Challenges in the management of older patients with acute coronary syndromes in the COVID-19 pandemic #covid19rftlks

Rowland, B. & Kunadian, V. |2020| Challenges in the management of older patients with acute coronary syndromes in the COVID-19 pandemic |

 

A review published in the BMJ Journal Heart sought to evaluate the challenges and the management strategies in the care of older patients presenting with acute coronary syndromes (ACS) in the context of the COVID-19 pandemic. It finds that edence is sparse on the optimal care of older patients with ACS with lack of robust RCTs.

Abstract

Ischaemic heart disease (IHD), in particular acute coronary syndrome (ACS), comprising ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina, is the leading cause of death worldwide. Age is a major predictor of adverse outcome following ACS. COVID-19 infection seems to escalate the risk in older patients with heart disease. Increasing odds of in-hospital death is associated with older age following COVID-19 infection. Importantly, it seems older patients with comorbidities such as cardiovascular disease (CVD), in particular IHD, diabetes and hypertension, are at the highest risk of mortality following COVID-19 infection. The evidence is sparse on the optimal care of older patients with ACS with lack of robust randomised controlled trials. In this setting, with the serious threat imposed by the COVID-19 pandemic in the context of rapidly evolving knowledge with much unknown, it is important to weigh the risks and benefits of treatment strategies offered to older patients. In cases where risks outweigh the benefits, it might not be an unreasonable option to treat such patients with a conservative or a palliative approach. Further evidence to elucidate whether invasive management is beneficial in older patients with ACS is required out-with the COVID-19 pandemic. Though it is hoped that the actual acute phase of COVID-19 infection will be short lived, it is vital that important clinical research is continued, given the long-term benefits of ongoing clinical research for patients with long-term conditions, including CVD. This review aimed to evaluate the challenges and the management strategies in the care of older patients presenting with ACS in the context of the COVID-19 pandemic.

Full article from Heart

Asthma and COVID-19: risks and management considerations #covid19rftlks

Centre for Evidence-Based Medicine | 28th May 2020

It is unclear if people with asthma (PWA) are at increased risk of contracting COVID-19 or of worse outcomes from COVID-19 infection. The evidence available is limited with some sources suggesting an underrepresentation of PWA in hospitalised cases, and others showing an increased risk of worse outcomes in PWA which may be associated with disease severity.

Consensus broadly holds that asthma medications should be continued as usual. Asthma care may be disrupted during the pandemic; self-management and remote interventions may be of benefit but have not been tested in this context.

This rapid review sets out to answer the following questions:

  • Are PWA at increased risk of contracting COVID-19?
  • Are PWA at increased risk of worse outcomes from COVID-19?
  • Are PWA at risk from COVID-19 related disruptions to care?
  • How should asthma be managed during the COVID-19 pandemic?
  • How should PWA be managed when presenting with COVID-19?

Full detail: Asthma and COVID-19: risks and management considerations

£5 million funding given to mental health community projects #covid19rftlks

Community projects supporting people with their mental health during the coronavirus (COVID-19) pandemic will benefit from their share of £5 million of additional funding | Department of Health and Social Care

  • Community projects nationwide set to receive share of £5 million government investment to expand mental health support
  • Cash boost will help existing services respond to global pandemic and protect nation’s wellbeing
  • Funding to be delivered by mental health charity Mind

Community projects supporting people with their mental health during the coronavirus (COVID-19) pandemic are set to benefit from their share of £5 million of additional funding, Mental Health Minister Nadine Dorries has announced.

Voluntary organisations from across the country – such as local Mind organisations, Ambitious about Autism, Support After Rape and Sexual Violence, LGBT Foundation and Campaign Against Living Miserably – will receive a financial boost to expand their existing support services.

This fund is administered by Mind as part of the Mental Health Consortia, made up of Mind, the Association of Mental Health Providers, Centre for Mental Health, Mental Health Foundation, the National Survivor User Network and Rethink Mental Illness.

Full detail at Department of Health & Social Care

Projected baselines of COVID-19 in the EU/EEA and the UK for assessing the impact of de-escalation of measures #covid19rftlks

European Centre for Disease Prevention and Control | 28 May 2020 | Projected baselines of COVID-19 in the EU/EEA and the UK for assessing the impact of de-escalation of measures

This report from the European Centre for Disease Prevention and Control aims to provide a short-term 30-day forecast of the expected number of COVID-19 cases, deaths and hospitalised cases (including general hospital ward and intensive care unit) under a set of assumptions.

Executive summary

After widespread transmission of SARS-CoV-2 in EU/EEA countries and the UK over several weeks, the COVID-19 epidemic reached its peak in most countries in April or early May 2020. Some countries have since experienced a sustained decrease in the number of reported cases, progressively reaching the level of transmission reported during the first week of the outbreak. Due to this decrease in transmission and improvements in epidemiological surveillance and healthcare capacity, a number of countries have decided to discontinue several non-pharmaceutical interventions and now plan to gradually phase out their ‘stay-at-home’ policies.

Mathematical modelling of COVID-19 transmission can be used to better analyse the epidemic development in a population over time, produce projections, and inform public health decision-making on interventions. It is particularly useful for the evaluation of public health measures, notably to understand the expected impact of their implementation or release on disease transmission-related indicators. The mathematical modelling approach also allows for the quantification of the uncertainty associated with these estimations and projections. In this report, a dynamic compartmental model of COVID-19 is presented. It aims to provide a short-term 30-day forecast of the expected number of COVID-19 cases, deaths and hospitalised cases (including general hospital ward and intensive care unit) under a set of assumptions. In this first analysis, the baseline scenario corresponds to a ‘status quo’ in which all control measures in place on 2 May 2020 will be continued until the end of the projection period (7 June 2020). The model is based on the epidemiological data and scientific evidence available at the time of publication. Further developments are expected as new information and epidemiological data become available.

