Coronavirus (COVID-19) Resources

The COVID-19 pandemic is a major health crisis straining the healthcare system and affecting us all. The IARS is committed to supporting our members who are addressing this illness on the front lines in any way we can.

IARS has assembled a content base with the latest peer-reviewed articles on COVID-19 from leading medical journals, sorted by topic and chronologically. In the COVID-19 Resource Newsletter healthcare professionals on the frontlines are given access to global peer experiences and education from publications hand-selected and reviewed by the IARS COVID-19 Scientific Advisory Board. All of these articles are openly available without login.

Click on a phrase below to see resources on that topic. To search by keyword, select Ctrl + F on a PC and Command + F on a Mac. Then, enter keyword and Enter.

Retractions:

I. SARS COV-2 Pandemic

    1. Epidemiology
      November 23, 2020
      • SAB Comment: Interferon (IFN) gets its name because it “interferes” with viral replication. Suspecting that interferon is inadequately produced and/or its actions blocked, two important Science papers (below) examined possible mechanisms. Zhang et al, reports finding loss of function gene variants in 3.5% of severe COVID-19 patients that control induction and amplification of Type I IFNs. The effects of these lifelong inborn variants, not found in mild disease or healthy controls, only are exposed with development of severe viral pneumonia. In the other paper, Bastard, et al, found (presumed preexisting) high-titer IgG neutralizing autoantibodies against Type I IFNs-alpha and -omega only in severe COVID-19. The autoantibodies occur in at least 2.6% of women and 12.5% of men. The defects in Zhang, if discovered early on, could be treated with Type I IFNs, and in Bastard, treated with Type I IFN-beta in particular, as autoantibodies against IFN-beta are rare.
        • Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. 10/23/2020. Zhang Q. Science.
          These authors examined 659 severe COVID-19 patients for mutations in genes involved in the regulation of type I and III interferon (IFN) immunity. Following exome or genome sequencing examining rare variants at 13 candidate loci they found genetic defects in 3.5% of severe patients at eight of the 13 candidate loci involved in the TLR3- (double stranded RNA-responsive) and Interferon-regulatory factor-7 (IRF7)-dependent induction and amplification of type I IFNs. These variants resulted in enrichment of loss of function variants not found in mild COVID-19 patients or healthy individuals. Early type I IFN administration may benefit patients with these inborn variants.
        • Autoantibodies against type I IFNs in patients with life-threatening COVID-19. 10/23/2020. Bastard P. Science.
          In COVID-19 pneumonia, at least 101/987 patients had low or undetectable serum IFN-α and high-titer neutralizing IgG autoantibodies (auto-Abs) against interferon-omega (IFN-ω) (13 patients), against the 13 types of IFN-α2 (n=36), or against both (n=52). In vitro, auto-Abs blocked IFNs inhibition of SARS-CoV-2. Auto-Abs were not present in asymptomatic or mild SARS-CoV-2 infection (n=663) and in only 4/1227 healthy individuals; 95/101 with auto-Abs were men. A B cell autoimmune phenocopy of inborn errors of type I IFN immunity (seen in Zhang) accounts for life-threatening COVID-19 in at least 2.6% of women and 12.5% of men who could be treated with IFN-beta.

      October 26, 2020

      • Targeting complement cascade: an alternative strategy for COVID-19. 10/19/20. Ram Kumar Pandian S. 3 Biotech.
        The authors present well-referenced experimental support that complement cascade inhibition will counteract COVID-19 inflammation. Complement dysregulation can lead to cytokine storm and ARDS pathology. Activation and deposits of complement components are seen in animal models and at autopsy of COVID-19 patients. Pre-clinical and clinical studies using current and pipeline agents show pathway inhibition aids ARDS recovery. Viral infections including COVID activate complement via the lectin pathway via mannose-binding lectin associated serine protease 2 (MASP2). Complement inhibitors including monoclonal antibodies, proteins, peptides and small molecules exhibit promise blocking the complement components and their downstream effects in various pathological conditions including SARS-CoV.

      October 19, 2020

      • Evidence of a wide gap between COVID-19 in humans and animal models: a systematic review. 10/7/2020. Ehaideb SN. Crit Care.
        In this comprehensive literature review, replication-competent animal models were assessed for recapitulating full-spectrum human COVID-19, as well as prophylaxis, therapies, or vaccines. Animals included nonhuman primates (n = 13), mice (n = 7), ferrets (n = 4), hamsters (n = 4), and cats (n = 1). All animals supported high viral replication in the respiratory tract with mild clinical manifestations, lung pathology, IgG antibodies and full recovery. Older animals had more severe illness. None developed respiratory failure, multiple organ dysfunction or death. Transient systemic inflammation was observed occasionally in nonhuman primates, hamsters, and mice. No animals unveiled cytokine storms or coagulopathy supporting a wide gap between human and animal disease.

      October 12, 2020

      • Susceptibility of tree shrew to SARS-CoV-2 infection. 9/29/2020. Zhao Y. Sci Rep.
        SARS-Co-V-2 research has been hampered by poor susceptibility of animal models to SARS‑CoV‑2 infection, particularly the mouse. These investigators examined if a domesticated tree shrew, a species genetically close to primates and used in hepatitis, influenza and other research may be useful. SARS-CoV-2-infected tree shrews showed no clinical signs except mild fevers. Histologically, low levels of virus shedding and replication in tissues were observed. Mild pulmonary abnormalities were the main changes observed. The tree shrew may not be suitable for COVID‑19 research. However, tree shrew may be a potential asymptomatic intermediate host of SARS‑CoV‑2 besides bats and pangolins.

      October 7, 2020

      September 30, 2020

      • New Studies on COVID-19 Epidemiology
        The following four articles examine risk factors for developing COVID-19, for having severe disease and for death. Common findings include an increased risk of infection and hospitalization in Blacks but no increase in mortality. It should be noted that the mentioned hospitalization rates may depend on socio-economic factors and may not be a clear indicator of severity of disease.
        • Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. 9/22/20. Rentsch CT. PLoS Med.
          This article presents a nationwide VA data set study (~6 million patients, February 8 to July 22) comparing positive COVID-19 test results with 30-day mortality. Healthcare disparities were explored by evaluating “associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence.” The study confirms prior reports indicating that “Black and Hispanic individuals experience excess burden of SARS-CoV-2 infection” but not increased mortality and notes that these disparities “are not entirely explained by underlying medical conditions or where they live or receive care.” The article contains interesting distinctions and reinforces the importance of designing “strategies to contain and prevent further outbreaks in racial and ethnic minority communities.”
        • Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. 9/23/20. Ioannou GN. JAMA Netw Open.
          This large study showed no increase in mortality associated with Black or Hispanic race, obesity, COPD, hypertension or smoking (contrary to what has been found in smaller, prior studies). It did find the expected association of increased severity and mortality with older age (≥50) and multiple comorbidities.
        • Association of Race and Ethnicity With Comorbidities and Survival Among Patients With COVID-19 at an Urban Medical Center in New York. 9/25/20. Kabarriti R. JAMA Netw Open.
          Among 5902 patients with positive COVID-19 diagnosis treated at a single academic center in urban New York, non-Hispanic Black and Hispanic patients had a higher proportion of more than 2 medical comorbidities and were more likely to require inpatient hospitalization, but had outcomes including mortality that were at least as good as, and maybe even marginally superior to, their non-Hispanic White counterparts when controlling for age, sex, and comorbid conditions at presentation.
        • Racial Disparities in Incidence and Outcomes Among Patients With COVID-19. 9/25/20. Muñoz-Price LS. JAMA Netw Open.
          This article investigates the goal-described patterns and outcomes of COVID-19 by race, controlling for age, sex, socioeconomic status, and comorbid conditions among 2595 urban patients. COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. The findings also imply that adverse outcomes and greater population mortality associated with Blacks early in the course of the US pandemic were primarily attributable to greater incidence of COVID-19 among African American residents rather than worse survival once hospitalized.

      September 21, 2020

      • The coronavirus is mutating – does it matter? 9/8/20. Callaway E. Nature.
        In an article from Nature, mutations in the SARS-CoV-2 are reviewed. Mutations in RNA viruses such as SARS-CoV-2 containing “proofreading” enzymes occur slowly. One distinct mutation in the spike protein gene occurs at the 614th amino-acid position: the aspartate (D, in biochemical shorthand) is replaced by glycine (G) in the virus’s 29,903-letter RNA code. The “D614G mutation” became the dominant SARS-CoV-2 lineage in Europe and the US. Despite early alarm, it does not enhance spread or affect antibody defense. More than 12,000 mutations in SARS-CoV-2 are catalogued. The author speculates that worrisome mutations could arise especially if antibody therapies producing selection pressure are not used wisely.

      September 4, 2020

      • Humoral Immune Response to SARS-CoV-2 in Iceland. 9/1/20. Gudbjartsson DF. N Engl J Med.
        Fifty-six percent of all SARS-CoV-2 infections in Iceland had been diagnosed with quantitative polymerase-chain-reaction (qPCR) assay, 14% had occurred in quarantined persons who had not been tested with qPCR (or who had not received a positive result, if tested), and 30% had occurred in persons outside quarantine and not tested with qPCR. Despite extensive screening by qPCR, a substantial fraction of infections were not detected, which indicates that many infected persons did not have substantial symptoms. But due to the low SARS-CoV-2 antibody seroprevalence, the Icelandic population is vulnerable to a second wave of infection.

      July 31, 2020

      • Targets of T Cell Responses to SARS-CoV-2 Coronavirus in Humans with COVID-19 Disease and Unexposed Individuals. 5/15/20. Grifoni A. Cell.
        To be effective, a COVID-19 vaccine has to elicit strong T cell immunity. Vaccines stimulate B cells to make antibodies against the virus. Helper T cells promote this. Those antibodies join with the virus, preventing it from entering a host cell and mark the virus for destruction. Once the virus infiltrates the host cell, antibodies are not effective. However, cytotoxic T cells can destroy infected host cells.
        T cell immunity does not prevent re-infection but reduces the severity of symptoms. Among patients recovered from COVID-19, CD4+ T cells were observed in all and CD8+ T cells were observed in about 70%. CD4+ responses to spike antigen correlated with IgG and IgA antibody titers. Each of M, spike, and N antigens accounted for 11%–27% of the total CD4+ response. The remaining responses were against other SARS-CoV-2 antigens. This suggests that vaccines that target multiple antigens may be more effective than the ones targeting only the spike antigen.
        T cell immunity is observed in persons infected and in about one-half of persons uninfected with SARS-CoV-2. The latter may have been previously infected with a virus such as one of the four human coronaviruses that cause colds. Thus, there is cross reactivity with other corona viruses. This may be a reason for variability in severity of clinical illness after infection.
        Many of the vaccine candidates lead to production of the spike protein and antibodies against it. If the vaccine does not produce the spike protein with correct confirmation, the generated antibodies may be binding but not neutralizing antibodies. This can promote viral replication or form complexes that trigger more inflammation. Memory B and T cells that recognize the virus can provide protective immunity for years although the antibody titers may decline within months. Efforts are being made to genetically modify certain immune cells to target the virus.

      July 22, 2020

      • Excess Deaths From COVID-19 and Other Causes, March-April 2020. 7/1/20. Woolf, SH. JAMA.
        The initial symptomatology, prodromal infective potential, anticipated course/severity, value of PPE and myriad additional variables were unknown when COVID-19 began its international journey. Early optimism in terms of containing and controlling the virus rapidly deteriorated as disease progression was recognized, the ability of asymptomatic carriers were known to be highly infectious and the initially unexpected benefit of universal face mask adoption created uncertainly about not only the viral spread but also the safety and reliability of the health system. Death is usually categorized accurately and reliable “death rate” statistics have been accumulated; the authors use seasonally adjusted U.S. death rates from December 29, 2013 to February 29, 2020 and compare historical to actual death rates reported between March 1, 2020 and April 2020 and include a secondary analysis in the five states most severely affected by the virus during the collection period. Careful data analysis was used to determine all-cause mortality and how COVID-19 influenced the total. The results attribute 65% of excess deaths to COVID-19-related causes and suggest that the total number is likely higher. Analysis was able to distinguish significant increases in other diseases during the period.
        Also included is an insightful discussion underscoring importance of accurate determination of COVID-19’s true impact on not only death but also on hidden morbidity (including COVID-19 delayed treatment and/or resource constraints) which is still being elaborated.
      • EDITORIAL: Mortality and Morbidity: The Measure of a Pandemic. 7/1/20. Zylke JW. JAMA.
        This editorial accompanying “Excess Deaths” further elaborates on the importance of, and difficulties associated with, estimating impact of COVID-19 on health systems and society. Peripheral effects are included and discussed. Together, the articles underscore the importance of classification and clarification in estimating disease impact, prevalence and spread in vulnerable populations and on society at large.
      • Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. 7/6/20. Pollan M. Lancet.
        Review by the SAB
        By Dr. Robert Coffey, on behalf of the SAB
        This article reports the results of antibody testing of 61,000 individuals across Spain, from April 27 to May 11, showing an overall national seropositive rate of only 5% (the majority of new diagnoses in Spain’s severe epidemic were made by May 1). Regions that experienced a more intense epidemic such as Madrid did have a seropositive rate of greater than 10%. Approximately one-third of the seropositive subjects reported having had no symptoms suggestive of COVID-19 infection. While specific locales such as Bergamo, Italy and some neighborhoods in Queens, NY may have seropositive rates high enough to confer local herd immunity, this does not seem to be occurring at a national level after severe epidemic episodes.

      July 20, 2020

      • SARS-CoV-2 infection protects against rechallenge in rhesus macaques. 5/20/20. Chandrashekar A. Science.
        Review by the SAB
        By Dr. Uday Jain, on behalf of the SAB
        Nine adult rhesus macaques infected with SARS-CoV-2 developed humoral and cellular immune responses leading to protective immunity. On re-challenge by SARS-CoV-2, there was a major attenuation of viral load in nasal mucosa and bronchoalveolar lavage in all of them. As the virus was still detectable, the protection was not sterilizing and the macaques could infect others. These results in primates suggest that patients who have COVID-19 may develop immunity to it. This is also essential for the development of a vaccine and determination of herd immunity.

      May 28, 2020

      • Duration of SARS-CoV-2 viral RNA in asymptomatic carriers. May 24. Yan X. Crit Care.
        Asymptomatic COVID-19 carriers are potentially a significant vector for the spread of SARS-CoV-2, but little is known about asymptomatic carriers. This research letter charts the RT-PCR positivity of 24 asymptomatic RT-PCR positive patients, showing persistent positivity can be lengthy (over 4 weeks). Viral cultures were not performed, so little can be said about infectivity of these asymptomatic carriers.

      May 27, 2020

      May 22, 2020

      May 21, 2020

      • Higher solar irradiance is associated with a lower incidence of COVID-19
        May 19. Guasp. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Jay Przybylo
        This is an interesting study using statistical evaluation of population density and solar and weather influences on COVID-19 spread that correlates high urban population density and low UV radiation to increased COVID-19 infection rates. The graphs are difficult to interpret.
      • Simulated Sunlight Rapidly Inactivates SARS-CoV-2 on Surfaces
        May 20. Ratnesar-Shumate. The Journal of Infectious Diseases.
        Opinion from SAB Member: Dr. Jay Przybylo
        This is a biodefense research article proving that simulated sunlight inactivates SARS-CoV-2. 90% of the virus on different surfaces became inactivated in between 7-14 minutes. Lower intensity light containing UV spectra took longer to achieve effect. Different than the article describing the effect of UV light on large populations in geographic regions investigating natural effects of the sun and climate, this article is specific to the actual virucidal effect of the light.

      May 19, 2020

      • Reduction and Functional Exhaustion of T Cells in Patients With Coronavirus Disease 2019 (COVID-19). May 1. Diao. Front. Immunol.
        Lymphopenia is a feature in Covid-19, however the number of T cells marking progressive disease is not known. This retrospective analysis from Wuhan, China examined 522 cases from December 2019 to January 2020. The critical numbers of total T cells, CD4+ and CD8+ T cells indicating more critical illness or impending death were less than 800, 300, or 400/μL, respectively. Also, these T cells expressed enhanced surface PD-1 and Tim-3, so called “exhaustion markers”. T cell numbers are negatively correlated to the “cytokine storm” mediators TNF-α, IL-6, and IL-10. This study suggests low T lymphocyte counts mandates early intervention.

      May 16, 2020

      May 11, 2020

      May 1, 2020

      • A SARS-CoV-2 protein interaction map reveals targets for drug repurposing. Apr 30. Gordon. Nature.
        332 SARS-CoV-2 human protein interactions were identified by cloning virus proteins in human cells and then identifying associated human proteins. 40% are associated with endomembrane compartments or vesicle trafficking pathways. 66 interactions are targeted by 29 approved drugs, 12 in clinical trials, and 28 preclinical compounds. Viral assays at Mt Sinai in NY and the Institut Pasteur in Paris identified 2 sets of agents with antiviral activity — those affecting translation (e.g. hydroxychloroquine and the more effective PB28) and those modulating Sigma1 and 2 receptors (e.g. haloperidol and dextromethorphan). Intriguing methodology for identifying existing compounds for clinical trials.

      April 30, 2020

      April 29, 2020

      • Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study
        Apr 27. Bi. The Lancet Infectious Diseases.
        Opinion from SAB Member: Dr. Barry Perlman
        Retrospective epidemiologic analysis demonstrating the benefits of contact surveillance, adequate availability of testing, and quarantines. There were 391 confirmed cases of COVID-19 Jan 14-Feb 12 and 1286 close contacts confirmed before Feb 9 in Hubei province. Suspected cases and contacts were tested by RT-PCR nasal swabs. Asymptomatic close contacts who tested positive were quarantined at central facilities, while those who tested negative were quarantined at home or a central facility. Infection rate did not differ significantly by age, with on average 7% of close contacts becoming infected, 77% of these contacts having any symptoms, and 3% of infections having severe disease at initial assessment. Median time to recovery was 22 days with older patients and those with severe disease having a longer time to recovery. Contact-based surveillance reduced the duration an infected person could spread disease in the community by 2 days as compared with symptom-based surveillance.

      April 28, 2020

      • How Could This Happen? Narrowing Down the Contagion of COVID-19 and Preventing Acute Respiratory Distress Syndrome (ARDS)
        Apr 25. Alaerts. Acta Biotheor.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        A biologist’s deeply scientific but also philosophical review of the history, epidemiology and the viral genomics of the Corona virus family. The author provides a helpful template for understanding the present pandemic outbreak and focuses on the role of the renin-angiotensin system in acute lung injury and ARDS and SARS-CoV action during infection. His suggestions for future research list: 1) The correlation and interaction with previous medication, particularly ACE-inhibitors; 2) Creating immunologic profiles, particularly for patients at risk for ARDS; and 3) The influence of viral genomic differences on infectivity, virus reproduction and shedding and biochemical entry routes with host cells. In addition, the range of immunological reactions to the virus by the host deserves further scrutiny and will be of great importance in the vaccine development. A valuable contribution to both clinician scientists and investigators searching to contribute to solve the COVID-19 puzzle.

      April 24, 2020

      April 23, 2020

      • Comparative tropism, replication kinetics, and cell damage profiling of SARS-CoV-2 and SARS-CoV with implications for clinical manifestations, transmissibility, and laboratory studies of COVID-19: an observational study. Apr 21. Chu. The Lancet Microbe.
        A science study with little clinical significance. A comparison of SARS-CoV-2 vs COVID-19 for entry and replication into numerous human and nonhuman cell lines. The authors state the article might be of pertinence to further cell studies on optimization of antiviral assays but not necessarily to human organs in the physiologic state — life.
      • Connecting clusters of COVID-19: an epidemiological and serological investigation
        Apr 21. Yong. The Lancet Infectious Disease.
        Opinion from SAB Member: Dr. Heinrich Wurm
        Fascinating account of a successful epidemiological disease tracking operation using RT-PCR and serologic testing to identify COVID-19 transmission among 3 clusters – 2 churches and a New Year’s gathering – in Singapore between mid-January and the end of February. While initial testing of all patients presenting with pneumonia using RT-PCR led to the diagnosis of overtly infected patients who were shedding virus, serologic testing played an important role in identifying convalescent cases or people with minimal symptoms, allowed assessment of disease penetration among the population and guidance towards containment efforts.
        • An accompanying editorial by Johns Hopkins epidemiologists, stresses the value of broad testing strategies to assess and contain the spread of COVID-19, particularly by measuring SARS-CoV-2-specific IgG antibody titers. It enumerates 4 distinct and valuable concepts gained from serological testing, including identifying potential candidates for donation of reconvalescent serum. It also points out several remaining challenges, among those sensitivity and specificity of the test, excluding cross reactivity to other viruses resulting in false positives, antibody kinetics determining the duration of immunity, as well as cost and portability of the test.
      • The important role of serology for COVID-19 control
        Apr 21. Winter. The Lancet Infectious Diseases.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        This accompanying editorial by Johns Hopkins epidemiologists stresses the value of broad testing strategies to assess and contain the spread of COVID-19, particularly by measuring SARS-CoV-2-specific IgG antibody titers. It enumerates 4 distinct and valuable concepts gained from serological testing, including identifying potential candidates for donation of reconvalescent serum. It also points out several remaining challenges, among those: sensitivity and specificity of the test, excluding cross reactivity to other viruses resulting in false positives, antibody kinetics determining the duration of immunity, and cost and portability of the test.

      April 21, 2020

      • Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans. Apr 10. Fox. medRxiv.
        As of March 31, 2020, New Orleans has had the highest death rate per capita in the US. This is a non-peer reviewed report of the cardiopulmonary findings of the first 4 autopsies performed. The patients were African Americans with obesity and HTN. 3 had IDDM and 2 had chronic kidney disease. Lung parenchyma was edematous and firm, consistent with ARDS. 3 had areas of lung hemorrhage. Only the lung from the patient who had been on methotrexate showed focal consolidation. All cases showed evidence of diffuse alveolar damage with DC4+ aggregates around thrombosed small vessels. Heart tissue showed atypical myocyte degeneration but no myocarditis. The findings suggest that in addition to targeting the virus itself, therapy should also focus on the thrombotic and microangiopathic effects and the maladaptive immune response.

      April 20, 2020

      • Clinical Characteristics of Covid-19 in New York City. Apr 17. Goyal. NEJM.
        A prelude to what’s coming to us
        NEJM article about experience of 2 NYC Hospitals of first 393 patients with COVID 19.
        Comorbidity was noted to be higher in NYC as compared to China. NYC outcomes were noted different as well with regard to: Higher number of patients were ventilated, lower oxygen earlier, renal replacement, fluids, need for vaso active drugs to maintain hemodynamic stability. 33% required ventilators, 10.2% Mortality, 33% extubated, 66% were discharged – these numbers were higher than China data all across.
      • Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period
        Apr 14. Kissler. Science.
        Opinion from SAB Member: Dr. Barry Perlman
        Viral, environmental, and immunologic data from other corona viruses were used to project SARS-CoV-2 transmission and determine social distancing measures that may be needed through 2025. Models suggest that SARS-CoV-2 could cause outbreaks in any season, exhibiting annual, biennial, or sporadic patterns depending on duration of immunity after infection. If similar to other coronaviruses, recurrent SARS-CoV-2 winter outbreaks are likely. Incidence through 2025 will depend on duration of immunity and cross immunity with other coronaviruses. In all models, infection resurgence occurred when social distancing measures were lifted, but restrictive social distancing could also decrease development of population immunity. In the absence of increased critical care capacity and effective new treatments or vaccines, intermittent social distancing will be needed through 2022. Increased critical care capacity, testing, and surveillance are needed to better determine what intermittent social distancing policies may maintain critical care availability while building population immunity.
      • Spread of SARS-CoV-2 in the Icelandic Population
        Apr 14. Gudbjartsson. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this study of corona virus spread in Iceland, using targeted testing of persons at high risk for infection and population screening, the frequency of coronavirus infection in the overall Icelandic population was stable from March 13 to April 1, which showed that containment measures in Iceland were working. Testing was a critical component and is a model for other countries.

      April 17, 2020

      • Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients. Apr 16. Seah IYJ. Ophthalmology.
        The nasolacrimal system can act as a conduit for viruses to travel from the upper respiratory tract to the eye. The authors measured the presence of SARSCoV-2 with viral isolation and quantitative reverse-transcription polymerase chain reaction (RT-PCR) analysis. As the 17 patients in the study were being monitored clinically via routine nasopharyngeal swabs, these results were compared with those of tears to understand further patterns of viral shedding. Of the 17 patients recruited, none demonstrated ocular symptoms. However, 1 patient developed conjunctival injection and chemosis during the stay in the hospital. Fourteen patients showed upper respiratory tract symptoms at presentation, including cough, rhinorrhea, and sore throat. No evidence was found of SARS-CoV-2 shedding in tears through the course of the disease even for the one patient with conjunctival injection.
      • Visualizing speech-generated oral fluid droplets with laser light scattering. Apr 15. Anfinrud, P. NEJM.
        NEJM letter to the editor, from the NIH, explaining and demonstrating sprays of secretions from speaking. The included graphic video illustrates the degree of droplet/aerosol formation from speech alone.

      April 15, 2020

      • Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. Mar 17. van Doremalen N. NEJM.
        This widely published letter to the editor addresses the viability of SARS-CoV-2 in aerosols and on various surfaces and compares it to SARS-CoV-1, the original severe acute respiratory syndrome coronavirus that is most closely related to the coronavirus responsible for the Covid-19 pandemic. Scientists from the National Institute of Allergy and Infectious Diseases, CDC, UCLA and Princeton participate in this work. It showed that under experimental conditions both viruses are detectable in aerosols for several hours and up to 24 hours on cardboard and stainless steel. The fact that the stability of the two SARS viruses were similar indicates that other factors, like high viral load in the upper respiratory tract and the possibility that people infected with the virus may shed and transmit the virus while asymptomatic, account for the difference in epidemiological characteristics.
      • Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Feb 14. Liang, W. Lancet Oncology.
        Cases with COVID-19 acute respiratory disease from 575 hospitals in China were monitored prospectively to determine whether cancer patients are at increased risk of COVID-19 and have a poorer prognosis. 18/1590 cases had a history of cancer, which is 3-4 times higher than the overall incidence of cancer in China. Cancer patients had an almost 5x higher risk of severe events — ventilation or death. Chemotherapy or surgery within the past month as associated with the highest risk. Lung cancer patients did not have a higher risk of severe events compared with other cancer patients. The authors suggest that during infectious disease events such as COVID-19, chemotherapy or elective cancer surgery should be postponed in endemic areas, and the increased risk to cancer patients should be taken into account regarding infection prevention and treatment.
      • Stability and Viability of SARS-CoV-2. Apr 14. Petti S. N Engl J Med.
        In follow-up to the experimental aerosol publication by van Doremalen et al., a number of letters to the editor address the fact that the message derived from the experiment created the impression in the lay press that there is proof of airborne transmission under non-aerosolizing conditions. In response, the authors reiterate their statement that the stability of aerosolized CoV-2 is similar to that of CoV-1. What follows from this finding is the fact that aerosols created by procedures (i.e. drilling) or patients (i.e.coughing) have been associated with nosocomial transmission of emerging viruses (SARS-Co-V-1 and MERS-CoV) and that there is no reason to believe COVID-19 will act differently under similar conditions.

      April 14, 2020

      April 13, 2020

      April 11, 2020

      • Comparative replication and immune activation profiles of SARS-CoV-2 and SARS-CoV in human lungs: an ex vivo study with implications for the pathogenesis of COVID-19 Apr 9. Chu. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Philip Lumb
        Ex-vivo investigation (excised donor lung segments from surgical patients with lung tumors) inoculated with either SARS-CoV-2 or SARS-CoV preparations. Infection and replication capacity of the two preparations were compared. Excellent methodology section detailing specimen and culture preparation, biohazard security and virology challenge and critical analysis. Results demonstrated that SARS-CoV-2 was more capable of infecting and replicating in lung tissue than SARS-CoV. The discussion includes the statement, “These findings may explain the high viral load in the respiratory secretions of COVID-19 patients during the early days on presentation or even during incubation, and thus the its person-to-person transmissibility.” This is a meticulously conducted experiment with well described methodology and important conclusions that provides insight into why COVID-19 propagates rapidly, has variable penetrance and clinical outcomes, and gives a theoretical rationale for early use of antiviral medication. An important study that could help define future therapeutic intervention and further ongoing research.
      • Coronavirus Disease 2019 in Children – United States, February 12-April 2, 2020. Apr 10. CDC COVID-19 Response Team. MMWR Morb Mortal Wkly Rep.
        22% of US population is < age 18. As of 4/2/20 1.7% of reported US COVID-19 patients were < age 18. Clinical data were only available for a small proportion —11%. Of those, 73% had symptoms of fever, cough, or shortness of breath compared with 93% of adults aged 18–64 years during the same period; 5.7% of all pediatric patients, or 20% of those for whom hospitalization status was known, were hospitalized, lower than the percentages hospitalized among all adults aged 18–64 years (10%) or those with known hospitalization status (33%). Three pediatric deaths were reported. These data support previous findings that children with COVID-19 might not have reported fever or cough as often as do adults, but due to the low percentage of cases with available clinical data, this conclusion should be considered preliminary.
      • Effect of throat washings on detection of 2019 novel coronavirus. Apr 10. Guo. Clin Infect Dis.
        11 COVID-19 positive patients were studied with 24 paired PCR testing from both nasal swabs and self-administered throat washings using 20 ml. saline. In 18 pairs of tests the results agreed (1 pair positive and 17 pairs negative) however in 6 pairs of tests the nasal swab was negative while the throat washing was positive. While this is a very small study conducted patients who were 48-57 days after symptom onset, it raises the question of whether throat washings may prove to be superior in sensitivity and simplicity for identification of PCR positive COVID-19 patients.
      • Presymptomatic Transmission of SARS-CoV-2 – Singapore, January 23-March 16, 2020. Apr 10. Wei. MMWR Morb Mortal Wkly Rep.
        As of March 17, Singapore had reported 243 cases of COVID-19 disease of which 157 were locally acquired. Of those 157, 10 patients from 7 clusters, (6.4%), were felt to have been transmitted 1-3 days before the source patient experienced onset of symptoms. The mechanism of transmission was not certain. Public policy implications are discussed.

      April 10, 2020

      April 9, 2020

      April 8, 2020

      April 5, 2020

      • Aerosol and Surface Stability of SARS-CoV-2 as Compared With SARS-CoV-1 Van Doremalen. Mar 17. NEJM.
        COVID-19 SAB Opinion from: Dr. W. Heinrich Wurmn
        This widely published letter to the editor of the NEJM addresses the viability of SARS-CoV-2 in aerosols and on various surfaces and compares it to SARS-CoV-1, the original severe acute respiratory syndrome coronavirus that is most closely related to the coronavirus responsible for the COVID-19 pandemic. Scientists from the National Institute of Allergy and Infectious Diseases, CDC, UCLA and Princeton participate in this work. It showed that the SARS-CoV-2 virus survives and is detectable in aerosols for several hours and up to 24 hours on cardboard and stainless steel. This indicates that the virus spreads through the air and by touching contaminated surfaces. The fact that the stability of the two SARS viruses were similar indicates that other factors, like high viral load in the upper respiratory tract and the potential that people infected with the virus may shed and transmit the virus while asymptomatic, account for the difference in epidemiological characteristics.

      April 4, 2020

      • Ten Weeks to Crush the Curve. Apr 1. Fineberg. NEJM.
        Editorial advocating 6 steps to “defeat” Covid-19 by early June: Establish united command, increase diagnostic test availability for everyone with symptoms, supply health workers with PPE and equip hospitals to care for surge, differentiate population based on presence or absence of current infection and treat accordingly, inspire and mobilize public, research.

      April 3, 2020

      March 31, 2020

      March 27, 2020

      March 26, 2020

      March 25, 2020

      November 13, 2006

    1. Diagnosis of Infection or Immunity (Including Organization / Reliability)
      Updated Daily between 4:00 pm and 5:00 pm EDT

      Updated Frequently

      November 23, 2020

      • Preexisting and de novo humoral immunity to SARS-CoV-2 in humans. 11/6/20. Ng K. Science.
        Using diverse assays for antibodies recognizing SARS-CoV-2 proteins, these investigators examined preexisting humoral immunity to the novel and older coronaviruses in humans. Using flow cytometry, predominately IgG class cross-reacting antibodies particularly targeting the S2 subunit of the spike glycoprotein were detectable in the SARS-CoV-2-uninfected, especially children and adolescents. SARS-CoV-2 infection induced higher titers of SARS-CoV-2 S-reactive IgG antibodies, targeting both proteolytically-cleaved S1 (attachment) and S2 (entry) subunits, along with contemporaneous IgM and IgA. Notably, SARS-CoV-2-uninfected donor sera exhibited specific neutralizing activity against SARS-CoV-2 and SARS-CoV-2 S pseudotypes. Cross-reacting immunological memory may be critical to understand susceptibility to SARS-CoV-2 infection.

      November 9, 2020

      October 23, 2020

      • Pasteurization Inactivates SARS-CoV-2 Spiked Breast Milk. 10/22/20. Conzelmann C. Pediatrics.
        Bench Research, Human Milk, and SARS-CoV-2. 10/22/20. Furman L. Pediatrics.
        A team of German virologists determined that the SARS-CoV-2 virus can be shed and is detectable in human breast milk but does not replicate in that environment. Inoculation of breast milk with various strains of the virus resulted in a 40-90% decrease in viral titer due to antiviral properties of breast milk alone. Heating to 63°C (145°F) for 30 minutes (Holder pasteurization) completely inactivated the virus.
        Welcoming these findings, an accompanying editorial by two US pediatricians is strongly in favor of allowing infected mothers to breastfeed their babies whenever possible as the milk duct epithelium’s lack of proteases required to allow virus entry prevents vertical transmission of COVID-19 from an infected mother.

      October 21, 2020

      • The duration of infectiousness of individuals infected with SARS-CoV-2. 10/13/20. Walsh KA. J Infect.
        The potential duration of patient infectiousness, as derived from virus culture and contact tracing studies, for those individuals in whom SARS-CoV-2 RNA is detected is summarized. Thirteen various quality studies and 2 large contact tracing studies were included. The data suggests that COVID-19 patients with mild-to-moderate illness are highly unlikely to be infectious beyond 10 days from symptom onset. Evidence from a limited number of studies indicates that patients with severe-to-critical illness, and/or those who are immunocompromised, may be infectious for a prolonged period, possibly for 20 days or more. Research is needed to confirm these findings and to provide information on the duration of infectiousness in subgroups such as children, and asymptomatic and immunosuppressed patients.
      • Transmission Dynamics by Age Group in COVID-19 Hotspot Counties – United States, April-September 2020. 10/15/20. Oster AM. MMWR Morb Mortal Wkly Rep.
        CDC analyzed temporal trends in percent test positivity by age group in COVID-19 hotspot counties before and after their identification as hotspots. Among 767 U.S. hotspot counties identified during June and July 2020 (24% of counties, 63% of population) early increases in the percent positivity among persons 24 years old and younger were followed by several weeks of increasing percent positivity in persons 25 years old and older, particularly those in the South and West. Addressing transmission among young adults is an urgent public health priority.

      October 5, 2020

      • Detection of SARS-CoV-2 with SHERLOCK One-Pot Testing. 9/16/2020. Joung J. N Engl J Med.
        Both CRISPR (clustered regularly interspaced short palindromic repeats)- based diagnostic tests and SHERLOCK (specific high-sensitivity enzymatic reporter unlocking) can detect viruses, but are not practical for Point of Care testing. The newly described “STOPCovid.v2” (SHERLOCK Testing in One Pot version-2) uses a novel magnetic bead RNA extraction with loop-mediated isothermal amplification and CRISPR-mediated detection, all in 15-45 minutes using minimal equipment and available reagents. Nasal swab testing showed a sensitivity of 93.1% and a specificity of 98.5%. STOPCovid.v2 false negative samples had RT-qPCR Ct values greater than 37. STOPCovid.v2 detected a viral load 1/30th detected by RT-qPCR.

      October 2, 2020

      • Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. 9/22/2020. Rentsch CT. PLoS Med.
        This article presents a nationwide VA data set study (~6 million patients, February 8 to July 22) comparing positive COVID-19 test results with 30-day mortality. Healthcare disparities were explored by evaluating “associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence.” The study confirms prior reports indicating that “Black and Hispanic individuals experience excess burden of SARS-CoV-2 infection” but not increased mortality and notes that these disparities “are not entirely explained by underlying medical conditions or where they live or receive care.” The article contains interesting distinctions and reinforces the importance of designing “strategies to contain and prevent further outbreaks in racial and ethnic minority communities.”
      • Sensitive Detection of SARS-CoV-2-Specific Antibodies in Dried Blood Spot Samples. 9/24/20. Morley GL. Emerg Infect Dis.
        Dried blood spot (DBS) samples can be obtained directly from patients without venipuncture and stored and shipped without refrigeration. DBS samples were compared to matched serum samples in 80 patients to detect coronavirus 2 spike antibodies with a relative 98.1% sensitivity and 100% specificity. The authors propose that DBS sampling offers an alternative for population-wide serologic testing in the coronavirus pandemic.

      September 30, 2020

      September 14, 2020

      September 9, 2020

      August 26, 2020

      August 17, 2020

      August 12, 2020

      • Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic. 8/7/20. JAMA Cardiol.
        Using discharge coding of >15,000 acute MI hospitalizations over 17 months from a multi-state US health system, a significant decrease in observed vs. expected numbers during the early COVID-19 period, March-May 2020, was observed in all regions. NSTEMI patients disproportionately decreased and hospital cardiac death rates increased, particularly in STEMI patients. Trends largely normalized by study end, May 10, 2020. These data suggest that patients avoided presenting to hospital with possible AMI during the early COVID-19 period, potentially forfeiting the benefit of early reperfusion in some cases.

      August 10, 2020

      • Characterization of the Inflammatory Response to Severe COVID-19 Illness. 6/25/2020. McElvaney OJ. ATS.
        This article offers a detailed measurement of inflammatory mediators in 20 severely ill patients compared with a group of moderately ill patients and a group of normal controls. It’s proposed that similar characterisations and treatment trials might someday allow for a tailor made treatment regimen of immune modulators to be given to each patient optimizing their recovery. The accompanying editorial highlights the finding in the original study that alpha-1-antitrypsin (AAF), which has an anti-inflammatory effect, is reduced in patients with severe Covid-19 pneumonia, and a trial of AAF supplementation may be warranted.

      August 5, 2020

      July 31, 2020

      July 27, 2020

      July 22, 2020

      • Impact of delays on effectiveness of contact tracing strategies for COVID-19: a modelling study. 7/16/20. Kretzschmar ME. Lancet Public Health.
        Review by the SAB
        By Dr. Lance Lichtor, on behalf of the SAB
        The authors used a mathematical model that describes the different steps of a symptomatic contact tracing strategy for COVID-19. They found reducing the testing delay (i.e., shortening the time between symptom onset and a positive test result, assuming immediate isolation) is the most important factor for improving contact tracing effectiveness. Reducing the tracing delay (i.e., shortening the time to trace contacts, assuming immediate testing and isolation if found positive) might further enhance contact tracing effectiveness, though this additional effect rapidly declines with increasing testing delay.
      • Redefining cardiac biomarkers in predicting mortality of inpatients with COVID-19. 7/17/2020. Qin JJ. Hypertension.
        Detailed, retrospective analysis of available cardiac biomarkers of 3219 patients admitted to 9 hospitals in Hubei province between December 31st, 2019 and March 4th, 2020. Entry criteria included patients from 18 to 75 years old with documented COVID-19 on admission (RT-PCR and/or Chest CT) and high sensitivity cardiac troponin (hs-cTnI) or CKMB on admission with primary endpoint 28-day mortality. Statistical processing includes additional biomarker profiles, primary and secondary cardiac effects and analysis suggesting that in COVID-19 need to redefine reference range for Upper Limit of Normal to understand impact of cardiac effects.
        The authors conclude “the abnormal cardiac biomarker pattern in COVID-19 patients was significantly associated with increased mortality risk, and the newly established COVID-19 prognostic cutoff values of hs-cTnI, CK-MB, (NT-pro)BNP, CK, and MYO were found to be much lower (~50%) than reference upper normal limits for the general population.” Valuable information that needs to be confirmed in different populations.

      July 10, 2020

      July 1, 2020

      June 29, 2020

      • Occurrence and Timing of Subsequent SARS-CoV-2 RT-PCR Positivity Among Initially Negative Patients. 6/7/20. Long DR. Clin Infect Dis.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        Detailed, retrospective electronic medical record data analysis showing that a small percentage of symptomatic patients who initially test negative for SARS-CoV-2 may have a positive result on repeat testing.
        A combined 21,000 patients underwent nasopharyngeal swab testing at Stanford and University of Washington. Testing was performed for either clinical reasons (symptoms with pertinent risk factors or clinical judgement) or universal asymptomatic preoperative screening.
        • 91% of the patients initially tested negative.
        • 96% of those who initially tested negative did not have a repeat test within 7 days and did not require subsequent care.
        • Of the remaining 626 patients who were initially negative and underwent repeat testing within 7 days for persistent or worsening symptoms, 14 of 338 (4.1%) UW and 8 of 288 (2.6%) Stanford patients were positive on repeat testing.
        • Subgroup analysis excluding UW asymptomatic preop patients yielded similar results.

        Overall occurrence of testing discordance for patients who had persistent or worsening symptoms was 3.5%, suggesting that the initial test was false negative.
        Nasopharyngeal swab RT-PCR testing sensitivity or specificity cannot be determined from this analysis due to:

        • lack of a gold standard confirmatory test to determine whether initial or subsequent results were false positive or false negative.
        • not all patients with an initial negative result were retested
        • incomplete clinical information regarding patients who had a negative result but did not undergo retesting.
        • possibility of newly acquired infection during the 7-day interval.
        • lack of complementary serology or RT-PCR testing of samples from other sites.

        However, it does support retesting of patients with a negative RT-PCR test who have persistent symptoms, although the optimal method of retesting needs to be determined.

      • The Laboratory Diagnosis of COVID-19 – Frequently Asked Questions. 6/8/20. Fang FC. Clin Infect Dis.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        This review from the clinical laboratories of the University of Washington breaks down information about testing for COVID-19 in a useful question-and-answer format. Subjects include PCR, serology, point-of-care testing, correlation with clinical disease, and biomarkers.

      June 5, 2020

      • Prevalence of Asymptomatic SARS-CoV-2 Infection: A Narrative Review
        June 3. Oran DP. Annals of Internal Medicine.
        Opinion from SAB Member: Dr. David M. Clement
        A well-written, concise review of 16 studies describing the prevalence and significance of asymptomatic persons infected with SARS-CoV-19. Four of five of the studies that included longitudinal serial testing to distinguish asymptomatic vs. presymptomatic persons showed otherwise healthy asymptomatic persons rarely (0-10%) became symptomatic. On the other hand, 89% of RT-PCR + nursing home patients were presymptomatic. Their conclusion is that asymptomatic infection is a significant factor in the rapid progression of the SARS-CoV-2 pandemic, and that current medical practice and public health measures should be modified to address this challenge.

      June 3, 2020

      • The role of SARS-CoV-2 antibodies in COVID-19: Healing in most, harm at times
        May 20. French MA. Respirology.
        Opinion from SAB Member: Dr. Edward S. Schulman
        This is an excellent commentary that all should read. Though some antibodies to the spike glycoprotein promote virus neutralization and other protective antibody functions, particular IgG antibodies might enhance the infection of immune cells and/or disease progression. One example is antibody‐dependent enhancement of virus uptake by macrophages by enhancing antibodies as described in dengue virus infection that has also been demonstrated for SARS‐CoV‐1. Therefore, current development of antibody-dependent strategies, whether human monoclonal antibodies, convalescent plasma or choosing the right target for vaccine is complex. Depending on the peptide targeted on the spike glycoprotein by the human immune system or the vaccine lab, neutralizing or enhancing activity may result. Simply having a “positive SARS-CoV-2 antibody” on a serological test may not be a license for a “passport.”
      • SARS-CoV-2 Antibody Testing – Questions to be asked
        May 25. Ozcurumez MK. Journal of Allergy and Clinical Immunology.
        Opinion from SAB Member: Dr. Barry Perlman
        Informative article by the COVID-19 Task Force of the German Society for Clinical Chemistry and Laboratory Medicine addressing the interpretation of antibody testing. Topics discussed include:
        • Possible indications for COVID-19 serology
        • Value of antibody testing in diagnosis
        • Does presence of antibodies indicate end of infectivity?
        • Does presence of antibodies indicate immunity?
        • Comparison of different assay technologies
        • Ensuring assay quality
        • Baseline samples from asymptomatic or healthy individuals
        • Estimating demand for antibody testing

        The paper points out that in a low prevalence setting, even a high specificity test can result in an unacceptable false positive rate, leading to an overestimate of population immunity and a lower estimate of viral mortality. False positive results may be minimized by selecting for higher prevalence with symptom screening or contact tracing.

      May 28, 2020

      May 27, 2020

      • Chronological Changes of Viral Shedding in Adult Inpatients with COVID-19 in Wuhan, China
        May 23. Huang. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Barry Perlman
        This is a retrospective study of 308 COVID-19 inpatients at one hospital in Wuhan between 1/11/20 and 2/21/20 who received > 5 ORF1ab gene RT-PCR tests. Viral loads (based upon cycle threshold) peaked 2-4 days after admission and then decreased with treatment. A rebound seen around 7, 16, and 22 days after admission was more common in non-severely ill patients. 43% of patients had positive tests after 2 negative tests. On day 30 of treatment most patients had undetectable virus by RT-PCR tests. High viral loads (cycle threshold < 30) correlated with critical illness, mortality, decreased serum albumin, decreased Th and Ts cells, lower lymphocyte, eosinophil, and basophil counts, and increased neutrophil counts, serum glucose, corrected calcium, LDH, CKMB, myoglobin, ultra TnI, and NT-proBNP. Sputum viral loads were higher than in nasopharyngeal samples, and respiratory loads were higher than in GI samples. The authors suggest that positive RT-PCR test rebound reflects surviving coronavirus particles.
      • Olfactory and gustatory function impairment in COVID-19 patients: Italian objective multicenter-study. May 21. Angelo Vaira. Head Neck.
        A 25 author study from Italy that was based on 345 patients who were either home-quarantined health care workers (161) or hospitalized patients (184), and all patients were swab positive for COVID-19. About 75% reported combined olfactory and taste disorders. Interestingly, of those who did not report any taste or smell disturbance, 30% had objective signs of odor dysfunction and those who had isolated odor or taste dysfunction had 20-30% more taste or odor dysfunction, that is the opposite dysfunction. Also, for 30%, the first sign of COVID-19 infection was chemo-sensitive dysfunction.
      • Predicting infectious SARS-CoV-2 from diagnostic samples
        May 22. Bullard. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Barry Perlman
        Many studies have assumed that “viral shedding” based on positive RT-PCR testing suggests presence of infectious virus. This is a retrospective cross-sectional Canadian study to determine whether presence of SARS-CoV-2 RNA by RT-PCR predicts infectivity. 26/90 (29%) samples positive by RT-PCR targeting the 122nt portion of the envelope gene incubated on Vero cells demonstrated viral growth. Only samples with RT-PCR cycle threshold (Ct) < 24 and symptom to test time (STT) < 8 days showed growth. Specificities for the thresholds of Ct > 24 and STT > 8 days were 97% and 96%, respectively. If confirmed by larger studies utilizing additional RT-PCR targets, these results suggest that Ct and STT can predict duration of infectivity with high specificity and would avoid the unnecessary isolation resulting from policies based upon 2 negative RT-PCR results.

      May 22, 2020

      • Olfactory Dysfunction and Sinonasal Symptomatology in COVID-19: Prevalence, Severity, Timing, and Associated Characteristics. May 19. Speth. Otolaryngol Head Neck Surg.
        The lead author was from the United States, though the patients were from Sweden. 103 patients were studied. The prevalence of hyposmia or anosmia was 61.2%, the mean onset was 3.4 days after symptoms of COVID-19 first appeared and was severe in nature and was strongly correlated with a concomitant loss of taste. 30% to 50% of participants experienced nasal obstruction or rhinorrhea, which they attributed to COVID-19. However, there was no correlation between these symptoms and OD. Only older age was negatively associated with having OD and female sex was possibly positively associated with having OD.
      • Olfactory Dysfunction in COVID-19: Diagnosis and Management
        May 20. Whitcroft. JAMA.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        This is a study that examines olfactory dysfunction both with and without COVID-19. The basis of olfactory dysfunction, as the authors explain, may be due to disruption of cells in the olfactory neuroepithelium, and that the virus may actually penetrate the brain and then have downstream effects on brain regions that may adversely affect olfactory function. The authors explain also how olfactory dysfunction should be assessed and how it might be treated.

      May 20, 2020

      • Clinically Applicable AI System for Accurate Diagnosis, Quantitative Measurements, and Prognosis of COVID-19 Pneumonia Using Computed Tomography
        May 17. Zhang. Cell.
        Opinion from SAB Member: Dr. Barry Perlman
        A variety of projects are investigating how artificial intelligence (AI) tools can be utilized during the COVID-19 pandemic. In this report, CT results from 4154 patients and clinical information from 843 patients in China were used to develop an AI system to diagnose COVID-19 pneumonia and differentiate it from other common (viral, bacterial, and mycoplasma) pneumonias. Data from retrospective and pilot prospective studies were used to validate the system, with sensitivities of 87-95% and specificities of 82-89%. System performance was superior to that of junior radiologists and comparable to mid-senior radiologists. It was found that lung CT findings correlated with clinical and biochemical evidence of disease severity in other organs systems. This AI system may assist in early diagnosis, prognosis prediction, management, evaluation of drug treatment efficacy, and follow up of COVID-19 patients.

      May 19, 2020

      • Antibody Testing For Covid-19
        May 15. Mathur. American Journal of Clinical Pathology.
        Opinion from SAB Member: Dr. Barry Perlman
        Accurate antibody tests can help with diagnosis, identify those with asymptomatic infections, determine prevalence in a population, aid in contact tracking, and measure progression to herd immunity. The 10 antibody tests that are currently FDA-approved have, on average, a sensitivity of 84.9% and a specificity of 98.6%. Sensitivities of these tests range from 58% to 94%. 90 additional tests are available for use, but are not yet FDA approved and don’t have sensitivity and specificity established. Table 2 demonstrates that positive predictive value varies widely depending on both the accuracy of the tests and local disease prevalence. When prevalence is high, such as in the greater NY area, antibody tests with specificity and sensitivity of 98% or better can be used as reliable screening tools. In areas of low prevalence, a test would need 100% specificity to avoid false positive results that could incorrectly indicate that someone is immune to COVID-19. The authors warn against using serologic tests not yet FDA approved with unknown accuracy to guide decision making.
      • Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction–Based SARS-CoV-2 Tests by Time Since Exposure
        May 13. Kucirka. Annals of Internal Medicine.
        Opinion from SAB Member: Dr. Barry Perlman
        This analysis illustrates that the predictive value of a negative SARS-CoV-2 RT-PCR test result depends on both pre test probability and test timing relative to exposure or symptom onset. Therefore, it applies more to “ruling out” infection in exposed patients and health care workers, rather than “clearing” asymptomatic patients for elective surgery. Using results from 7 previous studies reporting SARS-CoV-2 RT-PCR results, a Bayesian hierarchical model was created to estimate the false-negative rate by day since symptom onset or virus exposure. The model assumed a typical 5-day incubation period to symptom onset. The probability of RT-PCR false negative decreased from 100% on day 1 of exposure to 20% on day 8 (3 days after typical symptom onset), and then increased again to 66% on day 21. Therefore, the lowest post test probability from 1 negative RT-PCR test is achieved when the test is done on day 8, 3 days after symptoms onset. However, the post test probability from a negative day 8 sample varied from 1.2% to 14% depending on the pretest probability. The model suggests that negative RT-PCR tests early or late in infection should not be used to rule out COVID-19 if suspicion is high based on clinical and epidemiologic information.

      May 16, 2020

      • A serological assay to detect SARS-CoV-2 seroconversion in humans
        May 12. Amanat. Nature Medicine.
        Opinion from SAB Member: Dr. Jay Przybylo
        A dense, technical Brief Communication stating in the first sentence that the authors developed “a serological enzyme-linked immunosorbent assay” that then proceeds to describe the purpose and method culminating in the assay to assess the presence of SARS-CoV-2 spike protein antibody.
      • Asymptomatic Seroconversion of Immunoglobulins to SARS-CoV-2 in a Pediatric Dialysis Unit
        May 14. Hains. JAMA.
        Opinion from SAB Member: Dr. Jay Przybylo
        This is a Research Letter describing the futility of limiting the spread of SARS-CoV-2 using a pediatric dialysis unit as an example. A single patient presented to the unit and was isolated for therapy. This initiated testing on everyone, patients and staff, in the unit. 38% of patients and healthcare workers who presented repeatedly to this unit seroconverted positive to the virus by serum evaluation over a two-week period, proof that this virus is rapidly spreading in unrecognized ways.
      • Corona Viruses and the Chemical Senses: Past, Present, and Future
        May 14. Pellegrino. Chemical Senses.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this review of chemosensory ability in patients with COVID-19, the authors sought to determine whether chemosensory dysfunction is the same with COVID-19 as it is with other pandemics including SARS and MERS and whether COVID-19 represents a special case of viral infection attacking the olfactory system. They also discussed whether the taste disturbances with COVID-19 are a misrepresentation of olfactory disturbances rather than the direct impact of SARS-CoV-2 on taste and chemical sensitivity of skin and mucous membrane pathways. First, whether taste disturbance is olfactory-dependent or instead reflects true taste loss in COVID-19 is currently unclear. Second, olfactory disturbances may not be as prominent in SARS and MERS as with COVID-19. Third, the reduction in sensitivity being associated with reduced ability to promote the clearing of pathogenic agents from the nasal cavities can only be speculated. Certainly, distinguishing each aspect of chemo-sensation in patients with confirmed and suspected COVID-19 diagnosis as well as with other respiratory illnesses is needed to determine whether the chemical senses are uniquely affected by COVID-19 infection.
      • Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: a population-based cohort study. May 12. Banerjee. The Lancet.
        Opinion from SAB Members: Drs. Barry Perlman and Heinrich Wurm
        BP: To better assess the impact of COVID-19 on mortality, EMR data from 3 862 012 individuals in the United Kingdom > 30 yrs old were used to model 1 yr mortality in excess of baseline and deaths due to underlying conditions. Based on reported prevalence, 1 yr mortality from underlying conditions were estimated. The excess COVID-19 related deaths were then modeled at varying relative COVID-19 mortality risks and suppression related prevalence scenarios. 20% of the study population had at least one high-risk condition and 10% had multiple conditions. Excess deaths from COVID-19 decreased with increasing suppression measures. At a relative risk of 2, full suppression would result in minimal excess mortality. These models could help determine appropriate social distancing and isolation measures, particularly for individuals at highest risk. However, the models don’t take into account non-linear increase in mortality rates if health systems become overwhelmed, the impact of poor compliance with social isolation policies, impact of specific morbidities or multiple co-morbidities on risk of COVID-19 mortality, or impact of social distancing on underlying conditions.
        HW: In this population-based cohort study, a team of authors from the Institute of Health Informatics at the University College of London, used 3.8 million electronic health records as the basis for their modeling. They estimated the excess number of deaths over 1 year under different COVID-19 incidence scenarios based on 4 different levels of transmission suppression and differing mortality impacts based on 3 different relative risk scenarios for the disease. The result is a model and an online tool for understanding mortality – in excess of the expected – due to the COVID-19 pandemic. It signals an urgent need for sustained, stringent suppression measures.

      May 15, 2020

      • Currently available intravenous immunoglobulin contains antibodies reacting against severe acute respiratory syndrome coronavirus 2 antigens. May 12. Díez. Immunotherapy.
        Antibodies against common human coronaviruses are present in the normal population. 2 IVIG products Gamunex-C and Flebogamma DIF were tested with ELISA assays from different manufacturers for crossreactive antibodies to SARS-CoV-2 and other coronaviruses including SARS-CoV and MERS-CoV. While cross reactivity was demonstrated, further research is needed to determine clinical efficacy and safety for COVID-19 treatment.
      • Real-time tracking of self-reported symptoms to predict potential COVID-19
        May 11. Menni. Nature Medicine.
        Opinion from SAB Member: Dr. Lydia Cassorla
        This interesting report may represent a sign of the future of disease prediction models. 2.6M users reported symptoms on a smartphone-based app during a 4 week period beginning 24 March 2020. 93.6% in GB (balance in US). 15,638 UK and 2,763 US app users reported having had an RT-PCR SARS-CoV-2 test, and having received the result. Of the UK cohort with a (+) COVID PCR test, 65% reported a loss of smell and taste, compared with 23% of those with a (-) test result. “We re-ran logistic regressions adjusting for age, sex and BMI to identify other symptoms besides anosmia that might be associated with being infected by SARS-CoV-2. All ten symptoms queried (fever, persistent cough, fatigue, shortness of breath, diarrhea, delirium, skipped meals, abdominal pain, chest pain and hoarse voice) were associated with testing positive for COVID-19 in the UK cohort…In the US cohort, only loss of smell and taste, fatigue and skipped meals were associated with a positive test result.” A prediction model was created including factors of age, sex, loss of smell/taste, cough, fatigue, and skipped meals. “In the UK test set, the prediction model had a sensitivity of 0.65 (0.62–0.67), a specificity of 0.78 (0.76–0.80), an area under the curve (AUC) of the receiver operating characteristic curve (ROC) (that is, ROC-AUC) of 0.76 (0.74–0.78), a positive predictive value of 0.69 (0.66–0.71) and a negative predictive value of 0.75 (0.73–0.77).” Application of the model to the US cohort showed similar sensitivity and increased specificity of 0.83. Limitations include self-selection of cohorts, self-reporting, testing selection bias, and in GB the influence of media reports. The authors recommend adding loss of smell/taste to WHO symptom list for COVID-19.
      • Risk Factors for Viral RNA Shedding in COVID-19 Patients. May 12. Fu. Eur Respir J.
        Retrospective study of 410 confirmed COVID-19 patients in China who received follow-up RT-PCR testing after symptoms started to improve. 14% had 1 negative test followed by 1 positive test. Median time to 2 consecutive negative tests was 19 days after symptom onset (range 3-44 days) and 7 days after fever resolution. 96% tested negative within 30 days of symptom onset. 40 patients had fever resolution after testing negative. Coronary heart disease, serum albumin < 35 g/L, and initiation of antiviral treatment > 7 days after symptom onset were independent risk factors for prolonged positive tests.

