Tag: patients

The effect of repurposed drugs on COVID-19 patients explained

There is a need for aggregation and analysis of the vast data that will be generated from the use of repurposed drugs such as Remdesivir, Favipiravir and Dexamethasone in the coming times to understand their true potential for COVID treatment

Repurposing broad-spectrum antiviral agents have been deemed ‘safe-in-man’ through testing on early phase clinical trials for COVID-19. In April 2020, an international collaborative research team conducted a large-scale drug repurposing survey to identify existing drugs that prevent the COVID-19 virus from replicating. The team consisted of scientists from the Sanford Burnham Prebys Medical Discovery Institute, Scripps Research Institute, University of California San Diego, University of California Los Angeles (all CA, USA), The University of Hong Kong (China), University of Vienna (Austria), Texas Biomedical Research Institute (TX, USA) and Icahn School of Medicine at Mount Sinai (NY, USA). The team discovered 300 drugs that could stop the virus from replicating. Utilising molecular tools such as PCR and immunofluorescence microscopy, the researchers were then able to determine 30 most effective candidates. A few are already under evaluation for use in COVID 19 around the world.

Back home, after extensive use of hydroxychloroquine, repurposed drugs Remdesivir, Favipiravir and Dexamethasone have been touted to show a lot of promise in early trials for the treatment of COVID-19. These drugs have been approved for treatment by the ICMR under emergency use authorisation conditions. There is an informed consent form which the prescribing doctor first explains to a patient before the patient starts the course. All patients will be observed and patient data will be analysed and submitted for review to the regulatory body in India. Now, each of these drugs responds differently and are utilised at different stages of the illness. For instance, as part of the FAITH trial, a combination of Umifenovir and Favipiravir has been used for ‘mild and moderate’ COVID-19 cases. Whereas, Remdesivir is for patients with more severe symptoms of the infection. Dexamethasone, a corticosteroid used in a wide range of conditions for its anti-inflammatory and immunosuppressant effects has been utilised to reduce the risk of death among severely ill patient. While all these drugs have shown some good outcomes in the initial trials some of these are termed as a wonder drug or miracle cure for COVID.

Express Healthcare in this article aims to understand the existing safety evidence on Indian patients from the clinician’s perspective.

So let’s begin with first understanding the advantages of repurposing drugs and then gain clarity on the original purpose of said repurposed drugs used for COVID treatment and why and how these drugs show promise for COVID treatment and what is the caveat emptor associated with these drugs.

The advantages of repurposed drugs

According to various scientific publications, repurposed drugs are an immediate response to the pandemic which has accelerated beyond the containment strategies. It is a strategy often used in the oncology space. A pharma technology review paper mention that borrowing drugs from other indications is a time saver because these drugs have proven themselves to be safe in pre-clinical and early clinical testing. They can be fast-tracked straight into the final stage of clinical development, Phase III and can be easily evaluated for their safety and efficacy as COVID-19 treatment. The expediency of this strategy has captured the imagination of pharma companies and university researchers committed to quickly resolving the COVID-19 pandemic. Some publications indicate the following benefits.

Creating access to patients sooner: Ensuring access to some treatment that can block or prevents a mechanism of action that a virus might use to replicate is very critical. This is where repurposed drugs come into the picture. Hospitals remain overwhelmed with patients who have contracted a virus for which no reliable treatments exist. Repurposed drugs could substantially accelerate the delivery of treatment and elevate the suffering of afflicted patients.

Relying on safety information from the existing drug: The primary reason that repurposed drugs have shorter development programmes is that sponsors can rely on existing drug safety data for a New Drug Application (NDA). Because the safety of the drug product has already been proven, typically fewer studies are required. Additionally, clinical trials to determine if a repurposed drug can halt disease progression can be relatively short-term and inexpensive since researchers generally know the safety profile and have a good idea of the proper dose and duration. Regulators can approve such drugs if several studies show consistent benefit when weighed against the observed side effects. Progress can be made with several candidates in consideration.

