Climate
Based on a 2018 systematic review of the SARS and MERS literature, authors identified key areas of research for these coronaviruses. They noticed that research was lacking in viral pathogenesis, clinical characterization, infection prevention and candidate therapeutics, and therefore recommend prioritizing research in these fields for the study of SARS-CoV-2.
Epidemiology
Contact tracing in Korea linked initial COVID-19 cases to several fitness class instructors. 26% of participants in their classes developed infection. Investigators speculate that the environment of a fitness class: a moist, warm atmosphere in a confined area coupled with turbulent airflow generated by intense physical exercise can lead to a higher rate of transmission.
IgG serology studies among staff members after a COVID-19 outbreak at a major German children’s and women’s hospital revealed the level of IgG did not correlate with symptom severity.
22% of the patients with COVID-19 did not develop a measurable immune response within 20 days.
Some participants (without COVID-19) had an elevated response (IgG {1.8%}, IgA {7.6%}) irrespective of positive contact history.
An initially asymptomatic 23 year old female with COVID-19 confirmed by RT-PCR was found to have spontaneous pneumomediastinum on chest CT. The pneumomediastinum resorbed after seven days and the patient was discharged on day 10. The authors speculate that this presentation could be due to membrane damage caused by the virus, although the finding is difficult to explain in this patient who had minimal symptoms.
Researchers in Belgium reviewed literature and postings on social media from March 15 to May 10, 2020 to summarize neurological manifestations of COVID-19. Reported neurological manifestations include acute cerebrovascular diseases, CNS infection, seizures, anosmia or ageusia, and Guillain-Barré syndrome.
Understanding the Pathology
Iranian neuroscientists performed a literature review investigating the neuroinvasive potential of coronaviruses, and found four suggested routes of entry into the central nervous system (CNS):
Through olfactory neurons in the olfactory epithelium
Via infected monocytes crossing the blood-brain barrier (BBB) to infect glial and neuronal cells
Through interaction of CoV and ACE2 receptors on BBB endothelial cells
Via Peripheral nerves (trans-synaptic transmission)
Management
Guidelines and recommendations for managing COVID-19 patients include:
Procedures for safely administering anesthetics
Conducting an interpreting EEGs
Description of the clinical approach for children
Perioperative management of COVID-19 positive patients.
Airway management in COVID-19 patients.
Monitoring procalcitonin levels may help identify patients at risk of severe disease - a meta-analysis of 4 studies found that “increased procalcitonin values are associated with a nearly 5-fold higher risk of severe SARS-CoV-2 infection.”
One case series explored the use of Hyperbaric Oxygen Therapy between 1-6 treatments for 90 minutes at 2.0 atmospheres to avoid using mechanical ventilation in 5 patients with moderately COVID-19. The successful treatment of all patients support further study of the treatment’s efficacy.
Adjusting the Guidelines
Guidelines and recommendations for practice during the pandemic include:
Minimization of viral spread for radiology departments.
Endoscopy in inflammatory bowel diseases.
Metabolic and bariatric surgery.
Resuming elective orthopedic surgery.
Urothelial cancer management.
Authors to urge providers to test for SARS-CoV-2 prior to initiating systemic steroids. A case report of an 80-year old female admitted to the hospital for acute relapse of ulcerative colitis was treated with steroids. The ulcerative colitis resolved; however, the patient developed severe COVID-19 and ultimately died.
A meta-analysis investigating outcomes in 51 patients who developed postoperative COVID-19 found a mortality rate of 27% suggesting the importance of preoperative testing of asymptomatic patients.
R&D: Diagnosis & Treatments
Korean laboratory proposes guidelines for diagnosing COVID-19.
They recommend:
Test Indications: Testing is appropriate to confirm suspected cases of COVID-19 and make decisions on continuing or discontinuing quarantine.
Diagnostic Methods: RT PCR is recommended, but the authors call for more studies to identify the optimal target gene for these tests. Repeat testing may be necessary.
Specimen Selection: For asymptomatic individuals, a combination of nasopharyngeal and oropharyngeal swabs is recommended. For patients with severe systems, lower respiratory tract specifics (sputum, bronchoalveolar lavage, tracheal aspirates) are recommended.
Biosafety: These recommendations are presented in the full report.
Click here to download the full report: