The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper

Umbilical cord: an allogenic tissue for potential treatment of COVID-19

The COVID-19 pandemic has placed an unprecedented burden on health care systems and economies around the globe. Clinical evidences demonstrate that SARS-CoV-2 infection produces detrimental levels of pro-inflammatory cytokines and chemokines that can lead to acute respiratory distress syndrome (ARDS) and significant systemic organ damage. Currently, there is no definitive therapy for COVID-19 or associated complications, and with the hope of a safe and effective vaccine in the distant future, the search for an answer is paramount. Mesenchymal stem cells (MSCs) provide a viable option due to their immunomodulatory effects and tissue repair and regeneration abilities. Studies have demonstrated that compassionate use of MSCs can reduce symptoms associated with SARS-CoV-2 infection, eliminate fluid buildup, and act as a regenerative technique for alveolar damage; all in a safe and effective way. With multiple autologous sources available for MSCs, each with their own respective limitations, allogenic umbilical cord (UC) and/or UC-derived Wharton's jelly (WJ) seem to be best positioned source to harvest MSCs to treat COVID-19 and associated symptoms. As an allogenic source, UC is readily available, easily obtainable, and is rich in immunomodulatory and regenerative factors. In this manuscript, we reviewed the current evidences and explored the potential therapeutic use of allogenic UC and/or WJ-derived MSCs for the treatment of COVID-19. Although, preliminary preclinical and clinical studies indicate that their use is safe and potentially effective, more multi-center, randomized, controlled trials are needed to adequately assess the safety and efficacy of UC and/or WJ-derived MSCs for the treatment of COVID-19.

Seroprevalence of SARS-CoV-2 infection among residents and workers of long-term care facilities in Ribeirão Preto, Brazil: an epidemiological survey

OBJECTIVE: Residents and workers in long-term care facilities (LTCF) for older adults share the same space, and residents are more susceptible to COVID-19 complications. The aim of this study was to determine the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies as an indication of previous infection of both residents and workers in LTCFs, as well as associated factors. METHODS: This epidemiological survey was conducted in Ribeirão Preto, Brazil, a medium-sized city. Stratified sampling was performed, with data collected on demographics, health, LTCF protective measures, activities of daily living, and cognition. A serological test was carried out on all selected individuals. RESULTS: The mean resident and worker ages were 80.62 (SD, 9.66) and 37.41 (SD, 12.42) years, respectively. The serological test was positive in 13.33% of the residents, who had 2.91 (SD, 1.28) chronic diseases and used 5.65 (SD, 2.79) medications. Dementia screening was negative in only 11.1%, and only 20% were independent in activities of daily living. The serological test results were positive in 25.93% of the workers, although SARS-CoV-2 had been previously detected in only 6.9%. The LTCF did not perform systematic screening of worker respiratory symptoms. CONCLUSIONS: There was a higher seroprevalence of SARS-CoV-2 among LTCF workers than residents. Systematic screening of worker symptoms before each shift was not regularly performed. The high prevalence of cognitive changes among LTCF residents can impede adherence to personal protection measures.

Answering the Challenge of COVID-19 Pandemic Through Innovation and Ingenuity

The novel coronavirus disease 2019 (COVID-19) pandemic has created a maelstrom of challenges affecting virtually every aspect of global healthcare system. Critical hospital capacity issues, depleted ventilator and personal protective equipment stockpiles, severely strained supply chains, profound economic slowdown, and the tremendous human cost all culminated in what is questionably one of the most profound challenges that humanity faced in decades, if not centuries. Effective global response to the current pandemic will require innovation and ingenuity. This chapter discusses various creative approaches and ideas that arose in response to COVID-19, as well as some of the most impactful future trends that emerged as a result. Among the many topics discussed herein are telemedicine, blockchain technology, artificial intelligence, stereolithography, and distance learning.

Predicting COVID-19 pneumonia severity on chest X-ray with convolutional neural network: A retrospective study

Objectives:

Radiological lung changes in COVID-19 infections present a noteworthy avenue to develop chest X-ray (CXR) -based testing models to support existing rapid detection techniques. The purpose of this study is to evaluate the accuracy of artificial intelligence (AI) -based screening model employing deep convolutional neural network for lung involvement.

Material and Methods:

An AI-based screening model was developed with state-of-the-art neural networks using Indian data sets from COVID-19 positive patients by authors of CAIR, DRDO, in collaboration with the other authors. Our dataset was comprised of 1324 COVID-19, 1108 Normal, and 1344 Pneumonia CXR images. Transfer learning was carried out on Indian dataset using popular deep neural networks, which includes DenseNet, ResNet50, and ResNet18 network architectures to classify CXRs into three categories. The model was retrospectively used to test CXRs from reverse transcriptase-polymerase chain reaction (RT-PCR) proven COVID-19 patients to test positive predictive value and accuracy.