Reduced cost of drug development programmes: These shorter development timelines and streamlined studies lead to significant cost savings for sponsors. Moving rapidly to the clinic with so many unanswered questions about efficacy carries considerable risk, and the scale of manufacturing needed for COVID-19 therapies is enormous. Especially in an uncertain funding environment, having a cost-optimised strategy for a well-understood active ingredient could enable a programme to progress to approval or authorisation.

Repurposed drugs and one big human trial…

We are all aware that the safety evidence of these 3 drugs is not originally licensed for Covid-19. They are part of clinical trials and have been authorised for emergency use under clinician supervision. Therefore experts also provide a word of caution on the use of these drugs.

According to Dr Balasubramanian Mahadevan, Ex-Medical Director at PD Hinduja, Saifee, Bhatia, Shushrusha and Lilavati Hospitals in Mumbai, drug repurposing is an emerging strategy where existing medicines, having already been tested safe in humans, are redeployed to combat difficult-to-treat diseases. 

While using such repurposed drugs individually may ultimately not yield a significant clinical benefit, carefully combined cocktails could be very effective, as was for HIV in the 1990s. In the absence of any vaccines to prevent COVID-19, there are many clinical trials (CT) taking place to find a treatment. These CTs are mainly focusing on either repurposing or repositioning the existing molecules. WHO has published a landscape of therapeutics which could be used for treating COVID-19, and some of them are undergoing CTs as well. Generally speaking, patents are not a concern when it comes to old molecules under CTs because these molecules are already out of patent protection. However, a few of these molecules are still under patent protection in many countries. Two in particular – Remdesivir and Favipiravir – are under patent protection in India. The generic availability of these medicines can facilitate compassionate use and CTs in India without depending on supply from the patent holders. Therefore, the Government of India should use the compulsory license or government use license to facilitate the generic production of these medicines.” 

Dr Mahadevan further elaborates on the different drugs on clinical trials in India in an article Drug repurposing and its impact (https://www.expresshealthcare.in/blogs/guest-blogs-healthcare/drug-repurposing-and-its-impact/422780/)

The clinical response so far…

To understand the current clinical response of these drugs and its actual utilisation in the Indian market, we spoke to some clinical experts who have been prescribing these drugs to their patients and are constantly monitoring the efficacies of the same. 

“All three drugs are beneficial when started at an early stage for the treatment. Once the patient is critical and on ventilatory support, their utility is limited. Having said that, Dexamethasone can be given to all patients, even the ones with mild changes on the chest CT scan. Favipiravir and Remdesivir are started to patients who require oxygen support and who we feel are likely to have a clinical deterioration,” says Dr Chinmay Godbole, Chief of Intensive Care, KJ Somaiya Hospital, Superspecialty Centre.

 Dr Samrat Shah, Consultant Internist, Bhatia Hospital states that the main treatment in COVID-19 revolves around three main drugs-antivirals, anti-inflammatory and anticoagulation. 

He further explains the antivirals first

FACTS of Favipiravir

  •  Favipiravir, Remdesivir contains the viral replication and it’s not viricidal (doesn’t destroy the virus directly). 
  •  It doesn’t have any major role in saving you from mortality but it can reduce the days of your suffering from COVID-19.

Antivirals like Remdesivir and Favipiravir are falsely hyped as lifesaving drugs.

Advantages of Favipiravir are:

  •  Favipiravir is effective in mild /moderate stages 
  •  It is easily administered orally

Disadvantages of Favipiravir include the following: 

  •  There is pill load because of a high dose of 18 tablets given on day one and followed by eight tablets per days for 7-14 days.
  •   It causes Hepatotoxic which is damaging or destructive to liver cells.

