COVID-19 Daily: No Treatment Guidance Yet, Staff 'Create Problems'

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APRIL 14, 2020 -- Here are the coronavirus stories Medscape's editors around the globe think you need to know about today: 

IDSA: No Recommendations for COVID-19 Treatment Yet

Many pharmacologic therapies are being used or proposed for treating patients with COVID-19, but an expert panel of the Infectious Diseases Society of America (IDSA) says there's not yet sufficient evidence to recommend any of them. The IDSA issued interim guidelines on medications for patients admitted to the hospital with COVID-19, most of which recommend their use only in the context of clinical trials — or not at all. 

"Over the last few weeks in caring for these patients, we have used therapeutic agents which were not proven and some of these patients had adverse reactions," the chair of the rapid guidelines panel told reporters. "As a team, we wondered, are we actually helping these patients or could we be potentially harming these patients by using these medications?" 

Hospital Staff "Create Problems," CEO Says

Administrators at Woodhull Hospital in Brooklyn, one of eleven in the New York City public system, host a daily conference call to inform employees of changing situations and policies. Recent calls have left staffers anxious about being reprimanded for speaking up about safety concerns for themselves and patients, employees told Medscape Medical News

In a meeting last week, a recording of which was obtained by Medscape Medical News, hospital CEO Gregory Calliste chastised employees for speaking to journalists about various concerns. "People are just taking things, and they're using things for their benefit and to be able to create problems for us who are trying to do our job," he said. "I'm just trying to do my job." 

Two Months Fighting COVID-19 in Wuhan

In late January, the then-unnamed COVID-19 outbreak flooded hospitals throughout Wuhan, China. One physician, the deputy chief of vascular surgery at Wuhan Union Hospital West Campus, described for Medscape Medical News what it was like for her and her specialist colleagues to retrain to work in COVID-19 treatment centers. 

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At first, they felt they "could not do the work needed to treat severe pneumonia," she said. But in time, "we've found that everyone has become very capable in the management of COVID-19."

Are Coronavirus Tests Fast-Tracked by FDA Accurate?

In the current COVID-19 pandemic, the US Food and Drug Administration (FDA) has allowed diagnostic tests for SARS-CoV-2 onto the market under looser-than-normal rules that don't require manufacturers to run clinical studies to prove their tests' accuracy. While this makes more tests available more quickly, the lack of clinical data has raised concerns about the prevalence of false negative results, ProPublica reports

"In diagnostic tests in particular, it's very difficult to know if something is failing," a former director of the FDA's Office of In Vitro Diagnostics and Radiological Health said. "When are you getting more erroneous results than you should? It's not always easy to figure out." 

Remdesivir Debate 

Information on the outcomes of patients who received Gilead Sciences' experimental drug remdesivir under compassionate use protocols, published last Friday, sparked much discussion and sharply diverging viewpoints among physicians on Twitter. More than 5000 tweets by physicians have mentioned remdesivir in the past 3 days, according to data from the healthcare social media monitoring service, Symplur. 

An open-label, randomized controlled trial of remdesivir is ongoing, but Medscape contributor John M. Mandrola, MD, recommends adding clinician blinding with a placebo infusion to the standard care control arms of the trial, he writes in an open letter to Gilead. "You don't want to spend millions of dollars and end up with a biased result."

"Russian Roulette" for HCPs

While mortality rates for COVID-19 are higher in patients who are older and have comorbidities, healthcare workers have also seen young, otherwise healthy people die of the disease, F. Perry Wilson, MD, MSCE, says in a commentary for Medscape. The mean death rates matter on a population level, but it's the disease's variance that makes it scary for healthcare workers. 

"Some people get mild disease, some people get ventilated, and some people die, despite having very similar baseline characteristics," he says. "That's why COVID-19 feels like gambling. Like Russian roulette."

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Labor & Delivery

In March, physicians at New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center in New York City began universal testing for SARS-CoV-2 for all pregnant women coming to the hospital to give birth. Of 215 women who delivered between March 22 and April 4, 33 tested positive for the virus, and 29 of those didn't have any symptoms at the time they were admitted, the physicians reported in the New England Journal of Medicine

Guidelines for the use of personal protective equipment (PPE) in obstetrics are "controversial" and differ between institutions, according to two physicians from the Medical College of Wisconsin in Milwaukee writing in the American Journal of Perinatology. 

The second stage of labor is not considered an aerosol-generating procedure, but during that time patients "are exerting extreme effort…and frequently blow out their breath, cough, shout, and vomit, all of which put the health care team at risk," the physicians write. They recommend that labor and delivery personnel have full PPE, including N95 masks, for the second stage of labor.

Palliative Care in PPE

Clinicians need to wear full PPE when caring for and interacting with COVID-19 patients, but that makes it more difficult for them to provide the emotional support they would like, several clinicians told Reuters. One medical resident who provides palliative care at Metropolitan Hospital Center in Manhattan, New York, recounted trying to tell an elderly patient with early signs of dementia that he could not yet go home to his family, while wearing layers of PPE. "You want to smile, you want to hold their hand," she said.

In Memoriam

As front-line healthcare workers care for patients with COVID-19, they commit themselves to difficult, draining work and also put themselves at risk for infection. Hundreds throughout the world have died. 

Medscape has published a memorial list to commemorate them. We will continue updating this list as, sadly, needed. Please help us ensure this list is complete by submitting names with an age, profession or specialty, and location through this form

Medscape Medical News
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