Welcome for this first Dragi Weekly post-lockdown! I hope that you and your patients have enough masks to protect yourselves. We have already written about it, but take care of yourself. The French High Health Authority has published "quick answers" on this topic: healthcare professionals distress: prevent, identify, guide (here in French). Happy reading !
1/ COVID-19
To begin with, I will share here the link (in French) of the atoute website from Dr. Dupagne, because it is very comprehensive and interesting.
Let us move on with hydroxychloroquine. In this NEJM paper, 1400 patients with a severe form of COVID received hyxdroxychloroquine or standard care, without randomization, in an American hospital. After inverse probability weighting according to the propensity score, no link was found between using hydroxychloroquine and the risk of death or orotracheal intubation. OK, but this is not randomized.
In an article from the BMJ, the outcome for hospitalized COVID patients with pneumonia receiving oxygen (but without criteria for ICU) was assessed in France. 84 patients received hydroxychloroquine out of 181 total patients, without randomization. At day 21, 76% of patients who received hydroxychloroquine were transferred to ICU (and 11% of deaths) versus 75% in the control group (and 9% of deaths). Once again, no statistical difference.
A retrospective study in the JAMA compared mortality of COVID patients who received azithromycin, hydroxychloroquine, both of them or neither of them. Once again, no difference in mortality between the different patient groups after adjusting on confounding factors.
So here comes a randomized controlled trial of 150 Chinese hospitalized patients with a moderate to mild COVID, receiving hydroxycholorquine + standard of care versus standard of care only. At day 28, no change to a more severe COVID form was found in around 80% of patients from both groups, whatever the treatment plan was, with no difference between the 2 groups. Adverse effects occur in 30% of patients with hydroxychloroquine versus 10% of patients without it. So, not only this medication is inefficient, even for low-severity patients, but it exposes them to adverse effects. This study was randomized so it is time now to try other molecules to fight COVID (and I send you back to this editorial by P. Glasziou about the "waste in COVID-19 research").
The French colleges of paediatricians (link in French here) have proposed an algorithm about the management of kids with a suspicion of COVID-19 and PCR indications (it applies from kindergartens to elementary schools, but it will prove to be some sports to do a swab to a child under 5). Globally, the PCR has to be done in case of symptoms if there is a COVID patient among close relatives or if there is no clear cause in case of no obvious contagion.
The French High Council of Public Health (in French here) has published guidelines for people with a suspicion of COVID as past medical history. If one of these people (patient A) is in contact with a COVID+ person (patient B), there are 2 possibilities:
- if patient A had a PCR positive once, no need for quarantine
- if patient A did not have a confirmed diagnosis by PCR, a serology is advised to establish the status regarding COVID. Quarantine is only advised if the serology does not show a previous infection.
Some data from BMJ about the lab tests for COVID: PCR has a sensibility between 70% and 98% in a study, but only 63% if we just look at the figure for nasopharyngeal swab. A table to compute the post-PCR test probability for a positive or negative result based on the clinical pre-test probability is given. Pre-test probability algorithm are seldom used in France (except for pulmonary embolism).
Pre-test probability
|
PCR negative
Post-test probability |
PCR positive
Post-test probability |
5%
|
1.6%
|
42%
|
15%
|
5%
|
71%
|
25%
|
10%
|
82%
|
50%
|
24%
|
93%
|
75%
|
49%
|
98%
|
90%
|
74%
|
99%
|
In the French study CORONADO including 1300 diabetic patients with COVID, the authors find out that only BMI was a risk factor for intubation or death within 7 days: but not the age, not the level of glycaemic control, not the ACEi/ARB drugs...
2/ Oncology
During lockdown, there has been a huge drop for cancer screening tests (bowel, breast and cervix). It will be important to see the consequences of this drop in the future, especially for mammograms...
3/ Infectious diseases
A multicentric retrospective study looked at the risk of infection from using NSAIDs for anterior sinusitis in children. The authors found out that taking NSAIDs was associated with an increase in intracranial and orbital complications for 30 patients who took NSAIDs versus 90 patients who did not (80% vs 44% of adverse effects). It is only retrospective but this is another argument against NSAIDs in infections.
4/ Rheumatology
A lot of things have already been tested in knee osteoarthritis. This article from Annals of Family medicine studied the efficacy of intra-articular injections of hypertonic dextrose, as part of prolotherapy (an alternative therapy method which aims to make musculo-skeletal structures proliferate). The authors randomized 76 patients to receive dextrose injections or saline solution. After 1 year, patients who had dextrose injections had a lower WOMAC pain score (-10 points on a scale of 50) as well as a lower WOMAC function score (same magnitude of difference). There were also better scores for quality of life (studied by EQ5D) and no adverse event was recorded. Overall, we need to wait for more studies before rushing on this miracle treatment.
5/ The qualitative study by @Petronille
This week's article is a French paper that studies the impact of the first pelvic exam for French women between 18 and 30 years old, recruited from the surgery of a general practitioner. For these women, this exam is viewed as a rite of passage towards the adult age (to be noted: a good mother-daughter relationship could have a positive impact on this experience). The pelvic exam should follow a discussion between the doctor and the patient, should be quick, gentle and painless and be followed by a phase of reinsurance - the moments for discussion being experienced as very important. For the included women, the patient-centered approach was more important than the exam by itself: compliance with the will of the patient, quality of the relationship, inclusion of each patient's individuality. The authors offer a guide to improve the management of this first exam, possibly limited by the premises, but that makes think about this exam (and the others) offered at the surgery. This guide includes the relationship aspect, put forward on the agenda by the patients' study, contrary to the very technical guidelines by the CNGOF (NFrench National College of Gynaecologists and Obstetricians, link here in French).
That's all for this week. Do not forget to subscribe on Facebook, Twitter or to the newsletter by e-mail if it is not already done. You have to put your e-mail address at the top right of the page and confirm the subscription thanks to an e-mail labelled "FeedBurner Email subscriptions", that will be sent to you and may end up in your junk folder.
I wish you very good week, full of rest, full of courage, full of sprinkles and joy in your life! Thanks for reading me each week!
@Dr_Agibus - free translation by @carttom
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