Elevate your critical appraisal skills as we review the first RCT of remdesivir and share the latest and greatest COVID-19 stories including: Llama antibodies, Stroke statistics, Future Waves, Exit Strategies and Awake Proning. We’re joined by everyone’s favorite Curbsider/internist/epidemiologist, Rahul Ganatra MD MPH (@rbganatra). Rahul provides critical appraisal of the newest randomized control trial (RCT) on remdesivir from the Lancet, and gives us a lesson on why statistical power is so important to consider. We also share updates on strokes, awake proning, pandemic predictions, and we reveal another reason to love llamas (besides those luscious lashes). Llama mia, here we go again!
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Written and Produced by: Sarah P. Roberts MPH, Rahul Ganatra MD, MPH, Emi Okamoto MD, Paul Williams MD and Matthew Watto MD
Cover Art: Beth Garbitelli
Hosts: Matthew Watto MD, Paul Williams MD, Rahul Ganatra MD MPH, Emi Okamoto MD , Sarah P. Roberts MPH,
Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.
Wrapp, D et al. Structural Basis for Potent Neutralization of Betacoronaviruses by Single-Domain Camelid Antibodies. Cell. May 28, 2020.
Researchers in Belgium found that antibodies from a llama (named Winter) immunized with coronavirus proteins were able to neutralize SARS-CoV-2 in cell cultures. The study was published in Cell and covered by the New York Times. Neutralizing antibodies are important as they inhibit the receptor binding and fusion, stopping viral entry into cells.
Wang, Y et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. April 29, 2020. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31022-9/fulltext]
For a step-by-step breakdown of the study, follow along with Dr Ganatra (@rbganatra) on his twitter learning thread (hashtag: #HowIReadThisPaper).
RDV was not associated with reduced time to clinical improvement in patients hospitalized with COVID-19. The study suffered from a Lack of power after enrollment stopped early. Additionally, baseline imbalances suggest the RDV group was sicker. Both issues raise the likelihood of a false negative result. Larger studies are needed. Watch out for future studies: NIAID (ACTT) trial and NIAID (ACTT 2 trial of remdesivir plus baricitinib)
Kansagra AP, Goyal MS, Hamilton S, Albers GW. Collateral Effect of Covid-19 on Stroke Evaluation in the United States. N Engl J Med. Published online May 8, 2020. doi:10.1056/NEJMc2014816
Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. 2020;382(20):e60. doi:10.1056/NEJMc2009787
Encourage patients and community members to seek immediate care if they experience even mild potential stroke symptoms; be alert for possible stroke symptoms in younger, previously healthy patients who are tested or presumed positive for COVID-19
Caputo ND et al. Early self-proning in awake, non-intubated patients in the emergency department: A single ED’s experience during the COVID-19 pandemic. Acad Emerg Med. Apr 22, 2020.
Worth trying if vigilant monitoring and frequent reassessments! Recommended 30-120 minutes prone, and changing between prone, lateral decubitus, and sitting. No cost and minimal risk.
Part 1 of CIDRAP discussing 3 possible scenarios for course of pandemic
Part 2 of CIDRAP discussing principles of crisis communication as well as possible ways to come out of quarantine and the likely repercussions that balance illness/death and economic recovery (see blue box below)
Where is this all going? Researchers from the Center for Infectious Disease Research and Policy (CIDRAP) extrapolate historical data from prior influenza pandemics to predict possible future scenarios for COVID-19. Be aware, the outbreak will likely last 18-24 months, nothing that it likely won’t end before 60-70% of the population is immune. Three scenarios describe future waves of the outbreak, which will depend much on control measures and other factors, and the authors advise leaders to prepare for the worst (a larger wave this fall 2020).
This pandemic will likely last for 18-24 months and multiple wave patterns are possible (based on knowledge from previous pandemics). Relaxing social distancing measures is a trade off between economics and health and safety.
Listeners will hone their skills in critical appraisal as they update themselves on all things COVID-19
After listening to this episode listeners will…
The Curbsiders report no relevant financial disclosures.
Ganatra R, Okamoto E, Williams P, Roberts SP, Watto MF. “#214 COVID Cakes 3: Llamas, Remdesivir, Strokes, Predicting the Future, and More!”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list May 18, 2020.
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Thanks for the show. This talks about how the government determined the value of a human life: https://www.npr.org/transcripts/835571843.
I was listening to your 5/1/819 podcast by about COVID 19. One topic was the observation that the number of strokes in the hospital has gone way down. Your hypothesis was that people are staying home due to fear of COVID 19. The very next topic was the case reports of thromboembolic strokes in young people due to COVID 19 eg a viral illness causing a hypercoagulable state. I would suggest that there may be actually less normal strokes occurring because they also are related to a hypercoagulable state caused by other viral illnesses that have gone down as a result of societal shelter in place policies. A quick review of the seasonality of strokes, suggests that they peak in the wintertime https://www.ahajournals.org/doi/full/10.1161/01.STR.27.10.1774 There is literature implicating pro-inflammatory conditions with strokes https://pubmed.ncbi.nlm.nih.gov/21060340/ And folks thought the study of infectious illnesses was so passe!