Could Sex/Gender Differences in ACE2 Expression in the Lungs Contribute to the Large Gender Disparity in the Morbidity and Mortality of Patients Infected With the SARS-CoV-2 Virus?

COVID-19 morbidity and mortality have significant gender disparities, with higher prevalence and mortality in men. SARS-CoV-2 enters the lungs through the ACE2 enzyme, a member of the renin-angiotensin system (RAS). Although there are no data for the lung, the expressions of RAS components in other tissues are modulated by sex hormones, androgens, and estrogens. However, there are no data on sex-specific differences in ACE2 expression. If there is a sex difference in the expression of ACE2 in the lung, this could theoretically explain the gender disparity in COVID-19 disease. More importantly, although modulation of ACE2 will certainly not provide a cure for the COVID-19 disease, modulation of ACE2 by sex hormone modulators, if they affect the expression of ACE2, could potentially be developed into a supportive therapy for COVID-19 patients.

Does vitamin D deficiency increase the severity of COVID-19?

The severity of coronavirus 2019 infection (COVID-19) is determined by the presence of pneumonia, severe acute respiratory distress syndrome (SARS-CoV-2), myocarditis, microvascular thrombosis and/or cytokine storms, all of which involve underlying inflammation. A principal defence against uncontrolled inflammation, and against viral infection in general, is provided by T regulatory lymphocytes (Tregs). Treg levels have been reported to be low in many COVID-19 patients and can be increased by vitamin D supplementation. Low vitamin D levels have been associated with an increase in inflammatory cytokines and a significantly increased risk of pneumonia and viral upper respiratory tract infections. Vitamin D deficiency is associated with an increase in thrombotic episodes, which are frequently observed in COVID-19. Vitamin D deficiency has been found to occur more frequently in patients with obesity and diabetes. These conditions are reported to carry a higher mortality in COVID-19. If vitamin D does in fact reduce the severity of COVID-19 in regard to pneumonia/ARDS, inflammation, inflammatory cytokines and thrombosis, it is our opinion that supplements would offer a relatively easy option to decrease the impact of the pandemic.

Back to the Future: Principles on Resuming Outpatient Services in the COVID-19 Era

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to outpatient care.

Analysing the variation in volume and nature of trauma presentations during COVID-19 lockdown in Ireland

AIMS

Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland.

METHODS

A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location.

RESULTS

A 21% decrease in radiologically proven trauma was observed on comparison with the same time-period last year. Additionally, a 40% reduction in trauma admissions was observed during the COVID-19 lockdown. A 60% reduction in sports-related injuries and road traffic accident-related injuries was noted during the national lockdown. However, a 17% increase was observed in patients sustaining trauma because of domestic accidents.

CONCLUSION

Variation was observed in both the volume and nature of trauma presentations during the COVID-19 lockdown. As would be expected, a reduction was seen in the number of injuries resulting from outdoor activities. Interestingly, increased rates of domestic injuries were seen during this period which could represent an unintended consequence of the prolonged period of lockdown.Cite this article: Bone Joint Open 2020;1-6:261-266.

Fatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c)

Background: Cardiac damage is frequently referred to in patients with SARS-CoV-2, is usually diagnosed by enzyme elevations, and is generally thought to be due to underlying coronary artery disease. There are references to cardiomyopathies accompanying coronavirus, but there has been no histologic confirmation.Case report: A previously healthy 17 year male old presented in full cardiac arrest to the emergency department after a 2 day history of headache, dizziness, nausea and vomiting. Autopsy demonstrated an enlarged flabby heart with eosinophilic myocarditis. There was no interstitial pneumonia or diffuse alveolar damage. Postmortem nasopharyngeal swabs detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known to cause coronavirus disease 2019 (COVID-19). No other cause for the eosinophilic myocarditis was elucidated.Conclusion: Like other viruses, SARS-CoV-2 may be associated with fulminant myocarditis.

Telemedicine for chronic pain management during COVID-19 pandemic

Treatment of chronic pain is an essential service. Due to lockdown, travel restrictions, social and physical distancing requirements or fear that health care facilities may be infected; patients may avoid visiting health care facilities in person. It is also imperative to decrease the risk of exposure of the health care workers (HCWs) to severe acute respiratory syndrome corona virus 2 (SARS CoV2) and to ease the overtly burdened health care system. But any disruption in pain practice will have alarming consequences for individuals, society, and whole of health care system and providers. In the current scenario of COVID-19 pandemic, telemedicine is emerging as a key technology for efficient communication and sustainable solution to provide essential health care services and should be considered for chronic pain patients (CPPs). Recently, Board of Governors in supersession of Medical Council of India along with National Institution for Transforming India (NITI Aayog) released “Telemedicine Practice Guidelines” enabling registered medical practitioners to provide healthcare using telemedicine. This article describes the challenges in CPPs during COVID-19 pandemic and the use of telemedicine as the rescue management vehicle for CPPs in current scenario.

