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Clinical Issues and Guidance

Promising Therapeutics Update

Rheumatology Alliance Data Refute Claims that Hydroxychloroquine Prevents COVID-19

Global COVID-19 Rheumatology Alliance has been formed to gather data that has been examined to determine the clinical benefits for patients who were treated with hydroxychloroquine (HCQ), NSAIDs, azathioprine, and other drugs, including biologic disease-modifying therapies, that theoretically may alter susceptibility to COVID-19. Within one week, the Alliance was able to identify 110 patients with COVID-19 who have been prescribed these medications and found evidence refuting anecdotal claims that HCQ prevents the development of COVID-19. Click here for more information.

Study Shows Hydroxychloroquine Has Limited Impact on COVID-19

A preprint article reports on the largest randomized, controlled open-label trial on the use of HCQ in the treatment of COVID-19. The study, conducted in China, showed no difference in viral conversion (positive viral shedding) between HCQ and standard care, some decrease in inflammatory markers, and no significant difference in clinical symptom resolution or clinical outcome. Some concerns about the study include the following: performance of the study (a multicenter trial), use of other antiviral drugs was not controlled, entry into the study was an average of 16 days after initiation of symptoms (a relatively late date to start treatment), and some patients had diarrhea in the HCQ group (though the dosages used in the study were higher than many other studies). No adverse cardiac events were noted.

CMS Releases Guidelines for Restarting Non-COVID-19 Essential Care

The Centers for Medicare & Medicaid Services (CMS) on April 19 issued the first phase of guidance to reopen health care systems in communities with low and stable incidence of COVID-19. The guidelines recommend a gradual transition to restart in-person care for patients with non-COVID-19 needs by encouraging physicians to evaluate the necessity of the care based on clinical needs and prioritizing surgical services and/or high-complexity chronic disease management. The agency urges health care facilities to consider establishing non-COVID care (NCC) zones to screen all patients and visitors—and routinely screen employees—for symptoms of COVID-19. CMS indicates that NCC zones should be designed to facilitate social distancing and should be located in buildings, on floors, or in rooms that have minimal crossover with COVID-19 areas. The agency notes that facilities and providers should collaborate with local and state public health officials to review the availability of personal protective equipment and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to restart or increase in-person care. Contact regulatory@facs.org with questions.

Coagulation Abnormalities, Hypercoagulability, and Empiric Anticoagulation for Thromboembolism in COVID-19 Infection

A number of recent studies have explored the connection between COVID-19 infection and coagulopathy, and over the last week it has become apparent that venous thromboembolic (VTE) disease is common in critically ill patients with severe COVID-19. This article describes how surgeons have developed a protocol to empirically anti-coagulate patients at highest risk/suspicion for VTE and to delay imaging until patient recovery. Click here to read more.

Analgesia and Sedation in Patients with COVID-19

Approximately 14 percent of patients with COVID-19 infection experience a severe form of hypoxic respiratory failure, with 5 percent requiring mechanical ventilation.1 The dyspnea, air hunger, physical discomfort of being intubated, and possibility of self-extubation have made sedation of these patients challenging, with many requiring high doses of multiple medications to achieve comfort. Moreover, in the subset of patients with low lung compliance and acute respiratory distress syndrome, use of low tidal volumes, controlled ventilation, and prone positioning require high levels of sedation and often neuromuscular blockade to permit proper ventilation.2,3 Click here to read more.

COVID-19 and Increased Requirements for Sedation

Surgeons and other physicians offer their recommendations for providing sedation and analgesia to COVID-19 patients. They also offer recommendations for using multimodal regimens to control to help limit the use of drugs that may be in short supply. Click here to read more.

Summary of CDC Mortality and Morbidity Weekly Report, 4-17-2020

Both during the new COVID-19 crisis acutely and during the restart period after the initial wave of infections, knowledge of the disease’s effects on health care workers is an important element in the decision-making process. On April 17, the Centers for Disease Control and Prevention (CDC) reported in their Mortality and Morbidity Weekly Report findings from February 12 through April 9.

  1. In the reported time period, more than 315,000 reports of COVID-19 infections were filed.
  2. Only 16 percent of these forms had “health care personnel” (HCP) as a reported data point.
  3. A total of 9,282 reports were filed:
    1. 55 percent were infected by direct patient care contact
    2. 92 percent had symptoms
    3. 8 percent were asymptomatic
    4. 90 percent did not require hospitalization
    5. 10 percent had a severe illness
    6. 27 deaths were reported in this group
    7. All ages were affected with death more commonly in the <65-year-old group, but deaths did occur in all age groups
  4. The CDC points out that the number of affected HCP probably is underreported.
  5. Because outcomes evolve over time, the final outcome data cannot be determined in this report. The data are descriptive, not quantitative.

Read the full article.

Royal College of Surgeons COVID-19 Update

In response to the rapidly evolving situation with COVID-19, the Royal College of Surgeons of England is producing special editions of its Colorectal Surgery Update to collate high-level guidance and policy and to point readers to available research. This newsletter covers topics such as detection and diagnosis, infection control and transmission, patient care, workforce issues, and mental health care well-being.