Covid-19 - Navigating the Uncharted

"War to the knife" against thromboinflammation to protect endothelial function of COVID-19 patients

In this viewpoint, we summarize the relevance of thromboinflammation in COVID-19 and discuss potential mechanisms of endothelial injury as a key point for the development of lung and distant organ dysfunction, with a focus on direct viral infection and cytokine-mediated injury. Entanglement between inflammation and coagulation and resistance to heparin provide a rationale to consider other therapeutic approaches in order to preserve endothelial function and limit microthrombosis, especially in severe forms. These strategies include nebulized heparin, N-acetylcysteine, plasma exchange and/or fresh frozen plasma, plasma derivatives to increase the level of endogenous anticoagulants (tissue factor pathway inhibitor, activated protein C, thrombomodulin, antithrombin), dipyridamole, complement blockers, different types of stem cells, and extracellular vesicles. An integrated therapy including these drugs has the potential to improve outcomes in COVID-19.

A preliminary clinico-epidemiological portrayal of COVID-19 pandemic at a premier medical institution of North India

CONTEXT

The outbreak and spread of severe acute respiratory syndrome coronavirus 2 has led to a global exigency of colossal and monstrous proportions in terms of public health and economic crisis. Till date, no pharmaceutical agent is known to manage in terms of prevention and treatment of coronavirus disease 2019 (COVID-19), the disease caused by a novel virus.

AIMS

The aim of the present work was to understand the underlying disease profile and dynamics that could provide relevant inputs and insight into pathophysiology and prevent further spread and evolve management strategies of COVID-19 patients from data-driven techniques.

SETTINGS AND DESIGN

A retrospective observational descriptive study was conducted on 29 COVID-19 patients admitted at a premier medical institution of North India in the months of February and March 2020.

METHODS

The patients were diagnosed with reverse transcription-polymerase chain reaction test. Demographic, clinical, and laboratory data were collected.

RESULTS

The mean age of population was 38.8 years with male preponderance, of which two patients were residents of Italy, and others hailed from semi-arid and Western sandy arid regions of Rajasthan (urban population). The major presenting symptom complex of said COVID-19 sample population included fever (48%), cough (31%), and shortness of breath (17%). Most of the patients (83%) had no comorbidity. No clinical correlation (r) could be appreciated between the duration of test positivity and age of afflicted COVID-19 patients (r = -0.0976).

CONCLUSIONS

The present evaluation of various facets of the ongoing global pandemic of COVID-19 is an attempt to portray early clinical and epidemiological parameters of the menace of COVID-19 patients admitted at SMS Medical College and Attached Hospitals, Jaipur.

A practical approach to the management of breast cancer in the COVID-19 era and beyond

The COVID-19 pandemic has resulted in a major shift in how breast services are being utilised and managed. The guidelines relating to this have been published by recognised medical associations from the UK, Europe and the USA, addressing many aspects of breast cancer care. There is an awareness that there may be limitations in resources during this time, and therefore, prioritisation strategies have been identified to ensure that breast cancer patients are appropriately treated, whilst reducing the risk of infection from COVID-19 to both patients and staff. Equally important is the consideration of how breast cancer services can be safely re-introduced, as infection rates from COVID-19 decline. However, until there is a definite management strategy for COVID-19, such as a vaccine being developed, it is likely that there will still be a significant impact from COVID-19 on breast cancer care. This paper, therefore, aims to highlight the current guidance and evidence regarding breast cancer management in the era of COVID-19, and also aims to look at future management strategies in this period of uncertainty.

Immunology of COVID-19: Current State of the Science

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected millions of people worldwide, igniting an unprecedented effort from the scientific community to understand the biological underpinning of COVID19 pathophysiology. In this Review, we summarize the current state of knowledge of innate and adaptive immune responses elicited by SARS-CoV-2 infection and the immunological pathways that likely contribute to disease severity and death. We also discuss the rationale and clinical outcome of current therapeutic strategies as well as prospective clinical trials to prevent or treat SARS-CoV-2 infection.

Immune Response, Inflammation, and the Clinical Spectrum of COVID-19

The current COVID-19 pandemic began in December 2019 in Wuhan (China) and rapidly extended to become a global sanitary and economic emergency. Its etiological agent is the coronavirus SARS-CoV-2. COVID-19 presents a wide spectrum of clinical manifestations, which ranges from an asymptomatic infection to a severe pneumonia accompanied by multisystemic failure that can lead to a patient's death. The immune response to SARS-CoV-2 is known to involve all the components of the immune system that together appear responsible for viral elimination and recovery from the infection. Nonetheless, such immune responses are implicated in the disease's progression to a more severe and lethal process. This review describes the general aspects of both COVID-19 and its etiological agent SARS-CoV-2, stressing the similarities with other severe coronavirus infections, such as SARS and MERS, but more importantly, pointing toward the evidence supporting the hypothesis that the clinical spectrum of COVID-19 is a consequence of the corresponding variable spectrum of the immune responses to the virus. The critical point where progression of the disease ensues appears to center on loss of the immune regulation between protective and altered responses due to exacerbation of the inflammatory components. Finally, it appears possible to delineate certain major challenges deserving of exhaustive investigation to further understand COVID-19 immunopathogenesis, thus helping to design more effective diagnostic, therapeutic, and prophylactic strategies.

Applying Telehealth Technologies and Strategies to Provide Acute Care Consultation and Treatment of Patients With Confirmed or Possible COVID-19

BACKGROUND AND PURPOSE

The COVID-19 pandemic continues to grow, with 19% of total confirmed patients classified as severe or critical experiencing complications such as dyspnea, hypoxia, acute respiratory distress syndrome, or multiorgan failure. These complications require rehabilitative care. Considering the contagious nature of COVID-19 and the necessity to decrease the volume of health care professionals entering confirmed COVID-19 patient rooms and becoming a potential disease vector, can audiovisual technologies employed by telehealth and telerehabilitation help?