Providing a paediatric trauma and orthopaedics service during the peak of the COVID-19 pandemic: The Royal National Orthopaedic Hospital experience

INTRODUCTION

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.

METHODS

All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.

RESULTS

Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households.

CONCLUSION

Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process.Cite this article: Bone Joint Open 2020;1-6:287-292.

Investigation of Some Antiviral N-Heterocycles as COVID 19 Drug: Molecular Docking and DFT Calculations

The novel coronavirus, COVID-19, caused by SARS-CoV-2, is a global health pandemic that started in December 2019. The effective drug target among coronaviruses is the main protease M^pro, because of its essential role in processing the polyproteins that are translated from the viral RNA. In this study, the bioactivity of some selected heterocyclic drugs named Favipiravir (1), Amodiaquine (2), 2'-Fluoro-2'-deoxycytidine (3), and Ribavirin (4) was evaluated as inhibitors and nucleotide analogues for COVID-19 using computational modeling strategies. The density functional theory (DFT) calculations were performed to estimate the thermal parameters, dipole moment, polarizability, and molecular electrostatic potential of the present drugs; additionally, Mulliken atomic charges of the drugs as well as the chemical reactivity descriptors were investigated. The nominated drugs were docked on SARS-CoV-2 main protease (PDB: 6LU7) to evaluate the binding affinity of these drugs. Besides, the computations data of DFT the docking simulation studies was predicted that the Amodiaquine (2) has the least binding energy (-7.77 Kcal/mol) and might serve as a good inhibitor to SARS-CoV-2 comparable with the approved medicines, hydroxychloroquine, and remdesivir which have binding affinity -6.06 and -4.96 Kcal/mol, respectively. The high binding affinity of 2 was attributed to the presence of three hydrogen bonds along with different hydrophobic interactions between the drug and the critical amino acids residues of the receptor. Finally, the estimated molecular electrostatic potential results by DFT were used to illustrate the molecular docking findings. The DFT calculations showed that drug 2 has the highest of lying HOMO, electrophilicity index, basicity, and dipole moment. All these parameters could share with different extent to significantly affect the binding affinity of these drugs with the active protein sites.

Pulmonary embolism: A complication of COVID 19 infection

The Coronavirus Disease 2019 (COVID 19) has been reported in almost every country in the world. Although a large proportion of infected individuals develop only mild symptoms or are asymptomatic, the spectrum of the disease among others has been widely variable in severity. Additionally, many infected individuals were found to have coagulation markers abnormalities. This is especially true among those progressing to severe pneumonia and multi-organ failure. While the incidence of venous thromboembolic (VTE) disease has been recently noted to be elevated among critically ill patients, the incidence among ambulatory and non-critically ill patients is not yet clearly defined. Herein, we present six patients who didn't have any hypercoagulable risk factors yet presented with pulmonary embolism in association with COVID 19 infection. Furthermore, we discuss the possible underlying mechanisms of hypercoagulability and highlight the possibility of underdiagnosing pulmonary embolism in the setting of overlapping symptoms, decreased utilization of imaging secondary to associated risks, and increased turnover times. In addition, we emphasize the role of extended thromboprophylaxis in discharged patients.

Enhanced Design of PPE Based on Electrostatic Principle to Eliminate Viruses (SARS-CoV-2)

The ongoing global pandemic due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is in the crucial stage. The vaccine is still at the developing stage. Currently, the only way to check the spreading of this virus is self-isolation. It is reported that a good number of health workers are infected while treating patients suffering from COVID 19. Therefore, an effort is made to develop a system that can enhance safety and check unwanted viruses. Although the complete specification of the SARS-CoV-2 is yet to be evaluated, the present work considers the characteristic of SARS-CoV-1, which closely relates to that of SARS-CoV-2. The proteins are one of the most important structural and functional molecules of the virus; therefore, few properties of a protein are considered. In this work, we propose a sanitization procedure of the personal protective equipment (PPE), such as gloves and masks, before and after the use, by employing high voltage charge generator (30 kV) from a very low DC source of 5 V to eliminate the virus from the surface of PPE. The positive output is connected to a metallic surface coated with carbon nanotubes (CNT) or a metallic surface ablated using lithography to achieve desired nano-grooves of 200 nm. At the tip of these nano-grooves, a very high electric field is generated which readily ionises the air in the vicinity of the tip. The high electric field alters the induced dipole of the protein of the virus, causing permanent damage in terms of electroporation. Further positive salt ions diffuse into the protein of the viruses, causing it inactive and disintegrate.

