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July 14 | Daily COVID-19 LST Report

CLIMATE:

· An opinion article by Swiss physicians titled “Is Clinical Effectiveness in the Eye of the Beholder?” warns against the implementation of treatments with unsound and incomplete evidence, arguing they may violate the principle of non-maleficence, or 'do no harm'. Hydroxychloroquine as an example of a drug that was widely adopted based off minimal in-vitro studies and unscientific promotion in the media. There is now a consensus that it does not offer therapeutic benefit and may have caused unnecessary harm through dangerous QT prolongation and diminished supply for patients with autoimmune diseases. The authors suggest that until effective treatments are proven, we should rely on social distancing and ensuring scientific journals and researchers are held to a high standard.


EPIDEMIOLOGY:

· A simulation model estimating the possible effect widespread use of remdesivir in South Africa - where the death rate is estimated at 85%-100% among patients who cannot obtain intensive care due to the lack of available ICU beds – predicted a reduction in COVID-19 mortality by 635 to 6,862 deaths (out of a projected 36,383 to 47,820 ICU patients as estimated by the South African National COVID-19 Epidemiology model (NCEM). These results suggest that remdesivir may reduce mortality indirectly by reducing the duration of illness and freeing up ICU beds.

UNDERSTANDING THE PATHOLOGY:

· This study investigates possible resistance to fibrinolysis as an additional underlying mechanism of the hypercoagulability in COVID-19. Investigators analyzed thromboelastometry profiles from five COVID-19 patients in France both before and after recombinant plasminogen activator administration (r-tPA), compared to 5 control samples. Results revealed a longer time to fibrinolysis in the COVID-19 samples, and acute pulmonary embolism in three out of the five COVID-19 patients despite thromboprophylaxis. The authors recommend larger prospective studies to further evaluate the fibrinolytic pathways involved in COVID-19 and to identify successful treatments for coagulopathy in this setting.

· Dermatologists review a possible underlying mechanism between severe COVID-19 and obesity, particularly focusing on ACE2 downregulation in SARS-CoV-2 infection leading to increased angiotensin II (Ang II) and angiotensin II type 1 receptor axis (AT1R) activation. The authors hypothesize that increased adipose tissue, which is known to produce angiotensinogen, also increases Ang II, thus contributing to renin-angiotensin-system dysregulation. Based on this hypothesis, they suggest ACE inhibitors, ARBs, Mas receptor agonists (antagonists of angiotensin I), and recombinant ACE2 may benefit patients with COVID-19; particularly those with obesity or metabolic disease.

MANAGEMENT:

· A case series of nine COVID-19 patients presenting with neurological symptoms discovered a common MRI finding of microbleeds in an unusual distribution (most notably the corpus callosum) suggesting a mechanism of damage to the endothelium of brain vessels (thrombotic microangiopathy) by SARS-CoV-2.

· Authors from Icahn School of Medicine at Mount Sinai performed a retrospective, single-center case series of seven COVID-19 stroke patients monitored for malignant cerebral edema (MCE). They found that of the 3/7 patients who underwent decompressive hemicraniectomy (DHC), 2 had favorable outcomes, suggesting that COVID-19 patients suffering from severe stroke may benefit from DHC and should not be excluded solely due to a positive COVID-19 test.

ADJUSTING PRACTICE DURING COVID-19:

· A review from the Department of Ophthalm