Thursday, August 6, 2020

176 CMAAO CORONA FACTS and MYTH COVID Informed Consent

176 CMAAO CORONA FACTS and MYTH COVID Pool test

 

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

 

1042:  Pooled COVID-19 Testing Feasible

Combining specimens from several low-risk inpatients in a single test for SARS-CoV-2 infection can allow hospital staff to stretch testing supplies and provide test results quickly for many more patients than they might have otherwise.

 

This strategy conserves personal protective equipment (PPE)], led to a marked reduction in staff and patient anxiety, and improved patient care.

 

The researchers published their findings July 20 in Journal of Hospital Medicine.

 

Pooled testing combines samples from multiple people within a single test. The benefit is if the test is negative, [you know that] everyone whose sample was combined…is negative. So you've effectively tested anywhere from three to five people with the resources required for only one test.

 

The challenge is that if the test is positive, everyone in that testing group must be retested individually because one or more of them has the infection.

 

For the current study, all patients admitted to the hospital, including those admitted for observation, underwent testing for SARS CoV-2. Staff in the emergency department designated patients as low risk if they had no symptoms or other clinical evidence of COVID-19; those patients underwent pooled testing.

 

Patients with clinical evidence of COVID-19, such as respiratory symptoms or laboratory or radiographic findings consistent with infection, were considered high risk and were tested on an individual basis and thus excluded from the current analysis.

 

Between April 17 and May 11, clinicians tested 530 patients via pooled testing using 179 cartridges (172 with swabs from three patients and seven with swabs from two patients). There were four positive pooled tests, which necessitated the use of an additional 11 cartridges. Overall, the testing used 190 cartridges, which is 340 fewer than would have been used if all patients had been tested individually. 

 

Among the low-risk patients, the positive rate was 0.8% (4/530). No patients from pools that were negative tested positive later during their hospitalization or developed evidence of the infection.

 

Pooling tests seems to work best for three to five patients at a time.

 

Larger batches increase the chance of having a positive test.

 

Pooled testing is mainly dependent on the COVID-19 positive rate in the population of interest in addition to the sensitivity of the [reverse transcriptase-polymerase chain reaction (RT-PCR)] method used for COVID-19 testing.

 

Pooled testing could increase testing capability by 69% or more when the incidence rate of SARS-CoV-2 infection is 10% or lower.

 

Asymptomatic population or surveillance groups such as students, athletes, and military service members are [an] interesting population to test using pooling testing because we expect these populations to have low positive rates, which makes pooled testing ideal.

 

[T]here is risk of missing specimens with low concentration of the virus.

 

These specimens might be missed due to the dilution factor of pooling (false negative specimens). We did not have a single false-negative specimen in our proof-of-concept study.

 

 

Monday, August 3, 2020

173 CMAAO CORONA FACTS and MYTH COVID

173 CMAAO CORONA FACTS and MYTH COVID 

Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev

1035: Studying primary human lung cells that were infected in the lab with SARS-CoV-2 showed how the cells began to accumulate large amounts of lipid droplets. After infection, the lung proteins downregulate the ability of lung cells to burn carbohydrates and fatty acids. Lung cells are not designed to hold fat, which could explain some of the severe damage to the lungs of patients with COVID-19. The virus is dependent on glucose uptake, cholesterol production, and fatty acid oxidation. More research is needed on the cholesterol drug fenofibrate before clinical trials can begin.

1036: The antihistamine cloperastine, which is mostly sold in Japan, blocks glucose uptake in lung cells and has shown a small effect in fighting COVID-19.


1037: Moderna: a robust immune response and protected against infection in a study on monkeys. The vaccine, MRNA-1273, given to non-human primates protected against infection in the lungs and nose, and prevented pulmonary disease in all animals. Results of the study in rhesus macaque monkeys were published in the New England Journal of Medicine.

It appeared to be an improvement over results of AstraZeneca's COVID-19 vaccine in a similar study. In the study Iinvolving 24 monkeys, Moderna tested doses of 10 micrograms or 100 micrograms of the vaccine against no treatment.

Both doses proved effective at protecting against viral replication in the lungs and lung inflammation, with the larger dose also protecting against viral replication in the nose of the animals.

1038: AstraZeneca and Oxford University - among the most advanced in human trials - in a similar animal study also appeared to prevent damage to the lungs and keep the virus from making copies of itself there. But the virus still actively replicated in the nose in that study.

