Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial.

Thomas S, Patel D, Bittel B, Wolski K, Wang Q, Kumar A, Il'Giovine ZJ, Mehra R, McWilliams C, Nissen SE, Desai MY. JAMA Netw Open. 2021 Feb 1;4(2):e210369. [CrossRef] [PubMed]

Objective: To examine whether high-dose zinc and/or high-dose ascorbic acid reduce the severity or duration of symptoms compared with usual care among ambulatory patients with SARS-CoV-2 infection.

Design, setting, and participants: This multicenter, single health system randomized clinical factorial open-label trial enrolled 214 adult patients with a diagnosis of SARS-CoV-2 infection confirmed with a polymerase chain reaction assay who received outpatient care in sites in Ohio and Florida. The trial was conducted from April 27, 2020, to October 14, 2020.

Intervention: Patients were randomized in a 1:1:1:1 allocation ratio to receive either 10 days of zinc gluconate (50 mg), ascorbic acid (8000 mg), both agents, or standard of care.

Outcomes: The primary end point was the number of days required to reach a 50% reduction in symptoms, including severity of fever, cough, shortness of breath, and fatigue (rated on a 4-point scale for each symptom). Secondary end points included days required to reach a total symptom severity score of 0, cumulative severity score at day 5, hospitalizations, deaths, adjunctive prescribed medications, and adverse effects of the study supplements.

Results: A total of 214 patients were randomized, with a mean (SD) age of 45.2 (14.6) years and 132 (61.7%) women. The study was stopped for a low conditional power for benefit with no significant difference among the 4 groups for the primary end point. Patients who received usual care without supplementation achieved a 50% reduction in symptoms at a mean (SD) of 6.7 (4.4) days compared with 5.5 (3.7) days for the ascorbic acid group, 5.9 (4.9) days for the zinc gluconate group, and 5.5 (3.4) days for the group receiving both (overall P = .45). There was no significant difference in secondary outcomes among the treatment groups.

Conclusions and relevance: In this randomized clinical trial of ambulatory patients diagnosed with SARS-CoV-2 infection, treatment with high-dose zinc gluconate, ascorbic acid, or a combination of the 2 supplements did not significantly decrease the duration of symptoms compared with standard of care.

Relationship Between Afternoon Napping and Cognitive Function in the Ageing Chinese Population

Cai H, Su N, Li W, et al. General Psychiatry 2021;34:e100361. [CrossRef]

Background Several studies have shown that afternoon napping promotes cognitive function in the elderly; on the other hand, some studies have shown opposite results. This current study further examined the relationship between afternoon napping and cognitive function in the ageing Chinese population.

Methods A total of 2214 elderly were included (napping group: n=1534; non-napping group: n=680). They all received cognitive evaluations by the Beijing version of the Montreal Cognitive Assessment, the Mini-Mental State Examination, and the Chinese version of the Neuropsychological Test Battery. Among all the subjects, 739 elderly volunteered to take blood lipid tests.

Results Significant differences in cognitive function and blood lipids were observed between the napping and the non-napping groups. Afternoon napping was associated with better cognitive function including orientation, language, and memory in the present study. Subjects with the habit of afternoon napping also showed a higher level of triglyceride than the non-napping subjects.

Conclusion The results demonstrated that afternoon napping was related to better cognitive function in the Chinese ageing population.

I am often asked by patients or spouses about daytime naps. Usually, I give a flip answer something like, "It's an old man's perogrative". This manuscript gives some assurance that it is not abnormal and might even be good. 

6-Month Consequences Of COVID-19 in Patients Discharged from Hospital: A Cohort Study

Huang C, Huang L, Wang Y, et al. Lancet. 2021 Jan 16;397(10270):220-232. [CrossRef] [PubMed]

The long-term health consequences of COVID-19 remain largely unclear. In the largest follow-up study of COVID-19 patients 1733 of 2469 discharged patients with COVID-19 from Wuhan, China were enrolled after 736 were excluded. Patients had a median age of 57·0 (IQR 47·0-65·0) years and 897 (52%) were men. The follow-up study was done from June 16, to Sept 3, 2020, and the median follow-up time after symptom onset was 186·0 (175·0-199·0) days. Fatigue or muscle weakness (63%, 1038 of 1655), sleep difficulties (26%, 437 of 1655) and anxiety or depression (23%, 367 of 1617) of patients were the most common symptoms reported. Patients who were more severely ill during their hospital stay had more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations, and are the main target population for intervention of long-term recovery. 

