A document by Mehreen Zaigham, written on Authorea.

Objectives: To determine clinical and laboratory features of pregnant woman with COVID-19 who require respiratory support. To recommend a management strategy that optimises maternal and fetal outcomes. Design: An observational cohort study of 7000 maternities between 1st March and 1st July 2020. Setting: Five maternity centres across a maternal medicine network in north-central London, UK Population: 69 pregnant women with confirmed acute SARS-COV2 Methods: Review of electronic healthcare records Main Outcome Measures: Clinical and laboratory features, maternal and fetal outcomes. Results: Respiratory support was needed by 15/69 . This cohort was more likely to present with dyspnoea (10/15 vs 10/54, p<0.001), a lower lymphocyte count (0.90.1 vs 1.40.1 x 109 cells/L; p<0.01) and hypokalaemia (3.80.1 vs 4.00.1 mmol/l, p<0.05). Radiological evidence of lung consolidation did not identify women in need of respiratory support. Women on respiratory support underwent childbirth at an earlier gestation than those who did not (36+4 vs 39+5 weeks, p<0.001), and required emergency c-section (6/15 vs 8/54, p<0.05). Childbirth did not improve respiratory function in those with severe disease, with 3 women remaining on invasive ventilation despite childbirth. Conclusions: Routine clinical data can identify pregnant women at risk of severe COVID-19. Pregnant women should be offered the same treatment as non-pregnant patients but iatrogenic childbirth should not be the default for women with severe disease. We propose a management pathway for pregnant women with severe COVID-19.

A document by Kam-lun Ellis Hon, written on Authorea.

ABSTRACT INTRODUCTION Tricuspid valve regurgitation (TR) and severe right ventricular (RV) systolic dysfunction may appear acutely after right atrial (RA) myxoma excision. Covid-19 infection may have a role in production of Heparin resistance. METHODS A case of post covid-19 infected RA myxoma was operated by surgical excision develop severe TR and acute right ventricular systolic dysfunction postoperatively for which Tricuspid valve ring annuloplasty was performed and RV was supported on Cardiopulmonary bypass (CPB). RESULTS RV dysfunction did not improve leading to cardiac arrest and death. Conclusion • Excision of RA myxoma can unmask the severe TR and severe RV systolic dysfunction not responsive to TV ring annuloplasty. • COVID-19 infection might have a role in production of heparin resistance. KEY WORDS: Covid-19, tricuspid annuloplasty, intraoperative heparin resistance, RV Dysfunction, cardiopulmonary bypass.

There is growing evidence that the clinical manifestations of COVID-19 are not just respiratory, but also gastrointestinal symptoms. The difference of organ infection should be considered. In addition, as a key molecule mediating viral infection of cells, angiotensin-converting enzyme 2 (ACE2) provides an important intervention means for the exploration of antivirus. This is particularly important as the pandemic intensifies.

A document by Gabriel Revon-Riviere, written on Authorea.

Background: The prevalence of prehospital delay is high among older adults with acute coronary syndrome (ACS), resulting in adverse health outcomes. The current study aimed to examine the associated factors of prehospital delay among patients with ACS during the COVID-19 pandemic. Methods: This cross-sectional study was conducted on a convenience sample of 300 older adults with ACS admitted to the emergency department. Bivariate and multivariate analyses, including stepwise linear regression, were used to explore the predictors of prehospital delay and length of stay. Results: Being widowed, education, pain intensity, the gradual onset of ACS symptoms, symptoms lasting for more than 30 minutes, feeling anxious about their ACS symptoms due to the COVID-19 pandemic, perceiving their symptoms as dangerous due to the COVID-19 pandemic, history of myocardial infraction (MI), and mode of transportation were associated with the time taken before seeking emergency care among older adults with ACS during the COVID-19 pandemic. Conclusion: Length of prehospital delay among the participants varied according to certain sociodemographic and clinical characteristics and biomarkers. Improved understanding of the associations between prehospital delay and these characteristics is crucial for achieving optimal ACS patient outcomes under the impacts of the COVID-19 pandemic.

