CMAAO Coronavirus Facts and Myth Buster: COVID Surge

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1052: Update on COVID-19: IMA-CMAAO Webinar on “Understanding Coronavirus differently”

15th August, 2020; 4-4.30pm

Participants: Dr KK Aggarwal, President CMAAO, Dr RV Asokan, Hony Secretary General IMA,Dr Ramesh K Datta, Hony Finance Secretary IMA, Dr S Sharma

Faculty: Dr KK Aggarwal, Padma Shri Awardee, President, CMAAO & HCFI

Key points from the discussion

The new coronavirus behaves in six different ways: Viral, bacterial, HIV-like, it causes immunoinflammation, thromboinflammation and cytokine storm.
This virus causes immune (antigen) triggered inflammation wherever ACE2 receptors are present. If there is pre-existing inflammation, it will flare up.
This is a disease of the inflammation of the digestive and metabolic fires of the body.
There are two types of fire or agni in the body: microbiome fire and my agni fire. The balance or imbalance between the two causes health and disease. This virus triggers and increases agni in the body, leading to disruption of the body’s thermostat, resulting in low grade fever.
If baseline CRP is less than 1, then no impact; if 1-3, then exacerbation of fire, and if more than 3, then there is high hyperinflammation leading to vasculitis, thrombus formation, neoangiogenesis and hypoxia.
The route of entry is GI or respiratory tract. The virus may be present in GI system much before it is seen in the respiratory system and even if not seen in the respiratory tract.
Skin biopsy may also be positive for the virus (Lancet).
If fragments of the antigen persist, the person may be a carrier; they may also cause recurrence of symptoms, reactivation of illness and trigger inflammation.
There are six antigens in COVID-19 virus: E, S, N, ORF 1a, ORF 1b and RDRP antigen. The RT PCR test assesses the antigens and not the virus.
E antigen is a must; it is common for all coronaviruses. If negative, no corona.
We do not know yet which antigen persists for more than 9 days. We must find out which of these antigens is infectious.
When we say RT PCR is positive, it is important to know which antigen is positive.
True Nat tests RDRP; Singapore, at airports, is testing N, ORF and S.
If we find out which part of the virus (antigen) is causing which inflammation, this could be a game changer.
In patients with insulin resistance, where there is already low grade inflammation, the trigger is faster and more significant.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster: RTPCR Memory T Cells

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With inputs from Dr Monica Vasudev

1046: A spurt of new studies has shown that a large proportion of the population — at some places, around 20-50% of people — might carry T cells that identify the new coronavirus despite having never encountered it before. Although it’s too early to ascertain how helpful they might be, but even a slight influence on immune response could make the disease milder.

While the new coronavirus was unknown until 8 months back, yet to some human immune cells, it was already something familiar.

This could be a case of family resemblance. For the immune system, pathogens with common roots can look alike, such that when a similar pathogen comes to call, the body may already have a clue of its intentions.

The presence of T cells has fascinated the experts, who state that it is too early to be able to tell if the cells will play a helpful, harmful or negligible role against the new coronavirus.

However, if these T cells exert even a modest influence on the body’s immune response, the disease might become milder. This could, in part, explain why some people become very sick while others don’t. (New York Times Excerpt)

SARS-CoV-2-specific T cell immunity in COVID-19, SARS and uninfected controls

Memory T cells that are induced by previous pathogens can build the susceptibility to, and clinical severity of, subsequent infections. There is limited information about the presence of pre-existing memory T cells in humans with the potential to recognize SARS-CoV-2.

In a recent paper published in Nature, researchers assessed T cell responses to structural (nucleocapsid protein, NP) and non-structural (NSP-7 and NSP13 of ORF1) regions of SARS-CoV-2 in 36 COVID-19 convalescents. Investigators noted the presence of CD4 and CD8 T cells recognizing multiple regions of the NP protein in all of them. Twenty three SARS-recovered patients were still found possess long-lasting memory T cells that were reactive to SARS-NP nearly 17 years after the 2003 outbreak, showing strong cross-reactivity to SARS-CoV-2 NP.

SARS-CoV-2 specific T cells were also identified in individuals with no history of SARS, COVID-19 or contact with SARS/COVID-19 patients (n=37).

SARS-CoV-2 T cells detected in uninfected donors had a different pattern of immunodominance, frequently targeting the ORF-1-coded proteins NSP7 and 13 as well as the NP structural protein.

Epitope characterization of NSP7-specific T cells exhibited recognition of protein fragments with low homology to ‘common cold’ human coronaviruses but it was conserved amongst animal beta-coranaviruses.

Therefore, infection with beta-coronaviruses tends to induce multispecific and long-lasting T cell immunity to the structural protein NP.

Understanding how pre-existing NP- and ORF-1-specific T cells present in the general population affect the vulnerability and pathogenesis of SARS-CoV-2 infection is important for the management of the COVID-19 pandemic.

[Bert NL, et al. Nature (2020)]

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster: COVID disputes

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With inputs from Dr Monica Vasudev

1040: Round Table Expert Zoom Meeting on “Role of e-mediation – online dispute redressal”

25th July, 2020, 11am-12pm

Participants: Dr KK Aggarwal, Dr AK Agarwal, Prof Mahesh Verma, Dr Ashok Gupta,

Dr Suneela Garg, Dr JA Jayalal, Dr Jayakrishnan Alapet, Dr Anil Kumar, Mrs Upasana Arora, Dr S Sharma, Dr KK Kalra, Advocate Ira Gupta

Key points from the discussion

Litigations in the COVID era are anticipated in large numbers. The new Consumer Protection Act came into effect in July. It has a separate chapter on mediation as a dispute redressal mechanism, so that timely justice or settlement can be done at affordable cost.
Disputes arise out of a communication gap; a mediator can fill this gap.
We need experienced, meaningful, respected and unbiased mediation cells.
Mediation is a voluntary process in which a mediator tries to bring together the disputing parties and reach a mutually agreeable solution. The mediator does not impose any decision or decides on the two parties; instead he/she creates a favorable environment, which helps to reach an amicable settlement.
Mediation allows the disputing parties to present their views directly and confidentially and importantly, without fear of any negative action. It eliminates the risk of litigation, saves time and energy as well as relationships and brings harmony. Parties themselves work out a solution.
In mediation, both parties have to agree to come willingly.
Cases related to medical law, family matters, neighborhood disputes, consumer cases, commercial matters can be discussed in the mediation cell.
Mediation cell is an independent body.
All mediation cells have to abide by certain principles, which are autonomy, beneficence, non-malfeasance, confidentiality, justice, voluntary, fast track, transparent and enforceable.
Steps of e-mediation: filing of complaint by an email, notice to other parties via email/sms/WhatsApp, hearing of both parties, identifying positions and underlying interests, identifying alternative solutions, revising and discussing solutions and reaching an agreement.
The mediator should be a neutral and impartial person. He/she is a facilitator in charge of the process and should improve communication between the disputing parties and promote voluntary decision making. The mediator cannot record the proceedings.
Any person regardless of caste, gender, religion, occupation can be a party to e-mediation. NGO, hospitals, educational institutes, public and private limited companies or sole proprietorship can be party to e-mediation.
Parties can file a complaint by writing or sending an email and explain using documents, charts, etc. They should be active listeners, give options, prepare for a future without litigation and maintain their relations with each other. They should not record the proceedings.
All relevant documents have to be submitted; complaint, supporting documents, reply by the other party, identity proofs and address proof; if a party is represented by another person, then authority letter is required.
Mediation has become all the more important now as Courts are closed on account of COVID and most people are working from home now.
Online dispute redressal is a new concept that is coming up in a big way in India; it reduces the cost of waiting; traveling is saved.
There are no state boundaries in e-mediation; anybody across the country can approach.
Patients usually lack faith in the mediation cells thinking that a mediator is biased, so mediator should be a third party, so that the settlement reached is unbiased.
In litigation, the case is filed in a court of law and there is a proper procedure of filing the case, of deciding the case. Since litigation is a time-consuming long-term process, there are alternate dispute redressal mechanisms like arbitration, mediation, conciliation, lok adalats.
In arbitration, one person as the arbitrator (agreeable to both) is decided by both parties, but since it is held according to the Arbitration & Conciliation Act, some proper procedure has to be followed.
Mediation came up for the first time in Section 89 of the Code of Civil Procedures.
In mediation, instead of going through proper procedure in the court, a third party (mediator) tries to conciliate and maintain relationship between two disputing parties together.
With telemedicine being used more and more, it is important to have online mediation cells, which can adjudicate the matter.
Proper documentation is the key for success in case of any dispute; this will save many litigations.
Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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