CASE DESCRIPTION

This case discusses the Baylor Scott and White Institute for Rehab (BSWIR) Physical Medicine and Rehabilitation (PMR) department COVID-19 acute care therapy team's creation of a telehealth strategy to provide early rehabilitative intervention without increasing the odds of disease transmission.

OUTCOMES

The COVID-19 therapy team created a simple process for identifying and triaging care for patients with possible or confirmed COVID-19. These patients were evaluated and treated by the dedicated team using telehealth strategies. A structured risk-benefit analysis was used to determine when in-room care was indicated.

DISCUSSION

Acute care physical therapy, occupational therapy, and speech-language pathology telehealth strategies can add value by mitigating COVID-19-related harm and influencing recovery, while not unnecessarily becoming additional disease vectors consuming personal protective equipment. COVID-19 is not only an aggressive respiratory illness similar to acute respiratory distress syndrome but also highly contagious and a risk for health care providers. Telehealth strategies allow therapists to intervene early, opening the possibility to maximize recovery and prevent harm or decompensation. Telehealth strategies can be more prevention-focused while the patient is experiencing relatively good health with goals to maximize strength and endurance before the disease process evolves to critical illness. As COVID-19 progresses, therapy can help mitigate potential complications associated with prolonged intensive care unit stay and ventilator management.

Global experience of orthopaedic trauma surgeons facing COVID-19: a survey highlighting the global orthopaedic response

Background

The COVID-19 (SARS-CoV-2) pandemic has significantly affected all aspects of healthcare, including orthopaedics. Due to the unique challenges presented by COVID-19 as well as the distinct timeframes that it will surge in different geographies, much can be learned from the experiences of orthopaedic professionals in many global settings. The goal of this project is to characterize the preparations, strategies, lessons, and personal experiences of orthopaedic trauma surgeons and departments across the world in combating COVID-19. In doing so, we will shed light on current practices and challenges, which may help us manage the current pandemic in addition to preparing for future global pandemics that may arise.

Methods

A 20-item questionnaire was sent out to 150 orthopaedic trauma surgeons representing 42 countries who were identified based on professional relationships and/or prior involvement in international meetings either led or participated by the senior author.

Results

The questionnaire was completed by 63 orthopaedic trauma surgeons representing 28 countries and 14 US states. The results of this study show that orthopaedic trauma departments across the world have been greatly impacted by COVID-19 with 91% of participating hospitals currently having a reduced case load compared with pre-COVID-19 and only 17% of respondents currently performing elective orthopaedic surgery. Furthermore, 30% of orthopaedic departments have deployed orthopaedic personnel to non-orthopaedic floors in order to help mitigate the increased patient load and 86% of respondents noted at least some shortage of PPE. Lastly 73% of participating orthopedic departments including those in LMICs, have incorporated telemedicine into their practice with a majority stating that it would most likely become a permanent change to their practice post-COVID-19.

Conclusion

To our knowledge, this is the largest data set characterizing global COVID-19 situations and responses of orthopaedic trauma practices around the world. There is much to be learned from each of the participants’ responses in order to persevere during the current pandemic, as well as to prepare for future pandemics as it relates specifically to orthopaedic trauma practices.

Artificial Neural Network Modeling of Novel Coronavirus (COVID-19) Incidence Rates across the Continental United States

Prediction of the COVID-19 incidence rate is a matter of global importance, particularly in the United States. As of 4 June 2020, more than 1.8 million confirmed cases and over 108 thousand deaths have been reported in this country. Few studies have examined nationwide modeling of COVID-19 incidence in the United States particularly using machine-learning algorithms. Thus, we collected and prepared a database of 57 candidate explanatory variables to examine the performance of multilayer perceptron (MLP) neural network in predicting the cumulative COVID-19 incidence rates across the continental United States. Our results indicated that a single-hidden-layer MLP could explain almost 65% of the correlation with ground truth for the holdout samples. Sensitivity analysis conducted on this model showed that the age-adjusted mortality rates of ischemic heart disease, pancreatic cancer, and leukemia, together with two socioeconomic and environmental factors (median household income and total precipitation), are among the most substantial factors for predicting COVID-19 incidence rates. Moreover, results of the logistic regression model indicated that these variables could explain the presence/absence of the hotspots of disease incidence that were identified by Getis-Ord Gi* (p < 0.05) in a geographic information system environment. The findings may provide useful insights for public health decision makers regarding the influence of potential risk factors associated with the COVID-19 incidence at the county level.

Compassionate Use of Remdesivir for Patients with Severe Covid-19

BACKGROUND

Remdesivir, a nucleotide analogue prodrug that inhibits viral RNA polymerases, has shown in vitro activity against SARS-CoV-2.

METHODS

We provided remdesivir on a compassionate-use basis to patients hospitalized with Covid-19, the illness caused by infection with SARS-CoV-2. Patients were those with confirmed SARS-CoV-2 infection who had an oxygen saturation of 94% or less while they were breathing ambient air or who were receiving oxygen support. Patients received a 10-day course of remdesivir, consisting of 200 mg administered intravenously on day 1, followed by 100 mg daily for the remaining 9 days of treatment. This report is based on data from patients who received remdesivir during the period from January 25, 2020, through March 7, 2020, and have clinical data for at least 1 subsequent day.