Anticoagulation, Bleeding, Mortality, and Pathology in Hospitalized Patients With COVID-19

Nadkarni GN, Lala A, Bagiella E, et al. J Am Coll Cardiol. 2020 Oct 20;76(16):1815-1826. [CrossRef] [PubMed]

The authors retrospectively examined patterns of anticoagulation and effects of these treatments in nearly 4400 adults admitted to New York City hospitals with COVID-19. Of the patients, 45% received prophylactic anticoagulation, 21% received therapeutic anticoagulation, and the remainder received none. Overall, 24% of the patients died in the hospital. After multivariable adjustment, prophylactic and therapeutic treatment were each associated with roughly a 50% reduction in mortality, relative to no anticoagulation. Rates of major bleeding were low (2%–3%). In addition, of 26 autopsies performed, thromboembolic disease was found in 42%; most of these patients had not received therapeutic anticoagulation. These observations would support a prospective, randomized, multi-center study.

2021 GOLD Guidelines Released

The 2021 GOLD guidelines have been released. To download the 2021 GOLD Pocket Guide paste the following link into your browser. 

https://goldcopd.org/wp-content/uploads/2020/11/GOLD-2021-POCKET-GUIDE-v1.0-17Nov20_WMV.pdf  

Are Financial Payments From the Pharmaceutical Industry Associated With Physician Prescribing? A Systematic Review

Mitchell AP, Trivedi NU, Gennarelli RL, Chimonas S, Tabatabai SM, Goldberg J, Diaz LA Jr, Korenstein D. Ann Intern Med. 2020 Nov 24. [CrossRef] [PubMed]

Financial payments from the drug industry to U.S. physicians are common and may influence physicians' clinical decision making and drug prescribing. The authors searched MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science, and EconLit for studies examining an association between receipt of industry payments (exposure) and prescribing (outcome). Thirty-six studies comprising 101 analyses were included. Most studies (n = 30) identified a positive association between payments and prescribing in all analyses; the remainder (n = 6) had a mix of positive and null findings. No study had only null findings. Of 101 individual analyses, 89 identified a positive association. Payments were associated with increased prescribing of the paying company's drug, increased prescribing costs, and increased prescribing of branded drugs. Nine studies assessed and found evidence of a temporal association; 25 assessed and found evidence of a dose–response relationship.

Sixty-Day Outcomes Among Patients Hospitalized With COVID-19

Chopra V, Flanders SA, O'Malley M, Malani AN, Prescott HC.  Ann Intern Med. 2020 Nov 11. Epub ahead of print. [CrossRef] [PubMed]

Although characteristics and in-hospital outcomes for persons with coronavirus disease 2019 (COVID-19) have been well described, less is known about the longer-term outcomes of hospitalized patients. This observational cohort study looked at patients hospitalized with COVID-19 (discharged between 16 March and 1 July 2020) at 38 hospitals participating in the MI-COVID19 initiative. Of 1648 patients with COVID-19 admitted to 38 hospitals, 398 (24.2%) died during hospitalization and 1250 (75.8%) survived. Of 1250 patients discharged alive, 975 (78.0%) went home whereas 158 (12.6%) were discharged to a skilled nursing or rehabilitation facility. By 60 days after discharge, an additional 84 patients (6.7% of hospital survivors and 10.4% of intensive care unit [ICU]-treated hospital survivors) had died, bringing the overall mortality rate for the cohort to 29.2%, and 63.5% for the 405 patients who received treatment in an ICU. Within 60 days of discharge, 189 patients (15.1% of hospital survivors) were rehospitalized. Cardiopulmonary symptoms (such as cough and dyspnea) were reported by 159 patients, including 92 with new or worsening symptoms and 65 with persistent loss of taste or smell. Fifty-eight patients reported new or worsening difficulty completing activities of daily living. Among 195 patients who were employed before hospitalization, 117 had returned to work whereas 78 could not because of ongoing health issues or job loss. Of the 117 patients who returned to work, 30 reported reduced hours or modified duties due to health reasons. Although postdischarge chart review was completed for all patients, telephone contact occurred in fewer than half. Despite these limitations, our study indicates that adverse events after COVID-19 hospitalization are common.