The model was developed at ECDC and applied at a national level for EU/EEA countries and the UK. When interpreting predictions of mathematical models for emerging diseases, it is essential to keep in mind the underlying assumptions, limitations and uncertainties resulting from gaps in scientific knowledge and in available data. The inherent sources of uncertainty and the limitations of the mathematical modelling approach taken here are discussed and should be considered when interpreting the results and making comparisons with other mathematical models of COVID-19 transmission.

An assessment of the risk associated with the COVID-19 epidemic and the response strategies applied or envisaged should be based on a comprehensive analysis taking in consideration current uncertainties, the specific epidemiological situation in each country, and outputs of models according to new scientific evidences. Future work in this area intends to promote data sharing and operational forecasting through an ‘ensemble modelling’ approach. This approach combines predictions from different mathematical models to improve on a single‐model forecast, offering more accurate predictions of epidemic trends and clarifying the uncertainties associated with these predictions.

Projected baselines of COVID-19 in the EU/EEA and the UK for assessing the impact of de-escalation of measures

Clinical impact of COVID-19 on patients with cancer #covid19rftlks

Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study | The Lancet | published 28th May 2020

Data on patients with COVID-19 who have cancer are lacking. In this article, the authors characterise the outcomes of a cohort of patients with cancer and COVID-19 and identify potential prognostic factors for mortality and severe illness.

The research found that among patients with cancer and COVID-19, 30-day all-cause mortality was high and associated with general risk factors and risk factors unique to patients with cancer. Longer follow-up is needed to better understand the effect of COVID-19 on outcomes in patients with cancer, including the ability to continue specific cancer treatments.

Full article: Clinical impact of COVID-19 on patients with cancer

“Evidence on the benefits and harms of using hydroxychloroquine or chloroquine to treat COVID-19 is very weak and conflicting”, reports systematic review into Hydroxychloroquine or Chloroquine for Treatment or Prophylaxis of COVID-19 #covid19rftlks

Hernandex, A.V., Roman, Y. M., Pasupuleti, V., Barboza, J.J., White, M.C. (2020). Hydroxychloroquine or Chloroquine for Treatment or Prophylaxis of COVID-19: A Living Systematic Review | Annals of Medicine | https://doi.org/10.7326/M20-2496

Abstract

Background:

Hydroxychloroquine and chloroquine have antiviral effects in vitro against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2).

Purpose:

To summarize evidence about the benefits and harms of hydroxychloroquine or chloroquine for the treatment or prophylaxis of coronavirus disease 2019 (COVID-19).

Data Sources:

PubMed (via MEDLINE), EMBASE (via Ovid), Scopus, Web of Science, Cochrane Library, bioRxiv, Preprints, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry from 1 December 2019 until 8 May 2020.

Study Selection:

Studies in any language reporting efficacy or safety outcomes from hydroxychloroquine or chloroquine use in any setting in adults or children with suspected COVID-19 or at risk for SARS-CoV-2 infection.

Data Extraction:

Independent, dually performed data extraction and quality assessments.

Data Synthesis:

Four randomized controlled trials, 10 cohort studies, and 9 case series assessed treatment effects of the medications, but no studies evaluated prophylaxis. Evidence was conflicting and insufficient regarding the effect of hydroxychloroquine on such outcomes as all-cause mortality, progression to severe disease, clinical symptoms, and upper respiratory virologic clearance with antigen testing. Several studies found that patients receiving hydroxychloroquine developed a QTc interval of 500 ms or greater, but the proportion of patients with this finding varied among the studies. Two studies assessed the efficacy of chloroquine; 1 trial, which compared higher-dose (600 mg twice daily for 10 days) with lower-dose (450 mg twice daily on day 1 and once daily for 4 days) therapy, was stopped owing to concern that the higher dose therapy increased lethality and QTc interval prolongation. An observational study that compared adults with COVID-19 receiving chloroquine phosphate 500 mg once or twice daily with patients not receiving chloroquine found minor fever resolution and virologic clearance benefits with chloroquine.

Limitation:

There were few controlled studies, and control for confounding was inadequate in observational studies.

Conclusion:

Evidence on the benefits and harms of using hydroxychloroquine or chloroquine to treat COVID-19 is very weak and conflicting.

Hydroxychloroquine or Chloroquine for Treatment or Prophylaxis of COVID-19: A Living Systematic Review available from Annals of Medicine

Push to reopen schools risks new wave of infections, says Independent SAGE #covid19rftlks

It is not safe enough for all schools to reopen on 1 June and in pushing ahead the government is risking a new surge in cases of covid-19 in some communities, an independent committee of experts has warned | via BMJ | 28th May 2020

The Independent Scientific Advisory Group for Emergencies (Independent SAGE) has now published its full report on schools reopening after a public consultation with parents and teachers in association with The BMJ and the online forum Mumsnet.

The report concluded that the government was ignoring the advice of its own scientists who carried out modelling showing the reproduction rate R rising above 1 if schools reopened.

Full editorial: Push to reopen schools risks new wave of infections, says Independent SAGE

See also: Covid-19: Delaying school reopening by two weeks would halve risks to children, says iSAGE | BMJ