COVID-19 Update June 1, 2020
The unofficial U.S. tally as of 8:00 a.m. ET Monday was 1,790,191 cases and 104,383 deaths, up about 4% and 3%, respectively, since Friday morning.
Acute Kidney Injury Seen in Most Severe COVID-19 Cases
New data from two health systems in New York City — where hospitals
struggled to keep up with dialysis demands as they were flooded with COVID-19 patients — detailed a high rate of acute kidney injury among infected patients.
In the first 1,000 patients with COVID-19 at New York-Presbyterian/Columbia University Irving Medical Center, 33.9% developed acute kidney injury.
Of the 236 who ended up in the ICU, 78% developed AKI, Ruijun Chen, MD, and colleagues reported in The BMJ.
A separate analysis of nearly 5,500 patients with COVID-19 treated by April 5 in the 13 hospitals of the Northwell Health system, the AKI rate was a similar 36.6%.
The rate was 89.7% among those on mechanical ventilation, Kenar Jhaveri, MD, of Northwell Health in Great Neck, New York, and colleagues reported in Kidney International.
New York City hospitals had described precarious situations with dialysis supply and machine shortages, with at least one death reportedly due to lack of capacity to cope with the surge of acute kidney injury during the peak of COVID-19 cases in the city.
The new data have implications for hospital preparedness as the pandemic continues, commented National Kidney Foundation President-elect Paul Palevsky, MD, of the University of Pittsburgh School of Medicine, who was not involved in the studies.
“What it does tell us is acute kidney injury is an important component of the disease process in patients who have COVID-19, particularly severe COVID-19,” he told MedPage Today. “Hospitals need to have surge capacity in providing dialysis to provide services. If we see a surge as social distancing is relaxed, as I’ve seen in reports from Alabama and Texas, they’re going to need to be prepared to increase acute dialysis services in hospitals.”
The rates were higher than expected from the initial reports from China and Italy, which suggested 0.5% to 29% overall AKI, “with most estimates on the lower end,” and the 19% reported initially from a Seattle ICU, Jhaveri’s group noted.
The variation in rates may have a number of components.
Age and number of comorbidities of the studied population matter, as does severity of illness, commented Ladan Golestaneh MD, of Montefiore Medical Center in New York City.
“It seems to me as if clinicians caring for these patients will be looking at comorbidity burden and need for ICU stay as strong indicators of AKI development, in which case they may need to prepare for provision of renal replacement therapy,” Golestaneh said.
“Our patients had a higher average body mass index, greater prevalence of hypertension, diabetes, and chronic pulmonary disease than those characterized in Italian and Chinese cohorts,” noted Chen’s group.
How AKI is identified is also a factor, Palevsky noted.
Jhaveri’s study of 5,449 patients admitted with COVID-19 used medical chart review with the KDIGO criteria to define AKI.
While about half of patients only reached stage 1 AKI, stage 2 developed in 22.4% and stage 3 in 31.1%. Of these, 14.3% required renal replacement therapy, and 96.8% of the 285 who did need dialysis were on ventilators.
Prognosis of those who developed AKI was poor as 35% died. It was “bleaker” with requirement for dialysis: 157 of the 285 such patients died and “only 9 were discharged from the hospital at the time of analysis.”
Chen’s group examined records for the first 1,000 patients with positive PCR tests for SARS-CoV-2 who were seen in the emergency department or hospitalized at their center, although testing criteria shifted during March and April.
In this cohort, 13.8% required inpatient dialysis overall, a rate which rose to 35.2% in the ICU.
The high rate of renal complications might have been in part due to limiting use of IV fluids when treating patients with acute respiratory distress syndrome as a lung protective fluid management strategy, Chen’s group noted.
“Alternatively, there might be inherent renal toxicity associated with the pathophysiology of COVID-19,” they wrote, “given that the rates of acute kidney injury are high even in patients not receiving intensive care or in those without acute respiratory distress syndrome.” (MedPage Today, May 29)
Primary Care Practices Fear They May Not Survive the Pandemic
Primary care practices focus on the preventive care that keeps patients healthy. Many of them are small but punch above their weight in providing access to services in underserved communities
A series of new surveys by researchers at NYU have found that the city’s primary care practices have been particularly hard hit by the pandemic. Many of them worry they may not come out on the other side.
Initial survey results collected in mid-April yielded responses from nearly 500 primary care practices across the city and revealed that the Covid-19 crisis was having a severe impact on 85% of them, NYU said. The most common sources of stress included shortages of personal protective equipment, which 53% of respondents reported. Nearly half noted strain from large volumes of patient calls, and 42% reported struggles with staff illness. For practices that remained open, more than half of patient visits were completed via video or telephone, the researchers found. However, some providers were unsure whether they would be reimbursed for them.
In the most recent iteration of surveys completed May 21, more than 120 practices responded, and 72% said that they were detrimentally affected by the crisis. More than 60% of respondents cited decreases in revenue as a severe source of stress.
“It is frustrating because small community clinics are completely forgotten,” one practice from Brooklyn responded. “We don’t get funds, and insurance carriers pay peanuts for televisits—that is, if they choose to pay.”
Though many primary care practices have applied for varying loan and grant programs to help ease some of the financial strain, there is concern they haven’t been a priority for federal relief.
“We all understand that the crisis is at the hospital level, but what’s remarkable is that in the midst of this overwhelming crisis of hospitalizations, people were forgetting there are other frontline health care workers, and they’re called primary care doctors and nurses,” said Dr. Donna Shelley, professor of public health policy and management at the NYU School of Global Public Health, who is leading the research.
The Medical Society of the State of New York also noted that more federal funding is needed to support physician practices during the pandemic following its own survey. And even large practices have noted the high costs of obtaining PPE.