      May 14, 2020

      • Dynamic profile for the detection of anti-SARS-CoV-2 antibodies using four immunochromatographic assays. May 12. Demey. J Infect.
        4 immunochromatographic lateral flow assay tests (LFA) from Asian manufacturers for Sars-CoV-2 IgM and IgG were evaluated and the kinetics of antibody detection in 22 RT-PCR positive patients were determined. Median antibody detection time from onset of symptoms ranged from 8-10 days depending on the manufacturer. Sensitivity range for detecting either IgM or IgG was 60-80% on day 10 but all assays were 100% sensitive on day 15. IgM was not detected in 3 patients with two of the assays and was not reliably detected prior to IgG. 1 cross reaction was seen with other human coronaviruses (other than SARS-CoV).
      • Gastrointestinal, hepatobiliary, and pancreatic manifestations of COVID-19
        Apr 29. Patel. Journal of Clinical Virology.
        Opinion from SAB Member: Dr. David M. Clement
        This paper is a good overview of the current literature on GI disease with COVID-19. A well written, concise review of the GI symptoms, laboratory abnormalities, outcomes, possible mechanisms of GI disease, and outcomes in COVID-19 patients with GI disease are included. The prolonged Rt-PCR positivity of fecal samples is discussed, concluding that this could be a significant mode of viral transmission, and should be taken into account.
      • Taste Changes (Dysgeusia) in COVID-19: A systematic review and metaanalysis
        May 1. Aziz. Gastroenterology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        The authors performed a retrospective analysis of published articles that reported on ageusia/dysgeusia as a symptom in laboratory-confirmed COVID-19 patients and found that almost half of the patients (49.8%) with COVID-19 have altered taste sensation. Though it is not certain that taste or smell changes can predict COVID-19, certainly the clinical feature can raise the suspicion of COVID-19 and lead to early testing and diagnosis.

      May 13, 2020

      • Prolonged Persistence of SARS-CoV-2 RNA in Body Fluids. May 9. Sun. Emerg Infect Dis.
        This prospective study from China reports on the results of serial PCR tests for hospitalized SARS-CoV-2 RNA from 49 patients, beginning with onset of symptoms. 43 mild and 6 considered severe cases. They sampled throat, sputum, NP, and feces every 3d. 95% of severe patients had clearance of RNA in all samples 7-8 days later than for mild cases, on average. Throat swab cleared first in mild but not severe cases. It is difficult to comment on their statistical findings as they collected only 32.75% of their desired samples for a variety of reasons. No asymptomatic patients included.
      • SARS-CoV-2 in pregnancy: symptomatic pregnant women are only the tip of the iceberg. May 11. Khalil. Am J Obstet Gynecol.
        A dramatically titled UK article testing all pregnant women presenting for delivery for COVID-19. During a 3-week period ending early in April, of the 129 pregnant women tested, only 1 presented with symptomatic infection. However, 7% tested asymptomatic positive. None of these women developed symptoms and all were discharged with healthy infants at ~2 days.

      May 12, 2020

      • COVID-19 Convalescent Plasma; Phase 2
        May 6. Knudson. Transfusion.
        Opinion from SAB Member: Dr. Louis McNabb
        This article discusses methodological issues in using convalescent plasma for COVID-19 patients, such as: donor selection, the fact that some donors have over ten times the antibody level of other donors, the existence of many different antibody tests, factoring in the weights of recipients, and pre- and post-antibody measurements in recipients.

      May 11, 2020

      • Considerations for Assessing Risk of Provider Exposure to SARS-CoV-2 after a Negative Test
        May 8. Long. Anesthesiology.
        Opinion from SAB Member: Dr. Barry Perlman
        The SARS-CoV-2 RT-PCR test is not 100% sensitive and, therefore, can result in a false negative. It has been questioned whether 1 negative test preop can be used to guide the level of PPE needed to adequately protect an anesthesiologist during an intubation or other aerosol generating procedure. Negative predictive value (NPV) and post test probability of SARS-CoV-2 infection were calculated based upon estimated prevalence in the population and test sensitivity and specificity. Using a “most likely” prevalence estimate of 1.0%, post test probabilities ranged from 1 in 89 to 1 in 1,636 with a median of 1 in 338. Based on the results: 1) If prevalence is uncommon, 1 negative test should provide “reassurance” regarding risk of exposure from an asymptomatic patient; 2) If surgical volume is high, exposure to aerosolized SARS-CoV-2 from asymptomatic, 1 test negative patients might occur on a regular basis; 3) If prevalence is high, full PPE should be used for test negative patients; 4) Due to estimate uncertainty in prevalence and testing sensitivity, there is a wide range in the calculated negative predictive value. The authors recommend that a lower threshold of NPV to justify use of universal airborne precautions regardless of preop test results be determined but be re-evaluated if prevalence estimates change.
      • Convalescent Plasma To Treat Coronavirus Disease 2019 (Covid-19): Considerations For Clinical Trial Design
        May 6. Barone. Transfusion.
        Opinion from SAB Member: Dr. Louis McNabb
        This article discusses many of the issues in collecting and administering convalescent plasma, and outlines the clinical trials in the USA currently in progress.
      • Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in severe patients with COVID-19. May 1. Sciascia. Clin Exp Rheumatol.
        Pilot, prospective, open, single arm, multi center study of off-label tociliuzamab, a humanized anti Il-6 receptor antibody, with 63 patients hospitalized with severe COVID-19 in Italy. Patients also received either lopinavir/ritonavir or darunavir/cobicistat. There was no significant survival difference with oral versus IV tociluzamab. D-dimer and CRP significantly decreased by day 1 of treatment. Administration within 6 days of hospital admission was associated with a 2x increased likelihood of survival. There were no severe-to-moderate adverse events from tociluzamab infusion.
      • Sample Pooling as a Strategy to Detect Community Transmission of SARS-CoV-2. Apr 6. Hogan. JAMA.
        In this research letter, a group of Stanford pathologists replicated a study done to determine the prevalence of trachoma in a population using RT-PCR in pooled samples to determine whether community transmission was in fact active during the early phases of SARS-CoV-2 arrival in the US when routine testing was done only on travelers and their contacts. There were two positives among 2888 nasal and lower respiratory samples tested both late in February when COVID-19 prevalence increased sharply. The pooled screening method is a lower cost method to test large populations quickly, using less reagents, and increase overall testing efficiency at an expected slight loss of sensitivity. The result is early detection of community transmission and timely implementation of appropriate infection control measures to reduce spread.
      • The Role of Antibody Testing for SARS-CoV-2: Is There One?
        Apr 29. Theel. Journal of Clinical Microbiology.
        Opinion from SAB Member: Dr. W. Heinrich Wurm, Dr. Barry Perlman
        WHW: This well-written correspondence presents a deep dive into the state-of-the-art SARS-CoV-2 serology as of mid-April 2020. While outlining the usefulness and applicability of serologic testing, the authors shed light on the absence of FDA oversight of a burgeoning industry of 91 manufacturers. This is a must read for anyone looking for: 1) A tutorial on the optimal use and interpretation of currently available serological testing; 2) verification studies used by laboratories; or 3) the role serologic testing plays in: a) Developing population immunity; b) Development of vaccine; c) Identifying convalescent plasma donors; d) Monitoring the response of vaccines. BP: Richly detailed commentary regarding the current state of SARS-CoV-2 serology testing. It points out the current lack of FDA oversight for serologic testing, which has resulted in a variety of approaches that differ in assay format, antibody detected, target antigen, and specimen type. In addition, it is not yet known whether antibody detection indicates clinical immunity. While some may decide not to read the entire article, the abstract provides a nice summary and useful information.
      • Tocilizumab for the Treatment of Severe COVID-19. May 5. Alattar. J Med Virol.
        Retrospective review of 25 ICU patients in Doha, Qatar with confirmed severe COVID-19 who received tociluzamab and were followed for 14 days. Patients received a median of 5 other antiviral medications. 92% had at least 1 adverse event, including anemia, increased ALT, or QT prolongation. Tociluzamab was associated with a rapid decrease in oral temperature and serum CRP. Significant radiologic improvement and decreased invasive ventilation were seen on days 7 and 14.

      May 8, 2020

      • Interpreting Diagnostic Tests for SARS-CoV-2
        May 6. Sethuraman. JAMA.
        Opinion from SAB Member: Dr. Barry Perlman
        Viewpoint from authors in India and Japan discusses interpretation of RT-PCR and ELISA serology testing. There are a variety of RT-PCR tests. Most target envelope, nucleocapsid, spike, RNA-dependent RNA polymerase (RdRp), or ORF1. Most have comparable sensitivities with the RdRp test showing lower sensitivity. RT-PCR nasal swab testing becomes positive as early as day one of symptom onset, peaks within the first week, and starts to decline by week 3. Sputum and fecal sample positivity persists longer than for nasopharyngeal samples. Of note, a positive result reflects presence of viral RNA and does not necessarily mean viable virus. IgM and IgG ELISA testing may be positive as early as day 4 of symptom onset, and rises in weeks 2 and 3. IgM declines by week 5 and disappears by week 7, while IgG persists beyond week 7. Antibody detection to NC protein is most sensitive, while antibody testing to the S receptor-binding domain is more specific and might indicate neutralizing antibodies. Paired testing with initial RT-PCR and then 2 weeks later can increase diagnostic accuracy. It is not known how long neutralizing antibodies will persist and provide protection.

      May 7, 2020

      • Molecular testing for acute respiratory tract infections: clinical and diagnostic recommendations from the IDSA’s Diagnostics Committee. May 6. Hanson KE. Clin Infect Dis.
        Diagnostics Committee of the Infectious Diseases Society of America recommendations for respiratory molecular testing based on comprehensive literature review. Highly sensitive and specific nucleic acid amplification tests (NAAT) are the diagnostic gold-standard in clinical virology and also has utility for bacterial pneumonia testing. Rapid testing may decrease unnecessary antibiotic use, improve antiviral prescribing, limit additional testing, shorten hospital and ED lengths of stay, and optimize infection control, but factors such as study design, sample sizes, and test accuracy, performance and resulting negatively impact ability to combine study results to demonstrate benefits. May be most useful clinically with intermediate pre-test probability and intermediate disease severity. Questions posed by the IDSA:
        • To test or not to test. Whether test result will impact therapy depends upon illness severity, symptom duration, comorbidities, possible immunosuppression, choices of testing and their availability, result turn-around time, and disease prevalence. Multiplex bacterial pneumonia panels are too new to evaluate test performance and clinical impact.
        • Which test. For influenza, CDC and IDSA recommend testing. For SARS-CoV-2, there are more than 24 NAATs authorized for emergency use, and results can be impacted by sampling site (nasal, oral, or lower airway) and when in the illness the sample is obtained. Optimal approach for COVID-19 testing has not been defined. Use of multiplex NAAT with or without bacterial testing needs further study.
        • Interpretation of bacterial DNA in lower resp. tract sample. Issues include colonization versus pathogen, false positive due to dead or impaired organisms, significance of organism quantitation.
        • Improved antibiotic stewardship due to NAAT testing. Rapid test results may allow antibiotics to be stopped, but false positives may increase antibiotic use.
        • Recommendations for future studies shown in Table 2.
      • What’s new in lung ultrasound during the COVID-19 pandemic. May 6. Volpicelli G. Intensive Care Med.
        A highly technical description from Europe of the differential diagnosis and possibly unique lung ultrasound findings in patients with COVID-19. Good videos and excellent table. This would be helpful for a provider in the ICU or ED already trained in lung ultrasound.

      May 5, 2020

      • Antibody Detection and Dynamic Characteristics in Patients with COVID-19
        Apr 19. Xiang. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Barry Perlman
        Serologic study of 85 SARS-CoV-2 RT-PCR test confirmed COVID-19 patients, 24 patients with symptoms but negative RT-PCR testing, and 60 controls. Serologic test was an ELISA for IgM and IgG against the SARS-CoV-2 nucleocapsid N protein. COVID-19 patients showed IgM by 4 days after symptom onset with peak by day 9. IgG increased sharply 12 days after symptom onset, with all COVID-19 patients positive for both IgG and IgM by day 30. For symptom positive but test negative patients, 88% had IgM and 71% had IgG, demonstrating false negative RT-PCR results. 3 controls had IgG but not IgM, which represent either false positives or asymptomatic infection. For RT-PCR confirmed patients: IgM sensitivity 77%, specificity 100%, PPV 100%, NPV 80%. IgG sensitivity 83%, specificity 95%, PPV 95%, NPV 84%. The authors suggest that IgG can be used to diagnose COVID-19 in pneumonia patients, and if negative, serology testing should be repeated 10 days after onset.
      • Role of serology in the COVID-19 pandemic
        May 1. Stowell. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Barry Perlman
        Editorial of serologic study by Xiang et al. which demonstrated ability to measure IgG and IgM in COVID-19 patients with good sensitivity and specificity. The editorial points out that variability in kinetics and magnitude of the serologic response, especially early in infection, can result in false negative results, and IgM results may be false positive. In addition, it is not known if positive serology correlates with disease immunity. Suggested uses for serologic testing: 1) COVID-19 symptoms but RT-PCR negative; 2) Populations to determine degree of community exposure; 3) Frontline healthcare workers; 4) Convalescent plasma donation.

      April 30, 2020

      • Covid-19 may present with acute abdominal pain. Apr 29. Saeed. Br J Surg.
        This is a report of evolving understanding of the range of presenting symptoms of Covid-19 patients. Of 76 patients presenting to the ER in Oslo, Norway, during a 15-day period with a chief complaint of abdominal pain, 9 were found to be positive for coronavirus. All 9 had other GI symptoms – 3 nausea, 5 nausea+vomiting and 1 diarrhea. 5 had fever. None complained of respiratory problems. When coronavirus infection was diagnosed, pulmonary evaluation revealed 6 had ground glass opacities on CT. The diagnoses included cholecystitis in 1 and appendicitis in 1 however the report indicates that all were discharged home for self-quarantine and none required ICU care. This led to modifications in their institutional protocols. “Droplet isolation and testing for COVID-19 are now performed on all patients with abdominal pain.”

      April 28, 2020

      • Updated diagnosis, treatment and prevention of COVID-19 in children: experts’ consensus statement (condensed version of the second edition)
        Apr 24. Shen. World Journal of Pediatrics.
        Opinion from SAB Member: Dr. Lydia Cassorla
        This review provides guidance in the form of an updated consensus statement regarding COVID-19 in children. In early February 2020, an expert committee with more than 30 Chinese experts from 11 academic medical organizations formulated the first edition of consensus statement on diagnosis, treatment and prevention of coronavirus disease 2019 (COVID-19) in children. According to the 28 February 2020 WHO COVID-19 situation report, pediatric cases in China accounted for 2.4% of 55,924 confirmed cases. Close contact with infected persons with or without symptoms is the main transmission route of SARS-CoV-2 to children, resulting in mostly clustered cases. “There is no direct evidence of vertical mother-to-child transmission, but newborns can be infected through close contact.”
        Risk factors, diagnosis, severity classifications, early warning indicators, differential diagnosis, and treatment are discussed. Risk factors for severe disease include underlying diseases, immunosuppressant Rx and age<3 months. Most manifestations and laboratory findings are similar to adults, with atypical symptoms such as GI manifestations and listlessness noted. The group recommends antipyretics such as ibuprofen and acetaminophen if T>38.5 degrees C, and nebulizer treatments to manage mucus plugs. “Antiviral drugs without clear evidences of safety and efficiency are not recommended to be used in pediatric patients. The revised antiviral drug therapy remains interferon-alpha (IFN-alpha) sprays and aerosol inhalation. We do not recommend using lopinavir/ritonavir, ribavirin or chloroquine phosphate in pediatric patients.” Intubation and controlled ventilation is recommended if non-invasive mechanical ventilation does not result in clinical improvement after 2 hours. Plasma exchange to treat cytokine storm, immunoglobulin and anticoagulation are mentioned. 27 references provided, including the group’s initial statement.

      April 24, 2020

      • Alterations in Smell or Taste in Mildly Symptomatic Outpatients With SARS-CoV-2 Infection. Apr 23. Spinato G. JAMA.
        Retrospective phone assessment of alteration in taste and smell among 202 consecutive patients who presented to an Italian outpatient facility. Using a symptom-based rhino-sinusitis outcome measure called Sino-Nasal Outcome Test-22 (SNOT-22), degree of impairment was assessed. 50% of patients had moderate to complete loss of taste and smell but only 12% found this to be an early symptom. There is strong evidence that the density of ACE2 receptors in the nasal mucosa is linked to this symptomatology and that it is specific to COVID-19 infection, but neither loss of taste or smell was assessed objectively in this study.
      • Sonographic signs and patterns of COVID-19 pneumonia
        Apr 21. Volpicelli. The Ultrasound Journal.
        Opinion from SAB Member: Dr. Barry Perlman
        This paper describes the use of lung ultrasound (LUS) for diagnosis of COVID-19 pneumonia, and discusses signs that distinguish it from classic ARDS. Sonographic signs with COVID-19 are similar to those seen with ARDS–clusters of B lines and small peripheral consolidations. More particular to early COVID-19 pneumonia is “a shining band-form artifact spreading down from a large portion of a regular pleural line, often appearing and disappearing with an on–off effect in the context of a normal A-lines lung pattern visible on the background.” It is important to also consider clinical presentation, symptom timing, laboratory findings and co-morbid diseases when using LUS for diagnosis or following progression of COVID-19. The use of LUS in the pediatric COVID-19 population is not discussed, but at the time of this review one small preliminary study of 8 pediatric patients showed LUS utility for both diagnosing and following the resolution of disease.

      April 23, 2020

      April 21, 2020

      • Profile of RT-PCR for SARS-CoV-2: a preliminary study from 56 COVID-19 patients. Apr 20. Xiao. Clin Infect Dis.
        Preliminary RT-PCR study on 56 recovering COVID-19 patients in Wuhan, China showed that virus shedding continued up to 6 weeks after symptom onset, with a mean time to negative RT-PCR conversion of 24 days. Patients with positive RT-PCR tests more than 24 days after symptom onset tended to be older and more likely to have HTN or DM. Of note, all patients had mild-moderate illness, none required ICU admission, and all recovered. Also, a second negative test was used for confirmation, although 4 patients tested RT-PCR positive after 2 consecutive presumably false negative results.
      • Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. Mar 3. Wang. JAMA Network.
        The rapid, coordinated and aggressive Taiwanese response to the pandemic threat that was quite successful through Feb 24. Dated article, not useful to front-line providers.
      • SARS-CoV-2 shedding and infectivity. Apr 19 Atkinson. Lancet.
        The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.
      • Smell and taste dysfunction in patients with COVID-19. Apr 19. Xydakis. Lancet Infect Dis.
        As the authors note in their first sentence of this letter to the editor: “The plural of an anecdote is not evidence,” and indeed, they provide little more evidence concerning taste and smell dysfunction than what’s already been described.
      • Category: Diagnosis of Infection or Immunity
        Testing for SARS-CoV-2: Can We Stop at Two?
        Apr 19. Lee. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Lydia Cassorla
        This report from Singapore highlights data as of Feb. 29, 2020 from a set of patients hospitalized with typical symptoms and a history of travel or contacts suggestive of COVID-19 illness. 72/80 (88.6%) tested negative on their first upper respiratory PCR, 5 were positive on the second day, and 3 turned positive on the third daily test. The authors stress that single or even two consecutive daily negative tests may not detect all infected patients. Their PCR test was developed and commercialized in Singapore, targeting N and ORF1ab genes. This report highlights an important point that repeated testing is often required to confirm infection. Readers should keep in mind that PCR tests are not all alike, and implementation such as swabbing location and technique vary. Therefore, sensitivity data can be expected to vary as well.
      • Well-aerated Lung on Admitting Chest CT to Predict Adverse Outcome in COVID-19 Pneumonia. Apr 18. Colombi. Radiology.
        Retrospective study of 236 ED patients in Italy admitted with positive RT-PCR tests and chest CT findings consistent with COVID-19 pneumonia. Lower zone predominance of ground-glass opacities and consolidations were most common findings. > 27% of lung with decreased aeration on admit CT was associated with 5x greater risk of ICU admission or death. Concomitant emphysema was about 2x more common in patients who were admitted to ICU or died.

      April 20, 2020

      April 14, 2020

      • A role for CT in COVID-19? What data really tell us so far Apr 11. Hope. The Lancet
        Opinion from SAB Member: Dr. Barry Perlman
        Opinion piece from academic radiologists that CT should not be used to diagnose COVID-19, as the described ground-glass opacities and consolidation are not specific. The positive predictive value of CT is low unless pre-test probability is high, and in one study of confirmed COVID-19 patients from the Diamond Princess cruise ship, 1/3 did not have CT lung opacities and 20% of symptomatic patients had negative CT findings. Further, use of CT during the pandemic is “logistically challenging” in terms of resource allocation, cleaning, and potential exposure of COVID-19 to caregivers and other patients.
      • Neutralizing antibody responses to SARS-CoV-2 in a COVID-19 recovered patient cohort and their implications. Apr 6. Wu. medRxiv.
        Study from China on 179 recovered patients hospitalized with “mild” COVID. Neutralizing antibody development peaked at day 10-15, thereafter remained stable, but 30% of patients had very low antibody titers. This information could help inform vaccine trials and selection of donors for immune globulin therapy.
      • The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society Apr 3. Rubin. CHEST.
        Opinion from SAB Member: Dr. Barry Perlman
        Recommendations from a multidisciplinary panel of radiologists, pulmonologists, and other disciplines from 10 countries on the use of chest X-ray (CXR) and CT for managing COVID-19 patients. Ultrasound was not considered due to the panel member’s limited experience with ultrasound in COVID-19 patients at the time of the meeting. They recommend that chest imaging should not be used for patients with suspected COVID-19 and mild clinical features. Rather, it is useful when patients are at risk for disease progression, develop worsening respiratory status, or have moderate-severe disease and high pre-test probability of COVID-19 infection. CT is more sensitive than CXR in mild or early COVID-19 infection, and for alternative diagnoses such as acute heart failure or pulmonary thromboembolism. However, local resources, expertise, infection control issues, and clinical judgment impact the decision as to which modality should be used. Table 2 provides a nice summary of the recommendations.

      April 13, 2020

      • Developing antibody tests for SARS-CoV-2. Apr 4. Petherick. The Lancet.
        Outlines the race to develop and approve a test with a different purpose—to assess not current viral infection, but immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). LC: A summary of achievements to date, test types, and challenges of widespread testing for immunity to SARS CoV-2.

      April 11, 2020

      April 10, 2020

      • PCR Assays Turned Positive in 25 Discharged COVID-19 Patients Apr 8. Yuan. Clinical Infectious Diseases.
        COVID-19 SAB Opinion from: Dr. Lydia Cassorla
        172 patients discharged from a Shenzhen hospital following clinical improvement and 2 consecutive day negative PCR tests for COVID-19 virus. They were then followed at home with nasal and cloacal swab PCR testing every 3 days during a planned 14-day quarantine. 25 patients (14.5%) re-tested positive and were returned to hospital. Some had new symptoms. The authors suggest that the pre-discharge testing may be more reliable in detecting persistent virus carriers if separated by 48 hours.

      April 9, 2020

      April 8, 2020

      April 4, 2020

      April 3, 2020

      • Developing antibody tests for SARS-CoV-2 Mar 3. Petherick. The Lancet.
        COVID-19 SAB Opinion from: Dr. Lydia Cassorla
        Outlines the race to develop and approve a test with a different purpose-to assess not current viral infection, but immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A summary of achievements to date, test types, and challenges of widespread testing for immunity to SARS CoV-2.

      April 2, 2020

      April 1, 2020

      March 31, 2020

      March 30, 2020

      March 27, 2020

      March 22, 2020

      March 16, 2020

    1. Risk Factors / Demographics / Resource Requirements / Outcomes
      November 9, 2020

      October 28, 2020

      October 26, 2020

      • Prediction models for covid-19 outcomes. 10/21/2020. Sperrin M. BMJ.
        A risk prediction algorithm to estimate hospital admission (n=10,776) and mortality (n=4,384) from covid-19 was created and validated using a UK dataset derived from 6.08 million 19-100 year old patients and validated with data from an additional 2.17 million. Study period was Jan 24-April 30 for the initial cohort and May 1-June 30, 2020 for the validation cohort. The model, including age, ethnicity, deprivation, BMI, and a range of comorbidities, predicted ¾ of deaths with excellent discrimination (Harrell’s C statistics >0.9). People in the top 20% of predicted risk of death accounted for 94% of deaths.
      • Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. 10/21/2020. Clift AK. BMJ.
        Editorial discussing the potential utility of prediction models referencing article 1528 and a second BMJ report published in September on the 4C mortality score (calculated at hospital admission to predict in-hospital mortality for patients with confirmed or likely covid-19). Models have serious shortcomings and require constant updating however may also inform public health policies, vaccine allocation, and provide decision support for treatment.

      October 2, 2020

      September 21, 2020

      • Racial/Ethnic Variation in Nasal Gene Expression of Transmembrane Serine Protease 2 (TMPRSS2). 9/10/20. Bunyavanich S. JAMA.
        Nasal epithelium contains a protease (transmembrane serine protease 2 – TMPRSS2) which facilitates SARS-CoV-2 virus entry into the body. In a racially diverse cohort participating in an asthma study between 2015 – 2018, Black individuals exhibited a significantly higher expression of TMPRSS2 in nasal epithelium compared with other self-identified races/ethnicities. This finding may shed further light on the observed higher burden of COVID-19 among Black individuals. Protease inhibitors, like camostat mesylate, are undergoing clinical trials to test their utility for COVID-19 treatment via TMPRSS2 inhibition.

      September 16, 2020

      September 2, 2020

      • Viral dynamics and immune correlates of COVID-19 disease severity. 8/28/20. Young BE. Clin Infect Dis.
        One hundred COVID-19 patients from Singapore underwent prospective study of infectivity and immune response on days 1, 3, 7,14, 21 and 28 after enrollment. No positive viral cultures were found in respiratory samples (n=21) obtained more than 14 days after symptom onset and all positive viral cultures occurred in patients with PCR cycle threshold values <30. Disease severity was associated with earlier seroconversion, higher peak IgM and IgG levels, and higher levels of inflammatory markers, but not duration of viral shedding by PCR. Results have implications for duration of isolation/quarantine and from whom to potentially obtain convalescent plasma.

      August 31, 2020

      August 17, 2020

      August 14, 2020

      August 7, 2020

      • Post-discharge venous thromboembolism following hospital admission with COVID-19. 8/3/20. Roberts LN. Blood.
        These authors identified 1,877 patients with COVID-19 discharged from the hospital, and noted that there were nine episodes of Hospital Associated Venous Thromboembolism (HA-VTE) diagnosed within 42 days compared with 2019 hospital discharge data. The authors calculated an odds ratio of 1.6 compared to historically “similar” groups of patients. They concluded that hospitalization of patients with COVID-19 does not appear to increase the risk of post-discharge HA-VTE compared to hospitalization with other acute medical illnesses. Their data suggests empiric post-discharge thromboprophylaxis is not necessary, thereby supporting the ACCP recommendations to not offer post-discharge thromboprophylaxis.
      • SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review. 5/30/2020. Narang K. Mayo Clin Proc.
        A long summary: 15 pages. There’s obviously different physiology concerning gestation and pregnancy. Earlier reports suggest higher rates of preeclampsia and other pregnancy-related complications. Angiotensin-converting enzyme 2 receptor is upregulated in normal pregnancy. So, with higher ACE2 expression, pregnant women may be at elevated risk for complications from SARS-CoV-2 infection. Upon binding to ACE2, SARS-CoV-2 causes its downregulation, thus lowering angiotensin-(1-7) levels, which can mimic/worsen the vasoconstriction, inflammation, and pro-coagulopathic effects that occur in preeclampsia. Indeed, early reports suggest that, among other adverse outcomes, preeclampsia may be more common in pregnant women with COVID-19.

      August 3, 2020

      July 22, 2020

      • Outcomes from intensive care in patients with COVID‐19: a systematic review and meta‐analysis of observational studies. 6/30/20. Armstrong B. Anaesthesia.
        Fascinating meta-analysis of 10,150 adult patients in 24 studies (enrollment was December 16, 2019 until May 28, 2020) from 11 countries with ICNARC (UK) database (national, rapidly updated registry) accounted for most cases in the study (results were unchanged when removed) with ICU death as primary endpoint. Mortality trended down from ~50% to 41.6% over time with confirmed by meta regression analysis by publication date indicating decreasing mortality. Discussion includes possibility of increasing sophistication of care outside ICU and despite likely increasing severity of ICU patients, therapeutic sophistication improvement was likely responsible for better outcome.
        Excellent analysis with interesting discussion and conclusions emphasizing need for better national data reporting in real time to better follow disease progression and resource utilization.

      July 20, 2020

      • Individualizing Risk Prediction for Positive COVID-19 Testing: Results from 11,672 Patients. 6/20/20. Jehi L. Chest.
        Review by the SAB
        By Dr. Lance Lichtor, on behalf of the SAB
        The authors of this article developed an online risk calculator that can identify individualized risk of a positive COVID-19 test. All patients from Cleveland Clinic in Ohio and Florida were tested, not just those who had the disease. Findings included: lower risk for Asians vs whites; lower risk for those who had pneumococcal polysaccharide vaccine and flu vaccine; higher risk with poor socioeconomic status; and reduced risk of testing positive in patients who were on melatonin, carvedilol, and paroxetine.
      • The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs. 7/8/20. Sachdeva R. Pediatr Crit Care Med.
        Review by the SAB
        By Dr. Philip Lumb, on behalf of the SAB
        This report is from a large pediatric ICU registry (Virtual Pediatric Systems, Los Angeles, CA), with data from over 200 hospital units and >1.5 million patient admissions. In order to determine the manner in which COVID-19 was affecting PICU’s, VPS expanded data collection related to COVID-19 to all Canadian and US PICU’s regardless of prior VPS membership to provide a near real-time dashboard including admissions, patient demographics and comorbidities, therapeutic interventions, deaths and length of stay. Data collection, from March 4 to May 20, represented 3,228 bed capacity comprising most US and Canadian resources from major teaching institutions to smaller hospitals with multifunctional PICU’s. At the peak of the admissions in late April, ~40% of admissions >18yo and ~12% >30yo indicating unusual age disparity than normally seen and providing insight into future PICU adjustments. Detailed description of analysis and future research directions are provided, demonstrating the value of high reliability registry with capability to provide rapid resource allocation and patient demographic, therapeutic and outcome information.

      May 28, 2020

      • A simple algorithm helps early identification of SARS-CoV-2 infection patients with severe progression tendency. May 21. Li Q. Infection.
        This study based on over 300 Chinese patients, creates a simple algorithm, named age-LDH-CD4 model, to identify COVID-19 patients with increased likelihood of disease progression.
      • COVID-19 and NSAIDS: A Narrative Review of Knowns and Unknowns
        May 24. Pergolizzi Jr. JV. Pain and Therapy.
        Opinion from SAB Member: Dr. Robert L. Coffey
        A brief commentary article reviewing the possible mechanisms for an increase in susceptibility to COVID-19 or for a worsened prognosis in patients taking NSAIDs. The possibility that the anti-inflammatory effects might in fact be helpful is noted. The previously reported association of NSAID use and poor outcome is described, but this may be due to the association of higher NSAID use with increasing age. The review of the literature presented here indicates that “to date there is no strong evidence in favor or disputing the use of NSAIDs in patients diagnosed with COVID-19.”
      • RAAS inhibitors do not increase the risk of COVID-19
        May 22. Fernández-Ruiz I. Nature Reviews Cardiology.
        Opinion from SAB Member: Dr. David M. Clement, Dr. Jay Przybylo
        DC: This editorial briefly reviews 5 recent retrospective studies that all confirm prior speculation that pre-COVID-19 use of ACE2 inhibitors and ARBs is not associated with increased susceptibility to COVID-19 and does not have harmful effects in patients with COVID-19. These results justify prior guideline advice to continue ACE2is and ARBs in the COVID-19 era.
        JP: An editor for Nature combined the results of multiple papers investigating the effect of ACEi and ARB therapy on the susceptibility to COVID-19, concluding that despite the lack of controlled studies, the aggregate of the cited studies provides proof that these drugs do not provide an entry portal for the infection and are safe to continue. This easily understood paper serves as a valuable resource for physicians of any specialty caring for patients on RAAS therapy who are infected with COVID-19.

      May 27, 2020

      • Association of renin-angiotensin-aldosterone system inhibitors with COVID-19-related outcomes in Korea: a nationwide population-based cohort study
        May 22. Jung. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Jay Przybylo
        In a Korean population of patients taking Renin-angiotensin-aldosterone system (RAAS) inhibitors, the risk of death was higher compared with non-users. However, after adjustment for age, sex, Charlson Comorbidity Index, immunosuppression, and hospital type, the use of RAAS inhibitors was not associated with higher mortality.
      • Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. May 22. Petrilli. BMJ.
        An extensive prospective outcome study from NYC from 4 Ac Care Hospitals with 394 ICU beds and 1357 non-ICU beds. Out of about 12,000 patients for that period, 5,279 patients were positive for COVID-19: 48.1% were treated as outpatients, and 51.9% required admission to hospital. Out of those who got admitted: 63.4% were discharged, 36.1% experienced critical illness, 24.3% who were discharged to a hospice or among the 990 patients with critical illness, 63.4% required mechanical ventilation, 10.3% required non-ICU care.
        The study involved those admitted without critical illness, and those admitted to ICU, mechanical ventilation, discharge to hospice, or death. Then fitted multivariable logistic regression models with admission and with critical illness as the outcomes to identify factors associated with those outcomes. Authors also looked at admission values objectively for prediction of outcome as well. They found mortality to be 57% among all ICU or ventilated patients slightly higher than ARDS mortality. Some of the markers (either admission or admission to hospital) were common for worse outcome: Admission from March 16 to April 5, age > 55 years, unknown for smoking history, BMI > 40, CHF, O2 Sat % < 92, low Lymphocyte, high normal for C reactive, D Dimers, Procalcitonin, Troponin.
        Overall, they found that age and comorbidities are powerful predictors of requirement for admission to hospital rather than outpatient care; however, the degree of oxygen impairment and markers of inflammation are most strongly associated with poor outcomes during hospital admission. The study has very elaborate, descriptive analysis backed by statistics. It has a self-explanatory graph of several categories of clinical values to outcome.
      • Incidence, clinical outcomes, and transmission dynamics of severe coronavirus disease 2019 in California and Washington: prospective cohort study
        May 12. Lewnard JA. BMJ.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        For the practicing clinician, this study represents an epidemiological deep dive using the Kaiser Permanente database of 1840 patients (as of April 22, 2020) in a prospective cohort study aimed to:
        1. Assess population-based rates of COVID-19 disease over time in three distinct geographic areas (Southern CA: 15.6, Northern CA 23.3, WA 14.7)
        2. Model
          • estimated hospital length of stay for survivors (9.3 days) and non-survivors (12.7 days)
          • ICU admission rates and median length of stay for males (48.5% and 10.6 days) and females (32% and 14.9 days)
          • Fatality risk by age group (median 18.9%; >80yrs: 37.3)
        3. Study transmission dynamics by following the effective reproduction number over the study period within each region.

        The authors conclude that hospitalizations have substantial lengths of stay, that probability of ICU stay is high, and that the effective reproduction number has fallen over time, coincident with social isolation regulations.

      • Proposed Modifications in the 6-minute Walk Test for Potential Application in Patients with mild Coronavirus Disease 2019 (COVID-19): A Step to Optimize Triage Guidelines. May 19. Mantha. Anesthesia & Analgesia.
        The authors propose to have patients perform the 6 minute walk test (while wearing a mask) to better discriminate between Covid-19 patients with mild pneumonia and those with severe pneumonia. They recommend adding this test to the established WHO criteria for severe pneumonia that includes 1) severe respiratory distress, 2) a respiratory rate of >30 breaths/min, or 3) an SpO2 ≤93% on room air. They propose a 1400 foot distance covered as the point of discrimination (approx 3 METS), but do not provide any patient data.

      May 19, 2020

      • Age and sex differences in soluble ACE2 may give insights for COVID-19. May 14. Edsfeldt. Crit Care.
        Research letter detailing longitudinal study of soluble ACE2 (sACE2) levels by gender and age to determine potential differences and possible determinants of COVID-19 susceptibility for elderly male patients based on observation that disease more prevalent in adults>children and men>women. sACE2 levels analyzed from individuals registered in the pediatric osteoporosis prevention (POP) study; from age 7.7 years to 23.5 years at 2 to 3 year intervals. Results indicated that sACE2 levels increase more as boys age than girls. Authors suggest results support for observations re: age and sex prevalence for COVID-19 susceptibility.

      May 16, 2020

      May 14, 2020

      • COVID-19 and Racial/Ethnic Disparities
        May 11. Hooper. JAMA.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this viewpoint article, the authors highlight the health disparities among African Americans and Latinos. The incidence of COVID-19 disease is higher, and the number of patients who die from the disease is greater in these groups of patients. It’s hard to know why, but social and structural determinants of health, racism and discrimination, economic and educational disadvantages, health care access and quality, individual behavior, and biology may be determinants. This is not the first time, in that pulmonary tuberculosis, for example, disproportionately affects persons of lower socioeconomic status. As the authors note, the “pandemic presents a window of opportunity for achieving greater equity in the health care of all vulnerable populations.”

      May 13, 2020

      • Prognostic Value of Leukocytosis and Lymphopenia for Coronavirus Disease Severity. May 8. Huang. Emerg Infect Dis.
        In this meta-analysis report from Los Angeles CA and Winston-Salem NC investigators analyzed data from 8 English-language studies representing 1280 unique adult cases of COVID-19 from China and Singapore, of which 46% were classified severe. “Pooled data across early studies validate a significant correlation between elevated leukocyte count and decreased lymphocyte count among patients with severe cases of COVID-19 compared with those with mild cases. Why lymphopenia is associated with severe illness remains unclear.”

      May 11, 2020

      • Association between ABO blood groups and risk of SARS-CoV-2 pneumonia. May 7. Li. Br J Haematol.
        In this brief study report of 265 COVID-19 patients from Wuhan, China, “The ABO blood group … showed a distribution of 39.3 %, 25.3 %, 9.8 % and 25.7 % for A, B, AB and O, respectively. The proportion of blood group A in patients infected with SARS-CoV-2 was significantly higher than that in healthy controls (39.3 % versus 32.3 %, P= 0.017), while the proportion of blood group O in patients infected with SARS-CoV-2 was significantly lower than that in healthy controls (25.7 % versus 33.8 %, P< 0.01).” The theory that adhesion of SARS-CoV-2 to ACE-2 receptor is inhibited by human natural anti-A antibodies is discussed.
      • Association Between Hypoxemia and Mortality in Patients With COVID-19. Apr 6. Xie. Mayo Clin Proc.
        Single center retrospective study of 140 patients with moderate to critical suspected or confirmed COVID-19 pneumonia in Wuhan, China. Those with SpO2 90% or less were more likely to be older, male, have HTN, and present with dyspnea. 26% died. Cutoff SpO2 of 90.5% showed a 85% sensitivity and 97% specificity for survival. Hypoxemia (SpO2 < 90%) despite O2 or dyspnea were independently associated with increased risk of death.

      May 8, 2020

      • Acute Physiology and Chronic Health Evaluation II Score as a Predictor of Hospital Mortality in Patients of Coronavirus Disease 2019
        May 7. Zou. Crit Care Med.
        Opinion from SAB Member: Dr. David M. Clement, Dr. Jagdip Shah
        DC: Especially in healthcare settings with overextended resources, accurately predicting mortality may or may not be useful for frontline providers. In this retrospective, single referral hospital study from China of 154 ICU patients with COVID-19, an admitting Acute Physiology and Chronic Health Evaluation (APACHE) II score of equal to or greater than 17 predicted mortality with a sensitivity of 96% and a specificity of 86%, better than other predictive indices.
        JS: This single, tertiary center, retrospective, small study (N= 154) in China compared three ICU scoring systems on day one of ICU admission to decide which one is a better predictive tool for survival (e.g. a futility index) with COVID-19 patients with MOF. The three scoring systems compared were APACHE II (age, Glasgow Coma Scale, vital signs, oxygenation, chemistry values, hematology values & organ insufficiency [0 to 71]; used for general critical illness), Sequential Organ Failure Assessments (PaO2:fiO2 ratio, mean arterial pressure, creatine, GCS, platelet count, bilirubin [0 – 24]; used for general critical illness), and Confusion, Urea, Respiratory rate, Blood pressure, Age 65 (CURB65; used for pneumonia). Their aim was to describe the difference of epidemiologic and clinical characteristics between survivors and deaths in an attempt to provide an effective clinical tool to predict the probability of death among patients with COVID-19 based on data about admission and the first day in the ICU. The APACHE II score performed better to predict hospital mortality in patients with COVID-19 compared with SOFA and CURB65 scores. APACHE II scores greater than or equal to 17, serve as an early warning indicator of death, which may help to provide guidance for making further clinical decisions. The authors’ conclusion is useful and applicable when you have a tremendous surge of ICU admissions in a short time, shortage of equipment, manpower (DRs & RNs), and patients with comorbidities. The authors capture a few hallmark comorbidities: hypoxic encephalopathy, abnormal Na & K, abnormal hepatic panel, a higher platelet:lymphocyte ratio, (an index of inflammatory process?). ROC & AUC is a tool for sensitivity/specificity index: AUC FOR APACHE II = 0.966, SOFA = 0.867, CURB65 = 0.844.

      May 7, 2020

      • An Italian programme for COVID-19 infection in multiple sclerosis
        Apr 30. Sormani. The Lancet Neurology.
        Opinion from SAB Member: Dr. Barry Perlman
        This article describes a program developed by the Italian MS Society, Italian MS Foundation, and MS Study Group of the Italian Neurological Society to help guide management of patients with multiple sclerosis during the COVID-19 pandemic. Case report forms were sent to >200 neurologists in Italy and data was collected on 232 patients with known or suspected COVID-19. 96% had mild infection. Of the 3% with critical infection, 1 recovered and 5 died. Further data collection is needed to determine if MS disease or treatment impacts COVID-19 infection.

      May 6, 2020

      May 5, 2020

      May 1, 2020

      • Correlation between Heart fatty acid binding protein and severe COVID-19: A case-control study. Apr 30. Yin. PLoS One.
        In patients who had measurements of heart fatty acid binding protein (HFABP), a serum cardiac specific biomarker for myocardial injury, the authors found a correlation between elevated HFABP and progression to severe COVID-19 illness. However only 46 of 245 patients had the test and the study had no control group. During hospitalization, severe illness was observed in 87.5% of HFABP positive patients vs. 40% in those who were HFABP negative (P = 0.002). We do not know why some patients had HFABP measured, making the results difficult to interpret.
      • COVID-19 Related Genes in Sputum Cells in Asthma: Relationship to Demographic Features and Corticosteroids
        Mar 27. Peters. American Journal of Respiratory and Critical Care Medicine.
        Opinion from C19SAB: Dr. Louis McNabb, Dr. Jay Przybylo
        LM: African Americans, males, and diabetics have increased expression of ACE2 and TMPRSS2 which might theoretically explain why these groups are at increased risk for COVID-19. Inhaled corticosteroids decreased expression of ACE2 and TMPRSS2 and theoretically might favorably modify the risk from COVID-19. JP: Thorough study demonstrating asthmatics taking inhaled corticosteroids might be at lower risk of significant COVID-19 infection via activity on the ACE2 receptor.
      • Obesity could shift severe COVID-19 disease to younger ages. Apr 30. Kass. The Lancet.
        A Lancet “Correspondence” from Johns Hopkins describing a negative correlation between age and BMI in 265 COVID-19 patients.
      • Patients with cancer appear more vulnerable to SARS-COV-2: a multi-center study during the COVID-19 outbreak
        Apr 29. Dai. Cancer Discovery.
        Opinion from C19SAB: Dr. J. Lance Lichtor
        Based on a retrospective analysis of patient information collected from 14 hospitals in Hubei Province, China, patients affected by the SARS-CoV-2 coronavirus for 105 hospitalized patients with cancer and 536 patients without cancer were compared. Patients with hematological cancer (1st), lung cancer (2nd), and cancers in metastatic stages demonstrated higher rates of severe events compared to patients without cancer. In addition, patients who underwent cancer surgery showed higher death rates and higher chances of having critical symptoms. In addition, patients on immunotherapy had the highest death rate and the most severe illness. It is expected that people with systemic disease should do less well. Unfortunately, the authors did not compare the two groups to hospitalized patients with cancer but without COVID-19.
      • Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs. Apr 29. Wadhera. JAMA.
        New York City has emerged as the epicenter of the COVID-19 outbreak. New York City is composed of 5 boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), each with unique demographic, socioeconomic, and community characteristics. Prior analyses have shown health inequities across these boroughs. The author relied on available public records from the recent past (census, age, M: F, race / ethnicity, education level, annual average income, available hospital bed, etc.) & current death rate from Covid-19 for each borough. Graphs & table suggests – Bronx: highest hospitalization & death rate, black population, lowest education, poverty & lowest income population of all the boroughs of NYC.
        The author provides raw data for comparison. Author provided table numbers but failed to make any conclusion for important health policy answers. Assumption people did not travel to another borough? Surge capacity for each hospital was not taken in account. The study is ongoing?

      April 30, 2020

      April 29, 2020

      April 28, 2020

      April 24, 2020

      April 23, 2020

      • COVID-19 and African Americans. Apr 15. Ingraham. JAMA.
        A very important social/cultural aspect of the pandemic, with preliminary data clearly laid out by author. But this will not help front-line workers, and as the author states, what to make of the disparities is not clear: “Data fully adjusted for comorbidities have not been reported but it is likely that some, if not most, of these differences in disease rates and outcomes will be explained by concomitant comorbidities.”
        Blacks have disproportionately been victims of COVID-19. Evidence of potentially egregious health care disparities is now apparent. Persons who are African American or black are contracting SARS-CoV-2 at higher rates and are more likely to die. COVID-19 has become the herald event that now fully exposes the deep and chronic social wounds in US communities. The Johns Hopkins University and American Community Survey indicate that to date, of 131 predominantly black counties in the US, the infection rate is 137.5/100,000 and the death rate is 6.3/100,000.5. This infection rate is more than 3-fold higher than that in predominantly white counties. Moreover, this death rate for predominantly black counties is 6-fold higher than in predominantly white counties. Comorbidities (HBP, DM, Obesity……) and preventive measures may not be able to be practiced, health care access…author claims many unstated factors are playing out. Public health is complicated and social reengineering is complex, but change of this magnitude does not happen without a new resolve.
      • Is Adipose Tissue a Reservoir for Viral Spread, Immune Activation and Cytokine Amplification in COVID-19. Apr 22. Ryan. Obesity (Silver Spring).
        Obesity has been recognized as a risk factor for poor outcome with COVID-19 infection. The paper theorizes that adipose tissue may act as a reservoir for increased viral spread, immune activation, and cytokine amplification. Nice review of adipose tissue cytokine pathways. Areas of research are suggested.
      • Symptom Screening at Illness Onset of Health Care Personnel with SARS-CoV-2 Infection in King County, Washington. Apr 17. Chow. JAMA.
        Typical symptom screening for Covid-19 will miss 20 percent of health care workers with the virus. Perhaps more alarming is that health care personnel worked a median of two days with symptoms.

      April 21, 2020

      • Binding of SARS-CoV-2 and angiotensin-converting enzyme 2: clinical implications. Apr 18. Murray. Cardiovasc Res.
        Literature review, mostly on a molecular cell-biology level, of the RAAS system as it may interact with SARS-CoV-2. Nothing new, and the conclusion is to follow the guidelines of many organizations to continue ACEI and ARBs in patients already on such drugs.
      • Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome
        Apr 9. Roncona. Journal of Clinical Virology.
        Opinion from SAB Member: Dr. Jagdip Shah
        A detailed, retrospective meta-analysis from 3 centers in northern Italy. 9 articles were included, which notably included data from China. This meta-analysis demonstrated that diabetic patients with COVID-19 infection have a higher risk to be admitted to the ICU during the infection. Moreover, diabetes increased the risk of mortality during the infection. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Quality assessment was performed using the Newcastle-Ottawa quality assessment scale. The main outcome was the risk of ICU admission in diabetic patients with COVID-19 infection while the second was the overall mortality risk in COVID-19 patients with diabetes. Data was pooled using the Mantel-Haenszel random effects models reporting odds ratio (OR) and 95% confidence interval (CI). Statistical heterogeneity between groups was measured using the Higgins I-squared statistic. Results: Among 1382 patients (mean age 51.5 years, 798 males), diabetes was the second most frequent comorbidity. Diabetic patients had a significantly increased risk of ICU admission (OR: 2.79, 95% CI 1.85–4.22, p < 0.0001, I-squared=46%). In 471 patients (mean age 56.6 years, 294 males) analyzed for the secondary outcome, diabetic subjects had higher mortality (OR 3.21, 95% CI 1.82–5.64, p < 0.0001, I-squared=16%).
      • Inflammatory bowel diseases and COVID-19: the invisible enemy. Apr 20. D’Amico. Gastroenterology.
        More of an opinion paper than anything, reviewing past literature on infections in IBD patients on immunosuppresives and biologics. Will not help those treating COVID-19 much.

      April 20, 2020

      April 17, 2020

      • Does COVID-19 Disprove the Obesity Paradox in ARDS? Apr 16. Jose RJ. Obesity (Silver Spring).
        A disporportionate number of non-survivors of COVID-19 patients are obese. The authors postulate that factors may include a chronic pro-inflammatory status, difficult airway, pulmonary elastance, compliance, potential pulmonary hypertansion and RV function may be contributing factors.
      • Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal. Apr 7. Wynants, L. BMJ.
        A review and appraisal of 27 prediction model studies for diagnosis, prognosis, and risk of hospital admission due to COVID-19. Age, temperature, and signs/symptoms were the most reported predictors of suspected disease. Age, sex, CT, CRP, LDH, and lymphocyte count predicted severe prognosis. However, all studies had high risk of bias due to reporting and methodology flaws, such as small sample sizes, non-representative control patients, exclusion of those who had not reached the clinical event of interest by the conclusion of the study, and model overfitting. The authors warn against using prediction models based on questionable data, and recommend that better and more standardized data collection and reporting methodologies are needed to determine the predictors that could be used to guide clinical decisions during the COVID-19 pandemic.

      April 14, 2020

      April 13, 2020

      • Covid-19: death rate is 0.66% and increases with age, study estimates. Apr 4. Mahase. BMJ.
        Based on aggregate data on cases and deaths in mainland China, the overall death rate from covid-19 was estimated at 0.66%, rising sharply to 7.8% in people aged over 80 and declining to 0.0016% in children aged 9 and under. They estimated that nearly one in five people over 80 infected with covid-19 would probably require hospital admission, compared with around 1% of people under 30. They also estimated that the average time between a person displaying symptoms and dying was 17.8 days, while recovering from the disease was estimated to take slightly longer, with patients being discharged from hospital after an average of 22.6 days. Estimated case fatality ratio for symptomatic patients in China was 1.38% (1.23% to 1.53%). For all infected patients, the ratio was. 0.66% (0.39% to 1.33%). Data on underlying health conditions was not available.

      April 11, 2020

      • Covid-19: death rate is 0.66% and increases with age, study estimates. Apr 1. Mahase. BMJ.
        Based on aggregate data on cases and deaths in mainland China, the overall death rate from covid-19 was estimated at 0.66%, rising sharply to 7.8% in people aged over 80 and declining to 0.0016% in children aged 9 and under. They estimated that nearly one in five people over 80 infected with covid-19 would probably require hospital admission, compared with around 1% of people under 30. They also estimated that the average time between a person displaying symptoms and dying was 17.8 days, while recovering from the disease was estimated to take slightly longer, with patients being discharged from hospital after an average of 22.6 days. Estimated case fatality ratio for symptomatic patients in China was 1.38% (1.23% to 1.53%). For all infected patients, the ratio was. 0.66% (0.39% to 1.33%). Data on underlying health conditions was not available.
      • Factors associated with prolonged viral RNA shedding in patients with COVID-19. Apr 10. Xu. Clin Infect Dis.
        Prolonged viral RNA shedding associated with male sex, treatment with steroids, and worse illness. Two-thirds of patients had prolonged viral RNA shedding (>15 days). RT-PCR testing, and not viral cultures were the tests used. This is a paper that could be combined with other PCR/culture papers in the future, to help clinicians.
      • Prediction for Progression Risk in Patients with COVID-19 Pneumonia: the CALL Score Apr 9. Ji. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Jack Lance Lichtor
        The authors, based on a retrospective analysis of 208 COVID-19 patients who were admitted to 1 of 2 hospitals in the Fuyang province in China, developed a score based on multivariate COX analysis. There was a stable group and the progressive group. These factors were found to be significant: age, comorbidity, lymphocyte count, D-dimer, and LDH. The nomogram demonstrated good accuracy in estimating the risk of progression of illness. The diagnosis of COVID-19 was based on real-time reverse-transcriptase polymerase chain reaction. The score may help to decide where to put patients with the disease: either at a district hospital or a tertiary center. A prospective study is needed to confirm.

      April 9, 2020

      April 8, 2020

      April 7, 2020

      April 2, 2020

      March 31, 2020

      March 30, 2020

      February 13, 2020

    1. Emerging Clinical Data and Guidelines (USA / International)
      November 23, 2020
      • Frequency of venous thromboembolism in 6513 patients with COVID-19: a retrospective study. 11/2/2020. Hill JB. Blood Adv.
        This single health-system venous thromboembolism (VTE) study described the use of standard heparin or LMWH prophylaxis in most of the 6513 COVID-19 patients. Dose was increased if BMI >40 and decreased if creatinine clearance < 30. Ninety-day VTE rate was 2.2% (n=86) when receiving prophylaxis vs. 11% without. Eighty-four of 86 VTE patients had received prophylaxis. PADUA Score was high in 89%. Including arterial thrombosis in 7 patients, the overall incidence of VTE was 3.1% and 7.2% if mechanically ventilated. Fifty percent inpatient VTEs met the definition of prophylaxis failure. Only three of 2075 hospitalized patients (0.14%) without VTE surviving to discharge had VTE after discharge. The authors conclude these data support a traditional approach to VTE prophylaxis both during and following hospitalization.
        SAB Comment: We note a surprisingly low rate of VTE in this large, retrospective study, equally divided between DVT and PE. It did not include thrombosis in the microcirculation or ECMO circuit. Most were failures or breakthroughs on VTE prophylaxis. One may question the use of so few risk factors for modification of standard dosing and the conclusion that the data support a traditional approach.
      • Immune suppression in the early stage of COVID-19 disease. 11/18/20. Tian W. Nat Commun.
        Using elegant quantitative advanced mass spectrometry proteomics and integrated data analysis with hierarchical clustering and functional correlational network strategies, these authors analyzed urine samples from COVID-19 (n=14), non-COVID-19 pneumonia cases (n=13) and healthy donors (n=10). A total of 5991 proteins were identified; 1986 proteins were significantly changed in the COVID-19 vs the other groups. More than 10 pathways significantly changed and 10x were more down-regulated than up-regulated. Showing heatmaps and protein interaction diagrams, the molecular signatures suggested a two-stage pathogenesis: immunosuppression and tight junction/cell-cell adhesion impairments early on and an activated immune response in late stages of severe COVID-19 pneumonia.
      • Safety and efficacy of inhaled nebulised interferon beta-1a (SNG001) for treatment of SARS-CoV-2 infection: a randomised, double-blind, placebo-controlled, phase 2 trial. 11/15/20. Monk PD. Lancet Respir Med.
        A small company-sponsored pilot study comparing the clinical course of 48 patients treated for 14 days with a daily dose of nebulized interferon beta-1a to the clinical course of 50 placebo-treated patients as assessed by 9-point WHO Ordinal Scale for Clinical Improvement [OSCI]. Patients receiving the medication had greater odds of improvement on the OSCI scale (odds ratio 2.32) and a higher percentage of recovered patients (58% vs 35%) at the end of the observation period (day 28). The medication was well tolerated compared with placebo. Larger studies are planned. These results contrast with the absence of effect noted in a prior trial of interferon beta-1a given subcutaneously.

      November 18, 2020

      • Acute Cardiovascular Manifestations in 286 Children with Multisystem Inflammatory Syndrome Associated with COVID-19 Infection in Europe. 11/9/20. Valverde I. Circulation.
        A European multi-institutional study of 287 children admitted with COVID-19 demonstrated a high incidence of cardiac involvement. Most children admitted suffered GI symptoms, rash and conjunctival changes in addition to cardiac involvement. Forty percent presented with cardiac shock. Markers of cardiac involvement were present on admission including D-dimers. Treatment was not controlled. 286 were eventually discharged. Twenty-five percent had a diagnosis of coronary artery dilation by echocardiography, requiring follow-up.
      • Comparison of Clinical Features and Outcomes in Critically Ill Patients Hospitalized with COVID-19 versus Influenza. 11/13/20. Cobb NL. Ann Am Thorac Soc.
        This is a retrospective cohort analysis “case matching” 74 seasonal influenza with 65 COVID-19 patients from 01/01/19 to 04/15/20. Diagnoses were confirmed by RT-PCR and ICU courses studied. COVID-19 patients had different demographics, longer prodrome, increased numbers of presenting symptoms and co-morbidities, higher incidence of ARDS, longer duration of mechanical ventilation and higher mortality. Includes an interesting discussion with tables.
      • Review of Cardiac Involvement in Multisystem Inflammatory Syndrome in Children. 11/9/20. Alsaied T. Circulation.
        Though the prevalence of multisystem inflammatory syndrome in children is unknown, there have been more than 300 cases now reported in the literature. It is more common in the US in Black and Hispanic children; typically occurs a few weeks after acute infection and the putative etiology is a dysregulated inflammatory response to SARS-CoV-2 infection. Persistent fever and gastrointestinal symptoms are the most common symptoms. Cardiac manifestations are common and include ventricular dysfunction, coronary artery dilation and aneurysms, arrhythmia and conduction abnormalities, vasodilatory or cardiogenic shock requiring fluid resuscitation, inotropic support, and in the most severe cases mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Most patients recover within days to a couple of weeks and mortality is rare. Long-term cardiovascular complications are not yet known.
      • Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. 11/10/2020. Botta M. Lancet Respir Med.
        This multicenter, retrospective, epidemiological study from the Netherlands examines 553 COVID-19 positive VE patients from 18 ICUs regarding the ventilatory variables (modes, TV, PEEP, *P, CTL) and its outcomes in 28 days in a comparative way.
        • The variations of ventilatory parameters were not different between ICUs,
        • COVID-19 ARDS allows for better use of lung-protective ventilation than does ARDS due to other causes,
        • All patients had low compliance,
        • No conclusion for Best PEEP,
        • Majority prefer to treat the refractory hypoxia by prone positioning,
        • An enormous burden on ICUs/hospital systems,
        • High tidal volume and low respiratory system compliance on the first day of ventilation were associated with a higher risk of 28-day mortality.

