COVID-19 INFECTION
sgRNA: A better measure of infectious potential
Infectious potential of clinically unremarkable individuals may persist beyond the 10-day and new 5-day periods announced by the CDC as indicated in a study published in the International Journal of Infectious Diseases.
Davies et al. analyzed subgenomic RNA (sgRNA) and E-gene sequences in a retrospective collection of PCR-confirmed SARS-CoV-2 positive samples from 176 individuals. The RNA was extracted from nasopharyngeal swab samples derived from individuals in the UK between March and November 2020. A majority only provided single samples, but 17 provided serial samples taken as a part of routine clinical care.
The researchers found that some patients returned positive sgRNA results up to 68 days after first testing positive. Thirteen percent of these still exhibited clinically relevant levels of the virus after 10 days but with no clinical features previously associated with prolonged viral clearance time.
"Our data provide evidence that a relatively substantial proportion of COVID-19 patients demonstrate persistence of viral sequences beyond the 10-day mark (which is currently used for infection control measures)," the researchers wrote.
They chose to look specifically at sgRNA for three reasons. First, assessments of longer-term shedding of infectious virus in otherwise clinically unremarkable individuals are lacking because the widely available tests only assess the presence of viral fragments, not replicating viral genomes. Individuals frequently test positive for viral fragments beyond 6 weeks of the onset of symptoms in a fluctuating positive/negative pattern.
Second, a positive result detected by a quantitative real-time PCR for viral genomic sequences does not represent the presence of a replication-competent virus since viral fragments can remain after viral clearance.
Third, though the gold standard for detecting the presence of a replicating virus is viral culture, this test is unsuitable for high throughput partially due to a lack of diagnostic labs with facilities to undertake the necessary cultures. It also carries the risk of infecting the staff.
sgRNA may be a better measure of infectious potential because it is produced by discontinuous transcription of virion structural genes during active replication. sgRNA may be a better proxy than E-gene viral load for replication and better suited for archival clinical assessment.
Regarding patient transmissibility, the authors suggest that potentially active SARS-CoV-2 can sometimes persist beyond 10 days, thus presenting a risk of onward transmission. Additional mitigation strategies might be warranted to reduce the risk of secondary cases in vulnerable settings.
Reference: Davies M, Bramwell LR, Jeffery N, et al. Persistence of clinically relevant levels of SARS-cov2 envelope gene subgenomic RNAS in non-immunocompromised individuals. Int J Infect Dis. 2021. doi:10.1016/j.ijid.2021.12.312.
COVID-19
Hospital death disparities among racial groups
Racial and ethnic disparities in mortality were found to exist between patients hospitalized with and without COVID-19 in a paper published in JAMA Health Forum.
Aiming to assess racial and ethnic disparities in hospital outcomes during the COVID-19 pandemic among Medicare beneficiaries, Zirui Song et al. examined Medicare inpatient data of 31,771,054 unique beneficiaries in a cross-section study before the pandemic (February 2020). 26,225,623 were non-Hispanic White, 2,797,462 were Black, 692,994 were Hispanic, and 2,054,975 belonged to other racial or ethnic minority groups. Of the total population examined in the study, between January of 2019 and February of 2021, 14,021,285 were hospitalized for either COVID-19 or other non-COVID-19 reasons. These patients included 11,353,581 non-Hispanic White, 1,656,856 Black, 321,090 Hispanic, and 689,758 other racial and ethnic minority groups.
A decline in non-COVID-19 hospitalizations in conjunction with the emergence of COVID-19 hospitalizations was qualitatively similar among beneficiaries of all racial and ethnic statuses examined in the study, the authors say. In-hospital COVID-19 mortality was not significantly different among Black patients relative to White patients. For Hispanic patients, in-hospital COVID-19 mortality was 3.5 percentage points higher when compared with their White counterparts.
Similarly, in-hospital COVID-19 mortality was about 3.5 percentage points higher for other racial and ethnic minorities.
Regarding non-COVID-19 hospitalizations, Black patients had an 0.5% increase over White patients, which the authors say represented a 17.5% differential increase relative to prepandemic baselines. This result was robust enough to expand definitions of mortality, the authors say.
Hispanic patients also experienced similar differential increases in expanded definitions of mortality and model specification, the authors write.
The authors also examined discharges to hospice and postacute care among this patient population and found further disparities.