Results:

A total of 460 RT-PCR positive hospitalized patients CXRs in various stages of disease involvement were retrospectively analyzed. There were 248 males (53.92%) and 212 females (46.08%) in the cohort, with a mean age of 50.1 years (range 12–89 years). The commonly observed alterations included lung consolidations, ground-glass opacities, and reticular–nodular opacities. Bilateral involvement was more common compared to unilateral involvement. Of the 460 CXRs analyzed, the model reported 445 CXRs as COVID -19 with an accuracy of 96.73%.

Conclusion:

Our model, based on a two-level classification decision fusion and output information computation, makes it a robust, accurate and reproducible tool. Based on the initial promising results, our application can be used for mass screening.

Infection Control Measures, in situ Simulation, and Failure Modes and Effect Analysis to Fine-Tune Change Management during COVID-19

Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations – from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains.

One of the mnemonics we use at SingHealth in responding to crisis is PACERS:

P: Preparedness (in responding to any crisis, this is critical)

A: Adaptability (needed especially with the ever-changing situation)

C: Communications (the cornerstone in handling any crisis)

E: Education (must continue, irrespective of what)

R: Research (new opportunities to share and learn)

S: Support (both physical and psychological).

This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.

Investigating the Psychological Impact of COVID-19 among Healthcare Workers: A Meta-Analysis

Previous meta-analyses were conducted during the initial phases of the COVID-19 pandemic, which utilized a smaller pool of data. The current meta-analysis aims to provide additional (and updated) evidence related to the psychological impact among healthcare workers. The search strategy was developed by a medical librarian and bibliographical databases, including Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for studies examining the impact of the COVID-19 pandemic on the psychological health of healthcare workers. Articles were screened by three reviewers. Heterogeneity among studies was assessed by I2 statistic. The random-effects model was utilized to obtain the pooled prevalence. A subgroup analysis by region, gender, quality of study, assessment methods, healthcare profession, and exposure was performed. Publication bias was assessed by Funnel plot and Egger linear regression test. Sixty-five studies met the inclusion criteria and the total sample constituted 79,437 participants. The pooled prevalence of anxiety, depression, stress, post-traumatic stress syndrome, insomnia, psychological distress, and burnout was 34.4%, 31.8%, 40.3%, 11.4%, 27.8%, 46.1%, and 37.4% respectively. The subgroup analysis indicated higher anxiety and depression prevalence among females, nurses, and frontline responders than males, doctors, and second-line healthcare workers. This study highlights the need for designing a targeted intervention to improve resilience and foster post-traumatic growth among frontline responders.

Role of lung ultrasonography in the diagnosis of COVID-19 patients admitted to the emergency department

Introduction

In this study, the use of lung ultrasonography (LUS) to diagnosis lung findings was evaluated in patients with suspected COVID-19 who were admitted to the emergency department (ED).

Methods

This observational clinical study was conducted in the ED of the Ankara City Hospital during the period April 1–30, 2020. Patients who were admitted to the ED were triaged as COVID-19 infected and who agreed to undergo LUS/LCT (lung computed tomography) were included in the study.

Results

Included in the study were 40 patients who had been prediagnosed with COVID-19. Pneumonia was detected with LCT in 32 (80%) patients, while the LUS examination identified pneumonia in 23 patients. The most common finding in LCT was ground-glass opacity (n = 29, 90.6%). Of the 23 patients with pneumonia findings in LUS, 15 (65.2%) had direct consolidation. Among the 32 patients who were found to have pneumonia as a result of LCT, 20 (62.5%) had signs of pneumonia on LUS examination, and 12 had no signs of pneumonia. In addition, 3 patients showed no signs of pneumonia with LCT, but they were misdiagnosed with pneumonia by LUS. The sensitivity of LUS in the diagnosis of pneumonia in the COVID-19 patients was 62.5%, while its specificity was 62.5%. In addition, its positive predictive value was 87.0%, and its negative predictive value was 29.4%.

Conclusion

LUS may also be used in the diagnosis of pneumonia in COVID-19 patients because it is a valuable and accessible bedside diagnostic tool.

Electronic supplementary material

The online version of this article (10.1007/s10049-020-00807-3) shows RT-PCR results of patients with a definitive diagnosis of COVID-19 by lung computed tomography and patients with pneumonia detected by lung ultrasonography.

The article and additional material are available at www.springermedizin.de. Please enter the title of the article in the search field. You will find the additional material under “Ergänzende Inhalte” in the article.

COVID-19 and Artificial Intelligence: the pandemic pacifier

COVID-19 remains a threat to the entire world. In an attempt to curb its spread and facilitate its treatment, the technological tool that is Artificial Intelligence (AI) is being researched as a potential alternative to conventional methods. Industrial Revolution 4.0 marks the dawn to the combination of digital, physical and biological systems, by application of digital skills such as Blockchain, Internet of things, Artificial Intelligence and Big data. AI tools in SARS-COV-2 pandemic are highly competitive to human performance, such as rapid screening and diagnosis of the disease, surveilling the efficacy of the treatment, keeping record and depicting active cases and mortality, inventions of medications and vaccines, relieving the workload of healthcare workers and extinguishing the spread of the disease. Contact tracing platforms like Aarogya Setu App, implemented by the Government of India, Australian Government's COVID Safe app, Trace Together- a Bluetooth-based contact tracing app developed in Singapore; based on syndromic mapping/surveillance technology. Artificial intelligence will become a mainstay in both the diagnosis and treatment of COVID-19 as well as similar pandemics in future. The application and system development will be challenging; the accuracy and rapidity of its use far outweigh this drawback. The current global technological leaders have proven that the retro modification of current data systems and applications have been indispensable in the war on COVID-19, thus permanently securing their development and application in future.

Otologic dysfunction in patients with COVID-19: A systematic review

OBJECTIVE

To describe otologic dysfunction in patients with the novel SARS-CoV-2.

REVIEW METHODS

Search strategies acquired for each database included keywords. The keywords use were-Otologic OR Vestibular OR Audiologic and COVID-19 OR Coronavirus OR SARS-CoV-2. Resulting articles were imported into a systematic review software and screened for appropriateness.To be eligible for inclusion in the analysis, the studies and case reports should have met the following criteria:Description of otologic dysfunction in COVID-19 patientspeer review Studies were excluded if:the description of the specific dysfunction was inadequatethere were no original case descriptions Data that met the inclusion criteria was extracted and analyzed.

RESULTS

A total of 62 articles were identified and screened, seven articles met the inclusion criteria and were analyzed. The articles were mainly case reports (5) with 2 case series. There were 28 patients in total identified with the largest study comprising 20 patients. All patients presented with hearing loss, 27 of whom had audiometry. Three patients had associated vestibular symptoms (vertigo, otalgia, and tinnitus).

CONCLUSION

SARS-CoV-2 is a probable cause of middle ear infections and sensorineural hearing loss, secondary to spread of the novel virus into the middle ear and related neural structures.

A Retrospective Study on the Use of Chinese Patent Medicine in 24 Medical Institutions for COVID-19 in China

Objective: This research aims to analyze the application regularity of Chinese patent medicine during the COVID-19 epidemic by collecting the names of the top three Chinese patent medicines used by 24 hospitals in 14 provinces of China in four time periods (January 20-22, February 16-18, March 01-03, April 01-03, 2020), and explore its contribution to combating the disease. Methods: 1) We built a database of the top three Chinese patent medicines used by 24 hospitals. 2) The frequency and efficacy distribution of Chinese patent medicine were analyzed with risk areas, regions, and hospitals of different properties as three factors. 3) Finally, we analyzed the differences in the use of heat-clearing and non-heat-clearing medicines among the three factors (χ² test) and the correlation between the Chinese patent medicine and COVID-19 epidemic (correlation analysis) with SPSS 23.0 statistical software. Results: 1) The heat-clearing medicine was the main use category nationwide during January 20-22, 2020. Meanwhile, there was a significant difference in the utilization rate of heat-clearing and non-heat-clearing medicine in different risk areas (p < 0.01). 2) The variety of Chinese patent medicine was increased nationwide during February 16-18, 2020, mainly including tonics, blood-activating and resolving-stasis, and heat-clearing medicines. Meanwhile, there was a significant difference in the utilization rate of heat-clearing and non-heat-clearing medicine in the southern and northern regions (p < 0.05). 3) Tonics, and blood-activating and resolving-stasis medicines became the primary use categories nationwide during March 01-03, 2020. 4) The tonics class, and blood-activating and resolving-stasis medicine were still the primary categories nationwide during April 01-03, 2020. Meanwhile, there was a significant difference in the utilization rate of heat-clearing and non-heat-clearing medicine in different risk areas (p < 0.01). Conclusion: Chinese patent medicine has a certain degree of participation in fighting against the COVID-19. The efficacy distribution is related to the risk area, region, and hospital of different properties, among which the risk area is the main influencing factor. It is hoped that future research can further collect the application amount of Chinese patent medicine used in hospitals all over the country, so as to perfectly reflect the relationship between Chinese patent medicine and the epidemic situation.

Camelid Inoculation With Middle East Respiratory Syndrome Coronavirus: Experimental Models of Reservoir Host Infection

Within the past two decades, three zoonotic betacoronaviruses have been associated with outbreaks causing severe respiratory disease in humans. Of these, Middle East respiratory s yndrome coronavirus (MERS-CoV) is the only zoonotic coronavirus that is known to consistently result in frequent zoonotic spillover events from the proximate reservoir host—the dromedary camel. A comprehensive understanding of infection in dromedaries is critical to informing public health recommendations and implementing intervention strategies to mitigate spillover events. Experimental models of reservoir disease are absolutely critical in understanding the pathogenesis and transmission, and are key to testing potential dromedary vaccines against MERS-CoV. In this review, we describe experimental infections of dromedary camels as well as additional camelid models used to further understand the camel’s role in MERS-CoV spillover to humans.

Chemocentric Informatics Analysis: Dexamethasone Versus Combination Therapy for COVID-19

COVID-19 is a biphasic infectious disease with no approved vaccine or pharmacotherapy. The first drug that has shown promise in reducing COVID-19 mortality in severely-ill patients is dexamethasone, a cheap, well-known anti-inflammatory glucocorticoid, approved for the treatment of inflammatory conditions including respiratory diseases such as asthma and tuberculosis. However, about 80% of COVID-19 patients requiring oxygenation, and about 67% of patients on ventilators, are not responsive to dexamethasone therapy mainly. Additionally, using higher doses of dexamethasone for prolonged periods of time can lead to severe side effects and some patients may develop corticosteroid resistance leading to treatment failure. In order to increase the therapeutic efficacy of dexamethasone in COVID-19 patients, while minimizing dexamethasone-related complications that could result from using higher doses of the drug, we applied a chemocentric informatics approach to identify combination therapies. Our results indicated that combining dexamethasone with fast long-acting beta-2 adrenergic agonists (LABAs), such as formoterol and salmeterol, can ease respiratory symptoms hastily, until dexamethasone's anti-inflammatory and immunosuppressant effects kick in. Our studies demonstrated that LABAs and dexamethasone (or other glucocorticoids) exert synergistic effects that will augment both anti-inflammatory and fibronectin-mediated anticoagulant effects. We also propose other alternatives to LABAs that are supported by sound systems biology evidence, such as nitric oxide. Other drugs such as sevoflurane and treprostinil interact with the SARS-CoV-2 interactome and deserve further exploration. Moreover, our chemocentric informatics approach provides systems biology evidence that combination therapies for COVID-19 will have higher chances of perturbing the SARS-CoV-2 human interactome, which may negatively impact COVID-19 disease pathways.

Knowledge and practice of COVID-19 prevention among community health workers in rural Cross River State, Nigeria: implications for disease control in Africa

Introduction

in developing countries, community health workers (CHWs) are essential, for provision of behaviour change communication towards prevention of coronavirus 2019 (COVID-19) infection at rural grassroots level. We aimed at assessing their level of knowledge and practice of preventive measures in a developing country setting.

Methods

total enumeration of all CHWs in a rural local government area in southern Nigeria was carried out, using cross-sectional descriptive study design. Pretested self-administered 15-item questionnaire was used to assess knowledge of COVID-19 including basic epidemiology, virology, preventive measures and use of personal protective equipment (PPE). Practice of preventive measures was also assessed. Each correct response to knowledge question contributed one unit to the total score which was converted to percentage. Total knowledge score of 50% or greater was considered satisfactory.

Results

complete data was obtained from eighty-six (86) respondents with mean age of 36.3±8.9 years (18-54 years). Mean total knowledge score was 28.14±12.8% (6.7 to 53.3%), and 9.3% (n=8) had score of at least 50%. Correct responses to appropriate sequence of putting on and removing personal protective equipment (PPE) were 5.8% (n=5) and 8.1% (n=7), respectively. Regular practice of use of face masks, goggles, gloves, and hand hygiene was found to be 50% (n=43), 12.8% (n=11), 30.2% (n=26), and 56.4% (n=48), respectively.

Conclusion

community health workers are grossly underprepared for provision of health education on COVID-19, due to their poor level of knowledge. Their capacity building through workshops and effective continuing education program are urgently needed.

Elias J, S. Campbell K, T. Naik M, J. Atwood W, Youssef E, A. Pachter J, Navaraj A, A. Seyhan A, Liang O, El-Deiry WS. MEK inhibitors reduce cellular expression of ACE2, pERK, pRb while stimulating NK-mediated cytotoxicity and attenuating inflammatory cytokines relevant to SARS-CoV-2 infection

COVID-19 affects vulnerable populations including elderly individuals and patients with cancer. Natural Killer (NK) cells and innate-immune TRAIL suppress transformed and virally-infected cells. ACE2, and TMPRSS2 protease promote SARS-CoV-2 infectivity, while inflammatory cytokines IL-6, or G-CSF worsen COVID-19 severity. We show MEK inhibitors (MEKi) VS-6766, trametinib and selumetinib reduce ACE2 expression in human cells. In some human cells, remdesivir increases ACE2-promoter luciferase-reporter expression, ACE2 mRNA and protein, and ACE2 expression is attenuated by MEKi. In serum-deprived and stimulated cells treated with remdesivir and MEKi we observed correlations between pRB, pERK, and ACE2 expression further supporting role of proliferative state and MAPK pathway in ACE2 regulation. We show elevated cytokines in COVID-19-(+) patient plasma (N = 9) versus control (N = 11). TMPRSS2, inflammatory cytokines G-CSF, M-CSF, IL-1α, IL-6 and MCP-1 are suppressed by MEKi alone or with remdesivir. We observed MEKi stimulation of NK-cell killing of target-cells, without suppressing TRAIL-mediated cytotoxicity. Pseudotyped SARS-CoV-2 virus with a lentiviral core and SARS-CoV-2 D614 or G614 SPIKE (S) protein on its envelope infected human bronchial epithelial cells, small airway epithelial cells, or lung cancer cells and MEKi suppressed infectivity of the pseudovirus. We show a drug class-effect with MEKi to stimulate NK cells, inhibit inflammatory cytokines and block host-factors for SARS-CoV-2 infection leading also to suppression of SARS-CoV-2-S pseudovirus infection of human cells. MEKi may attenuate SARS-CoV-2 infection to allow immune responses and antiviral agents to control disease progression.

CALL Score and RAS Score as Predictive Models for Coronavirus Disease 2019

BACKGROUND

 Coronavirus disease 2019 (COVID-19) is a novel infectious disease of multi-system involvement with significant pulmonary manifestations. So far, many prognostic models have been introduced to guide treatment and resource management. However, data on the impact of measurable respiratory parameters associated with the disease are scarce.

OBJECTIVE

 To demonstrate the role of Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase (CALL) score and to introduce Respiratory Assessment Scoring (RAS) model in predicting disease progression and mortality in COVID-19.

METHODOLOGY

 Data of 252 confirmed COVID-19 patients were collected at Pak Emirates Military Hospital (PEMH) from 10th April 2020 to 31st August 2020. The CALL score and proposed factors of RAS model, namely respiratory rate, oxygen saturation at rest, alveolar arterial gradient and minimal exercise desaturation test, were calculated on the day of admission. Progression of disease was defined and correlated with measured variables. Univariate and multivariate Cox regression analysis for each variable, its hazard ratio (HR) and 95% confidence interval (CI) were calculated, and a nomogram was made using the high-risk respiratory parameters to establish the RAS model.

RESULTS

 Progression of disease and death was observed in 124 (49.2%) and 49 (19.4%) patients, respectively. Presence of more than 50% of chest infiltrates was significantly associated with worsening disease and death (p-value <0.001). Death was observed in 100% of patients who had critical disease category on presentation. Regression analysis showed that the presence of comorbidity (n: 180), in contrast to other variables of CALL score, was not a good prognosticator of disease severity (p-value: 0.565). Nonetheless, the CALL model itself was validated to be a reliable prognostic indicator of disease progression and mortality. Some 10 feet oxygen desaturation test (HR: 0.99, 95%CI: 0.95-1.04, p--value: 0.706) was not a powerful predictor of the progression of disease. However, respiratory rate of more than 30 breaths/minute (b/m) (HR: 3.03, 95%CI: 1.77-5.19), resting oxygen saturation of less than 90% (HR: 2.41, 95%CI: 1.15-5.06), and an elevated alveolar-arterial oxygen gradient (HR: 2.14, 95%CI: 1.04-4.39) were considered statistically significant high-risk predictors of disease progression and death, in the formed RAS model. The model resulted in 85% (95%CI: 80%-89%) of area under the receiver operating characteristic curve (AUROC), with substantial positive (76%, 95%CI: 68%-83%) and negative predictive values (80%, 95%CI: 73%-87%) for a cutoff value of seven. Patients with higher CALL and RAS scores also resulted in higher mortality.

CONCLUSION

 CALL and RAS scores were strongly associated with progression and mortality in patients with COVID-19.

The Social Distance Scale (v1): A Screening Instrument to Assess Patient Adherence to Prevention Strategies during Pandemics

BACKGROUND

This paper describes the development of a brief self-report screening measure of adherence to social distancing and self-protective behaviors in pandemic situations. Items measured behaviors currently established as primary strategies to prevent and reduce the spread of the COVID-19 infection.

METHODS

An item pool of 29 questions was generated with the aim of estimating the frequency of specific behaviors and were written to avoid confounding the description of behavioral actions with evaluative judgements. Responses were collected from 401 young adults using an anonymous online survey.

RESULTS

An Exploratory Factor Analysis was conducted with the purpose of item reduction and subscale development. A 14-item Social Distance Scale emerged, consisting of four subscales: Isolation from Community (IC), Work from Home (WH), Family Contact (FC), and Protective Behaviors (PB). The initial psychometric evaluation of the scales indicated adequate internal consistency and test-retest reliability. (4) Conclusions: The Social Distance Scale (v1) is a promising new instrument which may be applied at the population or individual level. It may be used in conjunction with COVID-19 testing to measure interactions between social distancing factors and transmission. In addition, a reliable screening measure has utility for health service providers to assess patient risk and to provide educational/counseling.

The CHIR Score for Evaluating the Hyperimmune Response in COVID-19: A Preliminary Concept

Similar to SARS and MERS, the host immune response to COVID-19 is implicated in the severity of the disease itself. Here, we investigate the possible use of scoring systems to help guide clinicians in their determination as to when to commence immunosuppressive treatment in COVID-19. We utilized the relatively established clinical and biochemical severity indicators from large cohort studies to develop a potential scoring system for the hyperimmune response in COVID-19.

Effectiveness of an Acute Care for Elders unit at a long-term care facility for frail older patients with COVID-19

The Acute Care for Elders (ACE) is a model of care addressed to reduce the incidence of loss of self-care abilities of older adults occurring during hospitalization for acute illness.

This observational study aimed to describe the effectiveness of an ACE unit at a long-term care facility to prevent functional decline (decrease in the Barthel Index score of >5 points from admission to discharge) in older adults with frailty (Clinical Frailty Scale score ≥5) and symptomatic COVID-19.

Fifty-one patients (mean age: 80.2 + 9.1 years) were included. Twenty-eight (54.9%) were women, with a median Barthel index of 50 (IQR:30–60) and Charlson of 6(IQR: 5–7), and 33 (64.7%) had cognitive impairment.

At discharge, 36(70.6%) patients had no functional decline, 6 (11.7%) were transferred to hospital and 4(7.8%) died.

An ACE unit at a long-term care facility constitutes an alternative to hospital care to prevent hospital-associated disability for frail older patients with COVID-19.

COVID-19 Blind Spots: A Consensus Statement on the Importance of Competent Political Leadership and the Need for Public Health Cognizance

As the COVID-19 pandemic continues, important discoveries and considerations emerge regarding the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pathogen; its biological and epidemiological characteristics; and the corresponding psychological, societal, and public health (PH) impacts. During the past year, the global community underwent a massive transformation, including the implementation of numerous nonpharmacological interventions; critical diversions or modifications across various spheres of our economic and public domains; and a transition from consumption-driven to conservation-based behaviors. Providing essential necessities such as food, water, health care, financial, and other services has become a formidable challenge, with significant threats to the existing supply chains and the shortage or reduction of workforce across many sectors of the global economy. Food and pharmaceutical supply chains constitute uniquely vulnerable and critically important areas that require high levels of safety and compliance. Many regional health-care systems faced at least one wave of overwhelming COVID-19 case surges, and still face the possibility of a new wave of infections on the horizon, potentially in combination with other endemic diseases such as influenza, dengue, tuberculosis, and malaria. In this context, the need for an effective and scientifically informed leadership to sustain and improve global capacity to ensure international health security is starkly apparent. Public health "blind spotting," promulgation of pseudoscience, and academic dishonesty emerged as significant threats to population health and stability during the pandemic. The goal of this consensus statement is to provide a focused summary of such "blind spots" identified during an expert group intense analysis of "missed opportunities" during the initial wave of the pandemic.

COVID-19 symptoms and SARS-CoV-2 infection among people living with HIV in the US: the MACS/WIHS combined cohort study

BACKGROUND

SARS-CoV-2 infection among People Living With HIV (PLWH) is not well-described.

OBJECTIVE

To study COVID-19 symptoms and SARS-CoV-2 PCR-based swab testing among participants of the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS).

METHODS

A telephone survey was collected April-June 30, 2020. Symptom and testing prevalence were explored. Multivariable logistic regression was used to examine the factors associated with SARS-CoV-2 positivity.

RESULTS

The survey was completed by 3411 participants, including 2078 (61%) PLWH and 1333 HIV-seronegative (SN) participants from across the US. Thirteen percent (n = 441) were tested for SARS-CoV-2 infection (13.4% of PLWH vs 12.2% of SN). Among those tested, positivity was higher in PLWH than SN (11.2% vs 6.1%, p = 0.08). Reasons for not being tested included testing not being available (30% of participants) and not knowing where to get tested (16% of participants). Most symptoms reported since January 2020 were similar in PLWH and SN, including headache (23% vs. 24%), myalgias (19% vs 18%), shortness of breath (14% vs 13%), chills (12% vs 10%), fever (6% vs 6%) and loss of taste or smell (6% vs 7%). Among PLWH who tested positive for SARS-CoV-2 DNA, the most common symptoms were headache (71%), myalgia (68%), cough (68%) and chills (65%). In multivariable analysis among those tested, the odds of SARS-CoV-2 positivity were higher among PLWH than SN (aOR = 2.22 95%CI = 01.01-4.85, p = 0.046) and among those living with others versus living alone (aOR = 2.95 95%CI = 1.18-7.40).

CONCLUSION

Prevalence and type of COVID-19 symptoms were similar in PLWH and SN. SARS-CoV-2 infection may be elevated among PLWH.

Colchicine, Aspirin, and Montelukast - A Case of Successful Combined Pharmacotherapy for Adult Multisystem Inflammatory Syndrome in COVID-19

Since the beginning of the COVID-19 pandemic, many therapeutic strategies have been tried, with mixed results, to prevent and treat adult multisystem inflammatory syndrome in COVID-19 (AMIS-COVID-19). The reason behind this may the complex web of highly intertwined pathophysiologic mechanisms involved in the SARS-CoV-2 infection and the corresponding human systemic response, leading to end-organ damage, disability, and death. Colchicine, high-dose aspirin, and montelukast are being investigated currently as potential modulators of AMIS-COVID-19 in patients who fail to improve with traditional therapeutic approaches. Here, we present a patient who presented with high fevers, extreme fatigue and dyspnea, and ongoing deterioration. As part of our clinical approach, we used the simultaneous combination of the three agents listed above, capitalizing on their different respective mechanisms of action against AMIS-COVID-19. Following the initiation of therapy, the patient showed symptomatic improvement within 24 h, with the ability to return to daily activities after 72 h of continued triple-agent approach. Based on this experience, we have reviewed the immunomodulatory basis of this regimen, including potential avenues in which it may prevent the development of cytokine release syndrome (CRS) and its clinical manifestation, AMIS-COVID-19. By blocking the early stages of an inflammatory response, via diverse mechanistic pathways, the regimen in question may prove effective in halting the escalation of CRS and AMIS-COVID-19 in acutely symptomatic, nonimproving COVID-19 patients.

Potential Immunotherapeutic Targets for Hypoxia Due to COVI-Flu

The world is currently embroiled in a pandemic of coronavirus disease 2019 (COVID-19), a respiratory illness caused by the novel betacoronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The severity of COVID-19 disease ranges from asymptomatic to fatal acute respiratory distress syndrome. In few patients, the disease undergoes phenotypic differentiation between 7 and 14 days of acute illness, either resulting in full recovery or symptom escalation. However, the mechanism of such variation is not clear, but the facts suggest that patient's immune status, comorbidities, and the systemic effects of the viral infection (potentially depending on the SARS-CoV-2 strain involved) play a key role. Subsequently, patients with the most severe symptoms tend to have poor outcomes, manifest severe hypoxia, and possess elevated levels of pro-inflammatory cytokines (including IL-1β, IL-6, IFN-γ, and TNF-α) along with elevated levels of the anti-inflammatory cytokine IL-10, marked lymphopenia, and elevated neutrophil-to-lymphocyte ratios. Based on the available evidence, we propose a mechanism wherein SARS-CoV-2 infection induces direct organ damage while also fueling an IL-6-mediated cytokine release syndrome (CRS) and hypoxia, resulting in escalating systemic inflammation, multi-organ damage, and end-organ failure. Elevated IL-6 and hypoxia together predisposes patients to pulmonary hypertension, and the presence of asymptomatic hypoxia in COVID-19 further compounds this problem. Due to the similar downstream mediators, we discuss the potential synergistic effects and systemic ramifications of SARS-CoV-2 and influenza virus during co-infection, a phenomenon we have termed "COVI-Flu." Additionally, the differences between CRS and cytokine storm are highlighted. Finally, novel management approaches, clinical trials, and therapeutic strategies toward both SARS-CoV-2 and COVI-Flu infection are discussed, highlighting host response optimization and systemic inflammation reduction.

Natural Killer cell activation, reduced ACE2, TMPRSS2, cytokines G-CSF, M-CSF and SARS-CoV-2-S pseudovirus infectivity by MEK inhibitor treatment of human cells

COVID-19 affects vulnerable populations including elderly individuals and patients with cancer. Natural Killer (NK) cells and innate-immune TRAIL suppress transformed and virally-infected cells. ACE2, and TMPRSS2 protease promote SARS-CoV-2 infectivity, while inflammatory cytokines IL-6, or G-CSF worsen COVID-19 severity. We show MEK inhibitors (MEKi) VS-6766, trametinib and selumetinib reduce ACE2 expression in human cells. In some human cells, remdesivir increases ACE2-promoter luciferase-reporter expression, ACE2 mRNA and protein, and ACE2 expression is attenuated by MEKi. In serum-deprived and stimulated cells treated with remdesivir and MEKi we observed correlations between pRB, pERK, and ACE2 expression further supporting role of proliferative state and MAPK pathway in ACE2 regulation. We show elevated cytokines in COVID-19-(+) patient plasma (N=9) versus control (N=11). TMPRSS2, inflammatory cytokines G-CSF, M-CSF, IL-1α, IL-6 and MCP-1 are suppressed by MEKi alone or with remdesivir. We observed MEKi stimulation of NK-cell killing of target-cells, without suppressing TRAIL-mediated cytotoxicity. Pseudotyped SARS-CoV-2 virus with a lentiviral core and SARS-CoV-2 D614 or G614 SPIKE (S) protein on its envelope infected human bronchial epithelial cells, small airway epithelial cells, or lung cancer cells and MEKi suppressed infectivity of the pseudovirus. We show a drug class-effect with MEKi to stimulate NK cells, inhibit inflammatory cytokines and block host-factors for SARS-CoV-2 infection leading also to suppression of SARS-CoV-2-S pseudovirus infection of human cells. MEKi may attenuate SARS-CoV-2 infection to allow immune responses and antiviral agents to control disease progression.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study

BACKGROUND

Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges.