FACTS of Remdesivir

  • Remdesivir is claimed to be effective in the severe and critical stage but its disadvantage lies in IV administration.
  •  It is also hepatotoxic and damaging or destructive to liver cells.
  •  Practically speaking viral replication ends in first 1-7 days, complications which occur in critical and severe COVID 19 post 7-8 days is due to an inflammatory response (SIRS). So this drug ideally should be used in the early stages when viral replication is happening to reduce the viral load in the body. 

Similarly, Dr Shah updates us on anti-inflammatory Steroids- Dexamethasone/MPS saying, Lifesaving as always, its key role is in severe and critical COVID 19 pneumonia and ARDS. This medicine should be used with extreme caution in early stages when viral replication is going on, early judicious use can boost the viral replication and lead to viremia.”

Similarly, Dr Kedar Toraskar, Chief of Critical Care, Wockhardt Hospitals, Mumbai Central, informs, Favipiravir is an oral antiviral used for resistant influenza in 2014. It has been repurposed in the view of this pandemic. There were trials in Japan, China and there are ongoing trials in India. It is a relatively safe drug but the only problem is the dose is high. The patients have to take nine pills on day one and 4 pills, twice a day, on subsequent days for at least 6-14 days. The total course is 7-14 days, and that’s the problem. Also, if the patient has underline gout, he/she needs to be careful, and the patient will have to be monitored for their liver function before taking it. The cost of Favipiravir is around Rs 100, so the cost comes to be around Rs 7,000 Rs for a full course of seven days, and it can be unaffordable for a common man. Also, the pill burden is high. It is not a wonder drug; we are still waiting for the trial reports. It has to be used in initial stages (first seven to eight days). It is used for mild to moderate symptoms. It helps or doesn’t help is still not known.”

He further explains the clinical efficacy of Remdesivir. “This drug is intravenous right now. It is also a repurposed drug and an antiviral. Right now, it has been licensed for moderate to severe patients. It has to be administered early (between six to 12 days). If it is used late then efficacy is not good. Again, clinical trials are ongoing and it is not a proven benefit. Recovery time from this drug is less but whether mortality is low, is not known yet. But, Remdesivir seems to be promising. On the first day, 200 milligrams are given and the second day, subsequent 100 milligrams, and the cost of this drug is Rs 5,000. For administering it, liver and renal function tests have to be monitored. It can’t be given to those patients having renal failure. One will have to use antivirals in an early stage. They won’t work after 10-12 days. Dexamethasone is a steroid. It was found useful in the recovery trial done in the UK. It is for patients who have hypoxia (oxygenation problems). It is not to be used in the early phase as it can harm the patient than doing good. It has to be started after 10 days. It is used for patients with respiratory failure. If it is used too late then also it will not benefit. It is a steroid and can also cause secondary infections also. Use it with caution and in the patients, who have high sugar.”

Dr Deepesh G Aggarwal, Consultant and HoD Critical Care Medicine, Saifee Hospital speaking about how these repurposed drugs have given us a fighting chance in combating COVID 19 when used appropriately, states, “Steroids and Remdesivir have been quite effective. Our experience with favipiravir is relatively lesser as it has been recently introduced. Injection Tocilizumab has been a lifesaver in patients with Cytokine storm.”

Further sharing his observation Dr Toraskar expounds, “We will have to see the trial results. Dexamethasone and steroids are helpful for us. In some patient so. Remdesivir seems promising but we have to keep a close watch on it. It is like an option that wasn’t available before. The timing of the drugs and patient selection is important. Antivirals like favipiravir and Remdesivir have to be used early on in the viremia phase in the first 10 days of symptom onset. Remdesivir is to be used for moderate to severe cases between fifth to 12th day. Steroids will be harmful in the viremia phase if used early. They have only shown proven benefit in patients who have respiratory failure requiring supplemental oxygen and ventilation. Start using it when available on compassionate grounds after discussing the pros and cons with the patient and their relatives. Steroids in low dose seem to work as proven by the recent recovery trial results and that has been our experience in the last two months too.”

