August 17, 2020

Background: The most severe SARS-CoV-2 infections result in an intense inflammatory response which can lead to acute lung injury and/or acute respiratory distress syndrome.  Theoretically, potential treatments for severe disease should have anti-inflammatory action without substantial side effects. One candidate medication is colchicine, which has traditionally been used to treat gout and pericarditis. It has yet to be determined if the use of colchicine might improve clinical outcomes by its combination of anti-inflammatory action with an acceptable safety profile in patients with COVID-19.

August 6, 2020

Background: As the COVID-19 pandemic continues a number of challenges have arisen. Amongst these is the ability of clinicians to predict which patients will suffer from early decompensation. It is well established that there are patients that will rapidly decline while others, who initially present similarly, will continue without disease progression. A clinical decision instrument (CDI) to guide clinicians can be useful placing patients requiring hospital admission at the correct level of care without over-utilizing ICUs or, putting patients on the floors who will suffer from early decompensation.

July 22, 2020

Take Home Points
  • Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms
  • Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli
  • All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice
  • Although not all patients will go to the operating room, surgical consult (Neurosurgery or Orthopedics) should be obtained emergently

July 16, 2020

Background: The cornerstones of sepsis management continues to include early identification, early appropriate empiric antibiotics, definitive source control, and vasopressors to support end organ perfusion. There have been multiple studies looking at the co-administration of hydrocortisone, ascorbic acid, and thiamine (known as HAT therapy or the metabolic cocktail) to help reduce mortality and reverse shock. Despite the original Marik study showing an association between HAT therapy and a 31.9% overall decrease in mortality and a 3-fold decrease in time to vasopressor discontinuation in patients presenting with severe sepsis and septic shock, the mortality benefit has not been reproduced in subsequent randomized clinical trials.  Studies focused specifically on the use of corticosteroids have demonstrated reduced time on vasopressors in patients in septic shock.  The bigger question is does vitamin C and thiamine add anything additional to help improve mortality (The ORANGES Trial)?

July 6, 2020

Background: Hydroxychloroquine (HCQ) is an antimalarial and immunomodulatory drug that is postulated to exert an antiviral effect by increasing intracellular pH resulting in decreased viral binding at the ACE2 receptor. Azithromycin is a macrolide antibiotic that also has anti-inflammatory and immunomodulatory properties which could help decrease viral replication and viral binding. Both of these medications have been used to treat COVID patients based on in vitro findings. However, in vitro studies often do not extrapolate to patient oriented outcomes. In June 2020 the US FDA revoked the prior emergency use authorization to HCQ and chloroquine (CQ) in patients with COVID-19. We now have yet another retrospective observational trial of HCQ, azithromycin, and the drugs in combination.