Frontiers in Emergency Medicine (E-Journal)
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Evaluation of the Incidence, Severity, and Mortality Rate of COVID-19 in Patients with Multiple Sclerosis Receiving Interferon β-1a
Get PDFWe enthusiastically read Payandemehr et al.’s study, which examined the effect of interferon β-1a (ReciGen, CinnaGen Co., Iran) on the severity of the disease in patients with COVID-19 and revealed that taking interferon β-1a (INF) significantly reduced the duration of hospitalization and the rate of mortality of hospitalized COVID-19 patients. INF is one of the main drugs in patients with relapsing-remitting multiple sclerosis (RRMS), and these patients mainly use this drug for a long time. We decided to examine whether the drug has an effect on the incidence rate of COVID-19 in MS patients and whether it affects the course of COVID-19 in case of infection. In November 2020, 75 RRMS patients treated with INF (ReciGen, CinnaGen Co., Iran) were evaluated for COVID-19. Fifty-seven and eighteen cases were female and male, respectively. Patients had a mean age of 36.9±7.2 years, disease duration of 7.0±4.4 years, and the INF use duration of 3.5±1.7 years. Of these 75 patients, only one patient (1.33%) tested positive for COVID-19. The patient was a 29-year-old female nurse working in the pediatric intensive care unit (ICU) and had been receiving INF for six years since the diagnosis of MS. She developed symptoms of cough, shortness of breath, lethargy, anorexia, constipation, and diarrhea in June 2020. The lung computed tomography (CT) scan indicated mild lung involvement, and the reverse transcription polymerase chain reaction (RT-PCR) test was positive for COVID-19. The patient continued her INF treatment, and the symptoms completely disappeared after five days. The patient did not require to be hospitalized during her COVID-19 infection. Therefore, the hospitalization rate due to COVID-19, hospitalization in the ICU, and mortality rate were zero in INF users. In a study by Sahraian et al. addressing 4647 MS patients revealed that the incidence of COVID-19 was 1.46%, which was similar to our findings concerning patients receiving INF. However, the hospitalization rate in the mentioned study was 25%, which was very different from that of our study. It should be noted that patients were taking a wide range of drugs in the mentioned study, and most of them were taking rituximab. Nevertheless, there was no relationship between the type of the administered drug and the chance of hospitalization in the mentioned study. Our findings suggest that there might be a link between the use of INF and non-hospitalization and lack of mortality in patients with MS infected by COVID-19. The obtained findings are in line with the results provided by Payandemehr et al.’s study. Although our study was observational and did not have a control group, it revealed that the INF administration might reduce the severity of the infection. However, the use of INF did not prevent COVID-19 infection. The positive effect of interferons on reducing the severity of COVID-19 has been indicated in other studies, as well. Considering its positive effect on COVID-19 and the fact that interferons have been used in the treatment of MS disease for many years, more attention should be devoted to administering this drug in patients with MS during COVID-19 as it can significantly reduce the risk of COVID-19 related complications
Why COVID-19?
Get PDFCOVID-19 is a highly contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an enveloped positive stranded RNA virus and the third member of the family Coronaviridae which has emerged as a zoonotic infection. The predecessor of this new pathogen caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Although corona viruses have been known since 1960’s, their familiar species were human pathogens and caused common cold and seasonal flu. SARS-CoV-2 is easily transmitted via respiratory secretions of an infected person, with a reproductive number (the average number of cases to which a single infected person will transmit the virus) of 1.4-2.5. Covid-19 has been estimated to have a case fatality rate of around 3%. As of today, asymptomatic transmission is assumed to be possible during the incubation period, which usually ranges from 2-14 days. The source of infection, animal host, and reservoir are currently unknown. In late December 2019, an outbreak of COVID-19 was reported from Wuhan city, China. The disease soon spread outside China borders and became rapidly prevalent all around the world. The pandemic announcement was officially made by World Health Organization (WHO) on 11 March 2020. Today COVID-19 has affected more than 212 countries and has made billions of people to be quarantined in their houses. Up to now, almost 1500000 confirmed cases of COVID-19 have been reported globally and the death toll has been declared to be 86000. In Iran, we are also facing this unprecedented global public health emergency, with about 65000 confirmed cases and 3993 deaths. This pandemic is beyond an expanding contagious disease and has influenced different features of life. Its enormous social, political, and specifically economic impacts all around the world are undeniable. In low- and middle-income countries this can potentially lead to a huge spike in poverty and collapse. Many vulnerable families have lost their income and access to the essential needs. Education systems have collapsed in many regions. The long-term effect of this global crisis has reduced economic growth even in developed countries. Economic effects of COVID-19 are estimated with dramatic variations. Orlik et al in Bloomberg hypothesized this cost to be $2.7 trillion. The political consequences are even harder to predict but quite significant and devastating, like the heated discussion, criticism and accusation flowing between the leaders of different countries. Since the pandemic is not yet over, the global influence will carry on to happen and make situation even more complicated. While the outbreak is evolving rapidly, health care systems across the world are actively fighting against the new virus. They have encountered many new challenges. Public health measures (such as active case finding, prompt isolation of cases and contacts tracing) to contain the spread of the disease in the society as well as provision of care for the unpredictably high number of people who are infected with the virus have stretched the healthcare system beyond its capacity. At the same time, protecting health care providers’ safety, which often requires provision of sufficient supplies of personal protective equipment, has definitely challenged the system. Societal demand for discovery of a definitive treatment and vaccine has also added to the complexity of the situation that the health care systems are facing. Studies about COVID-19 are increasingly being performed and published; many of them have not yet been fully reviewed and criticized by the academic community. Practitioners often find it difficult to find, appraise and apply the information they need amid the turbulence of their clinical practice. Furthermore, there are still many questions to be answered. The most efficient method for personal protection, methods of viral transmission, most accurate diagnostic approaches, and effective treatment options are yet to be determined. This special issue of the Advanced Journal of Emergency Medicine plans to specifically focus on COVID-19 by gathering the relevant scientific information available. We hope that by publishing high quality papers, this journal can provide its readers with further required information. Appropriate management of patients suffering COVID-19 as well as controlling this pandemic are our ultimate aspirations. We encourage further researches in this field by all scientists and physicians all across the world to be able to eradicate COVID-19 as soon as possible
The COVID-19 Pandemic and the Health Care Providers; What Does It Mean Psychologically?
