Early Remdesivir to Prevent Progression to Severe Covid-19 in Outpatients.

BACKGROUND: Remdesivir improves clinical outcomes in patients hospitalized with moderate-to-severe coronavirus disease 2019 (Covid-19). Whether the use of remdesivir in symptomatic, nonhospitalized patients with Covid-19 who are at high risk for disease progression prevents hospitalization is uncertain. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving nonhospitalized patients with Covid-19 who had symptom onset within the previous 7 days and who had at least one risk factor for disease progression (age ≥60 years, obesity, or certain coexisting medical conditions). Patients were randomly assigned to receive intravenous remdesivir (200 mg on day 1 and 100 mg on days 2 and 3) or placebo. The primary efficacy end point was a composite of Covid-19-related hospitalization or death from any cause by day 28. The primary safety end point was any adverse event. A secondary end point was a composite of a Covid-19-related medically attended visit or death from any cause by day 28. RESULTS: A total of 562 patients who underwent randomization and received at least one dose of remdesivir or placebo were included in the analyses: 279 patients in the remdesivir group and 283 in the placebo group. The mean age was 50 years, 47.9% of the patients were women, and 41.8% were Hispanic or Latinx. The most common coexisting conditions were diabetes mellitus (61.6%), obesity (55.2%), and hypertension (47.7%). Covid-19-related hospitalization or death from any cause occurred in 2 patients (0.7%) in the remdesivir group and in 15 (5.3%) in the placebo group (hazard ratio, 0.13; 95% confidence interval [CI], 0.03 to 0.59; P = 0.008). A total of 4 of 246 patients (1.6%) in the remdesivir group and 21 of 252 (8.3%) in the placebo group had a Covid-19-related medically attended visit by day 28 (hazard ratio, 0.19; 95% CI, 0.07 to 0.56). No patients had died by day 28. Adverse events occurred in 42.3% of the patients in the remdesivir group and in 46.3% of those in the placebo group. CONCLUSIONS: Among nonhospitalized patients who were at high risk for Covid-19 progression, a 3-day course of remdesivir had an acceptable safety profile and resulted in an 87% lower risk of hospitalization or death than placebo. (Funded by Gilead Sciences; PINETREE ClinicalTrials.gov number, NCT04501952; EudraCT number, 2020-003510-12.).

Challenges in managing ST elevation myocardial infarction during the COVID-19 pandemic.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may contribute to delayed presentations of acute myocardial infarction. Delayed presentation with late reperfusion is often associated with an increased risk of mechanical complications and adverse outcomes. Inherent delays are possible as every patient who is acutely sick is being considered a potential case or a career of COVID-19. Also, standardized personal protective equipment precautions are established for all members of the team, regardless of pending COVID-19 testing which might further add to delays. AIM: To compare performance measures and clinical outcomes of all patients who presented to our facility with ST elevation myocardial infarction (STEMI) during the COVID-19 pandemic to same time cohort from 2019. METHODS: All patients who presented to our facility with STEMI during the pandemic were compared to a matched cohort during the same time period in 2019. STEMI with unknown time of symptom onset and inpatient STEMI patients were excluded. Primary outcome was major adverse cardiac events (MACE) in-hospital and up to 14 d after STEMI, including death, myocardial infarction, cardiac arrest, or stroke. Significant differences among groups for continuous variables were tested through ANOVA, using SYSTAT, version 13. Chi-square tests of association were used to compare patient characteristics among groups using SYSTAT. Relative risk scores and associated tests for significance were calculated for discrete variables using MedCalc (MedCalc Software, Ostend, Belgium). RESULTS: There was a significantly longer time interval from symptom onset to first medical contact (FMC) in the COVID-19 group (P < 0.02). Time to first electrocardiogram, door-to-balloon time, and FMC to balloon time were not significantly affected. The right coronary artery was the most common culprit for STEMI in both the cohorts. Over 60% of patients had one or more obstructive (> 50%) lesion(s) remote from the culprit site. In-hospital and 14 d MACE were more prevalent in the COVID-19 group (P < 0.01 and P < 0.001). CONCLUSION: This single academic center study in the United States suggests that there is a delay in patients with STEMI seeking medical attention during the COVID-19 pandemic which could be translating into worse clinical outcomes.

Patient Perspectives With Telehealth Visits in Cardiology During COVID-19: Online Patient Survey Study.

BACKGROUND: The rise of COVID-19 and the issue of a mandatory stay-at-home order in March 2020 led to the use of a direct-to-consumer model for cardiology telehealth in Kentucky. Kentucky has poor health outcomes and limited broadband connectivity. Given these and other practice-specific constraints, the region serves as a unique context to explore the efficacy of telehealth in cardiology. OBJECTIVE: This study aims to determine the limitations of telehealth accessibility, patient satisfaction with telehealth relative to in-person visits, and the perceived advantages and disadvantages to telehealth. Our intent was two-fold. First, we wanted to conduct a rapid postassessment of the mandated overhaul of the health care delivery system, focusing on a representative specialty field, and how it was affecting patients. Second, we intend to use our findings to make suggestions about the future application of a telehealth model in specialty fields such as cardiology. METHODS: We constructed an online survey in Qualtrics following the Patient Assessment of Communication During Telemedicine, a patient self-report questionnaire that has been previously developed and validated. We invited all patients who had a visit scheduled during the COVID-19 telehealth-only time frame to participate. Questions included factors for declining telehealth, patient satisfaction ratings of telehealth and in-person visits, and perceived advantages and disadvantages associated with telehealth. We also used electronic medical records to collect no-show data for in-person versus telehealth visits to check for nonresponse bias. RESULTS: A total of 224 respondents began our survey (11% of our sample of 2019 patients). Our recruitment rate was 86% (n=193) and our completion rate was 62% (n=120). The no-show rate for telehealth visits (345/2019, 17%) was nearly identical to the typical no-show rate for in-person appointments. Among the 32 respondents who declined a telehealth visit, 20 (63%) cited not being aware of their appointment as a primary factor, and 15 (47%) respondents cited their opinion that a telehealth appointment was not medically necessary as at least somewhat of a factor in their decision. Both in-person and telehealth were viewed favorably, but in-person was rated higher across all domains of patient satisfaction. The only significantly lower mean score for telehealth (3.7 vs 4.2, P=.007) was in the clinical competence domain. Reduced travel time, lower visit wait time, and cost savings were seen as big advantages. Poor internet connectivity was rated as at least somewhat of a factor by 33.0% (35/106) of respondents. CONCLUSIONS: This study takes advantage of the natural experiment provided by the COVID-19 pandemic to assess the efficacy of telehealth in cardiology. Patterns of satisfaction are consistent across modalities and show that telehealth appears to be a viable alternative to in-person appointments. However, we found evidence that scheduling of telehealth visits may be problematic and needs additional attention. Additionally, we include a note of caution that patient satisfaction with telehealth may be artificially inflated during COVID-19 due to external health concerns connected with in-person visits.

Improvised rental housing to make cities COVID safe in India.

•COVID-19 necessitates relook at existing living conditions in the developing countries, with Indian cities as case study•With 3935 persons per hectare, Dharavi is one of the most crowded slums in the world, with 80% households on rent•Living conditions-socio-economics, neighbourhood circumstances and household crowding significantly abet the pandemic•As COVID recovery, Indian government on July 8, initiated affordable rental housing complexes for urban poor and migrants.•We recommend land monetization, real estate trusts, progressive designs, digital lease management, and tax on second house.