RESULTS

Of the 61 patients who received at least one dose of remdesivir, data from 8 could not be analyzed (including 7 patients with no post-treatment data and 1 with a dosing error). Of the 53 patients whose data were analyzed, 22 were in the United States, 22 in Europe or Canada, and 9 in Japan. At baseline, 30 patients (57%) were receiving mechanical ventilation and 4 (8%) were receiving extracorporeal membrane oxygenation. During a median follow-up of 18 days, 36 patients (68%) had an improvement in oxygen-support class, including 17 of 30 patients (57%) receiving mechanical ventilation who were extubated. A total of 25 patients (47%) were discharged, and 7 patients (13%) died; mortality was 18% (6 of 34) among patients receiving invasive ventilation and 5% (1 of 19) among those not receiving invasive ventilation.

CONCLUSIONS

In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%). Measurement of efficacy will require ongoing randomized, placebo-controlled trials of remdesivir therapy. (Funded by Gilead Sciences.).

Continuous Renal Replacement Therapy for a Patient with Severe COVID-19

The outbreak of coronavirus disease 2019 (COVID-19) is a global health threat. It is a respiratory disease, and acute kidney injury (AKI) is rare; however, if a patient develops severe AKI, renal replacement therapy (RRT) should be considered. Recently, we had a critically ill COVID-19 patient who developed severe AKI and needed continuous RRT (CRRT). To avoid the potential risk of infection from CRRT effluents, we measured severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genetic material in the effluents by qRT-PCR, and low copy numbers of the viral genome were detected. Due to unstable hemodynamic status in critically ill patients, CRRT should be the first choice for severe AKI in COVID-19 patients. We suggest prevention of clinical infection and control during administration of RRT in the acute phase of COVID-19 patients with AKI or multiple organ failure.

Interferon-Induced Transmembrane Protein (IFITM3) Is Upregulated Explicitly in SARS-CoV-2 Infected Lung Epithelial Cells

Current guidelines for COVID-19 management recommend the utilization of various repurposed drugs. Despite ongoing research toward the development of a vaccine against SARS-CoV-2, such a vaccine will not be available in time to contribute to the containment of the ongoing pandemic. Therefore, there is an urgent need to develop a framework for the rapid identification of novel targets for diagnostic and therapeutic interventions. We analyzed publicly available transcriptomic datasets of SARS-CoV infected humans and mammals to identify consistent differentially expressed genes then validated in SARS-CoV-2 infected epithelial cells transcriptomic datasets. Comprehensive toxicogenomic analysis of the identified genes to identify possible interactions with clinically proven drugs was carried out. We identified IFITM3 as an early upregulated gene, and valproic acid was found to enhance its mRNA expression as well as induce its antiviral action. These findings indicate that analysis of publicly available transcriptomic and toxicogenomic data represents a rapid approach for the identification of novel targets and molecules that can modify the action of such targets during the early phases of emerging infections like COVID-19.

Neurological manifestations and implications of COVID-19 pandemic

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China and rapidly spread worldwide, with a vast majority of confirmed cases presenting with respiratory symptoms. Potential neurological manifestations and their pathophysiological mechanisms have not been thoroughly established. In this narrative review, we sought to present the neurological manifestations associated with coronavirus disease 2019 (COVID-19). Case reports, case series, editorials, reviews, case-control and cohort studies were evaluated, and relevant information was abstracted. Various reports of neurological manifestations of previous coronavirus epidemics provide a roadmap regarding potential neurological complications of COVID-19, due to many shared characteristics between these viruses and SARS-CoV-2. Studies from the current pandemic are accumulating and report COVID-19 patients presenting with dizziness, headache, myalgias, hypogeusia and hyposmia, but also with more serious manifestations including polyneuropathy, myositis, cerebrovascular diseases, encephalitis and encephalopathy. However, discrimination between causal relationship and incidental comorbidity is often difficult. Severe COVID-19 shares common risk factors with cerebrovascular diseases, and it is currently unclear whether the infection per se represents an independent stroke risk factor. Regardless of any direct or indirect neurological manifestations, the COVID-19 pandemic has a huge impact on the management of neurological patients, whether infected or not. In particular, the majority of stroke services worldwide have been negatively influenced in terms of care delivery and fear to access healthcare services. The effect on healthcare quality in the field of other neurological diseases is additionally evaluated.

Early Detection and Assessment of Covid-19

Background: Since the Covid-19 global pandemic emerged, developing countries have been facing multiple challenges over its diagnosis. We aimed to establish a relationship between the signs and symptoms of COVID-19 for early detection and assessment to reduce the transmission rate of SARS-Cov-2. Methods: We collected published data on the clinical features of Covid-19 retrospectively and categorized them into physical and blood biomarkers. Common features were assigned scores by the Borg scoring method with slight modifications and were incorporated into a newly-developed Hashmi-Asif Covid-19 assessment Chart. Correlations between signs and symptoms with the development of Covid-19 was assessed by Pearson correlation and Spearman Correlation coefficient (rho). Linear regression analysis was employed to assess the highest correlating features. The frequency of signs and symptoms in developing Covid-19 was assessed through Chi-square test two tailed with Cramer's V strength. Changes in signs and symptoms were incorporated into a chart that consisted of four tiers representing disease stages. Results: Data from 10,172 Covid-19 laboratory confirmed cases showed a correlation with Fever in 43.9% (P = 0.000) cases, cough 54.08% and dry mucus 25.68% equally significant (P = 0.000), Hyperemic pharyngeal mucus membrane 17.92% (P = 0.005), leukopenia 28.11% (P = 0.000), lymphopenia 64.35% (P = 0.000), thrombopenia 35.49% (P = 0.000), elevated Alanine aminotransferase 50.02% (P = 0.000), and Aspartate aminotransferase 34.49% (P = 0.000). The chart exhibited a maximum scoring of 39. Normal tier scoring was ≤ 12/39, mild state scoring was 13-22/39, and star values scoring was ≥7/15; this latter category on the chart means Covid-19 is progressing and quarantine should be adopted. Moderate stage scored 23-33 and severe scored 34-39 in the chart. Conclusion: The Hashmi-Asif Covid-19 Chart is significant in assessing subclinical and clinical stages of Covid-19 to reduce the transmission rate.