Preoperative assessment organization in the time of the outbreak COVID-19

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Maintaining the health of clinical workforce during COVID-19 pandemic is a top priority.

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Extraordinary measures could greatly reduce the risk of cross-contamination for both staff and non-infected patients.

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Airway assessment is a critical time for the consultant anesthetist.

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Projecting the airway examination via a mirror can be a useful idea to minimizing viral contamination.

Recommendations for the measurement of the QT interval during the use of drugs for COVID-19 infection treatment. Updatable in accordance with the availability of new evidence

COVID-19 infection has shown rapid growth worldwide, and different therapies have been proposed for treatment, in particular, the combination of immune response modulating drugs such as chloroquine and hydroxychloroquine (antimalarials) alone or in combination with azithromycin. Although the clinical evidence supporting their use is scarce, the off label use of these drugs has spread very quickly in face of the progression of the epidemic and the high mortality rate in susceptible populations. However, these medications can pathologically prolong the QT interval and lead to malignant ventricular arrhythmias such that organized guidance on QT evaluation and management strategies are important to reduce morbidity associated with the potential large-scale use.

Successful intravenous immunoglobulin treatment in severe COVID-19 pneumonia

We describe a 42-year old woman, admitted to our Department after 15 days of persistence of respiratory failure and treated with infusion of intravenous immunoglobulin with a successful outcome.

[Caring for the caregiver: The emotional impact of the coronavirus epidemic on nurses and other health professionals]

La crisis sanitaria provocada por la pandemia del virus COVID-19 ha vuelto a destacar el papel de los profesionales sanitarios como elemento clave para su contención, que sufren una alta tensión marcada por la presión asistencial y la falta de medios de protección. Ante esta tensión, resulta relevante analizar el impacto emocional en los profesionales sanitarios de la pandemia de coronavirus y los recursos de afrontamiento para disminuir o atenuar este impacto. Destacan el estrés, los trastornos del sueño y los síntomas depresivos. Se ofrecen algunas estrategias que han sido utilizados por profesionales que anteriormente han sufrido la presión del COVID-19 y les han sido de utilidad. Por último, se señalan algunas recomendaciones cuya eficacia es conocida para el manejo del impacto emocional.

Early experience with remdesivir in SARS-CoV-2 pneumonia

At present, there is no definitive antiviral treatment for coronavirus disease 2019 (COVID-19). We describe our early experience with remdesivir in four critically ill COVID-19 patients. Patients received a 200 mg loading dose, followed by 100 mg daily intravenously for up to 10 days. All patients had been previously treated with other antivirals before remdesivir initiation. One patient experienced a torsade de pointes requiring cardiac resuscitation and one died due to multiple organ failure. Three patients showed biochemical signs of liver injury. Lymphocyte count increased in all patients soon after remdesivir initiation. Nasal swab SARS-CoV-2 RNA became negative in three of four patients after 3 days of therapy. We observed an in vivo virological effect of remdesivir in four critically ill, COVID-19 patients, coupled with a significant burden of adverse events. Although limited by the low number of subjects studied, our preliminary experience may be relevant for clinicians treating COVID-19.

Creating Backup Management Resources for Spine Care during the Coronavirus Disease 2019 Pandemic

During this unprecedented time of the coronavirus disease 2019 (COVID 19) pandemic, most countries are struggling to optimize their healthcare resources. Although the prevention and treatment of COVID 19 has become the priority for the majority of the population, most medical professionals are facing the challenge of balancing the management of this pandemic and treating patients with other diseases. Healthcare professionals from all specialties are facing this situation and designing guidelines and recommendations that are contributing to the literature that is crucial for disease management at the current time. We share our experience with two ends of the spectra that we currently observe in spine patients. One group of patients included the non-operative cases that presented with back pain. Further, we discuss our experience with operative precautions and digitally assisted discharge.

Commentary on "Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open label non-randomized clinical trial" by Gautret et al

The results of a clinical trial comparing hydroxychloroquine with or without azithromycin to the standard of care for the treatment of COVID-19 were recently published by Philippe Gautret et al. This study provides outstanding results for the combination of hydroxychloroquine and azithromycin over the standard of care, but the evidence was deemed insufficiently robust to warrant a public health decision to widen the use of hydroxychloroquine for the treatment of COVID-19. We provide a scientific critical review of the Gautret et al. publication, put the results in the context of the current knowledge, provide an evaluation of the validity of the results (from a methodologic perspective), and discuss public health implications. The study has a number of limitations, including small sample size, lack of comparability between patients in active treatment and control arms, lack of blinding, use of interim analyses without controlling for the risk of type 1 error, use of analysis in the per-protocol population instead of the intention-to-treat population, and inconsistencies between the study protocol and article. However, none of these observations is of a nature to reverse the conclusions. The study brings useful knowledge consistent with available evidence and clinical practice from China and South Korea, which could have prompted quicker policy decision-making.

