Clinical Edge Journal Scan

Clinical Edge Journal Scan Commentary: COVID-19 December 2021

Dr. Bhadelia scans the journals, so you don’t have to!

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Nahid Bhadelia, MD, MALD

COVID-19 outcomes for specific populations as well as utility of therapeutics remain important research questions. A study in Lancet HIV, examined outcomes specifically for HIV positive individuals compared to their seronegative counterparts. Prior studies have been conflicting in their results in terms mortality or morbidity and its association with HIV positivity, at least in patients with well controlled HIV infection. Most of these studies examined only hospitalized patients. Yang et al present data from a large US based surveillance study of 1,436,622 COVID-19 inpatient and outpatient cases, including 13,170 HIV positive patients. The study examined COVID-19 cases from 54 clinical sites across United States, comparing hospitalization, mortality, and clinical severity between HIV positive and negative participants. Investigators found HIV positive patients had higher odds of COVID-associated death and (adjusted OR, 1·78, 95% CI 1·71–1·84) and hospitalization (1·20, 95% CI 1·15–1·26), after adjusting for covariates. Odds for both these outcomes were greater among HIV patients who were older, male and those who identified as black, Hispanic or Latinx. HIV infection markers were also examined with these COVID-19 outcomes, and lower CD4 count was associated with higher odds of severity of disease as well as hospitalization and death, whereas viral suppression was associated only with decreased hospitalization. For me, the findings of this study underscore how COVID-19 outcomes among HIV patients can be determined by multiple layers of medical and social vulnerabilities that are faced by these patients.

A second study answered a question I am often asked about neurological sequalae such as Guillain Barre syndrome among patients with COVID-19 infection, compared to risk of the same from vaccines. Patone et al linked country wide data from English National Immunisation (NIMS) Database of COVID-19 vaccinations with patient level data to examine incidence of neurological adverse events such acute central nervous system (CNS) demyelinating events, encephalitis meningitis and myelitis, Guillain–Barré syndrome, Bell’s palsy, myasthenic disorders, hemorrhagic stroke and subarachnoid hemorrhage in the 28 days following either having a positive SARS-CoV-2 test, or neither ChAdOx1nCoV-19 or BNT162b2 vaccines. The study reported increased incidence risk ratios (IRR) of hospitalization or death related to all of the aforementioned neurological events in patients with SARS-CoV-2 infection, particularly in the time right after diagnosis. There was a small increase in IRR for Guillain-Barre syndrome (IRR, 2.90; 95% confidence interval (CI): 2.15–3.92 at 15–21 days after vaccination) and Bell’s palsy (IRR, 1.29; 95% CI: 1.08–1.56 at 15–21 days) with ChAdOx1nCoV-19. However, this was lower than what was seen after a positive SARS-CoV-2 test (Guillain–Barré syndrome (IRR, 5.25; 95% CI: 3.00–9.18) and Bell’s Palsy, (IRR, 1.34; 95% CI: 0.91–1.97). There was a slightly increased association seen between hemorrhagic stroke and the first dose of BNT162b2, with IRR at 1–7 days (IRR, 1.27; 95% CI: 1.02–1.59) and 15–21 days (IRR, 1.38; 95% CI: 1.12–1.71). However, this risk was dwarfed compared to risk for hemorrhagic stroke seen up to 7 days after a positive SARS-CoV-2 test (IRR, 12.42; 95% CI: 7.73–19.95 at day 0; IRR, 2.01; 95% CI: 1.29–3.15 at 1–7 days). The results highlight immense increase of neurological events after SARS-CoV-2 infection.

Lastly, the RECOVERY trial reported out results of colchicine treatment arm, where 5,610 patients were assigned to standard of care (SOC) with colchicine compared to 5,730 who just received standard of care. The ongoing RECOVERY trial has been an incredibly power tool in helping identify both some effective treatments as well as shedding light on the limited utility of others. No significant differences were seen between the treatment and SOC only arms in all-cause mortality (rate ratio [RR], 1.01; P = .77), the probability of being discharged alive within 28 days (RR, 0.98; P = .44), or the risk of progressing to invasive mechanical ventilation or death (RR, 1.02; P = .47). The large sample size as well as the well-controlled design provides good evidence that colchicine will not make the COVID-19 treatment arsenal.

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