CMAAO Coronavirus Facts And Myth Buster: COVID-19 Update

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With inputs from Dr Monica Vasudev

1035: An analysis of primary human lung cells that were infected in the lab with SARS-CoV-2 revealed how the cells accumulated large amounts of lipid droplets. Following infection, the lung proteins downregulate the ability of lung cells to burn carbohydrates and fatty acids. Lung cells cannot hold fat. This could possibly explain some of the severe damage that is done to the lungs of patients with COVID-19. The virus depends on glucose uptake, cholesterol production, and fatty acid oxidation. Additional research is needed on the cholesterol drug fenofibrate before clinical trials can start.

1036: The antihistamine cloperastine, mostly sold in Japan, tends to block glucose uptake in lung cells and has shown some effect in fighting COVID-19.

1037: Moderna’s experimental COVID-19 vaccine led to a strong immune response and provided protection against infection in monkey study. The vaccine, MRNA-1273, when given to non-human primates provided protection against infection in the lungs and nose, and prevented pulmonary disease. Results of the study were published in the New England Journal of Medicine.

It appears to be an improvement over the results of AstraZenecas COVID-19 vaccine in a similar study. This study included 24 monkeys, where Moderna tested 10 micrograms or 100 micrograms of the vaccine against no treatment.

Both doses were found to be effective in protecting against viral replication in the lungs and lung inflammation. The larger dose also protected against viral replication in the nose of the animals.

1038: A vaccine being developed by AstraZeneca and Oxford University is among the most advanced in human trials. In a similar animal study, this vaccine also appeared to prevent damage to the lungs and prevent the virus from replicating. However, the virus actively replicated in the nose.

1039: A cohort of 145 patients below 1 month to 65 years separated by age noted that the youngest children had significantly lower median cycle threshold (CT) values compared to older children or adults. This indicated that they had equivalent or more viral nucleic acid in their upper respiratory tract than other age groups. These differences amounted to a 10- to 100-fold greater amount of SARS-CoV-2 in the nasopharynx of young children, noted the authors in a research letter in JAMA Pediatrics. However, these findings were limited to detection of viral nucleic acid and not infectious virus.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster: COVID Loss of Smell

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With inputs from Dr Monica Vasudev

1030: Loss of smell associated with less severe COVID-19 infection: A study published in the Annals of Allergy, Asthma & Immunology, has revealed that loss of smell seems to be an independent positive prognostic factor of less severe COVID-19 infection.

The study enrolled 949 patients with COVID-19. The patients were assessed at Rush University Medical Center from February 1, 2020, through April 3, 2020. In all, 198 (20.9%) patients reported loss of smell. Anosmia was shown to have a significant association with younger age (mean age, 46 vs 49 years; P = .02), female gender (64.7% vs 52.8%; P = .003), and higher body mass index (33.6 vs 31.5; P = .001).

Anosmia had a significant association with decreased hospitalization (odds ratio [OR] = 0.69), admission to intensive care unit (OR = 0.38), intubation (OR = 0.43) and acute respiratory distress syndrome (OR = 0.45). The results continued to be significant following further adjustment for allergic rhinitis and chronic rhinosinusitis.

Loss of smell was also associated with less lymphopenia and higher albumin levels, pointing to a less severe reaction to COVID-19 in patients with smell loss when compared with those with intact smell, suggested researchers.

Mean lymphocyte count was 1.84 ± 3.69 among patients with anosmia compared to 1.11 ± 0.81 among those without smell loss (P = .001). The levels of albumin were 3.02 ± 0.83 versus 2.77 ± 0.83, respectively (P = .02). Other laboratory values and inflammatory markers had no link with anosmia.

The study also revealed a significant association between anosmia and history of pre-existing smell dysfunction (OR = 4.66), allergic rhinitis (OR = 1.79), and chronic rhinosinusitis (OR = 3.70), in comparison with patients without loss of smell. [DG Alerts Excerpts]

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster: Paradigm shifts in COVID-19

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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 predictably 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 now we 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).
  • 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, is now joined by masking also at home.
  • Distancing of 3 feet has changed to 6 feet; with microdroplets, this distance is now 9 feet.
  • We started in 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-dimer is high, give anticoagulant; if early presentation, give antiviral, etc.
  • From mandatory ventilation, the concept has changed to noninvasive ventilation.
  • Children to grandparents; now children pose 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 of 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 tested person, there are 20 untested individuals; 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.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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