Purpose: Given that nearly a quarter of the US physician workforce are international medical graduates (IMGs), many of whom remain on temporary work visas for prolonged periods due to processing delays, the pandemic has posed unique challenges to these frontline workers and has arbitrarily limited our physician workforce. Objective: The objective of the study is to understand the role of IMG physicians practicing in the US, their limitations and challenges due to immigration related issues. Methods: Using a cross-sectional survey across social media platforms, we obtained data from IMGs regarding their role in healthcare, to the impact of visa-related restrictions on their personal and professional lives. Results: A total of 2630 IMGs responded to the survey, Hospital Medicine (1684, 65.7%) being the predominant specialty encountered. 64.1% were practicing in Medically Underserved Areas (MUA) or Health Professional Shortage Areas (HPSA), with 45.6% practicing in a rural area. Nearly 89% of respondents had been involved with direct care of COVID-19 patients, with 63.7% assuming administrative responsibilities for COVID-19 preparedness. 93% physicians expressed inability to serve in COVID-19 surge areas due to visa-related restrictions. 72% physicians reported that their families would be at risk for deportation in case of their disability or death. Most respondents (98.8%) felt that permanent resident status would help alleviate the above concerns. Conclusion: Easing immigration restrictions could prove significantly bolster the current physician workforce and prove beneficial in our response to the COVID-19 pandemic.

We report a 64-years old man with B-cell CLL infected by SARS-CoV-2 during his hospitalization for a spondylodiscitis. Because of his health conditions the duration of the antiviral therapy was restricted to one week where we observed a transient disappearance of CD19+/CD5+ B-lymphocytes in peripheral blood.

This article proposes an extension of the hygiene hypothesis to explain chronic inflammatory diseases (CIDs) and their increase with westernization. Instead of emphasizing microbes that are missing/reduced due to westernization, a hypothesis is proposed that emphasizes the importance of microbes that are relatively novel. Environmental microbes encountered in association with a pre-agricultural lifestyle would presumably be the most coevolved with the human immune system and thus less likely to promote chronic disease. Post-hunter-gatherer era microbes (PHMs) are microbes that are encountered more frequently and/or at higher levels since humans ceased to live as nomadic hunter-gatherers. It is hypothesized that some PHMs, particularly those increasing with westernization, colonize human tissues and dysregulate/suppress the immune system. This hypothesized colonization of PHMs could cause allergy/hypersensitivity reactions leading to physiological stress, attacks on self-tissue, hypersensitivity reactions to similar cross-reacting environmental microbes and other allergens/antigens, greater vulnerability to diverse infections (e.g., COVID-19) and CIDs. Low-level colonization with diverse PHMs could explain high levels of comorbidities among CIDs, allergic responses to self-tissue (auto allergy), allergies to varied microbial taxa and allergen-initiated stress effects. Allergic reactions and the stress they cause might be adaptive by promoting expulsion and avoidance of potentially dangerous microbes. This is consistent with the observation that selective IgE deficiency leads to increased levels of diseases such as asthma, chronic rhinosinusitis, otitis media and autoimmune disease. PHMs that could be related to CIDs include microbes in tobacco smoke, increased Candida albicans and Aspergillus fumigatus that occurs in some situations, and increased exposure to Pseudomonas fluorescens and Yersinia spp. Additionally, fungi that tolerate multiple extreme environments have been found to be more likely to be opportunistic pathogens. This might suggest that microbes associated with human-created novel and extreme environments (e.g., antibiotics, xenobiotics) would have an increased ability to colonize and persist in humans. The PHM hypothesis could help explain contradictory findings on diet, why many chronic inflammatory diseases resemble chronic infections and why stress and xenobiotics are associated with CID incidence and exacerbations. Four foundations and 11 related hypotheses are discussed. Examples discussed include sarcoidosis, inflammatory bowel disease, asthma, long-term COVID-19 and Kawasaki disease.