Get PDFIn late 2019, the COVID-19 epidemic began in Wuhan, China, which quickly spread around the world, becoming an international concern and pandemic. As with previous SARS and Influenza H1N1 pandemics, medical staffs providing services to patients are exposed to increased levels of mental stress. This review article introduces these symptoms based on the experience of previous pandemics and the data available on COVID-19 pandemic, introducing the underlying and protective factors against mental distress. Evidence suggests that levels of stress, depression and anxiety symptoms increase in health care providers. Moreover, these symptoms are more common in women, nurses, and people who are at the frontline of providing health care services for COVID-19 patients. Given the need to pay attention to maintain and promote the mental health of medical workers to provide effective services, this review offers suggestions to the effective management of these conditions at the individual and organizational levels
Fighting COVID-19: What Are the Available Options?
Get PDFSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus, and its infection, coronavirus disease 2019 (COVID-19), have quickly become a worldwide threat. It is essential for clinicians to learn about this pandemic to manage patients. Among different aspects of the condition, is the treatment of this disease. Unfortunately, currently there is no effective treatment option that can be supported by evidence-based medicine. This review analyzes information from literature on treatments
Comparison of Three Methods for NG Tube Placement in Intubated Patients in the Emergency Department
Get PDFIntroduction: Tubular feeding is used, in patients who cannot take food through their mouths, but their digestive system is able to digest food. This method is safe and affordable for the patient and results in maintaining the function of the digestive system and reducing the risk of infection and sepsis. Objective: The purpose of this study was to compare the three methods of the NG tube placement in intubated patients in the emergency department. Methods: This study is a randomized, prospective clinical trial conducted between 2016 and 2018. 75 patients who had been referred to the emergency department were enrolled in the study and divided into three groups, to have their NG tube insertion using either the conventional method (Group C), or using brake cable (Group B) or applying Rusch intubation stylet (Group S) for highwayman's hitch or draw hitch. Results: The mean duration of NG tube insertion was not significant between three groups (p=0.459), but the mean duration of NG tube insertion in group B was 18.43 ± 2.71 seconds and less than the other groups. NG tube insertion by first attempt in the group B was associated with the highest success rate. There was no significant difference, however, in the success rate in NG tube insertion on first and second attempts (p=0.376, p=0.353). Conclusions: The use of brake cable as a guide wire during insertion of a nasogastric tube increases the success rate on first attempt. No meaningful difference, however, was noted in the overall success rate in NG tube insertion on first and second attempts
Conventional Radiograph Is Still Advised in the Diagnostic Work-up of a Shoulder Dislocation; a Letter to the Editor
Get PDFDear editor:
A shoulder dislocation is a common diagnosis at the emergency department, showing an incidence of 23.9 per 100,000 person-years. In the current diagnostic work-up, a radiograph is often used to confirm the dislocation. As radiographs are associated with radiation exposure, the ultrasound has been proposed as an alternative. Therefore, the study by Entezari et al is of great importance in evaluating the applicability of the ultrasound. However, the authors suggest that the ultrasound can be used as an alternative to the radiograph. In our opinion, an important advantage of the radiograph has not been discussed and we question some decisions that were made in terms of methodology. Therefore, we think that this study has to be seen in the light of these remarks
Changes in End-Tidal Carbon Dioxide (ETCO2) vs. Changes in Central Venous Oxygen Saturation (ScvO2) and Lactate Clearance as a Quantitative Goal Parameter in Treatment of Suspected Septic Shock Patients
