{"id":2235,"date":"2020-05-01T15:40:04","date_gmt":"2020-05-01T22:40:04","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2235"},"modified":"2020-05-01T15:40:04","modified_gmt":"2020-05-01T22:40:04","slug":"42920-more-news-and-information-on-covid-19","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2235","title":{"rendered":"4\/29\/20 More News and Information on COVID-19"},"content":{"rendered":"

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer<\/strong><\/p>\n

See below for this week\u2019s extensive collection of news and information on COVID-19, curated for topics of interest to primary care providers.<\/p>\n

These summaries are being posted as blogs on phcprimarycare.org<\/a>.\u00a0 We have also posted a draft of our recommendations for re-opening outpatient practices on the blog.<\/p>\n

Your team at Partnership HealthPlan is here to help and support you as you adapt to this new medical world we are all now living in!<\/p>\n

    \n
  1. Optimizing physical exams conducted by video<\/u>.\u00a0 Several physicians with extensive experience in providing primary care by telemedicine have posted videos sharing their best practices.\u00a0 Here are some links to some of the ones that are particularly helpful.\n
      \n
    1. General overviews of best practices: <\/u>\n
        \n
      1. \u201cBedside\u201d manner by video<\/a> (10 minutes)<\/li>\n
      2. General physical exam<\/a> (5 minutes)<\/li>\n<\/ol>\n<\/li>\n
      3. Provider directed patient self-exam <\/u>\n
          \n
        1. Overview<\/a> (16 minutes)<\/li>\n
        2. Free CME from Stanford<\/a> (15 minutes)<\/li>\n
        3. Patient assisted virtual palpation<\/a> (3 minutes)<\/li>\n<\/ol>\n<\/li>\n
        4. Best Practice on Observation<\/a> (4 minutes)<\/li>\n
        5. Specific Types of Exam\u00a0<\/u>\n
            \n
          1. Abdominal exam<\/a> (6 minutes) <\/span><\/li>\n
          2. Neurologic exam<\/a> (20 minutes)<\/li>\n
          3. Musculoskeletal exam<\/a> (6 minutes)<\/li>\n<\/ol>\n<\/li>\n
          4. Orthopedic exams<\/u>\n
              \n
            1. Knee<\/a><\/li>\n
            2. Hip and Groin<\/a>; Sample exam<\/a><\/li>\n
            3. Shoulder Exam: flexion<\/a>, adduction<\/a>, abduction<\/a>; preparation for patients before visits<\/a><\/li>\n
            4. Neck: range of motion,<\/a> nerve root compression<\/a><\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n
                \n
              1. COVID Testing<\/u>\n
                  \n
                1. Antibody tests covered by PHC and MediCal<\/u>.\u00a0 MediCal codes (86318, 86328, 86769) are a benefit with an <\/span>effective date of April 10, 2020.\u00a0<\/a> The code for the single step method test is 86318, which has a Medi-Cal rate posted. \u00a0\u00a0Rates have not yet been set by the state for the other two tests.\u00a0 We recommend checking the CLIA status of these tests before ordering them to conduct in your office.<\/span><\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

                  B. Caution:\u00a0 Antibody tests using Lateral Flow Assay have variable sensitivity.<\/u>\u00a0 \u00a0 \u00a0 \u00a0(From UCSF ID<\/a>)\u00a0 Researchers in the UK<\/a> (pre-print) evaluated a panel of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0antibody-based COVID-19 tests \u2013 a novel Enzyme-linked immunosorbent\u00a0 \u00a0 \u00a0 \u00a0 \u00a0assay (ELISA) in the lab and 9 commercially-developed Lateral-Flow\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Assays (LFAs) to be used at the point of care.\u00a0Serum of patients diagnosed\u00a0 \u00a0 \u00a0 \u00a0with COVID-19 served as the positive controls and serum of patients in UK\u00a0 \u00a0 \u00a0 \u00a0before December 2019 served as negative controls. ELISA identified\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0COVID-19 IgM or IgG antibodies in 34\/40 cases and 0\/50 controls, yielding\u00a0 \u00a0 \u00a0 \u00a0a sensitivity and specificity of 85% and 100%. The sensitivity of ELISA IgG\u00a0 \u00a0 \u00a0 \u00a0improved to 100% when restricted to patients exhibiting symptoms for \u226510\u00a0 \u00a0 \u00a0 \u00a0days. No patients were IgM positive but IgG negative by ELISA. LFA had a\u00a0 \u00a0 \u00a0 \u00a0sensitivity of 55-70% with a specificity of 95-100%. IgG titers rose for 3\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0weeks post symptom onset and began to fall by 8 weeks, but remained\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0above the detection threshold. This small study was limited by small\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0sample sizes and has not yet been peer reviewed.\u00a0Bottom line:<\/strong> This study\u00a0 \u00a0 \u00a0 \u00a0suggests ELISA is best used to identify COVID-19 exposure 10 or more\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0days following symptoms. Despite being available at point of care,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0currently available LFAs have variable sensitivity.\u00a0Whether a positive\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0antibody test to COVID-19 by one of these tests correlates with immunity is\u00a0 \u00a0 \u00a0 \u00a0not known.<\/p>\n

