Does proning work?

In a study published in JAMA, researchers performed a prospective study in which 24 hospitalized patients with SARS-CoV-2 rested in the "prone" positions (i.e. on their stomachs). Most patients lie on their backs in hospital beds, though proning is thought to help to improve oxygenation to the back of the lungs. Most of the study patients initially required minimal oxygen; 67 percent required less than 4 liters of oxygen per minute by nasal cannula, with average respiratory rater of 18 breaths per minute. Arterial blood gas samples, which allow physicians to track oxygen levels, were collected before proning, during proning, and 6 and 12 hours after proning. The majority of patients (63 percent) tolerated proning for greater than 3 hours and a total of 25 percent of all patients "responded" well. Arterial oxygen levels (PaO2) among the patients who proned for greater than 3 hours increased from a mean of 73.6 mmHg to 94.9 mmHg during proning. Those differences abated after patients returned to laying on their backs. Notably, four patients who did not tolerate proning were intubated and placed on mechanical ventilators within 24 hours. This study corroborates recommendations for the so-called "rotisserie" method of proning (stomach, side, back head of bed up, other side, repeat) as this allows patients more 'proning' time and less 'back' time. However, close monitoring is required, as some patients still progress to respiratory distress despite the intervention.

What’s happening to strokes and heart attacks during the pandemic?

A paper in The Lancet analyzed ambulance calls from a UK ambulance service between January 10, 2018 and April 19, 2020. Looking at the year-on-year change in calls by quarter for major heart attacks (known as "STEMIs") and strokes, the researchers found 9 fewer calls for STEMI (95% CI: —21.8 to 3.6) and 22 fewer calls for stroke (95% CI: —47.6 to 4.2) during the covid-19 lockdown period, though these results did not achieve statistically significance. (See note below explaining "CI"). The authors conclude that this data does not provide evidence that people are reluctant to call an ambulance when they experience symptoms of stroke or heart attack. However, both confidence intervals were wide and strongly favored the "negative values," suggesting that there might truly be a trend towards fewer calls for these conditions during the pandemic. These results may corroborate findings in The New England Journal of Medicine that stroke imaging in the US has decreased by 39% between February 2020 (pre-pandemic) and March 26-April 8, 2020. However, interpreting this study is complicated by a decrease in stroke imaging which began prior to the first stay at home order in the US. Furthermore, neuroimaging for stroke may be an inappropriate measurement for actual strokes given in the US, where the bar to perform CT scans is known to be extremely low. Thus, it is unclear if the decrease in imaging reflects self-triage by patients or whether fewer major strokes are being seen in ERs. Many physicians are worried that serious illnesses are being shrugged off by patients who are scared to come to the ER. Unfortunately, neither study definitively addresses this concern. Note: 95% confidence intervals essentially state margins of error for averages. For example, the authors calculated that around 9 fewer emergency calls were made for heart attacks; but they are 95% confident that the "true" number is between 21.8 fewer calls and 3.6 more calls.


Loan Relief for Providers

Representative Carolyn B. Maloney last week announced the "Student Loan Forgiveness for Frontline Health Workers Act." The intent, as described by Maloney, is to relieve frontline providers "of the debt they incurred to train for this critical work—in graduate degree programs or other professional certification." The Department of Health and Human Services would be tasked with the creation of a nine-member task force in conjunction with the Departments of Education and Treasury to determine what qualifies as "significant contribution" to coronavirus mitigation, as well as the definitions of healthcare workers, students, laboratory workers, researchers, and a catchall for those involved in the pandemic response. Qualifying federal loans would be forgiven by the Department of Education, and private loans would be assumed by the Department of the Treasury. No refunds would be available for previous loan payments, nor could forgiven loans be claimed in federal tax filings. Applicants would have two years from the creation of the program to apply; loans incurred by workers who died of covid-19 would be eligible for consideration. The House of Representatives.

New York City’s Safety-Net Hospitals Face Financial Collapse

New York City's safety-net hospitals are facing possible closure due to losses related to the coronavirus pandemic and Medicaid cuts by New York State. The city has 29 non-profit safety-net hospitals. They are not part of the city's public hospital system, so they won't be bailed out by City Hall, and they can't tap into generous lines of credit as wealthy Manhattan hospitals can. The Brooklyn Hospital Center, for example—where 79 percent of patients are on Medicaid or combined Medicaid and Medicare or are uninsured—needs $100 million to stay in the black over the next four months. Federal funding formulas have historically dispersed funds inequitably: Of the $12 billion allocated to hospitals in the last federal stimulus bill, the Brooklyn Hospital Center received only $35.2 million. It remains to be seen whether the U.S. Department of Health and Human Services will follow through on a promised "significant infusion of money for high-impact areas." Politico, The New York Times.

Trouble in Texas as Covid-19 Cases Soar

Texas reported over 1,800 newly diagnosed cases of covid-19 on Saturday with more than 700 of those in the panhandle city of Amarillo. An outbreak in the Texas panhandle is largely to blame for the jump. With local testing increasing, case counts are expected to continue to rise. An additional 33 deaths were reported, increasing the total fatalities in the Lone Star state to 1,305. On Monday, Texas will reopen to 25 percent capacity in gyms, non-essential businesses, and offices. Hospital beds and ventilators are not currently felt to be in short supply. CBS News.

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