Association of Peer Comparison Emails with Electronic Health Record Documentation of Cancer Stage by Oncologists

Sinaiko AD, Barnett ML, Gaye M, Soriano M, Mulvey T, Hochberg E. JAMA Netw Open. 2020 Oct 1;3(10):e2015935. [CrossRef] [PubMed]

In a randomized pilot study of 56 oncologists at the Massachusetts General Hospital, the authors sent emails with peer comparison data on the proportion of an oncologist’s patients with cancer stage documentation in the machine-readable structured fields in electronic health records (EHRs). Sending these emails were associated with increased documentation of patients’ stage in the EHR by 9.0 percentage points, a relative increase of 69%. The association was observed among oncologists’ new, but not established, patients. The findings suggest interventions using peer comparisons could change physician performance on the EHR among oncologists.

Modeling COVID-19 scenarios for the United States

IHME COVID-19 Forecasting Team. Nat Med. 2020 Oct 23. Epub ahead of print. [CrossRef] [PubMed]

We use COVID-19 case and mortality data from 1 February 2020 to 21 September 2020 and a deterministic SEIR (susceptible, exposed, infectious and recovered) compartmental framework to model possible trajectories of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the effects of non-pharmaceutical interventions in the United States at the state level from 22 September 2020 through 28 February 2021. Using this SEIR model, and projections of critical driving covariates (pneumonia seasonality, mobility, testing rates and mask use per capita), we assessed scenarios of social distancing mandates and levels of mask use. Projections of current non-pharmaceutical intervention strategies by state-with social distancing mandates reinstated when a threshold of 8 deaths per million population is exceeded (reference scenario)-suggest that, cumulatively, 511,373 (469,578-578,347) lives could be lost to COVID-19 across the United States by 28 February 2021. We find that achieving universal mask use (95% mask use in public) could be sufficient to ameliorate the worst effects of epidemic resurgences in many states. Universal mask use could save an additional 129,574 (85,284-170,867) lives from September 22, 2020 through the end of February 2021, or an additional 95,814 (60,731-133,077) lives assuming a lesser adoption of mask wearing (85%), when compared to the reference scenario.

Modeling COVID-19 scenarios for the United States

IHME COVID-19 Forecasting Team. Nat Med. 2020 Oct 23. Epub ahead of print. [CrossRef] [PubMed]

We use COVID-19 case and mortality data from 1 February 2020 to 21 September 2020 and a deterministic SEIR (susceptible, exposed, infectious and recovered) compartmental framework to model possible trajectories of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the effects of non-pharmaceutical interventions in the United States at the state level from 22 September 2020 through 28 February 2021. Using this SEIR model, and projections of critical driving covariates (pneumonia seasonality, mobility, testing rates and mask use per capita), we assessed scenarios of social distancing mandates and levels of mask use. Projections of current non-pharmaceutical intervention strategies by state-with social distancing mandates reinstated when a threshold of 8 deaths per million population is exceeded (reference scenario)-suggest that, cumulatively, 511,373 (469,578-578,347) lives could be lost to COVID-19 across the United States by 28 February 2021. We find that achieving universal mask use (95% mask use in public) could be sufficient to ameliorate the worst effects of epidemic resurgences in many states. Universal mask use could save an additional 129,574 (85,284-170,867) lives from September 22, 2020 through the end of February 2021, or an additional 95,814 (60,731-133,077) lives assuming a lesser adoption of mask wearing (85%), when compared to the reference scenario.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