                  C. Persistent virus shedding associated with lower levels of SARS-CoV2 IgG:\u00a0 <\/u>\u00a0 \u00a0 \u00a0persistent infection?<\/u> A recent report showed that some patients shed viral\u00a0 \u00a0 \u00a0 \u00a0 \u00a0RNA in stool<\/a> for a prolonged period after symptoms resolved and viral RNA\u00a0 \u00a0 \u00a0 \u00a0is no longer detectable in nasopharyngeal swabs.\u00a0 Another analysis from\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0China<\/a> of a subset with renewed detection of RNA after several negative\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0tests found an association with lower levels of viral-specific IgG.\u00a0 This\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0suggests that a suboptimal immune response is associated with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0persistent or recurrent infection.\u00a0 More study is needed, but this\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0reinforces\u00a0caution needed<\/strong> when interpreting positive COVID antibody\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0tests, especially the LFA tests, as noted above.<\/p>\n

                  D. PCR\/RNA tests using sputum contain more viral material than<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Nasopharyngeal swab.<\/u> This pre-publication summary<\/a> showcases another\u00a0 \u00a0 \u00a0 \u00a0 \u00a0option for appropriate settings, and may be collectable via self-collection.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0This may generate more droplets in collection process, but saves swabs\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0which are often in short supply.<\/p>\n

                    \n
                  1. COVID Epidemiology Updates<\/u>\n
                      \n
                    1. Using COVID RNA tests of sewage for population monitoring.<\/u> As noted previously, SARS-CoV2 RNA has been detected in stool of many individuals with symptomatic COVID.\u00a0 A recent report<\/a> found that SARS-CoV2 can infect the enterocytes of the human GI tract, suggesting that virus shedding is directly from the GI tract.\u00a0 Several countries<\/a> have used RNA detection in sewage to detect COVID-19 infection in a community several days before<\/em> the first symptomatic cases are confirmed.<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

                      \u00a0 \u00a0 According to an article in Nature<\/a>, several groups are conducting these\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 sewage tests in the United States.\u00a0 One area of development<\/a> is to look at\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 the RNA load in sewage to estimate community prevalence of infection.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 KQED reported<\/a> that ten Bay Area Counties and Shasta County are testing\u00a0 \u00a0 \u00a0 \u00a0 sewage; a separate report<\/a> indicated that Lake county has conducted tests.\u00a0 \u00a0 \u00a0 \u00a0 In Lake county the sewage tests converted from negative to positive a few\u00a0 \u00a0 \u00a0 \u00a0 days before the first cases were identified and confirmed.<\/p>\n

                      \u00a0 \u00a0 Once a community believes it is COVID-free for a period of time, sewage\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 testing may be able to confirm this, and act as an early warning of the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 return of COVID to a community.\u00a0 Decades ago, this methodology was used\u00a0 \u00a0 \u00a0 extensively in tracking polio incidence in communities.<\/p>\n

                      B. Heat and humidity of the environment may decrease transmission<\/u> COVID\u00a0 \u00a0 \u00a0 \u00a0 is spreading quickly around the world in countries with a wide variety of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 climates.\u00a0 Urban crowding seems to be one of the larger risk factors.\u00a0 Other\u00a0 \u00a0 \u00a0 respiratory viruses have less transmission in the warmer months of the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 year.\u00a0 This may be partly due to the thicker protective mucous in warmer\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 and moister climates, and partly due to more prolonged indoor exposure\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 to people in cooler weather.\u00a0 An elegant analysis<\/a> of data from multiple\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 countries suggests that there is some slowing of the COVID doubling\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 rate in more tropical climates compared to more temperate climates.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 This is a mathematical\/epidemiological modelling exercise; it will be\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 interesting follow further data analysis from within the United States.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Somewhat suggestive: COVID spread was more rapid and harder to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 control in the Midwest and Northeastern states which are emerging from\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 winter, compared to states in the West and Southwest.<\/p>\n

