May 31, 2021

Earlier this year, my home shop began administering the Johnson & Johnson COVID-19 vaccine to patients in the emergency department (ED). Thirteen years of experience in emergency medicine has afforded me many opportunities to counsel patients on lifestyle modifications, death and dying, tPA administration, and many other complex medical issues. However, I’ve never experienced a more polarizing topic than the COVID-19 vaccination. My initial attempts were met with a few quick wins. While in fast-track, a middle-aged Hispanic man presented with an injury to his left knee. I suspected a patellar tendon rupture, and while we waited for the orthopedist to evaluate his knee, I offered him the COVID-19 vaccine. He smiled acceptingly and slapped his left shoulder with his right hand, signaling the location he wished to receive his vaccine and said: “Yeah! I’ll take it.” “I want it too!” His wife exclaimed. Though not yet a patient, she sat patiently at her husband’s bedside, awaiting the orthopedists. She was quickly registered and vaccinated. 

May 27, 2021

Background: We have all seen the wide spectrum of illness caused by COVID-19 ranging from asymptomatic disease on one extreme all the way up to critical illness, acute respiratory disease and ultimately death at the other extreme.  In the most critically ill there are thoughts that a viral-induced hyperinflammatory immune response (i.e. cytokine storm) is the culprit.  The main gatekeeper of the cytokine storm is, granulocyte-macrophage colony-stimulating factor (GM-CSF) which in turn can stimulate increases in inflammatory markers such as IL-6, CRP, d-dimer, and ferritin.  Medications that can inhibit or slow down upstream effects of GM-CSF could have beneficial effects. However, there is a lack of robust evidence to support this claim. Now we have the newest kid on the block…Lenzilumab. Lenzilumab is an anti-human GM-CSF monoclonal antibody that directly binds to GM-CSF and prevents signaling through its receptor.

May 13, 2021

Background Information: Over one year into the pandemic many therapies to treat COVID-19 have targeted innumerable aspects of the virus. Most recently, the use of corticosteroids to treat the virus’ excessive inflammatory effects has become the front and center of therapy in patients requiring oxygen therapy.1 The RECOVERY trial showed a mortality benefit when using Dexamethasone in severe cases where oxygen therapy or mechanical ventilation was required.2 Interestingly, compared to other corticosteroids, high doses of Methylprednisolone are actually the preferred agent for anti-inflammation in pulmonary diseases as it achieves a more direct effect on cell membrane associated proteins.3 The authors of the following paper sought to investigate the effectiveness of methylprednisolone compared to Dexamethasone in hypoxemic ICU patients with COVID-19.

April 5, 2021

Background Information:

The use of corticosteroids in patients with pneumonia secondary to COVID-19 has been a controversially hot topic, particularly early on in the pandemic. Prior evidence seen in Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome have led some to argue against their use due to delayed viral clearance.1 More recent evidence related to SARS-Cov-2 has specifically shown reduced mortality and reduced need for mechanical ventilation with corticosteroids.2-4 More recently, the RECOVERY Trial showed an improvement in 28-day mortality among patients on oxygen therapy who received Dexamethasone.5 Little information exists in the literature about patients with moderate to severe disease who do not warrant ICU level of care but require hospital admission due to the extent of their illness. The authors of this study designed and conducted a pragmatic, partially randomized control trial to evaluate the possible benefit of methylprednisolone in hospitalized patients with moderate to severe COVID-19 pneumonia.

March 30, 2021

Background: COVID-19 vaccination is ramping up both in the US as well as throughout the world. Randomized clinical trials looking at the efficacy of the mRNA vaccines demonstrated 94% to 95% reductions in symptomatic cases (Polack 2020). Randomized clinical trials are considered the gold standard when evaluating therapies. However, they are not without limitations. Mass vaccination rollouts do not mirror the settings we see in the highly controlled environments of a randomized clinical trial. It will be important to note if suboptimal adherence to vaccination scheduling and handling logistics will affect the vaccines’ effectiveness. As we continue to vaccinate, we need to further assess the real-world effectiveness of the vaccines.
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