Sunday, July 26, 2020



Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev

1009: Can the Virus Disrupt the Endocrine System?

Through its effects on angiotensin-converting enzyme 2 (ACE2), researchers from Louisiana State University say that SARS-CoV-2 may disrupt various endocrine functions throughout the body.

1010: Potential Treatments, but Hard to Test
Dipyridamole a cheap, FDA-approved drug typically prescribed with blood thinners to prevent strokes, could help patients with COVID-19.

1011: Researchers at Johns Hopkins wanted to test another cheap generic drug — alpha-blocker prazosin, which prevents inflammatory surges.

1012: Oral petechial lesions observed in a small number of COVID-19 patients in addition to skin rash exanthem, is a new symptom of the virus. Madrid researchers examined the oral cavity of 21 patients with the virus who also had a skin rash, and published their findings in a research letter in JAMA Dermatology.  The presence of enanthem in a patient with a skin rash is a useful finding that suggests a viral aetiology rather than a drug reaction.

1012: Test to Guide Steroid Treatment: Hospitalized COVID-19 patients with high levels of inflammation may benefit significantly from dexamethasone and other steroids. Researchers at Albert Einstein College of Medicine and Montefiore Health System in the Bronx, New York, concluded that patients with low levels of inflammation may experience a significantly higher risk for severe outcomes with steroid use. They also found that a C-reactive protein test can help physicians decide which patients are likely to benefit.

1013: Combination Therapy Quells Cytokine Storm: In a new study, the combination of high-dose methylprednisolone and tocilizumab was associated with faster respiratory recovery, lower likelihood of mechanical ventilation, and fewer in-hospital deaths among COVID-19 patients experiencing a hyperinflammatory state known as a cytokine storm compared with those who received supportive care alone. Researchers compared patients who received the treatments with historic controls and found that participants in the treatment group were 79% more likely to achieve at least a two-stage improvement in respiratory status.

1014: Bleeding complications linked to antithrombotic strategy used in non‐critically ill COVID-19 patients: Findings from a study in the Journal of Thrombosis and Haemostasis dispute the currently adopted strategy of giving weight-adjusted doses of anticoagulants to non-critically ill patients with COVID-19 in the absence of thromboembolic complications. Researchers led by Raffaele Pesavento, MD, Department of Medicine, University of Padua, Padua, Italy, noted that "the increasing awareness that low-dose anticoagulants may be ineffective for prevention of thrombotic complications in the course of COVID-19, including the development of micro-thrombosis in the lung vessels, has induced several clinicians to consider the use of sub-therapeutic or even therapeutic doses of antithrombotic agents in all admitted patients, challenging their hemorrhagic potential. The results of our retrospective cohort study do not support this strategy."

"As (sub)-therapeutic doses of antithrombotic drugs failed to reduce the risk of fatal or non-fatal thrombotic complications while simultaneously increasing the haemorrhagic risk, their use in patients with non-critically ill COVID-19 should be discouraged," the authors said.
SOURCE: Journal of Thrombosis and Haemostasis

1015: Clinical improvement of severe COVID-19 pneumonia in a pregnant patient after caesarean delivery:  A case of COVID-19 in a pregnant patient with severe respiratory compromise, whose clinical status significantly improved after caesarean delivery was described in BMJ Case Reports.
A 35-year-old gravida 10 para 7 at 29 3/7 weeks gestation presented to the labour and delivery unit with a 2-week history of cough and fever. The patient also reported dyspnoea that worsened with ambulation, myalgias and dysuria. On the day of presentation, she became increasingly hypoxic, requiring 8 L/min of oxygen via nasal cannula. A COVID-19 nasopharyngeal PCR test on admission was positive and her laboratory results were significant for lymphopenia and elevated LDH, D-dimer and C reactive protein (CRP). Additionally, her chest X-ray findings were consistent with COVID-19, with extensive patchy airspace opacities in the middle and lower lung fields. 
In the SICU, the patient’s condition worsened on hospital day 2 with increasingly elevated oxygen requirements. On hospital day 3, she received tocilizumab 400 mg intravenously. Nonetheless, her respiratory status continued to worsen, and by hospital day 5, she required 15 L/min of oxygen through a Venturi mask with desaturation of her SpO2 to the low 80th percentile on ambulation.
Despite worsening respiratory status, the patient’s acute phase reactants “remarkably” improved, where her CRP down-trended from 179 mg/L at admission to 7.4 mg/L by day 5. Throughout her hospitalisation in the SICU from hospital days 2 to 9, the patient remained afebrile but was visibly tachypneic with increased work of breathing. Meanwhile, her D-dimer level continued to rise, peaking at 3037 ng/mL. 
Because the patient remained dependent on 15 L/min of oxygen and showed signs of clinical worsening with potential imminent need for intubation, an interdisciplinary team agreed on proceeding with caesarean delivery with neuraxial anaesthesia for expedited delivery, and possible intraoperative intubation if the patient was unable to tolerate prolonged supine position. 
The patient eventually underwent an uncomplicated primary caesarean delivery at 30 5/7 weeks gestation with spinal anaesthesia on hospital day 10, while being maintained on 15 L/min of oxygen during the procedure and she did not require intubation. A male neonate was delivered and his chest X-ray on day of life 3 showed no evidence of pulmonary disease, and COVID-19 nasopharyngeal PCR testing collected 2 hours after delivery and on day of life 3 were negative.
The patient’s clinical status rapidly improved postoperatively, where she had a SpO2 to the low 90th percentile on room air at 2 hours post-caesarean, which improved to 100% on 15 L/min of oxygen in the recovery room, and her cough and work of breathing significantly improved. Her oxygen requirements gradually decreased, and by postoperative day 2, she was weaned to 4 L/min of oxygen via nasal cannula. 
The patient remained on therapeutic enoxaparin postpartum until she was stable enough to obtain a CT angiogram, given the continued concern for a concomitant pulmonary embolism. Her CT angiogram was negative for pulmonary embolism, but consistent with COVID-19 infection, showing extensive bilateral patchy ground glass infiltrates and small consolidations. Meanwhile, COVID-19 nasopharyngeal PCR tests continued to be positive on postoperative days 7, 8 and 9. Nonetheless, the patient was discharged on postoperative day 9 as she was symptomatically improved, saturating well on room air and meeting all postoperative milestones. Eventually, her COVID-19 test was negative on postoperative day 14.
In cases of severe respiratory distress from COVID-19 pneumonia, patients may experience a reversal in poor respiratory status after the physiological changes of pregnancy are removed.
This is the first case to describe the use of tocilizumab for COVID-19 infection in a pregnant patient.
Tocilizumab exposure during pregnancy has mostly been studied in patients with severe rheumatologic diseases.
SOURCE: BMJ Case Reports

1016: Antibody levels in patients with mild COVID-19, appear to drop by half within 36 days. The research was conducted by F. Javier Ibarrondo, PhD, and colleagues and was published online on July 21 in a letter to the editor of The New England Journal of Medicine. Ibarrondo is associate researcher at the David Geffen School of Medicine at University of California, Los Angeles (UCLA). (The original letter incorrectly calculated the half-life at 73 days.)

1017: Although acute kidney injury is seen in a substantial minority of patients with severe COVID-19, no evidence of the presence of SARS-CoV-2 was found in kidney biopsies from a small series of such patients, according to researchers.

Kidney biopsy research shows that the kidney injury from COVID-19 virus happens due to complications of the disease and is not because of direct viral infection of the kidney. [Journal of the American Society of Nephrology]

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