decreases on the same day. The largest sector that saw a decrease in CO2 emissions was surface transportation/city congestion.
Strengths: Data is publicly available, transparent about using estimated values from sector activity, methods detailed.
Limitations: The values of daily CO2 emissions were estimated changes based on sector activity. Real-time measurements using satellite is not reliable. Typically, only annual emission values are reported. Scope of pandemic is unknown, future estimates may change.
Conclusions: The decrease in April daily CO2 emissions was about 17% due to decreased energy demands from social confinement policies. Predicted values for average 2020 emission is an annual decrease of 5.7%. In the 2008 global financial crisis, a decrease of 1.4% was also observed, but in 2020 the emissions grew to 5% increase. Similarly, the IMF and others predict a rebound increase in emissions of 5.8% (global) and 3.5% (USA) in 2021. This study is meaningful because CO2 emissions have been linked to premature deaths of susceptible individuals and more understanding is needed to appropriately advise patients.
The Remdesivir Saga Continues: Remdesivir for the Treatment of Covid-19 — Preliminary Report
P: The population was 1,063 randomized patients from clinical sites in the United States, Denmark, the United Kingdom, Greece, Germany, South Korea, Mexico, Spain, Japan, and Singapore.
I: Remdesivir was given via IV as a 200 mg. loading dose on day 1. Subsequently, a 100 mg. remdesivir maintenance dose was given on day 2 through 10 or “until hospital discharge or death.”
C: A matching placebo was given via IV that was equivalent in both duration and volume as the intervention drug (remdesivir).
O: Per the authors, “the primary outcome was the time to recovery, defined by either discharge from the hospital or hospitalization for infection control purposes only.”
Strengths: Large, multi-national population used. Peer-reviewed, double-blind, randomized control trial. Demographic and medical conditions were well-balanced between the intervention and control groups.
Limitations: For patients receiving intubation or extracorpeal membrane oxygenation (ECMO) at baseline, the median recovery time could not be estimated. The authors believe this may be due to follow-up windows that were too short. The trial is ongoing; thus, this limitation may be overcome with more data.
Conclusion: Hospitalized patients with COVID-19 who were treated with remdesivir recovered quicker than those treated with placebo. In fact, patients in the remdesivir group had a median recovery time of 11 days, while those in the control group had a median recovery time of 15 days. However, patients who were already intubated or receiving ECMO at baseline did not experience the recovery benefit. This seems to suggest that remdesivir is most effective when given prior to the onset of severe lung disease. Though mortality was decreased in the remdesivir group compared to placebo, the difference is not significant. The trial is still ongoing, so perhaps additional data will reveal the effects of remdesivir on mortality. In any case, the results of the present study support remdesivir use for hospitalized COVID-19 patients to decrease recovery times.
April 27-May 1
Special population: How is immunosuppressive status affecting children and adults in SARS-CoV-2 infections? A systematic review.
Journal: J Infect
P: immunocompromised COVID-19 patients
I: clinical outcomes (mortality, ICU admission, etc)
C: COVID-19 patients who are not immunocompromised
Limitations: of the 110 patients included, most were cancer patients (rather than an even distribution of types of conditions)
Strengths: systematic review, 16 different articles included, 110 patients
Conclusions: A systematic review yielded 16 relevant articles of 110 immunosuppressed patients (cancer, transplantation, immunodeficiency). Of these patients, 65.5% recovered or did not require intensive care, 5.5% needed intensive care or invasive ventilation, and 20.9% died. Based on their results, children and adults with immunosuppression do not seem to have a more severe disease course compared to the general population. The major risk factors for severe disease course seem to be elderly age, obesity, diabetes, cardiovascular problems, and male sex rather than immunodeficiency."
Uncommon presentations: Evaluation of ocular symptoms and tropism of SARS‐CoV‐2 in patients confirmed with COVID‐19
Journal: Acta Ophthalmol
P: Previously hospitalized, COVID-19 positive patients
I: Ocular symptoms in COVID-19
C: Pre- and post-COVID-19 ocular symptoms
Strengths: 56 lab confirmed patients, detailed ocular history obtained using both Ocular Surface Disease Index (OSDI) and Salisbury Eye Evaluation Questionnaire (SEEQ)
Limitations: Reliant upon subjective recall for both pre- and post-COVID eye symptoms
Conclusion: Ocular symptoms are relatively common in COVID‐19 disease and may appear just before the onset of respiratory symptoms.
