@Atul_Gawande: How to Reopen

Atul Gawande outlines what has worked at their hospital system –this is a very important read: Amid the Coronavirus Crisis, a Regimen for Reëntry

An excerpt:

Experts have identified a few indicators that must be met to begin opening nonessential businesses safely: rates of new cases should be low and falling for at least two weeks; hospitals should be able to treat all coronavirus patients in need; and there should be a capacity to test everyone with symptoms. But then what? 

In the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread…

Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus.

  • a military boot camp found that a top-down program of hand washing five times a day cut medical visits for respiratory infections by forty-five per cent.
  • the six-foot rule goes a long way to shutting down this risk. But there are clearly circumstances where that is not sufficient.
  • testing when people have symptoms is important; with a positive result, a case can be quickly identified, and close contacts at work and at home can be notified. And, with a negative result, people can quickly get back to work…Daily check-ins are equally important (Owing to false-negative test results, you are still required to wait until your fever has been resolved, and your symptoms have improved, for seventy-two hours.)
  • nonetheless, patients who do not yet show symptoms, or have just begun to, are turning out to be important vectors of disease. That’s why we combined distancing with masks. They provide “source control”—blocking the spread of respiratory droplets from a person with active, but perhaps unrecognized, infection. [Most masks] are designed to safeguard others, not the wearer.

Surgical masks are effective at blocking ninety-nine per cent of the respiratory droplets expelled by people with coronaviruses or influenza viruses. The material of a double-layered cotton mask—the kind many people have been making at home—can block droplet emissions, as well. And the sars-CoV-2 virus does not last long on cloth; viral counts drop ninety-nine per cent in three hours

Evidence of the benefits of mandatory masks is now overwhelming. Our hospital system would not be able to stop viral spread without them

Drunk Driving Deaths Fall, Unexpected Problem Related to “Frozen” Movie, and Hydroxychloroquine Trial

Briefly noted: Gen Surgery News: Drunk Driving Deaths Fall Thanks to Ride-Sharing Services

“Retrospective analysis of a Level I trauma center has found a direct correlation between the introduction of ride-sharing services and a decline in alcohol-related motor vehicle accidents. Over the six-year study period, the percentage of motor vehicle collisions that were related to alcohol decreased from 39% to 29% with the availability of ride-sharing apps such as Uber and Lyft….

As Dr. Friedman explained, alcohol-related motor vehicle collisions account for approximately 30% of all U.S. traffic fatalities. …a total of 1,474 patients were involved in alcohol-related motor vehicle collisions during the study period. Average annual alcohol-related traffic accidents and fatalities decreased with the availability of ride-sharing services, said Dr. Friedman, who noted that the biggest impact was observed in the 21- to 24-year-old group.”


A young girl swallowed her “Frozen” movie earring –next time instead of swallowing it, she should ‘let it go’


NEJM Full Text: Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19

“Hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive hydroxychloroquine (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360)….[However] in this observational study involving patients with Covid-19 who had been admitted to the hospital, hydroxychloroquine administration was not associated with either a greatly lowered or an increased risk of the composite end point of intubation or death. Randomized, controlled trials of hydroxychloroquine in patients with Covid-19 are needed.”

Freedom from Composite End Point of Intubation or Death. The shaded areas represent pointwise 95% confidence intervals.


 

COVID-19 in Children from Italy

NEJM: Children with Covid-19 in Pediatric Emergency Departments in Italy

Key points:

  • Children younger than 18 years of age who had Covid-19 composed only 1% of the total number of patients; 11% of these children were hospitalized, and none died
  • The Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) study involved a cohort of 100 Italian children younger than 18 years of age with Covid-19 (median age 3.3 years)
    • .Common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%) (especially if <2 years)
    •  Fever, cough, or shortness of breath occurred in 28 of 54 of febrile patients (52%)
    •  Of the 9 patients who received respiratory support, 6 had coexisting conditions

My take: This study provides additional data indicating that severe outcomes are rare in children with Covid-19.

Related article from NY Times: How Coronavirus Mutates and Spreads

An excerpt:

Researchers have found that the coronavirus is mutating relatively slowly compared to some other RNA viruses, in part because virus proteins acting as proofreaders are able to fix some mistakes. Each month, a lineage of coronaviruses might acquire only two single-letter mutations.

In the future, the coronavirus may pick up some mutations that help it evade our immune systems. But the slow mutation rate of the coronavirus means that these changes will emerge over the course of years.