More data required and stringent rules against black marketing

Just as clinical experts point out that these drugs certainly bring hope to healthcare providers and patients alike, their application should be strictly monitored. Most doctors clearly indicate that the high dose of these drugs can be detrimental to patients. Moreover, there is a need for aggregation and analysis of the vast data that will be generated in the coming times. Only then can the true potential of these repurposed drugs be judged. Another issue that healthcare providers are currently facing is the shortage of drugs such as Remdesivir. 

Dr Godbole raises his concerns on the shortage of drugs. “We should have some way to procure these drugs easily as currently procuring them is a challenge. More importantly, since these are observed to be life-saving drugs, it should be made available easily. Further, the awareness of the indications of these drugs is important. We do not want hoarding of these essential drugs by anyone,” he notifies. 

Likewise, an industry source informed Express Healthcare that in many places, especially in Mumbai, Remdesivir is not available easily and is sold in black. The cost of which varies between Rs 50,000 to Rs 85,000 per vial. In order to tackle this menace, drug company Hetero, which has obtained a license to supply Remdesivir (COVIFOR 100 mg vial) has been directly contacting hospital pharmacies to ensure the drug is available at the right price. However, when Express Healthcare contacted the Pharma company, the company informed that the stocks for Remdesivir will be available only after July 10, 2020.

sourcelink: https://www.expresshealthcare.in/clinical-research/the-effect-of-repurposed-drugs-on-covid-19-patients-explained/422843/

Blood types and COVID-19 risk confirmed

Blood type may play a pivotal role in driving disease severity among coronavirus disease (COVID-19) patients. Genetic analysis of COVID-19 patients has shown that people with blood type O seemed to be protected against severe disease. In contrast, those with blood type A may experience complications tied to the viral infection.

A team of European scientists has found that two genetic variations may show who is more likely to get very sick and even die from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Further, they found a link to blood type, suggesting that some people are predisposed to COVID-19 severe disease.

The study findings, published in The New England Journal of Medicineshed light on why some people have a higher risk of being infected with the coronavirus and developing worse symptoms.

In three completely separate studies, researchers from Columbia UniversityIran’s Mazandaran University of Medical Sciences, and various Chinese institutions all arrived at similar findings.

Respiratory failure in COVID-19 patients

The pathogenesis of severe COVID-19 and the associated respiratory failure is still unclear, but the higher mortality is consistently tied to older age and being male. Further, people with underlying health conditions are more likely to develop severe COVID-19, including hypertension, diabetes, being obese, and cardiovascular disease.

The relative role of clinical risk factors in determining the severity of COVID-19 has not been clarified. Now, the new study underscores other predisposing factors that may make some people vulnerable to the infection.

Genetic analysis

The team studied more than 1,900 severely ill coronavirus patients in Spain and Italy, two of the hardest-hit countries at the peak of the coronavirus pandemic. They compared the patients from seven hospitals to 2,300 people who were not sick. Overall, they analyzed more than 8 million single-nucleotide polymorphisms and conducted a meta-analysis of the two case-control panels.

The team has found that a cluster of variants in genes that are involved with immune responses was more common in people with severe COVID-19. The genes are also associated with a cell-surface protein known as angiotensin-converting enzyme 2 (ACE2), which the coronavirus uses to enter and infect cells in the body.

One of the gene clusters increased the risk of getting severe COVID-19 by 77 percent. The researchers believe that discovering these gene clusters may ramp up the development of new vaccines and therapeutics for the coronavirus disease.

Blood type

The researchers also found that people with blood type A had a 45 percent increased risk of contracting the coronavirus and developing respiratory failure compared to people with other blood types. On the other hand, people with blood type O had a 35 percent lower risk of developing severe COVID-19 illness.