Pulmonary embolism in COVID-19: Ventilation and perfusion computed tomography

This is an illustrated case about CT ventilation and perfusion in Covid patient.

[The effects of quarantine for SARS-CoV-2 on sleep: An online survey]

Objectif

Déterminer l’évolution du sommeil chez les Français pendant le confinement motivé par la pandémie du SARS-CoV-2 et définir les facteurs comportementaux associés à un sommeil détérioré.

Méthodologie

Une enquête en ligne via les réseaux sociaux pendant la période de confinement. Les questions ont ciblé les conditions de confinement, les comportements relatifs au sommeil et les éléments de l’environnement potentiellement perturbateurs du sommeil (exposition à la lumière et activités sportives).

Résultats

Au total, 1777 participants ont été inclus dont 77 % femmes, 72 % âgés de 25–54 ans. Les conditions de confinement les plus fréquentes étaient en couple avec enfants (36 %) et en maison avec jardin (51 %). Quarante-sept pour cent rapportent une diminution de la qualité du sommeil en confinement. Les facteurs associés à une détérioration du sommeil retenus par l’analyse multivariée sont une diminution de la durée du sommeil (OR 15,52 — p < 0,001), un coucher plus tardif (OR 1,72 — p < 0,001), un lever plus matinal (2,18 — p = 0,01), des horaires plus irréguliers (OR 2,29 — p < 0,001), une diminution de l’exposition à la lumière du jour (OR 1,46 — p = 0,01) et une augmentation de l’utilisation des écrans le soir (OR 1,33 — p = 0,04).

Conclusion

La mauvaise qualité subjective du sommeil en confinement est associée à une modification des comportements relatifs au sommeil et de l’exposition à la lumière (moins de lumière du jour et plus d’écran le soir). Pour optimiser le sommeil en confinement, des horaires adaptés et réguliers, une exposition de plus d’une heure/jour à la lumière du jour et l’éviction des écrans le soir sont à conseiller.

Inter-hospital communication and transfer practices during COVID-19 Pandemic in Karachi, Pakistan. A brief overview

Objective:

To discuss the referral mechanisms established for safe and expeditious inter-facility transfer of COVID 19 positive patients to ensure their referrals through establishing proper communication channels.

Methods:

Mobile phone and WhatsApp based groups, administrated by The Indus Hospital were established in April 2020. Through detailed reports and frequent communication, factors like bed and ventilator availability across these facilities are shared. Weekly reports through zoom meetings updating the key stake holders, discussion of problems faced and planning for the week ahead are also done.

Result:

The establishment of these groups has been successful in ensuring referral to and from The Indus Hospital to various healthcare facilities across Karachi using appropriate ambulance services.

Conclusion:

The development of referral mechanisms is the need of the day that has been highlighted through the COVID 19 pandemic. It is our hope that these mechanisms are sustained after the pandemic and result in improvement in patient outcome through proper referrals.

Performing the nasopharyngeal and oropharyngeal swab for 2019-novel coronavirus (SARS-CoV-2) safely: How to dress, undress, and technical notes

Background

To show how to safely perform nasopharyngeal and/or oropharyngeal swabs for 2019‐novel coronavirus.

Methods

The video describes in detail the dressing and undressing procedures of health personnel, with the appropriate personal protective equipment. Technical notes for the execution of the nasopharyngeal and oropharyngeal swab are also provided to avoid sampling errors.

Results

The undressing phase is the procedure with the highest risk of self‐contamination for the health worker. Following the various steps as shown in the video, there were no cases of contagion among the otolaryngology team appointed to perform the swabs for SARS‐CoV‐2 testing.

Conclusions

This study demonstrates the technical feasibility of safely performing nasopharyngeal and/or oropharyngeal swabs for identification of SARS‐CoV‐2 viral RNA.

Impact of COVID 19 lockdown on orthopaedic surgeons in India: A survey

BACKGROUND

In the fight against COVID 19, the government of India announced a 3 weeks lockdown of the entire country of 1.3 billion people on 24th March 2020.

METHODS

One week after the lockdown was announced, we conducted an anonymous online survey of the orthopaedic surgeons in India through social media platforms to assess the impact of the lockdown during COVID 19. The survey had a total of 13 questions with (3-5) options and was designed with an aim to understand the perception and the state of mind of the Orthopaedic surgeons in the lockdown situation.

RESULTS

The survey was completed by 611 orthopaedic surgeons from 140 cities in India. There were 22.5% orthopaedic surgeons who said that they were definitely stressed out, and 40.5% who said they were mildly stressed out. As the age decreased, the percentage of orthopaedic surgeons feeling "definitely stressed out" increased. Disruption of life-work balance and uncertainties regarding return to work were other strongly associated factors with the "definitely stressed out" group.

