May 26, 2020

Background: The saga of Remdesivir for treatment of COVID-19 continues. We previously covered two studies of this drug on REBEL EM (Link is HERE & Link is HERE). One trial (≈200pts) showed no difference in the primary outcome of median time to clinical improvement and the second trial was a compassionate release study which gave us no real clinical information due to its design. A third study was mentioned in the first post from the NIAID, but we didn’t really review it, as much as mention it, as no data was made available.  It was a little teaser from the National Institute of Allergy and Infectious Diseases (NIAID). Despite these facts the FDA approved remdesivir for use and we have had no robust data supporting its use except for the tease of the NIAID study.  Part 1 of the NIAID trial was just published in the NEJM as a preliminary report and we will review here on this post: Remdesivir ACTT-1.

May 24, 2020

This publication has now been retracted by Lancet (June 4, 2020) Background: There is no conclusive evidence that chloroquine, or its derivative hydroxychloroquine, with or without a second-generation macrolide is effective in COVID-19 treatment or prophylaxis. Laboratory studies have shown antiviral and immunomodulatory properties in vitro. The small retrospective observational trials thus far have had mixed results in efficacy.  However, these medications are well known to have cardiovascular adverse effects via QT interval prolongation leading to ventricular arrhythmias. Despite the potential harms and the absence of convincing data to support treatment with these drugs, they are widely prescribed to COVID-19 patients.

May 23, 2020

Disclaimer: This post explores some of the pathophysiologic findings in severe SARS-CoV-2 infection. It explores possible mechanisms-based and posits theories BUT, this is not a clinical post. The hypothesis and findings here are not confirmed and extrapolation to management is unclear. Understanding of the mechanisms of COVID-19 is badly needed if we are to find treatments that may be beneficial. The leading cause of mortality in patients with COVID-19 is hypoxemic respiratory failure most frequently resulting in ARDS.  However, the mechanisms that bring patients from infection to ARDS are unknown:  is it diffuse alveolar damage (DAD), endothelial damage, or some combination of both? Although it may seem ridiculous to consider these two entities as separate, as the alveolar-capillary interface is submicrons in size, we want to know if one of these two entities is driving the injury more than the other? There have been some interesting pathological reports that have been published looking at the histopathology of COVID-19, and many more discussions about the similarities to other viral pneumonias (i.e. H1N1). A recent publication in NEJM compares the pathology of COVID-19 vs H1N1.

May 19, 2020

While the rate of prepublications on COVID19 continue to be cranked out, we at REBEL EM have reduced our blog post production. It’s not because we’re reading less, but  we’ve reported enough on small, retrospective, observational studies that don’t tell us anything more than we already know.  At this point in time we know enough about what does and doesn’t work, so we wanted to focus on important literature that may affect practice. Going forward that will be our focus with updates in a less rapid-fire rate and more useful way to digest the information. For this COVID-19 update we have picked four papers that are we thought are worthy of mention.

May 17, 2020

There is a lot we still do not know when it comes to COVID-19 pathophysiology. We are learning every day, and as we navigate the waters of the unknown, there are a few that boldly dare to try and understand what is happening in this disease process that may go against mainstream thinking. COVID-19 is new and therefore will require new thinking and new questions but should also be balanced with not grasping for straws and randomly doing things that could be deleterious. Below is a proposed lung injury model that may be right or could be wrong. However, the only way we can further understanding is by feedback and edits until we can get to the right answer. The purpose of this post is not to tell you what you are doing is wrong, but instead putting a model out there so that we can work on this together to find an answer. This is not a recommendation on how to treat patients, but a proposal that needs feedback and work. We felt it was a good starting place for all of us to work together to figure this thing out. Thank you to Dr. Farid Jalali, MD for putting his thoughts down on COVID-19 acute lung injury to help as a starting point.