CODA Collaborative, Flum DR, Davidson GH, Monsell SE, et al. N Engl J Med. 2020 Oct 5. Epub ahead of print. [CrossRef] [PubMed]

Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. The authors conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days. In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The authors conclude that for the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients with Pneumonia

Freburger JK, Chou A, Euloth T, Matcho B. JAMA Netw Open. 2020;3(9):e2012979. Published 2020 Sep 1. [CrossRef] [PubMed] 

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Patients from 12 acute care hospitals in a large health care system in western Pennsylvania were analyzed for the number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6). Of 30,746 patients, the 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95%CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95%CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95%CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting. The authors conclude that the number of physical and occupational therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis

WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, Sterne JAC, Murthy S, et al. [published online ahead of print, 2020 Sep 2]. JAMA. 2020;10.1001/jama.2020.17023. [CrossRef] [PubMed]

JAMA published five papers concerning the use of steroids to treat people with severe COVID-19, including three new studies which can be found here, here, and here. There is also a well-written editorial and a meta-analysis which is summarized here.

Prospective meta-analysis from 7 randomized clinical trials evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The trials were conducted in 12 countries from February 26, 2020, to June 9, 2020, and the date of final follow-up was July 6, 2020. 28-day all-cause mortality was lower among patients who received corticosteroids compared with those who received usual care or placebo (summary odds ratio, 0.66). The authors conclude that administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality in critically ill patients with COVID-19. 

Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020

Yip L, Bixler D, Brooks DE, et al. MMWR Morb Mortal Wkly Rep. 2020;69(32):1070-1073. Published 2020 Aug 14. [CrossRef] [PubMed]

Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands and is an important part of the CDC recommendations to prevent spread of COVID-19. On June 30, 2020, the CDC received notification from Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. The later results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve. 62 poison center call records from May 1 through June 30, 2020 of alcohol-based hand sanitizer-associated methanol poisoning. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

Risk of COVID-19 Among Front-Line Health-Care Workers and The General Community: A Prospective Cohort Study

Nguyen LH, Drew DA, Graham MS, et al. Lancet Public Health. 2020. Published Online July 31, 2020 [CrossRef]

The authors sought to assess risk of COVID-19 among front-line health-care workers compared with the general community and the effect of personal protective equipment (PPE) on risk. They did a prospective, observational cohort study in the UK and the USA of the general community, including front-line health-care workers, using self-reported data from the COVID Symptom Study smartphone application (app) from March 24 (UK) and March 29 (USA) to April 23, 2020. Participants were voluntary users of the app and at first use provided information on demographic factors (including age, sex, race or ethnic background, height and weight, and occupation) and medical history, and subsequently reported any COVID-19 symptoms. Among 2,035,395 community individuals and 99,795 front-line health-care workers, 5545 reported a positive COVID-19 test over 34 435 272 person-days. Compared with the general community, front-line health-care workers were at increased risk for reporting a positive COVID-19 test (adjusted HR 11·61, 95% CI 10·93–12·33). Secondary and post-hoc analyses suggested adequacy of PPE, clinical setting, and ethnic background were important factors. The authors conclude that the health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds.

Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020

Tenforde MW, Kim SS, Lindsell CJ, et al. MMWR Morb Mortal Wkly Rep. ePub: 24 July 2020. [CrossRef]

Prolonged symptom duration and disability are common in adults hospitalized with severe coronavirus disease 2019 (COVID-19). Characterizing return to baseline health among outpatients with milder COVID-19 illness is important for understanding the full spectrum of COVID-19–associated illness and tailoring public health messaging, interventions, and policy. During April 15–June 25, 2020, telephone interviews were conducted with a random sample of adults aged ≥18 years who had a first positive reverse transcription–polymerase chain reaction (RT-PCR) test for SARS-CoV-2, the virus that causes COVID-19, at an outpatient visit at one of 14 U.S. academic health care systems in 13 states. Interviews were conducted 14–21 days after the test date. Respondents were asked about demographic characteristics, baseline chronic medical conditions, symptoms present at the time of testing, whether those symptoms had resolved by the interview date, and whether they had returned to their usual state of health at the time of interview. Among 292 respondents, 94% (274) reported experiencing one or more symptoms at the time of testing; 35% of these symptomatic respondents reported not having returned to their usual state of health by the date of the interview (median = 16 days from testing date), including 26% among those aged 18–34 years, 32% among those aged 35–49 years, and 47% among those aged ≥50 years. Among respondents reporting cough, fatigue, or shortness of breath at the time of testing, 43%, 35%, and 29%, respectively, continued to experience these symptoms at the time of the interview. These findings indicate that COVID-19 can result in prolonged illness even among persons with milder outpatient illness, including young adults. Effective public health messaging targeting these groups is warranted. Preventative measures, including social distancing, frequent handwashing, and the consistent and correct use of face coverings in public, should be strongly encouraged to slow the spread of SARS-CoV-2.