CONCLUSION

The psychological impact of the lockdown during COVID 19 on orthopaedic surgeons may become a potential concern that will require addressal through open discussion.

LEVEL OF EVIDENCE

diagnostic level 4.

COVID-19 Pandemic: Impact of Quarantine on Medical Students' Mental Wellbeing and Learning Behaviors

BACKGROUND AND OBJECTIVES

The novel coronavirus COVID-19 pandemic causes great public health and socioeconomic harms. Worldwide many countries implemented quarantine policies to minimize the spread of this highly contagious disease. The present study aim was to investigate the impact of quarantine on the medical students' mental wellbeing and learning behaviors.

METHODS

In this descriptive study, we used a questionnaire with a Five-Point Likert Scale to collect the information. The questionnaire was distributed among 625 medical students through their emails with a response rate of 530 (84.8%), majority 294 (55.47%) being female. The survey questionnaire consisted of total 20 items; 12 items were related to psychological wellbeing and stress-allied queries and 08 items were about learning behaviors.

RESULTS

The findings encompass two important characteristics related to quarantine, psychological wellbeing, and learning behaviors. A combined cohort of 234 medical students, either female or male, (which was 44.1% of the total responders) showed a sense of being emotionally detached from family, friends and fellow students, 125/ 530 (23.5%) medical students felt disheartened. Both female and male medical students showed a marked decrease in their overall work performance. Moreover, 56.2% of the total students (61.5% of the females and 49.5% of the males) felt a decrease in the time they spent studying.

CONCLUSIONS

Both female and male medical students have identified that quarantine has caused them to feel emotionally detached from family, fellows, and friends and decrease their overall work performance and study period. The findings also show that one fourth of the medical students who participated in this study felt disheartened during the quarantine period. The long-term quarantine due to COVID-19 pandemics may causes further worsening in the psychological and learning behaviors of these medical students.

COVID-US: A simplified approach to cardiopulmonary ultrasound in suspected and confirmed COVID-19 patients in surge crisis

The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has placed an unprecedented challenge on healthcare systems across the globe. Rapid assessment of the cardiorespiratory function to monitor disease progression and guide treatment is essential. Therefore, we have designed the COVID-US: a simplified cardiopulmonary ultrasound approach to use in suspected and confirmed COVID-19 patients, to aid front-line health workers in their decision-making in a surge crisis.

Janus kinase inhibitor baricitinib is not an ideal option for management of COVID-19

The Wuhan outbreak of novel Corona virus infection has been the global focus since December 2019. This infection has become a global pandemic. It is highly important to understand the virology of the pathogen and to explore the therapeutic options for management of this pandemic. Drug repurposing strategies are being considered for management of COVID 19. Among the identified drugs, Baricitinib has become a keen interest for researchers because of its ability to inhibit the viral assembly by the prevention of Clarithrin associated endocytosis. We tried to explore the reasons on why Baricitinib is not an ideal option for COVID 19.

COVID-19 Presenting with Seizures

This case report examines a male with no previous history of seizures initially admitting to the medical service later upgraded to ICU after respiratory failure developing multiple episodes of seizures. Laboratory values on admission, neurological investigations, as well as review of current literature on COVID-19 encephalitis is provided.

Anesthetic Management of Patients with COVID 19 Infections during Emergency Procedures

OBJECTIVES

The aim of the present study was to prevent cross-infection in the operating room during emergency procedures for patients with confirmed or suspected 2019 novel coronavirus (2019-nCoV) by following anesthesia management protocols, and to document clinical- and anesthesia-related characteristics of these patients.

DESIGN

This was a retrospective, multicenter clinical study.

SETTING

This study used a multicenter dataset from 4 hospitals in Wuhan, China.

PARTICIPANTS

Patients and health care providers with confirmed or suspected 2019-nCoV from January 23 to 31, 2020, at the Wuhan Union Hospital, the Wuhan Children's Hospital, The Central Hospital of Wuhan, and the Wuhan Fourth Hospital in Wuhan, China.

INTERVENTIONS

Anesthetic management and infection control guidelines for emergency procedures for patients with suspected 2019-nCoV were drafted and applied in 4 hospitals in Wuhan.

MEASUREMENTS AND MAIN RESULTS

Cross-infection in the operating rooms of the 4 hospitals was effectively reduced by implementing the new measures and procedures. The majority of patients with laboratory-confirmed 2019-nCoV infection or suspected infection were female (23 [62%] of 37), and the mean age was 41.0 years old (standard deviation 19.6; range 4-78). 10 (27%) patients had chronic medical illnesses, including 4 (11%) with diabetes, 8 (22%) with hypertension, and 8 (22%) with digestive system disease. Twenty-five (68%) patients presented with lymphopenia, and 23 (62%) patients exhibited multiple mottling and ground-glass opacity on computed tomography scanning.

CONCLUSIONS

The present study indicates that COVID 19-specific guidelines for emergency procedures for patients with confirmed or suspected 2019-nCoV may effectively prevent cross-infection in the operating room. Most patients with confirmed or suspected COVID 19 presented with fever and dry cough and demonstrated bilateral multiple mottling and ground-glass opacity on chest computed tomography scans.

Technology Enhanced Assessment (TEA) in COVID 19 Pandemic

Online teaching and learning is not a new phenomenon. For the last many years, it has been mainly used as a part of face to face teaching. Assessment is an essential part of teaching and learning, as it establishes the achievement of course learning outcomes by the students. Computer-based assessment is in place for a long time now, however, online assessments have been less practiced. This is because of the issues of validity, reliability and dishonesty. During the COVID 19 pandemic, the educational environment has taken a paradigm shift in many medical schools, both nationally and internationally. This situation demands a method of assessment that is safe, valid, reliable, acceptable, feasible and fair. This paper describes the different formats of online assessment and their application in formative and summative assessments during and after the COVID 19 pandemic.

SARS-CoV-2 and DPP4 inhibition: Is it time to pray for Janus Bifrons?

Diabetes could be a risk factor for severity and mortality in patients with coronavirus disease 2019 COVID-19. It has been hypothesized that DPP4 inhibition, a therapy currently available for type 2 diabetes, might represent a target for decreasing the risk of the acute respiratory complications of the COVID-19 infection but (1) lack of demonstration of SARS-CoV2 binding to DPP4 (2) possible protective role of sDPP4 in Middle East respiratory Syndrome (MERS-CoV) (3) demonstrated inhibition and downregulation of DPP4 by HIV1 and MERS-CoV and (4) not exclusive role of the receptor binding in tropism of the Coronavirus family, support that DPP4 inhibition at present doesn't represent a plausible approach to mitigate COVID-19.

Effectiveness of simulation based teaching of ventilatory management among non-anaesthesiology residents to manage COVID 19 pandemic - A Quasi experimental cross sectional pilot study

BACKGROUND AND AIMS

Simulation is one of the important learning tools when it comes to skill acquisition and as a supplemental tool for training in high stake situations like COVID-19. The aim of this study is to meet the global requirements of knowledge on ventilatory management, prepare and to evaluate the effectiveness of the teaching module for non-anesthesiology trainees on COVID-19 patients.

METHODS

Quasi experimental cross sectional pilot study was conducted with a sample of twenty-six trainees. A teaching module was prepared and validated which consisted of lectures, audio-video sessions, demonstrations with hands-on training, debriefing, analytical-phase and reflection. Pre and Post evaluations from student t-test and direct observation of procedural skills (DOPS) were used for knowledge and skill assessment respectively and feedback obtained from Likert's score.

RESULTS

Pre- and Post-tests had a mean score of 7.42 ± 2.12 and 14.92 ± 2.9 respectively (P value 0.00001). DOPS included 16 point score, in which 23 trainees (88.4%) met the expectations and above expectations as per training objectives. A five-point Likert's score feedback revealed satisfactory and highly satisfactory scores of 100% (ABG), 96.1% (mechanical ventilation), and 84.6% (ventilation in COVID-19 patients). Overall satisfaction for the workshop among respondents was 100 per cent. Confidences of handling scores were 84.5% (interpreting ABG), 65.3% (maneuvering mechanical ventilation), and 96.15% (intubation in COVID-19 patients).

CONCLUSION

A planned teaching module in ventilation management helps to train non-anaesthesiologists more effectively as a part of COVID-19 preparedness. Simulation with debriefing based training to the medical fraternity is the best alternative in the present pandemic and it will also ensure the safety of health care professionals.

A Statement of Solidarity on COVID-19 Pandemic 2020 by the South Asian Family Physicians

The World Organization of Family Doctors (WONCA) is a not-for-profit organization and was founded in 1972 by member organizations in 18 countries. WONCA now has 118 Member Organizations in 131 countries and territories with a membership of about 500,000 family doctors and more than 90 percent of the world's population. WONCA has seven regions, each of which has its own regional Council and run their own regional activities including conferences. WONCA South Asia Region is constituted by the national academies and colleges and academic member organizations of this region namely India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan, and the Maldives. In the background of the ongoing COVID 19 pandemic, the office bearers, academic leaders, practitioners, and researchers of primary care from the South Asia Region have issued a solidarity statement articulating the role of primary care physicians.

