With input from Dr Monica Vasudev

1. A study of the lungs of individuals who died from COVID-19 noted persistent and extensive lung damage in most cases.
2. COVID-19 is not just a disease caused by the death of virus-infected cells, but is possibly the result of these abnormal cells persisting for long periods inside the lungs.
3. The researchers analyzed samples of tissue from the lungs, heart, liver and kidneys of 41 patients who died of COVID-19 at Italys University Hospital of Trieste from February through April 2020.
4. Extensive destruction of the lung architecture was found, with healthy tissue almost completely substituted by scar tissue.
5. About 90% of the patients had several characteristics which were unique to COVID-19 compared to other forms of pneumonia. One of these was the presence of extensive blood clotting of the lung arteries and veins. Another was that certain lung cells appeared to be abnormally large and had many nuclei, which is due to the fusion of different cells into single large cells in a process called syncytia. The research, published in the Lancet journal EBioMedicine, also noted that the virus was still present in many cells. The presence of these infected cells seems to be accountable for the major structural changes observed in lungs, which can persist for weeks or months.

SOURCE: https://bit.ly/2I82nQU EBiomedicine, online November 3, 2020.

1140: COVID-19 does not independently increase the risk of pulmonary embolism

1. Some patients with COVID-19 have a pro-thrombotic state, with potential for developing blood clots in different parts of their bodies.
2. The overall group of patients with COVID-19 are not at a considerably higher risk than patients who come to the hospital for other diseases, noted Dr. Mark M. Hammer of Harvard Medical School in JACC: Cardiovascular Imaging.
3. The study included patients who were tested for SARS-CoV-2 by RT-PCR from March 1 through May 1 and had undergone computed tomography pulmonary angiography (CTPA) within seven days before and 14 days after the test.
4. The only significant difference in PE incidence was evident in patients who had a CTPA within a day of the COVID-19 test, 14.1% of whom were positive for PE, compared to 7.7% of COVID 19-negative patients (P=0.04). This could be attributed to the fact that the patients with COVID-19 had not yet received prophylactic anticoagulation.
5. High rate of blood clotting is not unique to COVID-19. Reports from previous pandemic of H1N1 influenza also mentioned high rates of blood clotting. These viruses can likely cause, in some patients, a strong inflammatory response, resulting in blood clotting.

SOURCE: https://bit.ly/3l7aFak JACC: Cardiovascular Imaging, online November 2, 2020.

1141: Mouthwashes with antiviral ingredients could have a role in decreasing COVID-19 transmission by reducing the viral load in the mouths of infected patients when they cough, sneeze or speak, suggested a paper published in the Journal of Dental Research.

Rinses that contain cetylpyridinium chloride or povidone-iodine can potentially diminish the oral coronavirus load. Other potential compounds include hydrogen peroxide, chlorhexidine, cyclodextrin, Citrox, and some essential oils.

People should use these mouthwashes as they can be infected and not realize it.

The study suggests using three doses of antiviral mouthwash the day before a meeting, and one dose on the morning of the event. COVID-19 patients should use the mouthwash regularly for a period of 7 to 10 days.

Source: Medscape

1142 Levels of CRP during the first 48 hours of hospital admission predict respiratory decline in COVID-19 patients

DG Alert: Among hospitalized patients with COVID-19, rising CRP during the first 48 hours of hospitalization appears to better predict respiratory decline compared to initial CRP levels or ROX indices, suggests a study published in Cell Reports Medicine.

Review of data obtained from the first 100 patients admitted to the Brigham and Women’s Hospital, Boston, Massachusetts, for COVID-19 infection suggested that among stable patients who did not require intubation at admission, elevated CRP levels in the first 48 to 72 hours of admission could precisely differentiate patients who would develop progressive respiratory failure from patients who would continue to be stable throughout the hospital course.

CRP level at admission was found to correlate with physiological measures of disease severity, including sequential organ failure assessment (SOFA) score, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), and interleukin-6 (IL-6).

All study patients presented to the hospital about 1 week after symptom onset. Only 1 patient needed high-flow nasal cannula, while 45 were intubated and on mechanical ventilation at some point during hospitalization. Treatment included administration of hydroxychloroquine, remdesivir versus placebo as part of a clinical trial, or tocilizumab. The overall mortality rate was 24%.

In all the patients, CRP levels reached a peak early within about 10 days of symptom onset; however, change in CRP <72 hours of admission was significantly different between patients with mild compared to progressive COVID-19 (P = .009). It was found to be similar between patients with progressive and severe disease (P = .81).

In comparison with patients with mild COVID-19, those with progressive disease appeared to have a more rapid rise in CRP levels drawn at 24 to 48 hours (182.0 ± 101 vs 97.6 ± 72 mg/L; P = 0.006) and 48 to 72 hours (190.1 ± 99 vs 90.2 ± 64 mg/L; P< .001) following admission.

The odds ratio of requiring advanced respiratory support was 16.9 (P = 0.01) when CRP values of >300 mg/L was achieved within 72 hours of admission.

The study indicated that examination of dynamic trends, rather than the absolute value at admission, can lead to strong associations with prognosis despite the use of a single laboratory value.

Trending CRP has predictive value for respiratory failure among initially non-critically ill patients on the general medical floor.

IL-6 was shown to be considerably raised in patients who required ICU level care at any point during their hospitalization compared to non-ICU patients. IL-6 levels had a striking correlation to CRP. IL-6 results took over 48 hours to return. In several institutions, CRP levels result within several hours and can capture rapidly evolving clinical courses that cytokine assays, which usually take over 1 to 2 days, cannot.

SOURCE: https://www.cell.com/cell-reports-medicine/fulltext/S2666-3791(20)30188-9, Cell Reports Medicine

1142: Aspirin — a cheap, over-the-counter drug — may help COVID-19 patients survive by helping prevent blood clots

A British Professor, Peter Horby of Oxford University, told a committee in the Parliament that aspirin is the latest drug added to the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, which is evaluating several treatments.

A study overseen by the University Of Maryland School Of Medicine has shown that COVID-19 patients had fewer complications when they took aspirin.

Researchers evaluated 412 patients with coronavirus infection. The study revealed that 98 of these patients received aspirin a week prior to hospitalization, or within 24 hours of admission. The study was published in Anesthesia and Analgesia.

The patients receiving aspirin had 43% lesser odds of being admitted to ICU, were 44% less likely to be placed on ventilator, and 47% less likely to die in the hospital.

Sources:

The Pharmaceutical Journal. "Aspirin added to RECOVERY COVID-19 trial, MPs told"https://www.pharmaceutical-journal.com/news-and-analysis/news/aspirin-added-to-recovery-covid-19-trial-mps-told/20208522.article?firstPass=false

Anesthesia and Analgesia. "Aspirin Use is Associated with Decreased Mechanical Ventilation, ICU Admission, and In-Hospital Mortality in Hospitalized Patients with COVID-19"https://journals.lww.com/anesthesia-analgesia/Abstract/9000/Aspirin_Use_is_Associated_with_Decreased.95423.aspx

University of Maryland School of Medicine. "New Landmark Study at UM School of Medicine Finds Aspirin Use Reduces Risk of Death in Hospitalized COVID-19 Patients"https://www.medschool.umaryland.edu/news/2020/New-Landmark-Study-at-UM-School-of-Medicine-Finds-Aspirin-Use-Reduces-Risk-of-Death-in-Hospitalized-COVID-19-Patients.html#:~:text=Hospitalized%20COVID%2D19%20patients%20who,School%20of%20Medicine%20(UMSOM)

 Researchers Say Aspirin May Help COVID Patients - Medscape - Nov 06, 2020.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA