The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic.  The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.

REBEL COVID-19

will serve as a summary of what is currently known, how to screen, when to test, and how to prevent spread, and any new data/information on COVID-19.

September 10, 2020

Background: There are three randomized clinical trials now published on remdesivir in the treatment of COVID-19 pneumonia (RCT 1, RCT 2, & RCT 3). The 1st trial, performed in China, was terminated early due the lack of patients to enroll and, as a result, did not give strong recommendations.  The 2nd trial (ACTT-1) showed a statistically significant 4-day reduction in time to recovery. However, it was also terminated early due to an interim analysis, which meant we do not have outcomes on 30% of patients enrolled.  Finally, the 3rd RCT compared a 5-day to a 10-day course of remdesivir and showed no difference in outcomes with more acute kidney injury in the 10-day course. All of these trials have significant issues leaving clinicians unsure of the efficacy of the drug, when to administer it, how long to give it for and, in which patient group it should be given. We now have our 4th RCT of remdesivir evaluating the efficacy and adverse events of remdesivir administered for 5- or 10-days vs standard care in hospitalized patients with moderate COVID-19.

September 5, 2020

Background: Over the past few years, corticosteroids have gained traction in the treatment of patients with ARDS and septic shock.  Trials such as APROCCHSS and ADRENAL have shown that the use of corticosteroids is associated with more rapid resolution of shock, weaning from mechanical ventilation in septic shock, and, potentially lower mortality. The RECOVERY trial, the largest RCT to date on the use of corticosteroids in COVID-19, showed treatment with dexamethasone (6mg/d for 10 days)  had an absolute mortality reduction of 11% in patients receiving mechanical ventilation   (IMV) (NNT = 9), 3.5% decreased mortality in patients requiring O2 but not IMV (NNT = 29) and an overall mortality reduction 3% (NNT = 3) compared to usual care alone.  However, there was a signal toward harm (not statistically significant) in patients not receiving respiratory support. In the September 2020 issue of JAMA, there were 3 RCTs (REMAP-CAP, CoDEX, & CAPE COVID) assessing corticosteroid therapy in critically ill patients with COVID-19, as well as a prospective meta-analysis. All 3 RCTs halted enrollment in June 2020 after the RECOVERY trial press release.  The prospective meta-analysis from the WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) working group pooled data from 7 trials (RECOVERY, REMAP-CAP, CoDEX, CAPE COVID, and 3 additional trials) with roughly 1700 patients. In this post we will review the REMAP-CAP, CoDEX, and CAPE COVID trials, as well as the prospective meta-analysis.

August 31, 2020

Case Presentation: A 4-year-old previously healthy Hispanic female presented to the ED with a diffuse rash and facial swelling, concerning for an apparent allergic reaction. She was rushed into the treatment area for evaluation of possible anaphylaxis and respiratory assessment. She was tachycardic with a heart rate in the 130s, tachypneic, and borderline hypotensive for her age. Initial exam was negative for wheezing or stridor, but she had edema to the face and neck with a red raised rash covering her face. Epinephrine, Benadryl, and Solumedrol were ordered STAT given concern for airway compromise secondary to a severe anaphylactic reaction.

August 27, 2020

The Coronaviridae family and its genera coronaviruses have been implicated as having neurotropic and neuroinvasive capabilities in human hosts (Bohmwald 2018). They have been associated with the development of neuropsychiatric symptoms, seizure activity, encephalomyelitis, acute flaccid paralysis, cerebral venous sinus thrombosis, Guillain-Barré syndrome, as well as cerebrovascular disease (Bohmwald 2018, St Jean 2004). Recently, there has been a growing body of evidence supporting the association of SARS-CoV2 with neurological abnormalities. A systematic review looking at the incidence of secondary neurological disease in patients diagnosed with SARS-CoV2 found rates to vary from 6-36.4% (Herman 2020). At the time of this submission, there have been ten reports of acute transverse myelitis (ATM) attributed to SARS-CoV2, and others are currently being submitted or are in pre-print at this time (See infographic below). ATM has a varied presentation and is associated with significant morbidity and mortality that necessitates increased awareness and vigilance on the part of the clinician. This has become especially important in light of a possible causal link of ATM to SARS-CoV2 with emerging cases during the COVID-19 pandemic. Here, we review the salient features of infectious ATM (both para-infectious and post-infectious) to increase recognition of this disease entity.

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.
0