Fever, flu and family physicians during COVID 19 pandemic 2020 in India

Fevers - undifferentiated, often unacknowledged, is one of the largest morbidity afflicting in primary care settings and the overall healthcare ecosystem in India. FEVER is probably also the largest public health entity in terms of DALY - (Disability Adjusted Life Years) impacting the working population both in urban as well as rural areas; however, it remains unaddressed by public health programs, which are largely organized through vertical disease-focused national programs. The family physicians see a high volume of undifferentiated fevers throughout the year with seasonal and regional variations in India. Family doctors are not formally linked with the public health programs as India continues to march on selective primary care. Family physicians and medical officers are the most vulnerable for exposure to undifferentiated patient load. The first two health workers who died of COVID 19 in India (Indore) were practicing family physicians. Two mohalla clinic doctors tested positive in Delhi and two other general practitioners have been found to be infected in Mumbai. The media discussions have been on increasing capacity for critical care and the number of ventilators etc., It is also important for the governments to urgently review the functionality of PHCs, CHCs and district hospitals, and create a framework of partnership with standalone family physicians and general practitioners as well as nursing home, small hospitals to play a constructive role in managing the epidemic.

Simple Economical Solution for Personal Protection Equipment (Face Mask/Shield) for Health Care Staff During COVID 19

Coronavirus disease 2019 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2. It has taken a toll of lots of lives since its outbreak. Infection prevention at present is an appropriate control measure in addition to other measure like hand hygiene and personal protective equipment (PPE). In our country with a large population, supplying PPE to all the health care workers of all hospitals definitely is an economic burden. Hence we have come up with an economic and simple solution for face mask.

Conjunctivitis can be the only presenting sign and symptom of COVID-19

Five cases of non-remitting conjunctivitis turned out to be the sole presenting sign and symptom of COVID-19. These patients tested positive on RT-PCR of naso-pharyngeal swabs and developed no fever, malaise, or respiratory symptoms throughout the course of their illness. They all fully recovered. In the current efforts to fight the spread of this virus, authors want to emphasize that atypical clinical presentations of COVID-19 can occur and a high level of suspicion should be maintained. Ocular involvement and transmission of SARS-CoV-2 should never be overlooked. In fact, conjunctival mucosae are susceptible to respiratory viruses and remain an important point of entry. For this reason, eye protection in the form of goggles or a face shield should be considered essential for all healthcare providers, even when taking care of patients who are not showing typical symptoms of COVID-19.

Efficacy of glutathione therapy in relieving dyspnea associated with COVID-19 pneumonia: A report of 2 cases

PURPOSE

Infection with COVID-19 potentially can result in severe outcomes and death from "cytokine storm syndrome", resulting in novel coronavirus pneumonia (NCP) with severe dyspnea, acute respiratory distress syndrome (ARDS), fulminant myocarditis and multiorgan dysfunction with or without disseminated intravascular coagulation. No published treatment to date has been shown to adequately control the inflammation and respiratory symptoms associated with COVID-19, apart from oxygen therapy and assisted ventilation. We evaluated the effects of using high dose oral and/or IV glutathione in the treatment of 2 patients with dyspnea secondary to COVID-19 pneumonia.

METHODS

Two patients living in New York City (NYC) with a history of Lyme and tick-borne co-infections experienced a cough and dyspnea and demonstrated radiological findings consistent with novel coronavirus pneumonia (NCP). A trial of 2 g of PO or IV glutathione was used in both patients and improved their dyspnea within 1 h of use. Repeated use of both 2000 mg of PO and IV glutathione was effective in further relieving respiratory symptoms.

CONCLUSION

Oral and IV glutathione, glutathione precursors (N-acetyl-cysteine) and alpha lipoic acid may represent a novel treatment approach for blocking NF-κB and addressing "cytokine storm syndrome" and respiratory distress in patients with COVID-19 pneumonia.

Airway management and COVID-19 patient -Saudi Anesthesia Society guidelines

The Saudi Anesthesia Society (SAS) in line with the Mission and Vision of the Kingdom of Saudi Arabia to contain the new coronavirus disease (COVID-19) is pleased to develop a statement regarding airway management of suspected/confirmed patients with this virus, to ensure the safe practice in dealing with the patient as well as protecting the medical staff from getting the infection. In this report, we have summarized the guidelines necessary for airway management of suspected/confirmed COVID-19 patient. Since the COVID-19 outbreak is up to date existed, therefore this report is considered as interim guidelines for airway management of the suspected/confirmed patients. The guidelines will be revisited and modified in the future, if necessary.