A pandemic of 2019 novel coronavirus diseases (COVID-19) outbreak is a major public health emergency that has spread in the fastest speed, and caused the most extensive infection world widely. Transbronchial biopsy (TBB) and computed tomography guided percutaneous needle biopsy (CTPNB) is the most common and significant method for the diagnosis of lung cancer. During the COVID-19 pandemic, the indications of TBB and CTPNB must be managed strictly. Therefore, it is extremely indispensable to perform meticulous and individualized management for lung cancer patients to protect the patients from COVID-19.

Background: Co-infections of SARS-CoV-2 with respiratory viruses, bacteria and fungi have been reported to cause a wide range of illness. Objectives: We assess the prevalence of co-infection of SARS-CoV-2 with seasonal respiratory viruses, document the respiratory viruses detected among individuals tested for SARS-CoV-2, and describe characteristics of individuals with respiratory virus co-infection detected. Methods: Specimens included in this study were submitted as part of routine clinical testing to Public Health Ontario Laboratory from individuals requiring testing for SARS-CoV-2 and/or seasonal respiratory viruses. Results: Co-infection was detected in a smaller proportion (2.5%) of individuals with laboratory confirmed SARS-CoV-2 than those with seasonal respiratory viruses (4.3%); this difference was not significant. Individuals with any respiratory virus co-infection were more likely to be younger than 65 years of age and male than those with single respiratory virus infection. Those with SARS-CoV-2 co-infection manifested mostly mild respiratory symptoms. Conclusions: Findings of this study may not support routine testing for seasonal respiratory viruses among all individuals tested for SARS-CoV-2, as they were rare during the study period nor associated with severe disease. However, testing for seasonal respiratory viruses should be performed in severely ill individuals, in which detection of other respiratory viruses may assist with patient management.

Coronavirus disease2019(COVID-19) is a pandemic with no specific therapeutic agents and substantial mortality. It is critical to find new treatments. Convalescent plasma, donated by persons who have recovered from COVID-19, is the acellular component of blood that contains antibodies, including those that specifically recognize SARS-CoV-2. Therefore, for COVID-19 patients, Convalescent plasma, could prove lifesaving, such as improving the clinical symptoms, increasing the neutralizing antibody, decreasing the viral load , reducing the death rate, with safety and without seriously ADE. Meanwhile, it is urgent to perform large sample randomized controlled trials to confirm the transfusion timing, dosage, frequency and actively prevent adverse outcomes that may occur, establishing a standard procedure for treatment from convalescent plasma collection, preservation, transport, to transfusion.

Background. Patients with severe asthma may have a greater risk of dying from COVID-19 disease. Angiotensin converting enzyme-2 (ACE2) and the enzyme proteases, transmembrane protease serine 2 (TMPRSS2) and FURIN, are needed for viral attachment and invasion into host cells. Methods. We examined microarray mRNA expression of ACE2, TMPRSS2 and FURIN in sputum, bronchial brushing and bronchial biopsies of the European U-BIOPRED cohort. Clinical parameters and molecular phenotypes, including asthma severity, sputum inflammatory cells, lung functions, oral corticosteroid (OCS) use, and transcriptomic-associated clusters, were examined in relation to gene expression levels. Results. ACE2 levels were significantly increased in sputum of severe asthma compared to mild-moderate asthma. In multivariate analyses, sputum ACE2 levels were positively associated with OCS use and male gender. Sputum FURIN levels were significantly related to neutrophils (%) and the presence of severe asthma. In bronchial brushing samples, TMPRSS2 levels were positively associated with male gender and body mass index, whereas FURIN levels with male gender and blood neutrophils. In bronchial biopsies, TMPRSS2 levels were positively related to blood neutrophils. The neutrophilic molecular phenotype characterised by high inflammasome activation expressed significantly higher FURIN levels in sputum than the eosinophilic Type 2-high or the pauci-granulocytic oxidative phosphorylation phenotypes. Conclusion. Levels of ACE2 and FURIN may differ by clinical or molecular phenotypes of asthma. Sputum FURIN expression levels were strongly associated with neutrophilic inflammation and with inflammasome activation. This might indicate the potential for a greater morbidity and mortality outcome from SARS-CoV-2 infection in neutrophilic severe asthma.

Purpose: The aim of this study is to determine the problems occurring during the COVID-19 pandemic period in patients treated with intravitreal (IV) injection for diabetic retinopathy, and to provide recommendations for treatment management in these patients. Methods: Twenty-nine eyes of 17 patients were included in this prospective, observational study. The frequency of hospital visits, treatments performed, and detailed ophthalmological examination findings, including optical coherence tomography findings and glycated haemoglobin (HbA1c) values, were recorded in the period before the COVID-19 pandemic. During the COVID-19 pandemic period, the detailed ophthalmological examination findings and HbA1c values were noted after the patients who had delayed their routine control time (>90 days) applied to the hospital. New treatments were planned according to the current situation. Results: Seventeen patients who were diagnosed with diabetic macular edema were included in the study; 10 were female (58.8%) and seven were male (41.2%). The mean time interval between following visits was 45.52±5.85 days during the pre-pandemic period, but it increased to 110.41±13.47 days during the COVID-19 pandemic period (p<.001). Visual acuity (LogMAR) was 0.44±0.36 in the pre-pandemic period and 0.76±0.48 during the COVID-19 pandemic period (p=.003). Central macular thickness was 300.10±85.56 µm in the pre-pandemic period and it increased to 387.10±144.48 µm during the COVID-19 pandemic period (p=.007). In three patients, complications of diabetic retinopathy that could not be cured by medical treatment developed and surgical treatment was recommended. Conclusions: Delays in the treatment of diabetic retinopathy may cause permanent impairment in visual functions. The COVID-19 pandemic has caused an increase in the hospital visit intervals of patients, and this situation has resulted in disruptions in the follow-up and treatment of patients with diabetic retinopathy. Alternative diagnosis and treatment practices are needed in order to manage these and similar processes smoothly.

Objective To evaluate relationships between cycle threshold values and COVID-19 presentations and clinical courses in women presenting for childbirth. Cycle threshold values from polymerase chain reaction (PCR) testing are inversely proportional to viral burden and may be important predictors of disease state and infectivity risk. Design Retrospective cohort study Setting Three Yale-New Haven Health Hospitals between 4/2/2020-5/14/2020 Population Women presenting for childbirth who underwent SARS-CoV-2 PCR testing Methods Electronic health records were reviewed for socio-demographics, medical comorbidities, pregnancy and postpartum course, and COVID-19 symptoms and exposures. Records of SARS-CoV-2 positive women were reviewed for symptom onset, duration, and relation to test timing, disease course, and neonatal SARS-CoV-2 results. Main Outcome Measures SARS-CoV-2 real-time PCR cycle threshold values from positive tests were compared between asymptomatic and symptomatic women and in relation to disease severity. In women with symptomatic COVID-19, cycle threshold values were evaluated as a function of time since symptom onset. Results 1,210 women gave birth during the study period with 84 (6.9%) positive for SARS-CoV-2. Higher cycle threshold values were seen in asymptomatic SARS-CoV-2 positive patients (8/38 (21.1%) of asymptomatic women had cycle threshold <30 compared to 22/32 (68.0%) of symptomatic women, p<0.0001). In symptomatic women, values increased as time from symptom onset increased. Conclusion This study demonstrates higher cycle threshold values in asymptomatic patients and symptomatic patients tested remote from symptom onset, signifying older infections and detection of lower levels of viral RNA. Assessment of standardized cycle threshold values may help to understand disease characteristics and progression.