However, it is not clear why blood type might influence susceptibility to severe disease. Dr. Robert Glatter, an emergency medicine doctor at Lenox Hill Hospital in New York City, noted that the genes controlling blood type might play a role in the makeup of cell surfaces. The changes in cell-surface structures might influence the susceptibility of the cell to be infected by the novel coronavirus.

“We also know from previous research that blood type affects clotting risk, and it’s now quite evident that critically ill patients with coronavirus demonstrate significant clotting,” Dr. Glatter explained.

The team emphasized that their findings may need further validation and investigation. This way, more information can be gathered on the link between blood type and coronavirus disease severity.

“Further exploration of current findings, both as to their usefulness in clinical risk profiling of patients with Covid-19 and toward a mechanistic understanding of the underlying pathophysiology, is warranted,” they wrote on the paper.

Global toll

The coronavirus pandemic has ravaged across the globe, actively spreading in many countries. The United States remains the country with the highest number of cases. The country’s case toll has surpassed 2.189 million infections, and its death toll topped 118,000.

Brazil trails behind the U.S., with over staggering 978,000 infections in since April. The death toll in the country has topped 47,000. Russia, India, and the United Kingdom have reported an increasing number of infections, with more than 560,000, 366,000, and 301,000, respectively.


COVID-19 patients experience neurological symptoms

People with SARS-CoV-2, which is the virus that causes COVID-19, can experience a variety of symptoms.

According to the Centers for Disease Control and Prevention (CDC), these are usually physical symptoms, such as fever or chills, a cough, fatigue, and shortness of breath.

Among the warning signs that indicate that a person needs emergency medical care, the CDC list confusion and an inability to wake up or stay awake.

Although the neurological symptoms associated with COVID-19 have received much less attention than the physical symptoms, some studies suggest that they are common among people with severe forms of the illness.

A study in the BMJ, for example, found that among COVID-19 patients who died at a hospital in Wuhan, China, 22% had experienced a disorder of consciousness, compared with only 1% of those who recovered.

preprint of another study of hospitalized patients in China found that overall, 25% had central nervous system symptoms or diseases. These included headaches, dizziness, impaired consciousness, uncoordinated muscle movements, seizures, and strokes.

These were more likely in those with severe disease. For example, 6% in the severe group had strokes, compared with 1% in the non-severe group.

In the first published study of its kind, researchers at the University of Cincinnati in Ohio and several Italian universities analyzed the findings of imaging investigations into hospitalized patients in Italy who experienced neurological symptoms with COVID-19.

The researchers have now published their results in the journal Radiology.

Second epicenter

After China, Italy became the second epicenter of the COVID-19 pandemic. Italy has now had more than 33,000 deaths.

The researchers analyzed the records of patients treated at the University of Brescia, the University of Eastern Piedmont in Novara, and the University of Sassari.

Out of 725 patients, 15% experienced neurological symptoms or disease. Of this 15%, 99% underwent a CT scan.

The most common neurological symptoms were “altered mental state,” which 59% of the patients experienced, and ischemic strokes, which 31% of the patients experienced.

Altered mental status” encompasses a wide range of possible signs and symptoms, including confusion, delirium, and coma.

Among the less common neurological symptoms were headache (12%), seizures (9%), and dizziness (4%).

Imaging revealed acute abnormalities in 47% of the patients. Among the most common findings were ischemic strokes, and in 6% of the patients, there were signs of intracranial hemorrhage.

Early interventions

“These newly discovered patterns could help doctors better and sooner recognize associations with COVID-19 and possibly provide earlier interventions,” says lead study author Dr. Abdelkader Mahammedi, an assistant professor of radiology at the University of Cincinnati.

The study was unable to shed light on whether or not SARS-CoV-2 directly damages the central nervous system. It might be that neurological symptoms are a side effect of critical illness. Lack of oxygen in the brain, for example, can cause confusion or loss of consciousness.