Digital triage for people with multiple sclerosis in the age of COVID-19 pandemic

We propose a possible approach for the remote monitoring of infection risk in people with multiple sclerosis, especially those on immunosuppressant drugs, during COVID-19 pandemic. We developed a digital triage tool to be sent to patients to quickly identify people with high risk of COVID-19 infection. This tool will also limit unnecessary accesses to the MS centers reducing the risk of spreading the infection.

Pharmacotherapy in COVID-19; A narrative review for emergency providers

INTRODUCTION

The COVID-19 pandemic has been particularly challenging due to a lack of established therapies and treatment guidelines. With the rapid transmission of disease, even the off-label use of available therapies has been impeded by limited availability. Several antivirals, antimalarials, and biologics are being considered for treatment at this time. The purpose of this literature review is to synthesize the available information regarding treatment options for COVID-19 and serve as a resource for health care professionals.

OBJECTIVES

This narrative review was conducted to summarize the effectiveness of current therapy options for COVID-19 and address the controversial use of non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). PubMed and SCOPUS were queried using a combination of the keywords "COVID 19," "SARS-CoV-2," and "treatment." All types of studies were evaluated including systematic reviews, case-studies, and clinical guidelines.

DISCUSSION

There are currently no therapeutic drugs available that are directly active against SARS-CoV-2; however, several antivirals (remdesivir, favipiravir) and antimalarials (chloroquine, hydroxychloroquine) have emerged as potential therapies. Current guidelines recommend combination treatment with hydroxychloroquine/azithromycin or chloroquine, if hydroxychloroquine is unavailable, in patients with moderate disease, although these recommendations are based on limited evidence. Remdesivir and convalescent plasma may be considered in critical patients with respiratory failure; however, access to these therapies may be limited. Interleukin-6 (IL-6) antagonists may be used in patients who develop evidence of cytokine release syndrome (CRS). Corticosteroids should be avoided unless there is evidence of refractory septic shock, acute respiratory distress syndrome (ARDS), or another compelling indication for their use. ACE inhibitors and ARBs should not be discontinued at this time and ibuprofen may be used for fever.

CONCLUSION

There are several ongoing clinical trials that are testing the efficacy of single and combination treatments with the drugs mentioned in this review and new agents are under development. Until the results of these trials become available, we must use the best available evidence for the prevention and treatment of COVID-19. Additionally, we can learn from the experiences of healthcare providers around the world to combat this pandemic.

Estimation of the net reproductive number of COVID-19 in Iran

Background: Estimating the net reproductive number of COVID-19 virus can reveal the rate and severity of the disease transmission in the Iranian society to health researchers and practitioners. Also, it signifies the importance of the disease to the community. Thus, the aim of this study was to determine the net reproductive number of COVID-19 in Iran and its different provinces. Methods: This study was conducted on the data of COVID-19 patients in Iran from February 21 to March 8, 2020. To determine the net reproductive number of COVID-19 in Iran, the serial interval and β value were first determined using linear regression analysis. Then, the net reproductive number values were calculated for Iran and its different provinces. Results: The results of this study showed that the net reproductive number of COVID-19 in Iran was 1.31. Using the available data up to March 15, 2020, the highest net reproductive number was in Mazandaran, Yazd, Isfahan, Qazvin, and Zanjan provinces, with values of 2.07, 1.86, 1.84, and 1.76, respectively. The net reproductive number also showed an increasing trend in Kohgiluyeh and BoyerAhmad province. Conclusion: It seems that although the net reproductive number of the virus had a decreasing trend in the provinces, it is still high. Therefore, sanitary measures in these provinces should be pursued more seriously. On the other hand, social distancing is a topic that should be taken into consideration, that is, social gatherings and contacts should be avoided as much as possible and strategies and facilities for this action should be developed by the government and health policymakers.

Consensus Statement On Immune Modulation in Multiple Sclerosis and Related Disorders During the COVID-19 Pandemic: Expert Group on Behalf of the Indian Academy of Neurology

Knowledge related to SARS-CoV-2 or 2019 novel coronavirus (2019-nCoV) is still emerging and rapidly evolving. We know little about the effects of this novel coronavirus on various body systems and its behaviour among patients with underlying neurological conditions, especially those on immunomodulatory medications. The aim of the present consensus expert opinion document is to appraise the potential concerns when managing our patients with underlying CNS autoimmune demyelinating disorders during the current COVID-19 pandemic.

Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic

The whole world is going through an unprecedented period during the pandemic of COVID-19. This pandemic has affected all aspects of daily life with far-reaching implications, especially in most aspects of healthcare. Practice of surgery across the globe is in a standstill as of now. When we restart surgical practices across world, we have to bring new protocols and practices in place to combat the transmission. This article discusses the major changes in surgical practice, which need to be brought in. This article is based on scientific information about transmission of virus and experiences of some of the authors from China, a country which successfully dealt with and contained the virus outbreak.