                      C.\u00a0Pre-symptomatic infections most infectious<\/u>.\u00a0 Another complex\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mathematical analysis of available data published in the journal Science<\/a>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 compares the degree and timing of infectiousness in the course of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 different infection scenarios:\u00a0 pre-symptomatic by droplet\/aerosol;\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 symptomatic by droplet\/aerosol; by environmental contact (fomites); from\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 asymptomatic individuals.\u00a0 The graphic below summarizes their\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 conclusions:\u00a0 tau represents the time since infection.\u00a0 Again, this is a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 model; more data will undoubtedly refine it; it reinforces the rationale for\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 population wide facial covering to reduce transmission.\u00a0 I speculate that\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 the decreased infectiousness of symptomatic individuals may be related\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 to greater caution taken in this phase.<\/p>\n

                      \"Blog<\/a><\/p>\n

                      D.\u00a0Why are mortality spikes greater than can be accounted by reported<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0COVID\u00a0 deaths, in countries around the world?<\/u> Last week, an analysis of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0reported mortality data<\/a> from around the world found that, in many\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0countries,\u00a0 the overall mortality rate increased sharply, but much more than\u00a0 \u00a0 \u00a0 \u00a0would be accounted for by COVID-reported deaths.\u00a0 A few days ago, a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0similar phenomenon was reported in the United States<\/a>, for the last two\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0weeks of March, when COVID deaths accounted for only 53% of excess\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0deaths.\u00a0 Here is the graphic:<\/p>\n

                      \"Blog<\/a><\/p>\n

                      \u00a0 \u00a0 \u00a0Interestingly, most of these excess deaths were in the Eastern US, the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0percentage is notably less in Michigan and absent in Washington state.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0There are multiple possible contributory explanations\/factors; more\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0analysis will shed more light on this.<\/p>\n

                      E. COVID deaths outside the hospital<\/u> (often at home), not counted in official\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 estimates; possibly related to the hypoxia without dyspnea described in a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 prior update.<\/p>\n

                      F.\u00a0Strokes in young patients<\/a>, related to hypercoaguable state induced by\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID infection, which may be due to the recently documented<\/a> direct\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 infection of endothelial cells by SARS-CoV2, with subsequent damage,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 promoting thrombogenesis.\u00a0 New York City found a doubling in the rate of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 strokes<\/a> in the past month, with half the cases in younger patients infected\u00a0 \u00a0 \u00a0 \u00a0 with COVID.<\/p>\n

                      G.\u00a0Patients not going to hospital due to fear<\/a>, dying of heart attacks, strokes,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0other emergency medical conditions.<\/p>\n

                      H.\u00a0Increase in suicides<\/a>.\u00a0\u00a0Of note for the first possibility:\u00a0 PHC now covers O2\u00a0 \u00a0 \u00a0 \u00a0sat monitors<\/strong> (HCPCS E0445) provided by DME companies.\u00a0 However,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0due to an international shortage, your local DME vendors may encounter\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0difficulty fulfilling a prescription for an oxygen saturation monitor.\u00a0 PHC is\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0working on an alternative consignment and distribution process for O2 Sat\u00a0 \u00a0 \u00a0 \u00a0monitors; more to come.<\/p>\n

                        \n
                      1. Updates on therapeutics<\/u>\n
                          \n
                        1. Tocilizumab for reducing cytokine storm<\/u>. (From UCSF ID<\/a>)\u00a0 Two recent papers seek to uncover the mechanisms behind the development of acute respiratory distress syndrome (ARDS) in a subset of COVID-19 patients often >7 days after onset of symptoms. Blanco-Mello et al<\/a> compared the transcriptional response of SARS-CoV-2 to other respiratory viruses including Influenza A in a variety of immortalized tissue culture cells, infection of primary airways cells, in vivo samples derived from SARS-CoV-2 infected ferrets, and finally from post-mortem samples collected from the lungs of humans who died with SARS-CoV-2 or normal lung biopsies. These studies, together with serum profiling in the ferret model, revealed a unique and inappropriate inflammatory response characterized by low levels of type I and type III interferons, elevated chemokines, and elevated Interleukin-6 (IL-6) expression.<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

                          \u00a0 \u00a0\u00a0Giamarellos-Bourboulis et al<\/a> compared 28 patients with COVID-19 and\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 ARDS to 26 patients COVID-19 without ARDS. Control groups included\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 patients with 2009 H1N1 Influenza A and patients with community acquired\u00a0 \u00a0 \u00a0 pneumonia-associated sepsis. Some patients with COVID-19 associated-\u00a0 \u00a0 \u00a0 \u00a0 ARDS had macrophage activation syndrome, and most had immune\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 dysregulation characterized by low expression of HLA-DR on a subset of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 monocytes (CD14 positive) that is triggered by monocyte hyperactivation,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 excessive IL-6 release, and profound lymphopenia. This pattern is distinct\u00a0 \u00a0 \u00a0 \u00a0 from ARDS-associated bacterial sepsis or 2009 H1N1 influenza. Together,\u00a0 \u00a0 \u00a0 \u00a0 these studies suggest that COVID-19 associated ARDS may be\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 characterized by both a reduced innate immune response coupled with an\u00a0 \u00a0 \u00a0 \u00a0 exaggerated inflammatory cytokine response.<\/p>\n