CVA and COVID-9: Large Vessel Stroke as a Presenting Feature of COVID-19 in the Young
P: Patients < 50 years of age with COVID-19
I: Stroke incidence in COVID-19 positive Patients
C: Typical presentation of COVID-19
Strengths: Noted comparison of incidence of younger patients with large vessel strokes in their hospital to prior admission statistics over the past 12 months to provide context. Comparison to data from Wuhan showing stroke incidence in COVID-19 positive patients. Included information on past medical history of each patient, particularly those that lead to increased stroke risk. Information on presentation, NIHSS, outcome, treatment.
Limitations: Small case series of 5 patients. Only included patients over a two-week period. Delayed presentation of patients due to reluctance to seek medical attention. Did not include information on when COVID-19 testing was obtained or risk factors for exposure in patients. Did not include information on COVID-19 respiratory symptoms or duration of symptoms.
Conclusions: Proposed that coagulopathy and vascular endothelial dysfunction may contribute to stroke incidence. Also proposed that reluctance to present to the hospital may be contributing to poor outcomes.
Remdesivir, our savior?: Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial.
Journal: The Lancet
P: 237 patients with laboratory-confirmed SARS-CoV-2 infection, with an interval from symptom onset to enrolment of 12 days or less, oxygen saturation of 94% or less on room air or a ratio of arterial oxygen partial pressure to fractional inspired oxygen of 300 mm Hg or less, and radiologically confirmed pneumonia
I: IV remdesivir (200 mg on day 1 followed by 100 mg on days 2–10 in single daily infusions)
C: Placebo infusions for 10 days
O: Time to clinical improvement up to day 28
Strengths: Randomised, double-blind, placebo-controlled, multicentre trial. Peer Reviewed.
Limitations: Some patients were using concomitant lopinavir-rotinavir, interferons, and corticosteroids. Only included severe patients. Additionally, the study was terminated prematurely because it was difficult to enroll patients in China, where the number of Covid-19 cases was decreasing. As a result, the researchers admitted to likely insufficient power to detect assumed differences in clinical outcomes, initiation of treatment quite late in COVID-19, and the absence of data on infectious virus recovery or on possible emergence of reduced susceptibility to remdesivir.
Conclusion: The use of remdesivir did not lead to a statistically significant difference in time to clinical improvement compared to placebo. There were a similar number of adverse events between groups however treatment was stopped in 12% of the remdesivir group due to adverse events compared to 5% of the control group.
These results seem to contradict the recent publicised results fo the NIH trial which is yet to be fully released to the public. What we know about this trial so far:
P: Hospitalized patients with advanced COVID-19 and lung involvement
I: 11 days of Remdesivir
C: 15 days of placebo.
Strengths: a randomized, controlled trial involving 1063 patients, A total of 68 sites ultimately joined the study—47 in the United States and 21 in countries in Europe and Asia.
Limitations: The preliminary results from this trial were drawn from an independent data and safety monitoring board (DSMB). The study still needs to be properly peer-reviewed.
Conclusions: Preliminary results indicate that patients who received remdesivir had a 31% faster time to recovery than those who received placebo (p<0.001). Specifically, the median time to recovery was 11 days for patients treated with remdesivir compared with 15 days for those who received placebo. Results also suggested a survival benefit, with a mortality rate of 8.0% for the group receiving remdesivir versus 11.6% for the placebo group (p=0.059), HOWEVER, these results were not statistically significant.
It begs the questions, as the results of RCTs of Remdesivir continue to be released, will a pooled meta-analysis demonstrate it to be a "game changer" or a therapy that adds costs with little clinical value?
NeuroScience: Is the Collapse of the Respiratory Center in the Brain Responsible for Respiratory Breakdown in COVID-19 Patients?
JOurnal: ACS Chem NeuroScience
Viewpoint article that addresses the growing evidence of neurological sequelae of SARS-CoV2 including anosmia, dysgeusia, etc. Specifically concerning is the devastating respiratory effects of the virus and how the central nervous system could be involved. The article specifically discusses the growing hypothesis that the virus may gain access to the brain via the olfactory bulb and from there target areas such as the thalamus and brainstem by trans-synaptic transfer. This theory seems to correlate well with case series in China which have shown neurologic symptoms as prevalent in COVID-19 patients and were very common in patients with severe infection according to their respiratory status.