In addition, of the 108 patients, 71% had one or more preexisting chronic conditions. These included hypertensiondiabetescoronary artery disease, and cerebrovascular disease.

In their paper, the researchers cite accumulating evidence to suggest that some people with severe COVID-19 experience a “cytokine storm,” in which the body produces an excess of pro-inflammatory molecules called cytokines. This can cause blood clots, which can, in turn, trigger ischemic strokes.

“This topic definitely needs more research,” says Dr. Mahammedi.

“Currently,” he adds, “we have a poor understanding of the neurological symptoms in COVID-19 patients, whether these are arising from critical illness or from direct central nervous system invasion of SARS-CoV-2. We hope further study on this subject will help in uncovering clues and providing better interventions for patients.”


Cancer and COVID-19: What’s the Outlook?

May 28, 2020 — Cancer patients diagnosed with COVID-19 who are otherwise generally healthy can and do survive the coronavirus, according to a new study that evaluated 928 patients with both conditions. But there was much bleaker news for cancer patients with COVID-19 who also had other medical issues, such as high blood pressure and diabetes.

Overall, the death rate from COVID-19 for cancer patients over the study’s 3-week follow-up was 13%, says study lead author Jeremy Warner, MD, an associate professor of medicine and biomedical informatics at Vanderbilt University, Nashville.

That’s higher than the estimated 5.9% case-fatality rate for the U.S.

When Warner looked at a small group of 86 patients who had no other medical problems in addition to the cancer and the coronavirus and had been functioning normally despite the cancer, he found that all of them survived.

Those at higher risk of dying included:

  • Older patients
  • Men
  • Smokers or former smokers
  • Patients with two other conditions
  • Those with active cancer
  • Patients who had taken the drug combination of hydroxychloroquine and azithromycin

Warner says 270 patients received the drug combination. At the time the study began, in mid-March, ”those were the most used drugs in the treatment of patients with COVID,” he says.

“What we did find was a three-fold risk of death in the patients who got the combination,” Warner says, but the researcher can’t explain the finding with certainty. “Whether it means the drugs themselves are causing harm, or that the patients were sicker, or maybe a combination, we just don’t know.”

The drug combination, popular when the study began, has been discredited since. In a recent analysis of hydroxychloroquine with or without an antibiotic such as azithromycin that looked at data from 671 hospitals and six continents, researchers could not confirm a benefit and found an association with decreased survival in the hospital and an increased risk of abnormal heart rhythms.

“These drugs should not be given outside a clinical trial, and clinical trials are needed to determine whether they help or hurt,” Warner says. Out of the 270 in this study who received the drug combination, Warner says that only two received them as part of a clinical trial.

Study Details

Researchers collected information on COVID-19 patients with cancer from 104 institutions as part of a clinical trial. The median age was 66, and breast cancer was the most common type, affecting 21% of patients, followed by prostate, gastrointestinal, and thoracic, including lung cancers. And 39% were on active cancer treatment when diagnosed with COVID-19. Cancer type was not linked to mortality.

Warner’s team is continuing to study the effects of COVID-19 on cancer patients. The data base is now over 2,200 patients. The use of the antiviral drug remdesivir is up dramatically, he says. The FDA granted remdesivir emergency use authorization to treat COVID-19 on May 1.

The data suggests that in some instances, COVID-19 patients who are doing well on cancer treatments might be able to continue them, but that others might consider changing to palliative care, Warner says.

“Patients with progressing cancer or impaired performance are at a higher risk of a bad outcome,” he says. “It’s pretty clear they shouldn’t continue aggressive therapies for the cancer if diagnosed with COVID-19.”

Second Cancer Study

A separate study found that patients with thoracic cancers, including of the lung, who also have COVID-19 are less likely to survive the coronavirus if they are over 65, are on chemotherapy, on steroids of more than 10 milligrams daily, or on anti-blood clot medicines.

The data base includes 428 patients: 141 who died, 169 who recovered, and 118 with ongoing data.

The two studies help shed understanding on the impact of the virus on cancer patients, says Howard A. Burris III, MD, president of the American Society of Clinical Oncology, who reviewed both presentations.

“With the virus causing pneumonia and lung damage in the infected patients who became ill, it is not surprising that our cancer patients with lung and other thoracic cancers are more vulnerable,” he says. The adverse outcomes with the azithromycin and hydroxychloroquine are being reported by others as well, he says.

He would encourage COVID-19 patients with cancer to seek out clinical trials for COVID-19 treatments, with guidance from their cancer specialists, infectious disease specialists, and lung doctors.


On the Other Side of the Curve: NYC Clinicians Catch Their Breath

For 59 days, Craig Smith, MD, surgeon-in-chief at NewYork-Presbyterian Hospital, had been posting a daily update about working through the COVID-19 crisis in New York. His messages came to an end last week, as his hospital and others in the state had reached the declining side of the coronavirus curve.

“With the terror diluted, people seem happier and the crisis feels less compelling, but fear is still there,” Smith wrote in his final update on May 12. “Fear of future surges, fear of economic struggle, and fear of the unknown, because ‘normal’ is gone.”

Many clinicians in New York are breathing a sigh of relief as the first wave of COVID-19 winds down, with new hospitalizations and deaths down significantly from a mid-April peak. After going on lockdown on March 22, the state has successfully flattened the curve.

Even emergency physician Craig Spencer, MD, MPH, also of NewYork-Presbyterian, was able to take a few days off last weekend: “Today was the first time since early March that I spent every waking moment with my daughter,” Spencer posted on Twitter.

But with Gov. Andrew Cuomo outlining steps for re-opening — albeit regionally, based on extended reductions in hospitalizations and deaths along with other criteria — New York City’s clinicians aren’t sure about exactly what the future holds. Will there be a second wave? When will it come? In the fall, after a summer reprieve? Will it be worse than the first?

Down from the Peak

David Reich, president and chief operating officer of The Mount Sinai Hospital in New York City, said healthcare workers are still stressed, but it’s a different type of stress from early days of the surge and the peak.

“Our stress levels were extraordinarily high when we didn’t know if we’d have enough staff, space, and ventilators as the number of patients was growing exponentially,” Reich told MedPage Today. “As the curve flattened, it was still stressful, but the staff felt they met the peak of this. Then they started to feel much more optimistic as we started to come down the curve.”

But, Reich noted, it’s “been a very slow climb down.”

Reuben Strayer, MD, an emergency physician at Maimonides Medical Center in Brooklyn, described his full trajectory in a post on his website. For clinicians at Maimonides, the warnings came in early March when patients started coming in with fever, chest pain, and trouble breathing.

By mid-March, patients were coming in sicker, and more lung CTs were being done, in an attempt to separate out the COVID-19 patients. By then, the majority — even those not coming in for COVID — had ground glass opacities.

“I saw a middle aged man who was on mile 40 of a 60-mile bicycle ride, came in in full spandex after getting hit by a car, fractured femur,” Strayer wrote. “No chest complaints, fever, nothing. … CT chest: peripheral ground glass opacities. That was when I realized how prevalent COVID was in New York City.”

By the last week of March, the emergency department “became a place familiar only to those who do battlefield medicine,” he wrote. The emergency department had transformed into an open ICU with patients on oxygen or ventilators. “Code blues were called overhead seemingly every 30 minutes.”

By mid-April, Strayer had contracted COVID-19 himself, right around the time the surge was peaking. Now back at work, he said the department is slow, mainly because people are afraid to come to hospitals for fear of catching the virus.

COVID-19 patients are still dying at Maimonides every day, “and we expect this to continue for many months,” Stayer wrote, “but now we can handle the volume.”