1039: A cohort of 145 patients younger than age 1 month to 65 years separated by age found that the youngest children had significantly lower median cycle threshold (CT) values than older children or adults, suggesting they had equivalent or more viral nucleic acid in their upper respiratory tract than other age groups, reported Taylor Heald-Sargent, MD, PhD, of Ann & Robert H. Lurie Children's Hospital in Chicago, and colleagues. These differences approximated a 10- to 100-fold greater amount of SARS-CoV-2 in the nasopharynx of young children, the authors wrote in a research letter in JAMA Pediatrics. Importantly, the researchers noted that their findings were limited to detection of viral nucleic acid and not infectious virus.





Sunday, August 2, 2020

171 CMAAO CORONA FACTS and MYTH COVID Train Travel

171 CMAAO CORONA FACTS and MYTH COVID Train Travel

 

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

 

1033: The risk of COVID-19 transmission in train passengers: an epidemiological and modelling study; Maogui Hu, Hui Lin, Jinfeng Wang, Chengdong Xu, et all; Clinical Infectious Diseases, 29 July 2020

 

Train is a common mode of public transport across the globe; however, the risk of COVID-19 transmission among individual train passengers remains unclear.

 

Methods: The study quantified the transmission risk of COVID-19 on high-speed train passengers using data from 2,334 index patients and 72,093 close contacts who had co-travel times of 0–8 hours from 19 December 2019 through 6 March 2020 in China. We analysed the spatial and temporal distribution of COVID-19 transmission among train passengers to elucidate the associations between infection, spatial distance, and co-travel time.

 

Results: The attack rate in train passengers on seats within a distance of 3 rows and 5 columns of the index patient varied from 0 to 10.3%, with a mean of 0.32%. Passengers in seats on the same row as the index patient had an average attack rate of 1.5%, higher than that in other rows, with a relative risk (RR) of 11.2. Travellers adjacent to the index patient had the highest attack rate of COVID-19 infections (RR 18.0,) among all seats. The attack rate decreased with increasing distance, but it increased with increasing co-travel time. The attack rate increased on average by 0.15% (p = 0.005) per hour of co-travel; for passengers at adjacent seats, this increase was 1.3% (p = 0.008), the highest among all seats considered.

 

Conclusions: COVID-19 has a high transmission risk among train passengers, but this risk shows significant differences with co-travel time and seat location. During disease outbreaks, when travelling on public transportation in confined spaces such as trains, measures should be taken to reduce the risk of transmission, including increasing seat distance, reducing passenger density, and use of personal hygiene protection.

 

 

 


172 CMAAO CORONA FACTS and MYTH COVID Informed Consent

172 CMAAO CORONA FACTS and MYTH COVID Informed Consent

 

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

 

1034: Round Table Expert Zoom Meeting on “Consent in Covid era - Need for Change”

 

1st August, 2020

11am-12pm

 

Participants

 

Dr KK Aggarwal

Dr AK Agarwal

Prof Mahesh Verma

Dr Ashok Gupta

Dr Shashank Joshi

Dr JA Jayalal

Dr Jayakrishnan Alapet

Dr Anil Kumar

Mrs Upasana Arora

Dr KK Kalra

Ms Ira Gupta

Dr Sanchita Sharma

 

Key points from the discussion

 

  • Covid-19 has changed the scenario today. There is an inherent risk due to the changing nature of the virus.
  • The requirements of presurgical patients are different; patients require more ICU stay.
  • Institutes and hospitals have to come out with new consent formats.
  • Introducing the subject, Dr Kalra shared modified formats of consent from American Society of Plastic Surgeons and one published in the Indian Journal of Surgery.
  • Time has come to revisit consent. Consent should now be “fully” informed consent and not just informed consent. Include informed refusal.
  • Blanket immunity may not work.
  • There is now a need to shift from written informed consent to video; record consent in audio-visual format.
  • There should be transparency in information provided to the patient. Include all points as can be imagined so there will be no counterpoints. Make it “foolproof”.
  • The regular consent form in a preprinted format is outdated. In a recent order in July, the National Consumer Disputes Redressal Commission (NCDRC) has held that the use of preprinted consents forms is not valid. 
  • Consent should be in the patient’s language, which he/she can understand. Consent will change in every counseling session.
  • MCI Code of ethics regulations specify that consent should be given by the patient or the spouse. In the Covid era, both husband and wife may be infected and may be hospitalized. So, now the “next of kin” should be identified for consent. Also, identify someone who will pay (guarantor).
  • For a patient under isolation, the routinely taken consent may not be valid; it can be challenged on the grounds that the patient was under mental stress etc.
  • Shift from consent to agreement; now a detailed consent will be required and every step should be recorded.
  • The landmark Samira Kohli judgement took into consideration the Bolam’s rule under which complications that occur <1% need not be informed to the patient/family. But now the definition of consent will change from this.
  • Include the words “as on today” in the consent when giving information to the patient; as new information about Covid is emerging almost every day.
  • We need to define guidelines; they are not mandatory; treatment may change from the guidelines based on the professional competence of the treating doctor. This needs to be included in the consent. Guidelines inflict on professional autonomy.
  • Define “off-label”; every treatment in Covid is off-label use.
  • Declare death when brain death occurs; do not wait for the heart to stop – follow organ transplantation guidelines for this. Extended CPR not allowed. Define the hours or how long will the body be kept in the hospital. Include such information in the consent.
  • Include a clause for DNR.
  • Put in a clause for compensation; write down your in-house redressal mechanism in case of a dispute.
  • Include clause of good faith.
  • Clearly define isolation rooms in the consent; in the western literature, isolation rooms mean negative pressure rooms.
  • Define presymptomatic cases in consent as sometimes patient brought in negative for Covid-19, but may become positive during hospitalization. This may become a dispute.
  • Be transparent about charges (ethical); whether insurance will cover or not.

 

 

 

 

 

 


Friday, July 31, 2020

170 CMAAO CORONA FACTS and MYTH COVID Loss of smell

170 CMAAO CORONA FACTS and MYTH COVID Loss of smell

 

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

 

1031: Trained Dogs Can Identify COVID-19 Infections?

After some training, dogs may be able to sniff out and identify people who are infected with the coronavirus, according to a study published in the journal BMC Infectious Diseases.

 

Eight dogs, which are part of the German Armed Forces, were trained for a week to detect the virus in samples of saliva. Then they were given more than 1,000 infected and non-infected samples and were able to detect 94% of cases. They correctly identified 157 positive samples and 792 negative samples but missed 30 positive samples and gave false positives for 33 samples.

 

The study was a small pilot project tested by the German Armed Forces, the University of Veterinary Medicine in Hannover and the Hanover Medical School.

 

Dogs are able to detect a specific smell of the metabolic changes that occur in those patients.

 

Trained dogs could be sent to airports, borders and sporting events to detect infections.

 

Within the medical field, dogs have been trained to detect cancer, malaria, and other bacterial and viral infections. [Medscape]

 

1034: Study details cardiovascular effects of COVID-19

As per a study published in JAMA Cardiology, cardiac inflammatory involvement is frequent among patients who have recently recovered from COVID-19 infection, regardless of pre-existing conditions. In a cohort of 100 German patients recently recovered from infection, cardiovascular magnetic resonance (CMR) revealed cardiac involvement in 78% and ongoing myocardial inflammation in 60%.

Cardiac involvement occurred irrespective of infection severity, overall course of COVID-19 presentation, the time from the original diagnosis, or the presence of cardiac symptoms.

The prospective observational study included patients who recovered from COVID-19 between April and June 2020. All patients included were at least 2 weeks out from being diagnosed with COVID-19, had resolution of respiratory symptoms, and had negative results on a swab test at the end of the isolation period.

Of the patients, 53 were male, with a median age of 49 years. The median time interval between COVID-19 diagnosis and CMR was 71 days. Of the patients, 67 recovered at home, while 33 required hospitalisation. Pre-existing conditions included hypertension, diabetes, and known coronary artery disease, but no previously known heart failure or cardiomyopathy was reported. Pre-existing conditions were similar between patients who recovered at home and patients who were hospitalised.

At the time of CMR, high-sensitivity troponin T (hsTnT) was detectable (≥3 pg/mL) in 71 patients and significantly elevated (≥13.9 pg/mL) in 5 patients. In addition, patients recently recovered from COVID-19 had lower left ventricular ejection fraction, higher left ventricle volumes, higher left ventricle mass, and raised native T1 and T2 compared with both control groups.

The most prevalent abnormality on CMR was myocardial inflammation, defined as abnormal native T1 and T2 measures, which was detected in 73 and 60 patients, respectively, followed by regional scar and pericardial enhancement, which was detected in 32 and 22 patients, respectively. Findings on classic parameters, such as volumes and ejection fractions, were mildly abnormal. 

There was a small but significant difference in native T1 mapping between patients who recovered at home versus patients who were hospitalised (median, 1122 ms vs 1143 ms; P = .02), but not for native T2 ,hsTnT, or N-terminal pro-b-type natriuretic peptide levels. Nonetheless, none of these measures were correlated with time from COVID-19 diagnosis.

