December 19, 2020

Back in April 2020, on REBEL Cast episode 79 we sat down to discuss COVID-19.  Specifically, we focused on not intubating patients early and why ARDSnet may not be the best ventilator paradigm for patients with COVID-19.  By popular demand, we decided to follow up on this podcast.  We are now just about 9 months since we recorded this podcast and I wanted to sit down with the same group and see if they had any amendments, they wanted to make regarding what we discussed.

December 16, 2020

Background: Throughout the COVID-19 pandemic, numerous therapeutic agents have been repurposed and applied empirically and within clinical trials. Prophylactic medications for COVID-19 could have a huge benefit, but studies to date haven’t panned out. Initially many therapeutic medications were used late in illness, and one of the criticisms of these negative studies was that the drugs were applied too late in the disease and therefore did not show any benefit. There were also numerous studies showing associations of benefit, but subsequent randomized clinical trials have failed to prove effectiveness in reducing mortality (i.e. Remdesivir, hydroxychloroquine, lopinavir/ritonavir, convalescent plasma, monoclonal antibody therapy). Ivermectin is an interesting medication that had fallen off my radar until recently.  It is an anti-parasitic medication, with potential anti-viral, and anti-inflammatory properties against SARS-CoV-2 and COVID-19. In this post we will review some of the current evidence in using Ivermectin as a prophylactic and therapeutic agent in COVID-19.

December 15, 2020

Background: The COVID-19 Pfizer BNT162b2 vaccine, let’s just call it the COVID-19 Pfizer vaccine (so I don’t have to keep writing BNT162b2) is a novel mRNA vaccine developed to give immunity against the SARS CoV2 virus. It is synthesized mRNA packaged in small lipid nanoparticles but must be stored at extremely low temperatures (-70 C and 2 - 8 C for 5 days ) to prevent degradation.  The mRNA encodes for a small portion of the SARS CoV2 virus known as the spike protein and does not encode for the entire virus itself. This small lipid nanoparticle is injected into your body and then enters the cell. The lipid nanoparticles serve to protect and preserve the mRNA from degradation and allows it to enter cells readily.  After the mRNA enters the cells, the ribosomes will then take the mRNA and begin to synthesize this information to produce the spike protein portion of the SARS CoV-2 virus. The spike protein is what is believed to help the SARS CoV-2 virus enter human cell, replicate, and then lead to the syndrome known as COVID-19. This spike protein is believed to be the immunogenic portion of the virus that the body will then recognize as foreign and begin to develop an immune response against. The vaccine is given in 2 doses that are to be administered 3 weeks apart.

December 7, 2020

Background: SARS-CoV-2 infection has resulted in a high mortality rate, with the majority of deaths resulting from respiratory failure. As waves of the pandemic continue to overwhelm healthcare systems throughout the world, a pragmatic risk stratification tool that would allow for the early identification of patients with COVID-19 infection who are at the highest risk of death could help guide the management of individual patients as well as resource utilization.  In a systematic review from April 2020, Wynants et al found that prediction models have rapidly entered the literature since the start of the covid-19 pandemic, but that they are of questionable quality and at high risk of bias, and as such are not ready for general use.  A prediction model based on a large cohort with high quality methods would be of great value to the medical community.  

December 5, 2020

Background: Despite limited high-quality evidence, many institutions are currently using convalescent plasma therapy (CPT) in the treatment of COVID-19.  The majority of the evidence for CPT comes from observational studies lacking placebo arms (US Expanded Access Program). Convalescent plasma therapy isn’t a novel treatment modality and has been used in the treatment of other infectious diseases (SARS, MERS, H1N1, Ebola, etc…) with mixed results. The theory behind CPT is it can supplement the patient’s immune response by administering plasma rich in antibodies from someone previously infected who has recovered.  Thus far the US Expanded Access Program, showed that giving convalescent plasma earlier (i.e. ≤3 days) and with higher titers (>18.45 S/Co) was associated with improved mortality in COVID-19 (This data cannot show causality as there was no randomization and no control arm) [3].
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