Use of Personal Protective Equipment Against Coronavirus Disease 2019 by Healthcare Professionals in Wuhan, China: Cross Sectional Study

Liu M, Cheng SZ, Xu KW, et al.  BMJ. 2020;369:m2195. Published 2020 Jun 10. [CrossRef] [PubMed]

The authors sought to examine the protective effects of appropriate personal protective equipment for frontline healthcare professionals who provided care for patients with coronavirus disease 2019 (COVID-19). 420 healthcare professionals (116 doctors and 304 nurses) who were deployed to Wuhan by two affiliated hospitals of Sun Yat-sen University and Nanfang Hospital of Southern Medical University for 6-8 weeks from 24 January to 7 April 2020. These study participants were provided with appropriate personal protective equipment to deliver healthcare to patients admitted to hospital with covid-19 and were involved in aerosol generating procedures. 77 healthcare professionals with no exposure history to covid-19 and 80 patients who had recovered from covid-19 were recruited to verify the accuracy of antibody testing. COVID-19 related symptoms (fever, cough, and dyspnea) and evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, defined as a positive test for virus specific nucleic acids in nasopharyngeal swabs, or a positive test for IgM or IgG antibodies in the serum samples. These study participants worked 4-6 hour shifts for an average of 5.4 days a week; they worked an average of 16.2 hours each week in intensive care units. All 420 study participants had direct contact with patients with COVID-19 and performed at least one aerosol generating procedure. During the deployment period in Wuhan, none of the study participants reported COVID-19 related symptoms. When the participants returned home, they all tested negative for SARS-CoV-2 specific nucleic acids and IgM or IgG antibodies (95% confidence interval 0.0 to 0.7%). Despite being at high risk of exposure, study participants were appropriately protected and did not contract infection or develop protective immunity against SARS-CoV-2.  

Use of Personal Protective Equipment Against Coronavirus Disease 2019 by Healthcare Professionals in Wuhan, China: Cross Sectional Study

Liu M, Cheng SZ, Xu KW, et al.  BMJ. 2020;369:m2195. Published 2020 Jun 10. [CrossRef] [PubMed]

The authors sought to examine the protective effects of appropriate personal protective equipment for frontline healthcare professionals who provided care for patients with coronavirus disease 2019 (COVID-19). 420 healthcare professionals (116 doctors and 304 nurses) who were deployed to Wuhan by two affiliated hospitals of Sun Yat-sen University and Nanfang Hospital of Southern Medical University for 6-8 weeks from 24 January to 7 April 2020. These study participants were provided with appropriate personal protective equipment to deliver healthcare to patients admitted to hospital with covid-19 and were involved in aerosol generating procedures. 77 healthcare professionals with no exposure history to covid-19 and 80 patients who had recovered from covid-19 were recruited to verify the accuracy of antibody testing. COVID-19 related symptoms (fever, cough, and dyspnea) and evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, defined as a positive test for virus specific nucleic acids in nasopharyngeal swabs, or a positive test for IgM or IgG antibodies in the serum samples. These study participants worked 4-6 hour shifts for an average of 5.4 days a week; they worked an average of 16.2 hours each week in intensive care units. All 420 study participants had direct contact with patients with COVID-19 and performed at least one aerosol generating procedure. During the deployment period in Wuhan, none of the study participants reported COVID-19 related symptoms. When the participants returned home, they all tested negative for SARS-CoV-2 specific nucleic acids and IgM or IgG antibodies (95% confidence interval 0.0 to 0.7%). Despite being at high risk of exposure, study participants were appropriately protected and did not contract infection or develop protective immunity against SARS-CoV-2.  