Levels of hsTnT were significantly correlated with native T1 mapping (P < .001) and native T2 mapping (P = .03). There was also a cross-correlation between native T1 and T2 (P < .001). Additionally, the authors noted a significant correlation of hsTnT with native T1 (P < .001) and left ventricle mass (P < .001). The associations of hsTnT with mapping measures remained significant despite controlling for the presence of comorbidities (overall or separately) or treatment received for COVID-19 infection.

Unlike these previous studies, the findings reveal that significant cardiac involvement occurs independently of the severity of original presentation and persists beyond the period of acute presentation, with no significant trend toward reduction of imaging or serological findings during the recovery period. [DG alert]

 

 

 

 

 

 

 

 

 

 

Wednesday, July 29, 2020

168 CMAAO CORONA FACTS and MYTH COVID Paradigm shifts in COVID 19

168 CMAAO CORONA FACTS and MYTH COVID  Paradigm shifts in COVID 19

Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev

1029:  Update on Covid-19

IMA-CMAAO Webinar on “Paradigm shifts in COVID-19”

25th July, 2020
4-5pm

Participants

Dr RV Asokan, Hony Secretary General IMA
Dr Ramesh K Datta, Hony Finance Secretary IMA
Dr Jayakrishnan Alapet
Dr Brijendra Prakash
Dr Sanchita Sharma

Faculty

Dr KK Aggarwal
Padma Shri Awardee
President CMAAO & HCFI

Dr KK Aggarwal elaborated on the paradigm shifts in the management of Covid-19 from the month of March to July, based on his experiences of patients with Covid-19.

Key points from the discussion

  • Covid-19 was first considered to be a viral pneumonia, but now it is known as a mysterious virus, which is predictable unpredictable.
  • It spares joints and larynx, so no joint involvement or hoarseness of voice; also, no lymph nodes involvement.
  • Covid-19 was earlier believed to be non-inflammatory, but we now know that it is predominantly an inflammatory disease.
  • Earlier, it was thought that the patient could become critical on any day of the illness; now we know that Days 3-6 are the days to watch.
  • Social distancing has changed to physical distancing.
  • From macrodroplets (surface to human transmission) earlier, we now talk of microdroplets (crowded ill ventilated rooms) today.
  • Surface to human transmission was the most important route of transmission; now it has become less important (heat and humidity)
  • The shift from no masking to mandatory masking in public has become the norm.
  • From simple masks, we have moved to N95 masks for all high risk patients (COPD, asthmatics)
  • Masking only when going out, now adds masking also at home.
  • Distancing of 3 feet has changed to 6 feet; with microdroplets, this distance is now 9 feet.
  • We started the pandemic with very high mortality (10%); now mortality is around 0.3%.
  • Institutional care has shifted to home care
  • In the early days, no treatments were available; but individualized treatment is now available. If inflammatory parameters are raised, then give steroids, if d-dimers are high, give anticoagulant, if early presentation, give antiviral etc.
  • From mandatory ventilation, the concept has changed to noninvasive ventilation.