Objectives: To follow-up pediatric CF patients—in terms of health status and nutritional status—via Telehealth services during the COVID-19 pandemic. Additional aims were to measure the level of anxiety in the patients and their parents, and to determine the COVID-19 transmission status in the CF patients. Materials and Methods: The CF team supported the patients via remote contact, including dedicated telephone lines. During Telehealth Services interviews, in addition to obtaining information about the patients’ anthropometric measurements, health status, and CF-related complaints, the State-Trait Anxiety Inventory (STAI) was administered to the patients and the Hospital Anxiety and Depression Scale (HAD) was administered to their parents. Results: The study included 144 pediatric CF patients (74 male and 70 female). Mean age of the patients was 8.9 years. In all, 42 (29.2%) of the patients were tested for COVID-19, of which 4 were positive. The mean STAI score was significantly lower in the patient group than in the control group (P < 0.001). The mean HAD anxiety score was significantly higher in the parents of the CF patients, as compared to the parents of the controls (P = 0.005). The mean HAD depression score was also statistically higher in the parents of the CF patients (P < 0.001). Conclusion: Telehealth is an innovative method for providing healthcare services while maintaining social distancing, avoiding the risk of exposure and spread of COVID-19. Telehealth services reduce patients’ and parents’ anxiety, and increases their confidence in managing CF-related complications.

Newborn screening (NBS) of cystic fibrosis (CF) is not available currently in Hungary. Pediatricians should be able to recognize the illness based on the symptoms alone. Lack of NBS causes differential diagnostic challenges for physicians and delayed diagnosis of CF. We present a case of a two-year-old girl who was transferred to our hospital as a suspected Covid-19 patient with one week history of fever and coughing in March 2020. As Covid-19 was excluded, the severity of the clinical picture pointed towards an acute exacerbation of an underlying chronic condition. Her symptoms such as tachypnea, wheezing, lung crackles, hepatomegaly and clubbing of the fingers were all consistent with undiagnosed CF. In the end, sweat chloride level and genetic test verified the diagnosis. This case emphasizes the need of NBS in Hungary.

I agree with their implications on the weakness of the US healthcare systeml,2. As of Oct. 30 in 2020 using the last 200 days open data3, the number of daily deaths due to the COVID-19 in the US can be predicted by the state-of-the-art curve fitting with the 6th degree polynomial:Nov. 6 daily deaths 959,Nov. 13 daily deaths 1017, andNov. 20 daily deaths 1002.Fig. 1 shows the predicted three red points on the number of deaths on Nov. 6, Nov. 13 and Nov. 21 respectively. The graph was created by the curve-fitting Python program: usdaily.py4. If the US does not change the current policy against the COVID-19 pandemic, the number of daily deaths will not be alleviated in the next three weeks.

Rationale, aims and objectives: This study aimed to determine the residents’ perspectives on clinical practice during the pandemic of coronavirus disease 2019 (COVID-19). Methods: A cross-sectional survey was carried out online among medical residents in our hospital. The survey covered basic information, condition of clinical practice, and perspectives related to the COVID-19. Results: total 174 (26.8%) residents responded and completed the survey. Nearly half of the residents (51.7%) expressed willingness of going to the frontline to fight against the virus and 62.3% of the residents showed good morale. Online courses were delivered to 87.9% of the residents with satisfaction at 89.7%. Approximate one third of the residents concerned the impact of the epidemic on graduation (34.0%) and taking up an occupation (32.8 %). Majorities (79.3%) determined to be a doctor after the pandemic. Notablely 40.2% of the residents thought they were underpaid. 21.8% of the residents reported to be unfairly treated in clinical practice. Overall no statistical differences were revealed between internal medicine and surgery residents, and between those married and singles, regarding the perceptions related to the COVID-19. Conclusion: Administrators should take cognizance of perspective of the residents and formulate corresponding strategies to reassure trainees’ safety and continuous training, address the residents’ concerns and get prepared for the second wave of COVID-19.

The coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world. The disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which first appeared in Wuhan, China in December, 2019. Ever increasing data is emerging about COVID-19 and its effects on the arterial and venous circulation. Clinical features associated with COVID-19 suggest that endothelial cell dysfunction and microvascular thrombosis are to a large part contributing to resultant multi-organ complications. This review is aimed at highlighting the critical aspects associated with COVID-19 and its presumed microvascular angiopathic complications leading to multi-organ dysfunction.

