Clinical Course of 4 Patients with Coronavirus (COVID-19)

Patients seen from Jan 1, Feb 15, 2020

3 of the 4 patients had cough and fever on presentation; the fourth patients was noted to have CT scan changes which was performed due to history of exposure

Oseltamivir was given to all patients and all patients recovered (difficult to say if it was drug or if it was recovery on their own).

Between 12 and 32 days, all patients became afebrile and had two consecutive negative RT-PCR (diagnostic test for the presence of virus in the body). One patient had some remaining finding on Chest CT by the end of follow up.

Somewhat surprising is that it took  up to 32 days to get rid of virus completely and that a patient may be a carrier up to 32 days. This is in contrast to commonly thought duration of up to 14 days.

Here is the link to the actual study.

COVID-19 (Novel Coronavirus) risk of Pandemic

A recent article estimated the case fatality rate (CFR) 5.3% and 8.4%. While the severity of COVID-19 is not as high as that of other diseases caused by coronaviruses, including severe acute respiratory syndrome (SARS), which had an estimated CFR of 17% in Hong Kong, and Middle East respiratory syndrome, which had an estimated CFR of 20% in South Korea, a 5%–8% risk of death is by no means insignificant. Further, there is strong possibility of presymptomatic transmission with a substantial impact on public health response to the epidemic as well as overall predictability of the epidemic during the containment stage

Peer Observations to Enhancing Bedside Clinical Teaching

In academic medical centers, residents and studies get bedside teaching and direct patients care experience by teaching clinical attendings. To improve their teaching skills, these teaching attendings need feedback on their teaching. Teaching attendings receive feedback through learner evaluations, which has been shown to improve teaching effectiveness, but to provide anonymity to the learner, these evaluations are usually aggregated and given to the attending months later, limiting timely improvements. In addition, learners may lack the framework to give effective feedback on teaching and may base evaluations on a variety of factors, such as a desire to achieve a good grade. It is not uncommon that a learner who received poor feedback during a clinical rotation gives poor evaluations to a teaching attending.

Peer observation with feedback is a solution to the drawbacks of learner evaluation of teaching attendings. Peer observation of teaching behaviors encourages reflection by both the observer and the teaching attending being observed, leading to increased confidence and performance. Peer observation of teaching skills in lecture or small group settings has been evaluated but there is a paucity of studies examining the effect of feedback provided by peers observing the teacher during bedside rounds.

One framework often used is the Stanford Faculty Development Program (SFDP). The SFDP describes seven domains of effective clinical teaching: learning climate, control of teaching session, communication of goals, promotion of understanding and retention, evaluation, feedback, and promotion of self-directed learning. Investigators for this study designed a survey tool using SFDP and used it for peer-observation of teaching skills. Such a study is tedious, time consuming, difficult to do, and requires very engaged faculty who is ready to volunteer significant amount of their personal time for observation.

The survey tool focused on five teaching domains (learning climate, control of session, promotion of understanding and retention, evaluation, and feedback) relevant to the inpatient teaching environment excluding the other two. Teaching attendings were observed at the beginning of a two-week teaching rotation, given feedback, and then observed at the end of the rotation. Overall, they completed 70 observations over 27 teaching attendings. Mean survey tool scores in teaching behavior domains ranged from 2.1 to 2.7. In unadjusted and adjusted analysis, each teaching observation was followed by higher scores in learning climate (adjusted improvement = 0.09; 95% CI = 0.02-0.15; p = 0.007) and promotion of understanding and retention (adjusted improvement = 0.09; 95% CI = 0.02-0.17; p = 0.01). The standardized observation tool had Cronbach’s alpha of 0.81 showing high internal validity.

The study shows that the peer observation of bedside teaching followed by feedback using a standardized tool is feasible and results in measured improvements in desirable teaching behaviors.

Hydrate or not to Hydrate that is the Question

A large amount of previous evidence have suggested that hydration of patients undergoing an intravenous contrast study reduces the risk of kidney injury. However, recently some data suggests that the contrast induced injury may simply be because patients who are undergoing emergent intravenous contrast study are sicker patients and are likely to develop kidney injury irrespective of getting contrast.

Timal and colleagues conducted a randomized controlled trial enrolling 523 patients with stage 2 chronic kidney disease and found that there was no benefit of giving intravenous fluids to patients who were getting intravenous contrast. The study details are here

Another Drug (Interferon beta-1A) is Found to be Ineffective in Patients with Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a life-threatening disease. It is characterized by leaky lungs blood vessels resulting in fluid in the lungs (pulmonary edema) which results in low oxygenation of the blood flowing through lungs. Usually, there is an underlying severe disease, often sepsis, that results in ARDS. Currently, the treatment of patients with ARDS is treatment of the underlying cause and supportive care with a hope that lungs will recover on their own.

The main mechanisms underlying underlying ARDS is an uncontrolled inflammatory response resulting in injury to the walls of the lung blood vessels leading to increased leakage of fluids into the lung alveoli. Interferon beta-1A (IBA) has been shown to reduce leakage from blood vessels and dampen inflammatory response. An early study showed some benefit.

A recently reported randomized controlled trial found no benefit of the drug. Investigators did not find any benefit with regard to ventilator free days or 28-day mortality. In fact, if anything, significant number of patients suffered adverse effects. While the study was not effective in showing a benefit, it raised important question about possibility of other therapies affecting the beneficial effect of this drug. In conclusion, more research is needed for this disease for which we have no therapies available.