A medical ethicist discusses unique ethical dilemmas that the COVID-19 pandemic has presented including individual rights vs public good, data collection, resource rationing, and vaccine trials.
Age demographics and travel histories of confirmed COVID-19 cases: Authors from the Hong Kong University of Science and Technology found that the largest incidence of positive cases occurred in the 15-24 age group (41%). Furthermore, (61%) had traveled to countries with known outbreak or been exposed to other infected travelers. These findings emphasize risk of transmission among younger, less symptomatic individuals and reveal the importance of travel restrictions/precautions during the pandemic.
A retrospective cohort study from China (n=104) analyzed predictors of severe VID-19 disease based on initial presentation. They found that older age (>63 years [odds ratio, OR=41.0; 95% CI: 2.8, 592.4]), decreased lymphocyte count (≤1.02×10^9/L [OR=6.1; 95% CI: 1.5, 25.2]), and elevated serum CRP (≥65.08 mg/L [OR= 8.9; 95% CI = 1.0, 74.2]) are key early predictors of severe disease.
Neurological effects of COVID-19: Nature Reviews Neurology highlights the significant evidence of CNS damage in COVID-19, noting the wide range of symptomatology and still undetermined mechanism injury.
Cytokine release syndrome (CRS) in COVID-19: Data from 11 patients with acute respiratory distress syndrome (ARDS) in Guangzhou, China indicated that 8/11 patients developed CRS with characteristics including a continuous fever, end-organ dysfunction, and coagulopathy. A substantial increase of interleukin 6 (IL-6) suggests it may act as a prognostic factor for CRS development in COVID-19 patients with severe pneumonia.
Understanding the Pathology:
Analysis of immune marker expression profiles of 24 patients in Germany found an association between severe COVID-19 disease and increased interactions between epithelial and immune cells. These data further implicate a heightened immune inflammatory response as a pathophysiological mechanism and suggest that dampening of immune hyperactivation, perhaps by targeting common endpoints of signaling pathways such as CCR1 and/or CCR5 pathways, has therapeutic potential.
Researchers from India hypothesize that the cytokine storm in COVID-19 may be caused by SARS-CoV-2 invasion of the vagus, facial, and glossopharyngeal nerve axons, leading to inflammation of the nucleus tractus solitarius (NTS) and ensuing dysregulation of cholinergic anti-inflammatory pathways and hypothalamic−pituitary−adrenal axis.
Transmission and Prevention:
An author from the University of California, San Francisco presents a counterargument to a nation-wide antigen and antibody screening program in the US, citing poor test sensitivity, increased risk to healthcare workers administering tests, and lack of correlation between antibody presence and viral neutralization.
A group of international researchers evaluating clinical indexes of 75 hospitalized COVID-19 patients in Zhejiang, China found that the proportion of abnormal IL-2, IL-4, and total cholesterol levels were significantly higher in critically-ill patients compared to moderate severity. This is consistent with previous studies, and suggests these may be a useful indicator for identification of severe disease.
Guidelines developed by Shoham Geriatric Medical Center (SGMC) in Israel to support physical therapy (PT) interventions for geriatric COVID-19 patients recommend direct contact PT treatments, as opposed to tele-rehabilitation, to address both functional and respiratory impairments of geriatric patients with COVID-19.
An opinion article from the Annals of Emergency Medicine critique the reported findings of the Richardson et. al., 2020 observational case series that found a mortality rate of 88.1% among patients requiring mechanical ventilation. The authors argue that the reported "higher-than-expected mortality" is due to "right censoring" since analysis occurred before most intubated patients had experienced the outcome of the study (death or discharge). They offer two possible solutions (stating the status of all patients at data collection or clarifying the uncertainty in results), illustrating ways future observational studies can avoid presenting disinformation.
Adjusting Practice During COVID-19:
Recommendations for neonatal and maternal care in low-resource settings during the COVID-19 pandemic included droplet precautions, hand hygiene, and physical spacing, in addition to outlining warning-signs of late-onset neonatal COVID-19 infection. The authors also recommend continuing standard of care with delayed cord clamping in excess of 30 seconds to assure adequate placental transfusion, allowing skin-to-skin contact following appropriate masking, hand-washing, and breast hygiene, and monitoring children for delayed COVID-19 infection after birth in addition to new droplet precautions.
R&D Diagnosis and Treatment:
Authors associated with Gilead Sciences Inc. present two first-in-human (FIH) phase I studies (a single-dose escalation study and a multiple-dose study) evaluating the safety and pharmacokinetics of IV remdesivir (RDV) in healthy participants for the potential use of RDV in COVID-19 treatment suggesting that a single-dose of RDV daily, whether as a solution or lyophilized formulation, is well-tolerated and safe to use in healthy adults, supporting the continued clinical investigation of RDV in COVID-19 therapy.
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