So far the brain has not neen considered one of the primary organs affected by the virus, but given the growing data, it will be helpful to really study in depth the link between these CNS deficits, especially anosmia, and how it correlates with severity of respiratory disease as it may alter the approach of triage and treatment earlier in the disease course.
Testing concerns: Detection and analysis of nucleic acid in various biological samples of COVID-19 patients
Journal:: Travel Med Infect Dis
P: confirmed COVID-19 patients
I: nasopharyngeal swab
C: other sample types (sputum, blood, feces, anal swabs)
O: positive test result of real-time fluorescence RT-PCR 2019-nCov NAT
Limitations: Chinese population; only 132 patients; only 1 medical center; the test used to confirm COVID-19 status was also one of the tests being compared in the study (nasopharyngeal swab)
Strengths: All tests were run in the same lab with the same testing kit, technician, and controls
Conclusions: These authors wanted to know which sample was the most reliable in terms of least false negatives. They took 132 patients that were confirmed positive via nasopharyngeal swab, and pulled multiple nasopharyngeal, sputum, blood, fecal, and anal samples. The positive rate of each sample’s 2019-nCov NAT were: nasopharyngeal 38.13%, sputum 48.68%, blood 3.03%, feces 9.83%, anal 10.00%. Based on this, they concluded that nasopharyngeal testing alone is not sufficient, and that the best testing seems to be from sputum. Evaluation of the data is concerning as there seems to be a high risk of false negatives that may prompt discharge and also explain why there have been reported cases of subsequent positive that may not necessarily mean reinfection. This paper poses the question of whether other sample site such as blood or digestive tract (fecal/anal swab) should be included in the discharge criteria. Given the short comings of our current tests, this link will also direct you to an older publication from February in which researchers came up with a point‐of‐care lateral flow immunoassay (LFIA) test product which detected IgM and IgG with a sensitivity of 88.66% and a specificity of 90.63%. Although contigent on a number of factors such as unknown limits of detection and variation in immune response between patients, there were some notable advantages when compated to RT‐PCR tests, including minimal need for equipment, ease of use and training allowing it to be used in a large number of settings.
Fecal Viral shedding: Diarrhea is associated with prolonged symptoms and viral carriage in COVID-19
Journal: Clin Gastroenterol Hepatol.
P: Diarrhea as an associated symptom of COVID-19
I: COVID-19 patients with diarrhea and viral carriage
C: COVID-19 patients with no diarrhea and corresponding viral carriage
Limitations: Case series. Relatively small number of cases, n=84. All patients were healthcare workers. No long term follow up, cases were followed for the duration of hospitalization during the time period of January 7th to February 19th.
Strengths: Comparison of viral carriage between COVID-19 patients with respiratory symptoms with vs. without diarrhea. Clear criteria for confirmation of diagnosis, monitored parameters, and tracking of viral RNA via stool RT-PCR testing.
Conclusions: 31% of the 84 patients studied had diarrhea and had longer duration of fever and dyspnea which was statistically significant from those without (p<0.05). Stool samples tested positive for RNA in 69% of those with diarrhea vs. 17% in those without. Those with diarrhea had lower proportion of testing negative by throat swab compared to those without during hospitalization. Demonstrated that elimination of viral RNA from stool took longer than elimination for the nose or throat. These results may have other interesting implications apart from further elucidating disease course, but also when developing new guidlines to minimize disease spread. In this interesting opinion piece, researchers pose the question that given the findings of viral shedding in stool whether exposure to bio-aerosols from toilets in hospitals can put healthcare workers, hospitalized patients, and environmental services staff at higher risk of severe or critical disease?