        The study supports low TV, Ppl< 30, low driving pressure, prone position in ICU.

      November 16, 2020

      • Association between red blood cell distribution width and mortality of COVID-19 patients. 11/7/2020. Lorente L. Anaesth Crit Care Pain Med.
        Red blood cell distribution width (RDW), a parameter of RBC form and size variability, is associated with increased mortality in a number of disease states. This prospective observational study from 8 Canary Islands ICUs analyzed data from 118 survivors and 25 deaths with COVID-19. RDW performed comparably to APACHE II and SOFA scores in predicting mortality and is easier to measure. Levels were higher on admission to ICU and when >13% predicted mortality. RBC transfusion, hemoglobin disorders, and myelodysplastic syndromes increase RDW values.
      • Frequency of venous thromboembolism in 6513 patients with COVID-19: a retrospective study. 11/2/20. Hill JB. Blood Adv.
        This single health-system venous thromboembolism (VTE) study described the use of standard heparin or LMWH prophylaxis in most of the 6513 COVID-19 patients. Dose was increased if BMI >40 and decreased if creatinine clearance < 30. Ninety-day VTE rate was 2.2% (n=86) when receiving prophylaxis vs. 11% without. Eighty-four of 86 VTE patients had received prophylaxis. PADUA Score was high in 89%. Including arterial thrombosis in 7 patients, the overall incidence of VTE was 3.1% and 7.2% if mechanically ventilated. Fifty percent inpatient VTEs met the definition of prophylaxis failure. Only three of 2075 hospitalized patients (0.14%) without VTE surviving to discharge had VTE after discharge. The authors conclude these data support a traditional approach to VTE prophylaxis both during and following hospitalization.
        SAB Comment: We note a surprisingly low rate of VTE in this large, retrospective study, equally divided between DVT and PE. It did not include thrombosis in the microcirculation or ECMO circuit. Most were failures or breakthroughs on VTE prophylaxis. One may question the use of so few risk factors for modification of standard dosing and the conclusion that the data support a traditional approach.

      November 11, 2020

      • Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy – SET-NET, 16 Jurisdictions, March 29-October 14, 2020. 11/5/20. Woodworth KR. MMWR Morb Mortal Wkly Rep.
        The authors of this article about pregnant women with SARS-CoV-2 state, “Among 3,912 infants with known gestational age born to SARS-CoV-2 infected women, 12.9% were preterm (<37 weeks), higher than a national estimate of 10.2%. Among 610 (21.3%) infants with testing results, 2.6% had positive SARS-CoV-2 results, primarily those born to women with infection at delivery.” Half of positive infants were preterm. Median maternal age was 28.9 years. Forty-six percent were Hispanic/Latina. One or more underlying medical condition was reported for 45.1%. Pre-pregnancy obesity was the most common (35.1%). Eight-four point four percent had infection identified in the third trimester. None had neonatal IgM, placental tissue or amniotic fluid testing; thus, routes of transmission could not be assessed.
      • Cytokine elevation in severe and critical COVID-19: a rapid systematic review, meta-analysis, and comparison with other inflammatory syndromes. 10/16/20. Leisman. Lancet.
        The hypothesis that a “cytokine storm” occurring later in severe COVID-19 disease may be causative for the excess inflammatory response noted in terminal disease has provoked studies of anti-cytokine therapies, specifically interleukin-6 antagonists. This systematic review and meta analysis of studies published between November 1, 2019 and April 14, 2020, including interleukin-6 levels in the results, compared cytokine levels in four disease categories associated with elevated levels: sepsis (5,320); cytokine release syndrome (72); ARDS unrelated to COVID-19 (2,767); and COVID-19 (1,245). While COVID-19 levels were raised, the mean interleukin-6 levels in all three other conditions were statistically higher than noted in COVID (e.g. 27 times higher in sepsis and 12 times higher in non-COVID ARDS while over 1,000 times in CRS). The authors question the impact of a “cytokine storm” in COVID-19 organ dysfunction. Other arguments offered a detailed, well-presented discussion.
      • Cytokine Levels in Critically Ill Patients With COVID-19 and Other Conditions. 9/3/20. Kox. JAMA.
        This retrospective, single-center study admitted 204 patients between 2010 and 2020 with sampling recorded plasma concentrations of proinflammatory cytokines TNF, IL-6 and IL-8 and determined (2020) in consecutively ventilated COVID-19 patients (49) with ARDS. Previously recorded levels in patients with bacterial septic shock with ARDS (51), septic shock without ARDS (15), out-of-hospital cardiac arrest (30), and multiple traumas (62) were compared with those from the COVID-19 population. COVID-19 patients had higher BMI, co-morbidities and cardiac dysfunction; however, cytokine levels were lower than in other diseases mentioned questioning the importance of a “cytokine storm” as a primary therapeutic target in COVID-19 disease.

      November 9, 2020

      • Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study. 11/3/2020. Griffiths F. Anaesthesia.
        As triage of ICU beds during COVID-19 becomes a topic of concern, this multicenter ethnographic study conducted between June 2015 and May 2016 in six UK NHS hospitals attempts to explore the decision-making process applied to ICU admissions through observations, interviews and retrospective analysis outside the pandemic. Fifty-five decision events were observed and analyzed and 44 physicians, varying in training and specialty, were interviewed. Results are reported in multiple vignettes and the heuristic nature of the decision-making process is reviewed. Suggestions for improving transparency, consistency and equity of decision‐making around ICU admission are offered.

      October 30, 2020

      October 28, 2020

      • Aspergillosis Complicating Severe Coronavirus Disease. 10/21/20. Marr KA. Emerg Infect Dis.
        Mounting evidence suggests that severe respiratory virus infections, especially influenza and coronavirus 2 infections, can be complicated by Aspergillus airway overgrowth with pulmonary infection characterized by mixed airway inflammation and bronchial invasion. This article reviews these issues succinctly and adds data on 20 COVID-19 patients to the growing world literature. The authors note that the syndromes of pulmonary aspergillosis complicating severe viral infections are distinct from classic invasive aspergillosis. They state that combined with severe viral infection, aspergillosis in COVID-19 pneumonia comprises a constellation of airway-invasive and angio-invasive disease and see an urgent need for strategies to improve diagnosis, prevention, and therapy.
        SAB comment: An article previously highlighted in the Newsletter clarifies some of the important issues specific to diagnosing and treating pulmonary aspergillosis in COVID-19 patients.

      October 19, 2020

      October 14, 2020

      • In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. 9/30/20. Hayek S. BMJ.
        This article discusses a multicenter (68 sites) US study which followed 5019 admitted COVID-19 patients, 701 (14%) of whom had in-hospital cardiac arrest. The influence of patient demographics, co-morbidities and critical care facilities on outcome are also described. Patients younger than 45 years were more likely to receive CPR with 21.2% (11/52) surviving to hospital discharge with normal or mild neurocognitive deficit compared to 2.9% in patients 80 years or older. The article confirms generally poor results of CPR in COVID-19 but provides interesting discrimination between age, ICU size and co-morbidities. It raises key questions regarding triage and informed assent discussions.

      October 12, 2020

      October 7, 2020

      • Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19. 9/28/20. Thapa S. JAMA Int Med.
        This research letter reports single-center results of CPR in 60 COVID-19 patients out of 1309 admitted between March 15 and April 3 who developed cardiac arrest (4.6%). Non-shockable rhythms presented in 52 (96.3%) with no patients surviving to discharge. The discussion notes results of CPR with those previously reported for in-hospital cardiac arrest (25% with 86% presenting non-shockable) and provides potential consequences of COVID-19. The authors suggest the importance of further research and consideration of guidelines for CPR in COVID-19.
      • Outcomes of Cardiopulmonary Resuscitation in Patients With COVID-19—Limited Data but Further Reason for Action. 9/28/20. Modes M. JAMA Int Med.
        Important discussion based on dismal post-CPR outcomes in accompanying research letter. While recognizing the difficulties of performing CPR in COVID-19 patients, the importance of developing a clearly defined care plan following a detailed, continuing discussion on outcome prognosis between the healthcare team and patient-family unit is emphasized. The concept of initiating an informed assent with the family in which the care team makes real-time decisions on DNAR (do not attempt resuscitation) is raised. Additionally, healthcare disparities and associated availability of advanced care directives highlight need for healthcare systems to adopt clearly defined protocols and emphasizes “goals of care” discussion between patients and families. Resource links provided.

      October 5, 2020

      • High Frequency of SARS-CoV-2 RNAemia and Association With Severe Disease. 9/23/20. Hogan CA. Clin Infect Dis.
        Paired nasopharyngeal and plasma samples from 85 COVID-19 patients, median age 55, revealed plasma RNAemia in 28/85 (32.9%), including 22/28 (78.6%) who required hospitalization, and older age (63 vs. 50 years; P = .04). In models adjusted for age, RNAemia was more frequent in individuals who developed severe disease including ICU admission (32.1% vs 14.0%; P = .04), invasive mechanical ventilation (21.4% vs. 3.5%; P = .02), and all 4 deaths. Plasma RNA persisted for a maximum of 10 days. Authors suggest potential utility as a prognostic indicator.
      • Reduced Monocytic Human Leukocyte Antigen-DR Expression Indicates Immunosuppression in Critically Ill COVID-19 Patients. 9/14/20. Spinetti T. Anesth Analg.
        Major histocompatibility complex (MHC) Class II molecules present processed extracellular proteins and are only expressed on the surface of “professional” antigen presenting cells such as dendritic cell and macrophages/monocytes. As such, there are clear implications for SARS-CoV-2. This small monocentric prospective study examined CD14+ monocytic HLA-DR (mHLA-DR) expression in 9 ICU vs. 7 non-ICU hospitalized COVID-19 patients. The investigators found on flow cytometry significant downregulation of surface expression of this marker indicating immunosuppression. The decrease found on ICU admission persisted on days 3 and 5. The authors suggest that immune monitoring in the ICU could indicate who might benefit from immunological intervention (e.g. GM-CSF, IFNγ).

      October 2, 2020

      September 30, 2020

      September 25, 2020

      • Probative Value of the D-Dimer Assay for Diagnosis of Deep Venous Thrombosis in the Coronavirus Disease 2019 Syndrome. 9/15/20. Gibson CJ. Crit Care Med.
        The authors tested the utility of the D-dimer assay for the diagnosis of deep vein thrombosis. Despite the excellent correlation between the D-dimer and the presence of DVT, the positive predictive value was 21.8%. DVT is only one aspect of the thrombotic problems in these patients. Many do not recommend leg duplex scanning using the sole criteria of D-dimer. One interesting aspect of this study was that all ICU patients received therapeutic anticoagulation. That may have been reflected in the low incidence of DVT discovered in these patients. Unfortunately, there are no data presented regarding the incidence of bleeding in these patients.
      • Stroke Risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases. 9/15/20. Fridman S. Neurology.
        This is a complex study of stroke characteristics in COVID-19 patients by an international team of neurologists who pooled results from 10 studies with their own case series for a total of 160 patients. Their goal is to estimate overall incidence of stroke (1.8%) and mortality (34.4%), determine risk factors, particularly in patients under age 50, and identify clinical phenotypes and associated mortality separating all strokes from ischemic etiology. Large vessel occlusion contributed to a high percentage of strokes in younger patients and occurred before the onset of COVID-19 symptoms in 49% of those cases, while pulmonary involvement correlated with strokes in older patients and poor outcomes.

      September 23, 2020

      September 21, 2020

      September 16, 2020

      September 9, 2020

      September 4, 2020

      • COVID-19-associated hyperinflammation and escalation of patient care: a retrospective longitudinal cohort study. 8/21/20. Manson JJ. Lancet Rheumatol.
        A retrospective observational cohort study of 269 consecutive adult inpatients from the UK during March 2020 identified a “hyperinflammatory” subgroup predictive of a considerably higher risk of severe disease or death based upon C-reactive protein >150 mg/ml or a doubling from >50 mg/L w/in 24 hours, or Ferritin levels >1500 μg/L. These simple biomarkers had a predictive hazard ratio of 2.2 (1.6-2.9) for next-day escalation of support or death. 40% of the subgroup died vs. 26% of others. Follow-up was > 28 days or until death.
      • Marked factor V activity elevation in severe COVID-19 is associated with venous thromboembolism. 8/24/2020. Stefely JA. Am J Hematol.
        This article studies Factor V association with COVID-19 in 102 patients. This is a well-done study and offers possible clinical effects on care and future routes for investigation. The authors found an extraordinary level of factor V elevation in COVID-19 patients which had not been observed in any patient group in the past. A number of other clotting parameters were also analyzed. This patient group consisted primarily of those representing severe cases requiring ventilators. Factor V changes were associated with the wide variety of other clotting parameters and clinical events. This reviewer is not surprised at alterations in factor V levels since this disease is associated with an incredible degree of activation of clotting and related systems.

      August 31, 2020

      August 26, 2020

      August 25, 2020

      August 19, 2020

      • Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients. 8/8/20. Helms J. Crit Care.
        Following up on the concept that neurotropism of the SARS-CoV-2 virus has been confirmed, French investigators focused on the neurological status of 140 consecutive patients with COVID-19 linked ARDS (mean age 62, 71% male) to determine the incidence of delirium and abnormal neurological exams. 84% developed delirium and of those, 69% presented with agitation and 63% had long-tract signs. Of 28 patients who underwent lumbar puncture and MRI, 65% had perfusion abnormalities and 61% had signs of a disturbed blood brain barrier, 64% showed inflammatory signs in CSF and one was PCR positive for SARS-CoV-2 in CSF. Delirium associated with ARDS and COVID-19 is a distinct entity caused by the corona virus which prolongs and complicates recovery, both short term and possibly in the long term as well.
      • Prominent coagulation disorder is closely related to inflammatory response and could be as a prognostic indicator for ICU patients with COVID-19. 8/8/20. Liu Y. J Thromb Thrombolysis.
        Interesting discussion highlighting interrelationship between inflammatory and coagulation systems; suggests coagulation abnormalities (PT, D-Dimer, FDP and AT III) can predict deterioration and mortality; also notes the neutrophil/lymphocyte ratio is a potential inflammatory marker in disease. Recognizes importance of prophylactic thromboprophylaxis and accurate timing of systemic anticoagulation.
      • Unspecific post-mortem findings despite multiorgan viral spread in COVID-19 patients. 8/12/20. Remmelink M. Crit Care.
        The authors found in this study of 17 patients, a great heterogeneity of COVID-19-associated organ injury and the remarkable absence of any specific viral lesions, even when RT-PCR identified the presence of the virus in many organs. Pulmonary findings revealed early-stage diffuse alveolar damage 15/17; microthrombi in small lung arteries in 11 patients and no evidence of myocarditis, hepatitis, or encephalitis. Onset of symptoms and death ranged from 2 to 40 days.

      August 17, 2020

      • Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK. 6/8/20. Knight M. BMJ.
        At all 194 obstetric units in the United Kingdom, 4.9 per 1000 pregnant women (n=427) were hospitalized with confirmed SARS-CoV-2 infection between March 1, 2020 and April 14, 2020. Sixty-nine percent were overweight or obese. Fifty-eight percent had symptom onset >32 weeks gestational age. By study end, 62% (n=266) had completed pregnancy with 259 live births, 3 still births and 4 lost pregnancies. Of those, 74% (n=196) were term births,16% (n=42) had C/section “due to COVID-19,” and 44% (n=114) had C/section for other reasons. Among all hospitalized, 10% needed ICU, 1% were placed on ECMO, and 1% died. Five percent of 265 infants were RNA+ for SARS-CoV-2. Results resemble USA reports.
      • COVID-19 and Dexamethasone: A Potential Strategy to Avoid Steroid-Related Strongyloides Hyperinfection. 7/30/20. Stauffer WM. JAMA.
        Dexamethasone is recommended for critically ill COVID-19 patients. One of its uncommon preventable complications is strongyloides hyperinfection caused by a nematode (roundworm). Seroprevalence of strongyloides ranges from 10-15% among migrants from less developed countries. The infection can last a lifetime. Hyperinfection appears to be independent of dose or duration of steroid. Its possibility should be considered if the patient deteriorates acutely. For outpatients, the authors recommend screening for strongyloides and treating with ivermectin if positive. For inpatients, they recommend presumptive treatment with ivermectin for patients not previously tested or treated for strongyloides.
      • Impact of the Coronavirus Infection in Pregnancy: A Preliminary Study of 141 Patients. 7/7/20. Nayak AH. J Obstet Gynaecol India.
        They studied 141 pregnant COVID positive women and 836 pregnant controls in Mumbai, India from April 1, 2020 to May 15, 2020. COVID-19 did not have a major adverse effect on maternal or newborn outcomes. Mortality was 2% and morbidity was low among COVID-positive mothers. Out of a total of 131 babies tested, only 3 tested positive on first swab and all tested negative on day 5. Vertical transmission of COVID-19 infection from mother to newborn was rare. This study reports fewer adverse outcomes than some others.

      August 14, 2020

      • Cerebrovascular Complications of COVID-19. 8/8/20. Katz JM. Stroke.
        Retrospective case review focusing on imaging confirmed stroke incidence among COVID-19 inpatients treated in a largely metropolitan health care system. 86 stroke patients were identified and compared to 499 stroke patients admitted a year earlier. COVID-19 patients were significantly more likely to have a stroke while hospitalized (48% vs 5%). Additional important findings among the COVID-19 group includes a predominance of ischemic stroke and a high frequency (67%) of non-focal neurologic presentations and a higher incidence among racial minorities.
        In-hospital stroke among COVID-19 patients is a strong independent risk factor and deserves a high grade of suspicion when patients develop neurologic symptoms.
      • Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2: A Systematic Review. 8/4/20. Abrams JY. J Pediatr.
        This article is a comprehensive description of multisystem inflammatory syndrome in children (MIS-C) authored by Centers for Disease Control scientists.

      August 12, 2020

      August 10, 2020

      August 5, 2020

      • EDITORIAL: COVID-19: a complex multisystem disorder. 6/30/20. Roberts CM. Br J Anaesth.
        COVID-19 has extensive effects on virtually all the organs. The virus binds to angiotensin converting enzyme 2 (ACE2) receptors present in vascular endothelial cells, lungs, heart, brain, kidneys, intestines, liver, pharynx, and other tissue. It can directly injure these organs. In addition, systemic disorders caused by the virus lead to organ malfunction. It can cause cytokine storm which can culminate in death. It causes inflammation, endotheliitis, vasoconstriction, hypercoagulability, and edema. Lymphocytopenia, elevated D-dimer, elevated fibrin degradation products (FDPs), and disseminated intravascular coagulation (DIC) are observed. Deep vein thrombosis (DVT), venous thromboembolism, pulmonary embolism (PE), systemic and pulmonary arterial thrombosis and embolism, and ischemic stroke are reported. In the heart, it can cause acute coronary syndrome, congestive heart failure, myocarditis, and arrhythmias. Kidney injury is usually secondary to systemic abnormalities. Stroke occurs even in young patients. Delirium and seizures are common. Anosmia and impaired sense of taste are reported. Psychological problems are common among patients as well as providers. Stool may contain virus. Lactate dehydrogenase may be elevated. Various skin manifestations including patchy erythematous rash are reported. Injury to an organ may become apparent long after the acute infection has subsided. Different organs may be affected at different times. Chronic injury may occur. Rehabilitation can be long and difficult.

      August 3, 2020

      • Characteristics and Strength of Evidence of COVID-19 Studies Registered on ClinicalTrials.gov. 7/27/20. Pundi K. JAMA Intern Med.
        As an indication of how difficult it is to obtain quality data, this evaluation of 1,551 clinical studies of COVID-19 patients listed on ClinicalTrials.gov up to May 19, 2020 found that only 29.1% were designed in a way that the results could possibly change clinical practice (i.e., be classified as Level 2 evidence by the Oxford Centre for Evidence-Based Medicine level of evidence framework). In the 664 randomized clinical studies included, only 14% included mortality as a primary or composite outcome (arguably the most important research question). The authors state that, “Even before results are known, most studies likely will not yield meaningful scientific evidence at a time when rapid generation of high-quality knowledge is critical.”

      July 31, 2020

      • COVID-19 pandemic and the skin: what should dermatologists know? 3/24/20. Darlenski R. Clin Dermatol.
        Skin manifestations of COVID-19 are like those of other viruses and chronic inflammatory diseases like acne, eczema, psoriasis, and rosacea. Vascular problems associated with skin manifestations can be neurogenic, microthrombotic, or immune complex-mediated.
        Of the patients with skin manifestations, a majority have patchy erythematous rash. Some have widespread urticaria or hives. A few also have chickenpox-like fluid-filled vesicles or blisters. They can have measles-like rashes. The most affected area is the trunk. Itching is mild or absent. Some patients have skin eruptions at symptom onset, and others after hospitalization. Lesions usually heal in a few days. Skin manifestations do not correlate with the severity of COVID-19.
        Patients may develop livedo reticularis. It is a purplish net-like discoloration of the skin, often a result of blood clotting abnormalities. Lacy, dusky rashes, including dead skin cells are observed on the arms, legs, and buttocks. They are associated with hypercoagulability. Petechiae are present. Nonpruritic blanching livedoid vascular eruption, possibly due to vaso-occlusion may be present. They appear as mottled, netlike red or pink patches. Also present are chilblains, which are purplish, slightly firm and often tender. COVID toes and fingers have frostbite-like areas with red or purple rash or hive-like eruption.
      • Distinct clinical and immunological features of SARS-COV-2-induced multisystem inflammatory syndrome in children. 7/23/2020. Lee PY. J Clin Invest.
        The authors retrospectively studied 28 confirmed cases of multisystem inflammatory syndrome in children at Boston Children’s Hospital from March to June 2020. Pediatric Multisystem Inflammatory Syndrome that includes classic features of Kawasaki disease, heterogeneous manifestations of systemic inflammation and shock. These children may exhibit heart failure, shock and coronary artery abnormalities, with a disproportionate representation among Blacks and Hispanics. Preexisting risk factors include obesity, asthma and heart disease. Acute respiratory distress syndrome was not a feature, but instead preponderance of cardiac complications including ventricular dysfunction and coronary abnormalities. The degree of inflammation as measured by CRP and procalcitonin is much greater in these children compared to those patients with COVID-19 pneumonia. Rapid diagnosis, multidisciplinary management and suppression of systemic inflammation was associated with a favorable outcome.
      • Genomewide association study of severe Covid-19 with respiratory failure. 6/17/20. Ellinghaus D. N Engl J Med.
        Genetic differences may in part explain the difference in response of different persons to SARS-CoV-2. They compared hospitalized patients with respiratory failure with controls. They studied 835 patients and 1255 controls from Italy and 775 patients and 950 controls from Spain.
        They found 3p21.31 gene cluster is a genetic susceptibility locus. Patients with blood group A were found to be at a higher risk of infection (odds ratio, 1.45) and develop more severe symptoms. Patients with blood type O were found to be at a lower risk of infection (odds ratio, 0.65). Although the results are statistically significant, the effect size is small. Results on the association with blood group has been reviewed by the SAB in several articles previously.

      July 29, 2020

      • Characterization of experimental and clinical bioaerosol generation during potential aerosol-generating procedures. 7/15/20. Doggett N. Chest.
        This prospective study from Toronto quantified aerosol production pre and post two presumed aerosol generating procedures (AGPs); intubations in pigs (n=16) and elective bronchoscopies in human adults (n=39). Though overall, there was a significant reduction in larger particle aerosols during the procedures, and no significant increase in small particle aerosolization during the procedures, some bronchoscopies did produce significantly increased small particle aerosols. The authors conclude that the variability of aerosol generation reinforces the need for PPE during AGPs, and that more research is needed, especially in the more uncontrolled environments typical of a COVID-19 surge.
      • Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. 7/20/20. Bilaloglu S. JAMA.
        This research letter reports retrospective data analysis from 3,334 consecutive hospitalized COVID-19 patients from four NYC hospitals. “Most” received low-dose thromboprophylaxis. Sixteen percent experienced thrombotic events defined as DVT, PE, MI, or CVA (no screening). ICU patients: 13.6% venous, 18.6% arterial. Ward points: 3.6% VTE, and 8.4% arterial. Mortality with event was 43% vs. 21% without. Age, male sex, Hispanic ethnicity, CAD, prior MI, and higher D-dimer at hospital presentation were associated with a thrombotic event, but not BMI or current smoking Hx.

      July 27, 2020

      • Pulmonary immune responses against SARS-CoV-2 infection: harmful or not? 7/19/20. Guillon A. Intensive Care Med.
        A brief, well written review of the literature on COVID-19 immune responses claiming that the critical processes occur primarily in the lung and that the immune injury phase of the disease is not well described as a generalized “cytokine storm.” A T-cell subpopulation called innate T-cells appears to be diminished and have impaired function in peripheral blood but is found in increased numbers and activation in the airways of these patients.

      July 24, 2020

      July 22, 2020

      • Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report. 7/17/20. The RECOVERY Collaborative Group. N Engl J Med.
        Click here to take this CME activity.Review by the SAB
        These authors (Nuffield /Oxford) provide preliminary results (recruitment ended on June 8) of the controlled, open-label-randomized evaluation of COVID-19 Therapy (RECOVERY) trial of dexamethasone in patients hospitalized with COVID-19. The primary outcome was mortality within 28 days after randomization.
        In patients hospitalized with COVID-19, the use of dexamethasone (6mg either IV or PO up to 10 days) resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support (may harm). In a 2:1 randomization, 2,104 patients received dexamethasone and 4,321 received the usual care. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82). There was a trend showing the greatest absolute and proportional benefit among patients who were receiving invasive mechanical ventilation (11.5 by chi square test for trend). Patients in the dexamethasone group had a shorter duration of hospitalization than those in the usual care group (median, 12 days vs. 13 days) and a greater probability of discharge alive within 28 days (rate ratio, 1.10; 95%). It is likely that the beneficial effect of glucocorticoids in severe viral respiratory infections is dependent on a selection of the right dose, at the right time, in the right patient. Viral replication peaks in the second week of illness in SARS, while viral shedding in SARS-CoV-2 appears to be higher early in the illness and declines, thereafter when dexamethasone is most effective. At that stage, the disease may be dominated by immunopathological elements, with active viral replication playing a secondary role.
      • Hospitalization and Mortality among Black Patients and White Patients with Covid-19. 6/25/20. Price-Haywood EG. N Engl J Med.
        Review by the SAB
        By Heinrich Wurm, on behalf of the SAB
        This retrospective cohort study takes a critical look at incidence, mortality and concomitant risk factors among black and white non-Hispanic members of the Ochsner integrated delivery health system.
        Black patients far exceeded white non-Hispanics in getting infected (70 vs. 30% of enrolled patients were PCR positive), requiring hospital admission (77%) and dying (71%). But black race was not independently associated with a higher mortality (HR death vs. white race 0.89; 95 CI, 0.68-1.17) when adjustments for differences in socio-demographic and clinical characteristics were made.
        Blacks had a greater prevalence of underlying disease (obesity, diabetes, hypertension, chronic kidney disease), presented with higher levels of inflammatory markers, elevated creatinine and were more likely to live in low-income areas and receive public insurance. Greater occupational exposure in service industries and higher incidence of morbid obesity and chronic kidney disease were also discussed.
      • Neurobiology of COVID-19. 6/30/20. Fotuhi H. J Alzheimer’s Dis.
        Review by the SAB
        By Heinrich Wurm, on behalf of the SAB
        This review by a panel of U.S. experts goes beyond analyzing neurological manifestations of COVID-19 and provides us with plausible and well-illustrated pathophysiological theories and a 3-stage evolution of a condition termed Neuro-COVID. A synopsis of worrisome post-COVID-19 neurological sequelae, ranging from poor memory and slow processing speed to lasting depression, Parkinson’s, multiple sclerosis and Alzheimer’s, concludes this remarkable publication and points us towards a future of COVID-related sequelae.
      • Race, Postoperative Complications, and Death in Apparently Healthy Children. 7/1/20. Nafiu OO. Pediatrics.
        In a retrospective article of over 170,000 healthy children with care provided by anesthesiologists, African American children suffered more postsurgical complications, especially bleeding and death.

      July 20, 2020

      • Deep immune profiling of COVID-19 patients reveals distinct immunotypes with therapeutic implications. 7/15/20. Mathew D. Science.
        Review by the SAB
        By Dr. Uday Jain, on behalf of the SAB
        Previously uncharted role of lymphocytes in COVID-19 is discussed. A wide variability in immune response was observed among hospitalized COVID-19 patients. Responses were barely detectable in about one-fifth of the patients. This was associated with pathology due to the virus and reduced survival. Remaining patients had CD8 and/or CD4 T lymphocyte and plasmablast responses that were heterogeneous among the patients and were divided into immunotypes. In many patients who became seriously ill with Covid-19, helper and killer cells do not work well cooperatively. An overabundance of helper cells is proinflammatory. An overabundance of killer T cells is not ideal but consistent with survival.
      • Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients. 7/16/20. Tabibi S. J Intensive Care Med.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        This report briefly discusses various approaches currently being investigated to treat SARS-CoV-2 with a focus on potential benefits of therapeutic plasma exchange (TPE). TPE may alleviate the need for polypharmacy to combat various cytokines along with their associated side effects and necessary adjustments for comorbidities. TPE has been used to treat H1N1-associated ARDS, myasthenia gravis, Kawasaki disease, early septic shock, and various multi-organ dysfunction syndrome phenotypes including thrombocytopenia purpura. Reports of its use to treat severe COVID-19 are reviewed. TPE appears generally safe. Concerns involve blood supply, availability, and potentially cost. A proposed set of criteria that overlap with those for convalescent plasma and Spectra Optia Apheresis System is outlined, including early ARDS, severe disease, and life-threatening disease. Clinical trials are underway.

      July 17, 2020

      • COVID-19 Disease Severity Risk Factors for Pediatric Patients in Italy. 7/16/20. Bellino S. Pediatrics.
        Click here to take this CME activity.Review by the SAB
        By Dr. Jay Pryzbylo, on behalf of the SAB
        This large pediatric study demonstrates that infection by COVID-19 increases with age (severe illness in the youngest) is uncommon in the pediatric age group with only 1.8% of total infections over all ages. The study reported only 4 deaths, all in children with complex underlying medical issues.
      • Covid-19: What do we know about “long covid”? 7/14/20. Mahase E. BMJ.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        This non-peer reviewed article discusses “Long COVID,” a term used for lasting effects after recovering from COVID-19 infection or symptoms that persist longer than expected.
        Ongoing health problems may include “breathing difficulties, enduring tiredness, reduced muscle function, impaired ability to perform vital everyday tasks, and mental health problems such as post-traumatic stress disorder, anxiety, and depression.”
        HNS England will be launching an online portal for those with long-term effects of COVID-19 to communicate with nurses, physiotherapists, and mental health specialists.
        A Facebook “long Covid Support group” has >7000 members, and the hashtag “longcovid” enables personal experiences to be shared on social media.
        Research on the long-term effects of COVID-19 infection is needed. The Post-hospitalization COVID-19 Study plans to follow 10,000 UK patients for a year, but it will not include milder cases that didn’t require hospital care.
      • Neurological manifestations of COVID-19: a systematic review. 7/15/20. Nepal G. Crit Care.
        Review by the SAB
        By Dr. Heinrich Wurm, on behalf of the SAB
        This well-organized review of the world literature up to May 20, 2020 analyses 37 articles, many of them case reports. The authors critically review each neurological symptom or disease entity currently known to exist with the intent to provide practitioners with an overview of a host of manifestations ranging from mild headaches to taste and smell disorders to strokes, hemorrhage and central and peripheral nervous system inflammatory reactions like encephalo-myelits and Guillain-Barré syndrome.
      • Relationship between ABO blood group distribution and clinical characteristics in patients with COVID-19. 6/21/20. Wu Y. Clin Chim Acta.
        Review by the SAB
        By Lydia Cassorla, on behalf of the SAB
        Retrospective case controlled study of Wuhan patients admitted to a single Chinese hospital 1/20/20 – 3/5/20. 187 study patients were admitted with COVID-19 while 1991 control patients were COVID negative individuals admitted during the same time period. The proportion of patients with type A blood in the COVID-19 group was significantly higher than that in the control group (36.90% vs. 27.47%, P = 0.006), while the proportion of patients with type O blood in the COVID-19 group was significantly lower than that in the control group (21.92% vs. 30.19%, P = 0.018). Blood group A patients had a higher risk of COVID-19 than non-A blood group patients. (OR = 1.544, 95% CI = 1.122–2.104, P = 0.006). Blood group O patients had a lower risk of COVID-19 than non-O blood group patients (OR = 0.649, 95% CI = 0.457–0.927, P = 0.018).

      July 15, 2020

      • Clinical Implications of SARS-CoV-2 Infection in the Viable Preterm Period. 7/3/20. Gulersen M. Am J Perinatol.
        Review by the SAB
        The authors in this article conducted a retrospective, logistic regression analysis for preterm birth (PTB) from boroughs in New York of patients diagnosed with COVID-19 infection with pregnancy between 23 and 37 weeks of gestation during March and April of 2020. PTB was noted to be in two groups: 23 to 33 weeks (n = 7/36) and the other one was 34+ (n = 18/29) with p= 0.0001. Most women with COVID-19 infection in the early preterm period recovered and were discharged home. The majority of PTB were indicated and not due to spontaneous preterm labor. Delivery during the current admission was noted as statistically significant for the group of patients with 34+ weeks. No correlation was noted with severity of the COVID-19 disease grade or treatment regimes (antibiotics and antimalarial) but no interleukins or steroids were given to the late group. Gestational age at diagnosis of COVID-19 infection had an odds ratio of 2.9.
      • Risk factors for myocardial injury and death in patients with COVID-19: insights from a cohort study with chest computed tomography. 7/8/20. Ferrante G. Cardiovasc Res.
        Review by the SAB
        By Dr. Philip Lumb, on behalf of the SAB
        Interesting study reporting admission CT Scan results on 332 consecutive patients with documented COVID-19 disease. Of these, 123 had myocardial injury defined as high-sensitivity troponin I above 20 ng/ml. Included patients had a median follow up of 12 days with 20.5% (68) deaths. Co-morbidities and course are well described; however, CT findings are consistent with lung involvement in COVID-19.
        The study concludes that “myocardial injury, as assessed by cardiac troponins, occurs in approximately one third of COVID-19 cases and is associated with an adjusted two-fold mortality increase. An increased PA diameter, as assessed on chest CT, is an independent predictor of both myocardial injury and death.”
      • Tocilizumab for treatment of mechanically ventilated patients with COVID-19. 7/11/20. Somers EC. Clin Infect Dis.
        Click here to take this CME activity.Review by the SAB
        By Dr. David Clement, on behalf of the SAB
        An observational, controlled study of 154 adult, ventilated COVID-19 patients, half of whom received tocilizumab. Tocilizumab-treated patients had a 45% reduction in hazard of death, improved status on some secondary outcomes, and twice as many superinfections. Extensive tables, figures and statistical analysis provide insight.  A randomized study is needed to confirm these findings.

      July 13, 2020

      • Characteristics and serological patterns of COVID-19 convalescent plasma donors: optimal donors and timing of donation. 7/6/20. Li L. Transfusion.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        Study from Wuhan, China of 49 blood donors who recovered from mild-moderate COVID-19 to determine optimum convalescent plasma donor strategy.
        Nucleocapsid (N) and Spike protein receptor-binding domain (S-RBD) antibodies were measured by ELISA assay. S-RBD ELISA results were correlated with a SARS-CoV-2 viral neutralization assay, as the authors state that recent studies suggest that S-RBD antibodies may provide immunity.
        N specific IgM declined 3 weeks after infection and reached low levels after 6 weeks. S-RBD and N specific Ig G increased after 4 weeks from symptom onset.
        Those who donated > 28 days from symptom onset, and whose fever > 38.5°C or lasted longer than 3 days, had higher levels of S-RBD IgG.
        Further studies with larger sample size, plasma from asymptomatic donors, and clinical validation are needed.
      • COVID-19 Clinical Trials: Unravelling a Methodological Gordian Knot. 7/7/20. Mathioudakis AG. J Thromb Thrombolysis.
        Review by the SAB
        By Dr. Lance Lichtor, on behalf of the SAB
        During a pandemic, in part because of the limit in a patient population that might shrink in the coming months, clinical trials might need to enroll a patient for more than 1 trial. In addition, because of the need to get information out quickly, interim data meta-analyses (or network meta-analyses) powered to evaluate key outcomes, may be useful. At least, strategies and methodologies need to be developed to allow the best use of data collected.
      • How to Quantify and Interpret Treatment Effects in Comparative Clinical Studies of COVID-19. 7/7/20. McCaw ZR. Ann Intern Med.
        Review by the SAB
        By Dr. Jay Pryzbylo, on behalf of the SAB
        Concise but in depth explanation using the example of two previously published articles to demonstrate that the statistical techniques used do not necessarily accurately describe the outcomes achieved. At issue is that negative outcomes (e.g., deaths) are not adequately accounted for in positive outcome statistical evaluation (days to recovery). The authors advance a method to do so that alters the outcomes of the studies.
      • Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19. 6/29/20. Arshad S. Int J Infect Dis.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        Multi-center retrospective observational study of 2,541 consecutive RT-PCR confirmed COVID-19 admissions from March 10 to May 2 in Detroit to determine impact of hydroxychloroquine +- azithromycin on inpatient mortality.
        Standard, uniform treatment guidelines established by a system-wide interdisciplinary COVID-19 task force also included corticosteroids and tocilizumab, which were used in 68% and 4.5% respectively.
        In hospital mortality:
        • Overall 18%
        • No hydroxychloroquine or azithromycin 26%
        • Azithromycin alone 22%
        • Hydroxychloroquine + azithromycin 20%
        • Hydroxychloroquine alone 13.5%
        • Mortality predictors were age > 65, CKD, decreased O2 sat on admit, ventilator use, and in contrast to previous studies, white race.

        Propensity matched regression analysis showed a mortality hazard ratio of .49 for patients who received hydroxychloroquine.
        Of note, no deaths due to major cardiac arrhythmias, such as torsades, were seen with hydroxychloroquine treatment.
        The authors suggest that early medication treatment (91% within 48 hours of admission), standardized dosing, and inpatient telemetry with electrolyte protocols may have accounted for the positive results seen with hydroxychloroquine.

      July 10, 2020

      • Incidence of pulmonary embolism in non-critically ill COVID-19 patients. Predicting factors for a challenging diagnosis. 6/29/20. Mestre-Gómez B. J Thromb Thrombolysis.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        Retrospective review of EMR data of 452 consecutive patients admitted to the general ward with COVID-19 (based on WHO clinical criteria and/or RT-PCR) in Madrid to determine the incidence of PE in non-critically ill COVID-19 patients and identify predictive factors.
        • 91 of these patients had CT pulmonary angiography (CTPA) to rule out PE, with 29 (32%) positive for acute PE.
        • Incidence of PE was 6.4% — 29/452 patients.
        • Of note, 79% were receiving prophylactic LMWH at the time PE was diagnosed
        • PE was not associated with a significantly increased risk of ICU admission or mortality
        • Multivariate analysis showed lack of history of dyslipidemia and elevated D-dimer were independent predictors of PE.
        • D-Dimer peak median was 2x higher in PE patients. Cut off predictor was > 5000 ug/dl.
        • Patients with history of dyslipidemia had a 9x lower risk of PE. It is not known if this is due to statin use prior to admission. Hospital statin administration was not significantly different among the two groups.

        While the study concludes that an elevated D-Dimer > 5000 ul/dl and lack of dyslipidemia history are independent predictors of COVID-19 related PE risk, it is limited by small sample size, retrospective nature, and lack of DVT studies.

      July 8, 2020

      July 6, 2020

      • Compassionate Use of Tocilizumab for Treatment of SARS-CoV-2 Pneumonia. 6/23/20. Jordan SC. Clin Infect Dis.
        Review by the SAB
        By Dr. Heinrich Wurm, on behalf of the SAB
        Single center review by a multidisciplinary team from Cedars-Sinai following 27, mostly intubated, patients with confirmed SARS-CoV-2 pneumonia who received a single dose of 400 mg tocilizumab intravenously under a compassionate use protocol. Decreasing vasopressor support and oxygen requirements as well as lower C-reactive protein levels and temperature were observed in a majority of subjects monitored to assess anti-inflammatory effectiveness and clinical improvement.
        Tocilizumab proved beneficial in reducing inflammation and improving clinical outcome including mortality. Final proof of the drug’s efficacy awaits a placebo-controlled trial, now underway.

      July 1, 2020

      • COVID and Coagulation: Bleeding and Thrombotic Manifestations of SARS-CoV2 Infection. 6/3/20. Al-Samkari H. Blood.
        Review by the SAB
        This is a retrospective observational study of data from 400 COVID-19 in-patients with D-dimer on admission to 5 affiliated Boston area hospitals between March 1 – April 5, 2020 with a data cutoff of April 8, 2020. All received prophylactic anticoagulation except one who was fully anticoagulated. Incidence of thrombosis and bleeding was similar to that reported in non-COVID-19 patients with equivalent illness severity. (9.5% had thrombosis and 4.8% hemorrhage w/ higher fractions in the critically ill.) There were no deaths from thrombosis and 1 from intracerebral hemorrhage. D-dimer on admission was predictive of thrombosis, bleeding, illness severity and death. The authors recommend that clinicians await the results of randomized clinical trials before increasing thromboprophylaxis dosages for COVID-19 patients, including the critically ill.

      June 8, 2020

      • Association of hypertension and antihypertensive treatment with COVID-19 mortality: a retrospective observational study. June 4. Gao C. Eur Heart J.
        This is a large retrospective observational cohort study regarding a history of hypertension in 2877 consecutive patients admitted to a Covid-19 hospital in Wuhan. No HTN: n=2027. HTN n=850. “A total of 34/850 (4.0%) patients died in the hypertension cohort and 22/2027 (1.1%) died in the no hypertension cohort (crude HR 3.75, 95% CI 2.19–6.41, P < 0.001; Figure 1A). After adjustment for confounders, hypertension was still associated with a two-fold increase in the risk of mortality as compared with no hypertension (adjusted HR 2.12, 95% CI 1.17–3.82, P = 0.013; Table 2). The time from symptom onset to discharge was comparable between the two cohorts; however, patients with hypertension had the propensity to develop more severe/critical COVID-19 disease (P for trend < 0.001) and were more likely to receive invasive mechanical ventilation (P < 0.001).”
        The SBP on admission was 10mmHg higher (136 vs. 126) in the HTN cohort, and DBP 80 vs. 83.5. Among the HTN group, there was no difference in admission BP between those on Rx. vs. those w/o Rx, and no difference between RAAS Rx and other anti-HTN Rx. 90 (64.3%) of the HTN by history patients that were untreated on admission received anti-HTN Rx after admission, none with RAAS inhibitors. 95% of patients on anti HTN Rx were continued, largely on the drugs they were on. (There appears to be an error in the percent calculations of RAAS inhibitor patients in their flow chart).
        Results of a meta-analysis including 3 additional Chinese studies with a combined total of 808 patients are also included in their discussion.
        “The main findings of this analysis can be summarized as follows: (i) after adjustment for confounders and compared with the non-hypertensive patients, the hypertensive patients continued to demonstrate a two-fold relative increase in the risk of COVID-19 mortality; (ii) the patients with a history of hypertension but without antihypertensive treatment were associated with a significantly higher risk of mortality compared with those with antihypertensive treatments; and (iii) the relative rates of mortality, the severity of COVID-19, and percentages of ventilation were not statistically different between the patients treated with RAAS inhibitors and non-RAAS inhibitors. However, in the meta-analysis, RAAS inhibitors tend to be associated with a lower risk of mortality.”
        As described above, these data showed that untreated hypertensive patients are at the highest risk. There are remaining questions: (i) which kind of medication should be given to those patients (CCBs or RAAS inhibitors); (ii) could such medications mitigate the risk of these patients; and (iii) will the use of RAAS inhibitors affect the risk of infection when equally exposed to the virus?
        Limitations: Retrospective, observational study. “While 2877 patients enrolled, only 183 patients with RAAS inhibitors and 527 patients with non-RAAS inhibitors were compared. (Statistically underpowered), our findings should be interpreted cautiously.” Short-term outcome study.
      • Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks. June 3. Parri N. Eur J Pediatr.
        We published a summary from China. Also, Docmatter had another summary from the MMWR which was a summary from the US. Is another similar one needed? They did reference that article: clinical presentation was only available in 9%. Yet their findings were similar to others: COVID-19 in children is mostly a mild disease.
      • Renin-angiotensin system inhibitors in the COVID-19 pandemic: consequences of antihypertensive drugs. June 4. Ruilope LM. Eur Heart J.
        An editorial concurring with the conclusions of the large retrospective by C. Gao et al. on the association of HBP and HBP Rx on mortality in Covid-19 patients. The author points out that after pooling previously published data in a study-level meta-analysis, patients taking RAAS blockers were actually shown to have decreased mortality rates, and suggests a need to investigate RAAS blockers as possible specific treatment for COVID-19 patients.

      June 5, 2020

      • Impact of anticoagulation prior to COVID-19 infection: a propensity score-matched cohort study
        May 27. Tremblay D. Blood.
        Opinion from SAB Member: Dr. Joseph Anthony Caprini, Dr. Anil Hingorani
        JC: This is a very clever analysis looking at patients who did or did not have therapeutic anticoagulation prior to developing the viral infection as a result of their underlying condition. The same analysis was done in patients on antiplatelet therapy. The results showed no benefit of either anticoagulation or antiplatelet therapy in changing all-cause mortality, mechanical ventilation, and hospital admission. They comment that the results of this study do not rule out the possibility that among some groups of patients suffering from the virus therapeutic anticoagulation following diagnosis may be important and beneficial. They further comment that their findings agree with the current recommendations of the American Society of Hematology that state that the benefit of therapeutic anticoagulation in patients with COVID-19 is unknown.
        AH: These data are from Mount Sinai. The authors use retrospective propensity matching for anticoagulation usage before COVID-19 diagnosis. No benefit of any single anticoagulation type was noted. The article suggests we may need multiple types of treatment. This paper is novel and raises good questions.
      • Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study
        May 29. CovidSurg Collaborative. The Lancet.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Joseph Anthony Caprini
        AH: 30-day results of an international cohort study assessing postoperative outcomes in 1128 adults with COVID-19 who were undergoing a broad range of surgeries. SARS-CoV-2 infection was diagnosed postoperatively in more than two-thirds of the patients (806 [71·5%]). The primary outcome was overall postoperative mortality at 30 days, and the rate was high at 23·8% (268 of 1128 patients). Pulmonary complications occurred in 577 (51·2%) patients and 30-day mortality in these patients was 38·0% (219 of 577).
        JC: This represents a very important study demonstrating a high incidence of relatively severe complications including death postoperatively. There are obvious flaws in this study as expressed by both the authors and in the subsequent editorial. Nevertheless, these data emphasize the importance of improved preventative measures including the vaccine as well as a multimodal therapeutic approach involving drugs representing hematologic immunologic and inflammatory pathways.

      June 3, 2020

      June 1, 2020

      May 29, 2020

      • Covid-19, Angiogenesis, and ARDS Endotypes
        May 21. Hariri L. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Louis McNabb
        AH: Editorial points out limitations of the Ackermann paper: n=7, none intubated, only 20% with noninvasive ventilation. Exact correlation with the time course of the disease and the findings are not clear.
        LM: Complimentary article to Ackermann’s paper suggesting that the small vessel disruption in COVID-19 may represent a specific ARDS histologic phenotype.
      • Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19
        May 21. Ackermann M. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Louis McNabb
        AH: This is an autopsy study of 7 COVID-19 patients compared to 7 H1N1 patients, age and gender matched with 10 controls. Tests performed: histology, electron microscopy and gene array. Widespread thrombosis with microangiopathy were seen. COVID-19 patients had more alveolar capillary microthrombi and new vessel growth–predominantly through a mechanism of intussusceptive angiogenesis. Gene analysis also showed more angiogenesis.
        LM: This study compared lung histology of 7 patients dying of COVID-19 vs. 7 patients dying of influenza. Key Points: 1) COVID-19 patients had 9 times more capillary micro-thrombi, 2) Disrupted capillary cell membranes with intracellular virus were seen, 3) Perivascular t-cell infiltration was seen, and 4) COVID-19 patients had 2.7 more times new vessel growth through the mechanism of intussusceptive angiogenesis.
      • The association of low serum albumin level with severe COVID-19: a systematic review and meta-analysis. May 26. Aziz M. Crit Care.
        Meta-analysis of 11 studies with 910 patients finding a significantly lower admission serum albumin (3.5 g/dL) in severe COVID-19 patients than in those with non-severe disease (4.0 g/dL). Of note, patient mean age was 48. The primary cause and clinical significance of this difference is not known.

      May 28, 2020

      • Alterations in Gut Microbiota of Patients With COVID-19 During Time of Hospitalization. May 14. Zuo T. Gastroenterology.
        Pilot, prospective comparison of fecal microbiomes in samples from 15 hospitalized COVID-19 patients in Hong Kong with samples from 6 patients hospitalized with community acquired pneumonia and 15 controls. Samples were collected 2-3 times a week until hospital discharge. Samples from COVID-19 patients had increased opportunistic pathogens and decreased beneficial commensals. Bacterial levels remained low and altered from a healthy microbiome even after RT-PCR tests became negative and respiratory symptoms had resolved. COVID-19 patients treated with antibiotics showed a larger change from a healthy microbiome. Baseline (but after admission) Coprobaccillus, Clostriium ramosum, and Clostridium hathewayi correlated with COVID-19 severity, while amounts of the anti-inflammatory Faecalibacterium inversely correlated with severity. Several Bacteroides species, which down regulate ACE2 expression, inversely correlated with viral load, suggesting that it may play a protective role. Study is limited by small sample size, unknown baseline microbiome prior to disease onset, lack of patients with asymptomatic or mild COVID-19.
      • Famotidine Use is Associated with Improved Clinical Outcomes in Hospitalized COVID-19 Patients: A Propensity Score Matched Retrospective Cohort Study. May 14. Freedberg DE. Gastroenterology.
        This retrospective cohort study from a single NY institution looked at the relationship between famotidine exposure of Covid-19 patients within 24 hours of hospitalization and death or endotracheal intubation from hospital day 2 to 30. They studied all Covid-19 positive patients from 2/25/20-4/13/20. 84 patients, representing 15% of 1,620 analyzed, were in the famotidine exposed group. Doses and route of adminstration varied. Median length of treatment was 5.8 days. Adjusted hazard risk of death or intubation was 0.42. PPIs did not show a protective effect. Next, 784 patients w/o COVID-19 were analyzed and famotidine exposure did not show a protective effect. A lower peak ferritin value was observed among famotidine-exposed patients, supporting the hypothesis that cytokine release in famotidine exposed patients may be lower in the setting of Covid-19. An untargeted computer modeling analysis identified famotidine as one of the highest-ranked matches for drugs predicted to bind 3CL (3), a SARS-CoV-2 protease.

      May 27, 2020

      • Critically ill patients with COVID-19 in New York City
        May 19. Grasselli. The Lancet.
        Opinion from SAB Member: Dr. Jagdip Shah
        This editorial describes the study by Matthew J. Cummings, et al as a high-quality example of research even when facing an overwhelming clinical workload. The authors claim that further studies are required to improve and personalize patient treatment, with particular attention to the role of initial non-invasive respiratory support strategies, timing of intubation, optimal setting of mechanical ventilation, and efficacy and safety of immunomodulating agents and anticoagulation strategies.
      • Detection of SARS-CoV-2 in human breastmilk. May 21 Groß. Lancet.
        In this study of 2 women with severe COVID-19 disease, one mother shed SARS-CoV-2 RNA from breast milk for 4 days. Interesting but a small study.
      • Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study
        May 19. Cummings. The Lancet.
        Opinion from SAB Member: Dr. Jagdip Shah
        1150 adults were admitted in this prospective study from 2 hospitals (Columbia, New York). Both hospitals were able to utilize more than double the ICU surge capacity. 257 were critically ill with confirmed COVID-19. The median age of patients was 62 years, 67% were men, 82% of patients had at least one chronic illness, (HTN, DM, BMI > 30). A high incidence of critical illness among racial and ethnic minorities in this pandemic is noted. 39% of patients had died and 37% remained hospitalized, 79% patients had to be mechanically ventilated for 18 days, 66% of 257 patients received vasopressors and 31% RRT. The authors present extensive respiratory and critical illness parameters on the first day of critical illness (medians): SOFA = 11, lowest PaO2:FiO2 = 129 mmHg, plateau airway pressure = 27 cmH2O, highest PEEP = 15 cmH2O.
        In the multivariable Cox model, older age (HR 1.31 per 10-year increase), chronic cardiac disease (HR 1.76), chronic pulmonary disease (HR 2.94), higher concentrations of interleukin-6 (HR 1.11 per decile increase), and higher concentrations of D-dimer (HR 1.10 per decile increase) were independently associated with in-hospital mortality. Univariate and multivariate HRs being somewhat similar suggest a higher confidence in the study and the group composition.
        Patients hospitalized with COVID-19 had a high frequency of invasive mechanical ventilation, extrapulmonary organ dysfunction, and substantial in-hospital mortality.
      • Features of 20‚133 UK patients in hospital with Covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study
        May 22. Docherty. BMJ.
        Opinion from SAB Member: Dr. David M. Clement
        This is a somewhat different twist on the numerous studies describing symptoms, co-morbidities and outcomes with COVID-19 inpatients. It is a prospective, observational cohort study from the UK of 20,100 inpatients who were tracked with a pandemic protocol written before the SARS-CoV-2 pandemic in response to the H1N1 and MERS epidemics. An army of 2,468 research nurses, administrators and medical students collected data using a pre-pandemic standardized form and protocol in 208 hospitals on about a third of RT-PCR positive patients. Of note, symptoms were present in overlapping clusters reflecting organ systems involved (lung, GI, musculoskeletal and musculo-cutaneous). Overall, symptoms, comorbidities and outcomes were somewhat similar to previous studies: 41% of patients were discharged alive, 26% died and 34% were still inpatients. In ICU patients, 32% died and 41% were still admitted. The utility of pre-pandemic preparation for many facets of care was apparent.
      • Pulmonary fibrosis and COVID-19: the potential role for antifibrotic therapy
        May 15. George. Lancet Respir Med.
        Opinion from SAB Member: Dr. Louis McNabb, Dr. Edward S. Schulman
        LM: This is an opinion article raising the issue of long-term pulmonary fibrosis in survivors of severe COVID-19 pneumonia/ARDS. The authors discuss the logic for considering anti-fibrotic drugs such as: pirfenidone and nintedanib. They also discuss many other experimental anti-fibrotic drugs and their potential mechanism of action in COVID-19.
        ESS: While it may eventually become pertinent to consider the theoretical role of anti-fibrotic agents in the treatment of COVID-19, it must be noted that we do not yet know the natural history of lung injury in survivors and whether fibrosis is a persistent feature. With regards to pirfenidone and nintedanib, these agents carry significant side-effect profiles including nausea, vomiting, diarrhea and liver injury that may preclude their use in critically ill COVID-19 patients. Furthermore, the authors of this paper acknowledge relationships including “personal fees with the companies marketing pirfenidone and nintedanib.”
      • Pulmonary fibrosis secondary to COVID-19: a call to arms?
        May 15. Spagnolo. Lancet Respir Med.
        Opinion from SAB Member: Dr. Louis McNabb
        This is a short article pointing out the potential for a large population of COVID-19 survivors with residual pulmonary fibrosis and its consequences.
      • Therapy with agents acting on the renin-angiotensin system and risk of SARS-CoV-2 infection
        May 22. Gnavi. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. Jay Przybylo
        This is a study with controls demonstrating that patients treated with ACE inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARBs), in particular those with diabetes or cardiovascular disease, were not more susceptible to SARS-CoV-19 infection due to drug therapy.

      May 22, 2020

      • Tracheostomy in the COVID-19 era: global and multidisciplinary guidance
        May 15. McGrath. Lancet Respir Med.
        Opinion from SAB Member: Dr. Jay Przybylo
        Presented by an international, multidisciplinary team, this article attempts to limit “conflicting recommendations” that have arisen in this pandemic regarding tracheostomies. Using COVID-19 as the example, the paper reviews the history of pandemics, searches the literature for guidance, and describes the issues of tracheostomy–in non-COVID-19 patients less than 50% of trached patients survive to leave the hospital and 12% are functional at 1 year while in COVID-19 the statistics are worse, suggesting a longer wait prior to tracheostomy. Using data on the infectious nature of COVID-19, the wait allows the detectable virus to drop below 50% of patients while allowing antibodies to become detectable in most. With this timing, the incidence of trach is 0.5%. The location of the procedure and the optimal procedure are discussed. The care of patients with emphasis on healthcare provider safety is discussed. The paper contains multiple, easily interpretable tables and graphs. Not a science paper with statistics and errors supplied, this paper promotes standards that can (should) be met worldwide.

