July 14, 2021

Take Home Points

1. Debriefing is critical. Studies show numerous benefits in terms of team communication and staff ability to regroup.
2. Start by gathering your team, thanking them for their work and noting that nothing could have changed the patient's ultimate outcome.
3. Summarize the events so everyone is on the same page and then prompt people to offer thoughts by asking "what went well? what could have gone better?"
4. Remember to end on a positive note to get everyone refocused and energized.

June 30, 2021

Take Home Points

- Unexplained tachycardia (or any abnormal vital sign) warrants investigation.
- Pain, induration, "woody" feel of any muscle group should raise suspicion of infection in that muscle group that has spread hematogenously especially in those with predisposing factors (e.g HIV, trauma, IVDA)
- Early pyomyositis will not necessarily have abscess formation
- Treatment consists of IV antibiotics, possible drainage or surgery for source control.

June 24, 2021

Background: Antibodies targeted at the SARS-CoV2 spike protein are an essential part of the body’s immune response to COVID19 infection. Infection with SARS-CoV2 stimulates the immune system to produce a polyclonal spike protein antibody response in the host. Vaccines have similar results and recent studies show that the antibody response is even more robust than with natural infection. These antibodies bind to numerous locations on the SARS-CoV2 spike protein limiting the virus’s ability to enter and infect host cells. 

One of the many massive challenges of the COVID19 pandemic has been the lack of targeted therapeutics. Extensive efforts have been invested into research with only glimmers of benefit for most drugs. The exception to this has been dexamethasone which was shown in the RECOVERY trial to have remarkable impacts on death in patients requiring O2 (NNT = 29) and in those requiring invasive ventilation (NNT = 8.5).  The RECOVERY Group has continued to perform excellent research but most of the investigated therapeutics including azithromycin, convalescent plasma, aspirin and colchicine have all fallen flat.

Monoclonal antibody infusions have gained national attention as a potential therapeutic in COVID patients and have been touted by medical experts. The goal of these drugs is to give patients antibodies prior to their body mounting a response in an effort to prevent progression of disease. We have previously reviewed the EUA drug bamlanivimab (LY-CoV555) - a monoclonal antibody. In that review, we note the absence of any difference in patient centered outcome as well as serious methodological flaws. We have also reviewed REGN-COV2 (casirivimab/imdevimab) noting the lack of any evidence of benefit as well as the suspect methodology. In January, in a post for Brief 19, I concluded that “there is no convincing data that monotherapy or a cocktail of antibodies improves meaningful outcomes in patients with COVID19.” However, the RECOVERY group has submitted a new study that was released as a preprint on June 16th, 2021.

June 16, 2021

Take Home Points
  • Neck movement (both extension and flexion) has the ability to cause cord damage.
  • Using hyperangulated blade in video laryngoscopy improves chances for glottic visualization in patients with a c-collar in place.
  • Ultimately, hypoxemia kills – Intubate the patient with what you have available, as there has not been shown to be a definitively superior technique.

June 14, 2021

Background: Outside of vaccines, effective pharmaceuticals for COVID19 continue to be evasive. Steroids have been a success (in patients who require supplemental O2) leading to additional studies investigating optimal drug and dose. Despite early excitement, we’ve seen high-quality studies demonstrate a lack of benefit for numerous drugs including colchicine, hydroxychloroquine, ritonavir etc. Some meds, like remdesivir and monoclonal antibodies (mAbs) targeting the spike protein of SARS-CoV2, are being widely used despite an absence of robust data supporting their use (Bamlanivimab, REGN-COV2, Remdesivir). 

Still, continued research and investigation is vital. One area research continues to focus on is the hyperactive inflammatory response that occurs as COVID19 progresses. Janus kinase-inhibitors (JAK-inhibitors) work by targeting and suppressing cytokine pathways. The ACTT-2 Trial published in the NEJM in December 2020 demonstrated a small decrease in time to recovery in patients treated with baricitinib (one day) that was barely statistically significant (PulmCrit 2020). Secondary outcomes (hypothesis generating) demonstrated improvements in progression of oxygen requirement and intubation as well as a non-significant trend towards decreased mortality. However, the majority of patients in this study did not receive steroids which became standard care in those with hypoxemia after the RECOVERY study. This raised questions about the utility of baricitinib when added to steroids. 

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