From the New England Journal of Medicine

Staying ahead of the wave: “For clinicians in areas that have not yet been hard hit, the pandemic wave will surely come. Persons under investigation for [coronavirus disease 2019 (COVID-19)] should be treated as if they are infected. These patients often have a progression of disease severity, with approximately 15% of admitted patients requiring upgrades in care. We hope that lessons from our center will help prepare other physicians and hospitals for what is likely to come so they can stay ahead of the wave.” OPEN ACCESS here.

Lupus anticoagulant and abnormal coagulation tests in patients with COVID-19: “Patients with [COVID-19] have a profound hypercoagulable state, and complicating venous thrombotic events are common. Abnormalities in coagulation screening measures, including a prolonged activated partial-thromboplastin time (aPTT), have been reported in patients with COVID-19. This finding could be seen as a reason to avoid the use of anticoagulation at both therapeutic and prophylactic doses.” OPEN ACCESS here.

COVID-19 in immune-mediated inflammatory diseases — case series from New York: “We report a prospective case series involving patients with known immune-mediated inflammatory disease (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, psoriasis, inflammatory bowel disease, or related conditions) who were receiving anticytokine biologics, other immunomodulatory therapies, or both when confirmed or highly suspected symptomatic COVID-19 developed.” OPEN ACCESS here.

Pandemic and persona: “The current crisis therefore offers an opportunity — owing to our shared vulnerability to the virus — for doctors to recognize more readily facts that can otherwise take years to learn: that we’re no different from our patients and that interacting with them in a manner similar to the one we naturally use with nonpatients can be gratifying for them and freeing for us. Doctors often equate professionalism with a kind of formal role playing and worry that deviations from this attitude might lead to excessive casualness or boundary problems. These are real concerns that must be considered — but without sacrificing clinical connection. Traditional medical procedures and attitudes do need to be learned. But I’m reminded that jazz great Charlie Parker reportedly said that the secret of improvisation was to learn the chord changes and then forget them. I think one way to successfully harmonize with patients is to learn the standard teachings of medical professionalism and then not exactly forget them, but allow them to resonate and even merge with one’s own persona.” OPEN ACCESS here.

Once upon a time … the hero sheltered in place: “‘It’s not your hill to die on,’ my sister-in-law texts me. I wonder: Whose hill is it, then? I have many colleagues whose age puts them at risk, some of whom are world-renowned for their scientific and clinical expertise. Should they be on the front lines? What about women who are pregnant or trying to conceive? What about physicians who haven’t cared for critically ill patients in decades, or who have a spouse or child at risk, or who are simply scared and don’t want to do it? What about other essential health care workers — those who clean rooms, transport patients, hand out masks — for whom the financial consequences of not working may be more stark? And what about trainees, many of whom, unlike me, don’t have a choice? We pay them the least, work them the hardest, and rely on them for the majority of direct patient interactions. The odds of survival are better if you’re young, but with so many people infected, some young ones will die. Given all the impossible conversations the pandemic has forced about how much we value any given life, why have there been so few about how much health care workers value our own?” OPEN ACCESS here.


Risk of QT interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (COVID-19): “In a cohort study of 90 hospitalized patients with coronavirus disease 2019, use of hydroxychloroquine with or without azithromycin for treatment of COVID-19 was associated with frequent QTc prolongation, and those taking hydroxychloroquine and azithromycin had greater QT prolongation than those taking hydroxychloroquine alone. One patient developed torsades de pointes. Meaning: Clinicians should carefully weigh risks and benefits if considering hydroxychloroquine and azithromycin, with close monitoring of QTc and concomitant medication usage.” OPEN ACCESS here.

Assessment of QT intervals in a case series of patients with coronavirus disease 2019 (COVID-19) infection treated with hydroxychloroquine alone or in combination with azithromycin in an intensive care unit: “This study raises safety concerns about the use of hydroxychloroquine with or without azithromycin for patients with COVID-19, particularly when both drugs are administered together. There were no baseline clinical factors associated with subsequent QT prolongation. In our cohort, close monitoring of patients (including continuous QTc interval monitoring, daily ECGs, and laboratory tests), which led to an interruption of these drugs for 17 patients (42.5%), may have averted further complications, including drug-induced torsades de pointes. Key limitations of the present case series include a potential lack of generalizability beyond the ICU. However, the finding that QTc intervals increased in more than 90% of patients raises concerns about the widespread use of hydroxychloroquine, with or without azithromycin, to treat COVID-19 in settings where patients cannot be adequately monitored.” OPEN ACCESS here.