Repurposing antimicrobial stewardship tools in the electronic medical record for the management of COVID-19 patients

During the COVID-19 pandemic, the antimicrobial stewardship module in our electronic medical record was reconfigured for the management of COVID-19 patients. This change allowed our subspecialist providers to review charts quickly to optimize potential therapy and management during the patient surge.

MADVent: A low-cost ventilator for patients with COVID-19

The COVID‐19 pandemic has produced critical shortages of ventilators worldwide. There is an unmet need for rapidly deployable, emergency‐use ventilators with sufficient functionality to manage COVID‐19 patients with severe acute respiratory distress syndrome. Here, we show the development and validation of a simple, portable and low‐cost ventilator that may be rapidly manufactured with minimal susceptibility to supply chain disruptions. This single‐mode continuous, mandatory, closed‐loop, pressure‐controlled, time‐terminated emergency ventilator offers robust safety and functionality absent in existing solutions to the ventilator shortage. Validated using certified test lungs over a wide range of compliances, pressures, volumes and resistances to meet U.S. Food and Drug Administration standards of safety and efficacy, an Emergency Use Authorization is in review for this system. This emergency ventilator could eliminate controversial ventilator rationing or splitting to serve multiple patients. All design and validation information is provided to facilitate ventilator production even in resource‐limited settings.

COVID-19 pandemic: Emerging perspectives and future trends

World is living on the edge. The human cost of COVID pandemic could be extraordinary. We find ourselves in a time of great economic, social, and medical uncertainty. The pandemic demands action on many fronts, from prevention to testing to treatment. We need to create simple, cheap, more accessible testing for SARS-CoV-2. A faster way has to be developed to identify antibodies that neutralize the virus. More than 100 vaccines for the SARS-CoV-2 are at various stages of development. Some six groups have already begun injecting formulations into volunteers in safety trials; others have started testing in animals. The biggest challenge is to determine which vaccine is ideal. Reason and science have to guide us. There is urgent need to critically appraise evidence in deciding how to treat patients. We need a drug or combination of drugs that work. Remdesivir has generated hope. It may prove to be a magic bullet. Countries like Taiwan, Vietnam, Singapore, Hong Kong, South Korea, New Zealand have done exceptionally well to contain the spread of COVID-19. It is widely believed that during the pandemic treatment suffers. Patients with diseases like cancer, diabetes, renal failure, CAD and pregnant women need special attention. As the pandemic pushes up levels of hunger among the global poor, governments must prevent devastating nutrition and health consequences for children missing out on school meals amid school closures. Nations will have endemic SARS-CoV-2 infection for the foreseeable future. A structured and well-coordinated approach is critical for tackling this global crisis.

Guidance for otolaryngology health care workers performing aerosol generating medical procedures during the COVID-19 pandemic

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for Coronavirus disease 2019 (COVID-19) has a predilection for infecting the mucosa of the upper and lower airways. Otolaryngologists and supporting health care workers (HCWs) are particularly at high risk of becoming infected while treating patients as many in-office procedures and surgeries are Aerosol Generating Medical Procedures (AGMP). Based on a review of the literature and various guidelines, recommendations are made to mitigate the risk to health care workers of becoming infected with SARS-CoV-2 while providing clinical care.

Recommendations

During the COVID-19 pandemic all elective and non-time sensitive Otolaryngology procedures should be deferred to mitigate the risk of transmission of infection to HCWs. For non-AGMPs in all patients, even COVID-19 positive patients Level 1 PPE (surgical mask, gown, gloves and face shield or goggles) is sufficient. If local prevalence is favourable and patients are asymptomatic and test negative for SARS-CoV-2, Level 1 PPE can be used during short duration AGMPs, with limited risk of infected aerosol spread. For AGMPs in patients who test positive for SARS-CoV-2 a minimum of Level 2 PPE, with adequate protection of mucosal surfaces, is recommended (N95/FFP2 respirator, gown, double gloves, goggles or face shield and head cover). For long duration AGMPs that are deemed high-risk in COVID-19 positive patients, Level 3 PPE can provide a higher level of protection and be more comfortable during long duration surgeries if surgical hoods or PAPRs are used. It is recommended that these procedures are performed in negative pressure rooms, if available. It is essential to follow strict donning and doffing protocols to minimize the risk of contamination.

Conclusions

By following strict infection prevention recommendations, the risk of HCWs becoming infected with SARS-CoV-2 while treating patients can be minimized. As the COVID-19 pandemic evolves rapidly, these recommendations should serve as guidance and need to be interpreted based on local factors and availability of healthcare resources.

