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By Christian Hoffmann &
Bernd S. Kamps

1 June

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Summary

First, test them all if there is a SARS-CoV-2 case in a nursing facility; summarize the “new normal” in Japan; and detect SARS-CoV-2 in human breast milk.

Afterwards, characterize the clinical course of 1000 patients in New York; learn that WHO halts one arm of the SOLIDARITY trial; and describe the impact of anti-coagulation prior to COVID-19 infection.

Finally, investigate small droplet aerosols in poorly ventilated spaces; present to your colleagues the spectrum of cardiac manifestations in COVID-19; and discuss the outcomes of 31 people living with HIV who were hospitalized for COVID-19.

Epidemiology

Dora AV, Winnett A, Jatt LP, et al. Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans – Los Angeles, California, 2020. MMWR Morb Mortal Wkly Rep. 2020 May 29;69(21):651-655. PubMed: https://pubmed.gov/32463809. Full-text: https://doi.org/10.15585/mmwr.mm6921e1

Again and again: Test them all, immediately. On March 28, 2020, two residents of a long-term care skilled nursing facility in Los Angeles had positive test results. From March 29-April 23, all residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal PCR testing. 8/99 (19%) residents and 8/136 (6%) staff members had positive test results. 14/19 residents were asymptomatic at the time of testing. Among these, eight developed symptoms 1-5 days after specimen collection and were later classified as presymptomatic.

 

Looi MK. Covid-19: Japan ends state of emergency but warns of “new normal”. BMJ. 2020 May 26;369:m2100. PubMed: https://pubmed.gov/32457055. Full-text: https://doi.org/10.1136/bmj.m2100

Japan has done a good job. This article explains why. Public adherence to the rules, along with cluster tracing and a ban on mass gatherings, seems to have achieved success in bringing the outbreak under control, alongside widespread mask use and hygiene being a normal part of Japanese etiquette. Japan has ended its state of emergency a week after its new infections fell below 50 a day.

 

Transmission

Somsen GA, van Rijn C, Kooij S, Bem RA, Bonn D. Small droplet aerosols in poorly ventilated spaces and SARS-CoV-2 transmission. Lancet Respir Med. 2020 May 27. PubMed: https://pubmed.gov/32473123. Full-text: https://doi.org/10.1016/S2213-2600(20)30245-9

Doors and windows open! Important study, analyzing droplet production due to coughs and speech by measuring the droplet size distribution, travel distance and velocity, and the airborne time in relation to the level of air ventilation (no ventilation, mechanical ventilation only, and mechanical ventilation supported by the opening of an entrance door and a small window). In the best ventilated room, after 30 s the number of droplets had halved, whereas with no ventilation this took about 5 min!

 

Tam PCK, Ly KM, Kernich ML, et al. Detectable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in human breast milk of a mildly symptomatic patient with coronavirus disease 2019 (COVID-19). Clin Infect Dis. 2020 May 30:ciaa673. PubMed: https://pubmed.gov/32472683. Full-text: https://doi.org/10.1093/cid/ciaa673

A second case of detectable SARS-CoV-2 RNA from human milk in a patient with COVID-19. Despite mild clinical symptoms, the patient had detectable virus in human milk in two separate samples taken ten days apart but interspersed with a number of negative results.

 

Clinical

Argenziano MG, Bruce SL, Slater CL, et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. BMJ. 2020 May 29. PubMed: https://pubmed.gov/32471884. Full-text: https://doi.org/10.1136/bmj.m1996

Characterization of the first 1000 consecutive patients with COVID-19 who received care at the emergency department in NYC hospital. Rates of renal complications were high: 33.9% of all patients and 78% of patients in intensive care units developed acute kidney injury. Concomitantly, 13.8% of all patients and 35.2% of patients in intensive care units required in-patient dialysis, leading to a shortage of equipment for dialysis and continuous renal replacement therapy.

 

Szekely Y, Lichter Y, Taieb P, et al. The Spectrum of Cardiac Manifestations in Coronavirus Disease 2019 (COVID-19) – a Systematic Echocardiographic Study. Circulation. 2020 May 29. PubMed: https://pubmed.gov/32469253. Full-text: https://doi.org/10.1161/CIRCULATIONAHA.120.047971

100 consecutive patients diagnosed with COVID-19 infection underwent complete echocardiographic evaluation within 24 hours of admission and were compared to reference values. Thirty two patients (32%) had a normal echocardiogram at baseline. The most common cardiac pathology was RV right ventricular (RV) dilatation and dysfunction (observed in 39% of patients), followed by LV diastolic dysfunction (16%) and LV systolic dysfunction (10%). The authors concluded that LV systolic function is preserved in the majority of patients, but LV diastolic and RV function are impaired.

 

Severe COVID-19

Tremblay D, van Gerwen M, Alsen M, et al. Impact of anticoagulation prior to COVID-19 infection: a propensity score-matched cohort study. Blood. 2020 May 27. PubMed: https://pubmed.gov/32462179. Full-text: https://doi.org/10.1182/blood.2020006941

Empiric therapeutic anti-coagulation (AC) is now being employed in clinical practice in many centers, and will be evaluated in randomized clinical trials. To adjust for bias due to non-random allocation of potential covariates among COVID-19 patients, the authors applied propensity score matching methods. Among > 3000 patients, propensity matching yielded 139 patients who received AC and 417 patients who did not receive treatment with balanced variables between the groups. Results suggest that AC alone is unlikely to be protective for COVID-19-related morbidity and mortality.

 

Comorbidities

Shalev N, Scherer M, LaSota ED, et al. Clinical characteristics and outcomes in people living with HIV hospitalized for COVID-19. Clin Inf Dis 2020, May 30. Full-text: https://doi.org/10.1093/cid/ciaa635

31 people living with HIV (PLWH) were hospitalized for COVID-19. All patients were on antiretroviral therapy and virologically suppressed at the time of admission. One was mild (3%), 2 moderate (6.5%), 21 severe (60%) and 7 were critical (23%). At the time of analysis, 8 (25.8%) patients had died, 21 (67.7%) were alive and discharged and 2 (6.5%) were alive and hospitalized. Four deaths occurred in subjects over 65 years of age and 4 in patients between 50 and 65 years of age.

 

Treatment

Mahase E. Covid-19: WHO halts hydroxychloroquine trial to review links with increased mortality risk. BMJ. 2020 May 28. PubMed: https://pubmed.gov/32467095. Full-text: https://doi.org/10.1136/bmj.m2126

The World Health Organization has halted the hydroxychloroquine arm of the SOLIDARITY trial after a large registry study found that the drug was linked with an increased risk of mortality and heart arrhythmias. The registry data are discussed.

 

Ektorp E. Death threats after a trial on chloroquine for COVID-19. Lancet Infect Dis. 2020 Jun;20(6):661. PubMed: https://pubmed.gov/32473139. Full-text: https://doi.org/10.1016/S1473-3099(20)30383-2

Whether or not to adopt HCQ to treat COVID-19 has turned into a political dispute that seems to benefit no one. This article describes how unfavorable outcomes have provoked animosity. Brazilian authors of the important JAMA study showing that higher doses are associated with higher mortality (the trial was discontinued) received death threats through social media and had to request police  protection,  which  was  kept  for  more  than  2  weeks. The Brazilian president’s son Eduardo Bolsonaro (who has 2 million Twitter followers) had called it “a fake study aimed at demonizing the drug”.