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CME / ABIM MOC / CE

2019-Coronavirus: What Clinicians Need to Know

  • Authors: CME Authors: Charles P. Vega, MD; Esther Nyarko, PharmD
  • CME / ABIM MOC / CE Released: 1/31/2020
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 1/31/2021
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Target Audience and Goal Statement

This article is intended for all healthcare providers.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Distinguish the most common presenting symptoms of the 2019 Novel Coronavirus
  • Identify current recommendations to prevent the potential spread of the 2019 Novel Coronavirus in the healthcare setting
  • Outline implications for the healthcare team


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


CME Authors

  • Charles P. Vega, MD, FAAFP

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Editor

  • Hazel Dennison, DNP, RN, FNP, CPHQ, CNE

    Associate Director, Accreditation and Compliance , Medscape, LLC

    Disclosures

    Disclosure: Hazel Dennison, DNP, RN, FNP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


Accreditation Statements



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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC / CE

2019-Coronavirus: What Clinicians Need to Know

Authors: CME Authors: Charles P. Vega, MD; Esther Nyarko, PharmDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 1/31/2020

Valid for credit through: 1/31/2021

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Note: This is the third of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.
Last updated March 19, 2020

Clinical Context

Concern continues to grow regarding the rapid spread and clinical effects of the 2019 novel coronavirus first described in Wuhan, China. According to report from the World Health Organization (WHO), there were 7818 confirmed cases of infection towards the end of January 2020. This quickly exceeded 120,000 cases as of March 12, 2020.[1] The COVID-19 outbreak quickly changed from a global emergency of international concern to a global pandemic as declared by WHO on March 11, 2020.

The outbreak of the COVID-19 coincided with China's Lunar New Year, its busiest travel period of the year. Travelers were faced with the daunting decision of whether to forgo national celebrations given the risk for infection and the CDC’s level 3 warning to avoid nonessential travel to China.  At the time, the Chinese government had already shut down all transportation in the city of Wuhan and other cities in Hubei province.

Many more individuals might still develop an infection with the COVID-19 as incubation period of the virus is currently estimated to range from 1-14 days. However, more detailed information from those already infected is needed to determine the infectious period of the virus. One key question is whether the virus can be transmitted during the incubation period or from an asymptomatic person. The WHO and CDC continue to monitor this rapidly advancing situation and have provided interim guidelines to aid healthcare professionals in the diagnosis and management of this infection. The WHO has published updated advice for international travel on their website.[2] https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

Huge knowledge gaps remain on the epidemiological, clinical, laboratory and radiological characteristics of this virus. The goal of this clinical brief is to provide information to healthcare professionals on quick facts they need to know to manage this outbreak.

Study Synopsis and Perspective

In a recently published study by Chaolin Huang, MD, from Jin Yin-tan Hospital, Wuhan, China, and colleagues, published online January 24 in the Lancet, the epidemiological, clinical, laboratory, and radiological characteristics of the COVID-19 2019 was described in patients who were admitted to designated hospitals in Wuhan, China, with laboratory-confirmed diagnosis of COVID-19. [3] Data were obtained from electronic medical records of patients (from December 16, 2019, to January 2, 2020), as well as from direct communication with patients and their families, using data collection forms. Data forms were independently reviewed by 2 researchers. They compared outcomes of patients admitted to the intensive care unit to outcomes of those who were not.

The researchers' findings indicated that of the 41 patients admitted with confirmed infection with COVID-19, 27 (66%) had been exposed to the seafood market in Huanan. One family cluster was identified. Of the 41 patients, 30 (73%) were men and less than half (32%) had some form of comorbid condition (diabetes, 20%; hypertension, 15%; cardiovascular disease, 15%). Common presenting symptoms of the illness were as follows:

• Fever, n=40 (98%)

• Cough, n=31 (76%)

• Lymphopenia, n=26 (63%)

• Dyspnea, n=22 (55%; median time to onset, ~8 days; interquartile range, 5.0-13.0 days)

• Myalgia or fatigue, n=18 (44%)

Other less common symptoms were sputum production (28%), headache (8%), hemoptysis (5%), and diarrhea (3%).

Abnormal findings on chest CT were 100% for all 41 patients. Ensuing complications included respiratory distress syndrome, 29%; anemia, 15%; acute cardiac injury, 12%; and secondary infection, 10%. Thirteen patients were admitted to the intensive care unit, and of these, 6 died. Laboratory findings of patients in the intensive care unit to non-intensive care unit patients showed higher plasma levels of interleukin 2 (IL-2), IL-7, IL-10, GSCF, IP10, MCP1, MIPQA, and TNF-α.

Patients were empirically managed with oral and intravenous antibiotics, oseltamivir (75 mg orally twice daily) and corticosteroid therapy (methylprednisolone 40-120 mg daily), given as a combined regimen with codiagnosis of community-acquired pneumonia.