      May 21, 2020

      • Cardiovascular implications of the COVID-19 pandemic: a global perspective
        May 10. Boukhris. Canadian Journal of Cardiology.
        Opinion from SAB Member: Dr. Jagdip Shah
        Cardiologists from across the world provide a holistic review of the present and future of their acute and chronic issues with clinical practice in this article. The article provides a comprehensive overview with evidence-based input of the pathophysiology and the dynamic cardiovascular implications of COVID-19. The authors have made an excellent effort to explain pathophysiology for noncardiac conditions, drug implication and their interactions as well. They noted that the information in references here is contemporary and relevant. It offers a detailed recommendation of existing pathways of care, the role of modern technologies (AI, social media, smartphones, telemedicine, etc.) to tackle the patient care issues in this pandemic, which other specialties can adopt. This is a practical, realistic proposal of novel management algorithms for the most common acute cardiac conditions with excellent tables and figures that are easy to read and follow.
        Although respiratory symptoms dominate the clinical presentation, COVID-19 is known to have potentially serious cardiovascular consequences, including myocardial injury, myocarditis, acute coronary syndrome, pulmonary embolism, stroke, arrhythmias, heart failure, and cardiogenic shock. The cardiac manifestations of COVID-19 may be related to the adrenergic drive, systemic inflammatory milieu and cytokine-release syndrome caused by SARS-CoV-2, direct viral infection of myocardial and endothelial cells, hypoxia due to respiratory failure, electrolytic imbalances, fluid overload, and side effects of certain COVID-19 medications known to be in practice currently.
      • Cardiovascular Safety of Potential Drugs for the Treatment of Coronavirus Disease 2019
        May 20. Aggarwal. The American Journal of Cardiology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        Any drug might have an effect on the heart. The authors have provided a nice summary of the cardiac safety of various drugs used to treat patients with COVID-19, including chloroquine/hydroxychloroquine, azithromycin, remdesivir and lopinavir/ritonavir, interferon-alpha, and briefly concerning some other therapies.
      • Neurologic complications of COVID-19
        May 10. Bridwell. American Journal of Emergency Medicine.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        Announced by the authors as, “A practical review of the literature aimed at the emergency medicine clinician”, this review of 60 recent papers dealing with the neurological impact of COVID-19 adds value for the clinician without being superficial. The avenues of direct viral assault via endothelial ACE-2 receptors, retrograde migration via the nasopharynx into the olfactory system, or via transsynaptic transmission, are highlighted, as well as the impact of secondary events like the systemic inflammatory response evoked by the virus and its impact on the blood brain barrier or the effect hypoxia may exert on cerebral autoregulation.
        In addition to highlighting clinical presentations, this review points to pre-existing neurological disease like stroke and Parkinson’s as an important risk factor not only for added neurological complications, but for severity of illness and mortality. A table listing the side effects of various pharmaceuticals used to treat COVID-19 provides another helpful addition for the practitioner.
      • The Relationship between Status at Presentation and Outcomes among Pregnant Women with COVID-19. 5/20/20. London V. Am J Perinatol.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        This is a single-center retrospective cohort study of pregnant women who tested positive for COVID-19 at one Brooklyn hospital from March 15 to April 15, 2020. Fifty-five SARS-CoV-2 positive pregnant women were followed to term and 1 had fetal demise at 17 weeks. Among parturients with COVID-19 symptoms at presentation (n = 33), 16 (48.5%) had Cesarean delivery, 9 (27.3%) had preterm birth <37 weeks of whom 7 were C/Section for maternal respiratory distress. Twelve (26%) required respiratory support including 1 who required mechanical ventilation. Among those who were asymptomatic at presentation (n = 22), 6 (27%) had Cesarean delivery, and there were no preterm births. Pregnant women who present without symptoms remained asymptomatic to a greater degree than has been reported from cohorts of older individuals. Initially, patients were only tested because of symptoms of potential exposure. Universal testing began during the study period and 13.3% of 76 asymptomatic patients tested after that date were COVID-19 positive. Of 48 neonates tested on day 0 by PCR, none tested positive for COVID-19. Conclusion: Pregnant women with COVID-19-related symptoms have a high rate of severe disease and preterm birth due to Cesarean delivery to treat maternal respiratory distress.

      May 20, 2020

      • Are Gastrointestinal Symptoms Specific for COVID-19 Infection? A Prospective Case-Control Study from the United States. May 19. Chen. Gastroenterology.
        Though this is the first prospective study of GI symptoms in COVID-19 patients, its findings are not surprising. This study from Baltimore was a prospective, case-controlled study of 340 consecutive patients tested by RT-PCR. Symptoms of anorexia and diarrhea, combined with the loss of smell and taste and fever predicted a positive test with 99% specificity. No mention is made of how patients were chosen for RT-PCR testing, no discussion of the influence of false negative test was given, and no patients under 18 yo were included.
      • COVID-19 update: Covid-19-associated coagulopathy
        May 15. Becker. Journal of Thrombosis and Thrombolysis.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Lydia Cassorla, Dr. Joseph Anthony Caprini
        AH: This article contains very detailed data on COVID-19 and its effects on coagulopathy that includes basic science.
        LC: This comprehensive and detailed analysis of COVID-19 associated coagulopathy (bleeding and thrombosis phenotypes) is a deep dive into both what is known and speculation about pathophysiology. Overlapping and distinguishing features relative to DIC and thrombotic microangiopathies (including TTP, HUS, pre/eclampsia) are reviewed. Lab features of COVID coagulopathy more resemble DIC, with the exception of the absence of low platelet count. A useful table for comparison is provided. Virchow’s triad of pro-thrombotic factors holds strong. (Abnormal blood flow, vascular injury and abnormalities within the circulating blood). US and international guidelines regarding thromboprophylaxis are reviewed as the world awaits more definitive data from ongoing clinical trials.
        JC: This is an incredibly important paper describing the sophisticated array of changes associated with this viral infection. It is must reading for those interested in learning more about the pathophysiology of the disease. There are too many important points in this paper to repeat otherwise we would rewrite the paper. Most sentences are packed with information. What is important for all of us to understand is that this viral infection is much more than the coagulation system gone wild. In addition, no amount of heparin anticoagulation will be the answer to controlling the morbidity and mortality associated with this disease. The important take away is a concept introduced nearly 50 years ago by the famous hematologist Oscar Ratnoff. He described a “tangled hemostatic web” where contact activation pathways of the blood beginning with factor XII (Hageman factor) resulted in a triggering of platelet, coagulation, fibrinolysis, complement, and kallikrein pathways. The clinical result was not only thrombosis but also systemic vascular changes consistent with activation of both the inflammatory and immunologic pathways. The implications of this work quite clearly involved therapeutic approaches not only involving anticoagulation but also perhaps antiplatelet, anti-fibrinolytic, anti-inflammatory, and anti-immunologic therapy. We know there are various stages of the disease and introducing these modalities at different times may also be important. I personally feel that this knowledge intensifies my zeal for providing early and adequate anticoagulation to these patients along with anti-inflammatory and anti-immunologic therapy to prevent the progression of the disease.
      • Below are three recent literature reviews on neurological manifestations and complications of COVID-19 as well as possible psychiatric and neuropsychiatric effects on patients that are now available. Relying primarily on case reports and pre COVID-19 coronavirus research there is strong suspicion that SARS-CoV-2 gains access to both the central and peripheral nervous system directly and possibly to a larger extent than observed in SARS or MERS. While the etiological mechanisms of anosmia remain unclear, this early sign may be a clue to the neurotropism of the SARS-CoV-2 virus. Separating primary neurologic injury from secondary effects of severe illness, hypoxia, hyper-inflammatory state and multi-organ failure, represents an additional hurdle. While new onset psychiatric illness is unlikely to follow COVID-19 recovery, patients are prone to suffer post-traumatic stress disorder and its complex symptomatology.
        • Neurological manifestations of COVID-19 and other coronavirus infections: A systematic review
          Apr 28. Montalvan. Clinical Neurology and Neurosurgery.
          Opinion from SAB Member: Dr. W. Heinrich Wurm
          This is a systematic review of 67 studies dealing with neurological manifestations of COVID-19, including encephalitis, Guillain Barre, multiple sclerosis, and stroke, but also reviewing available evidence of neurotropism of CoV observed during SARS and MERS. Direct viral access to the CNS through the cribriform plate and olfactory bulb and dissemination via trans-synaptic transfer to the peripheral nervous system remains under investigation, as is the invasion of the medullary cardiorespiratory center as a postulated cause of refractory respiratory failure observed in COVID-19. Future research into the expression of ACE2 receptors in neurological tissues could be the key to some of these questions.
        • Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic
          May 18. Rogers. The Lancet Psychiatry.
          Opinion from SAB Member: Dr. W. Heinrich Wurm
          This systematic review and meta-analysis of 70+ papers deals primarily with psychiatric sequelae of SARS-CoV and MERS-CoV and suggests that among patients admitted to hospital for severe SARS or MERS coronavirus infections, delirium is common acutely, whereas post-traumatic stress disorder, depression, anxiety, and fatigue are common in the following months. COVID-19 patients are likely to experience delirium, confusion, agitation, and altered consciousness, as well as symptoms of depression, anxiety, and insomnia but at this point there is not enough data to determine the overall extent and impact of such sequelae. Based on their review, the authors believe there is no indication that COVID-19 results in new onset mental illness.
        • Neurological manifestations and complications of COVID-19: A literature review
          Apr 24. Ahmad. Journal of Clinical Neuroscience.
          Opinion from SAB Member: Dr. W. Heinrich Wurm
          Narrative review covering the neurological manifestations of COVID-19 based on an English language literature search which at the time of submission (April 24th) consisted of only two series: one retrospective chart review from China (245 patients, 45% neurologic involvement), and one observational study from France (58 patients, 84% neurological involvement). Following a brief discussion of SARS-CoV2’s access to central and peripheral neurons, the authors postulate the two prime mechanisms responsible for neurological injury to be hypoxia and the COVID-19 immune response. What follows are a series of case reports of central and peripheral nervous system effects, including encephalopathies, encephalitis, and strokes, as well as anosmia, myelitis, Guillian Barre syndrome and a poorly defined but not infrequently seen syndrome of skeletal muscle damage accompanied by CPK elevations, severe muscle pain and signs of concomitant kidney and liver injury. The authors conclude with a call for clinicians to track and report more detailed information on neurological manifestations of COVID-19.
      • Unique Patterns of Cardiovascular Involvement in COVID-19. May 11. Hendren. J Card Fail.
        The authors described the variable presentations of cardiac involvement in COVID-19 within the broader spectrum of symptomatic SARS-CoV-2 infection, something that has previously been proposed. There are two phenotypes: cardiac involvement superimposed on top of the typical pulmonary predominate symptoms or isolated or predominate cardiac presentation. Though fever is common with typical pulmonary involvement, not so in the predominate cardiac phenotype. The troponin level with an isolated cardiac presentation can be absent or markedly elevated depending on the presentation. Though with a cardiac predominate disease there may be chest pain due to a myocardial infarction, patients with COVID-19 disease superimposed on pulmonary disease. Much speculation.

      May 19, 2020

      • Angiotensin II infusion in COVID-19-associated vasodilatory shock: a case series
        May 15. Zangrillo. Critical Care.
        Opinion from SAB Member: Dr. Philip Lumb
        This research letter details a trial of angiotensin II (ANGII) in 16 patients with vasodilatory shock resistant to high dose catecholamine (norepinephrine > 0.25 mcg/kg/min) as either first line or rescue infusion in a compassionate use protocol. Patients demonstrated improvement in oxygenation parameters associated with ANGII infusion; catecholamines were withdrawn or significantly reduced after 24 hours. Small series with interesting and favorable results.
      • Risk Factors of Severe Disease and Efficacy of Treatment in Patients Infected with COVID-19: A Systematic Review, Meta-Analysis and Meta-Regression Analysis. May 14. Zhang. Clin Infect Dis.
        This is an extensive meta-analysis and meta-regression of 45 studies (Asia only) with 4,203 patients, noted rates of intensive care unit (ICU) admission (10.9%), mortality (4.3%) and acute respiratory distress syndrome (ARDS) (18.4%). The investigators followed up with the regression analysis of these patients and studied the associations with the key epidemiological features, clinical characteristics, laboratory investigations, radiological findings, treatment details for outcomes of COVID-19. The investigators have statistically significant proof for their finding that: 1. elevated LDH is a significant predictive marker of ARDS; 2. Both elevated leukocyte count and elevated LDH suggests clinically a secondary infection and its complication on multi-systems which also predict the mortality; 3. Treatment with the anti-retroviral drug lopinavir-ritonavir was not associated (antiviral treatment likely to be all 6, 4 or 2 drugs) with any additional significant benefit on complications or outcome; and 4. corticosteroids were associated with possible harm.
        Strength: Extensive statistical proof while addressing biases. The publications included were GRADE (A method of exclusion) then addressed by several filters for the non-validity, has excellent graphs and tables. The secondary outcome (infection – 8.9% cardiac injury 7.8 %..) noted. Subgroup analysis for antiviral drugs and steroids are also complementary to the investigation.
        Weakness: No mention of -> Prone benefits, convalescent plasma therapy OR HCQ, LDH and its association with shock or antiviral Meds. Asian patients only (High tobacco?).
      • Smell and taste alterations in Covid-19: a cross-sectional analysis of different cohorts
        May 14. Paderno. Allergy & Rhinology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this study of a little over 500 patients who were either hospitalized or in quarantine with laboratory confirmed SARS-CoV-2 disease, whose data was collected between March 27 and April 1 via survey, the prevalence of olfactory and gustatory dysfunction was greater than 50%. There was a higher prevalence in home-quarantined patients (79% vs 72%). Hospitalized patients, though, had more dyspnea and a lower rate of flu-like syndrome. Indeed, because of a severe clinical condition and a decrease in oral intake, the perception of olfactory and gustatory dysfunction in the inpatient setting was likely lower than for outpatients. Outpatients were also younger, healthier, were less likely to smoke, and were more likely female.
      • Understanding pathophysiology of hemostasis disorders in critically ill patients with COVID-19
        May 15. Joly. Intensive Care Medicine.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Joseph Anthony Caprini
        AH: This review of the literature of COVID-19 and its effects on coagulation is complete and bridges into the clinical effects of this knowledge.
        JC: This paper describes a number of interesting observations regarding the pathophysiology and clinical manifestations of this disease. The focus of this paper on heparin, while important, does not adequately reflect to the reader what is involved in the correlation between pathophysiology and various treatment modalities. The Becker paper captures more fully the myriad of pathophysiologic mechanisms, and provides a good source for the interested reader regarding these interactions in COVID-19. The bottom line for the treating physician is there is going to be a combination of therapeutic modalities including heparin at various stages of the disease needed to blunt the pathophysiologic changes described in this paper. Thromboelastography is mentioned in this paper as a possible way to measure the sum total of these effects using a global test. I’m a strong proponent of this method, having worked with it for many years, but it is not quite ready for clinical application except in prospective studies correlating the results with known hemostatic tests. Reminding us that evidence-based data is not available for full anticoagulation isn’t very helpful, especially since there are a number of reports showing a variety of beneficial effects with these treatment doses.

      May 16, 2020

      • A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection
        May 13. Phelan. JAMA Cardiology.
        Opinion from SAB Member: Dr. Barry Perlman
        Expert consensus opinion from members of the American College of Cardiology’s Sports & Exercise Cardiology Council, with input from national leaders in sports cardiology, regarding when those recovered from COVID-19 can return to recreational or competitive sports. Acute cardiac injury, based on elevated troponin, EKG changes, or ECHO abnormalities, occur in up to 22% of hospitalized COVID-19 patients. After myocarditis, return to play should require “normalization of ventricular function, absence of biomarker evidence of inflammation, and absence of inducible arrhythmias.” ECHO, stress testing, and rhythm monitoring are used to determine risk stratification after 3-6 months of exercise restriction. An algorithm is provided based on COVID-19 testing and symptoms: 1) Asymptomatic COVID-19 positive athletes or those who have detected antibodies indicating prior infection can slowly resume activity after 2 weeks; 2) If mild or moderate symptoms, a minimum of 2 weeks cessation of exercise training after symptoms resolve is recommended, and if cardiovascular evaluation including cardiac biomarkers and imaging reveal evidence of cardiac involvement, myocarditis return-to-play guidelines should be followed; 3) For those who were hospitalized or had more severe COVID-19, myocarditis return-to-play guidelines should be followed, and if cardiac biomarkers and imaging are normal after cardiac reevaluation graded, resumption of exercise can start at a minimum of 2 weeks after symptom resolution.
      • AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19
        May 1. Sultan. Gastroenterology.
        Opinion from SAB Member: Dr. David M. Clement
        This is an excellent paper from the American Gastroenterological Association for frontline workers wanting to understand and care for patients with GI disease during the COVID-19 pandemic. It starts with a detailed meta-analysis (47 studies with 10,890 patients) of GI symptoms and abnormal LFTs in patients with COVID-19. Overall, 10% of COVID-19 patients had GI symptoms and 15% had elevations of AST and/or ALT. Both GI symptoms and elevated LFTs were more common outside China. Occasionally, GI symptoms presented before other COVID-19 symptoms. Though fecal RT-PCR testing is commonly positive, culture of SARS-CoV-2 is rarely successful. Numerous tables are included, such as the GI side effects of commonly used COVID-19 drugs. Based on all pooled information, guidelines are presented for frontline providers dealing with GI symptoms in the COVID-19 era. These include, among others, checking for other etiologies of GI symptoms in outpatients, following LFTs on COVID-19 inpatients, not testing stool, and following outpatients with GI symptoms alone in case they develop COVID-19.
      • Anaesthesia and intensive care in obstetrics during the COVID-19 pandemic. May 6. Morau. Anaesth Crit Care Pain Med.
        This is a complete recommendation list to all personnel, how to prepare for COVID-19 environments at labor and delivery (L&D) room. The author points out that L&D cannot afford to hold back and has to continue to perform the duty irrespective of the pandemic which is of high transmissibility and infectivity of this virus. The authors have provided management skills required for this disease in detail regarding all system involvements and their complications that pertain to parturient. The authors review the antenatal, post and intra natal care, role of triage, role of testing for COVID-19, anesthetic care, pain treatment, staff training…and stresses the need for PPE but be prepared for telemedicine where it’s possible, infection control, and a need to be vigilant of known complications to mother/fetus and offers practical points. A helpful guide to all L&D staff.
      • Development and Validation of a Clinical Risk Score to Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19. May 12. Liang. JAMA Intern Med.
        Developed a prediction model for composite end point of ICU admit, need for a ventilator, and death based on ten variables: cxray abnormality, age, hemoptysis, dyspnea, unconsciousness, # of comorbidities, cancer hx, neutrophil/lymphocyte ratio, LDH, and direct bilirubin.
      • Gastrointestinal and Liver Manifestations of COVID-19. Mar 1. Agarwal. J Clin Exp Hepatol.
        A brief literature review of GI symptoms and elevated LFTs in COVID-19 patients. Mostly data from China, somewhat dated.

      May 15, 2020

      May 14, 2020

      • Liver injury is associated with severe Coronavirus disease 2019 (COVID-19) infection: a systematic review and meta-analysis of retrospective studies. May 10. Parohan. Hepatol Res.
        From 212 articles from around the world (English & non-English literature), 20 articles were selected from various sources by Iranian investigators, 3,428 patients were entered in meta-analysis with complete records. They followed by a systematic review and meta-analysis, analyzing the laboratory findings and trying to ascertain the mechanism of liver injury caused by COVID-19 infection. Here is an excellent effort for the collection, analyzing and applying of appropriate statistics for the data by the authors. They noted that a mild to moderate derangement of liver profile (AST, ALT, total Bilirubin and Albumin levels) was associated with severe outcome from COVID-19 infection. But offer a limited inference of mode of injury except to point out a derangement of endothelial ACE2 cells in liver and or in biliary tree, perhaps toxicity of anti-viral drugs and inflammatory cytokine production abnormality or maybe part of MOF.
      • RAAs inhibitors and outcome in patients with SARS-CoV-2 pneumonia. A case series study. May 9. Conversano. Hypertension.
        Retrospective, observational study of 191 confirmed COVID-19 patients from one Italian hospital. 50% had HTN, and 70% of those were on ACEI or ARBs. 28 patients were still hospitalized at the end of the study. Age, HF, and CKD were univariate predictors of mortality, but HTN and ACEI/ARB treatment were not.

      May 13, 2020

      • Characteristics and clinical significance of myocardial injury in patients with severe coronavirus disease 2019. May 12. Shi. Eur Heart J.
        No real news here, but large number of cases and associated data illustrate that cardiac involvement is an important predictor of death with COVID-19. All consecutive patients admitted to Renmin Hospital of Wuhan University between 1/1/20 and 2/23/20 with laboratory-confirmed COVID-19 were included in this retrospective study. Data from 671/1001 unique severe cases with adequate information was analyzed. Study period ended on a given date, not with definitive outcome. A great deal of data is presented, not only regarding myocardial injury. 62(9.2%) died of whom 75.8% had elevated initial cardiac troponin (cTnl), vs 9.7% of survivors. Among many other factors, (none surprising), elevated cTnI, CK-MB and NT-ProBNP levels were predictors of risk for in-hospital death, along with age, CV morbidities and inflammatory response. cTnI > 0.026 ng/mL was associated with a hazard ratio of 4.56.
      • Characteristics and outcomes of patients hospitalized for COVID-19 and cardiac disease in Northern Italy. May 9. Inciardi. Eur Heart J.
        A retrospective case review of 92 consecutive COVID-19 patients admitted to a single center in Italy. Those with pre-existing heart disease (AF, CHF, CAD) had higher rates of thrombo-embolic and pulmonary complications, and higher death rates.
      • Clinical and histological characterization of vesicular COVID-19 rashes: A prospective study in a tertiary care hospital
        May 8. Fernandez‐Nieto. Clinical and Experimental Dermatology.
        Opinion from SAB Member: Dr. Barry Perlman
        There are now many reports of COVID-19 patients presenting with or having associated cutaneous lesions. This is a prospective observational study of vesicular lesions in 24 COVID-19 patients in Spain. 29% had prior history of dermatologic conditions. 75% had a disseminated pattern with the rest having a more localized one. Median rash duration was 10 days. Rashes developed a median 14 days after COVID-19 diagnosis, prior to COVID-19 treatment in 71%. Skin biopsy in 2 patients showed histology consistent with viral infection. PCR tests performed on vesicular fluid in 4 patients were negative in 4/4 for SARS-CoV-2 and herpes virus.
      • Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a US cohort study. 5/12/20. Pierce-Williams RAM. Am J Obstet Gynecol MFM.
        Review by the SAB
        By Dr. Jay Pryzbylo, on behalf of the SAB
        Data-rich, multicenter study of COVID-19 severe and critically ill women in third trimester pregnancy. Of the many findings, critically ill women required intubation, delivered prematurely mostly for maternal risk, the newborns were COVID-19 negative, 1 of 64 women required a tracheostomy. Matched to a non-pregnant control group, pregnancy did not alter outcome.
      • Coronavirus Disease-2019 with Dermatologic Manifestations and Implications: An Unfolding Conundrum. May 9. Almutairi. Dermatol Ther.
        4 categories of dermatological effects of COVID-19 are discussed:
        1. Cutaneous manifestations. Include urticaria, varicella-like vesicles, transient livedoid eruptions, livedoid vasculopathy, purpuric eruptions, lichenoid photodermatitis, erythroderma, photo-contact dermatitis, and generalized pustular figurate erythema
        2. Skin changes from lifestyle alterations, such as prolonged PPE contact and excessive personal hygiene
        3. Medication adverse cutaneous effects. For example, chloroquine and hydroxychloroquine can aggravate pre-exisitng psoriases or cause potentially severe cutaneous reactions
        4. Effect on primary skin diseases and their treatment. Guidelines recommend continuing immune-modulating treatments despite COVID-19
      • Cutaneous manifestations of the Coronavirus Disease 2019 (COVID-19): a brief review. May 7. Tang. Dermatol Ther.
        Review of 14 PubMed articles on cutaneous manifestations of COVID-19 in 88 patients. Skin lesions were typically erythematous, urticarial, or vesicular. 1 patient had no other symptoms.
      • Cutaneous Signs in COVID-19 Patients: A Review
        May 10. Wollina. Dermatologic Therapy.
        Opinion from SAB Member: Dr. Barry Perlman
        Detailed review describing reported cutaneous symptoms of COVID-19. ACE2 receptors are found in skin and adipose tissue. SARS-CoV-2 associated pulmonary and cutaneous fibrosis both involve transdifferentiation of adipocytes or lipo-fibroblasts into myofibroblasts. Adipocytes can act as a viral reservoir. The different cutaneous manifestations are described, along with differential diagnosis and associated COVID-19 presentation. Chilblain-like acral eruptions, purpuric and erythema multiforme-like lesions have been seen in children and young adult patients with asymptomatic or mild COVID-19. Acro-ischemic lesion and maculopapular rash are often seen in adult patients with more severe disease. Urticaria with pyrexia can be an early symptom of SARS-CoV-2 infection. Attention to cutaneous signs may aid in diagnosis, triage, and risk stratification of COVID-19 patients.

      May 12, 2020

      • In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China
        Apr 2. Shao. Resuscitation.
        Opinion from SAB Member: Dr. David M. Clement
        This study documents the poor outcomes for in-hospital cardiac arrest (IHCA) in severe COVID-19 patients. It is a retrospective, observational study from China, of 136 patients with IHCA. Most were monitored, had witnessed arrests, and received CPR in under a minute. Most IHCA had respiratory causes, 94% had asystole or PEA, and only 6% had shockable rhythms. Return of spontaneous circulation was achieved in 13%, with 3% surviving at least 30 days and only one patient surviving with an acceptable neurologic outcome at 30 days.
      • Misinformation During the Coronavirus Disease 2019 Outbreak: How Knowledge Emerges From Noise
        Apr 1, 2020. Rochwerg. Critical Care Explorations.
        Opinion from SAB Member: Dr. Lydia Cassorla
        This well articulated narrative review by authors from Canada, New Zealand, and the US outlines the challenges and opportunities for both the media and researchers to develop knowledge in the face of an information storm. Much of the media is driven by corporate interests rather than a desire to meticulously vet sources and research quality, fanning hysteria. There are important benefits to the “live update” culture, however, consumers are advised to carefully consider the reliability of their sources in both lay press and medical publications. During a pandemic, conventional research and publishing practice are out of synch with the need for rapid information and dissemination, as they require months to years. Major publications have prioritized and made accessible COVID-19 related work to help overcome barriers to rapid, peer-reviewed work and combat misinformation. Nonetheless, some reports remain questionable. The concept of “living guidelines”, frequently updated as evidence emerges, is discussed. The authors highlight the benefit of advance planning to accelerate clinical trials, governmental support, targeted funding and collaboration with industry to optimize the reliability of research output when pandemics occur.
      • Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. Dec. 18, 2003. Smith. BMJ.
        Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. The study highlights a. The importance of the conclusion when writing and reading a manuscript and b. Randomization might not always be possible: in designing studies, investigators must always consider equipoise.
      • Seven alternatives to evidence based medicine. Dec. 19, 1999. Isaacs. BMJ.
        A short, easy to read, tongue in cheek (maybe) analysis of decision making styles when there is inadequate evidence on which to base a clinical decision. Cheer up! We have all been there in the past, and frequently find ourselves in this situation with COVID-19.

      May 11, 2020

      • Respiratory advice for the non-respiratory physician in the time of COVID-19
        May 4. Bennett. Clinical Medicine Journal.
        Opinion from SAB Member: Dr. David M. Clement
        A pre-print review from the British Thoracic Society mostly describing one approach to the pre-ICU respiratory care of hospitalized COVID-19 patients. The emphasis is on coordinated assessments, cooperation between personnel, and the systematic alteration of respiratory treatments as patient parameters hit certain thresholds. Healthcare worker safety and efficiency, do-not-intubate preferences (“ceilings of care”), proning before intubation, oxygen therapy (esp. CPAP) and triggers for transfer to the ICU are reviewed. Several tables and diagrams help explain this strategy.
      • Should COVID-19 take advice from rheumatologists?
        May 7. Kernan. Lancet Rheumatology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        Anakinra is a drug that has had success treating patients with auto-inflammatory diseases and now, there is evidence that the drug may also be useful in managing patients with COVID-19 disease who also have acute respiratory distress syndrome. The authors summarized the results seen in the study “Interleukin-1 blockade with high-dose anakinra in patients with COVID-19, acute respiratory distress syndrome, and hyperinflammation: a retrospective cohort study” (below). As the authors note: “these and other emerging data rightly focus more attention on the host inflammatory response and might herald a shift in how we approach the host-virus relationship.”
      • Interleukin-1 blockade with high-dose anakinra in patients with COVID-19, acute respiratory distress syndrome, and hyperinflammation: a retrospective cohort study
        May 7. Cavalli. Lancet Rheumatology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        The authors first noted that of 16 patients treated between March 10 and March 17, 2020 with COVID-19, ARDS, and hyper-inflammation who were managed with CPAP outside of the ICU, that 21-day survival was 56%. Another similar group of patients receive low dose anakinra (100 mg twice a day) and did not do much better. But when instead high-dose intravenous anakinra (5 mg/kg twice daily) was used, survival increased to 90% at 21 days.
      • Targeting the inflammatory cascade with anakinra in moderate to severe COVID-19 pneumonia: case series. May 6. Aouba. Ann Rheum Dis.
        When some people are fighting a COVID-19 infection, it may not be the virus itself that’s causing distress, but the exaggerated host response in the form of a cytokine storm the body uses to fight off the infection. In this letter to the editor, the authors used anakinra, an anti-IL-1 blocking drug, in this study administered subcutaneously for 9 consecutive patients with SARS-CoV-2 infection confirmed by reverse transcription-PCR on nasopharyngeal swabs hospitalized in a non-ICU, with oxygen flow of ≤6L/min, and C reactive-protein levels ≥50mg/L. One patient developed acute respiratory failure 6 hours after the first and only dose of anakinra, leading to premature treatment cessation and ICU admission. The other 8 patients had good outcomes and C reactive protein (CRP) levels decreased steadily but only partially by 6 days in all, and normalized in 5/8 patients by day 11. In addition, at last followup, all patients were alive. The study was not randomized, but the results are promising.

      May 9, 2020

      • Lupus Anticoagulant and Abnormal Coagulation Tests in Patients with Covid-19
        May 5. Bowles. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. Philip Lumb
        Authors note that while a prolonged aPTT may indicate caution in prescribing anticoagulants, they report a coagulation screening series of 216 patients positive for COVID-19 of which 44 (20%) had a prolonged aPTT. Lupus anticoagulant assays were performed in 34 patients and 31 (91%) tested positive. Authors suggest that a persistent presence of Lupus anticoagulant can be associated with a “thrombotic tendency within the antiphospholipid syndrome” and that a prolonged aPTT in the presence of COVID-19 should not “withhold use of anticoagulants for thrombosis while awaiting further investigation of a prolonged aPTT, nor withhold thrombolytic therapy in the face of high risk PE on the basis of a prolonged aPTT alone.”

      May 8, 2020

      • Autoimmune hemolytic anemia associated with Covid-19 infection. May 7. Lazarian. Br J Haematol.
        Opinion from SAB Members: Drs. Philip Lumb and Joseph Anthony Caprini
        PL: Series of 7 Covid-19 positive patients from six different French and Belgian hospitals who developed autoimmune hemolytic anemia during admission. Patient demographics presented with associated co-morbidities; timeframe consistent with development of cytokine storm. Authors recommend screening for presence of a lymphoid clone in patients with Covid-19 infections and autoimmune cytopenias.
        JAC: The abstract states it well and I include it here- “Although the pathophysiology underlying severe Covid‐19 remains poorly understood, accumulating evidence argue for hyperinflammatory syndrome causing fulminant and fatal cytokines release associated with disease severity and poor outcome (Mehta et al, 2020).
        However, the spectrum of complications is broader and include among others various autoimmune disorders such as autoimmune thrombocytopenia, Guillain-Barré and antiphospholipid syndrome (Zhang et al, 2020; Zulfiqar et al, 2020; Toscano et al, 2020). In this report we describe 7 patients from 6 French and Belgian Hospitals who developed a first episode of autoimmune hemolytic anemia (AIHA) during a Covid-19 infection.”
      • Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study
        May 6. Wichmann. Annals of Internal Medicine.
        Opinion from SAB Member: Dr. Lydia Cassorla, Dr. Joseph Anthony Caprini
        LC: This fascinating report from Hamburg Germany describes the findings of complete autopsy reports, as mandated by law, of the first 12 consecutive known COVID-19 deaths in their city. “In all cases the cause of death was in the lungs or the pulmonary vascular system”. Unsurprisingly, patients were older (10/12 >60 yrs) and all had pre-existing co-morbidities and pneumonia at death. They trended obese with BMI of >30 in 5 and nearly 30 in a sixth. The focus of the report is on the high incidence (7/12 or 58%) of venous thrombosis with 4/12 dying of PE. D-dimer was measured in 5 patients on admission, all elevated. 3/5 of those with elevated D-dimer had venous thrombosis including 2 PE deaths. 3 patients had some form of anticoagulation therapy, including 2 PE deaths. There is a trove of additional information in this report as each death resulted in a full autopsy, a post mortem total body CT in all but 2, histopathology and virology. SARS–CoV-2 RNA was present in high titers in the lungs in all, and in the blood in 6/10. The authors suggest that their findings support proactive anticoagulant therapy for hospitalized patients as well as potentially for outpatients. JC: In this autopsy study of 12 consecutive patients who died of COVID-19, we found a high incidence of deep venous thrombosis (58%). One third of the patients had a pulmonary embolism as the direct cause of death. Furthermore, diffuse alveolar damage was demonstrated by histology in 8 patients (67%). The CT images of the ground glass appearance in the lungs is chilling. They indicate the need for more than heparin and some have raised the possibility of steroids. The association between fatal outcomes and pre-existing risk factors, particularly CV disease is also striking.

      May 7, 2020

      • ACE2, COVID-19, and ACE Inhibitor and ARB Use during the Pandemic: The Pediatric Perspective. May 6. South AM. Hypertension.
        A thorough description of the effect of COVID-19 on renin-angiotensin including perspective particular to pediatrics including small percentage of affected patients. The significance is that pediatrics is the focus with the conclusion: At this time, there is no evidence that children with hypertension, cardiovascular disease, or chronic kidney disease, and/or those who are taking ACE inhibitors or ARBs, are at increased risk of SARS-CoV-2 infection or more-severe COVID-19.
      • Coronavirus disease 2019 (COVID-19) and the renin-angiotensin system: a closer look at angiotensin-converting enzyme 2 (ACE2)
        May 5. Zemlin. Annals of Clinical Biochemistry: International Journal of Laboratory Medicine.
        Opinion from SAB Member: Dr. Barry Perlman
        In depth review of SARS-CoV-2, COVID-19, the renin-angiotensin system, the relationship between ACE2 and COVID-19, use of ACE-I and ARB with COVID-19, and possible RAS related targets for COVID-19 treatment.
      • Early recovery following new onset anosmia during the COVID-19 pandemic – an observational cohort study. May 6. Hopkins C. J Otolaryngol Head Neck Surg.
        Post-viral loss of sense of smell accounts for up to 40% of anosmia cases. Nasal respiratory and epithelial cells and olfactory epithelial cells have high levels of ACE2. Survey of 382 patients with presumed COVID-19 — only 15 had been tested and of those 80% were positive. 86% had complete anosmia and 12% had severe anosmia. For 17% this was their only symptom. 80% reported improvement in 1 week. Recovery plateaued after 3 weeks. Limitation of study was low rate of confirmatory COVID-19 testing.
      • High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study
        May 4. Helms. Intensive Care Medicine.
        Opinion from SAB Member: Dr. Louis McNabb, Dr. Joseph Anthony Caprini
        LM: Study of 150 patients in an ICU setting. The main clinical threat was PE at 16%. There was a high incidence of catheter clotting, particularly for patients on dialysis (28/29). Most of patients were on at least prophylactic anticoagulation. 67% of patients were still intubated at time of data analysis, which may have led to underestimation of thrombotic risk, Lupus anticoagulant was found in 50/57 patients. No DIC was noted, but this result may reflect early termination of the study. Curiously, non-COVID-19 patients with ARDS had higher D-dimer levels. JC: In a prospective cohort study, we have shown that sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients with COVID-19 ARDS during their ICU stay, mainly pulmonary embolisms (25 patients, 16.7%). Despite anticoagulation, a high number of patients with COVID-19 ARDS developed life-threatening thrombotic complications, meaning that higher anticoagulation targets than in usual critically ill patients should probably be considered.
      • Incidence of venous thromboembolism in hospitalized patients with COVID-19
        May 5. Middeldorp. Journal of Thrombosis and Haemostasis.
        Opinion from SAB Member: Dr. Louis McNabb
        This is an article describing 198 hospitalized patients of which 38% were in the ICU. 20% were diagnosed with VTE, of which 13% were symptomatic. Most patients were on prophylactic anticoagulation in the medical units. Patients in the ICU received BID prophylactic anticoagulation (double standard regimen). The key point to this paper is that clinicians need to be vigilant looking for VTE in patients with less severe COVID-19 disease.
      • Interim Guidance for Basic and Advanced Life Support in Children and Neonates With Suspected or Confirmed COVID-19. May 6. Topjian A. Pediatrics.
        A prepublication Scientific Statement from the American Association of Critical Care Nurses and including authorship of physicians across North America. A step by step guide to resuscitating children from time of birth on with special attention to COVID-19.
      • Olfactory Dysfunction: A Highly Prevalent Symptom of COVID-19 With Public Health Significance. May 6. Sedaghat AR. Otolaryngol Head Neck Surg.
        In this state of the art review, the scientific evidence that relates to olfactory dysfunction in the face of COVID-19 is reviewed. A high prevalence of olfactory dysfunction is noted in patients with COVID-19 using objective measures of olfactory testing. Also, the presence of olfactory dysfunction might also be useful to predict patients who might develop COVID-19. Most patients with olfactory dysfunction will note improvement after 1-2 weeks just as symptoms of COVID-19 improve.
      • The Prevalence of Olfactory and Gustatory Dysfunction in COVID-19 Patients: A Systematic Review and Meta-analysis. May 6. Tong JY. Otolaryngol Head Neck Surg.
        In this meta-analysis of 10 studies, all published in 2020, that included patients from studies in North America, Europe, and Asia, 1600 patients were analyzed. Over 50% of patients had some level of olfactory dysfunction and almost 50% had some level of gustatory dysfunction. For many patients also, olfactory dysfunction was a presenting symptom. Screening patients for olfactory dysfunction may be indicative of COVID-19 infection.
      • Understanding Observational Treatment Comparisons in the Setting of Coronavirus Disease 2019 (COVID-19)
        May 5. Thomas. JAMA Cardiology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this editorial, concerning patients with COVID-19, hypertension, diabetes, and cardiovascular disease may be vulnerable and are more likely to be taking angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). Based on the Mehta study (below), patients taking those drugs can continue taking the drugs given the current pandemic given the fact that these patients are not more likely to be susceptible to the disease, though based on a secondary analysis, the severity of disease might be greater in terms of need for hospitalization and ICU admission. Yet, it’s possible also that the presence of cardiovascular disease and other comorbidities lowers the threshold on the part of referring clinicians to hospitalize and move to the ICU those individuals considered to be at higher risk than the general population. These secondary findings, though real, should not be considered as causal.
        • Association of Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers With Testing Positive for Coronavirus Disease 2019 (COVID-19)
          May 5. Mehta. JAMA Cardiology.
          Opinion from SAB Member: Dr. J. Lance Lichtor
          As has been discussed in previous articles this newsletter has referenced, SARS-CoV-2 binds to the extracellular domain of the transmembrane angiotensin-converting enzyme 2 (ACE2) receptor to gain entry into host cells; patients who are taking angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers are theoretically at an increased risk for becoming infected with SARS-CoV-2 or may have worse outcomes; upregulation of angiotensin-converting enzyme 2 may improve outcomes in infection-induced acute lung injury in patients with SARS-CoV or SARS-CoV-2 infections; and in certain high-risk patients, the withdrawal of ACEIs or ARBs may be harmful. In this retrospective analysis of 18,472 patients tested for SARS-CoV-2, taking either an angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers was not associated with an increase in the likelihood of testing positive for SARS-CoV-2 infection.
      • Venous thromboembolism and heparin use in COVID-19 patients: juggling between pragmatic choices, suggestions of medical societies
        May 4. Profidia. Journal of Thrombosis and Thrombolysis.
        Opinion from SAB Member: Dr. Lydia Cassorla, Dr. Joseph Anthony Caprini
        LC: This editorial states that while most guidelines are currently recommending antithrombotic prophylaxis for all hospitalized COVID-19 patients, and full anticoagulation for a subset, questions remain about which population may benefit from therapeutic doses of anticoagulation. It is a call to share data via registries and arrive at a consensus at a time when randomized controlled clinical trials may not be able to answer the question in a timely manner. JC: This is a very good discussion from the data driven point of view including extrapolation of pre-existing data to the clinical presentation and course of patients with COVID-19. Unfortunately, it is a whole new ball game and we need to learn on the job.

      May 6, 2020

      • Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel
        May 3. Qureshi. International Journal of Stroke.
        Opinion from SAB Member: Dr. Barry Perlman
        Multinational expert consensus for management of acute ischemic stroke in COVID-19 patients. 5% incidence of acute ischemic stroke is noted in COVID-19 patients, and such events are associated with older age, hepatic and renal dysfunction, HTN, DM, cerebrovascular disease, and elevated D-dimers. Mortality rate of 38% dependent on severity of COVID-19 infection. Possible undiagnosed COVID-19 infection should be suspected in patients with acute stroke, as some may have difficulty communicating due to the stroke. Since renal insufficiency is common with COVID-19 infection, risk of contrast-induced nephropathy should be considered prior to neuroimaging. Coagulation assessment can help determine risk benefit of IV rt-PA. Mechanical thrombectomy with low threshold for intubation and general anesthesia may be considered on case-by-case basis. Single or dual antiplatelet therapy may be considered for patients who do not receive IV rt-PA or mechanical thrombectomy. Risk of healthcare provider infection and mitigation strategies are also discussed.
      • Medical treatment options for COVID-19. May 4. Delang. Eur Heart J Acute Cardiovasc Care.
        There is an urgent need for treatment for this COVID-19 pandemic from all quarters of the world. Several clinical trials with COVID-19 patients are evaluating “repurposed drugs”, but there is no uniformity in timing, duration of treatment and study endpoints. Currently, there are registered clinical trials pertaining to one or more clinical outcomes in 66% of the studies, virological in 23%, radiological in 8%, or immunological in 3%. Repurposing of existing antiviral and immunomodulating drugs is an important strategy, because the safety profile of these drugs is well known. In the solidarity (started in April worldwide), a clinical trial launched by the WHO, is appealing due to simplicity. On 7 March 2020, the most frequently evaluated antiviral therapies were lopinavir/ritonavir (LPV/r) (n=15), chloroquine (n= 11), arbidol (n= 9), hydroxychloroquine (n= 7), favipiravir (n=7) and remdesivir (n= 5). Immune modulating drugs: IL-6 inhibitors – receptor antagonist – Tocilizumab (Actemra) and Granulocyte-macrophage colony-stimulating factor. Both critical role immune response and/or macrophage activation syndrome (MAS).

      May 5, 2020

      • Acute myocardial injury is common in patients with Covid-19 and impairs their prognosis
        Apr 6. Wei. Heart.
        Opinion from SAB Member: Dr. Philip Lumb
        101 patient prospective study from January to March 10, 2020 in Sichuan, China with primary endpoints including cardiac injury defined by above normal high-sensitivity troponin T (hs-TnT) levels. Study confirms that myocardial involvement in COVID-19 is common and that elderly and patients with underlying cardiovascular disease at increased risk.
      • Cardiac considerations in patients with COVID-19
        May 1. Calvillo-Argüelles. CMAJ.
        Opinion from SAB Member: Dr. Louis McNabb
        Five key points on cardiac considerations for COVID-19 in a convenient one-page summary.
      • Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic
        Mar 17. Driggen. JACC.
        Opinion from SAB Member: Dr. Jay Przybylo
        An exhaustive State-of-the-Art Review with complete recommendations concerning every phase of COVID-19 cardiac involvement from presentation by phone through hospitalization and including all forms of cardiac pathology to healthcare worker precautions. Multiple tables with reviews from previous studies and 100+ references included.
      • Characteristics, treatment, outcomes and cause of death of invasively ventilated patients with COVID-19 ARDS in Milan, Italy. May 1. Zangrillo. Crit Care Resusc.
        Many with COVID-19 end up requiring critical care and then die. It might be useful to better predict who might die to better plan critical care resources. Of 73 invasively ventilated patients with COVID-19 ARDS in a referral centre in Milan, Italy male sex and hypertension were disproportionately common; one in 15 patients was treated with ECMO; and one in five with RRT. Most patients received vasopressors and neuromuscular blocking agents, three out of four patients were treated with prone positioning, and three in ten received a tracheostomy. After a medical followup of 20 days, about 15% died. This was a single center study, and though more granular data was provided, this was not really a guide concerning who should or should not receive intensive care.
      • Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-CoV-2, discharged from two hospitals in Wuhan, China. May 2. Wang. Crit Care.
        Retrospective study of 107 COVID-19 patients discharged from 2 hospitals in Wuhan, China.
        Week 1 after onset — fever, though dyspnea, lymphopenia, multi-lobar pulmonary infiltrates. In severe cases, thrombocytopenia, acute kidney injury acute myocardial injury and ARDS.
        Week 2. Fever, cough, systemic symptoms, and thrombocytopenia began to resolve with persistent lymphopenia in mild cases, while in severe cases leukocytosis, neutrophilia, and multi-organ dysfunction were seen.
        Week 3. Mild cases clinically resolved with persistent lymphopenia. Severe cases showed persistent lymphopenia, severe ARDS, refractory shock, anuria, coagulopathy, thrombocytopenia, and death.
        88 survived. Duration of active viral shedding in survivors was 13 days. Non-survivors were older, predominantly male, had more co-morbidites such as HTN or CV disease, and were more likely to present with with dyspnea, diarrhea. They had higher neutrrophil count, D-dimer, BUN, creatinine, HS-troponin I, CK, CK-MB, LDH, ALT, and AST and had lower platelets. Causes of death included refractory ARDS, septic shock, sudden cardiac arrest, hemorrhagic shock and AMI.
      • Coagulopathy associated with COVID-19
        May 4. Lee. CMAJ.
        Opinion from SAB Member: Dr. Louis McNabb
        5 key points in a concise one-page summary on where we are in our understanding of coagulopathy issues for COVID-19.
      • COVID-19 and acute myocardial injury: the heart of the matter or an innocent bystander?
        Apr 30. Cheng. Heart.
        Opinion from SAB Member: Dr. Philip Lumb
        Short but valuable review of myocardial involvement in COVID-19 with relevant literature reviews, and a useful table of potential mechanism and diagnostic limitations in myocardial injury. Recognizes the current therapeutic dilemmas facing clinicians in order to maximize myocardial preservation and/or recovery.
      • COVID-19 and Neonatal Respiratory Care: Current Evidence and Practical Approach. May 3. Shalish. Am J Perinatol.
        An international group of perinatologists reviewed reports of COVID-19 infections under 10 y/o noting the incidence is rare, less than 1% of all cases. In newborns the number is lower. Recommendations for care are listed.
      • Inhibitors of the Renin-Angiotensin-Aldosterone System and Covid-19
        May 1. Jarcho. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. David M. Clement
        Editorial reviewing the theoretical concerns for the use of ARB/ACEI drugs during the COVID-19 epidemic, and three observational clinical studies that conclude these drugs seem not to influence the course of the disease. This is consistent with other studies and guidelines from pertinent organizations; that ARB/ACEI drugs should be continued if a patient develops COVID-19 disease.
      • Olfactory and Gustatory Dysfunction in Coronavirus Disease 19 (COVID-19)
        May 1. Luers. Clinical Infectious Diseases.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        72 patients with polymerase chain reaction confirmed COVID-19 agreed to participate and were enrolled in this study. Reduced olfaction was noted in 74% and a reduced sense of taste was noted in 69%. 68% reported both symptoms. Both symptoms occurred on average on the 4th day after first symptoms were noted, though 13% noted reduced olfaction and taste on the first day of COVID-19 symptoms.
      • Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19. May 2. Reynolds. N Engl J Med.
        A retrospective, observational study from New York of 12,594 patients on various anti-hypertensive medications. Sophisticated statistical analysis showed no association of any class of drugs (including ARBs/ACEIs) and the presence or severity of COVID-19 disease.
      • The Renin-Angiotensin-Aldosterone System in Coronavirus Infection-Current Considerations During the Pandemic. May 4. Augoustides. J Cardiothorac Vasc Anesth.
        An editorial reviewing what is known, being studied, and speculated about the RAAS system’s contributions to the clinical spectrum of COVID-19 disease.

      May 2, 2020

      • Cardiovascular Consequences and Considerations of Coronavirus Infection – Perspectives for the Cardiothoracic Anesthesiologist and Intensivist During the Coronavirus Crisis
        May 1. Augoustides. Journal of Cardiothoracic and Vascular Anesthesia.
        Opinion from C19SAB: Dr. Barry Perlman
        Editorial discussing causes of cardiovascular collapse in patients with severe COVID-19, focusing on Cardiogenic shock, vasoplegic shock, acute coronary ischemia, and right ventricular failure.
      • COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options
        Apr 30. Guzik. Cardiovascular Research.
        Opinion from C19SAB: Dr. Philip Lumb, Dr. Lydia Cassorla
        PL: Detailed, research-oriented discussion on cardiovascular implications of COVID-19 infection. Mechanisms of infection described with experimental justification for potential interventions; recognizes supportive care required for most cases. Discusses (albeit briefly) progression to invasive therapies including ECMO. Basic science oriented with clearly described mechanisms and exhaustive review of available literature with references to match. LC: This comprehensive review of COVID-19 illness with a particular eye toward cardiovascular ramifications may raise more questions than it answers. However, it is well written and thoroughly referenced to be consumed when time permits careful reading. Regarding CV complications: “The most common cardiac complications include arrhythmia (AF, ventricular tachyarrhythmia, and ventricular fibrillation), cardiac injury (elevated hs-cTnI and CK), fulminant myocarditis, and heart failure.” The authors point out that since cardiac manifestations often occur >15 d after onset of symptoms, they are possibly a result of host-driven phenotypes and/or secondary effects of medications. They mention that inclusion bias may result from specific factors in the area where a pandemic begins and expect data to differ as the disease population changes. Surprisingly, a history of smoking or chronic lung disease is less of a risk for poor outcomes than with SARS-CoV (2003) or MERS. HTN/CV disease are risk factors for advanced disease and death but not for infection and may partly be a proxy for age. When acute myocardial injury occurs, PCI may not always benefit patients as their ischemia may be due to Type 2 MI or myocarditis.
      • Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy
        Apr 23. Lodigiania. Thrombosis Research.
        Opinion from SAB Member: Dr. J. Lance Lichtor, Dr. Joseph Anthony Caprini
        JLL: Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. The study is based on retrospective data for 388 admitted hospitalized patients with COVID-19. All ICU patients received thromboprophylaxis and 75% of those admitted to general wards also had thromboprophylaxis. Thromboembolic events occurred in almost 8% of patients which included pulmonary embolism. A little over half of the patients with PE did not receive anticoagulant treatment. Hospital mortality was associated with a high rate of thromboembolic complications. Rapidly increasing D-dimer levels were observed in non-survivors. A true incidence is difficult to determine since, as the reader is told in the discussion, a low number of specific imaging tests were performed. JC: The low incidence of thrombotic events on the ward compared to the ICU is one feature of this series. The fact that 58% of thrombotic events were not on anticoagulation is telling. We know all patients should be on anticoagulation. That has not been their routine practice in the past in many medical patients not in ICU. The paper sends the wrong message advocating for more tests which exposes scanners and machines to risks that may be avoided. Giving everyone anticoagulation and adjusting the dose based on co-morbidities and when the D-dimers skyrocket using full dose anticoagulation. We are learning as we go along but more heparin or LMWH is the developing trend.

      May 1, 2020

      • Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases
        Apr 29. Casas. British Journal of Dermatology.
        Opinion from C19SAB: Dr. Barry Perlman
        Description of 5 clinical patterns of cutaneous lesions associated with 375 COVID-19 cases in Spain, in order of associated severity of disease: 1. Acral areas of erythema with vesicles or pustules (Pseuo-chilblain). Appears late, more common in younger patients; 2. Other Vesicular eruptions. More common in middle aged patients; 3. Urticarial lesions; 4. Maculopapular eruptions. Most common; 5. Livedo or Necrosis. Consistent with occlusive vascular disease.
      • Factors associated with mortality in patients with COVID-19. A quantitative evidence synthesis of clinical and laboratory data. Apr 20. Martins-Filho. Eur J Intern Med.
        For this meta-analysis a literature search performed January 1- April 06, 2020 led to screening 8692 titles and abstracts among which 73 full-text articles were assessed for eligibility and 69 were excluded, 11 due to potential overlapping data. Data in the report is from only four retrospective Chinese studies encompassing 852 unique patients (489 male and 363 female) with confirmed SARS-CoV-2 infection by RT-PCR: 603 survivors and 249 non-survivors. The study reports increased risk for in-hospital death in older patients (MD= 13.8, 95%CI 8.0 to 19.7), male gender (RR= 1.3, 95%CI 1.1 to 1.4), with comorbidities (RR= 1.6, 95%CI 1.4 to 2.0) and dyspnea (RR= 1.8, 95%CI 1.4 to 2.2). The report details the relative risk for death of dozens of clinical and laboratory findings. There are no surprises.
      • Hypercoagulation and Antithrombotic Treatment in Coronavirus 2019: A New Challenge. Apr 30. Violi. Thromb Haemost.
        The authors analyzed variables regarding clotting and fibrinolysis along with platelet count in COVID-19 patients, according to disease severity and survival. Tables and algorithms are clearly presented.  The conclusion of this report is to treat those with pneumonia that is severe or associated with elevated D-dimer levels but not those with mild disease without additional risk factors for thrombosis. In contrast, opinion in the US appears to be swinging toward prophylaxis in most if not all hospitalized COVID-19 patients.
      • Persistent hiccups as an atypical presenting complaint of COVID-19. Apr 30. Prince. Am J Emerg Med.
        A case report of a patient who presented with hiccups, for which a CT was obtained. This was abnormal and SARS-CoV-2 testing was positive. Hiccups resolved on hydroxychloroquine.
      • Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia
        Apr 30. Pei. Journal of the American Society of Nephrology.
        Opinion from C19SAB: Dr. Barry Perlman
        Retrospective study of EMR data from 333 COVID-19 patients hospitalized with pneumonia in China. Patients with CKD or on dialysis were excluded. 75% had hematuria, proteinuria, or acute kidney injury. 82% had suspected intrinsic AKI. Severity of pneumonia was an independent risk factor for AKI. 46% with AKI had complete recovery of kidney function within 3 weeks of illness onset. Renal involvement correlated with a 9X increased rate of mortality. No deaths occurred in patients with pre-renal AKI, or in whom hematuria or proteinuria resolved.

      April 30, 2020

      • Clinical phenotypes of SARS-CoV-2: Implications for clinicians and researchers
        Apr 11. Rello. European Respiratory Journal.
        Opinion from C19SAB: Dr. Barry Perlman
        Discussion of COVID-19 clinical experience in Italy and Spain. Lymphocytopenia, low procalcitonin, and elevated LDH and CRP are characteristic. Hypercoagulability is common, with increased risk of thrombotic and embolic events. Severe cases have elevated D-Dimer and INR, and low fibrinogen and platelet count. Use of prophylactic unfractionated heparin is suggested for all hospitalized COVID-19 patients. 5 phenotypes of COVID-19 infection are described to guide individualized therapy (Table 2): 1. Most common is benign, with fever, headache, mild respiratory symptoms, malaise. Normal CXR and no hypoxemia; 2. 80% of hospitalized patients. Hypoxemia or small CXR opacities. Should be monitored closely due to risk of rapid deterioration. Typically hypovolemia and hyper-inflamed. Good candidates for clinical trials of anti-virals, anti-inflammatories, or anti-fibrotics; 3. 15% of China hospitalizations. Greater hypoxemia and high respiratory rates. High IL6. Also candidates for clinical trials. Prone position may help avoid intubation. Consider intubation if respiratory alkalosis with increasing hyperventilation on high O2; 4. Severe hypoxemia requiring intubation. Pulmonary hypoxic vasoconstriction with normal lung compliance. Probably due to pulmonary microvascular thrombosis. Advise no delay in intubation, especially when BB coalescent lines are present in more than 3 fields. Nitric oxide or prostacyclin may be helpful. PEEP typically should be 8-10 cm H2O with tidal volumes 6-9 mL/kg. Avoid recruitment maneuvers, prone positioning; 5. Less common. Advanced disease with acute lung injury or co-infection causing high procalcitonin. More common when intubation is delayed by non-invasive ventilation treatment. Low lung compliance < 40 mL/cm H2O. Suggest ARDS strategy with high PEEP and prone positioning.
      • Fatal Invasive Aspergillosis and Coronavirus Disease in an Immunocompetent Patient. Apr 29. Blaize. Emerg Infect Dis.
        The gold standard to prove invasive disease is to show fungal invasion in tissue samples. Although at least 4 out of 6 reported patients died, there was no corroboration with autopsy findings. Also the “immunocompetent patient” had asymptomatic and untreated myelodysplastic syndrome.
      • Objective evaluation of anosmia and ageusia in COVID-19 patients: a single-center experience on 72 cases
        Apr 27. Vaira. Head & Neck.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        Among 72 COVID-19 patients, almost 75% had chemosensory dysfunctions during the course of their COVID-19 disease, with taste disorders in 12%, 14% with olfactory dysfunction, and 41% with combined dysfunction. 66% had recovery of chemosensitive dysfunction, with recovery in <5 days in 19 patients. Using an objective test, 80% of these patients still revealed a certain degree of residual hypoosmia or hypogeusia after resolution of their illness.
      • Updates on What ACS Reported: Emerging Evidences of COVID-19 with Nervous System Involvement. Apr 29. Baig. ACS Chem Neurosci.
        Author claims that there is a CNS connection with COVID-19. Anosmia, dysgeusia, ataxia, and altered mental status could be early signs of the neurotropic potential of this virus. There are reported cases of acute necrotizing hemorrhagic encephalopathy (was reported in a female with a 3 day history of cough, fever, and altered mental status who was COVID-19 positive), Acute G, B & Encephalitis. This is a view point.