Art of prevention: Life in the time of coronavirus

The novel coronavirus disease 2019 (COVID-19) has continued to progress since its discovery in December 2019. A cluster of patients with atypical pneumonia identified in Wuhan, China, served as the epicenter of this recent epidemic. This family of viruses is responsible for the common cold along with the infamous severe acute respiratory syndrome epidemic in 2002 and Middle East respiratory syndrome in 2012. The Southern China Wholesale Market reportedly has connections to the original 27 cases in Wuhan, China. The worldwide confirmed case total has eclipsed 1,450,000, with more than 83,000 deaths. Patient presentation ranges from mild respiratory illness to acute respiratory distress syndrome and subsequent death. Early epidemiologic studies of viral spread support the hypothesis that COVID-19 can remain latent with an extended and infectious incubation period. The U.S. government has issued level 3 precautions for most international travel, along with prohibiting entry to foreign nationals traveling from China, Iran, the United Kingdom, the Republic of Ireland, and the European Schengen area (e.g., France, Italy, Germany). Prevention remains the mainstay in treating and defeating the COVID-19 epidemic. Anyone infected or suspected of being infected should self-quarantine at home or admit themselves to a specified hospital with infrastructure to handle the situation. The combination of prevention and containment provides the best opportunity to stall the spread of COVID-19.

COVID-19 kills at home: the close relationship between the epidemic and the increase of out-of-hospital cardiac arrests

AIMS

An increase in out-of-hospital cardiac arrest (OHCA) incidence has been reported in the very early phase of the COVID-19 epidemic, but a clear demonstration of a correlation between the increased incidence of OHCA and COVID-19 is missing so far. We aimed to verify whether there is an association between the OHCA difference compared with 2019 and the COVID-19 epidemic curve.

METHODS AND RESULTS

We included all the consecutive OHCAs which occurred in the Provinces of Lodi, Cremona, Pavia, and Mantova in the 2 months following the first documented case of COVID-19 in the Lombardia Region and compared them with those which occurred in the same time frame in 2019. The cumulative incidence of COVID-19 from 21 February to 20 April 2020 in the study territory was 956 COVID-19/100 000 inhabitants and the cumulative incidence of OHCA was 21 cases/100 000 inhabitants, with a 52% increase as compared with 2019 (490 OHCAs in 2020 vs. 321 in 2019). A strong and statistically significant correlation was found between the difference in cumulative incidence of OHCA between 2020 and 2019 per 100 000 inhabitants and the COVID-19 cumulative incidence per 100 000 inhabitants both for the overall territory (ρ 0.87, P < 0.001) and for each province separately (Lodi: ρ 0.98, P < 0.001; Cremona: ρ 0.98, P < 0.001; Pavia: ρ 0.87, P < 0.001; Mantova: ρ 0.81, P < 0.001).

CONCLUSION

The increase in OHCAs in 2020 is significantly correlated to the COVID-19 pandemic and is coupled with a reduction in short-term outcome. Government and local health authorities should seriously consider our results when planning healthcare strategies to face the epidemic, especially considering the expected recurrent outbreaks.

Modeling shield immunity to reduce COVID-19 epidemic spread

The COVID-19 pandemic has precipitated a global crisis, with more than 1,430,000 confirmed cases and more than 85,000 confirmed deaths globally as of 9 April 20201-4. Mitigation and suppression of new infections have emerged as the two predominant public health control strategies5. Both strategies focus on reducing new infections by limiting human-to-human interactions, which could be both socially and economically unsustainable in the long term. We have developed and analyzed an epidemiological intervention model that leverages serological tests6,7 to identify and deploy recovered individuals8 as focal points for sustaining safer interactions via interaction substitution, developing what we term 'shield immunity' at the population scale. The objective of a shield immunity strategy is to help to sustain the interactions necessary for the functioning of essential goods and services9 while reducing the probability of transmission. Our shield immunity approach could substantively reduce the length and reduce the overall burden of the current outbreak, and can work synergistically with social distancing. The present model highlights the value of serological testing as part of intervention strategies, in addition to its well-recognized roles in estimating prevalence10,11 and in the potential development of plasma-based therapies12-15.

Assessing changes in US public trust in science amid the COVID-19 pandemic

OBJECTIVES

The emergence of the coronavirus disease 2019 (COVID-19) and subsequent pandemic has led to the most substantive large-scale, open, and public social discussion of epidemiology and science in recent history. In the United States (US), extensive debate has ensued as to the risk posed by the disease, whether the health system is prepared to manage a high volume of critical cases, whether any number of public health responses are necessary and appropriate, and the appropriate ways to prevent, manage, and treat the pandemic. I hypothesized that the interplay between scientists, policymakers, and the public in an open forum was associated with increased overall public trust in science and scientists, but that this was moderated by political orientation and/or religious commitment. In the context of a public health emergency, it is important to understand the degree to which science and scientists are trusted to produce information that can provide reassurance and also can explain the details of a highly complex event such as a viral pandemic while providing actionable recommendations.

STUDY DESIGN

The study design was analytic cross-sectional.

METHODS

Data were obtained on March 17-18, 2020, from a sample of 242 US-based Amazon Mechanical Turk users. Respondents completed a 49-question survey consisting of key sociodemographic variables, political affiliation, religious commitment, and two iterations of the Trust in Science and Scientist Inventory (one for March 2020, and one for December 2019 using retrospective recall). Changes in mean level of trust and interaction with political affiliation and/or religious commitment were assessed using mixed ANOVA via the general linear model.

RESULTS

On a scale from 1 (low trust) to 5 (high trust), the mean level of trust in science and scientists was static; 3.82 in December 2019 and 3.81 in March 2020. Conservative political orientation and high religious commitment were associated with significantly less overall trust in science; the interaction effect suggested that liberal trust in science decreased slightly from December 2019 to March 2020, whereas conservative trust increased slightly.

CONCLUSIONS

Counter to my expectations, the overall level of trust in science remained static after the first several months of COVID-19 in the US, although there is some evidence that political orientation was associated with magnitude and directionality of change in trust. Continued examination of these trends is important for understanding public response to epidemiologic recommendations.

