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One-Minute Telegram Archive

Introduction

This article contains a collection of content written for the One-Minute Telegram, a biweekly newsletter that presents the newest medical research condensed into just one minute of reading. This newsletter is designed for all of our colleagues who want to stay current on the latest medical literature without having to comb through and dissect medical studies themselves. It is peer-reviewed by our team of physician editors and integrated into the Amboss library. Even after a long night shift or a busy day on the wards, it should go down easy. Sign up via the link in “Tips and Links” below.

May 2020

Edition 1 - May 07, 2020

Ebola drug remdesivir – emergency use authorized but effectiveness for treatment of COVID-19 still under investigation

One-Minute Telegram 1-2020-1/3 - Remdesivir, a nucleotide analog that inhibits viral RNA polymerases, has been proven to be effective against SARS-CoV-2 in vitro [1] and its relative safety has already been demonstrated in a phase 3 trial [2] in patients with Ebola.

Gilead Sciences, the producer of remdesivir, has published data on an international group of 53 patients hospitalized with COVID-19, who were selected based on undisclosed criteria. The study cohort consisted of mostly male (70%) patients within the age range of 23 to 82 years (median 64 years). 64% of the patients were receiving some form of invasive ventilation, of which 8% were on extracorporeal membrane oxygenation (ECMO), while 23% were on ambient air or low-flow oxygen.

The authors report that 68% of patients showed improvement in oxygen-support class during a median follow-up of 18 days. However, nearly one quarter of patients had serious adverse effects. The most serious adverse effects (multiple organ dysfunction, septic shock, acute kidney failure) were more commonly reported in patients already being mechanically ventilated.

The take-home message? Although the study showed clinical improvement with remdesivir in the majority of participants, its small sample size, intransparent selection criteria, and lack of a control group make any conclusions regarding the drug's therapeutic effectiveness against SARS-CoV-2 tentative at best. Moreover, adverse effects were common, in some cases even life-threatening. Sponsored studies that are currently being conducted (NCT04252664, NCT04257656) will hopefully allow for a more rigorous assessment of remdesivir, but for now it remains authorized for emergency use by the FDA based on preliminary results from the Adaptive COVID-19 Treatment Trial (NCT04280705).

  • Title of study: Compassionate Use of Remdesivir for Patients with Severe Covid-19 [3]
  • Authors: Grein et al.
  • Journal: NEJM
  • AMBOSS links: COVID-19

Neurological symptoms may precede fever and cough in COVID-19

One-Minute Telegram 1-2020-2/3 - Evidence that the loss of smell and taste may precede respiratory symptoms in COVID-19 was found early in the course of the pandemic. An observational case series from Wuhan, China, has now investigated the presence of further neurological symptoms in hospitalized patients.

The study reviewed the records of 214 patients with confirmed SARS-CoV-2 infection who were hospitalized between January 16 and February 19, 2020. Neurological symptoms were identified in about one third of the patients. Nonspecific symptoms such as dizziness (16.8%), headache (13.1%), and muscle injury (10.7%) were most frequently reported, but impaired consciousness (7.5%) and acute cerebrovascular disease (2.8%) were also seen, especially in those with severe disease. In some patients, neurological symptoms occurred early in the course of disease and in others they even manifested before respiratory symptoms developed.

This study had significant limitations, as it was a small, retrospective, observational study that relied on medical record screening. Furthermore, the study failed to corroborate the results of previous studies (Yan et al. [4], Vetter et al. [5]), which report significantly higher rates (50–75%) of loss in taste and smell during the early stages of COVID-19.

The take-home message? While not a perfect study, it does remind us to consider COVID-19 on the differential in patients presenting with neurological symptoms, as these may precede respiratory manifestations.

  • Title of study: Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China [6]
  • Authors: Mao et al.
  • Journal: JAMA Neurology
  • AMBOSS links: COVID-19

Vaping kills – but who is at risk?

One-Minute Telegram 1-2020-3/3 - The CDC has been tracing e-cigarette, or vaping, product use-associated lung injury (EVALI) since August 2019. It is strongly linked to vitamin E acetate, an additive sometimes found in vape cartridges, and can cause acute respiratory distress syndrome (ARDS).

Previous research has focused mainly on patients who have survived EVALI. Now, Werner et al. have compared 2,558 hospitalized patients who survived EVALI with 60 hospitalized patients who died of EVALI in the US as of January 7, 2020. The study included the entire population of patients hospitalized for EVALI in the US and, therefore, P values were not reported.

The majority of hospitalized patients were male, of non-Hispanic white ethnicity, and had reported combined or alternating use of products containing nicotine and THC. Not surprisingly, the patients who died were older and more frequently had a history of chronic respiratory and cardiac disease than those who survived. About half of the patients who died had been seen previously in an outpatient setting, suggesting that outcomes could have been improved by earlier diagnosis and treatment. Furthermore, about two-thirds of the patients who died had a preexisting mental disorder.

The take-home message? Screening outpatients for underlying cardiac and pulmonary disease and explicitly inquiring about e-cigarette or vaping use may help to identify those at risk of developing life-threatening EVALI. Also, e-smoking kills!

  • Title of study: Hospitalizations and Deaths Associated with EVALI [7]
  • Authors: Werner et al.
  • Journal: NEJM
  • AMBOSS links: ARDS
  • 1. Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020; 30(3): pp. 269–271. doi: 10.1038/s41422-020-0282-0.
  • 2. Mulangu S, Dodd LE, Davey RT, et al. A Randomized, Controlled Trial of Ebola Virus Disease Therapeutics. N Engl J Med. 2019; 381(24): pp. 2293–2303. doi: 10.1056/nejmoa1910993.
  • 3. Grein J, Ohmagari N, Shin D, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. N Engl J Med. 2020. doi: 10.1056/nejmoa2007016.
  • 4. Yan CH, Faraji F, Prajapati DP, Boone CE, DeConde AS. Association of chemosensory dysfunction and Covid-19 in patients presenting with influenza-like symptoms. International Forum of Allergy & Rhinology. 2020. doi: 10.1002/alr.22579.
  • 5. Vetter P, Vu DL, L’Huillier AG, Schibler M, Kaiser L, Jacquerioz F. Clinical features of covid-19. BMJ. 2020: p. m1470. doi: 10.1136/bmj.m1470.
  • 6. Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. 2020. doi: 10.1001/jamaneurol.2020.1127.
  • 7. Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. N Engl J Med. 2020; 382(17): pp. 1589–1598. doi: 10.1056/nejmoa1915314.
last updated 05/20/2020
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