  • Children to grandparents; now children are no risk for transmission to adults or other children.
  • Menstruation reduces severity of illness.
  • We have shifted to no steroids to early low dose steroids.
  • Hydroxychloroquine (HCQ) for all to no HCQ for mild cases.
  • Late discharge – earlier patients were kept for 30-40 days; now patients are discharged early (Day 6) if no complications, to home quarantine
  • Thinking of death to thinking recovery
  • No pooled test to pooled test
  • We have now understood that after 9 days of illness, the virus is non-culturable and the person is non-infectious, the presentation is post-Covid sequelae due to persistent inflammation, or hypercoagulable state. Before 9 days, it is covid.
  • No Ct value to Ct value of RTPCR to find out if cohort isolation can be done; low Ct value means high viral load.
  • Testing has moved from antigen RTPCR to rapid antigen and now antibodies testing (total vs IgG)
  • Isolation to cohort isolation (multiple infected persons in a family can stay together)
  • Isolation and now isolation/quarantine/monitoring
  • From no oxygen at home to oxygen at home
  • Closed camps/OPDs to open sunlight camps – microdroplets are killed in sunlight
  • Earlier testing was done only for symptomatic persons, but now liberal testing
  • A mandatory government prescription has now become non-mandatory
  • When it first began in Wuhan, China, it was pulmonary COVID and CT diagnosis was a must; but now it is also recognized as non-pulmonary COVID, involving GIT, CNS.
  • Typically, fever at the time of presentation; now no fever presentation
  • Asymptomatic persons are really not asymptomatic; they may have some atypical symptoms such as diarrhea, sore throat etc.
  • High grade fever, which is classically associated with viral illness to low grade (100oF) exertional persistent fever, due to persistent inflammatory process
  • The six minute walk test (6MWT) was meant for only COPD, heart failure patients, but it is now mandatory from Day 3-6. If the patient desaturates by 5% on walking, this is indicative of pneumonia with thrombosis. This is an emergency.
  • Transmission from joint families to nuclear families
  • No toilet transmission, now toilets are recognized as a covid chamber
  • Contact time from 30/10 minutes to 15/5 minutes in closed areas
  • Testing till Ag negative to no testing to confirm when Ag will become negative
  • Fear to no or less fear
  • Mortality is two times that of the government figures reported
  • For every 1 tested people, there are 20 untested; for every 20 Covid patients, there are 80 patients with corona-like illness.
  • Stigma to less stigma
  • Low mortality to high mortality amongst doctors
  • Ignorance to knowledge
  • Engineering (AII rooms) to social engineering (test for 5 parameters when screening - – temperature (low grade, does not respond to paracetamol), SpO2 (happy hypoxia), loss of smell, loss of taste (give jaggery – first taste to go is sweet taste) and hand grip strength)
  • New loss of smell and taste has been seen in 20-30% of patients; the disease is mild in nature.
  • We now know that plasma therapy is effective if given early.







Tuesday, July 28, 2020

167 CMAAO CORONA FACTS and MYTH COVID

Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev


1019: Kim Jong-un, North Korea’s leader, placed Kaesong City, near the country’s border with the South, under lockdown and declared a national emergency after acknowledging that his country might have its first case of the coronavirus.  A North Korean who defected to South Korea three years ago but secretly crossed back into Kaesong City last week was “suspected to have been infected with the vicious virus,” the North’s official Korean Central News Agency said on Sunday. Until now, North Korea, one of the world’s most isolated countries, has said that it has no cases of Covid-19, although outside experts have questioned the claim.

1020: Vietnam, which had gone 100 days without a case of locally transmitted coronavirus, said on Saturday that a 57-year-old man in the central city of Danang had tested positive for the virus. A second man has since tested positive. How they were infected remained a mystery.
Vietnam, will evacuate tens of thousands of tourists from Danang after four residents there tested positive this weekend.

1021: President Jair Bolsonaro of Brazil said on Saturday that he no longer had the coronavirus, appearing to have experienced only mild symptoms from a scourge he has repeatedly downplayed. More than 86,000 people in Brazil have died from the virus.

1022: Australia on Sunday reported its highest one-day death toll — 10 people, all in the state of Victoria.

1023: France will do COVOD 19 testing free for all

1024:  Biocon suffered a setback on Sunday with the Union health ministry announcing that the firm’s itolizumab drug has not been included in national treatment protocol for Covid-19 patients. Less than two weeks ago, the Drug Controller General of India had given permission for the drug’s use on moderate to severe coronavirus patients, leading to a surge in the company’s share price.

1025: Hong Kong is shutting down all dine-in restaurant service and limiting public gatherings to two people after it recorded more than 100 new cases for the sixth day in a row.

1026: President Trump’s national security adviser, Robert O’Brien, has tested positive for the coronavirus, making him the most senior White House official known to have contracted the virus.

1027:  Japan takes masks to a new level:  In Japan, where masks were widespread even before the pandemic, there has been a big push to innovate. Inventors have dreamed up masks with motorized air purifiers, Bluetooth speakers and even sanitizers that kill germs. In South Korea, the electronics giant LG has created a mask powered with fans that make it easier to breathe. One company is trying to build a mask with a translator. Masks were first used in epidemics in the early 20th century, when Wu Lien-teh, a doctor of Chinese descent, began promoting simple gauze masks to battle an outbreak of pneumonic plague. During the 1918 flu, the practice went global.

1028: perinatal transmission of COVID-19 unlikely if precautions taken: Mothers positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at delivery are unlikely to transmit the infection to their infants during the perinatal period provided proper precautions are undertaken, a study in The Lancet Child & Adolescent Health has found. "This is the largest cohort of neonates born to mothers positive for SARS-CoV-2 at the time of delivery, with prospective follow-up up to 1 month of life," Christine M Salvatore, Departments of Pediatrics, Weill Cornell Medicine, New York Presbyterian—Komansky Children's Hospital, New York, NY, and colleagues noted.