Oncology Nursing During a Pandemic: Critical Reflections in the Context of COVID-19

OBJECTIVES

To provide a critical reflection of COVID-19 in the context of oncology nursing and provide recommendations for caring for people affected by cancer during this pandemic.

DATA SOURCES

Electronic databases, including CINAHL, MEDLINE, PsychINFO, Scopus, professional web sites, and grey literature were searched using Google Scholar.

CONCLUSION

Nurses are key stakeholders in developing and implementing policies regarding standards of care during the COVID-19 pandemic. This pandemic poses several challenges for oncology services. Oncology nurses are providing a pivotal role in the care and management of the novel COVID-19 in the year landmarked as the International Year of the Nurse.

IMPLICATIONS FOR NURSING PRACTICE

It is too early to tell what shape this pandemic will take and its impact on oncology care. However, several important clinical considerations have been discussed to inform oncology nursing care and practice.

Deployment of a computerized ward visitor registration system in coronavirus disease 2019 epidemic: Experiences of a large academic medical center in Taiwan

BACKGROUND

Visitors to hospitalized patients during an epidemic might themselves be carriers and are therefore likely to spread the disease in wards. Although measures were taken to restrict hospital visits, traditional paper-based registration is insufficient to screen and monitor the numbers of visitors to a large hospital.

METHODS

Throughout March 2020, during the coronavirus disease 2019 crisis, a computer system was deployed in the 2800-bed Taipei Veterans General Hospital (Taipei, Taiwan) to register, screen, and monitor inpatient visitors. This system comprised three parts: online registration form, entrance check-in interface, and registration database. The early utilization of this newly deployed system was then analyzed.

RESULTS

A total of 22,336 visits were recorded between March 11, 2020, and March 31, 2020, with 1064 a day on average. Out of these visits, 18.1% (n = 4049) had made online reservations within 48 hours. On the other hand, of all 4941 online reservations, 18.1% (n = 892) were no-shows. In the last 12 days of the study period, eight prospective visitors were identified as ineligible by the computer system, and so their visits were denied.

CONCLUSION

Using a computer system, the hospital was able to enforce restrictions on hospital visits. Although the online registration system had not been fully used yet in the early phase of adoption, its superiority from the standpoint of disease control should enable hospital managers to consider abolishing on-site visitor registration.

Using Machine Learning to Predict ICU Transfer in Hospitalized COVID-19 Patients

OBJECTIVES

Approximately 20-30% of patients with COVID-19 require hospitalization, and 5-12% may require critical care in an intensive care unit (ICU). A rapid surge in cases of severe COVID-19 will lead to a corresponding surge in demand for ICU care. Because of constraints on resources, frontline healthcare workers may be unable to provide the frequent monitoring and assessment required for all patients at high risk of clinical deterioration. We developed a machine learning-based risk prioritization tool that predicts ICU transfer within 24 h, seeking to facilitate efficient use of care providers' efforts and help hospitals plan their flow of operations.

METHODS

A retrospective cohort was comprised of non-ICU COVID-19 admissions at a large acute care health system between 26 February and 18 April 2020. Time series data, including vital signs, nursing assessments, laboratory data, and electrocardiograms, were used as input variables for training a random forest (RF) model. The cohort was randomly split (70:30) into training and test sets. The RF model was trained using 10-fold cross-validation on the training set, and its predictive performance on the test set was then evaluated.

RESULTS

The cohort consisted of 1987 unique patients diagnosed with COVID-19 and admitted to non-ICU units of the hospital. The median time to ICU transfer was 2.45 days from the time of admission. Compared to actual admissions, the tool had 72.8% (95% CI: 63.2-81.1%) sensitivity, 76.3% (95% CI: 74.7-77.9%) specificity, 76.2% (95% CI: 74.6-77.7%) accuracy, and 79.9% (95% CI: 75.2-84.6%) area under the receiver operating characteristics curve.

CONCLUSIONS

A ML-based prediction model can be used as a screening tool to identify patients at risk of imminent ICU transfer within 24 h. This tool could improve the management of hospital resources and patient-throughput planning, thus delivering more effective care to patients hospitalized with COVID-19.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection: let the virus be its own demise

There has been a collaborative global effort to construct novel therapeutic and prophylactic approaches to SARS-CoV-2 management. Although vaccine development is crucial, acute management of newly infected patients, especially those with severe acute respiratory distress syndrome, is a priority. Herein we describe the rationale and potential of repurposing a dual plasmid, Vigil (pbi-shRNA^furin-GM-CSF), now in Phase III cancer trials, for the treatment of and, in certain circumstances, enhancement of the immune response to SARS-CoV-2.

Challenges and Priorities in Responding to COVID-19 in Inpatient Psychiatry

This Open Forum focuses on specific challenges, contingency planning considerations, and downstream impacts of COVID-19 on inpatient psychiatric care. COVID-19 is a novel coronavirus that has been declared a pandemic. Challenges for inpatient psychiatry include risky close contact among staff and patients, space constraints, and structural barriers in care delivery. Nuanced considerations of five contingency planning strategies in response to COVID-19 are described, including COVID-19-specific precautions, visitor restrictions, physician workforce considerations, operational adjustments, and group therapy changes. Organized leadership and clear communication are identified as early priorities in pandemic response to minimize misinformation and address immediate challenges.