METHODS

After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission.

RESULTS

The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%).

CONCLUSION

Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

Current Approaches to COVID-19: Therapy and Prevention

The coronavirus disease-2019 (COVID-19) pandemic has affected millions of people worldwide. As our understanding of the disease is evolving, our approach to the patient management is also changing swiftly. Available new evidence is helping us take radical decisions in COVID-19 management. We searched for inclusion of the published literature on treatment of COVID-19 from around the globe. All relevant evidences available till the time of submission of this article were briefly discussed. Once advised as blanket therapy for all patients, recent reports of hydroxychloroquine with or without azithromycin indicated no potential benefit and use of such combination may increase the risk of arrhythmias. Clinical evidence with newer antivirals such as remdesivir and favipiravir is promising that can hasten the patient recovery and reduce the mortality. With steroids, evidence is much clear in that it should be used in low dose and for short period not extending beyond 7 days in moderate to severe hospitalized patients. Low-molecular-weight heparin should be initiated in all hospitalized COVID-19 patients and dose should be based on the coagulation profile and risk of thromboembolism. Immunomodulatory drugs such tocilizumab may be considered for severe and critically ill patients to improve the outcomes. Though ulinastatin can be a potential alternative immunomodulator, there is lack of clinical evidence on its usage in COVID-19. Convalescent plasma therapy can be potentially lifesaving in critically ill patients. However, there is need to generate further evidence with various such therapies. Though availability of a potent vaccine is awaited, current treatment of COVID-19 is based on available therapies, which is guided by the evidence. In this review, we discuss the potential treatments available around the globe with current evidence on each of such treatments. How to cite this article: Dixit SB, Zirpe KG, Kulkarni AP, Chaudhry D, Govil D, Mehta Y, et al. Current Approaches to COVID-19: Therapy and Prevention. Indian J Crit Care Med 2020;24(9):838-846.

COVID-19: Brief check through the pathologist's eye (autopsy archive)

During the COVID-19 pandemic, many deaths occurred especially among the old patients with cardiovascular comorbidities. Many questions have been asked and few simple answers have been given. The autopsy data are few and the aspects often observed are pulmonary diffuse alveolar damage (DAD), myocarditis, acute myocardial infarction (AMI), and disseminated intravascular coagulation (DIC); these aspects are not only in COVID-19 but also in other viral infections and in sepsis. It should be considered that coronavirus with its pathological organ changes have already been described in the years preceding the pandemic.

Short Term Home Oxygen Therapy for COVID-19 patients: The COVID-HOT algorithm

Innovative solutions are required to effectively address the unprecedented surge of demand on our healthcare systems created by the COVID-19 pandemic. Home treatment and monitoring of patients who are asymptomatic or mildly symptomatic can be readily implemented to ameliorate the health system burden while maintaining safety and effectiveness of care. Such endeavor requires careful triage and coordination, telemedicine and technology support, workforce and education, as well as robust infrastructure. In the understandable paucity of evidence-based, protocolized approaches toward HOT for COVID-19 patients, our group has created the current document based on the cumulative experience of members of the Joint ACAIM-WACEM COVID-19 Clinical Management Taskforce. Utilizing available evidence-based resources and extensive front-line experience, the authors have suggested a pragmatic pathway for providing safe and effective home oxygen therapy in the community setting.

Serum Neopterin Levels and the Clinical Presentation of COVID-19

In Coronavirus disease 2019 (COVID-19), it is important to evaluate disease activity and investigate possible biomarkers. Therefore, in this study, we investigated the relationship between disease activity and serum levels of possible immune activation marker neopterin in patients with COVID-19. The study enrolled 45 patients (23 females, 51.1%) treated for COVID-19. The patients were divided into two groups according to their clinical presentation: those who recovered quickly (Group 1) and those who worsened progressively (Group 2). The neopterin and C-reactive protein levels were high in all patients on admission. In Group 1, neopterin concentrations and serum neopterin/creatinine ratios were significantly higher on admission compared to Day 14 of the disease, whereas in Group 2, levels were significantly higher at Day 14 of the disease than on admission. Neopterin levels at admission were significantly higher in Group 1. The serum neopterin concentrations at admission were markedly higher in patients with a derived neutrophil–lymphocyte ratio (dNLR) > 2.8 compared to those with a dNLR ≤ 2.8 (p < 0.05). Serum neopterin levels can be used as a prognostic biomarker in predicting disease activity in COVID-19.