Other DIagnostics: Laboratory data analysis of novel coronavirus (COVID-19) screening in 2510 patients
Journal: Clinica Chimica Acta
P: screened patients for COVID-19
I: NAT and hematology data
C: Influenza A and B vs COVID-19 vs negative patients
Limitations: Screening data from only 1 hospital in China; although 2510 patients screened, only 32 were positive for COVID-19, only 57 were positive for Influenza A, and only 84 were positive for Influenza B
Strengths: 2510 patients total included; the same lab with the same testing kits were used to determine both COVID-19 and Influenza positivity; many hematologic indices were included, including cell counts, differentials, and many biochemical indicators
Conclusions: Of the 2510 patients screened, 32 (1.3%) were COVID-19 positive via pharyngeal swab (with 8 of those also having positive fecal samples), 57 (2.3%) were Influenza A positive, and 84 (3.3%) were Influenza B positive. Therefore, Influenza was more prevalent than COVID-19. When comparing hematology indices fo COVID-19 patients to negative patients, HFLC%, MPV, MONO%, TP, and ALB were increased, whereas PLT-I, WBC, LYMPH#, BASO%, BASO#, EO%, EO#, PLT, PCT, IG%, NEOT#, urea, and IP were decreased. Compared to patients infected with influenza A/B, MPV, PDW, TP, ALB, ALT, CO2CP were increased, whereas EO%, EO#, IP, and CK-MB were reduced. Therefore, hematologic indices can be used to differentiate between these two infections.
Practice Recs: Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations
Journal: Br J Anaesth
P: COVID-19 patients
I: emergency intubation
C: case series from 2 different hospitals
O: results and consequences of intubation
Limitations: Chinese population only; only 202 patients
Strengths: multiple centers included; retrospective
Conclusions: The authors wished to determine recommendations for tracheal intubation in COVID-19 patients. Their results from compiling the data from the 2 hospitals in the retrospective study include: Among the COVID-19 patients requiring urgent intubation, the majority were males (67.3%) and older (63.4% > 65 yo). Hypoxaemia was predominant (75.2%) and hypotension was common (17.8% during and 22.3% afterwards). A technique based on RSI and videolaryngoscopy enabled prompt tracheal intubation and was universally successful. Cardiac arrest
occurred in 2%, and pneumothorax and early mortality were both observed (5.9% and 10.4% respectfully). Despite differing approaches to PPE, there was no intubation-related healthcare worker COVID-19 infection up to 14 days post-procedure. The authors also included a flow chart of tracheal intubation strategy based on their collected data
THerapeutics: An exploratory randomized controlled study on the efficacy and safety of lopinavir/ritonavir or arbidol treating adult patients hospitalized with mild/moderate COVID-19 (ELACOI). *Disclaimer! not yet peer reviewed*
P: 86 patients with mild/moderate COVID-19
I: Lopinavir/ritonavir or arbidol monotherapy
C: No antiviral medication
O: Average time of positive-to-negative conversion of SARS-CoV-2 nucleic acid and conversion rates at days 7 and 14.
Strengths: Randomized control trial (2:2:1)
Limitations: Small sample size. Study did not include patients with severe or critical disease or patients with many comorbidities. Study was conducted at only one center.
Conclusion: Lopinavir/ritonavir and arbidol did not shorten the time of positive-to-negative conversion of COVID-19, nor did they improve the symptoms of COVID-19 or pneumonia on lung CT imaging at 7 days and 14 days. Moreover, more patients treated with LPV/r progressed from mild/moderate to severe/critical status than patients from the other two groups. This data is consistent with previous retrospective and clinical data that lopinavir/ritonavir and arbidol have not been effective in treating COVID-19.
BOnus short read: UPSURGE OF DEEP VENOUS THROMBOSIS IN PATIENTS AFFECTED BY COVID-19: PRELIMINARY DATA AND POSSIBLE EXPLANATIONS
Journal: Journal of Vascular Surgery: Venous and Lymphatic Disorders
During the last month, the authors have noticed a remarkable increase in the diagnosis of DVT at their Italian medical center among patients infected by coronavirus disease 2019. They cite the most frequent localization at the iliac-femoral-popliteal axis, followed by the brachial-axillary veins and the calf veins. They discuss possible mechanisms, including the previously studied link between DVT and ARDS in influenza A H1N1, as well as known increase in procoagulant factors, such as D-dimer and tissue factor, in other community-acquired pneumonias. Lastly they discuss possible contribution of CPAP as a component, especially in patients with involvement of the upper limbs. Given the increase in cases of PE and DVT noted in the US as well, this paper asserts the need to gather formal data to establish the incidence, mortality rate, and the opportunity of a screening program and prophylactic therapy in these patients.