Time to Reflect

Suraj Saggar, DO, chief of infectious disease at Holy Name Hospital in Teaneck, New Jersey, which was at the center of one of the state’s early outbreaks, said clinicians who worked for weeks on end are now dealing with PTSD as they have time to reflect on their experiences.

“All doctors are used to non-stop work,” he said, “but this was something we’ve never experienced. The anxiety and fear of bringing it home. But you settled into a pattern and just got used to it. You come home exhausted, you wake up and do it again.”

“Now that you have time to reflect, you realize you missed things,” Saggar said. “Even if I was physically at home, I wasn’t there mentally.”

While clinicians are used to dealing with loss, the volume of it has an even greater impact now, Saggar said.

“You’re always aware when you have losses, but when you see families wiped out, patients in their 40s and 50s with young kids, sometimes children, it hits home,” he said. “Before there was just so much volume you didn’t have time to reflect. You would triage, treat, and move on.”

Cleavon Gilman, MD, an emergency medicine resident at NewYork-Presbyterian, said being outside the hospital seeing people sitting on blankets in parks “plays tricks on your mind” because it’s such a disconnect from being inside, where he would see 20-somethings being intubated.

Gilman worked as a U.S. military corpsman in Iraq in 2004 and said his experience in New York was “worse. I can’t escape this experience,” he told MedPage Today. “Everyone I know can be in danger.”

Return to ‘Normal’

Saggar said Holy Name has taken steps to bring patients back in for non-COVID issues, including an intense cleaning and developing pathways so that the “slow trickle of COVID patients” never interact with those who come to the hospital for other reasons.

Patients will be asked to bring minimal items from outside the hospital, and all meals will be provided, as a way to minimize outside items that may not be sanitized appropriately.

Brian Lima, MD, director of the heart transplant program at North Shore Hospital in Manhasset, New York, had his cardiothoracic ICU converted into a COVID-19 ICU, where he spent the past two months managing ventilators and treating the sickest patients.

Now that his regular CICU has returned, “we’re slowly starting to do more regular heart surgery, and we’re going to resume doing heart transplants.”

Lima, who recently wrote a book about his journey to building Long Island’s only heart transplant program, says he’s “cautiously optimistic” about getting back to a semblance of normal. All patients will be tested for COVID before procedures, but given issues with false negatives, clinicians will continue to wear N95s and other personal protective equipment (PPE).

“It’s going to be that way for the foreseeable future,” Lima told MedPage Today. “As long as we have to cohabitate with COVID, we’re going to practice universal precautions.”

Reich noted that convincing patients to come back to the hospital is critical but difficult. “It’s time to turn our attention to people who have not been getting care for all these weeks now,” he said. “We need to create an environment where people feel safe, so they can come and have their disease treated. Not everything can be done via telemedicine.”

Subsequent Waves?

Many states are re-opening, but are “nowhere near ready to come off of lockdown, from a public health perspective,” Stayer wrote on his website. “But the public won’t tolerate this much longer, so we’re going to open up, and new cases/deaths will start to rise.”

Gilman said he’s not optimistic that future waves will be prevented or easier to deal with.

“Cases are down because people are in quarantine,” Gilman told MedPage Today. “The reality is that this virus is still in the community. We have no treatment, no vaccine.”

He expects a second wave as early as June or July “because people are going outside and to the beaches now. When the temperature spikes again, people are going to go outside and spread the virus.”

Saggar said it’s impossible to predict what will happen next, but is hopeful that, at least in northern New Jersey, which is less densely populated than New York City, testing and contact tracing infrastructure can be an appropriate guard.

“The hope of this has always been that if we do have cases we can quickly do containment,” he said. “We’ve done the social mitigation to move to that containment process.”

He noted, however, that in January and February, his team had constant meetings and planning for the arrival of COVID-19, but “when things happened, they exceeded our wildest expectations.”

“We all anticipate further surges, I think that’s inevitable,” he said, “but hopefully we can limit them.”