      April 29, 2020

      April 28, 2020

      • Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: A meta-analysis. Apr 26. Santoso. Am J Emerg Med.
        A retrospective, cardiac injury causes death. Conclusion unable to link the deaths to cytokine storm or myocarditis, but able to state all who died had elevated troponin.
      • Incidence of thrombotic complications in critically ill ICU patients with COVID-19
        Apr 13. Kloka. Thrombosis Research.
        Opinion from C19SAB: Dr. Anil Hingorani, Dr. Lydia Cassorla
        AH: This paper presents real world data on thromboembolism with COVID-19 patients in the ICU. It gives the clinician realistic expectations of the incidence of thromboembolism in these critically ill patients and explores prophylaxis strategies.
        LC: The incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital was observed for 4 weeks. (March 7-April 5, 2020). Among 184 ICU patients with proven COVID-19 pneumonia, 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still in the ICU at the conclusion of the observation period. All patients received at least standard doses of thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CT pulmonary angiography and/or ultrasonography confirmed venous thrombosis in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio 1.05/per year) and coagulopathy were independent predictors of thrombotic complications. None developed DIC. The findings were all the more striking given that ¾ of the study patients were still in ICU at the end of the observation period. The authors recommend low molecular weight heparin prophylaxis in higher dose ranges in all ICU patients, vigilance, and a low bar for diagnostic tests to confirm thrombosis but not full therapeutic anticoagulation for all ICU patients with COVID-19 illness “even in the absence of randomized evidence”. There have been many other reports regarding the high incidence of thrombotic complications in COVID-19 patients. The question of when to use prophylactic or therapeutic anticoagulation in severely ill patients that will likely be further clarified as data and studies emerge.
        • UPDATE: Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis
          May 9. Klok. Thrombosis Research.
          Opinion from SAB Member: Dr. Louis McNabb, Dr. Anil Hingorani
          LM: This article reported on 184 COVID-19 patients in the ICU. The initial evaluation demonstrated a thrombotic rate of 31%. Follow up 17 days later showed a thrombotic rate of 49%. The PE rate was 65/184, and most patients were on prophylactic anticoagulation. Given the high risk of VTE in COVID-19 patients, we need immediate trials on regimens of anticoagulation to reduce thrombotic complications.
          AH: A review of 184 ICU COVID-19 patients in the Netherlands. The patients had a high incidence of VTE despite prophylaxis and 3% had arterial thrombosis. Patients with thrombotic complications had five-fold increased risk of all-cause death.
      • Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes. Apr 27. Doyen. Lancet.
        Case report of COVID-19 related myocarditis. 69 yr old with history of HTN on b-blocker admitted in Nice with COVID-19 ARDS. EKG showed LVH and diffuse inverted T waves. HSTI was 9000 nl/L. ECHO showed LVH with normal wall motion and EF. Initially started on antiplatelet therapy but coronary angiography was negative. MRI was consistent with apical and inferolateral myocarditis. Negative workup for other causes of myocarditis. He was treated with hydrocortisone for 9 days and discharged from ICU after 3 weeks. Suggestion for measuring troponin and ruling out myocardial infarction if myocarditis is suspected in COVID-19 patients.
      • No SARS-CoV-2 detected in amniotic fluid in mid-pregnancy. Apr 26. Yu. Lancet Infect Dis.
        In this letter to the editor, 2 pregnant women developed COVID-19 infection early during their pregnancy and in the second trimester, the two women were both positive for SARS-CoV-2 total antibodies in their serum and negative for SARS-CoV-2 RNA in throat swabs. RT-PCR tests of the patients’ amniotic fluid collected during their second trimester were negative, and tests for SARS-CoV-2 IgM and IgG in amniotic fluid were also negative. As the authors admit, the virus might not have been detectable due to gestation age, ideally performed after 18–21 weeks’ gestation, based on Zika virus data. The sample size was also very small.
      • Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vertical Transmission in Neonates Born to Mothers With Coronavirus Disease 2019 (COVID-19) Pneumonia. Apr 26. Hu. Obstet Gynecol.
        In this research letter, the authors describe 7 pregnant women diagnosed with COVID-19, who were otherwise healthy during pregnancy and who after pregnancy recovered from COVID-19. 6/7 mothers underwent C-section and for one, the baby was delivered vaginally before the C-section could be performed. 1/7 infants was positive for COVID-19, but that infant as well as the other children subsequently were without symptoms of the disease. What’s not clear is if the mothers were chosen sequentially, if there were inclusion and exclusion criteria, when the mothers acquired COVID-19 and when they recovered.

      April 25, 2020

      April 24, 2020

      • Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2
        Pediatric Infectious Diseases Society. Apr 22, 2020.
        Kathleen Chiotos; Molly Hayes; David W Kimberlin; Sarah B Jones; et al
        Opinion from SAB Member: Dr. Barry Perlman
        Recommendations from a multidisciplinary panel of infectious disease physicians and pharmacists from 18 North American institutions regarding the use of antiviral treatment for severe COVID-19 infection in children.
        The panel addressed the following questions:
        1. Are antiviral agents indicated in children with COVID-19?
        2. What criteria define the pediatric population in whom antiviral use may be considered?
        3. Does presence of any underlying medical condition or characteristic warrant different criteria for antiviral use based on increased risk of COVID-19-related morbidity or mortality?
        4. What agents are preferred if antiviral therapy is offered to children with COVID-19?
        The panel concluded that most pediatric COVID-19 patients have mild disease and just require supportive care. A small proportion develop severe illness requiring respiratory support. Most of these, and some children with critical illness, also only require supportive care. In the absence of available data, possible risk factors for severe COVID-19 in children were discussed–cardiovascular or pulmonary disease, diabetes, cancer, obesity, young age, immunocompromise. On a case by case basis, if antiviral medication is used, remdesivir is recommended as the preferred agent, with hydroxychloroquine as an alternative if remdesivir is contraindicated or not available. Hydroxychloroquine/azithromycin combination and lopinavir-ritonavir are not recommended. Preferably, antivirals should be used as part of a clinical trial, but as of 4/14/20 no US trials are enrolling children < age 12. Of note, subsequent to acceptance of this manuscript, preliminary results from a hydroxychloroquine retrospective analysis and a remdesivir clinical trial, both involving adult COVID-19 patients, did not show benefit. Additional studies are ongoing.
      • Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. April 2020. Shi. The Lancet Infectious Diseases.
        Another chest CT article, this time with 81 patients.
      • Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review. Apr 23. Castagnoli R. JAMA Pediatr.
        Italian authors, retrospective, metanalysis of literature (PUBMD, Cochrane…) from all China except one Singapore, Pediatric population with + PCR. They Identified 815 articles, selected 18 studies (Bias, exclusion criteria addressed with a referee author). N= 1065 includes 444 < 10 years age and 553 >10 but < 19. Slightly higher M >: F ratio. Software assistance, tightness of statistics – but no mention. Majority had mild symptoms, moderate < 20 patient & 1 kid < Shock. No vertical transmission but mainly contact from family. Asymptomatic manifestation for majority noted. 8 patients with rectal swab + ve in spite of – ve NP. Author concludes weakness of study: 3 month window, China factor, no adult comparison, no viral load to clinical picture or viral to immunity….
      • Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study. Apr 23. Zheng S. BMJ.
        In this retrospective cohort study, 3497 respiratory, stool, serum, and urine samples were collected from 96 hospitalized Covid-19 patients and evaluated for SARS-CoV-2 RNA viral load. Disease severity was mild in 22 and severe in 74. Infection confirmed in all patients by sputum and saliva testing. RNA was detected in the stool of 55 (59%) and in the serum of 39 (41%) patients. The urine was positive in 1 patient. The median duration of virus in stool (22 days, interquartile range 17-31 days) was longer than in respiratory (18 days, 13-29 days; P=0.02) and serum samples (16 days, 11-21 days; P<0.001). The median duration of virus in the respiratory samples of patients with severe disease (21 days, 14-30 days) was longer than in patients with mild disease (14 days, 10-21 days; P=0.04). In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group. Virus duration was longer in patients > 60 yrs old and in males. 78 (81%) patients received glucocorticoids and 33 (34%) antibiotic treatment. All patients received antiviral Rx with interferon α inhalation, lopinavir-ritonavir combination, arbidol, favipiravir, and darunavir-cobicistat combination. The authors claim no deaths in this group. The main conclusions were that the virus persists for a longer time in stool than in respiratory or serum samples and that patients with more severe disease have a longer respiratory viral persistence with a greater load. This potentially affects their ability to transmit disease to others.

      April 23, 2020

      • Central Nervous System Involvement by Severe Acute Respiratory Syndrome Coronavirus -2 (SARS-CoV-2). Apr 22. Paniz-Mondolfi. J Med Virol.
        In this case report of 1, a 74 yo patient with Parkinson’s with a positive nasopharyngeal swab test for SARS-CoV-2 by real-time reverse-transcription-polymerase-chain-reaction amplification was noted to be confused when admitted. He expired on day 11 and at post-mortem, was noted to have viral particles in brain capillary endothelium and actively budding across endothelial cells, though the nature of the virus in the brain was not otherwise defined.
      • Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Feb 24. Huang. The Lancet.
        Detailed review of clinical features of COVID-19 presentation and progression from Wuhan; patient data collected prospectively on 41 patients with COVID-19 confirmed by real-time RT-PCR and next-generation sequencing admitted between December 16th, 2019 and January 2nd, 2020. Analysis and information well presented.
      • CT imaging features of 4,121 patients with COVID-19: a meta-analysis. Apr 22. Zhu. J Med Virol.
        Meta-analysis of 34 retrospective studies that describes the lung CT characteristics of patients with COVID-19. The most common charachteristics were bilateral and multi-lobar ground glass opacities. 8% of CTs were normal. Analysis did not include any clinical or outcome information, and suggested CT could help with diagnosis.
      • Faecal calprotectin indicates intestinal inflammation in COVID-19. Apr 22. Effenberger. Gut.
        Austrian PAP Letter to the Editor of GUT noting that fecal calprotectin levels are elevated in 40 COVID-19 inpatients with active diarrhea.
      • Kidney disease is associated with in-hospital death of patients with COVID-19. Mar 20. Cheng. Kidney International.
        A retrospective study, regression analysis, single center 701 (600 + 101 with possibly raised baseline serum creatinine, BUN & low GFR) patient in Wuhan with a possible renal insuffiency and one without. Preexisting renal compromise will progress to acute kidney injury and to a higher mortality. In this cohort, approximately 13% of patients had underlying kidney disease. More than 40% had evidence of abnormal kidney function and 5.1% had acute kidney injury (AKI) during their hospital stay. There was a dose dependent relationship between AKI stages and death, with an excess risk of mortality by at least 4 times among those with stage 3 AKI. Kidney disease is a major complication of COVID-19 and a significant risk factor of death. Nonetheless, the study findings suggest that early identification of those at risk, interventions to provide appropriate support, and avoidance of nephrotoxins, vigilance may help to improve the prognosis of patients with COVID-19. Sudden loss of kidney function, ACE2 association are part of hypothesis. Hazard ratio (3 to 8) with increasing proteinuria, hematuria, AK Stage 3, rising kidney markers.
      • Lung–kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Dec. 9, 2019. Joannidis. Intensive Care Medicine.
        Consensus report summarizing findings of a June 2018 conference on lung and kidney interactions in critical illness (18 pages, 123+ references). Using ADQI 21 methodology, including critical review of available clinical and research evidence, an international panel of pulmonologists, nephrologists and critical care specialists created clinical recommendations and suggestions for future research.
        Clinical recommendations with high quality evidence included lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections. Consensus statements linking AKI and ARDS were developed and the effect of ECMO and RRT on either organ system was explored.
        COVID-19 attacks both organ systems and much of this work applies to clinical scenarios clinicians face daily in critical care units around the globe. Despite its volume, this report (18 pages, 123 references), may be of value to clinicians dealing with the impact of COVID-19 on the front lines today.
      • Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized with COVID-19 in the New York City Area
        Apr 22. Richardson. JAMA.
        Opinion from SAB Member: Dr. David M. Clement, Dr. J. Lance Lichtor
        DC: This is a case review of a 12 hospital system in New York City, detailing the characteristics and outcomes of 5,700 patients admitted between March 1 and April 4. Besides the usual co-morbidities (hypertension, obesity and diabetes), only 31% of patients were febrile at triage, 14% needed ICU admission, 12% were intubated and of those intubated, 88% died. This provides an early window into the US experience. The supplementary tables provide a wealth of clinical data. JLL: In this review of 5700 patients admitted between March 1, 2020, and April 4, 2020 to any of 12 Northwell Health acute care hospitals, some clinical characteristics and outcomes were described. The median time to obtain polymerase chain reaction testing results was 15.4 hours, and common morbidities included hypertension, obesity and diabetes. 30% were febrile, almost 20% had a respiratory rate greater than 24 and almost 30% needed supplemental oxygen. The overwhelming majority had a positive COVID-19 test result on the first attempt. About 15% were treated in the ICU; 12% were treated with mechanical ventilation and 3% were treated with kidney replacement. About 20% died. Patients between 18 and 65 were more likely to be treated in the ICU, receive mechanical ventilation, compared to patients older than 65 years. Mortality rates were lower than reported in China.

      April 22, 2020

      • Audiological profile of asymptomatic Covid-19 PCR-positive cases. Apr 21. Mustafa MWM. Am J Otolaryngol.
        Viral infections can cause hearing loss. 20 confirmed positive but asymptomatic COVID-19 patients were compared with 20 controls with normal hearing. The COVID-19 patient group had significantly worse high frequency pure-tone thresholds and transient evoked otoacoustic emission amplitudes, suggesting damage to cochlea hair cells. The paper recommends further research to determine the mechanism of this effect.
      • COVID-19: impact on cancer workforce and delivery of care. Apr 20. Mayor. The Lancet Oncology.
        A Lancet “News” piece stressing the adaptations being made to care for cancer patients during COVID-19. Centralization of cancer care, telemedicine, modifying chemo and radiation treatments and splitting teams of cancer care workers are mentioned.
      • Category: Emerging Clinical Data and Guidelines
        Diarrhea is associated with prolonged symptoms and viral carriage in COVID-19
        Apr 13. Wei. Clinical Gastroenterology and Hepatology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        In this retrospective analysis of 84 patients with SARS-CoV-2, diarrhea occurred in 31% of patients, and patients with diarrhea had a higher incidence of headache, myalgia or fatigue, cough, sputum production, nausea and vomiting and duration of symptoms and hospital stays were longer for patients who had diarrhea. The digestive system is also a potential pathway for SARS-CoV-2 infection. Though the diarrhea could have been due to antibiotic use–all patients received antibiotics (46% used two antibiotics) and intestinal probiotics relieved diarrhea, which is consistent with diarrhea secondary to antibiotic use.
      • Dynamic profile of RT-PCR findings from 301 COVID-19 patients in Wuhan, China: a descriptive study. Apr 11. Xiao. J Clin Virol.
        More than 2 negative RT-PCR tests may be needed to document viral clearing. Retrospective study of of 301 Wuhan COVID-19 patients with mild – moderative symptoms. Average contagious period (positive RT-PCR test) was 20 days, with 26% still testing positive after 4 weeks. Patients < 65 converted on average earlier than older patients. 23% of the 70 patients with 3 documented consecutive RT-PCR tests had a positive test after 2 negative tests. Throat swab tests had a higher flare negative rate of 41%.
      • What Has the COVID-19 Pandemic Taught Us so Far? Addressing the Problem from a Hepatologist’s Perspective. Apr 21. Méndez-Sánchez. J Clin Transl Hepatol.
        Editorial with 12 international authors.
        The authors outline that hepatic injury during COVID-19 illness may be due to systemic inflammation, liver ischemia and hypoxia, exacerbation of pre-existing liver diseases, and drug-related liver injury. ACE2 is expressed in the epithelial cells of bile ducts “however, in the studies conducted so far, no increase in bile duct injury markers, such as gamma-glutamyl transferase and alkaline phosphatase, has been observed.” “It is a matter of debate whether COVID-19 is directly responsible for the development of liver injury, or whether the observed changes are secondary to the systemic inflammation triggered by infection.“ The authors make no specific recommendations other than to emphasize adherence to general recommendations such as social distancing and appropriate hand washing to curtail spread of the virus until treatment or vaccines are available.

      April 21, 2020

      • Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Mar 1. Liang. The Lancet Oncology.
        In this letter to the editor, the authors note that COVID-19 patients can have cancer and note that patients with cancer might have a higher incidence of COVID-19 than the general population and that patients with cancer may also have a worse outcomes with COVID-19 disease.
      • Digestive Symptoms in COVID-19 Patients With Mild Disease Severity: Clinical Presentation, Stool Viral RNA Testing, and Outcomes. Apr 18. Han. Am J Gastroenterol.
        Patients with mild Covid-19 illness may present with GI symptoms. This study from Wuhan China identified 206 Covid-19 patients with mild disease of whom 48 had GI symptoms (nausea, vomiting, or diarrhea) alone, 69 had both GI and Respiratory symptoms, and 89 had only respiratory symptoms. All were followed until they had two consecutive daily PCR tests for SARS-CoV-2. Those who presented with GI symptoms waited longer on average to seek treatment, (16 vs. 11.6 days) a longer duration of illness until PCR tests were negative, and a greater likelihood to have positive stool tests.
      • Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period
        Apr 16. Iacucci. The Lancet.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        This is an international consensus paper by 9 academic centers and 4 societies on the management of inflammatory bowel disease (IBD) and the indications for urgent endoscopy during and after the COVID-19 pandemic. The panel identified 4 clinical scenarios requiring urgent endoscopy and provides well-organized algorithms for each situation. If urgent endoscopy is indicated, ruling out COVID-19 infection and a diagnosis of irritable bowel syndrome (IBS) are high priorities, as COVID-19 infection frequently starts with GI symptomatology (52% in one study). Strict precautions are advised to protect providers and the environment from aerosolized transmission during an endoscopy. An algorithm dealing with post-pandemic gridlock in the endoscopy suite is helpful in prioritizing postponed diagnostic and therapeutic interventions.
      • Risk Factors Associated with Disease Severity and Length of Hospital Stay in COVID-19 Patients. Apr 20 Liu. J Infect.
        Pre-Proof article from China which reptrospectively studied 99 patients who recovered from COVID-19 and identified risk factors for severe disease. Since study was retrospective, did not include deaths, and had nothing new.
      • The performance of chest CT in evaluating the clinical severity of COVID-19 pneumonia: identifying critical cases based on CT characteristics. Apr 19. Lyu. Invest Radiol.
        Retrospective study from a single center in China regarding utility of CT scan in diagnosis of COVID19. N= 51. Three groups: mild, moderate, and severe. All groups were tested and scored on: 1. clinical score, 2. qualitative score, 3. quantitative, 4. AI score. Don’t know who were excluded. Stastics had fitness test besides standard tests (P…… ) Comparing mild to severe. Their conclusion: “The combined use of qualitative and quantitative indicators could distinguish cases at different clinical stages, might provide help to facilitate the fast identification and management of critical cases, thus reducing the mortality rate. Critical cases had higher total severity score (>10) and total score for crazy-paving and consolidation (>4) than ordinary cases, and had higher mean lung density (>-779HU) and full width at half maximum (>128HU) but lower relative volume of normal lung density (≦50%) than ordinary/severe cases. CT imaging findings could help to continuously monitor the treatment effects objectively in the follow-up as well as provide guidance for clinical management and treatment.”

      April 20, 2020

      • Joint statement on safely resuming elective surgery after the COVID-19 pandemic
        Apr 17. American College of Surgeons; American Society of Anesthesiologists; Association of periOperative Registered Nurses; American Hospital Association.
        Opinion from SAB Member: Dr. Jagdip Shah
        In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS), the U.S. Surgeon General and many medical specialties such as the American College of Surgeons and the American Society of Anesthesiologists recommended interim cancelation of elective surgical procedures. Physicians and health care organizations have responded appropriately and canceled non-essential cases across the country. Many patients have had their needed, but not essential, surgeries postponed due to the pandemic. When the first wave of this pandemic is behind us, the pent-up patient demand for surgical and procedural care may be immense, and health care organizations, physicians and nurses must be prepared to meet this demand. Facility readiness to resume elective surgery will vary by geographic location. The following is a list of principles and considerations to guide physicians, nurses and local facilities in their resumption of care in operating rooms and all procedural areas.
      • Sequential analysis of viral load in a neonate and her mother infected with SARS-CoV-2. Apr 17. Han MS. Clin Infect Dis.
        An interesting manuscript: 27-day old neonate, born almost at 39 wks and her mother were diagnosed with COVID-19. About a month after the baby was born, her mother and father developed symptoms of COVID-19 and the baby and mother both tested positive and were hospitalized. Though at its early stage, the viral load was highest in the nasopharynx, up until the 18th day it was high in the infant’s stool, when respiratory specimens were negative. It’s not clear if virus detected in stool and urine was viable, still important to wash hands after changing a diaper.

      April 17, 2020

      • COVID-19 pneumonia: different respiratory treatments for different phenotypes? Apr 16. Gattinoni L. Intensive Care Med.
        Clinical observations from experienced researchers conclude two types of lung disease exist variably in COVID-19 patients; patient presentation may depend on severity of infection, initial patient response to hypoxemia and the time from symptom onset to hospital admission. Type L is described as low elastance with retained lung compliance, low VA/Q ratio and normal lung weight. As hypoxemia worsens, patient generated large tidal volumes increase negative intrathoracic pressure which may cause further lung damage. Type H is defined as high elastance due to increased pulmonary edema, high shunt, high lung weight and high lung recruitability. Excellent discussion and physiologic explanation for managing patients with different lung support strategies and ventilatory assistance in both stages. Important discussion for all physicians engaged in treating COVID-19 patients who may present at different stages of the disease which require different ventilatory strategies which may prevent deterioration if treated early in the course.

      April 16, 2020

      April 15, 2020

      April 11, 2020

      April 10, 2020

      • Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. Apr 9. Zhang. NEJM.
        Case report and comparison with 2 other COVID-19 patients in Wuhan who presented with coagulopathy, antiphospholipid antibodies, and multiple cerebral infarcts. SARS-CoV-2 was confirmed with RT-PCR or serologic testing. All three patients had histories of multiple co-morbidities. The case report patient was age 69 with a history of HTN, DM, and CVA. He had leukocytosis, thrombocytopenia, elevated PT. aPTT, fibrinogen, and D-dimer. Patients 2 and 3 did not have leukocytosis or as markedly elevated D-dimer, and patient 3 had a normal Plt count. All 3 showed presence of anticardiolipin IgA and anti-B2-glycoprotein I IgA and IgG antibodies, and negative lupus anticoagulant.

      April 9, 2020

      • Clinicolaboratory study of 25 fatal cases of COVID-19 in Wuhan. Apr 8. Tu. Intensive Care Med.
        An interesting read that just reaffirms what we already know about the subset of patients who are most likely to die and their abnormal lab values more likely associated with death, i.e., interleukin-6, C-reactive protein and D-dime. Single center retrospective analysis focusing on fatality markers of the disease by comparing lab data of survivors with non-survivors. Among 174 patients, mortality was 14.4%. Older males with comorbidities (diabetes, heart disease, COPD) were at higher risk and non-survivors had pronounced lymphocytopenia, abnormal coagulation, elevated D-dimer levels and showed evidence of cytokine abnormalities with high IL-6 and CRP levels.

      April 8, 2020

      April 5, 2020

      • Early Lessons From the Frontline of the 2019-nCoV. Feb. 11. Zhang. The Lancet.
        C19SAB Opinion from: Dr. Jack Lance Lichtor
        A physician working on the frontline in Wuhan explained what treating patients with this disease taught him. Though we complain in the US about the lack of early detection, a lack of understanding that patients may be contagious during the incubation period, the lack of availability of protective equipment, the inability to get certain drugs, the lack of hospital beds for patients with other diseases, and the lack of enough hospital beds for patients with COVID-19 disease, this physician explained that in China they had the same issues as we have here.
      • Preparing for a COVID-19 Pandemic: A Review of Operating Room Outbreak Response Measures in a Large Tertiary Hospital in Singapore. Mar 11. Wong. Canadian Journal of Anaesthesia.
        COVID-19 SAB Opinion from: Dr. Lydia Cassorla
        This is a well-illustrated in-depth discussion of multiple aspects of a major Singapore medical center’s approach to caring for patients in the COVID-19 era, with 72 references cited. Preparation for a pandemic involves considering the different levels in the hierarchy of controls as well as the different phases of the pandemic. In the OR setting, these measures include the modification of infrastructure and processes, management of staff and patients, infection prevention strategies, and clinical recommendations.

      April 3, 2020

      April 2, 2020

      April 1, 2020

      March 31, 2020

      March 30, 2020

      March 26, 2020

      March 25, 2020

      March 24, 2020

      March 20, 2020

      March 17, 2020

      March 16, 2020

      March 15, 2020

      March 2020

      February 2020

      • Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) Feb 16. WHO.
        Opinion from SAB Member: Dr. Barry Perlman
        Joint Mission was a series of meetings and field visits from February 16-24, 2020 by 25 Chinese and international experts, headed by Dr. Bruce Aylward of WHO and Dr. Wannian Liang of the People’s Republic of China. The major objectives: 1) To enhance understanding of the evolving COVID-19 outbreak in China and the nature and impact of ongoing containment measures; 2) To share knowledge on COVID-19 response and preparedness measures being implemented in countries affected by or at risk of importations of COVID-19; 3) To generate recommendations for adjusting COVID-19 containment and response measures in China and internationally; and 4) To establish priorities for a collaborative program of work, research and development to address critical gaps in knowledge and response and readiness tools and activities. It was recommended that “uncompromising and rigorous” non-pharmaceutical measures to contain transmission, proactive surveillance, rapid diagnosis and isolation, and tracking and quarantine of close contacts should be employed globally.
    1. COVID-19 Patients
      September 16, 2020
      • Time-critical goals of care in the Emergency Department during COVID-19: A three-stage protocol. 6/17/20. Nakagawa S. Journal of the American Geriatric Society.
        This is an important and ethically relevant research letter discussing applicability of initiating palliative care discussions in the Emergency Department (ED) and defining a “clear goal of care” in this COVID-19 pandemic. The author proposes a simple 3-stage communication approach (1. sharing knowledge, 2. clarifying goal of care, and 3. negotiating treatment options) with the patient’s family and ED physicians that allows clinicians to quickly share the clinical picture, effectively assess the patient’s values, and make a goal recommendation for care during our rapidly progressing crisis. The 3-stage tool is very practical and saves resources while preserving the patient’s autonomy and wishes.

      July 24, 2020

      • The Structural and Social Determinants of the Racial/Ethnic Disparities in the U.S. COVID-19 Pandemic: What’s Our Role? 7/17/20. Thakur N. Am J Respir Crit Care Med.
        A call to arms for critical care and pulmonary specialists: black, Latinx, and Native Americans test positive for and die from coronavirus at higher proportion than other racial and ethnic groups. Their mortality rates far exceed the proportion of the population that these groups represent. Historically disadvantaged communities have reduced capacity to adopt preventive measures. Minority communities with low socioeconomic status (SES) and/or limited English proficiency receive less public communication during crisis and pandemics; access to testing and care is greatly limited in low-SES and minority communities. This article advocates for under-represented minority patients, who are becoming critically ill and dying at disproportionate rates.

      July 20, 2020

      • CPR in the COVID-19 Era – An Ethical Framework. 7/9/20. Kramer DB. N Engl J Med.
        Review by the SAB
        By David Clement, on behalf of the SAB
        This opinion paper provides important reading on the ethics of how the surge of patients with COVID-19 complicate standard CPR practices. An ethical framework of three crisis standards is proposed: acknowledge resource limitations, forgo CPR in certain circumstances, and impose selective constraints on CPR to ensure the safety of healthcare personnel. Hospitals need to develop such explicit crisis standards for CPR to help clinicians and the public understand when strict adherence to established resuscitation protocols may no longer be appropriate.

      May 27, 2020

      • Saving Lives Versus Saving Dollars: The Acceptable Loss for Coronavirus Disease 2019. May 18. Ashkenazi. Crit Care Med.
        This is in response to the previous article “Adult ICU Triage During the Coronavirus Disease 2019 Pandemic. Who Will Live and Who Will Die?” Recommendations to Improve Survival in CCM.
        A thought provoking reply: Care for patient vs. population and simultaneously incorporating a principal of “life for ‘Fittest for a survival’” while accepting the strategic “retrieve” in this pandemic.
        The author questions the article’s recommendation of a triage algorithm based on various criteria—except for the age.
        The formula in question is based on 1. Performance score; 2. ASA score; 3. Number of organ failures; and 4. Predicted survival. Performance score and predicted survival has indirectly incorporated the age of the patient in consideration for “greater good to great number of people / year.”
        The author makes a cerebral argument for a need for strategic pre-planning of the national capacities (based on ICU beds) and capabilities (surge of 100 + Supply + Space) of a pandemic. Here the policy maker should consider as an “acceptable loss,” which represents the ultimate balance between saving lives and keeping life routines. This includes defining the “price” that we are willing to “pay” in order to be able to save the most lives and life-years and to lower the morbidity rate while, at the same time safeguarding the economy and individuals at workplaces and the fabric of social existence. Social distancing, quarantine, tracking and monitoring are medical aspects of a pandemics but does cause a collateral damage in the area with 1. Loss of lives due to suicides; 2. Psychiatry diseases; 3.Delayed chronic treatment; 4. Domestic violence; and 5. Economic losses. An evaluation of the “acceptable loss” is a professional, financial, ethical, legal, social, cultural, and historical dilemma. The COVID-19 pandemic has shown a dichotomy of the society: “the objective element” of the lethal virus and “controlled element” of the overprotective reaction for those who are not at risk, while vulnerable populations are left unprotected.
        ICU Triage needs to be 1. Differential diagnosis with comorbidities – risks stratification of population; 2. International surge – share and care of equipment and valuable resources; 3. Awareness to differential age; and 4. Meta leadership at stages (country, state, city level). The author appeals a medical triage, acceptable loss is based on two basic principles: beneficence and distributive justice.
        In a big country that is fractured at several levels, these suggested principals will need “a well-orchestrated political will” in this pandemic. On the other side, success for a smaller, monolithic, resources poor, undemocratic country from the author’s perspective in this pandemic.

      May 14, 2020

      May 13, 2020

      • Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival
        May 6. Sprung. Critical Care Medicine.
        Opinion from SAB Member: Dr. Jagdip Shah
        The authors review 3 methods of triage (Andorran Model, Medical Benefit, and Manchester Triage System), in 3 countries (Spain, Ecuador, and the Netherlands). They then compared results with current COVID-19 pandemic ICU care profiles. The Netherlands ICU was able to increase capacity 4-fold and was able to decrease mortality while other ICUs in Ecuador and Spain more than doubled ICU bed capacity and experienced an increased mortality of almost 2- to 3-fold. Triage is to be used only in crisis mode, not in contingency mode (e.g. when demand for ICU bed is increased >100%). Here the authors make an appeal for a flexible, simple and powerful tool implemented by a triage committee that may include doctors with relevant experience (palliative care, critical care, administration), nurses, social workers, and ethicists for ICU admission and discharge. The authors recommend a triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) with “first come, first served” being applied for patients with otherwise equal priorities/benefits. Prognosis is an important factor to consider with emphasis on biologic age being needed for COVID-19, specifically. Fairness by age, gender, race ethnicity, sex preference, financial status, social worth is also recommended. The triage model proposed here is based on the priority (1 to 4) label of all ICU seeking patients. The triage committee will make color coding of each patient seeking ICU based on: 1. performance score (The premorbid baseline condition using the Eastern Cooperative Oncology Group Performance Score + the Clinical Frailty Score + the Karnofsky Performance Scale), 2. ASA class, 3. SOFA score, 4. predicted survival. The triage committee reviews all ICU admitted patients Q24 hrs and also Q14 days for discharge from the ICU. The authors make a plea for health workers to get priority for treatment with a blessing from the government/communities that they serve. Administrators in the committee are likely to guide space, staff and supplies. An excellent graphic clearly written for the current pandemic is included.

      April 21, 2020

      April 13, 2020

      April 11, 2020

      April 8, 2020

      • Patients who are improving could have treatment withdrawn if others could benefit more. Apr 2. Mahase. BMJ.
        Doctors could be forced to withdraw lifesaving treatment from stable or improving patients.
      • Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19: Assessing the Risks and Identifying Needed Reforms Apr 1. Cohen. JAMA.
        COVID-19 SAB Opinion from: Dr. Philip Lumb
        Sobering discussion on potential legal liability for physicians and organizations following triage protocols that refuse, withdraw, and reassign or withdraw lifesaving equipment (ventilators) from non-consenting patients. The discussion is well founded and provides a call for state legislatures to enact similar statutes to a ‘”Maryland statute in place since 2004, indicating that “A health care provider is immune from civil or criminal liability if the health care provider acts in good faith and under a catastrophic health emergency proclamation” with health care provider defined to include most health care facilities.”‘ The discussion notes the possibility of criminal and/or civil charges in certain situations and urges rapid action at state level to create 120-day, self-expiring legislation to hold harmless institutions and physicians who make triage decisions following defined protocols. (Reference A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic JAMA. Mar 27, 2020. Douglas B. White MD MAS; Bernard Lo MD)

      April 3, 2020

      March 31, 2020

      March 29, 2020

      March 23, 2020

      March 18, 2020

    1. Healthcare Workers
      May 15, 2020
      • Medically Vulnerable Clinicians and Unnecessary Risk During the COVID-19 Pandemic
        May 13. Janvier. The American Journal of Bioethics.
        Opinion from SAB Member: Dr. Philip Lumb
        This is an intellectually provocative discussion on appropriate tasks for retired physician volunteers in COVID-19 areas. The article entertains appropriate conflict between “wishing to be in the front line” versus more appropriate and potentially intellectually valuable activities that entertain less risk for volunteers and the health system.
    1. Society
      April 30, 2020

      April 25, 2020

      • What the Great Pandemic Novels Teach Us
        Apr 23. Pamuk. The New York Times.
        Opinion from SAB Member: Dr. J. Lance Lichtor, Dr. David M. Clement
        JLC: Though not really a science paper, this piece shows, based on literary history, how eerily similar the current pandemic is compared to what has happened over the last 400 years in terms of initial response (denial); the carelessness, incompetence and selfishness of those in power that infuriates the masses; how institutions are unsure how to deal with many of the issues; how rumor and the spread of false information has been a universal and unprompted response, including how the disease is foreign, and is brought in with malicious intent; the intensity of suffering; and finally the terror all of us feel which shows how fragile our lives are and how we all share the same humanity. Fear may cause us to withdraw, but it also teaches us to be humble and practice solidarity.
        DC: One may question the historical accuracy of novels. During the current pandemic some countries (New Zealand, Australia and Taiwan for example) have largely avoided baseless rumors and false information. But the human tendency for such dysfunctional approaches to pandemics are wonderfully illustrated in this article.

      April 21, 2020

      • The Untold Toll – The Pandemic’s Effects on Patients without Covid-19. Apr 18. Rosenbaum. NEJM.
        An articulate, appropriately emotional and well written article on the peripheral and usually undocumented costs of COVID-19’s effects on other (frequently emergency) patient care priorities. Details experiences with delayed coronary angiography, rushed decisions to perform bilateral mastectomy, and inadequate post procedural follow-up. Timely, thoughtful and obvious future implications when “routine” access to medical care resumes.

III. Clinical Care / Prevention

April 24, 2020

  • Anesthesia ICU Transition Materials. University of Utah.
    Four videos lasting over three hours, from the University of Utah, designed to update the ICU knowledge of anesthesiologists (and others) in preparation for a COVID-19 surge. These are well done, thorough and very clinically applicable. Discussions cover most topics from PPE to self-care and sustainable staffing, to specifics of ventilator management and more.

April 7, 2020

April 2, 2020

April 1, 2020

March 11, 2020

March 7, 2020

    1. Pulmonary Management
      November 23, 2020
      • Diaphragm Pathology in Critically Ill Patients With COVID-19 and Postmortem Findings From 3 Medical Centers. 11/16/20. Zhonghua S. JAMA Internal Med.
        This research letter describes evaluation of autopsy specimens of diaphragm muscle obtained from 26 consecutive deceased COVID-19 patients, 24 of whom had been on mechanical ventilation for a mean of 12 days. Specimens from 8 deceased non-COVID-19 patients mechanically ventilated for a similar amount of time were used as a control group. ACE-2 receptors were present on diaphragm myofiber membranes in all patients. Viral RNA was found in the myofibers of 4 of the 26 COVID-19 patients. Significantly more fibrosis was present in the diaphragms of the deceased COVID-19 patients than in the diaphragms of the control patients predicting more diaphragmatic weakness in the COVID-19 patients.

      November 16, 2020

      • Analgesia and sedation in patients with ARDS. 11/10/2020. Chanques G. Intensive Care Med.
        A “state of the art“ narrative review by an international panel of experts written to support clinicians in their management of ARDS patients. Proper ventilator settings, followed by analgesia, then sedation, then neuromuscular blockers form the heart of suggested approaches to analgesia and sedation. Separate sections address ARDS and COVID-ARDS, and several flow diagrams suggest various treatments. An “ABCDEF-R” approach is suggested.
      • Current and evolving standards of care for patients with ARDS. 11/6/20. Menk M. Intensive Care Med.
        Written by an international group of experts, this narrative review is a succinct and up-to-date review of caring for ARDS and COVID-ARDS patients, and is very useful for a frontline worker wanting a broad overview. It briefly explains the studies that establish the current standards and discusses therapies of promising interest (evolving standards). Nicely summarized in a table and discussed in the text are: ventilatory management (tidal volume, PEEP, driving pressure, mechanical power, etc.), ventilation adjuncts (proning, neuromuscular blockade, ECMO, etc.) and pharmacotherapy (steroids, fluid therapy, etc.).
      • Prone position in ARDS patients: why, when, how and for whom. 11/10/20. Guérin C. Intensive Care Med.
        This is a thorough and excellent review of the use of prone position in ARDS including a detailed explanation of its effects on pulmonary physiology, gas exchange and hemodynamics. The significant benefits in mortality are discussed. As noted in many studies, the improvement in mortality does not correlate with the degree of oxygenation improvement but appears more likely to be related to a decrease in ventilator-induced lung injury. Specific recommendations and cautions for practical application are provided. The use of prone positioning in spontaneously breathing, non-intubated patients is commonly used with COVID-19, and studies are planned to verify if this strategy can reduce the rate of intubation and improve survival.

      November 9, 2020

      • Combining lung ultrasound and Wells score for diagnosing pulmonary embolism in critically ill COVID-19 patients. 11/4/20. Zotzmann V. J Thromb Thrombolysis.
        This article presents the results of a retrospective evaluation of 20 ICU COVID-19 patients who had all undergone CT pulmonary angiography and lung ultrasound for suspected pulmonary emboli in a tertiary referral ARDS/ECMO center. The study showed that subpleural consolidations ≥ 1cm detected in lung ultrasound were found frequently in COVID-19 ARDS patients with pulmonary embolism. By combining a Wells score ≥ 2 and a lung ultrasound showing subpleural consolidations, PE could be predicted with a sensitivity of 100% and a specificity of 80% in these 20 patients, 12 of whom were found to have pulmonary emboli by CT pulmonary angiography.

      October 28, 2020

      • What have we learned ventilating COVID 19 patients? 10/12/20. Trahtemberg U. Intensive Care Med.
        These leaders in ARDS research provide a crisp review of ventilatory management of COVID-19-induced ARDS (CARDS), based on the underlying pathophysiology and contend that the similarities in the spectrum of CARDS versus that of non-COVID ARDS outweigh the differences. They find a paucity of data exists to justify early intubation. They favor lung protective ventilation for all patients, and they argue for prone positioning for patients with moderate-to-severe ARDS (PaO2/FiO2 ratio < 150 mmHg). In summary they write, “ventilatory management of patients with COVID-19 ARDS should be similar to that for other causes of ARDS, tailored to the specific patient.”

      October 26, 2020

      • Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study. 10/21/20. Chiumello D. Intensive Care Med.
        This detailed Italian physiologic study compared 32 COVID-19 ARDS (CARDS) patients with two other matched historical groups of typical ARDS patients; one matched with the CARDS patients by SpO2/FiO2, and one matched by respiratory compliance. As noted previously by this group (but not some studies by other groups), they found CARDS patients to have higher compliance than the group of non-COVID ARDS patients who were matched for SpO2/FiO2. They also found the CARDS patients had lower SpO2/FiO2 than non-COVID ARDS patients who were matched for compliance. Increasing PEEP from 5 to 15 improved oxygenation in CARDS patients but did not improve respiratory mechanics or CO2 clearance as usually seen in ARDS. These authors continue to recommend low PEEP and low driving pressure in early CARDS.

      October 19, 2020

      October 9, 2020

      October 7, 2020

      October 2, 2020

      September 23, 2020

      September 14, 2020

      September 2, 2020

      • Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies. 8/28/20. Grieco DL. Crit Care.
        This article provides a detailed comparison of the respiratory mechanics of 30 COVID-19 ARDS patients measured within 24 hours of initial intubation with 30 non-COVID matching ARDS patients based on PaO2/FiO2, FiO2, PEEP, and tidal volume. The average compliance and ventilatory ratio were slightly higher in COVID-19 patients. Inter-individual variability of compliance was similar in both groups. In COVID-19 patients, PaO2/FiO2 was linearly correlated with respiratory system compliance. High PEEP improved PaO2/FiO2 in both cohorts, but more remarkably in COVID-19 patients. Recruitability was not different between cohorts. The authors conclude that overall the respiratory mechanics were similar in the two groups but were marked by prominent intra-group variability in both.

      August 31, 2020

      August 25, 2020

      August 19, 2020

      August 12, 2020

      August 10, 2020

      August 5, 2020

      July 27, 2020

      • Pulmonary embolism in hospitalised patients with COVID-19. 7/10/20. Whyte MB. Thromb Res.
        A single center retrospective review of the results of 214 computer tomography pulmonary angiography studies performed on hospitalized Covid-19 patients with suspected pulmonary emboli. 31% of studies were positive for pulmonary emboli which represents 5.4% of all patients admitted during the study’s time interval. Elevated Wells score greater or equal to 4 did not predict results. Median D-dimer was 8000 ng/ml for patients with a positive study versus 2060 ng/ml for patients with a negative study, but low D-dimer had limited utility excluding patients with pulmonary emboli.

      July 24, 2020

      • Personalized Ventilation to Multiple Patients Using a Single Ventilator: Description and Proof of Concept. 7/17/20. Han JS. Crit Care Explor.
        A proof of concept: the authors used components readily available in their hospital to assemble two “bag-in-a-box” breathing circuits. This shared ventilator function is proposed as a “last ditch” ventilatory assist device and not as a preferred ventilation mode. In a time of crisis where resources are limited, they introduced a system of multiple secondary breathing circuits driven by a ventilator in preference to that of simply splitting the breathing circuits. The authors hope, though, that this will not be needed. But these were all test conditions, not actually used on a patient.
      • The role of chest radiography in confirming Covid-19 pneumonia. 7/18/2020. Cleverley J. BMJ.
        An introductory summary of chest X-ray findings in COVID-19 pneumonia for the non-radiologist. Characteristic findings are illustrated however none is diagnostic. Studies show that X-ray imaging may initially appear normal or lag behind disease progression. Chest CT has been shown to be more sensitive however its initial use varies among countries. Includes no mention of chest ultrasound.

      July 21, 2020

      July 20, 2020

      July 13, 2020

      July 10, 2020

      • Review of influenza-associated pulmonary aspergillosis in ICU patients and proposal for a case definition: an expert opinion. 6/22/20. Verweij PE. Intensive Care Med.
        Review by the SAB
        Although the number of COVID-19-associated aspergillosis (CAPA) cases that have been reported is a small number, in two series, similarities and differences with Influenza with Invasive Aspergillosis (IAP) and COVID-19 are pointed out. Here a group of authors (EU, USA and Taiwan) are seeking to change the definition of IAP (inclusive of clinical and radiological signs). They make a point that an under-estimation of IAP requires a need for vigilance for IAP in the ICU, an early diagnosis, holding steroids, judicious use of antiviral to avoid a fatal outcome due to an IAP patient in comparison to Influenza with IAP.
        For CAPA:
        • 85% host factors are -ve but Lymphopenia/monocyte hyperimmune response is present
        • IPA tracheobronchitis is not known
        • The entry point ACE 2 – anti-fungal immunomodulation by antifungal not likely?
        • Serum GM + ve – need a study in COVID-19 to understand the implication.
        • No specificity of secondary infection organism types.

      July 8, 2020

      July 6, 2020

      June 8, 2020

      June 4, 2020

      June 3, 2020

      • ICU and Ventilator Mortality Among Critically Ill Adults With Coronavirus Disease 2019
        May 26. Auld SC. Critical Care Medicine.
        Opinion from SAB Member: Dr. Philip Lumb, Dr. Jagdip Shah
        PL: Results of an observational cohort study of 217 patients admitted to Emory Healthcare System ICUs between March 6th and April 17th with RT-PCR confirmed COVID-19 disease, 165 of whom required invasive ventilation with a reported mortality rate of 33.9% (56/165) and a hospital mortality of 35.7%. Patient demographics, other supportive therapies (ECMO, RRT, Etc.), laboratory values and pulmonary characteristics well described with clear delineation between survivors and non-survivors. Authors discuss ICU preparation and pre-peak awareness as characteristics promoting more favorable outcomes than previously reported under surge conditions.
        JS: Authors form Emory conducted a retrospective cohort study of critically ill patients with COVID-19 in 6 designated ICUs which were adequately staffed and stocked. 217 patients were admitted to the ICU and 165 were treated with mechanical ventilation in the ICU. A total of 59 died (in the ICU or in hospital) and 88 were discharged out of the hospital. Statistically significant baseline parameters associated with non-survivors were: age > 75, BMI > 40, pre-existing chronic kidney disease. The ICU parameters associated with non-survival were: SOFA score on the day of admission > 7, rise of d Dimer > 1600 ng/dl, C-reactive protein > 183, PaO2:FiO2 < 144, use of mechanical ventilation, use of vasopressors, use of continuous renal replacement therapy, and hospital stay > 11 days. The authors claim that timely start of mechanical ventilation with lung protective strategy likely improves the outcome (the overall mortality in this study was 31%).
      • Respiratory Mechanics of COVID-19 vs. Non-COVID-19 Associated Acute Respiratory Distress Syndrome
        Apr 20. Haudebourg AF. American Journal of Respiratory and Critical Care Medicine.
        Opinion from SAB Member: Dr. Robert L. Coffey
        A prospective, observational study comparing the respiratory mechanics and lung recruitability of 30 consecutive COVID-19 ARDS patients and 30 consecutive non-COVID-19 ARDS patients of similar severity. In contrast to other reports, compliance, while ranging widely, was similar in the two groups and did not appear to worsen in COVID patients over the 15 days after their initial symptoms. The lung recruitment measure (R/I ratio) was significantly higher in the COVID-19 ARDS patients. The authors could not discern subgroup phenotypes within these 30 COVID pneumonia patients.

      May 27, 2020

      • A proposed lung ultrasound and phenotypic algorithm for the care of COVID-19 patients with acute respiratory failure
        May 21. Denault. Canadian Journal of Anesthesia/Journal canadien d’anesthésie.
        Opinion from SAB Member: Dr. Robert L. Coffey
        This is an opinion piece from a group of physicians in Quebec based on a literature review and patient care experience that recommends the use of lung ultrasound and the previously validated ROX index [(SpO2/FiO2)/RR] to better distinguish between the proposed Type L and Type H COVID-19 pneumonia phenotypes. A guide to differentiated ventilator support strategies is offered, but no patient outcome data is presented. While the concepts are interesting and bedside lung ultrasound offers a low risk imaging technique, it is not clear to me that the ventilator strategies suggested differ significantly from standard high quality lung protective ARDS care.
      • Distinct phenotypes require distinct respiratory management strategies in severe COVID-19. May 11. Robba. Respir Physiol Neurobiol.
        An opinion piece from Italian physicians based on a literature review and their extensive experience caring for patients with Covid-19 pneumonia. They recommend classifying patients into three phenotypes based on CT scan results (1. Focal ground glass opacities, 2. Atelectasis and peribronchial opacities, 3. Patchy ARDS-like pattern) and provide recommendations for specific support strategies according to the physiology typically associated with each of these CT scan types. Since no patient outcome data is presented, it’s not clear that their strategies are superior to others, and they themselves state that these “might” guide therapy and ventilator settings.
      • Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019-Induced Acute Respiratory Distress Syndrome: A Multicenter Descriptive Study
        May 18. Yang. Critical Care Medicine.
        Opinion from SAB Member: Dr. David M. Clement, Dr. Jagdip Shah
        DC: Though ECMO was shown to be an effective management choice in H1N1 ARDS, the utility of ECMO in COVID-19 is unclear. This study helps us to understand the use of ECMO with COVID-19 respiratory failure. This is a descriptive, retrospective, uncontrolled study from China of 59 ventilated patients, 21 of whom received ECMO for worsening respiratory failure. Of the 21 treated with ECMO, 12 died (57%), 9 were weaned off ECMO, and 6 were discharged. Of patients ventilated without ECMO, 63% died (NS compared with ECMO). This shows that ECMO is not a hopeless endeavor in certain circumstances with COVID-19 respiratory failure.
        JS: Here, Chinese authors retrospectively review the outcomes from 21 patients (2 hospitals) who received extracorporeal membrane oxygenation support (ECMO). When the optimal lung-protective strategy and prone position were both proven to be ineffective, patients would be considered for ECMO if any one of these criteria were met:
        1. PaO2/FiO2 less than 50 mm Hg over 3 hours;
        2. PaO2/ FiO2 less than 80 mm Hg over 6 hours;
        3. arterial blood gas pH less than 7.25 and PaCO2 greater than 60 mm Hg over 6 hours, as well as RR greater than 35 breaths per minute;
        4. RR greater than 35 breaths per minute, arterial blood gas pH less than 7.2, and Pplat greater than 30 cm H2O;
        5. complicated with cardiogenic shock or cardiac arrest.

        They adopted these doctrine from the H1N1 experience. The results showed a tendency of decline in mortality but with no significant difference. No ECMO 63.2% vs ECMO 57.1%; p=0.782. Noted in the study, 12 patients died and nine survived. The authors imply “we should have started earlier.”

      May 22, 2020

      • Continuous positive airway pressure to avoid intubation in SARS-CoV-2 pneumonia: a two-period retrospective case-control study. May 19. Oranger. Eur Respir J.
        The use of CPAP has been controversial with COVID-19 respiratory failure. This retrospective, case control research letter/study from France of 66 patients casts some light on this controversy. Two periods of time, one with and the other without CPAP, were analyzed for intubation rate in similar COVID-19 patients in a dedicated pulmonary unit. In the non-CPAP period, 6 intubations and two deaths occurred by day 7 (57%), and in the CPAP period, 9 intubations and no deaths occurred by day 7 (23%). No CPAP patients crashed requiring emergency intubation, and acquisition of COVID-19 by HCW was similar during the two time periods.
      • Factors Associated With Intubation and Prolonged Intubation in Hospitalized Patients With COVID-19
        May 19. Kur. Otolaryngology–Head and Neck Surgery.
        Opinion from SAB Member: Dr. David M. Clement
        A retrospective, observational study from Chicago of 486 adult inpatients with COVID-19 that is nicely written and provides a wealth of clinical data. The focus of the study was on demographics and risk factors associated with intubation and time to extubation. 28% (138) of patients were intubated and of those, 56% were extubated, 15% died and 28% were still intubated. Age, male sex and a history of diabetes were independent risk factors associated with intubation. Age and BMI>30 predicted a longer time to extubation. Among the data are some interesting findings, such as 1/3 of patients were intubated in the ED, SpO2 was below 90 in 12% of non-intubated patients, only one non-intubated patient died, and 4% were treated with ECMO. There are limitations acknowledged (e.g. criteria for intubation), but overall the study provides a useful window into a COVID-19 surge. We feel this paper pairs nicely with a previous paper reviewed by the SAB that covered the timing and indications for tracheostomy Tracheostomy in the COVID-19 era: global and multidisciplinary guidance.
      • Technologies to optimize the care of severe COVID-19 patients for healthcare providers challenged by limited resources
        May 19. Rubulo. Anesthesia & Analgesia.
        Opinion from SAB Member: Dr. Lydia Cassorla
        This excellent and comprehensive summary from multinational European and North American authors reviews techniques and approaches that may be of particular utility in limited-resource settings. Topics discussed: ETT positioning, processed EEG for drug conservation, neuromuscular monitoring, paperless documentation in isolation settings, adaptation of anesthesia machines for the ICU, point-of-care diagnostics including testing for infection, point-of-care US, and thromboelastography. One might think of every medical center as limited in resources, therefore, I suspect most readers will find useful information here.

      May 16, 2020

      • Editorial: Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?
        May 15. Telias. JAMA.
        Opinion from SAB Member: Dr. Philip Lumb
        This is an intelligent discussion and summary of related articles that demonstrates interesting observations regarding prone positioning despite small sample sizes, lack of controls and limited outcome benefits in clinical studies. Taken in context of related case studies, this editorial stimulates discussion and further clinical trials.
      • Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID-19: Preliminary Case Series From Lombardy, Italy. May 12. Turri-Zanoni. Otolaryngol Head Neck Surg.
        Most interesting statement in paper: “early recommendations worldwide seem to suggest waiting at least 14 days of endotracheal intubation to avoid clinically futile procedures for patients…” Remainder is common sense infectious disease protection.
      • Potential for Lung Recruitment and Ventilation-Perfusion Mismatch in Patients With the Acute Respiratory Distress Syndrome From Coronavirus Disease 2019
        Apr 28. Mauri. Critical Care Medicine.
        Opinion from SAB Member: Dr. Louis McNabb
        In this article, ventilated patients with COVID-19 were given PEEPs of 5 and 15 cmH2O. The degree of lung recruitment was variable among the participants and most of the V/Q mismatch was attributed to increased dead space ventilation.
        • Dealing With the CARDS of COVID-19
          May 13. Marini. Critical Care Medicine.
          Opinion from SAB Member: Dr. Louis McNabb
          This is an editorial response to above article that describes different phases of COVID-19 lung involvement, which require different ventilator strategies. The author describes the potential pathophysiologic causes of V/Q mismatch.
      • Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit
        May 15. Sartini. JAMA.
        Opinion from SAB Member: Dr. Philip Lumb
        This is a research letter describing observations on non-invasive ventilation (FiO2 0.6; 10 cm H2O CPAP) in the prone position (PP) on April 2nd, 2020. Measured outcomes of proning during the observation period included SPO2, respiratory rate, and comfort and tolerance of PP, before, during and after proning. Fifteen patients were identified and during proning, all demonstrated increased oxygenation, decreased RR, and adequate comfort. The clinical status of patients followed up at day 14 (April 16, 2020) included: 9 discharged home, 1 improved, 3 continued pronation, 1 intubated and in ICU, and 1 died. As the authors state, “Limitations include the small number of patients, short duration of NIV in the prone position, and lack of a control group. Comparisons of NIV in the prone position with oxygen by face mask or NIV in the standard position are needed. Importantly, selection bias is possible.”
      • Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure
        May 15. Elharrar. JAMA.
        Opinion from SAB Member: Dr. Philip Lumb
        This research letter includes 24 patients entered into a spontaneous breathing prone positioning trial. Reported outcomes: 1) ability to tolerate position for specified and increasing times; 2) PaO2 increase in prone position (PP); 3) sustained PaO2 increase on resupination; 4) progression of disease. The article notes that of 5 patients requiring intubation, 4 did not tolerate prone position for > 1 hour. Out of 24 patients, 15 (63%) tolerated PP > 3 hours, oxygenation increased in 6 (25%), and sustained following resupination in 3 (12%). As authors note, the study had several limitations–the sample was small, a single episode of PP was evaluated, the follow-up was short, clinical outcomes were not assessed, and causality of the observed changes cannot be inferred.

      May 15, 2020

      • Mechanical Ventilation in COVID-19: Interpreting the Current Epidemiology
        Apr 26. Wunsch. American Journal of Respiratory and Critical Care Medicine.
        Opinion from SAB Member: Dr. Jay Przybylo
        A plea for action using COVID-19, ARDS and ventilatory support for the example of demonstrating the differences in care that exist internationally and regionally. No aspect of the choice to ventilate exists in a rational, prescribed manner. As evidence, the author cites the JAMA article with 88% New York mortality in mechanically ventilated patients, the difference between the 29% mechanically ventilated patients cited in China compared to 89.9% in the U.S., and the difference in ventilatory assistance between 18.6% and 42.0% in California alone. The author cautions that differences in care resulted in differences in outcomes, publications and conclusions. COVID-19 has amplified these differences in care.
      • Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)
        May 12. McGrath. Anaesthesia.
        Opinion from SAB Member: Dr. David M. Clement
        Prolonged ventilation necessitating tracheostomy is not uncommon with the COVID-19 pandemic. To address most questions about tracheostomies, UK stakeholder organizations involved in tracheostomy care developed consensus guidelines based on the available literature, expert opinion, and existing multidisciplinary guidelines. These guidelines address infectivity of patients with respect to tracheostomy, indications and timing, aerosol-generating procedures, risks to staff, insertion procedures, and management following tracheostomy. The paper is long but well organized, and starts out with the key points, such as recommending an apnea test, the use of full muscle paralysis for tracheostomy insertion, and plans to define and limit trach care post-insertion to reduce virus exposure to staff.
      • Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome
        May 12. Beloncle. Annals of Intensive Care.
        Opinion from SAB Member: Dr. Jay Przybylo
        A follow-up to a previous case report prospective study demonstrating the effect of high vs low PEEP on two groups of mechanically ventilated SARS-CoV-2 patients divided into highly vs poorly recruitable lung mechanics. Determining the R/I ratio, the ratio between the recruited lung compliance and CRS at a PEEP of 5 cmH2O, might lead to better ventilatory management.
      • Subphenotyping ARDS in COVID-19 Patients: Consequences for Ventilator Management
        May 12. Bos. Annals of the American Thoracic Society.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        As the authors note, there are phenotypes that can be used as a basis to treat patients with ARDS. For example, patients with focal lung pathology respond better for ventilation to prone positioning, though their lungs are not as recruitable. The authors in a retrospective sequential analysis of 70 patients in The Netherlands tried to see if the same was true in patients with COVID-19 and found that that was not the case.

      May 12, 2020

      • Nonsedation or Light Sedation in Critically Ill, Mechanically Ventilated Patients. Mar 19. Olsen. NEJM.
        The study involves 710 patients from 7 ICUs of 3 Scandinavian countries from 2014 – 2017. Randomized, retrospective, propensity score match (several exclusion) for ventilated patients with light sedation and no sedation. The sedation protocol involves Propofol, midazolam, M, clonidine (not dex.) …. The characteristics of the patients at baseline were similar in the two trial groups, except for the score on the Acute Physiology and Chronic Health Evaluation (APACHE) II, which was 1 point higher in the nonsedation group (RASS -1.3 to – 2.3). The difference of Delirium 1 day less, Thrombotic event 2.5%, Primary outcome 90 days mortality – sedation group lower than nonsedation ? Secondary: 1 day less of delirium, Thrombotic event 2.5% higher and Mech. Vent – one day less in nonsedation group. Most other were no different or statistically not significant.