Point-of-Care Lung Ultrasound Findings in Patients with COVID-19 Pneumonia

Patients with novel coronavirus disease (COVID-19) typically present with bilateral multilobar ground-glass opacification with a peripheral distribution. The utility of point-of-care ultrasound has been suggested, but detailed descriptions of lung ultrasound findings are not available. We evaluated lung ultrasound findings in 10 patients admitted to the internal medicine ward with COVID-19. All of the patients had characteristic glass rockets with or without the Birolleau variant (white lung). Thick irregular pleural lines and confluent B lines were also present in all of the patients. Five of the 10 patients had small subpleural consolidations. Point-of-care lung ultrasound has multiple advantages, including lack of radiation exposure and repeatability. Also, lung ultrasound has been shown to be more sensitive than a chest radiograph in detecting alveolar-interstitial syndrome. The utilization of lung ultrasound may also reduce exposure of healthcare workers to severe acute respiratory syndrome-coronavirus-2 and may mitigate the shortage of personal protective equipment. Further studies are needed to evaluate the utility of lung ultrasound in the diagnosis and management of COVID-19.

Impact of the COVID-19 Outbreak on the Management of Patients with Cancer

The coronavirus SARS-CoV-2 (COVID-19) outbreak is having a profound impact on the management of patients with cancer. In this review, we comprehensively investigate the various aspects of cancer care during the pandemic, taking advantage of data generated in Asia and Europe at the frontline of the COVID-19 pandemic spread. Cancer wards have been subjected to several modifications to protect patients and healthcare professionals from COVID-19 infection, while attempting to maintain cancer diagnosis, therapy, and research. In this setting, the management of COVID-19 infected patients with cancer is particularly challenging. We also discuss the direct and potential remote impacts of the global pandemic on the mortality of patients with cancer. As such, the indirect impact of the pandemic on the global economy and the potential consequences in terms of cancer mortality are discussed. As the infection is spreading worldwide, we are obtaining more knowledge on the COVID-19 pandemic consequences that are currently impacting and may continue to further challenge cancer care in several countries.

Flattening the Mental Health Curve: COVID-19 Stay-at-Home Orders Are Associated With Alterations in Mental Health Search Behavior in the United States

BACKGROUND

The coronavirus disease (COVID-19) has led to dramatic changes worldwide in people's everyday lives. To combat the pandemic, many governments have implemented social distancing, quarantine, and stay-at-home orders. There is limited research on the impact of such extreme measures on mental health.

OBJECTIVE

The goal of this study was to examine whether stay-at-home orders produced differential changes in mental health symptoms using internet search queries on a national scale.

METHODS

In the United States, individual states vary in their adoption of measures to reduce the spread of COVID-19; as of March 23, 2020, 11 of the 50 states had issued stay-at-home orders. The staggered rollout of stay-at-home measures across the United States allows us to investigate whether these measures impact mental health by exploring variations in mental health search queries across the states. This paper examines the changes in mental health search queries on Google between March 16-23, 2020, across each state and Washington, DC. Specifically, this paper examines differential changes in mental health searches based on patterns of search activity following issuance of stay-at-home orders in these states compared to all other states. The participants were all the people who searched mental health terms in Google between March 16-23. Between March 16-23, 11 states underwent stay-at-home orders to prevent the transmission of COVID-19. Outcomes included search terms measuring anxiety, depression, obsessive-compulsive, negative thoughts, irritability, fatigue, anhedonia, concentration, insomnia, and suicidal ideation.

RESULTS

Analyzing over 10 million search queries using generalized additive mixed models, the results suggested that the implementation of stay-at-home orders are associated with a significant flattening of the curve for searches for suicidal ideation, anxiety, negative thoughts, and sleep disturbances, with the most prominent flattening associated with suicidal ideation and anxiety.

CONCLUSIONS

These results suggest that, despite decreased social contact, mental health search queries increased rapidly prior to the issuance of stay-at-home orders, and these changes dissipated following the announcement and enactment of these orders. Although more research is needed to examine sustained effects, these results suggest mental health symptoms were associated with an immediate leveling off following the issuance of stay-at-home orders.

[The "Historic Study" SOLIDARITY-Research's Answer to the Sars-CoV-2 Pandemic]

This paper is part of Forum COVID-19: Perspectives in the Humanities and Social Sciences. The novel coronavirus (Sars-CoV-2) poses a huge challenge to the world community. Knowledge about the virus and its properties is limited, but there is a great need to base political and medical decisions on scientific knowledge. This situation is leading to a dynamization of research. A prominent example of such a development is SOLIDARITY. The epistemological dimensions of this trial, which is coordinated by the WHO, and the resulting ethical implications are discussed in this article.

Managing Close Contacts of COVID-19 Confirmed Cases in Metropolitan Areas in China

The novel coronavirus (COVID-19) outbreak has rapidly spread across the world. As medical systems continue to develop vaccines and treatments, it is crucial for the public health community to establish nonpharmaceutical interventions (NPIs) that can effectively mitigate the rate of SARS-Coronavirus-2 (SARS-CoV-2) spread across highly populated residential areas, especially among individuals who have close contact with confirmed cases. A community-driven preparedness strategy has been implemented in metropolitan areas in China. The Chinese Center for Disease Control and Prevention (CCDC) has required that all COVID-19 confirmed cases be recorded and documented in a national notifiable disease surveillance system (NDSS). After receiving reports of newly confirmed cases, an epidemiological services team at the CCDC or trained medical professionals at local clinical facilities start a case-contact investigation. A task force performs home visits to infected individuals. Persons under investigation (PUIs) can stay in designated quarantine facilities for 14 days or in special circumstances can be quarantined at home. This community-based approach involved all stakeholders including local public health departments, public safety authorities, neighborhood councils, and community health centers.

Health Care Team Training and Simulation-Based Education in Obstetrics During the COVID-19 Pandemic

Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic.

