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June 30 | Daily COVID-19 LST Report

Climate:

· Italian Cardiologists discuss how low-quality evidence during the COVID-19 pandemic is an unavoidable step in the process of understanding an emerging infectious disease, but lacks utility for guiding patient management and may lead to widespread use of potentially ineffective treatments and increased public distrust.

· Authors affiliated with the Boston Health Care for the Homeless Program (BHCHP) clinic utilize the case report of a 66-year-old COVID-19 positive patient who developed diabetic ketoacidosis to highlight their newly implemented pandemic response system designed to improve care for this vulnerable population.



Epidemiology:

· Molecular biologists from Spain explore gender differences in COVID-19, hypothesizing that the location of the angiotensin-converting enzyme 2 (ACE2) gene on the X chromosome may explain the greater fatality rate in males compared with females.

· Researchers describe how the well-established Total Risk Assessment (TRA) evaluation and Infected Patient's Ratio (IPR) tools can be combined to create a model that predicts inflection points, plateaus, ICU and ventilator thresholds, and Total Fatality Ratios (TFR) for the COVID-19 pandemic. Their results suggest this tool can predict the impact of lockdown and social distancing measures and guide policy decision moving forward.


Understanding the Pathology:

· Authors from Columbia University Medical Center report the pathological findings of post-mortem adrenal glands in COVID-19 patients (n=5). Their findings include: arteriole fibrinoid necrosis in the parenchyma, capsule, and peri-adrenal adipose tissue; apoptotic endothelial cells with cellular debris; and red fibrinoid material staining with Masson's trichome stain. The underlying mechanism of adrenal vasculopathy is unclear, and warrants further investigation.

· Dutch authors concur with the above hypothesis that ACE2 gene location on X-chromosomes may explain greater disease severity in males with COVID-19, and postulate that co-expression of ACE2 and ADAM17 (also on X chromosome) may also produce increased ACE2 in circulation.


Transmission & Prevention:

· A review of 39 studies (n= 33,867) of influenza, SARS-CoV-1, and MERS outbreaks compared efficacy of N95, surgical, and cloth masks for preventing viral spread. They found that in healthcare settings, N95 masks were most effective at prevented SARS-CoV-1 transmission. However, in community settings, masking had little effect on influenza transmission (possibly due to noncompliance and greater usage during pandemics vs yearly flu).

· An international group of researchers propose a COVID-19 testing algorithm to prevent resurgence of the virus as nations begin to reopen, that balances the need to restart economies with the reality of limited testing resources. They prioritize those with the highest risk of exposure (i.e. essential workers) until testing capacity is appropriately scaled up.


Management:

· Anesthesiologists from India write to agree with a previous article by Gattinoni et al. stating that the lung disease of COVID-19 be split into two time-related phases, type L (low elastance and low ventilation:perfusion ratio) and type H (high elastance, high right-to-left shunt, high lung weight and high recruitability). The authors hypothesize type L may be caused by diffuse pulmonary microvascular thrombosis and should be treated with high flow nasal cannula and ECMO to prevent further lung injury and subsequent development of type H disease.

· A review of potential drug-drug interactions (DDIs) in patients taking medications for Alzheimer's Disease (AD) with concurrent COVID-19 infection recommends providers briefly review CYP450 metabolism of several key treatments used in both conditions. They note that memantine may be the safest Alzheimer's medication in this context due to its limited hepatic metabolism and low risk for DDIs.


Adjusting the Practice During COVID-19:

· Authors from Singapore describe their construction and implementation of an Emergency Medical Department (EMD) extension facility that successfully accommodated 5,004 suspected COVID-19 patients with no infection prevention and control breaches. They urge other hospitals to consider implementing similar facilities to increase surge capacity and reduce the demand on the main EMD isolation facilities.

· A systematic review that assessed the validity of tele-neuropsychology (TNP) in assessing older adults (aged 65+), concluding that specific cognitive screeners, language tests, attention/working memory tasks, and memory tests demonstrated high validity, suggesting that TNP may be the preferred modality for this high-risk population during the COVID-19 pandemic.

· The importance of exercise during quarantine in type 2 diabetic patients: Authors describe how 150 minutes of aerobic and resistance exercise weekly can improve metabolic health, immune responses, and anti-inflammatory to pro-inflammatory cytokine ratio, suggesting that physical activity may be helpful in cultivating a better response to COVID-19 infection and could result in a less severe course.


R&D Diagnosis and Treatments:

· A bioinformatic analysis by authors from China compared the gold standard RT-PCR to a novel nanopore targeted sequencing (NTS) to accurately identify SARS-CoV-2, findings that NTS can identify SARS-CoV-2 and other respiratory viruses within 6-10 hours, and that the 22/61 suspected COVID-19 cases missed by RT-PCR were identified by NTS. Authors propose that NTS may complement RT-PCR for diagnosing COVID-19 patients despite the longer turnaround time and increased operational skill.

· Italian researchers review how dipeptidyl peptidase-4 (DPP4; also known as CD26 lymphocyte surface protein) can stimulate the production of IL-6 and TNF-α and has been implicated in pulmonary diseases. DPP4 inhibitors (gliptins), currently used in treatment of type-2 diabetes mellitus, have been shown to reduce lung inflammation and injury, suggesting a potential therapeutic use in patients with COVID-19.

· A commentary by the London Metropolitan University and University of Hartfordshire proposes using small extracellular vesicles (sEVs) from engineered mesenchymal stromal/stem cells (MSCs) as an alternative therapy to soluble recombinant ACE2 in SARS-CoV-2 infection. They cite the potential ability to inhibit viral binding to the ACE2R, increase phagocytic activity, and anti-inflammatory effects as theoretical mechanisms of protection.

· Researchers in New York review the current literature on passive immunization, finding that plasma infusions with SARS-CoV-2 antibodies may be an effective short-term treatment. They predict increased use of treatment with monoclonal antibodies within the next year, but also recommend close monitoring of these patients for antibody-mediated adverse events.


Mental Health and Resilience:

· Online surveying of 500 people from 45 US states between March 27 and April 5, 2020 revealed that job loss and social isolation had a statistically significant indirect impact on suicide risk through feelings of “perceived burdensomeness” and “thwarted belongingness”. The authors advocate that increased awareness of these emotions during the pandemic by providers is needed to mitigate a potential secondary suicide crisis.

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