      May 11, 2020

      May 7, 2020

      • Application of Lung Ultrasound during the COVID-19 Pandemic: A Narrative Review
        Apr 30. Convissar. Anesthesia & Analgesia.
        Opinion from SAB Member: Dr. David M. Clement
        An excellent review of the literature on the use of point of care ultrasound (POCUS) with the current COVID-19 pandemic and previous viral epidemics. Typical POCUS findings (thick irregular pleural lines, B lines, A lines during recovery) are as good or better for diagnosis and followup compared with CXR or CT, and are nicely shown on accompanying videos. “Lung ultrasound may be preferred over chest radiography or computed tomography in the diagnosis and monitoring of COVID-19 patients due to its ease of bedside use, low associated cost, and reduced risk of infectious spread.”

      May 6, 2020

      May 5, 2020

      May 1, 2020

      April 29, 2020

      • COVID-19 Associated Pulmonary Aspergillosis. Apr 27. Koehler. Mycoses.
        The authors performed a chart review of patients in 2 separate ICUS with COVID-19 and acute respiratory distress syndrome and noted that in 5/19 patients, with moderate to severe acute respiratory distress syndrome without underlying immunocompromising disease, they had invasive pulmonary aspergillosis. Whether this represented invasive disease or colonization is not clear.

      April 28, 2020

      • Management of COVID-19 Respiratory Distress
        JAMA. Apr 24, 2020.
        John J. Marini; Luciano Gattinoni
        Opinion from SAB Member: Dr. Louis McNabb
        Discusses the differences in the lung mechanics and approaches to treatment in the early vs. the late phase of lung injury in COVID-19. Primary goal is to prevent patient self-induced lung injury from increased transpulmonary pressures from patient’s hypoxic drive.
      • The role of extracorporeal life support for patients with COVID-19: Preliminary results from a statewide experience
        Apr 25. Sultan. Journal of Cardiac Surgery.
        Opinion from SAB Member: Dr. Jagdip Shah
        Preliminary report of ECMO from Pittsburgh/Pennsylvania describing their experience of the first 10 patients on ECMO. All patients were cannulated in a venovenous configuration. As of 9Apr2020, 2 patients were successfully liberated from ECMO support after 7 and 10 days, 1 patient was on a weaning course, 1 death occurred after 9 days on ECMO due to multiorgan dysfunction, and all other patients were still on ECMO with a median time of support of 11 days (IQR, 4‐14).

      April 25, 2020

      • Acute Pulmonary Embolism Associated with COVID-19 Pneumonia Detected by Pulmonary CT Angiography. Apr 24. Grillet. Radiology.
        Retrospective study of patients that received contrast CT’s of chest. 23 of 100 positive for PE. Patients with PE tended to be sicker and more likely on ventilators. No data on treatment of PTS with PE or their outcome.
      • Acute Pulmonary Embolism in COVID-19 Patients on CT Angiography and Relationship to D-Dimer Levels
        Apr 23. Leonard-Lorant. Radiology.
        Opinion from SAB Member: Dr. Philip Lumb, Dr. Louis McNabb
        PL: Reports 32/106 (30% [95%CI 22-40%]) COVID-19 positive patients were diagnosed positive for acute PE on pulmonary CT angiography between March 1st and March 31st. Noted in this series incidence correlated with increased D-dimer levels; sensitivity 32/32 positive PE with D-dimer >2660 mcg/L (100% [95%CI 88-100]) with a specificity of 49/74 (67% [95%cI 52-79]) on CT angiography. Authors confirm higher incidence of PE in COVID-19 patients with elevated D-dimer, suggested secondary to COVID induced activation of blood coagulation secondary to systemic inflammatory response and recommend increased awareness of and surveillance for PE complications. LM: The results of this article give a theoretical basis for routine use of full dose anticoagulation in COVID-19 patients. The efficacy of such a practice should be explored in controlled studies with prophylactic anticoagulation as a comparator.

      April 24, 2020

      April 22, 2020

      • Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Mar 20.
        Jay: In essence, the original article described ensuring ECMO services around the world meet the guidelines as listed for service development but did not go into direct patient care, ie. pump flow rates or patient determinants of success, labs and vital signs. The first LOE enters the discussion of a single measurement of patient success, HGB levels. Still left out of the discussion is actual scientifically derived recommendations on the entire process of patient management…Lancet Respir Med…
        An article by an international authorship neither a LOE or research article, rather a “how to” recommendation for the world to implement ECMO when needed. Discusses in depth the team, equipment and patient transfer, but does not list recommendations of patient management.

      April 21, 2020

      April 20, 2020

      April 16, 2020

      April 15, 2020

      April 14, 2020

      • Point-of-care lung ultrasound in patients with COVID-19 – a narrative review Apr 10. Smith. Anaesthesia. 
        Opinion from SAB Member: Dr. Barry Perlman
        Review on the use of ultrasound imaging for the diagnosis and management of COVID-19 patients with associated lung injury and respiratory failure. Ultrasound can detect COVID-19 associated pleural line irregularities and B-line artifacts caused by interstitial thickening, inflammation, and small consolidations. These changes increase with severity of disease, so point-of-care ultrasound can be used to follow disease progression and aid in clinical decision making. The authors make recommendations regarding a standardized ultrasound lung exam, scoring system, and training of additional providers in the use of lung ultrasound.

      April 11, 2020

      April 10, 2020

      April 8, 2020

      • Extracorporeal membrane oxygenation (ECMO): does it have a role in the treatment of severe COVID-19? Apr 7. Hong. Int J Infect Dis.
        This article reviews success in decreasing mortality with ECMO in ARDS, SARS and MERS. However, data that ECMO reduces mortality in Covid-19 is lacking at this time. Also, ECMO will not be available at every location where it may be needed.
      • The use of high-flow nasal oxygen in COVID-19 Apr 4. Lyons. Anaesthesia.
        COVID-19 SAB Opinion from: Dr. David M. Clement, Dr. Jack Lance Lichtor
        David Clement: A summary of the studies of high flow nasal oxygen (HFNO), a review of various conflicting guidelines for its use with COVID-19 patients, and a common sense approach (mainly to avoid rigid thinking) that may help front line workers decide whether to use it or not. PPE, negative pressure rooms, modification of flow rate are advised if HFNO is used. Jack Lance Lichtor: Though high-flow oxygen therapy may have some benefit in patients with acute hypoxaemic respiratory failure, aerosolization may result in COVID-19 virus spread. Yet, if the use of this form of oxygen therapy is felt to be useful, then it should be used in a negative pressure room.

      April 6, 2020

      April 5, 2020

      April 4, 2020

      March 31, 2020

      March 20, 2020

      March 16, 2020

      March 2020

      February 12, 2020

    1. Cardiovascular / Hemodynamic Management
      Updated Frequently

      November 23, 2020

      • SAB Comment: These two studies used data from the same database.
      • COVID-19-associated Non-Occlusive Fibrin Microthrombi in the Heart. 11/16/2020. Bois MC. Circulation.
        In this very interesting study a “detailed cardiac evaluation of a series of COVID-19 individuals undergoing postmortem evaluation is provided, with four aims: 1) describe the pathologic spectrum of the myocardium; 2) compare to an alternate viral illness; 3) investigate angiotensin converting enzyme 2 (ACE2) expression; and 4) provide the first description of the cardiac findings in patients with cleared infection.” These findings were compared in 3 groups of patients including COVID-19 patients (n=15 including 3 cleared), influenza A/B (n=6), and non-virally mediated deaths (n=6). There were 16 COVID-19 cases with non-occlusive microthrombi compared with 2 cases each in the other groups. Focal myocarditis was seen in 4 active patients and one cleared case. ACE2 endothelial expression was lower in those with COVID-19 while myocardial expression did not differ by disease category, sex, age, number of disease comorbidities. Virus was not present in myocardial cells. Cardiac amyloidosis was seen in 4 cases and myocarditis was present in one-third of cases. The authors conclude that the high incidence of microthrombi in the cardiac vascular is a potential reason to use anticoagulants in these patients. A higher risk of complications including death may be seen in patients with cardiac disease, particularly those with amyloidosis.

      November 16, 2020

      • Neutrophil extracellular traps and thrombosis in COVID-19. 11/5/20. Zuo Y. J Thromb Thrombolysis.
        Forty-four patients with COVID-19 had blood collected for neutrophil extracellular traps (NETs) and neutrophil activation. Eleven of these patients developed thrombosis despite at least prophylactic heparin. Thrombosis in COVID-19 was associated with higher levels of circulating NETs and calprotectin (neutrophil activation). These data further add to the characterization of COVID-19 and the stepwise understanding of how to combat the epidemic.

      November 9, 2020

      November 4, 2020

      • Characterization of Myocardial Injury in Patients With COVID-19. 10/30/20. Giustino G. J Am Coll Cardiol.
        This retrospective, international, multicenter cohort study (7 hospitals in NYC and Milan) reviewed 305 patients with documented RT-PCR COVID-19 diagnosis with myocardial injury diagnosed at admission or during hospitalization. Inclusion criteria included elevated cardiac troponins, EKG abnormalities and full TTE examination. Findings indicated that severity of cardiac disease indicated by serial increases in troponins associated with graded TTE abnormalities (none, moderate, severe) was a useful prognostic indicator of outcome. Of 305 patients, myocardial injury was documented by elevated troponins in 190 (62.3%). When compared with patients with no myocardial injury, increasing severity of myocardial injury was associated with increased mortality with discrimination noted between “no” and minor TTE abnormalities versus significant abnormalities and increased inflammatory biomarkers and troponins. Effects of co-morbidities and BMI were noted as additional risk factors for myocardial damage and TTE abnormalities.
      • Cardiac Injury in COVID-19-Echoing Prognostication. 10/30/20. Lavie CJ. J Am Coll Cardiol.
        This editorial is best summarized in the following direct quote underlining the importance of the Giustino et al manuscript. “The current recommendations of the American College of Cardiology (ACC) endorse the measurement of cTn levels when a diagnosis of acute myocardial infarction is being considered in patients with SARS-CoV-2 infection. This indication seems somehow inadequate according to the information collected by Giustino et al. (above), (12), whereby there is now evidence that Tn-positive COVID-19 patients may benefit from routine TTE, which would allow practitioners to garner useful prognostic information and to establish specific therapeutic options in patients with cardiac injury.” An excellent discussion and table are included in the editorial.
      • Characteristics of cardiac injury in critically ill patients with COVID-19. 10/24/20. Doyen D. Chest.
        This prospective study of 43 consecutive COVID-19 positive patients admitted to two French ICUs was designed to characterize incidence and time course of cardiac injury by serial measurements of cardiac biomarkers (troponin), EKGs and echocardiographic investigations. Extensive cardiac involvement documented with 49% demonstrating injury on ICU admission and 70% experiencing injury within the 14-day observation window. New atrial dysrhythmias, and RV and LV systolic as well as diastolic dysfunction noted with greater RV systolic dysfunction associated with increased disease severity. Conclusion: Cardiac injury is common in COVID-19, occurs early in disease, and patients with injury exhibit more RV than LV systolic dysfunction.

      October 30, 2020

      • Venous Thromboembolism in COVID-19. 10/25/20. Schulman S. Thromb Haemost.
        This is an excellent review regarding the mechanisms and pathogenesis of the disease biomarkers and their clinical usefulness. Risk assessment models are discussed as well as the type and strength of prophylaxis based on available evidence. Recommendations or position statements from 10 sources are discussed along with treatment recommendations according to current guidelines. Thrombosis prophylaxis with low molecular weight heparin is recommended for most hospitalized patients along with a recommendation against escalating anticoagulant doses. Therapeutic anticoagulation is advised only in response to a very high suspicion or in the presence of documented venous thromboembolism. An excellent algorithm regarding VTE treatment is presented.

      October 23, 2020

      October 2, 2020

      • Biomarkers for the prediction of venous thromboembolism in critically ill COVID-19 patients. 9/14/20. Dujardin RWG. Thromb Res.
        These authors present a prediction model for venous thromboembolism (VTE) in critically ill COVID-19 patients. They studied 127 adult patients with confirmed infection admitted to the intensive care unit. Testing included daily liver and renal function, and C-reactive protein (CRP). Twice weekly D dimer, fibrinogen, and antithrombin levels were done. Weekly duplex scans in all, and chest CT done based on clinical suspicion. The probability of a VTE with a D dimer greater than 15,000 ng/ml and a CRP greater than 280 was 98%. Hypoxemia and other variables were not predictive. Study suggests inflammation is a driving force for the development of VTE.

      September 30, 2020

      • Cardiopulmonary exercise and the risk of aerosol generation while wearing a surgical mask. 9/11/20. Helgeson SA. Chest.
        The authors quantified the number of various-sized airborne particles 6 feet from exercising normal volunteers wearing type II procedural surgical masks. They found there was a minimal increase of particle number at low and moderate exercise but a doubling of the ambient baseline of small respirable particles (0.3–0.5 micrometer) with very hard exercise. Larger droplet sized particles were not significantly increased during any stage of exercise. These results may be applicable to gyms and health clubs if all participants wear surgical masks.

      September 25, 2020

      • COVID-19 concerns aggregate around platelets. 9/10/20. Battinelli EM. Blood.
        This is a well-written, useful editorial which describes the essence of the following two papers, including its limitations and future steps.
      • Platelet gene expression and function in patients with COVID-19. 9/10/20. Manne B. Blood.
        Using platelet RNA sequencing, this group profiles gene expression in the platelets of COVID-19 patients (n= 41) and finds altered gene expression profiles in pathways associated with ubiquitination, antigen presentation, and mitochondrial dysfunction. Patients with COVID-19 have higher levels of platelet activation at rest and increased interactions with neutrophils, monocytes, and T cells compared with healthy donors. Platelet functionality studies demonstrate hyperactivity, as evidenced by increased aggregation, spreading on fibrinogen and collagen through upregulation of the MAPK pathway, and increased thromboxane generation. These new data help extend prior data into the basic science of the hypercoagulable state of COVID-19.
      • Platelet activation and platelet-monocyte aggregate formation trigger tissue factor expression in patients with severe COVID-19. 9/10/20. Hottz E. Blood.
        This group demonstrates that COVID-19 is associated with increased platelet activation. They show that the platelets of critically ill COVID-19 patients exhibit increased platelet aggregation and platelet-monocyte aggregation. Further, these changes correlate with a worse outcome. Changes in platelet activation were associated with increased platelet expression of P-selectin and CD63. Platelets from patients with severe COVID-19 infection induce monocyte-derived tissue factor (TF) expression that is diminished by pretreating COVID-19 patient platelets with an anti–P-selectin neutralizing antibody or the clinically approved anti-αIIb/β3 monoclonal antibody, abciximab. These data are new and add to the understanding of the role that platelets play in the hypercoagulable state of COVID-19.

      September 21, 2020

      • Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients. 9/9/20. Mouhat B. Eur Respir J.
        This article reviews 162 patients who had computed tomography pulmonary angiography (CTAP) with clinical pulmonary deterioration taken from 349 patients with COVID-19 in a French hospital. Twenty-seven percent had pulmonary embolism (PE). Review of their data with multivariate analysis demonstrates lack of anticoagulation and D-dimer > 2590 ng/ml to be predictive of PE. A D-dimer level >2590 ng/mL−1 was associated with a 17-fold increase (!), and lack of anticoagulation with a 4-fold increase in the risk of PE. Linearity was verified for D-dimers in the study population (test of linearity <0.001). This paper adds more details to the literature and helps guide the clinician.

      September 14, 2020

      • Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19. 6/29/20. Paranjpe I. JACC.
        The authors studied 2,773 hospitalized patients with COVID-19. Therapeutic anticoagulation was administered to 28% of these patients and survival between those who received prophylactic versus therapeutic anticoagulation was similar. In patients who required mechanical ventilation who received treatment doses of anticoagulation, in-hospital mortality rates were lower. Bleeding was more common for intubated patients. Prospective randomized trials will be needed to confirm these findings but the results in this study are very encouraging. These preliminary results provide some guidance for selecting therapeutic heparin in critical situations.
      • Coagulation biomarkers are independent predictors of increased oxygen requirements in COVID-19. 8/17/20. Rauch A. J Thromb Haemost.
        This well-done study from Lille, France of 234 patients admitted with COVID-19 presents new data. von Willebrand factor (VWF) levels were associated with severity and oxygen need in COVID-19 at admission; low factor VIII (FVIII)/VWF ratio at admission is predictive of increased oxygen requirements; and coagulation biomarkers predict outcome independently of major comorbidities in COVID-19. Furthermore, FVIII is predictive of early thrombotic events irrespective of BMI in COVID-19.
      • Safety Update: COVID-19 Convalescent Plasma in 20,000 Hospitalized Patients. 7/19/20. Joyner MJ. Mayo Clin Proc.
        This was a study based on a collaborative effort of the FDA, Mayo Clinic and the national blood banking community. Over 20,000 patients received convalescent plasma in the US. In this report of 20,000 patients, the one week mortality was 13%; transfusion reactions were <1% (n=78). This is important data supporting the use of convalescent plasma. However, these data examined the safety of its use not the efficacy. While these data are important, we will be looking forward to further information in the future.

      September 9, 2020

      • Anticipating and managing coagulopathy and thrombotic manifestations of severe COVID-19. 8/16/20. Godoy LC. CMAJ.
        This is an interesting, informative, and well-written review. The explanation of the pathology beginning with the viral spike protein invading the cells facilitated by ACE2 followed by a cascade of reactions involving inflammatory and immunological pathways resulting in widespread endotheliitis is well stated. The clarity of the authors’ approach is refreshing. A summary of current recommendations is presented along with interesting individual studies that stimulate the reader and the researcher to pursue additional studies. It’s interesting to note that the reported bleeding rate using full anticoagulation is not much different than using lower doses.

      August 31, 2020

      August 5, 2020

      • Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. 8/4/20. Lala A. JACC.
        This is a retrospective analysis of troponin-I levels taken within 24 hours of admission from 2,736 patients admitted to Mount Sinai Health System hospitals between February 27 and April 12. Thirty-six percent of patients showed elevated levels (normal <0.03 ng/ml). After correction for co-morbidities and clinical severity, small elevations were associated with increased morbidity and mortality. Elevations greater than three times normal (>0.09ng/ml) were associated with significantly higher risk. Troponin may be a useful indicator of cardiac involvement and may aid disease stratification.
      • EDITORIAL: Myocardial Injury in COVID-19 Patients: The Beginning or the End? 8/1/20. Uriel N. J Am Coll Cardiol.
        This editorial accompanies the article by Lala et al entitled, “Prevalence and Impact of Myocardial Injury in Patients Hospitalized with COVID-19 Infection,” and suggests pathophysiological pathways of cardiac involvement and underscores the importance of troponin-I elevations as markers of disease severity and outcome. The editorial reinforces the importance of cardiac involvement in COVID-19 disease and suggests troponin elevations could be a useful adjunct in disease stratification.

      August 3, 2020

      July 31, 2020

      • COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up. 6/16/20. Bikdeli B. J Am Coll Cardiol.
        This article is an excellent clinically relevant review of thrombotic complications of COVID-19. Systemic and pulmonary venous and arterial thrombosis and thromboembolism are common in COVID-19. Thrombi are observed in virtually every organ. This is caused by inflammation, platelet activation, hypercoagulability, endothelial dysfunction, constriction of blood vessels, stasis, hypoxia, muscle immobilization, and disseminated intravascular coagulation (DIC).
        Fever and inflammation cause hypercoagulability and impair fibrinolysis. Cytokine interleukin-6 (IL-6) levels correlate with hypercoagulability and disease severity.
        Elevated antiphospholipid antibodies are associated with thrombosis. The liver increases production of procoagulant substances. Prothrombin time and activated partial thromboplastin time are moderately prolonged. Moderate thrombocytopenia is observed. C-reactive protein is elevated. Cytokine storm and excessive systemic inflammation are associated with lymphocytopenia, elevated D-dimer, elevated fibrin degradation products (FDP), and DIC. D-dimer levels and DIC are prognostic.
        Guidelines recommend thromboprophylaxis. Prophylaxis with low-molecular weight or regular heparin, fondaparinux, or a direct oral anticoagulant such as apixaban or rivaroxaban should be considered. Heparins bind tightly to COVID-19 spike proteins impeding the entry of the virus into cells. Heparins also downregulate IL-6 and reduce immune activation. A non-randomized study suggests that among patients requiring mechanical ventilation, systemic anticoagulation may be associated with reduced mortality without increasing major bleeding. However, systemic anticoagulation has not proven to be beneficial in ARDS due to other etiologies. After hospital discharge prolonged prophylaxis may be beneficial.

      July 27, 2020

      • A proposal for staging COVID-19 coagulopathy. 7/21/20. Thachil J. Res Pract Thromb Haemost.
        Authors from three continents propose a framework within which to stage COVID-19 associated hemostatic abnormalities, and potentially guide treatment. A theory that infected lung epithelium acts as the epicenter of coagulation with early stages that are difficult to diagnose is described, along with a 3-stage disease model. Currently there are no reliable markers to guide treatment; however patterns and questions for researchers are outlined. A table outlines 11 current international clinical trials on approaches to coagulopathy and are listed on clinicaltrials.gov.

      July 24, 2020

      • Blood type and outcomes in patients with COVID-19. 7/12/2020. Latz C. Ann Hematol.
        Retrospective study of 1289 SARS-CoV-2 + patients /7648 tested patients w/ known ABO blood type. No blood group had an increased or decreased risk of severe disease, inflammatory markers, intubation, or death.  Type A had the expected risk of +PCR, type A, type O had a lower risk and types B and AB and Rh+ patients had a higher risk.  These results contrast w/ previous reports, however data are not fully comparable.

      July 17, 2020

      • ABO Phenotype and Death in Critically Ill Patients with COVID-19. 7/1/20. Leaf RK. Br J Haematol.
        Review by the SAB
        By Lydia Cassorla, on behalf of the SAB
        In this Letter to the Editor, ABO blood type data from adults admitted to ICUs over 38 days in the 67-center Study of the Treatment and Outcomes in critically ill Patients from COVID-19 (STOP-COVID) study were analyzed. Patients were followed until hospital discharge, death, or May 8, 2020 – a date that included a minimum of 28 days follow-up for those still hospitalized. 2033/3239 (62.8%) had ABO data available. 799/2033 (39.3%) died within 28 days. Death rates were similar across ABO phenotypes in all race/ethnicity categories, as well as Rh status. Among White patients, the observed distribution of ABO phenotypes differed from expected, primarily due to blood type A being over-represented (45.1% observed vs. 39.8% expected) and blood type O being under-represented (37.8% observed versus 45.2% expected). Among Black and Hispanic patients the observed and expected distributions of ABO phenotypes were similar.

      July 10, 2020

      July 8, 2020

      June 3, 2020

      • The Spectrum of Cardiac Manifestations in Coronavirus Disease 2019 (COVID-19) – a Systematic Echocardiographic Study
        May 29. Szekely. Circulation.
        Opinion from SAB Member: Dr. Paul D. Scanlon
        This is a prospective survey of echocardiographic findings in 100 patients admitted with COVID-19–20% had repeat echo during clinical deterioration. At baseline, 61 had mild disease (no O2), 29 had moderate disease (non-inv O2), and 10 had severe disease (intubated). 32 had normal baseline echos, 39 had RV dilatation and dysfunction, 16 had LV diastolic dysfunction only, 10 had LV systolic dysfunction. Of the 20 who deteriorated, 12 (60%) had RV deterioration, of whom 5 (25%) had DVT (possible PE?). 5 (25%) had decrease in LVEF. Lung US was c/w ARDS, without evolution to cardiogenic pulmonary edema.

      May 21, 2020

      • Cardiovascular phenotypes in ventilated patients with COVID-19 acute respiratory distress syndrome
        May 18. Evrard. Critical Care.
        Opinion from SAB Member: Dr. Philip Lumb
        This is a comparison of TEE findings in 18 COVID-19 patients with 23 seasonal flu (A-H1N1) patients ventilated for flu-associated ARDS from previous 2 years. While COVID-19 patients were older, disease was less severe (SAPSII, SOFA, less vasopressor support). Cardiac findings indicated that left ventricular failure, acute and severe cor pulmonale were higher in flu. Interestingly, the authors report, “Hypovolemic and hyperkinetic phenotypes were similarly observed in both groups. Despite similar tidal volume and PEEP level, COVID-19 patients had significantly higher P/F ratio and respiratory-system compliance, and lower driving pressure than flu patients.” The manuscript includes illustrative tables. This is a preliminary study requiring further investigation to elucidate cardiac phenotypes during COVID-19 disease.

      May 20, 2020

      May 6, 2020

      • Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19. May 4. New York City Health Department.
        Based on 2020 Health Alert #13 from the New York City Health Department, multi-system inflammatory syndrome, recently reported by authorities in the United Kingdom, is also being observed among children and young adults in New York City and elsewhere in the United States and includes features of Kawasaki disease or features of shock. If a patient is less than 21 years old, with persistent fever (four or more days), and either incomplete Kawasaki disease, typical Kawasaki disease, and/or toxic shock syndrome-like presentation; and there is no alternative etiology identified that explains the clinical presentation, the patient should be presented to the New York City Health Department. The findings have been published: Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 2020; doi: 10.1542/hpeds.2020-0123; and Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020 Mar 28;395(10229): 1033-1034. DOI: 10.1016/S0140-6736(20)30628-0.

      May 5, 2020

      May 2, 2020

      • Renin–Angiotensin–Aldosterone System Blockers and the Risk of Covid-19
        May 1. Mancia. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. David M. Clement
        This is the first large study confirming smaller studies and various recommendations on ACEI and ARBs use in COVID-19 patients. A case-control study from Italy of 6,272 COVID-19 patients looking for an association between ACEI or ARB use and the risk of COVID-19 disease. No association was found between pre-infection ARB/ACEI use and susceptibility or severity of SARS-CoV-2 infection. Starting ACEI or ARB drugs during infection was not studied.

      May 1, 2020

      • A Marker of Systemic Inflammation or Direct Cardiac Injury: Should Cardiac Troponin Levels be Monitored in COVID-19 Patients? 4/29/2020. Atallah. Eur Heart J Qual Care Clin Outcomes.
        Detailed discussion of potential evolution of cardiac injury during COVID-19 demonstrating increased mortality in patients developing cardiac dysfunction. Discusses enzymatic increases that aid in prognosis and risk classification. Troponin level increases associated with other markers of inflammation (IL-6). Also noted were increases in D-dimer and indications of a procoagulant state that could lead to ischemia, thrombosis and subsequent cardiac injury.
        “In summary, there are several mechanisms that could be at play to explain myocardial injury in relation to COVID-19 infection, that include but are not limited to: Myocarditis, sepsis and associated systemic inflammatory response, pro-coagulant condition, destabilization of coronary plaque, and hypoxia.”
        Manuscript concludes with 7 recommendations and is published on behalf of the European College of Cardiology.
      • Current perspectives on Coronavirus 2019 (COVID-19) and cardiovascular disease: A white paper by the JAHA editors
        Apr 29. Gupta. Journal of the American Heart Association.
        Opinion from C19SAB: Dr. David M. Clement
        A “White Paper” from the international editorial board of the Journal of the American Heart Association, thoroughly addressing the important aspects of cardio-vascular disease during the COVID-19 pandemic. Very long, but well organized to highlight the important conclusions on troponin elevations, hypertension (RAS), vascular events (including hypercoagulability), arrhythmias (i.e. long QT with some drugs), myocardial injury, ECMO, healthcare worker protection and ethics. Of note, explanations of the pathophysiology of CV disease usually circle back to the inflammatory response to COVID-19. Statins and antiplatelet therapy recommended. A thorough overview of the current knowledge.

      April 30, 2020

      • COVID-19-related myocarditis in a 21-year-old female patient
        Apr 13. Kim. Eur Heart J.
        Opinion from SAB Member: Dr. Barry Perlman
        Report of 21-year-old South Korean patient with COVID-19 and elevated Troponin I of 1.26 ng/ml and NT-proBNP of 1929 pg/ml. Chest CT showed multifocal consolidation and bilateral peripheral lower lobe ground-glass opacification. EKG showed NSIVCD and multiple PVCs. ECHO showed severe LV systolic dysfunction. Cardiac CT showed normal coronary arteries but myocardial edema and hypertrophy with lateral LV subendocardial perfusion defect. Cardiac MRI was also consistent with myocardial edema with extensive transmural late gadolinium enhancement. Her treatment or clinical course were not discussed.
      • Troponin and BNP Use in COVID-19
        Mar 18. Januzzi. American College of Cardiology.
        Opinion from SAB Member: Dr. Barry Perlman
        Discussion of troponin and BNP elevations in COVID-19 patients. While increased levels of both biomarkers are common in these patients and are associated with an unfavorable course, the mechanism is not clear as severe respiratory illness can cause both to rise. Cardiomyocytes have abundant distribution of ACE2, which suggests that the troponin rise may be due to direct, nonischemic myocardial damage due to myocarditis. It is recommended that troponin and BNP be measured in COVID-19 patients only if acute MI or heart failure are suspected clinically. ECHO or coronary angiography should only be performed if results are expected to impact outcome.

      April 28, 2020

      April 24, 2020

      • Lung Ultrasound in Children With COVID-19. Apr 23. Denina M. Pediatrics.
        Study involves a US application of 8 pediatric patients in Italy. The author concludes: practical, PoC application may be superior concurrent confirmation with radiological for hard evidence and superior for one patient who was recovering who had a clear X-ray but a presence of a Curly B line. None of them were ventilated, 2 patients were on oxygen. No pictures in the article, and a small number. US can replace X-ray in pediatrics.

      April 22, 2020

      • Category: Treatment / Prevention of COVID-19
        Endothelial cell infection and endotheliitis in COVID-19
        Apr 20. Varga. The Lancet.
        Opinion from SAB Member: Dr. Philip Lumb
        Interesting discussion exploring angiotensin converting enzyme 2 (ACE2) receptors on developing pathophysiology of organ failure in COVID-19 infection. 3 case reports of multi-organ failure with detailed postmortem histology demonstrating endotheliitis in multiple organs (lung, heart, kidney, GI tract), all of which express ACE2 receptors as do endothelial cells. While the mechanism of vascular derangement in COVID-19 is unknown, the possibility of endothelial cell involvement by the virus is explored. Pathology indicated direct viral infection of endothelial cells and diffuse endotheliitis in examined necropsy specimens. The authors conclude that their findings support treatment with “therapies to stabilize the endothelium while tackling viral replication, particularly with anti-inflammatory anti-cytokine drugs, ACE inhibitors, and statins.” (References supplied).

      April 21, 2020

      • Clinical Implications of SARS-Cov2 Interaction with Renin Angiotensin System
        Apr 16. Brojakowska. Journal of the American College of Cardiology.
        Opinion from SAB Member: Dr. Jay Przybylo
        A data-rich review for physicians/scientists describing what is known to date and what is proposed for study of the complex interactions of COVID-19 and the Renin Angiotensin System activity. A combination of animal and human findings covers multiple body organs with an emphasis on the cardiopulmonary system. The virus needs the Angiotensin Converting Enzyme to enter the cell. ACE inhibitors upregulate the receptor but are integral in inactivating anti-inflammatory pathways. At present the recommendation is to continue the ACE inhibitors. More to follow, hopefully in time to have an effect.

      April 20, 2020

      April 17, 2020

      • Neurologic Features in Severe SARS-CoV-2 Infection
        Apr 15. Helms. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. Louis McNabb
        Observational study describing neurologic deficits such as agitation (69%), cortical spinal tract signs (67%), confusion (65%), and dysexecutive syndrome post discharge (33%). MRI demonstrated frontotemporal hypoperfusion in 11/11 pts with perfusion imaging. Curiously, all 7 pts with CSF samples tested negative for SARS-CoV-2 infection. Many of the findings would be anticipated in elderly patients (median age 63) in average ICU census without COVID-19 infection.
      • Suspected myocardial injury in patients with COVID-19: Evidence from front-line clinical observation in Wuhan, China. Apr 16. Deng Q. Int J Cardiol.
        This article from Wuhan n= 112 patients. ITS pre proof. Retrospective study. Comparison was 2 group of 4 patients with COVID 19 + VE: A: Those who survived and possibly d/c home to B: those who didn’t survive. Excluded 5 patient with pre existing cardiac conditions (CHF, MI 4 days ago ). Stastic believable: p, fitness test.…Lot of redundant numbers / lab….No biopsy or Nuclear study. Extensive data collection of these patients. Ongoing as patient (61) are still in hospital. Troponin & BNP not remarkable until 1 week before the death both of them rises, CPK & LDH late elevation. Covid-19 caused myocarditis – no solid evidence. Inflammatory process/hypoxia are likely cause of myocarditis. 5 Patients had pericardial effusion. TR Flow velocity.., PUM PR, CVP, stiffness of RT/ LT vent , wall motion ……. All Normal to high Normal. No other ECHO / EKG – All non specific. Hypoxia on vent support , ECMO (14), MOF, Cytokine Strom (no inflammatory markers – IL Panel), Met. Acidosis, renal/ liver failure, Abnormal coag. Profile …before Death. Pulm. Hypertension -> ARDS related? From the clinical standpoint and front-line data analysis in our study, though there was evidence of myocardial injury and 12.5% COVID-19 patients had cardiac abnormalities similar to myocarditis, the characteristic changes of cardiac troponin I over time and the absence of typical signs on echocardiography and ECG have suggested that myocardial injury is more likely related to systemic consequences rather than direct damage by the 2019 novel coronavirus. The elevation in cardiac markers was probably due to secondary and systemic causes and can be considered as the warning sign for recent adverse clinical outcomes of the patients.
      • The Science Underlying COVID-19: Implications for the Cardiovascular System. Apr 16 Liu PP. Circulation.
        This is a review article that is published ahead of print. It is well written and detailed and describes the relationship between COVID-19 and the cardiovascular system. Briefly, whereas COVID-19 is primarily a respiratory infection, it has important systemic effects including on the cardiovascular and immune systems. Between 8-28% of patients with COVID-19 infections will manifest troponin release early in the course of the disease, reflecting cardiac injury or stress. The presence of troponin elevation, or its dynamic increase during hospitalization, confers up to 5 times the risk of requiring ventilation, increases in arrhythmias such as VT/VF, and 5 times the risk for mortality. One feature of the virus is that it has enhanced ACE2 receptor binding affinity. Given that ACE2 receptors are located in the human oral pharynx and upper airway, this allows for person-to-person transfer. ACE2 has been confirmed recently as the SARS-CoV-2 internalization receptor that helps to facilitate cell entry. TMPRSS2 and ACE2 are co-expressed in lung, heart, gut smooth muscle, liver, kidney, neurons and immune cells35. Their distribution may help to explain patient symptoms or laboratory findings in COVID-19. And there is more described in the article.

      April 15, 2020

      April 11, 2020

      April 9, 2020

      April 8, 2020

      April 4, 2020

      April 3, 2020

      March 28, 2020

      March 27, 2020

      March 24, 2020

      March 20, 2020

    1. Multisystem Disease Management
      September 14, 2020

      September 4, 2020

      • SARS-CoV-2 another kind of liver aggressor, how does it do that?. 8/29/2020. Lozano-Sepulveda SA. Ann Hepatol.
        This is an overview of all the recent findings regarding the molecular biology of the virus and its several modes of assault on liver disease in COVID. Authors conclude the cross-talk cellular protein virus is pivotal for its harmful injury to the liver. Admits the pathogenesis is multifactorial, evolving understanding of pathogenesis. Its natural history of the disease is unestablished. It has an informative cartoon.
      • SARS-CoV-2 RNA in serum as predictor of severe outcome in COVID-19: a retrospective cohort study. 8/28/2020. Hagman K. Clin Infect Dis.
        These authors in this retrospective study have an observation for COVID-RNA in Serum (n= 61, + ve=high viral load e.g. unable to control viral replication) at admission (10th day symptoms) met with an outcome of critical disease or mortality with the hazard ratios of 7.2 and 8.6, respectively for critically ill patients compared to serum PCR negative (n= 106) group. Authors infer -Not detecting COVID-RNA in serum indicated a high chance of uncomplicated recovery. The disease severity was based on clinical profile (age, comorbidities) in this cohort. Noted with statistics age (& other comorbidity), decreases the ability to control viral replication. Detection of COVID in serum likely to be due to the inflammatory response or hematogenous spread of virus possibly more advanced stage of the infection/ inflammation. Other potential antiviral therapies (Remdesivir, convalescent plasma, steroid, IL 6 blockers) may have roles clearing the infection especially serum PCR positive patients to avoid the development of critical disease/death. Both groups had all the available (& variable) treatment (convalescent plasma, steroid, antiviral drugs). The PCR in serum was done 2 different methods in an overlap.

      August 25, 2020

      • What every intensivist should know about COVID-19 associated acute kidney injury. 8/11/20. Ostermann M. J Crit Care.
        Acute kidney injury (AKI) is a serious complication in the ICU (incidence < +/- 30%) with COVID-19 patients. The authors explore various etiologies: hypovolemia, hemodynamic instability, inflammation (direct viral invasion, microvascular thrombosis, and dysregulated renin-angiotensin-aldosterone system (RAAS) and of ACE II, iatrogenicity as well). There are no specific therapies for prevention or management of AKI guidelines. Detailed discussion of alternatives to renal replacement therapy (RRT) and other supportive measures are described. An overwhelming need for RRT practice is likely to be determined by the ground reality. A close collaboration between critical care medicine and renal services is essential when resources may be scarce.

      August 19, 2020

      • Association Between Anxiety and New Organ Failure, Independently of Critical Illness Severity and Respiratory Status: A Prospective Multicentric Cohort Study. 7/30/20. Mazeraud A. Crit Care Med.
        Interesting, multi-center prospective study evaluating patient’s admission anxiety level on new organ system failure within seven days following ICU admission. While not directly related to COVID-19 (or any specific admission diagnosis), patients identified with moderate to severe anxiety (State anxiety-assessed using state component of State-Trait Anxiety Inventory State) associated with disease severity (Simplified Acute Physiology Score II and Sequential Organ Failure Assessment) associated with increased risk for further deterioration when compared to lower stress comparators. Interesting with obvious implications for current pandemic given long prodrome with variable symptomatology and outcome increasing general anxiety in population with some estimates indicating a recent reported 25% incidence of suicidal ideation in younger age groups.

      July 27, 2020

      • Inflammation Profiling of Critically Ill Coronavirus Disease 2019 Patients. 7/23/2020. Fraser DD. Crit Care Explor.
        Report of a study comparing inflammatory profiling using multiple immunoassays between COVID-19 positive and negative ICU patients and a matched series of normal controls identifying a unique combination of six analytes distinguishing COVID-19 disease. Reported analytes were: tumor necrosis factor; granzyme B; heat shock protein 70; interleukin-18; interferon-gamma-inducible protein 10; and elastase 2.
        Discussion notes COVID-19 patients demonstrate findings consistent with systemic inflammation including increased circulating cytokine levels and lymphopenia potentially characterizing the “purported” cytokine storm frequently mentioned.
        Authors conclude: “In summary, we report sustained elevations in a unique combination of inflammatory analytes in COVID-19+ ICU patients. Our exploratory data are consistent with the slow, or absent improvement in COVID-19+ patients despite state-of-the-art ICU care, and could aid future hypothesis-driven research using larger ICU cohorts.”

      July 24, 2020

      • COVID-19 and the kidney: what we think we know so far and what we don’t. 7/22/20. Farouk SS. J Nephrol.
        Review by the SAB
        These authors are troubled by existing data related to true incidence, etiopathology, and its management with Covid-19. A heterogeneous report, with respect to population size, location, severity of illness, and definitions of acute kidney injury (AKI), show a wide range of rates of AKI occurrence in patients, from 1-46% and an equally wide percentage range of patients who were treated with kidney replacement therapy (KRT) (10-35%). Most patients with KRT were in the ICU (data was from the UK, Ireland, Italy, China, and the USA) and it has overwhelmed the nephrology services the world over. Potential explanations for these differences include the prevalence of co-morbid conditions and heterogeneity along racial and ethnic lines, local institutional policies about KRT timing, the use of extracorporeal KRT beyond classical “nephrological” indications. Using AKI as defined by “the 2019 Kidney Diseases: Improving Global Outcomes Consensus Conference” may standardize the whole process (a work in progress?). Mode of injury is also noted to be multifactorial. Though the link between AKI and poor outcomes is clear, prevalence and outcomes of COVID-19 in patients with chronic kidney disease and end-stage kidney disease has not yet been reported. In patients on immunosuppression like those with kidney transplants or glomerular disease, COVID-19 has presented a management dilemma.

      July 13, 2020

      • Thromboelastography Profiles of Critically Ill Patients With Coronavirus Disease 2019. 6/26/20. Yuriditsky E. Crit Care Med.
        Review by the SAB
        By Dr. Philip Lumb, on behalf of the SAB
        Interesting retrospective study of 64 critically ill COVID-19 patients with available/reported thromboelastograph studies within 72 hours of ICU admission; 50% showed hypercoagulable profile defined as a Clotting Index (CI) >3. It is noted that D-Dimer > 2,000 ng/ml associated with median CI 3.4 while D-Dimer <2,000 ng/ml median CI 2.1. Discussion indicates TEG profiles consistent with fibrinogen and platelet effect and authors suggest further studies evaluating platelet aggregation profiles. While value of TEG evaluation in COVID-19 patients has not been confirmed, nonetheless further investigation is warranted as results consistent with clinical severity markers, D-Dimer elevations and requirements for appropriate and timely anticoagulation.

      July 8, 2020

      May 14, 2020

      • Coronavirus Disease 2019, Prothrombotic Factors, and Venous Thromboembolism. May 12. Schulman. Semin Thromb Hemost.
        Nice short review of coagulation abnormalities in COVID-19 patients. States we need randomized clinical trials, before making recommendations advocating more aggressive anticoagulation to prevent VTE in COVID-19 patients.
      • Hyperinflammatory shock in children during COVID-19 pandemic. May 11. Riphagen. Lancet.
        A Correspondence to Lancet describing a hyperinflammatory shock syndrome in a cluster of children, 8 in a population of 2 million, however a 3-fold increase from normal over the 10-day inclusion period. 1 child died. Confusing, the article states that respiratory involvement did not occur, yet the included table shows 5 children suffered tachypnea. Only 2 of 8 children were proven COVID-19. Prior to publishing, another cohort of children has been admitted. Though not listed, the authors imply the COVID-19 diagnosis approached 50%. All children received immunoglobulin and aspirin.

      May 11, 2020

      • Pathogenesis and Treatment of Kawasaki’s Disease
        Sept. 17, 2005. Yeung. Opinion in Rheumatology.
        Opinion from SAB Member: Dr. Jay Przybylo
        This article defining Kawasaki Disease (“…an infectious trigger leads to massive activation of the immune system, resulting in a prolonged self-directed immune response at the coronary arteries”) equates COVID-19 as Kawasaki Disease in a small number of young children.

      May 8, 2020

      May 2, 2020

      • Category: Expression of Concern
        Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19 – published in the New England Journal of Medicine on May 1, 2020, subjected to an expression of concern on June 2, and retracted on June 4.
        Expression of Concern: Mehra MR et al. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med. DOI: 10.1056/NEJMoa2007621.
        June 2. Mehra MR. The New England Journal of Medicine.
        The Lancet published the following Expression of Concern about an article previously cited and summarized by this Scientific Advisory Board in the 5MAY2020 Newsletter.
        ‘On May 1, 2020, we published “Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19,” a study of the effect of preexisting treatment with angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) on Covid-19. This retrospective study used data drawn from an international database that included electronic health records from 169 hospitals on three continents. Recently, substantive concerns have been raised about the quality of the information in that database. We have asked the authors to provide evidence that the data are reliable. In the interim and for the benefit of our readers, we are publishing this Expression of Concern about the reliability of their conclusions.
        Studies of ACE inhibitors and ARBs in Covid-19 can play an important role in patient care. We encourage readers to consult two other studies we published on May 1, 2020, that used independent data to reach their conclusions.’

      May 1, 2020

      • COVID-19 Pandemic ARDS Survivors: Pain after the Storm?
        Apr 27. Vittori. Anesthesia & Analgesia.
        Opinion from C19SAB: Dr. W. Heinrich Wurm
        A look beyond the acute phase of COVID-19 by an international panel of specialists in pediatric critical care, pain management and anesthesiology, alerting us of the challenges ahead as survivors will have to deal with the after effects of ARDS, severe illness, isolation, PTSD, and the altered reality of post-COVID-19 society. Specifically, the panel calls for a multidisciplinary commission of experts to issue recommendations on monitoring symptoms, create best practices to prevent sequelae, establish a registry for survivors (both patients and care givers), and embark on multicenter studies to track chronic pain and other physical and psychological sequelae of the disease and the impact it has on health care workers and families.

      April 30, 2020

      April 29, 2020

      • Caution Needed on the Use of Chloroquine and Hydroxychloroquine for Coronavirus Disease 2019
        Apr 24. Fihn. JAMA.
        Opinion from SAB Member: Dr. Jay Przybylo
        Data from Brazilian researchers previously discussed now published. Study stopped when high dose chloroquine was found to result in more deaths in a group of patients with concurrent heart disease and associated other diseases. Of great interest is the accompanying editorial that addresses multiple issues associated with COVID-19 and chloroquine use.
      • COVID-19 and its implications for thrombosis and anticoagulation
        Apr 27. Connors. Blood.
        Opinion from C19SAB: Dr. Anil Hingorani, Dr. Louis McNabb
        AH: This article reviews the worldwide literature regarding the effects of COVID-19 on the hematologic system and proposes prophylaxis and treatment options for these patients that is clinically relevant and well organized. LM: Good overview on mechanisms of sepsis-induced coagulopathy. Concludes no data at this time for full anticoagulation of COVID-19 patients in the ICU setting unless proven or suspected VTE. The authors note that COVID-19 do not have propensity to bleed. Many centers are using moderate dosing of anticoagulation, i.e., BID LMWH in the ICU.
      • Patient blood management during the COVID-19 pandemic – a narrative review. Apr 27. Baron. Anaesthesia.
        Expert international consensus statement providing blood management recommendations during the COVID-19 Pandemic. Recommendations include management of the supply chain, donation precautions, elective surgery management and other important aspects of blood utilization. While designed to aid practitioners during the COVID-19 pandemic, nonetheless the recommendations may be considered more generally applicable for future use.

      April 28, 2020

      April 24, 2020

      April 23, 2020

      April 21, 2020

      April 17, 2020

      • Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Apr 16. Arachchillage DR. J Thromb Haemost.
        This is a pre-proof editorial. 11.5 % patients in Wuhan had consumptive coagulopathy -> DIC with PT, D Dimer, FSP high. Platelets – either N or low N. Caution with VV ECMO & ARDS Careful anti coagulation, ICH with Plt. Even if Platelet N be vigilant.
        DIC prognostic marker for COVID-19. A rise of D Dimer & Reduction of Platelet on VV ECMO = pump failure.
      • Gastrointestinal Symptoms and COVID-19: Case-Control Study from the United States
        Apr 8. Nobel. Gastroenterology.
        Opinion from SAB Member: Dr. Barry Perlman
        Retrospective, case-control study of COVID-19 associated gastrointestinal symptoms, including diarrhea and nausea/vomiting, in NYC patients and essential personnel who had nasopharyngeal swab testing for respiratory symptoms. 278 COVID-19 positive and 238 negative patients were included. Patients with GI symptoms at time of testing had a 70% increased risk of testing positive for COVID-19, while absence of GI symptoms did not impact the likelihood of a positive test result. Increasing BMI also correlated with increased risk of a positive test result. 35% of patients who tested positive had GI symptoms, and these patients were more likely to have illness lasting one week or greater. However, they had a significantly lower death rate and a non-significant lower rate of ICU admission. Of note, the paper does not discuss follow-up testing or the final diagnosis of the patients who had negative testing on presentation but went on to hospital admission (171), ICU admission (30) or death (3), so presumably a significant number of these patients had initial false negative tests and were actually COVID-19 positive.
      • Immune Thrombocytopenic Purpura in a Patient with Covid-19. Apr 16. Zulfiqar AA. N Engl J Med.
        Single case which responded to rxn with steroids, ivg, and eltromopag.

      April 10, 2020

      • Considerations for Drug Interactions on QTc in Exploratory COVID-19 (Coronavirus Disease 2019) Treatment Mar 25. Roden. Circulation.
        COVID-19 SAB Opinion from: Dr. Barry Perlman
        Hydroxychloroquine and azithromycin have both been associated with QT prolongation and torsades de pointes. The combination on QT prolongation or arrhythmia risk has not been studied. Seriously ill patients can have other risk factors for arrhythmias, such as hypokalemia, hypomagnesemia, fever, and inflammatory state. The authors recommend not using these meds if patient has known congenital long QT syndrome, withholding or withdrawing them if QTc > 500 msec, avoiding other medications that can prolong QTc, and correcting hypokalemia to > 4 mEq/L and hypomagnesemia to > 2 mg/dL. They point out that optimal ECG monitoring may not be possible in critically ill COVID-19 patients.
      • ISTH interim guidance on recognition and management of coagulopathy in COVID-19 Mar 25. Thachil. Journal of Thrombosis and Haemostasis.
        Opinion from SAB Member: Dr. Barry Perlman
        Lymphopenia is common with COVID-19, and severely ill patients are likely to have coagulopathy. The following is an interim guidance statement on management of COVID-19 coagulopathy: 1) Upon presentation of COVID-19, the measurements advised, in order of importance, are of d-dimer, prothrombin time, and platelet counts. 2) Increased d-dimers are commonly reported in patients with severe illness and may predict mortality. Three- to four-fold increases in d-dimer may signal the need for admission in patients without other clear indicators of severity. 3) Prolongation in prothrombin times and degree of thrombocytopenia (100–150×109/L) have been modest. 4) In addition to the above parameters, fibrinogen should be monitored; nonsurvivors with severe illness have developed disseminated intravascular coagulation around day 4; significant worsening in these parameters at days 10 and 14 was also reported. 5) The panel advises use of prophylactic dose low-molecular-weight heparin unless there is active bleeding or a platelet count of <25×109/L; it is hoped that this strategy will impact septic-like coagulopathy and protect against venous thromboembolism. 6) Bleeding has been rare, but if present, panelists advise keeping platelet counts >50×109/L (and >20×109/L goal in nonbleeding patients), fibrinogen >2.0 g/L, and the prothrombin ratio <1.5.
      • Practice of novel method of bedside postpyloric tube placement in patients with coronavirus disease 2019. Apr 9. Yuan. Critical Care.
        Report of a Chinese version of Dobhoff tube: claims to insert in the second part of duodenum “easier” in Covid patient. No objective evidence.

      April 9, 2020

      April 8, 2020

      April 3, 2020

    1. Treatment / Prevention of COVID-19 (Current / Future)
      November 2, 2020
      • SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19. 10/28/20. Chen P. N Engl J Med.
        This BLAZE-1 phase 2 interim safety analysis involved 452 mild or moderate COVID-19 outpatients within three days of diagnosis. In a study funded by Eli Lilly, patients received a single infusion of spike-protein-RBD neutralizing antibody LY-CoV555 in one of three doses (700, 2800 or 7000 mg) or placebo. Change from baseline viral load by quantitative RT-PCR at day 11 was the primary outcome and decreased in all groups. Only the middle, 2800 mg dose significantly diminished load more than placebo at day 11. All doses reduced symptoms on days 2-6, and hospitalizations (1.6% vs. 6.3%), particularly in high-risk cohorts. Although 70% had high-risk co-morbidities, no deaths occurred.

      October 30, 2020

      • Aspirin Use is Associated with Decreased Mechanical Ventilation, ICU Admission, and In-Hospital Mortality in Hospitalized Patients with COVID-19. 10/23/20. Chow JH. Anesth Analg.
        This multi-center cohort study of 412 COVID-19 patients explored the theory that aspirin’s anti-platelet and anti-inflammatory properties might be beneficial in lowering the risk of serious outcomes. Ninety-four patients who had taken aspirin within 7 days of admission were compared with 314 patients who had not. Aspirin use was independently associated with decreased hazard ratio (HR) of mechanical ventilation (HR 0.56), ICU admission (HR 0.57), and in-hospital mortality (HR 0.53). There were no differences in major bleeding (p=0.69) or overt thrombosis (p=0.82) between aspirin users and non-aspirin users and confounding variables were carefully controlled. Potential mechanisms are discussed including aspirin’s ability to lower interleukin-6, C-reactive protein, and macrophage stimulation. Randomized controlled trials are necessary to confirm these results.
      • Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review. 10/23/20. Weatherald J. J Crit Care.
        Using a “rapid review” technique, these authors from Calgary synthesize 35 studies (none randomized) evaluating the effect of awake proning in 414 COVID-19 patients with respiratory failure. All but one study showed improvement in oxygenation while prone, but generally not sustained when returned to the supine position. 29% of patients went on to require intubation. The authors conclude that “many questions remain unanswered when considering the use of awake prone positioning.”
      • Convalescent plasma in the management of moderate covid-19 in adults in India: open label phase II multicentre randomized controlled trial (PLACID Trial). 10/22/20. Argwal A. BMJ.
        A randomized, controlled trial of convalescent plasma (CP) in 227 treated and 224 control hospitalized patients with moderate COVID-19 from 39 hospitals in India. Patients who received 200 ml of CP x 2 had less dyspnea and fatigue and a 24% higher rate of negative PCR on day 7 (P<0.05). No difference in the levels of inflammatory markers such as ferritin, C-reactive protein, D-dimer, or LDH was observed. However, there was no difference in progression to severe disease or mortality at 28 days between groups, including a subgroup of patients who received plasma with neutralizing antibody titers >1:80.
      • Convalescent plasma is ineffective for covid-19. Lessons from the Placid Trial. 10/22/20. Pathak EB. BMJ.
        In light of the prevalence of micro-thrombosis and the large number of thrombotic complications in COVID-19 patients, authors of this accompanying editorial highlight the pro-thrombotic properties of plasma and recommend that future blinded convalescent plasma (CP) trials exclude plasma without detectable neutralizing antibodies or treatment of control groups with other plasma. They point out that coagulation-related events in previous CP trials were not rigorously screened for their potential relationship to the treatment.

      October 26, 2020

      • Efficacy of Tocilizumab in Patients Hospitalized with Covid-19. 10/21/20. Stone JH. N Engl J Med.
        This is a prospective, randomized, placebo-controlled study where treated patients received a single dose of 8mg/kg of tocilizumab (161 of 243 enrolled patients). The results showed that tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with COVID-19.
      • Time to Reassess Tocilizumab’s Role in COVID-19 Pneumonia. 10/20/20. Parr JB. JAMA Intern Med.
        The author’s conclusions in this excellent editorial are informed by three studies (two are randomized prospective) reported in this issue of JAMA Internal Medicine and by two additional randomized prospective studies. Although observational studies by the STOP-COVID investigators and others report mortality benefit and other positive outcomes, findings from the randomized prospective trials described herein (total of 542 patients treated) do not support routine tocilizumab use in COVID-19. A well-constructed summary table of the five studies is provided.

      October 21, 2020

      • Famotidine Use Is Not Associated With 30-day Mortality: A Coarsened Exact Match Study in 7158 Hospitalized COVID-19 Patients from a Large Healthcare System. 10/15/20. Yeramaneni S. Gastroenterology.
        This large retrospective study from HCA Healthcare repudiates 2 smaller studies from Columbia and Hartford which reported a two-fold reduction in risk of death or intubation for COVID-19 inpatients. One thousand one hundred twenty-seven patients (15.7%) received famotidine and 6031 (84.3%) did not. Applying multivariable logistic regression within a carefully matched cohort showed no association between in-hospital famotidine use and 30-day mortality after adjustment for WHO severity, smoking status, and listed medications.
        SAB Comment: Due to famotidine’s ability to inhibit a protease essential for SARS-CoV-2 virus replication in vitro, it is under intense study in many centers. A clinical trial administering high-dose IV treatment (120 mg IV q8h) is currently under way at Columbia.

      October 19, 2020

      • Acute Respiratory Distress Syndrome: Contemporary Management and Novel Approaches during COVID-19. 10/5/20. Williams GW. Anesthesiology.
        This is a succinct, well-written review of best practice treatment strategies for non-COVID-19 ARDS with research-based updates on appropriate strategies for COVID-19 associated-ARDS treatments. Figures and brief descriptions are provided on the research supporting low tidal volumes, PEEP levels, prone positioning, PaO2 targets, steroid treatment, fluid management, ECMO and early neuromuscular blockade.
      • Blood purification therapy with a hemodiafilter featuring enhanced adsorptive properties for cytokine removal in patients presenting COVID-19: a pilot study. 10/12/2020. Villa G. Crit Care.
        Italian preliminarily prospective observational study of 37 patients receiving immunomodulatin or support of renal function using Baxter’s oXiris heparin-coated extracorporeal hemodiafilter Feb-April 2020. Compared to the expected (65%!) mortality rates, as calculated by APACHE IV, the mean observed rates were 8.3% lower after treatment. Reduction in serum IL-6 concentrations correlated with improved organ function, measured as decreased SOFA score. The best improvement in mortality rate was observed in patients receiving early treatment during in ICU. Anticoagulation regimens were inconsistent. 7 treatments (19%) resulted in clotting.
      • Convalescent plasma for patients with severe COVID-19: a matched cohort study. 10/10/20. Rogers R. Clin Infect Dis.
        This small study from 3 hospitals compared 64 recipients of 1-2 units of CP (median 7 days after symptom onset) with 177 matched controls. Neither in-hospital mortality (~15%) nor overall rate of hospital discharge differed significantly, although the rate of hospital discharge among patients older than 65 years who received convalescent plasma (CP) was significantly higher (RR 1.86, 95% CI 1.03 – 3.36). There was a greater than expected frequency of transfusion reactions in the CP group (2.8% per unit transfused). Authors suggest adequately powered randomized studies should target patients older than 65 years when assessing CP treatment efficacy.
      • The impact of protocol-based high-intensity pharmacological thromboprophylaxis on thrombotic events in critically ill COVID-19 patients. 10/12/20. Atallah B. Anaesthesia.
        This study was conducted to discover if high-intensity thromboprophylaxis would lead to fewer thrombotic events in COVID-19 positive patients. These patients were selected for high-intensity thromboprophylaxis when the D-dimer level was > 2ug/ml, and for therapeutic anticoagulation when the level was >3ug/ml. High-intensity thromboprophylaxis (enoxaparin 40 milligrams bid), but not therapeutic anticoagulation was associated with fewer thromboembolic events. Low D-dimer levels were independently associated with fewer venous thromboembolism events. Bleeding events in the high intensity thromboprophylaxis group were 2.7% compared to 16.5% using therapeutic anticoagulation. The authors conclude that high intensity thromboprophylaxis may reduce the incidence of thrombotic events without a significant increase in bleeding.
      • Treatments Considered for COVID-19. 10/15/20. The Medical Letter.
        This latest edition of The Medical Letter’s “Treatments Considered for COVID-19” was released on October 15, 2020 and included comprehensive (over 100 pages) up-to-date tables of drug, vaccine and other treatment classes. The columns include “Drug and Dosage,” “Efficacy,” “Adverse Effects/Interactions” and “Comments,” all with thorough referencing.
        Updates added to this edition include:
        • remdesivir – new guidelines from NIH and IDSA,
        • convalescent plasma – new guidelines from IDSA,
        • monoclonal antibodies, mesenchymal stem cell therapy, corticosteroids – new guidelines from NIH and IDSA,
        • IL-6 Inhibitors – new guidelines from IDSA; JAK inhibitors – data from NIH’s ACTT-2 trial on baricitinib, and
        • antimalarials – results from the RECOVERY trial, PPIs, vaccines and SSRIs.