                          \u00a0 \u00a0 A preprint report of a study<\/a> of 30 patients with severe, deteriorating COVID\u00a0 \u00a0 \u00a0 \u00a0 pneumonia treated with tocilizumab to block IL-6 eliminated the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 development of cytokine storm, compared to a matched control group.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Larger studies are in process.<\/p>\n

                          B.\u00a0Alpha-lipoic acid reduces systemic inflammatory response in COVID<\/u>.\u00a0 \u03b1-\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Lipoic acid (ALA), as an antioxidant, has been confirmed to reduce\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 systemic inflammatory response in patients with acute coronary syndromes,\u00a0 \u00a0 \u00a0 liver transplantation patients, and kidney-pancreas combined\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 transplantation\u00a0 patients.\u00a0 A preprint of a study<\/a> suggests a benefit in\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 reducing cytokine storm in critically ill patients with COVID.\u00a0 Again, more\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 study is needed.<\/p>\n

                          C.\u00a0Remdesivir:\u00a0 <\/u>Gilead announced that their trial of Remdesivir has reached\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0its primary endpoint, which likely means a survival benefit has been found.\u00a0 \u00a0 \u00a0 \u00a0More information and detail will be coming soon.<\/p>\n

                            \n
                          1. Focus on inpatient care issues with COVID patients<\/u>.\u00a0 Given the seroprevalence data from Santa Clara (the COVID hot-spot in Northern California), it is likely that over 97% of residents of PHC counties have not yet been infected with COVID-19.\u00a0 There is a strong possibility that we will see an increase in COVID hospitalizations in the future, with recruitment of community physicians to assist with their care.\u00a0 All physicians therefore need to learn the essentials of caring for COVID inpatients.\u00a0 Here are some highlights to help prepare.<\/li>\n<\/ol>\n

                            A.\u00a0Free clinical simulation of caring for patient with COVID on general hospital<\/u>\u00a0 \u00a0 \u00a0 \u00a0floor<\/u>.\u00a0 This simulation<\/a> takes about 15-20 minutes and hits on many\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 highlights of caring for COVID inpatients that are not in the ICU.\u00a0 I highly\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 recommend it.\u00a0 <\/em>The next three items are elaborations of some themes of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 this simulation.\u00a0 The subsequent five items relate more to critically ill\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 patients in the ICU.<\/p>\n

                            B.\u00a0Risk factors for deterioration<\/u>.\u00a0 There are many models for estimating the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 risk of deterioration.\u00a0 Here is one called the Early WArning Score<\/a> (EWAS),\u00a0 \u00a0 \u00a0 \u00a0 using just 5 factors: age, underlying chronic disease, neutrophil to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 lymphocyte ratio, C-reactive protein, and D-dimer levels.<\/p>\n

                            \"Blog<\/a><\/p>\n

                            \u00a0 \u00a0 Low risk is a score of 0-2, medium risk is a score of 2.5-3, high risk is a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 score of 3.5 to 4.5.\u00a0 The 14-day cumulative incidence of clinical\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 deterioration in the low-risk group was 1.8%, which was significantly lower\u00a0 \u00a0 \u00a0 \u00a0 than the incidence rates in the medium- (14.4%) and high-risk (40.9%)\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 groups.\u00a0 Note the heavy weight given to elevated D-dimer level.<\/p>\n

                            C.\u00a0Aerosolization of COVID with different types of oxygen therapy.\u00a0 <\/u>The\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 simulation above indicates that less hazardous aerosol is released into the\u00a0 \u00a0 \u00a0 \u00a0 room with a non-re-breather mask than with other high-flow oxygen delivery\u00a0 \u00a0 \u00a0 methods.\u00a0 This study<\/a> casts some doubt on this popular wisdom, indicating\u00a0 \u00a0 \u00a0 \u00a0 that the aerosolization of all oxygen delivery methods are about the same.\u00a0 \u00a0 \u00a0 \u00a0 Bottom line:\u00a0 wear a tightly-fitting, fit-tested N95 when entering the room of\u00a0 \u00a0 \u00a0 \u00a0 a COVID patient on oxygen.<\/p>\n