That bodes well for vaccines currently in development for Covid-19. If people get vaccinated in 2021 against the new coronavirus, they may well enjoy a protection that lasts for years.

Related blog posts:

Costly Free COVID-19 Testing and Timely Tweets

From NPR: COVID-19 Tests That Are Supposed To Be Free Can Ring Up Surprising Charge

An excerpt:

This reality means some medical providers… must rule out other respiratory diseases before ordering a COVID-19 test, leaving some patients with a difficult choice. Do they seek medical attention and risk a high medical bill? Or do they forgo care altogether?

A second hole in these federal protections may leave patients holding the bill for their COVID-19 test. The law prohibits insurers from charging patients for testing, but it does not block medical providers from doing so. If an insurer does not cover the total amount charged by a provider, the patient may get balance-billed, or slapped with a surprise charge.

From USAToday:

Related blog post:‘Quietly’ Testing Famotidine for COVID-19

From NY Times:

COVID Toes

USA Today (4/27/20): Doctors find more cases of ‘COVID toes’ in dermatological registry. Here’s what they learned

An excerpt:

Dr. Esther Freeman, director of Massachusetts General Hospital Global Health Dermatology and member of the AAD task force on COVID-19, said COVID toes are pinkish-reddish “pernio-like lesions” that can turn purple over time…

While experts can’t confirm why COVID toes appear, they have some educated guesses. One could be inflammation in the toes’ tissue… Another hypothesis is inflammation of the blood vessel wall, medically known as vasculitis. And finally, … it is possible COVID toes could be caused by small blood clots that form inside the blood vessel…

COVID toes have appeared in some cases of asymptomatic patients. The majority of the toe cases manifested simultaneously or after more common COVID-19 symptoms, rather than before.  

My take: During this pandemic, I need to look at my patient’s feet.

Measles Outbreak, 2018-2019 & More on Coronavirus in Georgia

A recent report (JR Zucker et al. NEJM 2020; 382: 1009-17) highlights an outbreak of a vaccine-preventable disease, measles.  Measles is much more contagious than the recent coronavirus; this is one reason why a vaccine is so crucial.

In total, there were 649 cases confirmed –most of the cases were in a close-knit community in Brooklyn, NY.  86% of the cases with a known vaccination history occurred in those who were unvaccinated. 49 required hospitalization.  The cost to the Department of Health was $8.4 million.

My take:  The health consequences and cost of not preventing measles is staggering -though being eclipsed by the coronavirus pandemic.  The toll in Europe has been much higher.  Worldwide more than 140,000 died from measles in 2018.

Related blog posts:

From Georgia Department of Health: COVID-19 Status Report

It is important to understand that some data, particularly in the last 2 weeks, may not be reported yet.

Related blog post (April 24): Why Georgia Isn’t Ready to Reopen

“Quietly” Testing Famotidine for COVID-19

Yesterday, I received two emails (first from Steven Liu) about an article in Science and today I’ve already seen this article is referenced in a CNN report:

New York Clinical Trial Quietly Tests Heartburn Remedy Against Coronavirus

Key points:

  • In China, a review of ~6000 patients suggested lower mortality in those taking famotidine (not statistically significant)
  • Famotidine may interfere with viral replication protease in the coronavirus based on computer modeling
  • A randomized trial with IV famotidine (large quantities are not available) is underway in New York using 9 times the dose used for heartburn.
  • The article notes that increased heart problems are common in those with reduced renal function
  • “We still don’t know if it will work or not”

My take: Famotidine may be a hot commodity –at least until studies are completed.  Based on experience with hydroxychloroquine, some of our patients may need to look for alternative acid blockers.

Related blog posts:

 

 

NY Times: Why Georgia Isn’t Ready, You Shouldn’t Drink Disinfectants/Bleach, Masks Help

 

Correction: Today’s earlier blog post has been updated:

  • For >1000 [calprotectin], the sensitivity 38%, specificity 100%, PPV 98%, and NPV 92%
  • Previously this line started with the following: “For >100”

From NY Times: Why Georgia Isn’t Ready to Reopen

Key points:

  • Georgia’s infection rates have not started to decline
  • Georgia has a low testing rate compared to other states
  • Georgia’s population rate is vulnerable with increased rates of diabetes and the 4th highest rates of uninsured individuals