      October 14, 2020

      October 12, 2020

      • Compassionate Use of Remdesivir in Pregnant Women with Severe Covid-19. 10/8/20. Burwick RM. Clin Infect Dis.
        This is a multicenter review of the outcomes for 67 pregnant and 19 immediate post-partum patients with moderate to severe COVID-19 treated with remdesivir. Outcomes were generally good, but there was no comparison to a control group. Remdesivir was well tolerated, with a low incidence of serious adverse events (16%). Most adverse events were related to pregnancy and underlying disease; most laboratory abnormalities were Grades 1 or 2. There was one maternal death attributed to COVID-19 and no neonatal deaths.
      • Remdesivir for Adults With COVID-19: A Living Systematic Review for an American College of Physicians Practice Points. 10/5/20. Wilt TJ. Ann Intern Med.
        Of the 89 pertinent articles that these authors reviewed, only 4 fit their strict criteria and were chosen for this review. They concluded that from the best evidence available so far, remdesivir probably improves recovery, reduces serious adverse events and may reduce mortality and time to clinical improvement in hospitalized adults with COVID-19. For patients not on a ventilator, a 5-day course may provide similar benefits to, and fewer harmful effects, than a 10-day course. The review is titled “Living” because these authors, from the VA system, plan to update their literature search every 2 months through December 2021.
      • Remdesivir for the Treatment of Covid-19 — Final Report. 10/8/20. Beigel JH. N Engl J Med.
        This article is a follow-up to the initial “preliminary report” that was published May 22, 2020 and was included as 47% of the patients in the review above. This “final report” of the ACTT-1 study provides later outcomes and analysis of the same 1062 patients in the “preliminary” report, randomized between February 21 and April 19 to receive 10 days of remdesivir or placebo. Similar to the analysis in the first report, those who received remdesivir had a median recovery time of 10 days compared with 15 days among those who received placebo. Kaplan–Meier estimates of mortality were 6.7% with remdesivir and 11.9% with placebo by day 15 and estimates of mortality by day 29 (new in this report) were 11.4% with remdesivir and 15.2% with placebo.
      • Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020). 10/6/20. Bai C. Eur Respir Rev.
        In this article, the Task Force (American Thoracic Society/European Respiratory Society coordinated International Task Force 29 July 2020) make consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but not with hydroxychloroquine except in the context of a clinical trial. COVID-19 patients with a venous thromboembolic event can be treated with therapeutic anticoagulant therapy for 3 months. Routine screening of patients for depression, anxiety and post-traumatic stress disorder was also suggested by the task force.

      October 9, 2020

      • Therapeutic versus prophylactic anticoagulation for severe COVID-19: A randomized phase II clinical trial (HESACOVID). 9/20/2020. Lemos ACB. Thromb Res.
        This paper randomized 20 COVID-19 patients requiring mechanical ventilation. Ten patients were assigned to either therapeutic enoxaparin (enoxaparin) or to prophylactic anticoagulation (SQ heparin). There was an increase in the PaO2/FiO2 ratio in the therapeutic group, p=0.0004 which was not seen in the prophylactic group, p=0.487. Patients in the therapeutic group had a rate of successful liberation from mechanical ventilation (hazard ratio: 4.0, p=0.031) and more ventilator-free days (15 days versus 0 days, p = 0.028). There was no difference in mortality.  While the dataset is small, it does show promise and is an introduction for larger upcoming trials.

      October 7, 2020

      October 5, 2020

      • Convalescent Plasma for the Treatment of COVID-19: Perspectives of the National Institutes of Health COVID-19 Treatment Guidelines Panel. 9/25/20. Pau AK. Ann Intern Med.
        Data are currently insufficient for the NIH to recommend for or against convalescent plasma (CP) for COVID-19. Enrollment in adequately powered US RCTs is slow.FDA analysis (4330 patients):
        • 7-day mortality following high-titer vs. low-titer plasma
          • No difference overall.
          • Intubated patients (~1/3) – No difference.
          • Non-intubated patients: 11% high-titer vs. 14% low-titer.
        • Non-intubated patients <80 years treated w/in 72 hrs. of diagnosis, 6.3% high-titer vs. 11.3% low-titer (P = 0.0008).

        Analysis of 3082 patients / 35,322 who received plasma by 4 July 2020 via Mayo Clinic’s parallel Expanded Access Program, developed to provide broader access to CP yet NOT designed to generate definitive safety or efficacy data as no untreated control group.

        • 30-day mortality 29.1% in low-titer group vs. 24.7% in the high-titer group (not statistically significant).
        • Suggestion that high-titer plasma beneficial when administered within 72 hours of Dx.
      • COVACTA trial raises questions about tocilizumab’s benefit in COVID-19. 9/9/20. Furlow B. Lancet Rheumatol.
        IL-6 has both pro-inflammatory (e.g. “cytokine storm”) and anti-inflammatory effects. Retrospective studies suggested that the IL-6 antagonist tocilizumab reduced mortality. On July 29, 2020, Hoffmann-La Roche announced results of COVACTA, a Phase 3 tocilizumab randomized controlled trial in severe COVID-19 pneumonia. Tocilizumab failed to meet the primary endpoint of improved clinical status or mortality. However, treated patients spent a week less in the hospital. The full results await publication. Proper timing of administration assessing clinical signs of hyperinflammation may prove crucial. The results of the much larger tocilizumab RECOVERY trial are pending.
      • High Potency of a Bivalent Human VH Domain in SARS-CoV-2 Animal Models. 9/4/2020. Li W. Cell.
        Using a phage-generated library, these investigators found spike glycoprotein (S) -receptor binding domain-avid high-affinity VH binder ab8. Bivalent VH, VH-Fc ab8, bound with high avidity to S and to patient-derived S-mutants. VH-Fc ab8 was markedly effective as a prophylactic and a therapeutic, interfering in ACE-2 binding in a mouse-adapted SARS-CoV-2 and in a hamster model. The potency was enhanced by its relatively small size vs. a complete antibody (80 vs. 150 kDa). S-specificity was shown; VH-Fc ab8 did not aggregate and did not bind to 5,300 human membrane-associated proteins. These data provide a strong rationale for its therapeutic evaluation.

      September 25, 2020

      • Glucocorticoid therapy does not delay viral clearance in COVID-19 patients. 9/22/2020. Ji J. Crit Care.
        This is a (LtE) retrospective observational study regarding glucocorticoids and Covid viral clearance. Out of 684 patients noted 29.5% had viral RNA clearance within 14 days after illness onset and 30.7% cases had viral RNA clearance between 14 and 28 days, and 39.8% cases had viral RNA clearance over 28 days. There were no differences on the age, gender, and underlying diseases between different groups. The degree of decrease in CD4 T cell and B cell counts on admission was related with the prolonged viral RNA clearance. The results show that GC therapy shortened hospital stay days but had no effect on the virus clearance time. This is true for the severe and critical patients as well. The GC treatment had no effect on the peripheral lymphocyte counts, including CD4 T cells, CD8 T cells, NK cells, and B cells.

      September 23, 2020

      • Bridging the Gap at Warp Speed – Delivering Options for Preventing and Treating Covid-19. 9/15/20. Slaoui M. N Engl J Med.
        This article summarizes ongoing initiatives by industry and the Departments of Defense and HHS to develop and distribute novel therapeutics safely and effectively by the end of 2020. Under the code name Operation Warp Speed (OWS), teams are focused on:
        • Creating passive immunity using convalescent plasma, hyperimmune globulin and monoclonal antibodies (mAbs);
        • Inhibiting viral replication using new and repurposed antivirals like remdesivir;
        • Prevention of disease in high-risk cohorts applying neutralizing mAbs; and
        • Developing novel immunomodulators and anticoagulants.

        OWS plans to attack COVID-19 using some of these options before an anticipated vaccine release in early 2021. The article does not address the progress of ongoing vaccine development efforts by OWS.

      September 21, 2020

      • Favorable outcomes of COVID-19 in recipients of hematopoietic cell transplantation. 9/8/20. Shah GL. J Clin Invest.
        From Sloan Kettering, a retrospective study of 77 COVID-19 PCR+ recipients of allogeneic and autologous hematopoietic cell transplant and chimeric antigen receptor T cell therapy (44% admitted). Of the 77 cellular therapy recipients, the results were: Allo = 35, Auto = 37, CAR-T = 5. The median time from cellular therapy was 782 days. Overall survival at 30 days was 78%. Clinical variables significantly associated with more severe disease (greater than non-rebreathing mask oxygen) or death were number of comorbidities, infiltrates and neutropenia. Worsening graft-versus-host-disease was not identified. The authors observed rapid recovery in lymphocyte populations across lymphocyte subsets which are critical to anti-viral responses and immune reconstitution.

      September 16, 2020

      September 14, 2020

      • COVID-19: more than a cytokine storm. 9/5/20. Riva G. Crit Care.
        This commentary from Modena, Italy cites the current overemphasis on therapies combating the cytokine storm of the innate COVID-19 immune response and “neglect” of fighting the adaptive immune response. Lymphocyte dysregulations in COVID-19 include lymphopenia (CD4+ and CD8+), T cell exhaustion and a skewing toward a low IFN-Ɣ CD4+ tolerogenic balance. Some of these adaptive deficiencies also are evident in cancer and with aging. The authors advocate trials with immunotherapeutic drugs that may reverse T cell impairment. Trials to determine appropriate immunomodulatory drugs, antibodies, biomarkers and their optimal timing are beginning.
      • Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients With Moderate COVID-19. 8/21/20. Spinner C. JAMA.
        In this international study (United States, Europe, and Asia) of COVID-19 patients with pulmonary infiltrates but oxygen saturation above 94% (moderate COVID-19 pneumonia), patients who received a 5-day course of remdesivir did better on day 11 than a comparable group of patients who received standard care only. However, a 10-day course of remdesivir failed to show clinical improvement compared to standard care. The results suggest that remdesivir works when given early and may not have additional benefit once patients progress to more severe illness.
      • Subcutaneous Enoxaparin Safely Facilitates Bedside Sustained Low-Efficiency Hemodialysis in Hypercoagulopathic Coronavirus Disease 2019 Patients-A Proof-of-Principle Trial. 7/23/2020. Neumann-Haefelin E. Crit Care Explor.
        Faced with recurrent filter clotting and incomplete dialysis in hypercoagulable COVID-19 patients needing renal replacement therapy, these authors changed therapeutic anticoagulation from unfractionated heparin to low molecular weight heparin. In their retrospective study of 3 patients, LMWH markedly increased successful completion of RRT. Their protocol reduces the risk of discarding important resources, filter and blood and at the same time provides adequate dialysis quality.

      September 4, 2020

      September 2, 2020

      • Anakinra in COVID-19: important considerations for clinical trials. 5/21/20. King A. Lancet Rheumatol.
        This comment is of interest for clinicians and researchers working with the Interleukin IL-1α and IL-1β inhibitory agent anakinra in COVID-19 patients with evidence of hyperinflammation. The authors review and critique 10 ongoing trials with anakinra and suggest using worsening lymphopenia as a marker of disease progression and severity and increasing C-reactive protein as evidence of worsening inflammation. They also favor subcutaneous administration due to the drug’s short half-life and implore the trial gate keepers to ensure collection of core outcome measures, like ferritin levels for current and future trials.

      August 31, 2020

      August 25, 2020

      August 19, 2020

      • Convalescent plasma for COVID-19. 8/8/20. Mucha SR. Cleve Clin J Med.
        While convalescent plasma has yet to be proven effective, it has generated great interest as a possible COVID-19 therapy and clinical trials are underway. For those interested in a well-written review of the questions and potential risks that must be taken into consideration, this report is a worthwhile read. Potential downsides include TACO, TRALI, antibody dependent enhancement of infection and attenuated immune response. Current limitations include obstacles to effective testing of donor neutralizing antibody levels. This topic is at the center of the current controversy surrounding a potential FDA emergency use authorization for convalescent plasma, (now on hold).
      • Late Onset Infectious Complications and Safety of Tocilizumab in the Management of COVID-19. 8/14/20. Pettit NN. J Med Virol.
        Tocilizumab while previously showing some positive results in treating COVID-19, in this controlled study demonstrated higher complication rates, especially infectious, and death.

      August 17, 2020

      • COVID-19: pharmacology and kinetics of viral clearance. 8/8/20. Farina N. Pharmacol Res.
        In addition to critically reviewing the results of currently available therapeutic options, investigators examined viral clearance dynamics in a cohort of 1000+ patients enrolled in a COVID-19 hydroxy-chloroquine and lopinavir/ritonavir research protocol at a single center in Milan. Viral clearance was assessed as time to negative RT-PCR as well as determining the proportion of patients with a negative test within 14 and 28 days. Significantly, persistence of the virus did not identify patients with higher mortality risk.

      August 14, 2020

      • The COVID-19 Vaccine Race: Challenges and Opportunities in Vaccine Formulation. 8/5/20. Wang J. AAPS PharmSciTech.
        This article is an in-depth review of vaccine development and delivery strategies, particularly as they apply to SARS-CoV-2. The proper choice of the type of vaccine, carrier or vector, adjuvant, excipients (other ingredients), dosage form, and route of administration can directly impact not only the immune responses and efficacy against COVID-19, but also the logistics of manufacturing, storing, distributing the vaccine and mass vaccination. The 13 vaccines under development (as of May 29, 2020) are nicely compared. The tables and graphics are excellent.

      August 12, 2020

      August 10, 2020

      • Therapeutic plasma exchange in adult critically ill patients with life-threatening SARS-CoV-2 disease: A pilot study. 7/31/20. Faqihi F. J Crit Care.
        This article reports preliminary data on total plasma exchange as rescue therapy for 10 consecutive eligible adult COVID-19 ICU patients. (Technique using Spectra Optia™ Apheresis System w/ Depuro D200 Adsorption Cartridge and volume replacement w/ 5% albumin or fresh frozen plasma if PT>37 sec.) All patients were mechanically ventilated and had life-threatening illness and cytokine release syndrome (average PaO2/FiO2 ratio 110, SOFA 11, APACHE II 22.5). After 5-7 treatments P/F >250 in all and vasopressors weaned. One on ECMO, 2 had PE, and there was 1 sudden death during ventilator weaning. Nine patients were discharged from hospital. No reported adverse effects. Confounding factors include steroid and other concurrent treatments.
        (Note: this is not convalescent plasma treatment.)
      • Editorial: Attenuating hyperinflammation in COVID-19: A change in paradigm? 7/23/20. Molnar Z. J Crit Care.
        This editorial accompanying Faqihi’s report of total plasma exchange as rescue therapy for life-threatening COVID-19 presents an interesting discussion of the history of our understanding of host-based detrimental “dysregulated immune responses” including “cytokine storm,” along with potential blood purification therapies. The good news is that multiple trials in this domain are registered on ClinicalTrials.gov.

      August 7, 2020

      August 3, 2020

      • Emerging pharmacological therapies for ARDS: COVID‑19 and beyond. 7/11/2020. Horie S. Intensive Care Med.
        Members of the Regenerative Medicine Institute of the National University of Ireland authored this exhaustive overview of the current state of promising emerging pharmacological therapies of ARDS in patients with and without COVID-19. The review focuses on ongoing clinical and preclinical trials and uses well-designed tables and diagrams to enhance a complex array of pathophysiological mechanism and therapeutic interventions ranging from immune response modulation, to epithelial and endothelial integrity repair, anticoagulation and COVID-19 specific antiviral and anti-inflammatory therapies.
        A valuable source, aimed at the research community, the authors express hope for identification of subtypes of ARDS and application to allow better targeting of specific therapeutic interventions in the future.

      July 31, 2020

      • Prevalence of Gastrointestinal Symptoms and Fecal Viral Shedding in Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. 6/11/20. Parasa S. JAMA.
        Gastrointestinal (GI) symptoms of COVID-19 include loss of appetite, nausea, vomiting, diarrhea, and abdominal discomfort. These symptoms might start before or occur with or without other symptoms such as fever, myalgias, and cough. Lower gastrointestinal tract is rich in ACE2 receptors.
        About 40% of the patients’ stool tests positive for SARS-CoV-2 RNA. This is primarily due to RNA fragments of the virus. One study showed live virus on electron microscopy in a small percentage of patients. These patients’ stools are infectious. Patients who have virus in the stool take longer to clear it. Although a small percentage of patients have GI symptoms, up to one-half shed virus in the stool. Virus protein shell is also found in gastric, duodenal, and rectal cells.
        More than one-half of COVID-19 hospitalized patients have elevated lactate dehydrogenase and other liver enzymes indicating injury to the liver or bile ducts. This is likely to be due to an overactive immune system or due to drugs causing liver damage.

      July 29, 2020

      • Considering the potential for an increase in chronic pain after the COVID-19 pandemic. 7/24/20. Clauw DJ. Pain.
        An International panel reviews the underlying factors likely to lead to or exacerbate chronic pain in individuals during a pandemic whether or not an infection actually takes place. Addressing both chronic pain management professionals and acute care providers, this synopsis reminds us of post-SARS syndrome and urges us to prepare for post-COVID-symptomatology which includes chronic debilitating illnesses, like chronic fatigue, irritable bowel syndrome and interstitial cystitis and other conditions marked by a chronic pain experience. Registries, awareness and multidisciplinary teams will be required to deal with this likely scenario.
      • Remdesivir for Severe COVID-19 versus a Cohort Receiving Standard of Care. 7/25/20. Olender SA. Clin Infect Dis.
        Pharma-sponsored proof of benefit of remdesivir in patients with severe COVID-19 is demonstrated by comparing patients’ clinical status on day 14 during two parallel studies. One is an international, 16-site retrospective cohort study of clinical outcomes in 800+ patients receiving standard-of-care treatment for severe COVID-19 infection; the other is an international, 45-center, phase 3, randomized, open-label trial comparing two courses of remdesivir in 312 patients. Remdesivir was associated with significantly greater recovery (74 vs 59%) and 62% reduced odds of death versus standard-of-care treatment.

      July 24, 2020

      • Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. 7/19/20. Thibault R. Crit Care.
        Review by the SAB
        By Dr. Heinrich Wurm, on behalf of the SAB
        French authors propose a flow chart and identify ten key issues for optimizing the nutrition management of COVID-19 patients in the ICU. Prominent among those is a preference for enteral nutrition whenever possible, attention to avoid the refeeding syndrome and awareness of the propofol infusion syndrome. Existing guidelines like GLIM* are valuable and their application encouraged. The use and limitations of indirect calorimetry during Covid-19 is discussed.
        * Global Leadership Initiative on Malnutrition

      July 17, 2020

      July 15, 2020

      July 14, 2020

      • Prevention of thrombotic risk in hospitalized patients with COVID-19 and hemostasis monitoring. 6/19/20. Susen S. Crit Care.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        Authors of this practical review article from a multinational European working group recommend a strategy to categorize thrombotic risk level and to increase anticoagulation above standard prophylactic doses for hospitalized COVID-19 patients with additional risk factors including obesity (BMI>30), respiratory failure, findings of major inflammation (D-dimer>3mcg/ml. or fibrinogen >8 g/L) or evidence of consumptive coagulopathy. They propose baseline testing repeated q48 hrs. and include a color-coded chart to quickly determine the risk category for individual patients. Not discussed: management of consumptive coagulopathy, thrombolysis, antiplatelet therapy, and arterial thrombosis. Their management strategy is based upon previously published international data.

      July 10, 2020

      • Improved Clinical Symptoms and Mortality on Severe/Critical COVID-19 Patients Utilizing Convalescent Plasma Transfusion. 6/23/20. Xia X. Blood.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        This article may be of interest to those looking to learn from the Chinese experience with convalescent plasma (CP). 138/1568 COVID-19 patients from this retrospective single-center Chinese cohort study received CP. Death (2.1% vs. 4.1%) and requirement for ICU care (2.4% vs. 5.1%) in the CP group were close to half of that in the untreated patients. Patients with higher initial lymphocyte counts and those who received CP treatment within 7 wks. from onset of clinical disease were more likely to respond.
      • Rate of venous thromboembolism in a prospective all-comers cohort with COVID-19. 7/2/20. Rieder M. J Thromb Thrombolysis.
        Review by the SAB
        By Dr. Lydia Cassorla, on behalf of the SAB
        This German prospective single-center study analyzed 190 ED patients with suspected COVID-19 March-April 2020. 49 SARS-CoV-2 positive (25.8%). 141 SARS-CoV-2-negative patients served as a control group. After 30-day follow-up, VTE was diagnosed in 3 SARS-CoV-2-positive patients (6.1%, including 2 ICU patients) vs. 5 SARS-CoV-2-negative (3.5%), however the difference was not statistically significant (p = 0.427). 30-day mortality was similar (6.1% vs. 5%, p = 0.720). COVID-19 disease severity correlated with the maximum D-dimer level during follow-up, but not D-dimer at admission.
        Dyspnea was more common in the SARS-CoV2 negative group (41.7% vs. 52.4%, p = 0.002), whereas cough (58.3% vs. 37.6%, p < 0.0001) and fever (75% vs. 48.2%, p < 0.0001) were more frequent in COVID-19 patients. The rate of hospital admission was higher in the SARS-CoV-2 positive group (81.6% vs. 66.7%, p = 0.068) D-Dimers at admission did not differ between both groups (1.1 ± 1.4 mg/l vs. 0.8 ± 1.7 mg/l, p = 0.3).

      July 8, 2020

      • Cardiopulmonary Resuscitation in Intensive Care Unit Patients With Coronavirus Disease 2019. 7/1/20. Cheruku S. J Cardiothorac Vasc Anesth.
        Review by the SAB
        By Dr. Philip Lumb, on behalf of the SAB
        Interesting discussion involving practical, ethical and medical (physicians, ICU staff and ancillary personnel) decisions and preparations to perform cardiac resuscitation in terminally ill COVID-19 patients. Focuses on planning and preparing appropriate patients for potential resuscitation by informed discussion with patient/family, insertion of central venous access lines with long IV connections for access and infusion outside patient care area. CPR performed with automated chest compressor. Other safety elements described to protect staff and value of simulation in preparation emphasized. Novel approach to preparing for and performing CPR in COVID-19 patients.
      • Revisiting the Protein C Pathway: An Opportunity for Adjunctive Intervention in COVID-19? 6/10/20. Mazzeffi M. Anesth Analg.
        Review by the SAB
        By Dr. Barry Perlman, on behalf of the SAB
        Discussion of hypercoagulability in COVID-19 with a focus on the anticoagulant and anti-inflammatory properties of Protein C. The authors suggest that two modulators of the Protein C pathway — recombinant thrombomodulin and 3K3A-APC — may be beneficial in the treatment of severe COVID-19 as they are not associated with an increased risk of bleeding.

      July 6, 2020

      • Drug-Induced Liver Injury and COVID-19 Infection: The Rules Remain the Same. 6/8/20. Olry A. Drug Saf.
        Review by the SAB
        By Dr. Philip Lumb, on behalf of the SAB
        Editorial noting that patients have been discontinued/withdrawn from studies because of suspected drug-induced liver damage that does not meet international guidelines for association. A summary of currently used drugs in COVID-19 and possible interactions that may cause liver damage is listed. However, the authors state that since many drugs used in therapeutic interventions may be related to liver damage, it is important to discuss acute liver injury on internationally defined biologic criteria “on the Upper Limit of Normal of serum alanine aminotransferase activity (ALT), serum alkaline phosphatase activity (ALP) and serum concentration of total bilirubin,” which are provided in the editorial as well as a severity grading score to include in association. Internationally recognized criteria for DILI should be satisfied to confirm the diagnosis prior to premature removal of patients from potentially important clinical trials.
      • Inhalational volatile-based sedation for COVID-19 pneumonia and ARDS. 6/25/20. Jerath A. Intensive Care Med.
        Click here to take this CME activity.Review by the SAB
        By Dr. Heinrich Wurm, on behalf of the SAB
        In light of a growing shortage of sedatives and intravenous anesthetics, this narrative review from Toronto highlights the benefits and technical details of volatile anesthetics for sedation in the critical care unit during the COVID-19 pandemic.
        Spearheaded in Europe – volatile anesthetics using in-line vaporizers may provide added benefits, like bronchodilatation and an anti-inflammatory effect, but safe use requires trained teams familiar with volatile anesthetics administration in the ICU. The authors provide a comprehensive and realistic review of available options and alternatives.

      July 1, 2020

      May 29, 2020

      • High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients
        Apr 22. Llitjos JF. Journal of Thrombosis and Haemostasis.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Lydia Cassorla
        AH: This French paper is a short communication where the authors describe venous duplex exams in 26 patients in the ICU with COVID-19. 8 patients were on prophylactic heparin doses and 18 were on therapeutic doses. All patients were intubated. The rate of VTE was 100% for the patients on prophylactic doses and 56% for those on therapeutic doses. 8 patients had PE. The authors do not mention the location of lower extremity DVT. This paper is novel and raises questions. It confirms data from a 48 patient series with 84% VTE incidence from China (Extremely High Incidence of Lower Extremity Deep Venous Thrombosis in 48 Patients with Severe COVID-19 in Wuhan).
        LC: This is a French retrospective study from March 19 to April 11, 2020 of 26 consecutive ICU patients from 2 units with severe COVID‐19 who were screened for VTE on ICU admission and at least every 7 days. 8 (31%) were treated with prophylactic anticoagulation, and 18 (69%) were treated with therapeutic anticoagulation. The overall rate of VTE in patients was 69%. The proportion of VTE was significantly higher in patients treated with prophylactic anticoagulation when compared with therapeutic anticoagulation (100% vs 56%, respectively, P = .03) 6 (23%) had PE. This documents a high incidence of VTE despite prophylaxis and supports trends towards more aggressive anticoagulation.
      • Understanding the COVID-19 coagulopathy spectrum
        May 21. Thachil J. Anaesthesia.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Lydia Cassorla
        AH: This editorial is a summary article covering the link of the immune system to thrombosis. The paper asks clinical questions concerning the use of additional anticoagulants (beyond heparin) for certain patients and raises the use of thromboelastography for clinical guidance.
        LC: This is a useful editorial that summarizes current trends in management and proposes an algorithm for management of COVID-19 related hypercoagulability. If no contraindications, inpatients should receive prophylaxis with LMWH, or unfractionated heparin if indicated. They propose a low bar for imaging (but not a screening regimen) and ramping up anticoagulation according to findings and potentially thrombolysis if the situation continues to worsen. The potential role of point-of-care TEG or ROTEM viscoelastic testing and questions for the future are addressed. While consideration of antiplatelet therapy and the results of more clinical trials are pending, perhaps the most important message is that each center should have a plan.

      May 28, 2020

      • Chloroquine or hydroxychloroquine for COVID-19: why might they be hazardous? May 22. Funck-Brentano C. Lancet.
        A commentary on a Lancet article that retrospectively reviewed the occurrence of significant ventricular arrythmias in 96,032 hospitalized Covid-19 patients from 671 hospitals in six continents. Groups of 1,868 to 6,221 patients each that were given chloroquine or hydroxychloroquine with or without a macrolide were compared to 81,144 control Covid-19 patients who received none of these drugs. While the occurrence of repetitive ventricular arrythmias was much higher in the treated groups (4.3-8.1% versus 0.3%), several lines of reasoning in this commentary suggest that the increase in these arrhythmias was not a major contributor to the increased death rate among these (presumably sicker) patients.
      • Lack of viral clearance by the combination of hydroxychloroquine and azithromycin or lopinavir and ritonavir in SARS-CoV-2-related acute respiratory distress syndrome. May 24. Hraiech S. Ann Intensive Care.
        Letter to the editor that showed a little more than a month after treatment with either hydroxychloroquine and azithromycin or lopinavir and ritonavir or control, that mortality was not different between groups. A retrospective analysis from France.
      • Remdesivir for the Treatment of Covid-19 – Preliminary Report
        May 22. Beigel JH. The New England Journal of Medicine.
        Opinion from SAB Member: Dr. Philip Lumb
        Results from the Adaptive COVID-19 Treatment Trial (ACTT-1), an international, double-blind, placebo-controlled trial of IV remdesivir in adults with documented COVID-19 disease hospitalized with evidence of lower respiratory tract involvement sponsored by the National Institutes of Allergy and Infectious Diseases (NIAID). Patients were randomly assigned to remdesivir or placebo for up to 10 days. It is important to note that “the initial primary outcome measure was the time to recovery, defined as the first day, during the 28 days after enrollment, on which a patient satisfied categories 1, 2, or 3 on the eight-category ordinal scale.”
        Patients were enrolled from February 21 until April 19 at 60 trial sites in the US, Denmark, UK, Greece, Germany, Korea, Mexico, Spain, Japan, and Singapore. Eligible patients were randomized to either study drug or placebo in a 1:1 ratio stratified by study site and disease severity at enrollment; routine therapy in place at the institution was continued. On March 22, the primary outcome was amended by trial statisticians (unaware of the treatment assignments or outcome data) and approved on April 2 prior to any outcome data being available. This change led to the early observation that is now widely recognized as the statement presented by the NIAID sponsors that “remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with COVID-19 and evidence of lower respiratory tract infection.” It is important to read the trial details to understand the reasons for the change and the validity of the results as reported.
        This is an example of a well conducted, adaptive platform clinical trial conducted under difficult circumstances across multiple institutions with appropriate Data Safety Monitoring Board (DSMB) oversight and interim analyses. On April 27, the DSMB reviewed results and because patient enrollment had been completed (patient follow up continuing) at the time of what had been intended to be an interim review, and it was noted that the remdesivir group had a shortened time to recovery when compared to placebo, these results were reported to the NIAID and subsequently made public.
        Hidden in the press coverage but of clinical concern is the now secondary outcome indicating the “odds of improvement were higher in the remdesivir group…than in the placebo group.” The discussion is particularly illuminating regarding the complexities of the study, the enrollment supervision complexity given travel restrictions (lack of study monitors), local and environmental controls and the nature of the study itself; the addition of an experimental therapy supported by routine care across all institutions involved. The authors conclude: “The full statistical analysis of the entire trial population must occur in order to fully understand the efficacy of remdesivir in this trial. These preliminary findings support the use of remdesivir for patients who are hospitalized with COVID-19 and require supplemental oxygen therapy. However, given high mortality despite the use of remdesivir, it is clear that treatment with an antiviral drug alone is not likely to be sufficient.”
        I found this manuscript a fascinating description of an adaptive trial undertaken in difficult circumstances that produced interesting, clinically relevant results that await further analysis for final determination of the remdesivir’s efficacy. However, it stimulated the inclusion of the drug into routine management of COVID-19 patients and suggests that early administration is likely to be of greater benefit.

      May 27, 2020

      May 22, 2020

      May 21, 2020

      • Rationale for Prolonged Corticosteroid Treatment in the Acute Respiratory Distress Syndrome Caused by Coronavirus Disease 2019
        Apr 2020. Villar. Critical Care Explorations.
        Opinion from SAB Member: Dr. Barry Perlman
        This is an opinion piece advocating for the use of corticosteroids in severe COVID-19 outside of trials. The occurrence rate of ARDS with COVID-19 is 17-41%. There is an association between ARDS and dysregulated systemic inflammation, and corticosteroids have been used to down-regulate systemic and pulmonary inflammation in non-viral ARDS due to bacterial pneumonia and sepsis. The 2017 Corticosteroid Guideline Task Force of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, based on 9 RCTs, found moderate quality/certainty of evidence that corticosteroids decrease duration of conventional mechanical ventilation and improve survival. A subsequent RCT also showed corticosteroid benefit in patients receiving low tidal volume ventilation. The authors opine that the WHO recommendation against the routine use of corticosteroids for viral pneumonia outside of clinical trials is based on incomplete evidence and flawed studies. 2 large studies showing benefit with SARS and H1N1 pneumonia, and small observational studies showing benefit with COVID-19 ARDS, support the viewpoint that there is currently no evidence to “deny the use” of corticosteroids outside of RCTs in COVID-19 patients with life threatening cytokine storm.

      May 20, 2020

      • Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic
        May 17. Belhadjer. Circulation.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        A summary of 35 children from France admitted for acute heart failure in febrile cardiogenic shock or left ventricular dysfunction and inflammatory state (all with fever (>38.5°C) and asthenia) that was temporally related to previous exposure to SARS-CoV-2. SARS-Cov-2 infection was confirmed in 31/35 patients (88.5%). 80% of patients were in cardiogenic shock requiring the use of intravenous inotropic drugs. Ten/35 patients (28%) required mechanical circulatory assistance with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) which was weaned and removed in all. All but one patient left the hospital after a median stay of 8 days. The point: not all children have a mild COVID-19 disease.
      • Should Clinicians Use Chloroquine or Hydroxychloroquine Alone or in Combination With Azithromycin for the Prophylaxis or Treatment of COVID-19?
        May 13. Qaseem. Annals of Internal Medicine.
        Opinion from SAB Member: Dr. Barry Perlman
        Practice points based on evidence review concluded on 4/17/20 by the University of Connecticut Health Outcomes, Policy, and Evidence Synthesis Group and developed by the Scientific Medical Policy Committee of the ACP.
        1. Do not use chloroquine or hydroxychloroquine alone or in combination with azithromycin as prophylaxis against COVID-19 due to known harms and no available evidence of benefits in the general population.
        2. Do not use chloroquine or hydroxychloroquine alone or in combination with azithromycin as a treatment of patients with COVID-19 due to known harms and no available evidence of benefits in patients with COVID-19.
        3. In light of known harms and very uncertain evidence of benefit in patients with COVID-19, using shared and informed decision making with patients (and their families), clinicians may treat hospitalized COVID-19–positive patients with chloroquine or hydroxychloroquine alone or in combination with azithromycin in the context of a clinical trial.

        Additional issues considered:

        1. Chloroquine and hydroxychloroquine are used to manage other major ailments, such as rheumatic diseases, with a known benefit and are in short supply in the United States.
        2. Inappropriate and overuse of antibiotics (e.g., azithromycin) is an important contributor to the antibiotic resistance, an immediate public health threat.

      May 16, 2020

      • A primer on viral-associated olfactory loss in the era of COVID-19
        Apr 9. Soler. Allergy & Rhinology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        A nice summary of olfactory loss associated with COVID-19 that helps to answer questions that include presentation and evaluation, natural history, mechanisms of disease and viral pathogens, pharmacologic treatment, olfactory training. The authors then conclude with some practical recommendations including the fact that COVID-19 should be considered if a patient has a sudden loss of smell and/or taste, patients with an acute loss of smell and taste after COVID-19 should assume smell loss is virally associated, oral or topical steroids should not be used to treat acute loss of smell with active COVID-19, olfactory training should be started sooner rather than later, and for persistent loss of smell, consult an otolaryngologist.
      • Interferon beta-1b for COVID-19
        May 8. Shalhoub. The Lancet.
        Opinion from SAB Member: Dr. Barry Perlman
        Studies of interferons alpha and beta have shown variable results with SARS-CoV and no significant benefit with MERS-CoV. This comment discusses the accompanying study of triple drug therapy (https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31042-4.pdf) including interferon beta-1b for patients with mild-moderate COVID-19 by Hung et al. While combination therapy with interferon showed benefit as compared to lopinavir-ritonavir alone, further studies with larger patient numbers and use of placebo controls are needed to determine: 1) whether patients with severe disease would benefit; 2) if interferon beta-1b has efficacy alone or in combination with other medications; 3) how best to treat patients when therapy is started more than 7 days after symptom onset; and 4) the optimum number of interferon beta-1b doses.
      • Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial. May 8. Hung. Lancet.
        Multicenter, prospective, open-label, randomized phase 2 trial with adult confirmed COVID-19 patients in 6 Hong Kong hospitals. 52 combination medication patients received lopinavir, ritonavir, ribavirin, and Interferon beta-1b. For 34 combination medication patients who started treatment after 7 days of symptom onset, interferon beta-1b was omitted due to concerns of pro inflammatory side effects. 41 controls received just lopinavir and ritonavir. Stress steroids were also given to patients requiring oxygen support, and approximately half the patients in each group received antibiotics. The time to negative nasopharyngeal swab RT-PCR (primary endpoint) was 7 days for the combination medication group and 12 days for the control group. The combination group also had earlier time to negative RT-PCR from other specimen locations, quicker alleviation of symptoms, earlier hospital discharge, and decreased IL-6 levels. One control patient withdrew due to 6x increased alanine transaminase, but there were no differences in mild, self limiting adverse effects between the 2 groups. Of note, for patients who started treatment > 7 days after symptom onset, there were no significant differences in outcome between the combination medication group (minus interferon beta-1b) and the control group, suggesting the beneficial effects of interferon beta-1b. However, it is not known if patients who start treatment after 7 days of symptoms onset would benefit from interferon beta-1B. Further, since severe COVID-19 patients were not included, further studies are needed to determine if these patients would benefit from the combination therapy.

      May 15, 2020

      • An Update on Current Therapeutic Drugs Treating COVID-19
        May 11. Wu. Current Pharmacology Reports.
        Opinion from SAB Member: Dr. W. Heinrich Wurm
        A review of common and not-so-common therapeutic agents in current use or under consideration to treat COVID-19 patients, collated by a group from Rutgers School of Pharmacy. Grouped into antivirals, supportive, miscellaneous and traditional herbal medicine, the discussion spans across a wide array of therapies currently used around the globe to deal with COVID-19. Mechanism action and logistics of use in COVID-19 as well as other viral illnesses is addressed, and pros and cons according to recent studies are reviewed. Ongoing trials worldwide are listed. Along with 175 citations, this paper represents a valuable reference for clinicians and investigators.
      • Evaluation of coagulation function by rotation thromboelastometry in critically ill patients with severe COVID-19 pneumonia
        May 11. Pavoni. Journal of Thrombosis and Thrombolysis.
        Opinion from SAB Member: Dr. Lydia Cassorla, Dr. Joseph Anthony Caprini, Dr. Anil Hingorani
        LC: While perhaps not available or familiar to many, ROTEM, a form of thromboelastography (TEG), is a clinically useful point-of-care tool that can help evaluate coagulopathy. It extends diagnostic capability beyond traditional coagulation studies by providing an evaluation of platelet function, clot strength, and fibrinolysis. The test takes about an hour to complete and requires user training. This Italian single center retrospective observational study evaluated ROTEM in 40 consecutive COVID-19 patients admitted to the ICU with multiple measurements over 10 days. In many, hypercoagulability without consumptive coagulopathy or secondary hyperfibrinolysis was detected. The article provides discussion of the potential value of ROTEM over conventional coagulation studies in COVID-19 to guide therapy and calls for prospective studies. JC: This is an interesting article introducing the concept of using viscoelastic measurements to correlate with clinical events in patients with a severe viral infection. This study is small but it does demonstrate the concept of hypercoagulability. I am not sure at this point given the widespread vascular damage associated with this disease how this unique technique is going to be clinically helpful. I’m not discouraging the use of this technique which I have used extensively in the past for other purposes, but realize that we need more work. One interesting thought is that we know many patients following hospitalizations are still at high risk of developing thrombotic complications. Furthermore, there have been attempts to identify patients who would benefit from extended anticoagulation based on risk factors including laboratory parameters such as D dimer. It would be interesting to learn whether this technique might be useful in deciding the length of extended anticoagulant prophylaxis based on the return of the thrombelastographic parameters to normal. AH: This is an evaluation of coagulation function by rotation thromboelastometry in critically ill patients with severe COVID-19 pneumonia (n=40). This is a point-of-care test to assess hypercoaguability for COVID-19, and is NEW data worth reviewing.

      May 14, 2020

      • COVID and the Renin-Angiotensin System: Are Hypertension or Its Treatments Deleterious? May 12. Zores. Front Cardiovasc Med.
        Review of the RAAS with implications for COVID-19. A decrease in cell surface ACE2 may reduce binding of SARS CoV-2 but result in greater activation of angiotensin type 1 receptor (AT1R) by angiotensin II, causing more severe tissue damage. Decreased ACE2 may also increase thrombosis development via metabolism to angiotensin IV and activation of the angiotensin type 4 receptor. In contrast, increased ACE2 on the cell membrane due to up regulation by ACEI or ARBs may increase viral binding but result in less the damage due to less AT1R activation by angiotensin II. Studies are needed to determine whether ACEI or ARBs are beneficial or harmful in COVID-19 patients, but current recommendations are to continue these medications if the patient had been taking them for hypertensive management prior to infection.
      • The tug-of-war between coagulopathy and anticoagulant agents in patients with COVID-19
        May 8. Canonico. European Heart Journal – Cardiovascular Pharmacotherapy.
        Opinion from SAB Member: Dr. Lydia Cassorla, Dr. Anil Hingorani
        LC: This brief report from the pharmacology literature outlines possible drug-drug interactions between anticoagulants and experimental drugs for COVID-19 patients including antivirals and anti-cytokine Rx. Most are due to hepatic metabolism. The interaction with cytochrome P450s and P-glycoprotein are the principal mechanism involved in DDIs. It includes a summary table that pretty much says it all. AH: Useful for listing drug to drug interactions of anticoagulants and other agents used for COVID-19, though I am not sure why they are using the older term NOAC rather than the safer term DOAC.
      • Tocilizumab therapy reduced intensive care unit admissions and/or mortality in COVID-19 patients
        May 6. Klopfenstein. Medecine et Maladies Infectieuses.
        Opinion from SAB Member: Dr. Philip Lumb
        Retrospective case-control study demonstrating possible benefit of Tocilizumab prescription (TCZ: recombinant humanized anti-interleukin-6 receptor [IL-6R] monoclonal antibody used in the treatment of rheumatoid arthritis) when combined with standard care. The article describes a small number of cases, but contains a well-referenced discussion that considers the theoretical basis for use; the methodology and results are clearly presented.

      May 13, 2020

      • Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State
        May 11. Rosenberg. JAMA.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        Among 1438 hospitalized patients with a diagnosis of COVID-19 in metropolitan New York, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. Although randomized double-blind clinical trials are the optimal study design, given the urgent need to respond to the COVID-19 pandemic in New York, this study was designed as an observational multi-center retrospective cohort study using data from the State Health Information Network for NY (SHIN-NY), the state’s public health information exchange network connecting New York State hospitals, supplemented by medical record reviews by trained chart abstractors to evaluate the clinical outcomes and adverse effects associated with hydroxychloroquine and azithromycin therapies for COVID-19. Of course, the interpretation of these findings may be limited by the observational design.
      • EDITORIAL: Hydroxychloroquine, Coronavirus Disease 2019, and QT Prolongation
        May 1. Bonow. JAMA Cardiology.
        Opinion from SAB Member: Dr. J. Lance Lichtor
        Hydroxychloroquine has been advocated and even politicized as a promising therapy because of its anti-inflammatory and potential antiviral properties. However, hydroxychloroquine prolongs the QT interval because of blockade of inward cellular potassium current and is known to be proarrhythmic, especially in the setting of other drugs that also prolong the QT interval. Azithromycin has also been increasingly recognized for risks of QT interval prolongation and sudden death. Excessive prolongation of QTc was observed in 14 of 40 patients (36%) in an intensive care unit, and 37 of 40 patients (93%) manifested an increase in QTc with hydroxychloroquine alone or in combination with azithromycin. In another study, 18 of 90 patients (20%) treated with hydroxychloroquine alone or in combination with azithromycin developed QTc prolongation of 500 milliseconds or more. As noted in the editorial, there’s a potential risk associated of QT prolongation with widespread use of hydroxychloroquine and the combination of hydroxycholoquine and azithromycin in ambulatory patients with known or suspected COVID-19.
      • Inflammation resolution: a dual-pronged approach to averting cytokine storms in COVID-19? May 10. Panigrahy. Cancer Metastasis Rev.
        Discusses inflammatory process and potential development of stimulation of inflammatory resolution as an adjunctive, novel, host-centric mechanism to clear inflammatory debris and aid recovery. Mechanisms of inflammation and dysregulated host response in disease states described and theoretical basis for therapeutic development advanced.
      • Our recommendations for acute management of COVID-19. May 10. Mojoli. Crit Care.
        A 16 step narrative on “how we do it” from an Italian critical care team. Listing of current practice ranging from “do not trust a negative nasal swab” to “we prefer lung ultrasound over other imaging techniques”.
        While much is familiar, there are surprises: “we introduce hydroxychloroquine 200 mg TID and azithromycin 500mg daily”, but no mention of anticoagulation, or proning.
        A quick and interesting read for anyone interested to explore how other units operate.

      May 12, 2020

      May 11, 2020

      • Evidence for and against vertical transmission for SARS-CoV-2 (COVID-19). May 3. A A. Am J Obstet Gynecol.
        Maternal-neonatal transmission of COVID-19 is discussed through evaluating previous published articles. The data presented is biased in two ways. In China, the bulk of deliveries is through C-section, 94%. Conclusions are drawn between delivery method of which there are too few vaginal deliveries. The data is also skewed by the authors evaluating neonatal results from 12 papers, but one paper supplies 50% of the data. Still, the paper provides an excellent description of IgG and IgM involvement post-delivery.
      • Rapid development of an inactivated vaccine candidate for SARS-CoV-2. May 6. Gao. Science.
        Chinese equivalents of the CDC are sharing their latest efforts to prophylactic treatment of COVID 19 in absence of clear therapeutic modalities. The authors claim to have developed a pilot-scale production of a purified inactivated SARS-CoV-2 virus vaccine candidate (PiCoVacc), which induced SARS-CoV-2-specific neutralizing antibodies in mice, rats and non-human primates. These antibodies neutralized 10 representative SARS-CoV-2 strains (may address other Corona / RNA SARS & MERS +/-), suggesting a possible broader neutralizing ability against SARS-CoV-2 strains. Three immunizations using two different doses (3 μg or 6 μg per dose) provided partial or complete protection in macaques against SARS-CoV-2 challenge, respectively, without observable antibody-dependent enhancement of infection. These data support clinical development of SARS-CoV-2 vaccines for humans. The authors, in development of the vaccine, isolated SARS-CoV-2 strains from the bronchoalveolar lavage fluid (BALF) samples of 11 hospitalized patients (including 5 patients in intensive care), among which 5 are from China, 3 from Italy, 1 from Switzerland, 1 from UK and 1 from Spain. The vaccine noted to elicit attenuated clinical, histopathologic, and bio chemical response. A smaller controlled double arm animal study to evaluate “Cytokine storm” response was encouraging as well. Phase I, II, and III will occur later this year!!
      • Severe acute respiratory syndrome coronavirus 2 detection in the female lower genital tract. Apr 29. Cui. Am J Obstet Gynecol.
        Case series from China of 35 COVID-19 + female patients, 37-88 yo, who had careful PCR testing of anal and vaginal sites, all negative.

      May 6, 2020

      • Randomized Clinical Trials and COVID-19: Managing Expectations
        May 4. Bauchner. JAMA.
        Opinion from SAB Member: Dr. Jagdip Shah
        Today there are more than 1,000 studies addressing various aspects of COVID-19 registered on ClinicalTrials.gov, including more than 600 interventional studies and randomized clinical trials (RCTs). It has become common practice to report the glimpses of preliminary results in social media and the popular press. The authors question how we (clinicians, press, public, politicians) should understand the results. The authors appeal to investigators to be strict on control groups, statistical power, proper selection of clinical endpoints, and blinding methods, and strongly advocates merging smaller trials for better robust outcomes. This article was open for comments and an excellent comment from Bhatt A. from Oxford points out that the International Committee of Medical Journal Editors (ICMJE) should be firmer in its proactive stance and guidance to ethics committee verdicts than simply relying on ethics approvals, which all small and uncontrolled studies will have, but which may not have meaning or purpose.
      • Severe ARDS in COVID-19-infected pregnancy: obstetric and intensive care considerations. Apr 14. Schnettler. Am J Obstet Gynecol MFM.
        Single case report in a high-risk pregnancy (age 39, mild myotonic dystrophy, and hx of prior cva on BCP). Patient did require ventilator and proning. Although patient had improved, still on vent at time of writing the article. Suggested algorithms for management at different gestational ages. Some outdated recommendations for treatment. Main interesting point is proning in pregnancy.

      May 5, 2020

      • Use of drugs with potential cardiac effect in the setting of SARS-CoV-2 infection. May 2. Sacher. Arch Cardiovasc Dis.
        French editorial for mitigating risk of arrhythmias due to COVID-19 treatment. Preliminary studies do not document QT prolongation related deaths from hydroxychloroquine/azithromycin, although in one study acute renal failure was a strong predictor of extreme QTc prolongation. Risk factors for QT prolongation and Torsades de pointes:
        1. Modifiable. Hypokalemia, hypocalcemia, hypomagnesemia, bradycardia.
        2. Non-modifiable. Congenital long QT syndrome, female, age > 65, baseline QTc>460 ms, cardiac disease, history of kidney or liver disease, sepsis.
        3. Related to COVID-19 infection. Myocarditis, arrhythmias, hypokalemia, ARF Cardiac workup and optimization prior to initiation of COVID-19 medication treatment should be guided by risk factors (Figure 1). ECG is required before starting drug combinations that can both cause QT prolongation. QTc < 460ms is considered low risk, while if > 500 ms QT prolonging drugs should be avoided or stopped.
        The importance of determining QTc accurately and methods for correctly calculating it are discussed.

      May 2, 2020

      • Testing an Old Therapy Against a New Disease: Convalescent Plasma for COVID-19. Apr 30. Rubin. JAMA.
        A Medical News article written more for general consumption than presenting scientific and clinical results. I first thought to go to the referenced articles that contained only a handful of patients with encouraging results. Then, I noticed a well-developed article summarizing all that has been done so far with transfused plasma including references into the 1890s. Puts the use of transfused plasma into a rational perspective.

      May 1, 2020

      • Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation
        Apr 28. Leisman. Intensive Care Medicine.
        Opinion from C19SAB: Dr. W. Heinrich Wurm
        A literature review aiming to classify COVID-19 as a vascular disease characterized by “a confluence of vascular dysfunction, thrombosis and dysregulated inflammation.” The author’s argument is based on the divergence of lung injury seen in the early stages of COVID-19 from typical ARDS, the elevation of pro-thrombotic markers and histopathological findings of endothelial injury. They consider the evidence of a cytokine storm as an underlying mechanism weak and propose “vasculopathy and dysregulated inflammation” to be the underlying cause leading to thrombotic microangiopathy in pulmonary, renal and other organ systems. A graphic demonstration of the SARS-CoV-2 infection of an endothelial cell initiating a cascade of ACE-2 mediated events, strengthens the argument: loss of angiotensin 2 results in loss of autoregulation and vasoconstriction leading to the hypoxic compliant lung injury described by Gattinoni.
        The author’s closing argument is to focus less on cytokine modulation and more on anticoagulation as a therapeutic measure and to investigate the use of angiotensin 2 therapy.
        This paper created a lively discussion among the members of the SAB as to its clinical relevance and applicability. It is hoped that it will do the same among our readers. Most importantly, we look forward to future multi-disciplinary research leading to a consensus on the mechanisms of COVID-19’s attack on multiple organ systems.
      • Inhaled Nitric Oxide and COVID-19. Apr 28. Ignarro. Br J Pharmacol.
        In this letter to the editor, the authors note that NO may have an antiviral effect and in patients with SARS-CoV, reversed pulmonary hypertension, improved severe hypoxia and shortened the length of ventilatory support. Whether the same will improve hypoxia in patients with COVID-19 infection with moderate to severe COVID-19 with pneumonia and under assisted ventilatory support is being studied.
      • Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Apr 29. Wang. The Lancet.
        2:1 randomized, placebo controlled double blind controlled study on 237 patients in Hubei province China on patients with confirmed COVID-19 disease of 10 days duration or less. No statistically significant results reported although trend to shorter time to clinical improvement requires confirmation in larger studies.

      April 30, 2020

      • The Role of the Renin-Angiotensin System in Severe Acute Respiratory Syndrome-CoV-2 Infection. Apr 29. Alfano. Blood Purif.
        Interesting discussion of ACE and ACE 2 receptors and related interactions and detailed explanation of logic to continue ACE inhibitors in patients with COVID-19. This is despite early concerns that ACE inhibitors and angiotensin II receptor blockers could affect ACE2 actions and exacerbate disease. While this recommendation is well-publicized, the explanation provides a good summary of the interactions and logic behind the recommendation.
      • Understanding the Renin-Angiotensin-Aldosterone-SARS-CoV-Axis: A Comprehensive Review
        Apr 18. Ingraham. European Respiratory Journal.
        Opinion from SAB Member: Dr. Jay Przybylo
        “Comprehensive Review” is an understatement. A basic science article that ties together the RAS to COVID-19 clinical implications. Addresses the infection and many of the symptoms that result. The article needs time to consume.
      • Use of tocilizumab for COVID-19 infection-induced cytokine release syndrome: A cautionary case report
        Apr 20. Radbel. CHEST.
        Opinion from SAB Member: Dr. Philip Lumb
        The article reviews experimental rationale for use of tocilizumab (IL-6 receptor antagonist) as COVID-19 therapy based on cytokine release syndrome (CRS) and subsequent secondary hemophagocytic lymphohistiocytosis which may add/cause to lung pathologies. Syndromes characterized by production of inflammatory cytokines including IL-6, IL-10 and TNF alpha providing therapeutic rationale for tocilizumab which is commonly used to treat CRS secondary to CAR T-cell therapy. 2 case reports detailing patient deterioration and death following tocilizumab therapy despite a decrease in CRP (IL-6 surrogate) following therapy. While no direct correlation to tocilizumab and mortality is suggested, authors caution against use.

      April 29, 2020

      April 25, 2020

      • Outcomes of hydroxychloroquine usage in United States veterans hospitalized with Covid-19
        medRxiv. Apr 23, 2020.
        Joseph Magagnoli; Siddharth Narendran; Felipe Pereira; Tammy Cummings; et al
        Opinion from SAB Member: Dr. Jay Przybylo
        Non-peer reviewed study. Hydroxychloroquine (HC) failed to reduce the need for mechanical ventilation but did result in more deaths when compared to a control group. This correlates with a study from Brazil stopped early because HC resulted in heart rhythm abnormalities.

      April 24, 2020

      April 23, 2020

      April 22, 2020

      • COVID-19: consider cytokine storm syndromes and immunosuppression. Mar 16. Mehta. The Lancet.
        Jay: Letter to Editor. Authors from a medical society (HLH Across Specialty Collaboration) use data from China to redefine Cytokine Storm as Haemophagocytic LymphoHistiocytosis (sHLH). No advance in therapy is advocated.
        Cassorla: “Secondary haemophagocytic lymphohistiocytosis (sHLH) is an under-recognised, hyperinflammatory syndrome characterised by a fulminant and fatal hypercytokinaemia with multiorgan failure. Cardinal features of sHLH include unremitting fever, cytopenias, and hyperferritinaemia; pulmonary involvement (including ARDS) occurs in approximately 50% of patients.” The authors raise the question of whether mortality from COVID-19 could be reduced by identifying the subset of patients with severe disease who have sHLH (using a scoring calculator), and treating with immunosuppression therapy.
      • NIH COVID-19 Treatment Guidelines
        Apr 21. NIH
        Opinion from SAB Member: Dr. David M. Clement
        A panel of U.S. physicians, statisticians, and other experts has developed treatment guidelines for coronavirus disease 2019 (COVID-19). These NIH guidelines, intended for healthcare providers, are based on published and preliminary data and the clinical expertise of the panelists, many of whom are frontline clinicians caring for patients during the pandemic. Using a familiar and standardized rating scheme, recommendations are made for, among other topics, prophylaxis, treatment modalities (oxygen, ICU ventilation, drugs, etc), pregnancy, children and dealing with concomitant medications. Ongoing drug treatment trials are summarized. Of note, the panel recommends against any drug prophylaxis pre- or post-exposure, and states “no drug has been proven to be safe and effective for treating COVID-19.”

      April 21, 2020

      • Clinical characteristics and risk assessment of newborns born to mothers with COVID-19. Apr 18. Yang. J Clin Virol.
        Small prospective study of 7 newborns delivered by cesarean section at 36 weeks or greater from COVID-19 infected women in Wuhan, China. 6 mothers had symptoms prior to delivery, and the 7th developed fever post delivery. 2 of 5 neonates admitted to NICU received nCPAP for mild respiratory distress. Their CXRs showed bilateral ground-glass opacities and granular high density shadows. All 7 were isolated from their mothers post delivery and after discharge from the hospital were isolated at home. Of the 6 newborns tested, no throat swabs, amniotic fluid, or umbilical cord blood were RT-PCR positive.
      • Flooded by the torrent: the COVID-19 drug pipeline
        Apr 18. Mullard. The Lancet.
        Opinion from SAB Member: Dr. Louis McNabb
        There are 180 currently enrolling trials with 150 trials pending. Many of these trials will not have enough patients enrolled to give reliable data. A potentially better model is WHO SOLIDARITY trials which enroll large numbers of patients in several countries. WHO SOLIDARITY is currently investigating remdesivir, hydroxychloroquine, lopinavir/ritonavir, and lopinavir/ritonavir in combination with interferon beta-1a. Results are expected to be coming out from the first trials to complete in the next 12 to 16 weeks.

      April 20, 2020

      April 17, 2020

      • Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19) A review. Apr 13. Sanders. JAMA.
        JAMA review detailing currently reported COVID-19 therapeutic strategies; cautions there is no cure and no specific therapies can be recommended. Reinforces basic medical care, treatment of infection and associated complications, etc. Therapeutic options well defined and described across categories. Recognition that future controlled trials necessary to define more appropriate management options.