Second-trimester miscarriage in a pregnant woman with SARS-CoV-2 infection: “This case of miscarriage during the second trimester of pregnancy in a woman with COVID-19 appears related to placental infection with [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)], supported by virological findings in the placenta. Contamination at the time of delivery, sampling, or laboratory evaluation is unlikely, as all other swabs were negative for SARS-CoV-2. No other cause of fetal demise was identified. There was no evidence of vertical transmission, but absence of the virus is not surprising given the stage of fetal development and short time of maternal infection. Whether SARS-CoV-2 crosses the placental barrier warrants further investigation.” OPEN ACCESS here.

Petechial skin rash associated with severe acute respiratory syndrome coronavirus 2 infection: “Viral rashes can be polymorphic. In this patient, the clinical picture resembled the periflexural petechial exanthem of parvovirus B19. Skin biopsy specimens from patients with this disease show a perivascular mononuclear inflammatory infiltrate, eosinophils, and extravasated erythrocytes; in addition, viral proteins from parvovirus B19 have been found within the endothelial cells of dermal vessels and could be implicated in the pathogenesis of purpura. We hypothesize that SARS-CoV-2 could affect the skin in a similar way. Some histologic features in this case (ie, mounds of parakeratosis, mild spongiosis, extravasated erythrocytes) overlap with those of pityriasis rosea, which is suspected to have a viral pathogenesis. Adverse drug reactions to supportive medications used in patients with severe viral infections are an important diagnostic consideration; however, in this case the rash preceded the initiation of lopinavir-ritonavir and hydroxychloroquine.” OPEN ACCESS here.

From the BMJ

Reducing risks from coronavirus transmission in the home—the role of viral load: “Care is needed when extrapolating evidence from other disease, but viral load is likely to be important for COVID-19. The precautionary principle suggests that people caring for household members who are unwell should be encouraged to take measures to reduce infecting viral load in order to reduce the incidence and severity of infection. Promoting infection control measures in the community is a priority for the UK government and will continue to be so as ‘stay at home’ policies are lifted. Dissemination of evidence based behavioural interventions may help increase adoption of public health advice and reduce viral load.” OPEN ACCESS here.

Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis: “Effective interventions are available to help mitigate the psychological distress experienced by staff caring for patients in an emerging disease outbreak. These interventions were similar despite the wide range of settings and types of outbreaks covered in this review, and thus could be applicable to the current COVID-19 outbreak.” OPEN ACCESS here.

COVID-19: the challenge of patient rehabilitation after intensive care: “Patients with the virus seem to be ventilated for far longer than the average ICU patient, causing higher levels of deconditioning, and there are more of them at any one time. Evidence from China shows that COVID-19 patients have neurological as well as respiratory after effects, so recovery will be longer and more complex. The UK government predicts that 45% of patients will need some form of low level medical or social input for recovery and that 4% will require more focused, ongoing intense rehabilitation in a bedded setting.” OPEN ACCESS here.

From the Lancet

Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial: “Between Feb 6, 2020, and March 12, 2020, 237 patients were enrolled and randomly assigned to a treatment group (158 to remdesivir and 79 to placebo); one patient in the placebo group who withdrew after randomisation was not included in the [intention-to-treat] population. Remdesivir use was not associated with a difference in time to clinical improvement (hazard ratio 1.23 [95% CI 0.87–1.75]). Although not statistically significant, patients receiving remdesivir had a numerically faster time to clinical improvement than those receiving placebo among patients with symptom duration of 10 days or less (hazard ratio 1.52 [0.95–2.43]). Adverse events were reported in 102 (66%) of 155 remdesivir recipients versus 50 (64%) of 78 placebo recipients. Remdesivir was stopped early because of adverse events in 18 (12%) patients versus four (5%) patients who stopped placebo early. Interpretation: In this study of adult patients admitted to hospital for severe COVID-19, remdesivir was not associated with statistically significant clinical benefits. However, the numerical reduction in time to clinical improvement in those treated earlier requires confirmation in larger studies.” OPEN ACCESS here.

The immune system of children: the key to understanding SARS-CoV-2 susceptibility?: “Evolution has endowed a survival advantage to children to combat known and unknown pathogens. The adult is also well protected by the balance of cells with high and low specificity. With ageing, malnutrition, immunosuppression, and co-morbid states, our immune system loses the ability to adapt to novelty. Although vaccines are the way forward, in emergency situations such as the COVID-19 pandemic, the investigation and use of immune tools that nature has endowed to children might improve management outcomes.” OPEN ACCESS here.