"Our study shows that Medicare patients' racial or ethnic background is correlated with their risk of death after they were admitted to hospitals during the pandemic, whether they came into the hospital for COVID-19 or another reason," said Zirui Song, MD, Harvard Medical School associate professor of healthcare policy and a general internist at Massachusetts General Hospital. "As the pandemic continues to evolve, it's important to understand the different ways COVID is affecting health outcomes in communities of color so providers and the policy community can find ways to improve care for those who are most disadvantaged."
References: Song Z, Zhang X, Patterson LJ, Barnes CL, Haas DA. Racial and ethnic disparities in hospitalization outcomes among Medicare beneficiaries during the COVID-19 pandemic. JAMA Health Forum. 2021;2(12):e214223. doi:10.1001/jamahealthforum.2021.4223.
HarvardMed. Study IDs racial, ethnic disparities in hospital mortality for COVID, non-COVID patients. https://hms.harvard.edu/news/pandemic-inequity.
PAIN MANAGEMENT
Better outcomes reported with CBT and yoga than long-term opioid therapy
Patients with chronic pain receiving long-term opioid therapy reported improvements in self-reported pain and greater reductions in pain impact 1 year after receiving cognitive behavioral therapy (CBT) in their treatment plans, found a randomized controlled trial. Extensive studies for alternative approaches to chronic pain management have been conducted in patients with specific types of chronic pain in specialty settings, as long-term opioid use targeting chronic pain has been associated with significant adverse health effects. This study published in Annals of Internal Medicine is, however, the first to examine alternative treatments for broad chronic pain in patients being treated with an opioid in a primary care setting.
In this study, researchers from Kaiser Permanente Washington Health Research Institute assigned 850 adult patients taking long-term opioid therapy for chronic pain to receive either usual care (n = 417) or a CBT intervention (n = 433) embedded in primary care, which included talk therapy and yoga-based adaptive movement. Assessments for selfreported measures of pain and disability were made quarterly over 12 months. The study found that those receiving the intervention reported greater reductions in pain impact and pain-related disability compared with the group receiving usual care. One in four patients receiving CBT reported a reduction of at least 30% in pain compared with one in six patients from the usual care group. A greater reduction in benzodiazepine use was observed in patients receiving CBT intervention.
However, neither group reported an impact on opioid usage. The effects of the intervention, though modest, persisted after treatment through the 12 months of study. Researchers believe this type of intervention is promising, considering the safety concerns of long-term opioid treatment for chronic pain, its limited efficacy, and the increasing demand for nonpharmacologic treatment.
Reference: DeBar L, Mayhew M, Benes L, et al. A primary care-based cognitive behavioral therapy intervention for longterm opioid users with chronic pain: a randomized pragmatic trial. Ann Intern Med. [e-pub Nov. 2, 2021]
IN APRIL, CELEBRATE
* Alcohol Awareness Monthhttps://pipnj.org/aam2021
* National Autism Awareness Monthhttp://www.autism-society.org
* National Minority Health Monthhttp://www.minorityhealth.hhs.gov/nmhm
* World Immunization Week (April 24-30)http://www.who.int/campaigns/world-immunization-week
DIABETES
Updates to Standards of Care
The American Diabetes Association (ADA) published changes to its Standards of Medical Care in the journal Diabetes Care.
Three major changes to the Standards are:
* Comorbidities should be considered when determining first-line therapy.
* All adults should be screened for prediabetes and type 2 diabetes beginning at age 35.
* Women with risk factors for developing diabetes should be screened within 15 weeks of pregnancy.
Other changes to the Standards include updates or additions to existing recommendations.
For instance, there are new recommendations and guidance regarding retinopathy, adequate carbohydrate intake prior to oral glucose tolerance testing, weight loss or the prevention of weight gain, monitoring and referral for formal assessment in patients with cognitive impairment, postbariatric hypoglycemia, the use of insulin with a glucagon-like peptide 1 receptor agonist for greater efficacy and durability, macular focal/grid photocoagulation and intravitreal injections of corticosteroids, and the use of continuous glucose monitors in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion.
Adults who are overweight or with obesity are now recommended to be referred to an intensive lifestyle behavior change program. More information for the influenza vaccine for people with diabetes and cardiovascular disease was added, along with COVID-19 vaccine information based on evolving evidence. To its recommendation for the use of diabetes technology in outpatient procedures, the ADA added that providers should consider allowing patients continued use of diabetes devices during inpatient or outpatient procedures when they can safely use them with supervision. Semaglutide was added to the ADA's list of FDA-approved medications, while ezetimibe's preferential use due to lower cost was removed.
Reference: American Diabetes Association. Diabetes Care. 2022;45(suppl 1). https://diabetesjournals.org/care/issue/45/Supplement_1.