Interesting Implications: COVID-19, Arrhythmic Risk and Inflammation: Mind the Gap!
P: Covid-19 patients with cardiac arrythmias
I: Evaluating unique pro-arrythmic role of high-grade systemic inflammatory state characteristic of COVID-19 (Specifically using CRP and IL-6 as markers)
C: Current belief is that myocardial damage causes enhanced arrhythmic risk. However, evidence in ICU patients, despite the high frequency of arrhythmias (~50% of cases), only a half showed acute cardiac injury.
Limitations: Opinion article reviewing past studies assessing role of inflammation in arrythmias, not COVID-19 specific.
Strengths: Provides basic science explanation for clinical observations that may influence treatment.
Conclusion: Suggests that factors other than myocardial damage are also involved in enhancing the arrhythmic risk in COVID-19. Food for thought that physicians should always consider COVID patients as those at increased arrhythmic risk. The extent of systemic inflammation, as reflected by circulating CRP (and IL-6) levels, should be considered to assess the benefit/risk ratio when considering use fo QT-prolonging medications. Additionally, provides merit to further investigation of the use of anti-IL-6 targeted therapies (tocilizumab,sarilumab) to COVID-19 patients as a way of reducing high arrhythmic risk.
Case Report: Abdominal and testicular pain: An atypical presentation of COVID-19
Journal: Am J Emerg Med.
P: Patients with SARS-CoV-2
I: Atypical presentation of SARS-CoV-2 patients
C: Typical presentation of SARS-CoV-2 patients
Limitations: Single case report. Details were provided on work up as well as the patient’s potential exposure.
Strengths: Inclusion of basic data on prevalence of atypical presentations and discussion of possible benefits of widespread PPE use for all patient interactions.
Conclusions: Case report of a 41-year-old who presented to the ED with abdominal, testicular, and back pain in addition to subjective fevers. No abnormal findings were found on chest x-ray. No respiratory complaints. Ground glass opacification revealed on CT at the lung bases. Found several days later to have tested positive for COVID-19. No PPE was worn during the duration of his ED visit. Authors concluded that PPE should be worn at all times as community spread increases.
Special population: Outcome of Coronavirus spectrum infections (SARS,MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Journal: American Journal ofObstetrics & Gynecology MFM
P: pregnant women with a confirmed Coronavirus related illness, defined as either SARS, MERS or COVID-19.
C: General population of pregnant women
Strengths: Meta-analysis. First systematic review exploring pregnancy and perinatal outcomes of coronavirus infections occurring during pregnancy.
Limitations: Majority of data from studies with small sample sizes and case reports
Conclusion: In pregnant women with coronavirus infections, including COVID-19, pre-term birth is most common, followed by miscarriage, preeclampsia, cesarean, and perinatal death. Although there have been numerous reports of neonatal infection, there are no confirmed cases of vertical transmission.
Diagnostics: "COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: single-center study and comprehensive radiologic literature review”
Journal: Eur J Radiol .
P: lab-confirmed SARS-CoV-2 patients hospitalized in Valduce Hospital (Italy)
I: imaging studies (US, CXR, CT)
C: other publications of COVID-19 patient imaging
Limitations: Single-center study; Small sample size of only 58 patients, not all having all imaging studies done; No comparison to non-COVID-19 patients to determine specificity; No follow-up
Strengths: Retrospective study of consecutive patients; Wide age range of adults
Conclusions: These authors attempted to provide an informative picture for radiologists to assist in a faster and sooner identification of COVID-19 pneumonia. Relevant for instances of high clinical suspicion but delayed laboratory test results.
Bonus Therapeutics: COVID-19: A Brief Overview of the Discovery Clinical Trial
A brief communication paper that focuses on the four treatments recommended by WHO and included in the first clinical trial of the European Discovery project. This study initiated on March 22, 2020 and will enroll 3100 patients.
Goal: determine the most effective specific drug to cure patients infected by SARS-CoV-2.
This article also details reasoning behind drug choices and recommended dosing/treatment regimens for each drug.
We are MCG students aiming to help the community stay informed on the COVID-19 pandemic and to provide updates on how MCG is adapting to educational and healthcare change.
Disclaimer: The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for informational purposes only.