      April 16, 2020

      • Remdesivir is a direct-acting antiviral that inhibits RNA-dependent RNA polymerase from severe acute respiratory syndrome coronavirus 2 with high potency. Apr 13. Gordan C. Journal of Biological Chemistry.
        No antiviral agents are currently approved to treat COVID-19. This study shows a probable mechanism of antiviral action for remdesivir and supports continued evaluation of its clinical effectiveness and safety.
        SARS-CoV-2 replication depends on viral RNA-dependent RNA polymerase (RdRp). Remdesivir (RDV) is a prodrug that when triphosporylated resembles ATP. It has been shown to have broad in vitro and animal model antiviral activity including SARS-CoV and MERS-CoV. The presumed mechanism of action is competition of remdesivir triphosphate for ATP, causing delayed chain-termination (termination after 3-5 more nucleotide incorporations). Human mitochondrial RNA polymerase has high selectivity for ATP over RDV-TP, consistent with low cytotoxicity of remdesivir. In this in vitro study of purified SARS-CoV, MERS-CoV, and SARS-Cov-2 RdRp, remdesivir triphosphate was efficiently incorporated into RNA, causing delayed termination of RNA synthesis after 3 additional nucleotides were incorporated (i+3). In comparison, chain termination did not occur with Lassa virus RdRp, which is consistent with its higher binding affinity for ATP over RDV-TP. The other antivirals sofosbuvir and ribavairin, and several nucleostide analogs, showed less competition with ATP in this model.

      April 15, 2020

      April 14, 2020

      April 13, 2020

      April 11, 2020

      April 10, 2020

      • Compassionate Use of Remdesivir for Patients with Severe Covid-19 Apr 10. Grein. NEJM.
        Opinion from SAB Member: Dr. Louis McNabb
        An uncontrolled, observational study showing the potential benefit of remdesivir (68% of patients had improvement in oxygenation). Larger, controlled studies are necessary to confirm efficacy.
      • COVID-19 and the RAAS-a potential role for angiotensin II? Apr 7. Busse. Critical Care. 
        COVID-19 SAB Opinion from: Dr. Jay Przybylo
        The most significant editorial I’ve read that posits the early use of angiotensin II might be beneficial by blocking the entry of the virus through the angiotensin-converting enzyme (ACE) receptor on the cell wall. Proposed that it is best if used early.
      • Is There an Association Between COVID-19 Mortality and the Renin-Angiotensin System—a Call for Epidemiologic Investigations. Mar 30. Hanff. Clin Infect Dis.
        Is there a relationship between the renin-angiotensin system and mortality due to Covid-19? Indeed, people with cardiovascular disease have a higher incidence of mortality due to the disease. Activation of the renin–angiotensin system (RAS) is significant in the pathogenesis of cardiovascular disease and specifically coronary atherosclerosis. But also, angiotensin-converting enzyme 2 (ACE2) is the functional receptor for SARS-CoV-2. More study is needed.
      • SARS-CoV-2 Vaccines: Status Report Apr 14. Amanat. Immunity.
        COVID-19 SAB Opinion from: Dr. Barry Perlman
        There are no existing vaccines or production processes for coronavirus vaccines. Studies on SARS-CoV-1 and the related MERS-CoV vaccines suggest that the S protein on the surface of the virus is an ideal target for a vaccine. Antibody titers in individuals that survived SARS-CoV-1 or MERS-CoV infections often waned after 2–3 years or were weak initially, so an effective SARS-CoV-2 vaccine will need to be efficacious longer to protect against recurrent seasonal epidemics. Currently an MRNA-based vaccine, which expresses target antigen in vivo after injection of mRNA encapsulated in lipid nanoparticles is the furthest along and in phase I clinical trials. Several other vaccines (live attenuated, inactivated virus, or focused on the S protein) are in the pre-clinical phase. Safety testing typically takes 3-6 months. Production of live attenuated or inactivated virus vaccines would probably be faster because of existing infrastructure. It is highly likely that more than one dose of the vaccine will be needed, spaced 3–4 weeks apart. Realistically, SARS-CoV-2 vaccines will not be available for another 12–18 months—too late to affect the first wave of this pandemic, but useful if additional waves occur later or in a post-pandemic scenario in which SARS-CoV-2 continues to circulate as a seasonal virus.
      • Structural and molecular modeling studies reveal a new mechanism of action of chloroquine and hydroxychloroquine against SARS-CoV-2 infection Apr 3. Fantini. International Journal of Antimicrobial Agents.
        COVID-19 SAB Opinion from: Dr. Barry Perlman
        Structural and molecular modeling showed that chloroquine can bind to sialic acids and gangliosides with high affinity. A new type of ganglioside-binding domain at the tip of the N-terminal domain of the SARS-CoV-2 spike (S) protein was identified, which may facilitate contact with the ACE-2 receptor. Chloroquine and the more potent hydroxychloroquine block binding of the viral spike to gangliosides, which the authors suggest may be the mechanism of action of these medications against SARS-CoV-2.
      • Use of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic: What Every Clinician Should Know Mar 31. Yazdany. Annals of Internal Medicine.
        COVID-19 SAB Opinion from: Dr. Barry Perlman
        Data to support the use of hydroxychloroquine and chloroquine for COVID-19 are limited and inconclusive. Given serious potential adverse effects, the hasty and inappropriate interpretation of the literature by public leaders has potential to do serious harm. 10 trials are under way, and information should be forthcoming within weeks. Treatment interruptions for those with SLE and other rheumatic diseases must be prevented, because lapses in therapy can result in disease flares and strain already stretched health care resources.

      April 9, 2020

      April 8, 2020

      April 7, 2020

      April 6, 2020

      April 4, 2020

      • Race to find COVID-19 treatments accelerates Mar 27. Kupferschmidt. Science. 
        COVID-19 SAB Opinion from: Dr. Jay Przybylo
        Remdesivir, developed by Gilead Sciences to combat Ebola and related viruses, shuts down viral replication by inhibiting a key viral enzyme, the RNA polymerase. It didn’t help patients with Ebola in a test during the 2019 outbreak in the Democratic Republic of the Congo. But in 2017, researchers showed in test tube and animal studies that the drug can inhibit the SARS and MERS viruses. As compassionate use, which required Gilead to review patient records; some doctors have reported anecdotal evidence of benefit, but no hard data. Remdesivir may be much more potent if given early. Chloroquine and hydroxychloroquine decrease acidity in endosomes, compartments that cells use to ingest outside material and that some viruses co-opt during infection. But SARS-CoV- 2’s main entryway is different: It uses its so-called spike protein to attach to a receptor on the surface of human cells. Studies in cell culture have suggested chloroquine can cripple the virus, but the doses needed are usually high and could cause severe toxicity. “Researchers have tried this drug on virus after virus, and it never works out in humans.” Hydroxychloroquine might actually do more harm than good. It has many side effects and can, in rare cases, harm the heart-and people with heart conditions are at higher risk of severe COVID-19. Lopinavir-ritonavir combination. Abbott Laboratories developed the drugs to inhibit the protease of HIV, an enzyme that cleaves a long protein chain during assembly of new viruses. The combination has worked in marmosets infected with the MERS virus, and has also been tested in patients with SARS and MERS, though those results are ambiguous. But the first trial with COVID-19 was not encouraging. SOLIDARITY combines these two antivirals with interferon-beta, a molecule involved in regulating inflammation that has lessened disease severity in marmosets infected with MERS. But interferon-beta might be risky for patients with severe COVID-19, Herold says. “If it is given late in the disease it could easily lead to worse tissue damage, instead of helping patients,” she cautions. Other approved and experimental treatments are in testing against coronavirus or likely soon to be. They include drugs that can reduce inflammation, such as corticosteroids and baricitinib, a treatment for rheumatoid arthritis. Some researchers have high hopes for camostat mesylate, a drug licensed in Japan for pancreatitis, which inhibits a human protein involved with infection. Other antivirals will also get a chance, including the influenza drug favipiravir and additional HIV antiretrovirals. Researchers also plan to try to boost immunity with “convalescent” plasma from recovered COVID-19 patients or monoclonal antibodies directed at SARS-CoV-2.

      April 3, 2020

      April 1, 2020

      March 31, 2020

      • Antihypertensive drugs and risk of COVID-19? Mar 26. Tignanelli. The Lancet.
        Suggestion that clinicians should consider withholding angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) because of a potential increased risk of worse clinical outcomes in patients with coronavirus disease 2019 (COVID-19) as well as calcium channel blockers as an alternative.

      March 30, 2020

      March 27, 2020

      March 23, 2020

      March 22, 2020

      March 21, 2020

      March 17, 2020

      March 16, 2020

      March 15, 2020

      March 12, 2020

      February 25, 2020

      • NIH clinical trial of remdesivir to treat COVID-19 begins Feb 25. NIH News Release. NIH
        Opinion from SAB Member: Dr. Jay Przybylo
        A small uncontrolled study from China suggested the drug demonstrated some efficacy. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro cell research from Feb. 4, 2020. This study intends to document the drug’s efficacy. Remdesivir is currently available to some patients through an NIH (National Institute of Allergy and Infectious Diseases) sponsored study being conducted through the Univ. of Nebraska Medical Center (NCT4280705), as well as several other clinical trials and expanded access programs (NCT04292730, NCT04292899, 2020-000936-23). Hopefully results soon.

    1. Anesthesia Care (All patients in COVID-19 era)
      October 19, 2020
      • Aerosolisation during tracheal intubation and extubation in an operating theatre setting. 10/12/20. Dhillon RS. Anaesthesia.
        This study reports measurements and size characterization of aerosols generated and spread throughout a standard positive pressure operating room (with 26 room volume air exchanges per hour) during intubation and extubation of 3 study patients. Face-mask ventilation, tracheal tube insertion and cuff inflation generated small particles 30–300 times above background noise that remained suspended in airflows and spread from the patient’s facial region throughout the confines of the operating room. The authors believe that these findings support careful use of PPE throughout standard ventilation operating rooms.

      October 14, 2020

      • A quantitative evaluation of aerosol generation during tracheal intubation and extubation. 10/6/20. Brown J. Anaesthesia.
        This is a pertinent report on measurement of 0.3-10 nm aerosolized particles using real-time, high-resolution environmental monitoring in ultraclean ORs with laminar flow ventilation and 500–650 air changes / hour. Tracheal intubation sequences including face-mask ventilation produced very low particle quantities (average concentration, 1.4 particles/L, n = 14, p < 0·0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 particles/L, n = 10), 15-fold greater than intubation (p = 0.0004) but 35-fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol-generating procedure.

      August 19, 2020

      • Infection Prevention Precautions for Routine Anesthesia Care During the SARS-CoV-2 Pandemic. 8/3/20. Bowdle A. Anesth & Analg.
        Authors promote precautions that are practical, affordable, and efficient to adjust routine anesthesia care to the current and near-future environment. Consideration for asymptomatic and pre-symptomatic SARS-CoV-2 infection, and the potential for false-negative tests inform recommendations to reduce the risk of transmission via anesthesia care behaviors. Universal N95 or higher respiratory protection is proposed for anesthesia providers with consideration given to whether the entire surgical team should use equivalent respiratory protection. Tables provide a useful summary of PPE, hand hygiene and other recommendations.

      July 15, 2020

      July 8, 2020

      May 29, 2020

      • Coagulation changes and thromboembolic risk in COVID-19 pregnant patients
        May 11. Benhamou D. Anaesthesia Critical Care & Pain Medicine.
        Opinion from SAB Member: Dr. Anil Hingorani, Dr. Joseph Anthony Caprini
        AH: A good review of the literature for prophylaxis for pregnant COVID-19 patients.
        JC: This article contains important information for the anesthesiologist including hematologic changes that reflect thrombosis more than an increased incidence of bleeding. I don’t agree with the authors opinion that only selective patients admitted to the hospital should receive prophylactic anticoagulation. Pregnancy is associated with a mild hypercoagulable state, and combining the effects of the virus one would logically conclude that prophylaxis is indicated unless there is an increased risk of bleeding. In my opinion the number one priority is to prevent the patient from developing a thrombotic complication. I would place less emphasis on neuraxial anesthesia. The incidence of thrombosis post discharge in these patients is significant particularly if they have comorbidities. Many of these patients may benefit from prophylaxis for a period of time during the convalescence. A careful detailed thrombosis risk assessment on admission, during hospitalization and updated upon discharge in my opinion should be a standard part of the workup of these patients. The choice of assessment can be whatever is a commonly used in the hospital and may vary widely according to countries.

      May 20, 2020

      • Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee
        May 17. Senturk. Journal of Cardiothoracic and Vascular Anesthesia.
        Opinion from SAB Member: Dr. Lydia Cassorla, Dr. Joseph Anthony Caprini
        LC: This report is the result of an opinion based survey of anesthesiologists experienced in thoracic surgery (TS) cases regarding management of patients for TS who are known or suspected of being SARS-CoV-2 positive. It is the result of 21 responses from Europe and Canada out of 28 survey requests sent to members of the European Association of Cardiothoracic Anaesthesiology. The report covers all aspects of care. Of interest, it shows a trend towards the choice of a bronchial blocker (BB) over double lumen endotracheal tube (DLT) for lung isolation in both previously intubated and non intubated TS patients. This is related to the potential for reduced aerosolization and reduced tube-changing procedures if the patient is already intubated or is to remain intubated post-op. The flow charts are useful. A nice review of the issues, albeit not data-based. A word of caution: while these practitioners may be rather experienced with the use of BBs, they can be more difficult to place and keep in place than a DLT.
        JC: This publication outlines the consensus recommendations of a group of expert anesthesia specialists who were surveyed regarding the overall approaches to general and specific aspects of airway management, preparations for anesthesia, lung isolation/separation procedures and ventilation itself. It is a very detailed analysis. The authors are quick to point out that the recommendations contained in this document are not claimed to be evidence-based or comprehensive. They do represent the opinion of experts regarding conducting routine daily practice and patience with this serious viral infection.

      May 8, 2020

      May 7, 2020

      • Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic. Apr 24. Gong Y. Anesthesia & Analgesia.
        Recommendations from The Task Force of the Chinese Society of Anesthesiology for Trauma and Acute Care about surgery in a hospital during the Covid-19 pandemic. The article looks like it is from high-powered anesthesiologists in Beijing. Somewhat repetitive information in this long review article. It’s complete information regarding the subject.
      • COVID-19 and Trauma Care: Improvise, Adapt and Overcome!
        May 1. Dutton. Anesthesia & Analgesia.
        Opinion from SAB Member: Dr. Jagdip Shah
        This article outlining the approach to trauma care in the era of COVID-19 emphasizes: PPE for the whole anesthesia team, use of negative pressure ORs, blood conservation, video laryngoscopy and safety precautions during extubation, the role of lung protective ventilation strategies–frequent manual breaths, a need to expand use of multimodal analgesia (regional techniques), care for multi-organ failure intra op, restrictive goal-directed fluid therapy, standard ASA monitoring and frequent laboratory values–especially the coagulation profile to guide patient care, guidelines that address the shortage of drug and equipment on the horizon, healthcare worker protection including donning and doffing, and the current chaos surrounding emergency and acute care surgery. It has guidelines on when to operate in the ER. It references useful resources for those practicing trauma care, including the COVID-19 Global DocMatter Community, the Trauma Anesthesiology Society DocMatter Community, and www.Intubatecovid.org — a website for like-minded trauma anesthesiologists. The authors wish lung ultrasound would be more frequently included in acute surgery / trauma, with less emphasis on CT scans in emergency care.
      • Utility of Tracheostomy in Patients with COVID-19 and Other Special Considerations
        May 5. Mecham. Laryngoscope.
        Opinion from SAB Member: Dr. Jay Przybylo
        A concise prepublication article describing the options for prolonged airway support in COVID-19. Begins with statistics on this pandemic vs earlier SARS-CoV. Provides pros and cons of OR vs bed space, positive pressure vs negative pressure rooms, and percutaneous vs open tracheostomy. The authors imply a percutaneous tracheostomy at the bedside prevents transporting the patient and exposing many people to the virus and might be the best solution in complex patients who are likely to require an artificial airway for a prolonged time.

      May 5, 2020

      May 1, 2020

      April 25, 2020

      • How to Rapidly Deploy Intubation Practice Changes in a Pediatric Hospital During the COVID-19 Pandemic. Apr 22. Brown. Anesthesia & Analgesia.
        Authors from Seattle Children are sharing the protocol for intubation for Covid-19 and unknown patients, anywhere in the hospital irrespective of age/HT/WT or comorbidity of these patients. It has good illustrations. Since Seattle is where Covid-19 started its journey in this country, they had to think fast, act, create something “out of box which will fit across the facility. They practiced on simulation to” perfect it “in the era of intubation and age of social distancing, aerosol, inline HEPPA filters, inline suctioning, video laryngoscope, covers for it, drugs, dirty / clean tray… the list looks complete. It’s worth following for those still trying to address the issue.

      April 21, 2020

      • COVID-19 pandemic: Greater protection for healthcare providers in the hospital hot zones? Apr 18. Ip. A&A.
        In this letter to the editor, the authors recommend that even in the OB suite, health care workers should be protected.
      • Interim considerations for obstetric anesthesia care related to COVID-19. Apr 5. SOAP. 
        This is interim guidance based on expert opinion of a group of SOAP representatives and differs from SOAP’s more formal consensus statements based on systematic reviews and delphi processes. This content will be updated regularly and integrates information and links to recommendations from the WHO and CDC. Has guidelines for L&D, pre-hospital screening, OB suite training, neonatal, staff, training, and simulation.
      • Neuroanesthesia Practice During the COVID-19 Pandemic: Recommendations from Society for Neuroscience in Anesthesiology & Critical Care (SNACC)
        Apr 15. Flexman. Journal of Neurosurgical Anesthesiology.
        Opinion from SAB Member: Dr. Lydia Cassorla
        These timely guidelines from the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) are recommended reading for those providing neuroanesthesia and neurocritical care during the COVID-19 pandemic. This document was created by a SNACC appointed task force to provide a focused overview of the COVID-19 disease relevant to neuroanesthesia practice through consensus-based expert guidance. This article provides information on the neurological manifestations of COVID-19, advice for neuroanesthesia clinical practice during emergent neurosurgery, interventional radiology (excluding endovascular treatment of acute ischemic stroke), transnasal neurosurgery, awake craniotomy and electroconvulsive therapy, as well as information about healthcare provider wellness. “Guidelines for the anesthetic management of endovascular therapy for acute ischemic stroke during the COVID-19 pandemic” are available in separate guidance from the SNACC. This report from a global group of neuroanesthesiologists reports on indications that CNS manifestations of COVID-19 such as lack of smell/taste and altered mental status may be due to direct invasion of the CNS. There are suggestions of an increased incidence of acute ischemic stroke as well. The authors review measures to establish urgency of procedures and decrease healthcare worker exposure to the virus from patients who nonetheless may require emergent/urgent neurosurgical and neuroradiologic procedures and ECT. 2 Printable graphics summarizing considerations for neurosurgical and ECT procedures are included.
      • Category: Clinical Care / Prevention; Anesthesia Care
        Sedation of mechanically ventilated COVID-19 patients: challenges and special considerations
        Apr 15. Hanidziar. Anesthesia & Analgesia.
        Opinion from SAB Member: Dr. Jagdip Shah
        A plea from MGH–guidelines are needed for sedation for COVID 19. The authors rationalize in an excellent way of all practical bed side issues for this subset of patients, covering each sedative agent and its pros & cons, prone positioning, drug shortages, staff preference for deeper sedation to avoid emergent re-intubations (which can expose staff to SARS-CoV-2), high sedation requirements, monitoring difficulties, drug interactions.

      April 20, 2020

      April 17, 2020

      April 15, 2020

      April 14, 2020

      • Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic
        Apr 9. McIntosh. Am J Perinatol.
        Opinion from SAB Member: Dr. Jagdip Shah, Dr. Brian McNabb
        JH: The author compared dose/duration of steroid use during pregnancy with steroid use in ICU for COVID-19 patients and came to the conclusion the maternal risks must be balanced against neonatal benefits. Concludes a cautious & careful consideration with all parties (F/M). BLM: Specific recommendations include no corticosteroids should be administered to COVID-19 positive or suspected gravid patients at > 32 weeks of gestation, MFM consultation to address risks and benefits of corticosteroid use is recommended for COVID-19 positive or suspected gravid patients at < 32 weeks gestation, no tocolysis in COVID-19 positive or suspected gravid patients who are not receiving steroids.

      April 11, 2020

      April 10, 2020

      April 9, 2020

      April 8, 2020

      April 5, 2020

      April 3, 2020

      April 2, 2020

      March 2020

IV. Infection Control

November 23, 2020

  • Influence of room ventilation settings on aerosol clearance and distribution. 11/16/20. Sperna Weiland NH. Br J Anaesth.
    This study from the Netherlands used actual hospital rooms and ventilation systems to measure the clearance of aerosols after a simulated aerosol generating procedure. Higher air exchange rates were much more effective than manipulating the pressure gradient (i.e. negative or positive pressure rooms). A freestanding air purification unit also markedly improved aerosol removal. In positive pressure rooms, small amounts of aerosol were detected in adjacent hallways. This information could be useful when deciding on the best location for aerosol-generating procedures in SARS-CoV-2 infected patients.

October 28, 2020

  • Reusability of filtering facepiece respirators after decontamination through drying and germicidal UV irradiation. 10/22/2020. Vernez D. BMJ Glob Health.
    A “drying cycle” (30 min, 70°C) plus 60 mJ/cm2 of UV-C irradiation (UVGI) effectively decontaminated 2 Staphylococcus aureus’ bacteriophages on 2 models of FFP2 disposable respirators (the European standard most similar to N95) with preserved functional characteristics after 10 cycles. (n=12) Testing included cultures, scanning electron microscopy, Fourier-transform infrared spectroscopy, 10–300 nm NaCl aerosol particle penetration, and visual inspection. 4 respirators treated with the heat alone showed complete decontamination of the phages however UVGI adds protection. H2O2 production during UVGI was observed. Respirators worn for 1 work shift showed slightly increased particle penetration. No fit testing reported.

October 19, 2020

  • COVID-19 Transmission in US Child Care Programs. 10/1/20. Gilliam WS. Pediatrics.
    This is an analysis of a survey completed in late May 2020 by 57,335 childcare providers from all 50 states that were asked about their exposure, their transmission mitigation efforts and whether or not they had ever tested positive for having COVID-19. While 427 (0.7%) of the respondents had tested positive, there was no association found between exposure to childcare and contracting COVID-19. The authors note that results may depend upon the mitigation efforts taken (outlined in the article) and on the relatively low prevalence rates across the United States at the time of the study. Transmission home to parents or siblings was not evaluated.
  • The Effect of Temperature on Persistence of SARS-CoV-2 on Common Surfaces. 10/7/20. Riddel S. Virology.
    In this study, SARS-CoV-2 viability was measured on polymer and paper bank notes, stainless steel, glass, vinyl and cotton cloth at 20, 30, and 40°C. High titer virus was applied, and samples stored in the dark at 50% relative humidity. Half-lives were a few days on all surfaces at 20°C and reduced to a few hours at 40°C. Hard surfaces support viable virus longer than absorbent ones. Some remained detectable for 28 days on nonabsorbent surfaces at ambient temperature. Fomite transmission may be more important than previously thought. Concerns regarding bank notes, touchscreens and mobile phones are of particular importance.

October 14, 2020

  • Duration of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infectivity: When Is It Safe to Discontinue Isolation? 10/8/20. Rhee C. Clin Infect Dis.
    In the review, SARS-CoV-2 is most contagious right before and immediately after symptom onset, and contagiousness rapidly decreases to near-zero about 10 days from symptom onset in mild-moderately ill patients and 15 days in critically ill and immunocompromised patients. The longest duration of viral viability reported is 20 days from symptom onset. Persistently positive SARS-CoV-2 RNA PCR does not indicate replication-competent virus and is not associated with contagiousness. Chain reaction assays that alternate between positive and negative results in recovered patients from COVID-19 most likely reflect sampling variability. The infection confers at least short-term immunity in most cases, but duration of immunity is unclear and several cases of re-infection have now been confirmed.

October 9, 2020

  • Survival of SARS-CoV-2 and influenza virus on the human skin: Importance of hand hygiene in COVID-19. 10/3/20. Hirose R. Clin Infect Dis.
    In this in vitro cadaveric skin model, and insert surfaces, these investigators noted that COVID viruses survive statistically significantly longer (8x) when compared with influenza virus. The authors found the virus can be completely inactivated within 15 seconds of exposure to 80% (w/w) ethanol. Thus, appropriate hand hygiene using ethanol-based disinfectants leads to rapid viral inactivation and may reduce the risk of contact infections. It should be noted that these studies were carried out at room temperature, which may allow longer viral viability compared with normal in vivo skin temperature.

September 23, 2020

  • The role of fit testing N95/FFP2/FFP3 masks: a narrative review. 9/15/20. Regli A. Anaesthesia.
    Fit testing confirms which respirator model provides adequate respiratory protection to an individual. Required to comply with respirator standards, fit testing is costly and not consistently performed. Quantitative fit testing is superior to qualitative fit testing; however, the tested respirator is discarded as it is punctured. Fit checking by the wearer is not a reliable substitute, although strongly recommended with each respirator donning. The role of potential aerosol transmission of SARS-CoV-2 is an area of active research and debate. N95 or higher-level protection is recommended for aerosol generating procedures.

September 16, 2020

September 14, 2020

  • The Effect of Ultraviolet C Radiation Against Different N95 Respirators Inoculated with SARS-CoV-2. 8/28/20. Ozog DM. Int J Infect Dis.
    This study from Michigan provides new data regarding the ability of ultraviolet (UV)-C to inactivate SARS-CoV-2 on specific N95 respirator models. A dose of 1.5 J/cm2 to each mask side was adequate for 3M 1860 and Moldex 1511. Straps of 3M 1860 required secondary decontamination. Three other models tested had residually detectable virus when cultured, confirming model-dependent heterogeneity and need for secondary strap decontamination found in previous studies. No fit testing was done. Implementation of UV-C decontamination of N95 respirators requires careful consideration of model, material type, design, and fit-testing following irradiation.

August 31, 2020

  • Immune response to SARS-CoV-2 in health care workers following a COVID-19 outbreak: A prospective longitudinal study. 8/11/2020. Fill Malfertheiner S. J Clin Virol.
    To continue the operation of German perinatology unit during the pandemic, the authors decided to study (complicated & sophisticated) longitudinally the immune response of 166 (RT PCR + Ve n= 31) health care workers for 8-12 weeks. The authors concluded that the immune response after a COVID-19 outbreak increases significantly over time but still approximately 22% of COVID-19 patients did not have a measurable serologic immune response within 60 days after symptoms. Additionally summarize that exposed co-workers did not develop any relevant IgG antibody levels over time. Meaning no silent seroconversion in HCW from diseased coworkers. IgA is not an adequate marker for long-term immunity. The HCW in the facility can be protected by the necessary measures that are taken fast and furiously with protective measures as neither immunity after infection nor herd immunity are reliable.
  • Microwave- and Heat-Based Decontamination of N95 Filtering Facepiece Respirators: A Systematic Review. 8/24/2020. Gertsman S. J Hosp Infect.
    This systematic review looked at data from 13 (2007-2020) reports involving heat or microwave-based decontamination of N95 respirators. Both 60-90°C heat and microwave methods were found generally effective to deactivate viral pathogens and maintain respirator fit and function. Higher heat and autoclave methods sometimes caused significant degradation. Firm conclusions difficult to reach due to heterogeneity of mask models, methods, and assessments as well as lack of real-world fit testing. No advice on number of cycles is reported. Monitoring of durability is strongly advised.

August 26, 2020

August 25, 2020

  • Inactivation of SARS-CoV-2 and Diverse RNA and DNA Viruses on 3D Printed Surgical Mask Materials. 8/12/20. Welch JL. Infect Control Hosp Epidemiol.
    In a step toward solutions for personal protective equipment (PPE) shortages, investigators tested viral disinfection methods on multiple 3D-printed materials. Complete inactivation of multiple viruses including SARS-CoV-2 was demonstrated with a single application of 10% bleach, quaternary ammonium sanitizer, 3% hydrogen peroxide or 70% isopropyl alcohol and exposure to heat (50°C, and 70°C). 70°C dry heat for 30 minutes completely inactivated all viruses tested. 70% isopropyl alcohol reduced viral titers significantly less well following a single application. Materials remained intact after 100 exposures.

August 7, 2020

  • Reopening Primary Schools during the Pandemic. 7/29/20. Levinson M. N Engl J Med.
    This is a narrative summary and commentary on the literature and debate around reopening primary schools in the US, written by educators and medical epidemiologists. Primary schools in many other countries have re-opened successfully for in-person classes, but that success hinged on low community transmission rates, and extensive testing and surveillance. The authors believe that there is time in the US to achieve successful reopening in some areas if resources and effort are increased. The argument is made that primary schools are essential services, and “whether (or how) to reopen primary schools is not just a scientific and technocratic question. It is also an emotional and moral one.”
  • Reprocessing filtering facepiece respirators in primary care using medical autoclave: prospective, bench-to-bedside, single-centre study. 8/4/20. Harskamp RE. BMJ Open.
    Dutch investigators studied standard autoclave machines for decontamination of FFP2 and FFP3 respirators. They found that one model of FFP2 (the closest European Standard to US N95 respirators) tolerated up to 3 decontamination cycles at 121°C x 17 min. without significant change in filtration, resistance, or fit. Others, including the tested FFP3 model (higher filtration), did not. Referenced published studies support efficacy of this temperature to kill SARS-CoV-2. This study corroborates great variation between mask models observed in other studies and the critical importance of careful fit testing with each donning when considering decontamination and reuse of filtering facepiece respirators.

July 22, 2020

  • Association Between Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among Health Care Workers. 7/14/20. Wang X. JAMA.
    This research letter from the Mass General Brigham healthcare system reports an association between the requirement for universal masking for their healthcare workers and a reduction in their percent positive COVID-19 PCR test results during a period of time when the disease continued to increase in the general population. The decrease in healthcare worker infections could have been confounded by other interventions inside and outside of the health care system, such as restrictions on elective procedures, social distancing measures, and increased masking in public spaces. However, the authors contend these results support universal masking as part of a multi-pronged infection reduction strategy in healthcare settings.

July 15, 2020

  • Factors affecting stability and infectivity of SARS-CoV-2. 7/6/20. Chan KH. J Hosp Infect.
    Review by the SAB
    Authors from a Chinese laboratory report the results of several (virus strain line, temperature, tissue infectivity dose, humidity, pH, etc.) experiments for the COVID-19 virus and its survival under different environmental situations. COVID-19 was able to retain viability for 3-5 days in dried form or 7 days in solution at room temperature, could be detected under a wide range of pH (2-13) conditions for several days and also 1-2 days in stool at room temperature but lost 5 logs infectivity. Common fixatives, nucleic acid extraction methods, and heat inactivation were found to significantly reduce viral infectivity. That will likely ensure hospital and laboratory safety during the COVID-19 pandemic but transmission related to food handlers and workers in meat and poultry processing facilities is possible. The presence of the virus on high-risk hospital surfaces should lead to concern about cleaning on other surfaces. It is estimated that 18% of infections are asymptomatic. With its propensity to cause milder infections, COVID-19 spreads more efficiently in communities in the absence of rigorous social distancing and environmental cleaning measures.

June 29, 2020

  • Wearing an N95 Respiratory Mask: An Unintended Exercise Benefit? 6/1/20. Davis BA. Anesthesiology.
    Review by the SAB
    By Dr. Lydia Cassorla, on behalf of the SAB
    The authors of this letter to the editor discuss the physiologic effects of N95 FFR use.  They review data from previous studies, particularly one by Sinkule in 2013 that measured the potential physiologic effects of using an N95 respirator with and without a surgical mask in front of it.  The data were generated using an automatic breathing and metabolic simulator.  Effects are largely due to increased work of breathing due to the resistance of the respirator, and increased dead space ventilation.  Vvaries with mask design (folded models have more VD than molded models) and tidal volume (lower tidal volumes increase % VD).  At 2 METs energy expenditure (~walking quietly) average inspired O2 is estimated to be 16.1-17.5% and CO2 is estimated to be 2.5-3.5%.  With increased efforts and associated ventilation, minute ventilation increases, along with the work of breathing. However, effects of dead space decrease.  Consequently, N95 users may experience multiple symptoms, even with minimal activity. Associated work of breathing and more marked thoracic pressure swings also generate cardiopulmonary training, a potential benefit.

June 5, 2020

  • Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis
    June 1. Chu DK. The Lancet.
    Opinion from SAB Member: Dr. Barry Perlman
    Meta-analysis published in Lancet and featured in the NYT 6/2/20 reporting that physical distancing > 1 m and use of face mask and eye protection decrease transmission of virus. However, a variety of issues limit the strength of their conclusions.
    2 m distance was more effective than 1 m. As compared with no mask use, N95 or similar respirators were more effective than surgical or cotton masks in decreasing risk of infection. Of note, no intervention provided complete protection from infection. The authors suggest the findings from this review of 172 observational (44 comparative) studies from 16 countries regarding COVID-19, SARS, and MERS transmission can be used to guide protection policies for the public and health-care workers.
    However, the analysis was based on non-randomized studies, most involved SARS and MERS, the impact of duration or setting (e.g. ward, ER, OR, ICU) of exposure was not addressed, most studies reported on bundled interventions, the need for appropriate fit and proper use of N95 masks to achieve maximum effectiveness was not considered, only three non-health-care setting studies were included, there was no direct effectiveness comparison of N95 or similar masks to surgical or cotton masks, and the conclusions were rated at a low to moderate degree of certainty.
    Therefore, further research is required to determine optimal protection from COVID-19 infection, and which are most appropriate for health-care versus non-health-care settings.

May 16, 2020

  • Considerations for Assessing Risk of Provider Exposure to SARS-CoV-2 after a Negative Test. May 8. Long. Anesthesiology.
    Decisions will need to be made about how to address airway management and degree of PPE going forward. This is a discussion of the statistical methods necessary to predict the risk of exposure of an anesthesiologist to SARS-CoV-2 if a patient has had a single negative test. The authors discuss the factors including prevalence in the population, volume of surgery, and degree of risk tolerance in the face of uncertainty. They suggest that policies should place a priority on a low threshold of negative predictive value and argue for universal airborne precautions, irrespective of preoperative test results.
  • The electronic medical record and COVID-19: is it up to the challenge?
    May 2. Pryor. American Journal of Infection Control.
    Opinion from SAB Member: Dr. Barry Perlman
    This is a discussion of existing EMR barriers during the COVID-19 pandemic. Currently, hospital infection prevention (IP) teamwork and communication with caregivers and other hospital staff involve too many manual processes. Identified areas in need of more EMR assisted automation include: notification and identification of suspected and positive COVID-19 patients, tracking infected and suspected inpatients and inter-facility transfers, and ensuring proper isolation orders are executed. For example, EMR screens should be more standardized across disciplines, improved EMR communication between health systems is needed, and IPs should receive more automated alerts regarding testing and patient disposition.

May 8, 2020

  • Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19. May 6. Powell-Jackson. The Lancet.
    Researchers from the Dept of Global Health and Development at the London School of Hygiene and Tropical Medicine set out to find studies investigating health care workers’ compliance with infection prevention and control practices in low-income countries. They found a few papers and decided to focus on data collected in 2018 in Tanzania as part of a randomized trial comparing private for profit dispensaries vs. health centers in faith-based dispensaries. The result was uniformly disappointing with only 7% compliance with hand hygiene and 5% with disinfection of reusable equipment. Nurses and midwives performed uniformly better than physicians and other health care workers.
    In a pandemic, this result will have implications on SARS-CoV-2 transmission among health care workers around the globe.

May 7, 2020

  • A Trial of Lopinavir-Ritonavir in Covid-19: Letter Series with Author Response
    May 5. Dalerba. The New England Journal of Medicine.
    Opinion from SAB Member: Dr. W. Heinrich Wurm
    This investigation from Wuhan, China, published in early April, elicited a number of responses which culminated in the following message: Abandoning an available antiviral at this stage of the pandemic based on a statistically under-powered trial is unwise. Larger cohorts, earlier enrollment and control for secondary therapies might yet point towards a role for these drugs in the management of the SARS-CoV-2 virus. Larger studies are currently underway.

May 5, 2020

  • COVID-19, superinfections and antimicrobial development: What can we expect? May 4. Clancy. Clin Infect Dis.
    Authors are concerned about superinfection of Covid-19 (700,000 deaths/year), drug resistance and no new drugs in the pipeline, a weak government response, a counterproductive regulation of prescription model, raw material for antibiotics coming from China and India, market forces drying out due to stakeholders…
    Coronavirus disease 2019 (COVID-19) arose at a time of great concern about antimicrobial resistance (AMR). No studies have specifically assessed COVID-19-associated superinfections or AMR. Based on limited data from case series, it is reasonable to anticipate that an appreciable minority of patients with severe COVID-19 will develop superinfections, most commonly pneumonia due to nosocomial bacteria and Aspergillus.
    Microbiology and AMR patterns are likely to reflect institutional ecology. Broad-spectrum antimicrobial use is likely to be widespread among hospitalized patients, both as directed and empiric therapy. Stewardship will have a crucial role in limiting unnecessary antimicrobial use and AMR. Congressional COVID-19 relief bills are considering antimicrobial reimbursement reforms and antimicrobial subscription models, but it is unclear if these will be included in final legislation. Prospective studies on COVID-19 superinfections are needed, data from which can inform rational antimicrobial treatment and stewardship strategies, and models for market reform and sustainable drug development. A plea for rational antimicrobial treatment and stewardship strategies, and models for market reform and sustainable drug development.
  • SARS-CoV-2 asymptomatic and symptomatic patients and risk for transfusion transmission. May 4. Corman. Transfusion.
    German authors caution on blood donor poll getting contamination by COVID-19. They noted low risk transfusion risk, but avoid all donor that + RN – PCR. 18 Patient with PCR positive, RNAemia (Actual RNA of virus) was neither detected in 3 patients without symptoms nor in 14 patients with flu‐like symptoms, fever or pneumonia (Mild to moderate symptoms). The only one patient with RNAemia suffered from acute respiratory distress syndrome (ARDS). Risk for SARS‐CoV‐2 transmission through blood components in asymptomatic SARS‐CoV‐2 infected individuals therefore seems negligible but further studies are needed to decease contamination. RNAemia is closely linked to IL 6. RNAemia is NOT considered as infectivity. Stresses need of standardization of RN – PCR all across the world. Male had higher incidence of + RNAemia.

April 28, 2020

  • It’s Not the Heat, It’s the Humidity: Effectiveness of a Rice Cooker-Steamer for Decontamination of Cloth and Surgical Face Masks and N95 Respirators. Apr 26. Li. Am J Infect Control.
    This study from Case Western University Medical School and the Cleveland VA Medical Center studied the inactivation of test organisms on surgical face masks (Precept; Arden, NC), 3M 1860 N95 respirators (3M; Saint Paul, MN), and cotton and quilting fabric cloth face masks using a rice cooker. Authors demonstrated that a short cycle of steam treatment (13-15 minutes total including heating and 5 min steam) applied via a commonly used kitchen rice cooker-steamer was effective for decontamination of methicillin-resistant Staphylococcus aureus (MRSA) and RNA virus bacteriophage MS2. Dry heat at the same temperature levels was much less effective.
  • N95 Mask Decontamination Information
    Apr 27. Cassorla L; Przybylo JH; Clement DM; Perlman B. IARS Coronavirus (COVID-19) Resources.
    Opinion from SAB Member: Dr. Lydia Cassorla
    Interest in decontamination and re-use of N95 and similarly rated particle filtering masks (e.g. Filtering Face Piece grades 2,3 [FFP2, FFP3]–Euro standards for N95 type masks) designed for single use has skyrocketed due to extraordinary demand that cannot be met during the current COVID-19 pandemic. For a decontamination technique to be considered worthy it must satisfy at least 4 criteria: 1) Effective in inactivating the targeted pathogen; 2) Preserve desired particle filtration after decontamination; 3) Preserve mask fit; 4) Be safe for reuse. The most promising techniques appear to involve heat (wet or dry), hydrogen peroxide, and ultraviolet light. Other decontamination techniques such as alcohols, high heat, and bleach were shown by multiple investigators to destroy the filtering properties of the masks. Readers should note constraints and limitations for each study. Not all assessed masks fit after processing. Decontamination was assessed using established norms or by the inactivation of pathogens other than SARS-CoV-2, due to tests being performed before the current pandemic or the risks that would have been incurred. How many times the fabric or whole masks were re-sterilized also varies. Some websites, such as those from the Centers for Disease Control and the industry-academic consortium N95Decon.org are being continuously updated with new information and potential recommendations as they become available. We have assembled potentially useful resources and references on this topic.
  • Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic
    Apr 23. Lockhart. Canadian Journal of Anesthesia/Journal canadien d’anesthesie.
    Opinion from SAB Member: Dr. W. Heinrich Wurm
    A call to arms from several Canadian anesthesia departments stressing the fact that protecting health care personnel from infection is the most important factor determining the success of a prolonged campaign against COVID-19. Their exhaustive recommendations exceed WHO standards in the area of high risk aerosol generating medical procedures (AGMPs) like endotracheal intubation and include head, neck and wrist protection. A sobering table highlights the odds-ratio of transmission for a number of anesthesia related procedures including AGMPs, but a reminder to avoid self-contamination during the doffing procedure is of equal importance. This guide is a valuable reference for practitioners, students and instructors.

April 25, 2020

  • Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility
    Apr 24. Arons. NEJM.
    Opinion from SAB Member: Dr. W. Heinrich Wurm
    Second epidemiological analysis of institutional spread of COVID-19 in a Kings County, WA Skilled Nursing Facility. Triggered by just one symptomatic patient who came in contact with an infected health care worker, this meticulous study highlights the spread of the virus over the next 23 days resulting in 57 (65%) additional infections. Most notably, 89% of asymptomatic residents testing positive one week into the outbreak, were symptomatic 4-7 days later. These findings underscore the role asymptomatic and pre-symptomatic patients play in spreading the virus, as well as the need for low threshold serial institutional testing.

April 21, 2020

April 20, 2020

April 16, 2020

April 15, 2020

  • Anesthesia Management and Perioperative Infection Control in Patients With the Novel Coronavirus. Apr 14. Li. J Cardiothorac Vasc Anesth.
    Review article discussing now established COVID-19 suspected or confirmed patients’ anesthetic management; tables included. While the information is interesting, current practice incorporates recommendations for screening, airway management and other precautions. No additional pertinent findings discussed.
  • Rapid COVID-19-related Clinical Adaptations and Unanticipated Risks. Apr 14. Schrock CR. Anesthesiology.
    Pall filter on the circuit caused hypercarbia….3 anesthesia providers…focused on anti viral regime…tolerated High Paco2!!! Paco2 of 100 mmHg. Corrected by taking Pall anti-viral filter = large dead space …….. Editorial: Caught up in the race to “do something” under current pandemic circumstances, clinicians may feel hesitant to reverse an even obviously harmful intervention (the addition of large dead space to small patients), because of concerns for the unknown consequences of a decision to remove the filter. We caution that from our experience, it is perhaps too easy to implement a hasty change and difficult to anticipate all clinical effects, and decision-makers cannot wholly rely upon subsequent providers to quickly correct our errors even when they become apparent.
  • Role of mask/respirator protection against SARS-CoV-2. Apr 14. Smereka. Anesthesia & Analgesia.
    N95 for high risk area. Surgical mask for low risk area. FFP 1, 2 & 3. Surgical masks – to protect against droplets or particles with a diameter > 100 μm, whereas SARS-CoV-2 virus is essentially spherical with a diameter of 60–140 nm, (thus 100 times smaller than the pore diameter.) FFP1, FFP2, and FFP3. The maximum internal leakage limit is 25% for FFP1, 11% for FFP2, and 5% for FFP3. Class P1 masks retain about 80% of particles smaller than 2 μm, P2 ones retain 94% of particles smaller than 0.5 μm, and P3 ones retain 99.95% of particles smaller than 0.5 μm (Table 1). N95 – NO INFECTION. N95: Dead space (face & mask area) efficiency decrease with long term use. Either way a mask with some “snugness” is better. Two masks may be better than one??

April 11, 2020

April 9, 2020

  • Alert for SARS-CoV-2 infection caused by fecal aerosols in rural areas in China Apr 7. Meng. Infection Control & Hospital Epidemiology.
    COVID-19 SAB Opinion from: Dr. Jagdip Shah
    SARS-CoV-2 can be detected in feces and urine of COVID-19 cases, especially the asymptomatic cases. SARS-CoV can persist in feces from infected people for as long as four days, and SARS-CoV-2 may persist in feces for a longer time. The feces may form high concentrations of viral aerosol and travel through the air to cause infection. Close the lid & then flush, ventilation system, spray disinfectant/wash floor weekly, skeptic to a smell in pumping station.
  • The Challenge of Preventing COVID-19 Spread in Correctional Facilities. Apr 8. Rubin. JAMA.
    A sobering assessment of the challenges the U.S. Prison system faces once COVID-19 gains access. Among the 146,000 inmates, 10,000 of the 146,000 are over 60 and 1/3 of all incarcerated in federal prison have underlying conditions. Valuable review of recently updated guidelines and policies and a worrisome highlight of the lack of basic items, like thermometers and hand sanitizers in some prisons. As of April 2, 75 inmates and 39 staff have been infected by COVID-19.

April 8, 2020

April 7, 2020

April 6, 2020

April 2, 2020

  • Universal Masking in Hospitals in the Covid-19 Era Apr 1. Klompas. NEJM. 
    COVID-19 SAB Opinion from: Dr. Jack Lance Lichtor
    Though not a panacea, universal masking may reduce the likelihood of transmission from asymptomatic and minimally symptomatic health care workers with COVID-19 to other providers and patients. In a patient with active COVID-19, meticulous hand hygiene, eye protection, gloves, and a gown are also important.

April 1, 2020

March 31, 2020

March 27, 2020

March 26, 2020

March 25, 2020

March 24, 2020

March 23, 2020

March 20, 2020

  • Information for Health Care Professionals. RECOMMENDATIONS: 
    • When caring for a patient with known or suspected COVID-19 infection.
    • When considering a procedure for a patient with known or suspected COVID-19.
    • When patients with known or suspected COVID-19 infection need to be transported.
    • When performing procedures on patients with known or suspected COVID-19 infection. March 20, 2020.

March 19, 2020

March 17, 2020

March 12, 2020

March 11, 2020

February 13, 2020

February 2020

V. Logistics / Resource Allocation (Current / Future)

October 26, 2020

  • Sensible Medicine—Balancing Intervention and Inaction during the COVID-19 Pandemic. 10/15/20. Seymour CW. JAMA.
    This article, which contains a discussion relevant for all practitioners engaged in clinical care cautions against abandoning clinical experience and consultation for early adoption of unproven and potentially harmful therapies. The authors urge that practitioners use sensible medicine, a blend between doing nothing and going all in. Their argument is well illustrated and supports the current therapeutic state in which good clinical care in well-managed ICUs following established protocols appears to be effective management strategy. No therapeutic agent has demonstrated significant mortality benefit with the exception of dexamethasone administered appropriately. The discussion supports the decision to steer a middle course with elegance and logic and is refreshing, timely and relevant.

September 9, 2020

May 29, 2020

May 16, 2020

  • Organ procurement and transplantation during the COVID-19 pandemic. May 11. Loupy. Lancet.
    The authors conclude that the COVID-19 pandemic has caused a dramatic loss of organs all across the world. Deceased organs denied means more preventable death likely in coming months. The overall reduction in deceased donor transplantations since the COVID-19 outbreak was 90.6% in France and 51.1% in the USA, respectively. In both France and the USA, this reduction was mostly driven by kidney transplantation, but a substantial effect was also seen for heart, lung, and liver transplants, all of which provide meaningful improvement in survival probability. Leaders of medical institutions will make difficult decisions about how best to deploy limited medical resources. The authors state that the data from public record suggests the only option is living related organ transplant.

May 15, 2020

  • COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU
    May 7. Verdiner. Anesthesia & Analgesia.
    Opinion from SAB Member: Dr. Jagdip Shah
    Practitioners from the American Society of Anesthesiologists (ASA), the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF), representing more than a dozen universities in the USA, created the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU working group. The specific goal is to address the shortage of critical care medicine (CCM) MDs in this current COVID-19 pandemic when supply is mismatched with demand, by fast-tracking anesthesiologists with short notice. This long article is formatted as a knowledge-based guideline. It addresses all possible potential areas of weaknesses in anesthesiology knowledge as it pertains to practicing in the ICU on day #1. The authors have provided state of the art information about the pathophysiology of COVID-19, pertaining to all the disciplines (respiratory, cardiovascular, renal, inflammation cascades, central nervous system, infection control, endocrinology, coagulation dichotomy, etc.) in a dynamic fashion. The article is a well referenced and complete effort to inform non-ICU physicians in simple formats of an inner working of the ICU regarding: multi-specialty involvement, scoring systems for patients, the ABCDEF Bundle (Assess, prevent, and manage pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of analgesia and sedation, Delirium: assess, prevent, and manage, Early mobility and exercise, and Family engagement and empowerment), drug therapy / interactions, supply shortages and their implications, managing codes, interpretation of monitors, ventilator synchronizations, proning, CPR, ARDS, glucose control, ECHO, ECMO, CRRT/dialysis/ultrafiltration, ethical philosophy, the role of the triage committee, and role of palliative care and hospice. The authors explain clearly that COVID-19 is a very different disease regarding its transmissibility to the caregivers, and stresses the need for adaptability of the healthcare system for a huge surge of ICU demand while optimizing the patients for greater benefit and greater good without wasting time, effort and resources.

May 2, 2020

  • Return to normal—prioritizing elective surgeries with low resource utilization. Apr 29. Wilson. Anesthesia & Analgesia.
    In an effort to commence elective surgery without overburdening their ICU, a large hospital in NYC did a statistical analysis of pre-COVID-19 elective surgeries, looking at ICU admission and ventilator use. Cardiac, abdominal and spine surgeries in patients with a high co-morbidity burden were at greatest risk. Such an organized approach to determining how to open to elective surgery is commendable, and is likely to vary in different institutions. Ventilation and ICU care may not be the limiting resource to make such decisions.

April 29, 2020

  • Regional Planning for Extracorporeal Membrane Oxygenation Allocation During COVID-19
    Apr 20. Prekker. CHEST.
    Opinion from SAB Member: Dr. Lydia Cassorla
    This pre-proof review from the University of Minnesota and the Mayo Clinic provides a well thought out and succinctly described framework for regional ECMO resource planning and operational deployment. Their approach involves regional situation awareness, a high degree of coordination between centers with ECMO capability, clinical decision support tools, involvement of expert clinicians in decision making and triage of resources to those most likely to benefit. It also addresses the ethical and practical aspects of not continuing to offer ECMO during a disaster, a decision best based upon a pre-existing framework. Priority for ECMO, which is described as a “trial of support rather than an indefinite resource assignment”, is based upon probability of survival, expected duration of ECMO, illness severity and patient age. A table outlines their framework for prioritization. Acute respiratory failure due to infection including flu and corona viruses is expected to require a “long” duration of >5 days with anticipated survival >60% if all other organ systems are intact. The authors anticipate that when more data of sufficient quality is available for COVID-19 patients treated with ECMO, it may become clearer how to optimally leverage this limited resource.

April 25, 2020

April 20, 2020

  • A conceptual and adaptable approach to hospital preparedness for acute surge events due to emerging infectious diseases. Apr 20. Anesi. Crit Care Explor.
    This narrative review provides a framework for factors that must be incorporated into an effective response to an epidemic or pandemic. The focus is on bringing order to what might otherwise be a chaotic situation. Graphics and definitions are useful in conceptualizing the many stressors and optimal responses to a surcharged system. Causes of healthcare capacity strain are defined as increased volume, increased acuity, special care requirements and resource reduction (relative to demand), and the “4 Ss” of surge preparation discussed: Space, Staff, Stuff, Systems. Perhaps most useful for clinical leaders, policy experts and healthcare administrators.
  • Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective. Apr 17. Griffin KM. Am J Respir Crit Care Med.
    This detailed report from Cornell outlines the adaptations implemented at a large university medical center in one of the epicenters of the SARS CoV2 pandemic. Topics include evolving indications for O2 therapy, intubation and ECMO, PPE, team models, physician staffing and expansion of duties, multidisciplinary care including infectious disease, critical care medicine (CCM), cardiology, anesthesiology, respiratory care, physical therapy, palliative care, and nursing. ICU care was standardized under supervision of CCM specialists regardless of patient location or provider background. Many adaptations in care were designed to limit opportunities for infection of workers, such as dedicated smart phones within ICU care rooms, monitors and care information outside rooms when feasible (compliant due to restricted visitors), bundled care, and dedicated or defined teams for many aspects of care such as invasive procedures and proning. Education, triage, and ethical considerations and wellness are also discussed.
  • The Utah Model: mental bandwidth and strategic risk generation in COVID-19 airway management. Apr 17. Runnels S. Anaesthesia.
    Correspondence regarding the Consensus guidelines for managing the airway in patients with COVID-19 by Cook et al.
    Two points are raised: “First, failure to minimise aggregate airway management risk poses a strategic threat to our medical systems, and two, it is critical to include the risk of mental bandwidth saturation as a risk for contamination.” They feel that protecting providers is the first principle of the current resource-constrained system. The authors provide a graph which shows that increasing aerosolization risk due to increasing airway management complexity correlates with increasing provider stress.

April 16, 2020

  • Balancing Supply and Demand for Blood during the COVID-19 Pandemic. Apr 13. Gehrie E. Anesthesiology.
    Thoughtful discussion on COVID-19 impact on disruption of normal sources to maintain national blood supply highlights decreased donations due to elimination of mobile blood drives at schools, universities and other public locations contrasting with continuing demand and overall decrease in donation which parallels other efforts to decrease demand over past decade. Further mitigation discussion recognizes cancellation of elective surgeries (living donor transplantation, etc.), “keeping the blood in the patient”, single unit transfusions in order to keep blood available for other needs. Recommendations: encourage healthy donors to go to donation centers and optimize currently available and practice recommended blood management techniques.

April 15, 2020

April 14, 2020

April 8, 2020

  • Ark of Life and Hope-Role of Cabin Hospital in Facing COVID-19. Apr 4. Shu. J Hosp Infect.
    Chinese government transformed public places into Cabin hospitals for the treatment of patients with mild and moderate COVID-19. Over one month, a total of 14 Cabin hospitals were opened in Wuhan, and more than 12,000 patients confirmed with COVID-19 were treated, most of whom were cured and discharged and only a few patients were transferred to designated hospitals for further treatment due to exacerbations. These played a crucial role in the prevention and treatment of COVID-19 patients, and quickly solved the problem of insufficient beds in a short period of time, which greatly accelerated the admission of patient, reducing the conversion rate from mild and moderate cases of COVID-19 to severe and critical cases.
  • Covid-19: Increased demand for steroid inhalers causes “distressing” shortages. Apr 5. Mahase. BMJ.
    Brief note regarding shortages of steroid inhalers with recommendation not the “stock pile.”
  • Essential care of critical illness must not be forgotten in the COVID-19 pandemic. Apr 5. Baker. Lancet.
    Lancet correspondence highlighting difficulties associated with CCM in low resourced environments and emphasizing excellent basic care as a fundamental requirement that may ameliorate disease progression and prevent complications from early disease. While important, states the obvious and is a future looking approach rather than an immediate aid, even in low income environments. Longer range awareness and planning should incorporate these principles which already are in effect in many such areas.
  • Fangcang shelter hospitals: a novel concept for responding to public health emergencies. Apr 6. Chen. Lancet.
    Defines criteria for creating temporary isolation hospitals designed to care for mild to moderate disease with provisions for triage to higher level care in traditional facilities if condition deteriorates. Hospital designed for basic care with important feature of isolating mild symptoms from community and home environment while providing appropriate medical and social care. A form of isolation that provides relief from traditional hospitals and supports home environment from contamination with infected family member. Different concept than current additional bed capacity construction in US. Cultural environment may make universal adoption problematic. The discussion is interesting and may prove useful in future epidemic/pandemic strategic planning.
  • Harnessing Our Humanity – How Washington’s Health Care Workers Have Risen to the Pandemic Challenge Apr 1. Rosenbaum. NEJM.
    COVID-19 SAB Opinion from: Dr. Philip Lumb
    Articulate discussion of challenges faced when balancing traditional medical treatment priorities with realities of equipment shortages (protective and therapeutic), patient isolation, loss of family support and healthcare worker tensions arising from the unknown challenges ahead. The discussion presents challenges across all areas including Trainees, Nursing staff, front line CCM and ED providers, Environmental Service Workers, Patients and their Families. Fundamental message is that clear direction and agile protocols are supportive and reassuring, but must be focused, adaptable and transparent.
  • Hospital surge capacity in a tertiary-emergency referral-centre during the COVID-19 outbreak in Italy. Apr 5. Carenzo. Anaesthesia.
    An Italian experience: the author reviews the steps of disaster preparedness: setting up a dedicated cohort COVID ICU with its own Command / Control & Coordination Center overseeing these several wings of an existing hospital. It was managing the dedicated: SPACE – each wing of building / supply constant monitoring demand / staff in shifts. Emphasizes the training of new recruits of qualified personnel from other specialties. Early importance of pre-Triage is mandatory and explains how this becomes more dynamic process with time. The hospital was broadly divided in Red/ yellow / green zone for patient & staff movement.
  • Monitoring behavioural insights related to COVID-19. Apr 6. Betsch. Lancet.
    Interesting insight into population management in times of crisis based on Weekly COVID Snapshot Monitoring (COSMO) initiated on March 3 in Germany. Contains links to COSMO and WHO Europe websites detailing data collection methodology and resources for information integration. Interesting insight and information.
  • Setup of a Dedicated Coronavirus Intensive Care Unit: Logistical Aspects Mar 30. Anesthesiology. Mojoli.
    COVID-19 SAB Opinion from: Dr. Jagdip Shah
    Short, informative article. There is a diagram about isolation ICU set up as a hospital is trying to increase “surge capacity” by 50%. The article explains exactly what/how to set up an isolation ICU.
  • Where Have All the Heart Attacks Gone? Apr 6. Krumholz. NY Times.
    Except for treating Covid-19, many hospitals seem to be eerily quiet.

April 7, 2020

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March 20,