Shelley and her colleagues are working with NYU Langone Health as well as the city Health Department on the research. She collectively calls the primary care practices the “silent safety net.”
“If 50% shut their doors, they worry that their patients would have nowhere to go,” Shelley said. One practice responded that members of its staff can speak four African languages, an essential part of providing quality care to the patients it serves.
If You Practice in Times Union Reach Area, Tell Patients You Are Open
We just launched a free Open for Business directory on TimesUnion.com so that you can let the Capital Region know you are open. They can also purchase gift cards to use at a later date if you include the link for that listing too. I attached the flyer for the instructions on how to post your business and it only takes 5-minutes. There are also upgraded package options if you choose to do that one instead, with other added features. Questions? Contact Cristi.Lalli@timesunion.com
Or call 518-454-5368 Cell:518-728-6453.
MSSNY Provides Access to PPE Supply Chain in Collaborative Effort with American Society of Plastic Surgeons
The Medical Society of the State of New York (MSSNY) is pleased to offer members access to purchase PPE supplies through the American Society of Plastic Surgeons (ASPS) PPE supply chain program. ASPS established the program earlier this month to help practices acquire difficult-to-access PPE and other needed supplies as states begin to lift restrictions on elective surgery and office-based procedures.
Items available range from N95 masks and face shields to hand sanitizer and alcohol wipes. New items are consistently being added and restocked. Please note that shipment times may vary from several days to several weeks. Some orders may be fulfilled by outside vendors with longer shipping times.
To see the available supplies and create an account to purchase items, visit this website.
MSSNY is proud to offer this benefit to our members and grateful to ASPS for extending this opportunity to help medical practices and patients in our state resume p ractice swiftly and safely. Join MSSNY at www.mssny.org.
Gilead: Short Course Remdesivir Tops Standard COVID-19 Tx
Hospitalized patients with moderate COVID-19 pneumonia treated with antiviral remdesivir plus standard of care were modestly more likely to show clinical improvement in a specified period than patients treated with standard of care alone, topline results from a randomized phase III open-label trial found.
In COVID-19 patients receiving treatment with intravenous remdesivir for 5 days in addition to standard treatment, odds of showing clinical improvement at day 11 were 65% higher (95% CI 9%-148%, P=0.017) versus those receiving standard of care, reported manufacturer Gilead Sciences in a press release on Monday.
This difference in improvement was only significant in the group receiving 5 days of remdesivir, with a non-significant difference among patients receiving 10 days of the drug (OR 1.31, 95% CI 0.88-1.95, P=0.18).
On day 11, a significantly higher proportion of patients in the 5-day group achieved at least a 1-point improvement in the ordinal scale (76% vs 66%). In the 10-day group, 70% achieved this endpoint.
Two-point improvements were achieved by 70% and 65% of the 5- and 10-day remdesivir groups, respectively, compared with 61% with standard care.
Rates of clinical worsening or death trended higher in controls (11%) versus both remdesivir groups (3% and 6% for 5 and 10 days, respectively).
Remdesivir is currently approved for emergency use authorization by the FDA to treat hospitalized patients with severe COVID-19. Recently, data from the ACTT-1 trial, which was sponsored by the National Institute of Allergy and Infectious Diseases, also found the drug was associated with shorter time to recovery compared to standard of care.
In the SIMPLE Moderate trial, 584 patients were randomized 1:1:1 into three groups: remdesivir for either 5 or 10 days, or standard of care alone. Primary endpoint was clinical status, which was assessed on a 7-point ordinal scale on day 11.
Similar to prior trials, remdesivir was well-tolerated, with nausea being the most common side effect, followed by diarrhea and headache, all of which occurred in more than 5% of patients in both treatment groups.
Last Updated June 01, 2020
NYSNA LAWSUIT v. NYSDOH for Failure to Enforce Regs re PPE Dismissed
A New York Supreme Court justice has dismissed a lawsuit against the state health department by New York’s largest nurses’ union seeking several workplace protections, saying the group’s allegations are beyond judicial review.
The New York State Nurses Association accused the state health department of failing to enforce regulations around the safe use of personal protective equipment, arguing it led to hundreds of NYSNA members testing positive for the coronavirus, and pressed for new work attendance policies. “While the Court is most sympathetic to the position of petitioner’s members and other healthcare workers, the law does not permit the Court to substitute its judgment for that of an administrative agency, such as respondent DOH,” New York State Supreme Court Justice Frank Nervo wrote in a Thursday decision. (Politico June 1)
Beyond COVID-19: 3 Financial Opportunities for Physicians
As the world emerges from quarantine, health, safety and financial concerns remain paramount.
As MSSNY’s preferred wealth manager for members, Altfest is offering a complimentary webinar, Beyond COVID-19: 3 Financial Opportunities for Physicians, which will address topics for physicians’ consideration during this time, including:
- Tax options to take advantage of in a potentially lower-income year
- Refinancing your mortgage
- Identifying investment opportunities in a volatile market
Date: Wednesday, June 3rd at 11:00am ET
Steven Novack, CPA, CFP®, Senior Financial Advisor, Altfest Personal Wealth Management
Benjamin Lake, CFA, CFP®, Senior Financial Advisor, Altfest Personal Wealth Management
There is no fee to attend this webinar. Enrollment is limited. You may submit questions in advance by emailing firstname.lastname@example.org by noon on Tuesday, June 2nd.
Want to speak with someone now about a personal financial concern? Through MSSNY, you are welcome to contact Altfest Personal Wealth Management for a complimentary personal financial planning review by calling (212) 406-0850, emailing email@example.com or visiting altfest.com/physicians.