Caring for Individuals With Intellectual and Developmental Disabilities in the COVID-19 Crisis

Individuals with intellectual and developmental disabilities (IDDs) are among our most medically vulnerable neurologic patient population. As such, they are at particular risk of psychosocial and medical harm during the coronavirus disease 2019 (COVID-19) pandemic. Here, we highlight strategies to decrease potential infectious exposures and ensure continued optimal neurologic care for individuals with IDD during the COVID-19 pandemic. Finally, in a climate of potential medical resource restriction, we offer some suggestions for advocacy on behalf of individuals with IDD.

Laboratory Diagnosis of COVID-19: Current Issues and Challenges

The COVID-19 outbreak has had a major impact on clinical microbiology laboratories in the past several months. This commentary covers current issues and challenges for the laboratory diagnosis of infections caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the preanalytical stage, collecting the proper respiratory tract specimen at the right time from the right anatomic site is essential for a prompt and accurate molecular diagnosis of COVID-19. Appropriate measures are required to keep laboratory staff safe while producing reliable test results.

The COVID-19 outbreak has had a major impact on clinical microbiology laboratories in the past several months. This commentary covers current issues and challenges for the laboratory diagnosis of infections caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the preanalytical stage, collecting the proper respiratory tract specimen at the right time from the right anatomic site is essential for a prompt and accurate molecular diagnosis of COVID-19. Appropriate measures are required to keep laboratory staff safe while producing reliable test results. In the analytic stage, real-time reverse transcription-PCR (RT-PCR) assays remain the molecular test of choice for the etiologic diagnosis of SARS-CoV-2 infection while antibody-based techniques are being introduced as supplemental tools. In the postanalytical stage, testing results should be carefully interpreted using both molecular and serological findings. Finally, random-access, integrated devices available at the point of care with scalable capacities will facilitate the rapid and accurate diagnosis and monitoring of SARS-CoV-2 infections and greatly assist in the control of this outbreak.

Standardization of enzyme-linked immunosorbent assays for serosurveys of the SARS-CoV-2 pandemic using clinical and at-home blood sampling

The extent of SARS-CoV-2 infection throughout the United States population is currently unknown. High quality serology is a key tool to understanding the spread of infection, immunity against the virus, and correlates of protection. Limited validation and testing of serology assays used for serosurveys can lead to unreliable or misleading data, and clinical testing using such unvalidated assays can lead to medically costly diagnostic errors and improperly informed public health decisions. Estimating prevalence and clinical decision making is highly dependent on specificity. Here, we present an optimized ELISA-based serology protocol from antigen production to data analysis. This protocol defines thresholds for IgG and IgM for determination of seropositivity with estimated specificity well above 99%. Validation was performed using both traditionally collected serum and dried blood on mail-in blood sampling kits, using archival (pre-2019) negative controls and known PCR-diagnosed positive patient controls. Minimal cross-reactivity was observed for the spike proteins of MERS, SARS1, OC43 and HKU1 viruses and no cross reactivity was observed with anti-influenza A H1N1 HAI titer during validation. This strategy is highly specific and is designed to provide good estimates of seroprevalence of SARS-CoV-2 seropositivity in a population, providing specific and reliable data from serosurveys and clinical testing which can be used to better evaluate and understand SARS-CoV-2 immunity and correlates of protection.

Repurposing Interleukin-6 Inhibitors to Combat COVID-19

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is a pandemic with major implications across the world. One of the most frequent causes of death from SARS-CoV-2 is fatal pneumonia from coronavirus disease 2019 (COVID-19), which is associated with the development of acute respiratory distress syndrome (ARDS). To date (as of April 2, 2020), other than supportive measures, there are no efficient therapeutic options for COVID-19-related ARDS, although the US Food and Drug Administration recently granted emergency authorization for the use of hydroxychoroquine/chloroquine for this indication (which is usually given with azithromycin). Although the pathogenesis for ARDS is under investigation, one of the major culprits is considered to be cytokine storm, especially from interleukin 6 (IL-6) release. Herein, we review potential use of IL-6 inhibitors, several of which are approved for other disease conditions, as potential novel treatment for the management of COVID-19-related ARDS.

Ion torrent-based nasopharyngeal swab metatranscriptomics in COVID-19

Herein, we describe the detection of a SARS-CoV-2 genome through metatranscriptome next-generation sequencing directly from the nasopharyngeal swab of a suspected case of local transmission of Covid-19, in Brazil. Depletion of human ribosomal RNA and use of an optimized in-house developed bioinformatics strategy contributed to successful detection of the virus.

The Psychological Impact of Confinement Linked to the Coronavirus Epidemic COVID-19 in Algeria

The COVID-19 pandemic continues to spread in countries around the world. The impact of this virus is very great on populations following the application of total and partial containment measures. Our study aims to study the psychological impact of total and partial containment applied in Algeria, on 23 March 2020, following the spread of the virus COVID-19 and also studied the habits and behaviors of the Algerian population during this new way of life and this through a cross-sectional survey launched after three days from the start of confinement to quickly assess the impacts over the period from 23 March to 12 April 2020, by an online questionnaire which allowed us to obtain 678 responses from Internet users, who live in confinement in Algeria. According to the gender variable, our sample includes 405 men, or 59.7%, and 273 women, representing 40.3%. The results of the statistical analysis carried out using SPSS version 22.0 software showed that 50.3% of the respondents were in an anxious situation during these first three weeks of confinement. In addition, 48.2% feels stressed, 46.6% of the respondents confirmed to be feeling in a bad mood, and 47.4% do not stop thinking throughout the day about this epidemic and how to protect themselves. In addition, the study shows that 87.9% of the respondents in Algeria found it difficult to follow the confinement instructions. A significant change in the habits of the population was noted especially for the time of going to bed, the time of waking up, and the use of the Internet as well as the hours devoted to daily reading.