Background: Coronavirus disease (COVID-19) has overwhelmed healthcare systems worldwide often at the cost of patients with serious non-COVID-19 conditions. Outcomes and risks of contracting COVID-19 in patients hospitalized during the pandemic are unknown. Objective: To report our experience in safely performing electrophysiology procedures during the COVID-19 pandemic. Methods: We examined non-COVID-19 patients who underwent electrophysiology procedures during the peak of the pandemic between March 16, 2020 and May 11, 2020 at seven Northwell Health hospitals. We developed a priority algorithm to stratify inpatients and outpatients requiring electrophysiology procedures and instituted a protocol to minimize hospital length of stay (LOS). All patients underwent post discharge 30-day tele-health follow-up and chart review up to 150 days. Results: A total of 217 patients underwent electrophysiology procedures, of which 86 (39%) patients were outpatients. A total of 108 (49.8%) patients had a LOS less than 24 hours, including 74 device implantations and generator changes, 24 cardioversions, five ablations, and one electrophysiology study. There were eleven (5.1%) procedure or arrhythmia related re-admissions and two (0.9%) minor procedural complications. Overall average hospital LOS was 83.4±165.1 hours and a median of 24.0 hours. For outpatient procedures, average hospital LOS was 9.4±13.4 hours and a median of 4.3 hours. Overall follow-up time was 83.9 ±42 days and a median of 84 days. During follow-up, two (0.9%) patients tested positive for COVID-19 and recovered uneventfully. No deaths occurred. Conclusion: During the peak of the COVID-19 pandemic, patients safely underwent essential electrophysiological procedures without increased incidence of acquiring COVID-19.

Coronaviruses (CoVs) are a large family of viruses responsible for the severe ill effects on human health. The most severe outbreak includes Severe Acute Respiratory Syndrome (SARS-CoV), Middle East Respiratory Syndrome (MERS-CoV) and Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). The COVID-19 poses major challenges to clinical management because no specific FDA-approved therapy yet to be available. Thus, the existing therapies are being used for the treatment of COVID-19, which are under clinical trials and compassionate use, based on in vitro and in silico studies. In this review, we summarized the potential therapies like small molecules, bioactive compounds, nucleoside and nucleotide analogs, peptides, antibodies, natural products, and synthetic compounds targeting the complex molecular interactions involved in COVID-19. In this review＞230 natural and chemically synthesized drug therapies were described with their recent advances in research and development being done in terms of their chemical, structural and functional properties. Further, provided insights on possible targets for viral cells, viral proteins, viral replication, and different molecular pathways for the discovery of novel viral- and host-based therapeutic targets against SARS-CoV-2.

The proposed approach presents substantial scientific evidence based on physics and clinical data to support a clinical trial of an energetic SARS-CoV-2 vaccine. This is particularly imperative in the absence of a pharmaceutical vaccine as well as its uncertain future efficacy and safety, considering the limited time for testing and rapid mutations of the virus. Some of the vaccine trials have already been halted due to volunteers falling ill. Physics and biophysics of the fundamental electromagnetic nature of the living matter, including microbes as well as water, support the imprinting of electromagnetic fields of microbes in water that elicits an immune response. Energetic vaccines can be rapidly mass-produced for both prophylaxis and treatment of the public and healthcare personnel against the original as well as mutated viral strains. These can be prepared through a standard homeopathic process, as well as an energy field imprinting device,* offering a unique potential in versatility, speed, and low cost in mass protection against the current and future public health emergencies. Other viral infections, epidemics, antibiotic-resistant, and vector-borne infections could be similarly addressed. Paradoxically, in spite of a general perception of homeopathy by physicians as the most alien and least scientific, among complementary and alternative medicine (CAM), it is just the opposite. Homeopathy carries formidable scientific support, with the specific proposed homeopathic model being fully in line with physicians’ superior knowledge of infectious diseases and medicine, making its adaptation into their practice intuitive and more effective than in the hands of non-MDs or DOs homeopaths. The practical advantage of the proposed homeopathic model in acute infections versus its oldest one of multisystemic, totality approach, yielding mixed results in chronic diseases, parallels a similar prevailing success of the corresponding conventional modalities in acute versus chronic diseases.