This study had some limitations, including small sample size, lack of serological detection, and risk factors. Interpretation of study findings is limited as well, but given the lack of other published studies on the COVID-19, it provides researchers a small window to characterize the virus. We can conclude that the COVID-19 infection is similar to severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome Coronavirus (MERS), and is equally associated with intensive care unit admission and significant mortality. Further studies are needed to further define this virus.

The CDC confirms that there are currently no vaccines against the coronavirus; however, Chinese scientists are vigorously working to create one. Treatment is supportive at this time. Risk may be reduced by infection control measures such as frequent hand washing in public areas and avoiding close contact with those with respiratory illnesses.

Based on what is known about other coronaviruses (eg, MERS-CoV and SARS-CoV), the CDC has provided interim guidance for healthcare professionals on the identification of potential infected patients and reporting and testing of specimens:

Clinical Features

 

Epidemiologic Risk

Fever and symptoms of lower respiratory illness (eg, cough, difficulty breathing)

and

In the last 14 days before symptom onset, a history of travel from Wuhan City, China
or
In the last 14 days before symptom onset, close contact with a person who is under investigation for COVID-19 while that person was ill

Fever or symptoms of lower respiratory illness (eg, cough, difficulty breathing)

and

In the last 14 days, close contact with an ill patient with laboratory-confirmed COVID-19

Source: http://www.CDC.gov/coronavirus/2019-nCoV/hcp/clinical-criteria

Immediate notification by healthcare providers to their local state health department, as well as infection control of their healthcare facility, is imperative.

The CDC recommends immediate testing of possible infected patients regardless of time of symptom onset, but discourages performing virus isolation in cell culture or initial characterization of viral agents identified in cultures of specimens from patients with suspected COVID-19 for biosafety reasons. Laboratory testing recommendations include collecting and testing from different sites and obtaining multiple clinical specimens. Additional guidance on collection, handling, and testing of specimen is available at CDC.gov.

The funder of the study had no role in study design, data collection, analysis, or interpretation.

Lancet. Published online January 24, 2020.

Study Highlights

  • A study by Huang and colleagues, published in the January 24, 2020, issue of the Lancet, characterized the clinical presentation of 41 patients admitted to hospital with confirmed infection of the COVID-19.
  • 73% of patients were men, and only 32% had underlying illness. The median age of patients was 49 years.
  • The most common symptoms of infection with the COVID-19 were:
    • Fever (98%)
    • Cough (76%)
    • Myalgia or fatigue (44%)
    • Sputum production (28%)
  • Less than 10% of patients had headache, diarrhea, and hemoptysis.
  • More than half of patients developed dyspnea, at a mean of 8.0 days after the onset of symptoms.
  • 63% of patients were found to have lymphopenia. Abnormal chest computed tomography was noted in all patients.
  • 29% of patients developed acute respiratory distress syndrome, and 32% were admitted to the intensive care unit; 15% of patients in this series died.
  • Routine respiratory precautions are recommended to community members to prevent infection with the novel coronavirus. There is no vaccine available.
  • Treatment of the COVID-19 is purely supportive.
  • According to the CDC, patients with fever and cough or shortness of breath should be considered for investigation for the novel coronavirus if they had traveled from Wuhan City, China, in the past 14 days or had close contact with someone with suspected or confirmed infection with COVID-19 in the past 14 days.
  • Patients with suspected infection with the novel coronavirus should be masked and placed in isolation immediately. Healthcare providers seeing patients under investigation for novel coronavirus should practice contact precautions (including goggles or face shield) and respiratory precautions.
  • Healthcare providers should immediately report cases suspicious for COVID-19 to local public health officials.
  • Specimens from patients under investigation for COVID-19 should be drawn from the lower respiratory tract, the upper respiratory tract, and the serum. Stool and urine samples may be collected and held.
  • Given the risk for infection, it is not recommended to perform virus isolation in cell cultures in suspected cases of COVID-19 infection.
  • The CDC will facilitate testing of these specimens for COVID-19.

Clinical Implications

  • In a recent study published, the most common symptoms of infection with COVID-19 were fever (98%), cough (76%), myalgia or fatigue (44%), and sputum production (28%).
  • Patients with suspected infection with COVID-19 should be masked and placed in isolation immediately. Healthcare providers seeing patients under investigation for the same should practice contact precautions (including goggles or face shield) and respiratory precautions. Healthcare providers should immediately report cases suspicious for COVID-19 to local public health officials.
  • Implications for the Healthcare Team: The healthcare team needs to monitor updates regarding the outbreak and update protocols regarding the evaluation and management of patients with suspected infection. Clinicians are encouraged to use available interim guidelines from the CDC and WHO. Clinicians in contact with patients suspected of COVID-19 should maintain contact and respiratory precautions. Team members should communicate frequently to remain current on updates from the CDC and WHO.

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