Welcome to a new week. Even as the incidence of coronavirus continues to grow dramatically in different regions of the country, levels across Erie County remain relatively stable. We have seen a slight uptick in hospitalizations which reminds us that we cannot slow down on the important work we are doing, but we are still far below the levels of early Spring. It is a good opportunity to remind everyone of the continued importance of face masks and physical distancing. Outside of Western New York, today marks the 231^st anniversary of the storming of the Bastille during the French Revolution and for those who have not yet prepared, tomorrow is the due date for federal taxes in 2020.

Bottom Line Upfront

• The incidence of COVID-19 remains low in Erie County even as it trends up across the nation
• Hospital census is up slightly but well below the levels in early Spring
• Updates in The Literature:
  • The Medical Letter has published a compendium of therapies for COVID-19
  • The majority of people under 60 do not develop symptoms after COVID-19 infection, but the risk of symptoms increases with age
  • Proton pump inhibitors may be associated with increased risk of infection
  • Men with low testosterone seem to be at great risk of COVID-19 infection
  • Warm weather does not seem to be decreasing the spread of the pandemic

Treatments Considered for COVID-19

• The July 6 edition of The Medical Letter included guidance on choosing appropriate therapy for patients with COVID-19 infection.
• While this is an important reference guide, it is important to remember that that these are not guidelines but rather summations of data without rigorous assessment.
• It is available at:

https://www.kaleidahealth.org/coronavirus/support/literature/Medical-Letter-Treatments-Considered-for-COVID-19-07062020.pdf

Updates In The Literature

Probability of Symptoms and Critical Disease After SARS-CoV-2 Infection

• A group of researchers at the University of Milan have just published an article as part of an attempt to quantify the probability of developing symptoms after being infected with the corona virus.
• They found that while the vast majority of people (73.9%) under the age of 60 did not develop symptoms, but that the risk increased with age. They specifically call out the fact that 6.6% of infected subjects over the age of 60 develop critical disease.
• To review their full study:

https://arxiv.org/ftp/arxiv/papers/2006/2006.08471.pdf

Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review

• The Journal of the American Medical Association published a review which outlines our current understanding of the coronavirus, how it spreads and steps we will need to take moving forward.
• It is a solid overview of what we have learned in the past several months and which questions remain unanswered
• It is available at:

https://jamanetwork.com/journals/jama/fullarticle/2768391?

Persistent Symptoms in Patients After Acute COVID-19

• A research letter was published in the July 9 issue of the Journal of the American Medical Association addressing the persistence of symptoms after acute COVID-19 infection.
• The letter suggests that at least in their study population 87.4% of patients reported persistence of at least one symptom after resolution of the acute infection
• the most common symptoms to persist were shortness of breath and fatigue
• the study is available at:
• https://jamanetwork.com/journals/jama/fullarticle/2768351

Increased Risk of COVID-19 Among Users of Proton Pump Inhibitors

• An article is just been released in the American Journal of Gastroenterology
• In the article, the authors report finding evidence of independent dose dependent relationship between the use of proton pump inhibitors and COVID-19 positivity.
• A link to the full article is available at:

https://journals.lww.com/ajg/Documents/AJG-20-1811_R1(PUBLISH%20AS%20WEBPART).pdf

Susceptible Supply Limits The Role of Climate in the Early SARS-CoV-2 Pandemic

• Early in the COVID-19 pandemic, there had been hope that warm weather would lead to a reduction in infections. Unfortunately, that has not turned out to be true.
• An article published in Science in May 2020 addresses this hypothesis.
• The authors concluded that while climate may play a role in modulating detailed aspects of size and timescales of a pandemic within a particular location,  the rate of immunity in a community is a much more important factor when assessing the spread of the virus.
• A link to the full article is available at:

https://science.sciencemag.org/content/early/2020/05/15/science.abc2535.full

Low testosterone levels predict clinical adverse outcomes in SARS‐CoV‐2 pneumonia patients

• An article in the May 2020 issue of Andrology looks at the connection between testosterone levels and COVID-19
• The authors found that there was a connection between decreased testosterone in men and an increase in morbidity/mortality from COVID-19 infections
• To see the full article:

https://onlinelibrary.wiley.com/doi/full/10.1111/andr.12821

Today’s theme is about our duty to serve as teachers.  We are now in early July. Over the past several weeks, we have re-opened our offices and operating rooms. Our hospitals are busy and now we are once again able to welcome visitors. With all that is going on, it is reasonable to see how any of us might have failed to notice the new faces that have joined our ranks. The end of June and early July is the time when we celebrate graduations, send students off and welcome the next class of learners. In this way, 2020 was no different. In the blink of an eye, the medical students have become interns. Interns are now residents, and the senior residents have returned as attendings. This is a normal process in the healthcare system. It occurs every year with little in the way of fanfare, but 2020 is no ordinary year. We are welcoming our new colleagues into hospitals learning to manage a pandemic.   Anyone who has been through the process of going from student to intern or resident to attending knows the pressure that comes with that new title and how much you must learn as you take on that new level of responsibility. It is a process which naturally takes time, but today it is being met by a year in which there is no time to waste. We all have a duty to help with this. We must remember William Osler’s exhortation that health care providers must “observe, record, tabulate, communicate,” and pay particular attention to that last part. Too frequently, there is a tendency to think that education is solely the responsibility of our colleagues who practice with the university. It is not. It is an obligation which we all share equally. We need to communicate.  We need to teach and to share what we have learned so that others can benefit. Each of us stands on the shoulders of giants. The art of medicine which we practice today was informed by the work of generations before us. Now is the time that we must pay this debt forward. We have always had a duty to study and learn, but today, more than ever, we have an obligation to share our experience. The knowledge in our heads is not yet in the textbooks.  We must work with students, residents and even our colleagues. We must share our successes and failures, and listen while they share theirs, so that, as a community, we can get better and provide everyone the care they need.

If you have questions, please reach out (coronavirusupdates@kaleidahealth.org) and we will do our best to get you the information you need.