                            D.\u00a0Heparin reduces hypoxia in hospitalized COVID patients.<\/u> Since we are\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0seeing a variety of blood clots in patients with COVID (strokes, pulmonary\u00a0 \u00a0 \u00a0 \u00a0 \u00a0emboli<\/a>, peripheral blood clots), and anti-coagulation is usually beneficial for\u00a0 \u00a0 \u00a0 \u00a0most hospitalized patients, it is not surprising that this study<\/a> found\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0improved hypoxia from use of prophylactic heparin in COVID inpatients\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0without active bleeding.<\/p>\n

                            E.\u00a0The range of survival for ventilated patients varies greatly by<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 hospital\/geography:<\/u> \u00a0From a survival rate of 12% in New York City<\/a> to a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 survival rate of 94% in at San Francisco General Hospital<\/a>.\u00a0 This is partly\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 related to the effect of an overwhelmed hospital system, in New York, but\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 another factor is the organization of health care delivery at different\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 hospitals.\u00a0 SFGH\u2019s CEO Susan Ehrlich has rigourously overseen the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 implementation of lean management methods<\/a> throughout their leadership\u00a0 \u00a0 \u00a0 \u00a0 structure, which led to strong independent, self-improving teams.\u00a0 I would\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 speculate that this is contributing to their amazing outcomes.<\/p>\n

                            F.\u00a0Outcomes poor for CPR in hospitalized COVID patients with cardiac arrest<\/u>.\u00a0 \u00a0 \u00a0\u00a0This report<\/a> notes that if patients with COVID get to the stage of cardiac\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 arrest, CPR is unlikely to lead to positive outcomes.\u00a0 Less than 1% of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID patients receiving CPR survived without permanent neurologic\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 sequelae.\u00a0 This is helpful information for advance care planning\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0conversation.<\/p>\n

                            G.\u00a0ST-segment elevation in COVID: clot vs. myocarditis?\u00a0 <\/u>Although the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0COVID virus infects blood vessel endothelial cells, potentially contributing\u00a0 \u00a0 \u00a0 \u00a0 \u00a0to blood clots (as noted earlier), this summary<\/a> found that most patients with\u00a0 \u00a0 \u00a0 \u00a0ST-segment elevation on EKG are found to have no obstruction of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0coronary\u00a0 arteries, suggesting that myocarditis from direct COVID infection\u00a0 \u00a0 \u00a0 \u00a0may be the more dominant underlying etiology, as first noted in\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Washington state\u2019s experience.<\/p>\n

                            H.\u00a0Many critically ill COVID patients found to have aspergillus superinfection<\/u>.\u00a0 \u00a0 \u00a0 \u00a0 This pre-print<\/a> found Aspergillus in 33% of lung specimens of intubated\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID patients.\u00a0 This might be colonization or superinfection, the latter\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 due to impaired immune response.\u00a0 Evaluating Bronchial secretions of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID patients for superinfection with both bacteria and fungus seems\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 prudent, to not miss a treatable superinfection.<\/p>\n

                            \u00a0I.\u00a0Gut microbiome associated with risk of cytokine storm?<\/u> Why do some\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID patients become seriously ill, while others do not?\u00a0 This analysis<\/a>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 speculates that the proteins produced by the gut microbiome (called\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 the\u00a0fecal metabolome)<\/em> may affect the probability of developing cytokine\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 storm.\u00a0 More analysis is needed to understand how this might be leveraged\u00a0 \u00a0 \u00a0 for prevention or treatment.<\/p>\n

                              \n
                            1. What is \u201cCrazy Paving\u201d and what does it have to do with COVID?<\/u> Crazy paving<\/strong>\u00a0refers to the appearance of\u00a0ground-glass opacity<\/a>\u00a0with superimposed\u00a0interlobular septal thickening<\/a>\u00a0and\u00a0intralobular septal thickening<\/a>, seen on\u00a0chest High Resolution CT<\/a>.\u00a0It is a non-specific finding that can be seen in a number of conditions.\u00a0Here are two CT scan views showing this pattern, along with a picture of a mosaic paved pathway that inspired this whimsical radiological description.<\/li>\n<\/ol>\n

                              \"Blog<\/a><\/p>\n

                              Crazy paving:\u00a0 not exactly a yellow brick road, but I\u2019ll say goodbye for now.<\/p>\n

                              Robert Moore, MD MPH MBA<\/strong><\/h5>\n
                              Chief Medical Officer<\/h5>\n","protected":false},"excerpt":{"rendered":"

                              By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer See below for this week\u2019s extensive collection of news and information on COVID-19, curated for topics of interest to primary care providers. 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