Latest COVID-19 research looks at plasma, prophylaxis, palliative care, periop risks

A randomized trial of convalescent plasma for severe COVID-19, published by JAMA on June 3, provided uncertain results. The Chinese trial included 103 patients (out of a planned 200—the study was halted early for lack of patients). The 52 patients who received plasma in addition to standard care did not have statistically significant improvements in clinical recovery or mortality within 28 days. However, these outcomes trended better in the plasma group, and the rates of viral polymerase chain reaction tests converting to negative within 72 hours were significantly better. There were two adverse events in the plasma group, both treated with supportive care. An accompanying editorial described the results as potentially hopeful. “Like remdesivir, convalescent plasma administration was associated with clinical improvement without a statistically significant effect on mortality, with the important caveat that remdesivir was evaluated in a larger study (n=1063 randomized patients), whereas [this study] was terminated prematurely and underpowered,” the editorial said. “Therapeutic success against such a complex and challenging disease as COVID-19 is likely to require more than 1 modality, and the results … provide optimism for the future of antibody therapy in this disease.”

Hydroxychloroquine was not effective as postexposure prophylaxis against COVID-19 in a trial published by the New England Journal of Medicine on June 3. It included 821 asymptomatic people who were recruited online based on their self-report of exposure to someone with confirmed COVID-19. The incidence of new illness suspected to be COVID-19 did not differ significantly between the 414 who received hydroxychloroquine and the 407 who got placebo (11.8% vs 14.3%; P=0.35). Side effects were more common with hydroxychloroquine, but no serious adverse reactions were reported. An accompanying editorial called the results “more provocative than definitive.” The editorialist expressed concern that “to some extent the media and social forces—rather than medical evidence—are driving clinical decisions and the global Covid-19 research agenda,” noting that more than 200 trials of hydroxychloroquine for the virus were posted on ClinicalTrials.gov as of June 1.

Palliative care does appear to be a helpful intervention during the pandemic, according to a research letter published by JAMA Internal Medicine on June 5. It included 110 patients from the ED of a New York hospital for whom palliative care consults were called during the pandemic. Most patients were community-dwelling, older than age 75 years, and lacking decision-making capacity at the time of presentation or documented advance directives. Before consultation, 91 of the patients were full code, and afterward, only 20 patients were (that number decreased further to nine at discharge). Sixty-one of the patients whose status changed during the consultation declined mechanical ventilation. Seventy-one patients died in the hospital and six patients were discharged on hospice. “The most important finding in this study was, after palliative care intervention in the ED, most patients and their surrogates opted to forgo mechanical ventilation and/or CPR, and that tendency further increased on discharge,” the authors said. An April Q&A in ACP Hospitalist Weekly focused on palliative care and the pandemic.

COVID-19 also appears to increase the risks of surgery for elderly patients, according to an international study published by The Lancet on May 29. It included 1,128 patients who had surgery earlier this year and were found to have COVID-19 either before or after surgery. Pulmonary complications occurred in 51.2%, and 30-day mortality was 23.8% (38.0% in patients with pulmonary complications). Mortality was higher with male sex, age 70 years or older, higher preoperative risk score, and emergency or major surgery. “Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery,” the authors said.

Other pandemic-related changes to medical practice were suggested by a JAMA Viewpoint published June 3. It proposed some changes to the 2021 residency application process, including adjusting the timeline and limiting the number of applications and interviews. The Alliance for Academic Internal Medicine also released guidance for the 2020-2021 residency application cycle and interview season, including conducting all interviews virtually and adopting a standardized template for letters of evaluation.

Finally, antibody testing for SARS-CoV-2 was the focus of a narrative review published by Annals of Internal Medicine on June 4. It discussed potential uses of antibody detection tests in practice and research and reviewed the types of assays currently available. The authors noted that “despite an explosion in the number and availability of serologic assays to test for antibodies against SARS-CoV-2, most have undergone minimal external validation to date.” They called for urgent research to “link specific serologic variables with immunity against SARS-CoV-2.”