COVID-19 brings to light the need for universal health care services and Italian authors demand further government investments in the development of such structures
The COVID-19 pandemic has created dissonance between practicality and the traditional four pillars of medical ethics: autonomy, beneficence, non-maleficence, and justice.
The decision to suspend non-urgent care goes against the justice and autonomy of patients whose care has been suspended/canceled.
Shortages of supplies such as ventilators may cause physicians to make choices about who to prioritize in treatment, which creates an ethical dilemma for the physician who is supposed to consider autonomy, beneficence, and non-maleficence in treating every patient.
The supply of PPE has also been lacking in many places, which creates a situation where the physician may have to make the choice to put their own health at risk in order to uphold these four principles of medical ethics for their patients.
Therefore, it is important to create succinct guidelines recognizing that these traditional four pillars may not be able to guide decision making, and informing physicians on how to evaluate and defend their decisions so that they can better use their professional judgment during the COVID-19 pandemic.
Authors speculate that anosmia is a specific symptom that can be used as a cheap and effective screening tool for COVID-19. Coupled with the fact that olfactory mucosa has a high expression of ACE2 transcript, they speculate that anosmia is due to direct damage to neuroepithelial stem cells.
Seattle area OBGYNs report that current studies are inadequate to definitively categorize pregnant persons with COVID-19 as low risk, even if do not have any other comorbidities. The literature shows that the adverse consequences of perinatal maternal infections may require years to manifest in children, and that we may not be seeing the full effects of COVID-19 on these infants for several years.
Understanding the Pathology
An author presents a possible explanation for thromboses in COVID-19 patients. They speculate that the virus could attack erythrocytes directly, resulting in antigen-antibody immune complex formation. This type III hypersensitivity reaction would release proteases that could destroy epithelium, mesothelium, and endothelium basement membrane as well as create antiphospholipid antibodies, which could lead to thrombosis.
Transmission & Prevention
A bioengineer affiliated with the Imperial College in London questions whether 2 meters (approximately 6.6 feet) is an appropriate distance for preventing droplet transmission of SARS-CoV-2 based on studies demonstrating exhalation behavior and travel of exhaled tobacco smoke (a possible surrogate for droplets) reaching a distance of up to 9 meters.
Guidelines and recommendations for managing COVID-19 patients include:
Pemphigus vulgaris patients
According to a retrospective study of 172 ICU patients with COVID-19, the ratio of IL-6 to lymphocytes was associated with an increased risk of a 28-day mortality and could be used as a way to identify patients who might require earlier interventions or therapeutic measures.
A prospective cohort study of 73 patients suffering from concurrent multiple myeloma (MM) and COVID-19 had a significantly higher mortality rate compared to the general population with COVID-19 (54.6% vs. 14.5%). Authors attribute this to poor health of cancer patients, weakened immune system due to systemic anti-cancer therapy, and elderly age, although they do not rule out a direct correlation between MM and SARS-CoV-2.
Adjusting Practice during COVID-19
Guidelines and recommendations for adjusting during the COVID-19 pandemic include:
Basic timeline of delaying pediatric neurosurgery procedures
Imaging and treatment of emergency care of large-vessel occlusion (LVO) stroke
A cardiology specialist at University of Hong Kong, China strongly urges the use of hand-held ultrasound scanners with disposable protective covers as an alternative for cardiopulmonary examination during COVID-19 pandemic after suffering from a right external auditory canal injury after using a disinfected stethoscope that had a loose ear tip.
R&D: Diagnosis & Treatments
A systematic review and meta-analysis conducted by Zhejiang University in China found that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are not associated with a significantly higher risk of COVID-19 infection (OR = 0.99; 95% CI, 0.95-1.04; P = 0.672), severity of disease among those infected with COVID-19 (OR = 0.98; 95%CI 0.87-1.09; P = 0.69), or mortality in those infected (OR = 0.73, 95%CI 0.5-1.07; P = 0.111). Additionally, ACEIs/ARBs were associated with a lower risk of mortality when the analysis was restricted to the four studies with patients treated with these vs other antihypertensive drugs (OR=0.48, 95% CI 0.29-0.81; P=0.006). Based on these results, the authors do not believe there is any indication to discontinue ACEIs/ARBs treatments during the COVID-19 pandemic.
A systematic review of 10 studies including 29 COVID-19 patients receiving tocilizumab found increased IL-6 levels (from a median of 71.1 pg/mL to 376.6 pg/mL) and decreased CRP levels (from a mean of 140.4 mg/L to 24.6 mg/L) following tocilizumab administration. This suggests likely improvement in the cytokine storm and hyper-inflammatory state, and warrants further randomized control trials to adequately evaluate tocilizumab as a viable therapy for COVID-19 pneumonia.
Mental Health & Resilience
Hainan Medical University in China emphasized the negative impacts of COVID-19 pandemic on vulnerable populations who have serious mental illness and face unique challenges due to physical and social lockdown, limited health literacy, and other barriers.
They recommend changes in legislation at state and federal levels, empowerment of mental health practitioners, strengthening mental health systems, and patient education to help address these needs during this COVID-19 pandemic.
A French prospective cohort study suggests that the COVID-19 pandemic promoted increased adherence to continuous positive airway pressure (CPAP) treatment in French patients with obstructive sleep apnea (OSA) (n = 7485; p<0.001 for all findings reported).
The authors posit that the COVID-19 pandemic might have imparted psychological pressure among patients using CPAP for OSA. Putative drivers of increased adherence include:
Massive communication of COVID-19 airway threat.
Overlap of cardiovascular comorbidities in COVID-19 and OSA patients.
Fear of hospitalization.
Increased time at home.
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