Measurement of Airborne Particle Exposure During Simulated Tracheal Intubation Using Various Proposed Aerosol Containment Devices During the COVID-19 Pandemic

Simpson JP, Wong DN, Verco L, Carter R, Dzidowski M, Chan PY. [published online ahead of print, 2020 Jun 19]. Anaesthesia. 2020;10.1111/anae.15188.  [CrossRef] [PubMed]

The COVID-19 pandemic has led to the production of novel devices intended to protect airway managers during the aerosol-generating procedure of tracheal intubation. Using an in-situ simulation model, we evaluated laryngoscopist exposure of airborne particles sized 0.3 - 5.0 microns using five aerosol containment devices (aerosol box; sealed box with and without suction; vertical drape; and horizontal drape) compared with no aerosol containment device. Nebulised saline was used as the aerosol-generating model for 300 s, at which point, the devices were removed to assess particle spread. Primary outcome was the quantity and size of airborne particles measured at the level of the laryngoscopist's head at 30, 60, 120 and 300 s, as well as 360 s (60 s after device removal). Airborne particles sizes of 0.3, 0.5, 1.0, 2.5 and 5.0 microns were quantified using an electronic airborne particle counter. Compared with no device use, the sealed intubation box with suction resulted in a decrease in 0.3, 0.5, 1.0 and 2.5 micron, but not 5.0 micron, particle exposure over all time-periods (p = 0.003 for all time periods). Compared with no device use, the aerosol box showed an increase in 1.0, 2.5 and 5.0 micron airborne particle exposure at 300 s (p = 0.002, 0.008, 0.002, respectively). Compared with no device use, neither horizontal nor vertical drapes showed any difference in any particle size exposure at any time. Finally, when the patient coughed, use of the aerosol box resulted in a marked increase in airborne particle exposure compared with other devices or no device use. In conclusion, novel devices intended to protect the laryngoscopist require objective testing to ensure they are fit for purpose and do not result in increased airborne particle exposure.

Dual LABA/LAMA Therapy versus LABA or LAMA Monotherapy for COPD: A Systematic Review and Meta-analysis in Support of the American Thoracic Society Clinical Practice Guideline

Mammen MJ, Pai V, Aaron SD, Nici L, Alhazzani W, Alexander PE. Ann Am Thorac Soc. 2020; [published online ahead of print, 2020 Jun 12]. [CrossRef] [PubMed[

There is uncertainty on the optimal first-line therapy for symptomatic COPD. Long-acting beta-2-receptor agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) have long been mainstays of treatment, though it is still not clear if dual therapy with LABA/LAMA is superior to monotherapy for symptomatic COPD. The authors conducted a systematic review to answer the following question: In patients with COPD who complain of dyspnea and/or exercise intolerance, is LABA/LAMA combination therapy more effective and equally safe compared to LABA or LAMA monotherapy? 24 studies were eligible for inclusion (n=45,441). Pairwise random-effects meta-analysis revealed reductions in hospital admissions (11% reduction, p<0.01) and acute exacerbations of COPD (20% reduction, p<0.002), all in favor of LABA/LAMA dual therapy. Although there is reduced dyspnea (0.10 standardized mean difference (SMD), p<0.001) and improved health-related quality of life (-0.13 standardized mean difference (SMD), p<0.001), both values did not meet a clinical meaningful difference threshold. LABA/LAMA combination therapy showed no difference in treatment-emergent adverse effects (risk ratio=0.99, p=0.34) when compared to either LAMA or LABA monotherapy. The authors conclude that based on the reviewed evidence, dual LABA/LAMA therapy is superior to either LABA or LAMA monotherapy based on the reduced risk of exacerbations and hospitalizations in patients with symptomatic COPD.