Health system quality in the time of COVID-19: “To facilitate accountability, the vision for widespread provider compliance with basic infection prevention and control guidelines will need to be set at the highest levels of leadership and cascade through health system management. Existing health system structures, such as direct facility financing, will need to be quickly leveraged to create incentive structures for compliance, and prohibitions against unsafe care need to be clearly and widely disseminated within the health system and to communities. Powell-Jackson and colleagues document serious shortcomings in the quality of health care in some contexts, but their findings also point to an important opportunity—with national and international attention turned to COVID-19, leaders can choose to make quality a priority and guide the health system towards an effective response.” OPEN ACCESS here.

Rapid distribution of information by SMS-embedded video link to patients during a pandemic: “In summary, this intervention is, to our knowledge, the first of its kind to communicate and evaluate a complex public health message at large scale by use of SMS-linked video. The high acceptability and patient satisfaction scores indicate that this intervention is a potential tool for rheumatology departments to contact selected patients, during and after the COVID-19 pandemic. This work demonstrates that SMS-linked technology is well placed to assist physicians, and might be of interest to national advisory bodies, hospitals, and primary care groups when planning mass health-care communication.” OPEN ACCESS here.

From the MJA

Clinical trials for the prevention and treatment of coronavirus disease 2019 (COVID-19): The current state of play: “There are many current candidate drugs in pre-clinical and early phase development and these form a pipeline for future large clinical trials if current candidate therapies prove ineffective or unsafe.” OPEN ACCESS here.

COVID, ACE inhibitors/ARBs, and cardiovascular diseases: “Angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) reduce morbidity, mortality and hospitalisations from hypertension and heart failure.  There are no convincing clinical data to support adverse or beneficial effects in COVID-19 patients in the face of theoretical arguments in both directions.  Most authoritative national and international bodies have released statements to the effect that the beneficial effects of ACE-I and ARBs are proven, the adverse effects in COVID-19 patients are not and have advised people to continue these drugs pending evidence to the contrary.” OPEN ACCESS here.

Australia’s national COVID-19 primary care response: “Australia’s primary care response to COVID-19 has seen rapid implementation of initiatives to protect the nation’s most vulnerable citizens, preserve existing health system function, support and treat people with COVID-19, and optimise workforce capacity. The implications: Australia’s investment in the primary care response to COVID-19 is enabling effective frontline care while mitigating spread, and protecting the ongoing health of the nation’s most vulnerable people.” OPEN ACCESS here.

First Nations people leading the way in COVID-19 pandemic planning, response and management: “Aboriginal and Torres Strait Islander public health practitioners and researchers have been pivotal in identifying the issues, setting priorities and suggesting solutions for culturally informed strategies.” OPEN ACCESS here.

A strategic framework to ease community-wide COVID-19 suppression measures: “To date, physical distancing and societal closure has proven highly effective at reducing community transmission and deaths due to Covid-19. However, staying in ‘lockdown’ indefinitely is problematic due to the wider health, social and economic damage arising from the control measures. The challenge now is how to ease restrictions in the absence of a ‘silver bullet’ therapy or vaccine. We outline a strategy for a phased progression from ‘suppress’ to ‘release’ and ‘restore’ stages that focuses on optimising the application of our existing tools and strategies coupled with improved pathways for community engagement and multi-sectoral cooperation.” OPEN ACCESS here.

COVID-19 and implications for thiopurine use: “Perhaps the best advice we can currently offer patients is that effective control of disease may carry less risk than poorly considered withdrawal of therapy. The Gastroenterological Society of Australia has issued recommendations that the minimum level of immunosuppression should be continued to control disease although a drug holiday may be considered in some patients with long term stable disease. This dilemma highlights the importance of online registries to gather vital data as we work together as a profession to provide evidence-based advice for our patients during this pandemic.” OPEN ACCESS here.

Implications of COVID-19 in an ageing population: “Asymptomatic transmission remains a constant threat to the elderly population and has implications for infection control measures; community surveillance must go beyond targeting only symptomatic individuals.” OPEN ACCESS here.

Employee presenteeism and occupational acquisition of COVID-19: “Presenteeism, where SARS-CoV-2 infected workers attend work while symptomatic, contributes to occupational acquisition of COVID-19. This is documented to have occurred in the North West Regional Hospital Outbreak among Tasmanian Health Care workers. It is also likely to be present among a newly recognised Melbourne abattoir outbreak. Infection prevention practices must account for presenteeism.” OPEN ACCESS here.

Tracking, tracing, trust: contemplating mitigating the impact of COVID-19 through technological interventions: “While many liberties have been curtailed during COVID-19, all modifications to existing rights are required, under law, to be legal, necessary and proportionate. These same standards apply to the use of technology. Legal protections need to be in place to ensure that protections are maintained, including protections to privacy. Without sound legal protections and safeguards, tracing apps will not only fail, but embed values that may not be those that represent the society we wish to be.” OPEN ACCESS here.


There will be a second wave of COVID-19 in Australia
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