Get PDFIntroduction: Physiologic indexes for therapeutic assessment of shock were introduced long time ago. Recent studies have evaluated central venous pressure (CVP), central venous oxygen saturation (ScvO2), lactate and end-tidal carbon dioxide (ETCO2) levels in this regard. Objective: To understand the potential diagnostic capability of ETCO2 in comparison with ScvO2, CVP and lactate in patients with suspected septic shock, we aimed to compare these parameters through a quantitative resuscitation treatment approach. Methods: In this cross-sectional study, 84 patients with suspected septic shock were selected randomly. All patients underwent quantitative resuscitation treatment approach. The following parameters were measured and recorded at baseline: ETCO2, CVP, ScvO2, mean arterial pressure (MAP), percentage of arterial oxygen saturation (SatO2), blood lactate levels, heart rate (HR), respiratory rate (RR), and the exact amount of urine output. At the time of treatment, and 3 hours and 6 hours after, all of the tests and measurements were re-implemented and registered by an emergency medicine specialist. Results: There was a significant positive correlation between ETCO2 and ScvO2 at all times (baseline: r=0.566, p<0.001; after 3 hours: r=0.409, p<0.001; after 6 hours: r=0.170, p>0.05). Furthermore, there was a significant inverse correlation between ETCO2 and lactate at all times (baseline: r= -0.538, after 3 hours: r= -0.677, after 6 hours: r= -0.799). There was no significant correlation between ETCO2 and CVP at any time (p>0.05). Conclusions: All parameters significantly changed over time, and the correlation between changes in ETCo2, ScvO2 and lactate clearance was significant
Prophylactic Recommendation for Healthcare Workers in COVID-19 Pandemic
No full textDuring COVID-19 pandemic, it seems that healthcare workers (HWs) are more prone to the infection than general population. Indeed, a high viral load atmosphere and infected medical equipment are sources for spreading the disease. Many HWs should care for patients in the intensive care units (ICUs) which are one of the most contaminated areas. However, despite the adequate protections, HWs are still exposed to the coronavirus. Moreover, some procedures such as tracheal intubation increase the risk of infection. Overall, the probability of contamination in HWs is three times more than that of other people. According to Keshavan et al., about 3300 Chinese HWs have been infected by COVID-19, with a mortality rate of 0.4%. In Iran, we have a large number of affected HWs, with 69 registered deaths until late March 2020. Most of them were young with no previous medical history. So we have to improve protection and plan additional arrangements against COVID-19.
There are several mechanisms for the antiviral activity of hydroxychloroquine. This drug is a weak base that concentrates on the intracellular sections including endosome and lysosome; so, viral replication in the phase of fusion and uncoating will be stopped. Also, hydroxychloroquine can change the ACE2 glycosylation and inhibits both S-protein binding and phagocytosis. The last mechanism would be the suppressing effect on cytokine production and the immunomodulatory effect of the drug. Based on in-vitro studies of chloroquine on SARS-CoV-1, its effective role as a prophylactic agent and a post-infection treatment has been raised. According to another cell-culture study, the preventive effect of the drug is estimated to be 24 hours before and 5 hours after the contamination. The weekly dose of 500 mg chloroquine, which is used for malaria prophylaxis, will result in a concentration below the EC50, which is not enough for inhibition of the novel coronavirus. But the minimum dosage, which is used for rheumatoid arthritis treatment (250mg daily) will result in plasma concentrations higher than EC50, which may be sufficient in this regard. Regarding this pharmacokinetics and in-vitro investigations a double-blind, randomized, placebo-controlled trial using chloroquine as a prophylactic agent for SARS-CoV-2 infection is ongoing. The recommended dose is a loading dose of 10 mg/kg from base drug followed by 150 mg daily (250 mg chloroquine phosphate salt). Subsequently, the number of infected patients will be assessed after 3 months. Another running clinical trial is a phase III triple blinded one employing hydroxychloroquine with 200mg daily dose for 60 days and the outcome as well as the rate of symptomatic infected patients will be evaluated. There is also another ongoing study on hydroxychloroquine as a COVID-19 post-exposure prophylactic agent prescribed within 3 days of either a HWs or household contact. The recommended dose is 800mg once, followed by 600 mg during 6 to 8 hours, then 600mg once a day for 4 consecutive days. Finally, the rate and severity of COVID-19 infections are compared. The study could probably show that 200-400mg of hydroxychloroquine per day is a reasonable prophylactic regimen for the exposed HWs.
To be more precise, our experience on the rheumatologic patients who tool 200 mg per day hydroxychloroquine, as well as the medical workers who received the same dose for prophylaxis against the novel coronavirus showed that hydroxychloroquine with a 200 mg/day dose can have a relative prophylactic effect on COVID-19. According to our data, the few cases who received 200mg of hydroxychloroquine per day, showed mild to moderate symptoms with no severe manifestations. However, the prophylactic dose of 400mg per day may be accompanied by some drug interactions and adverse effects in the long term; so 200mg of hydroxychloroquine is a rational prophylactic dose for practitioners who are exposed to the high viral load environment
Coronavirus Disease (COVID-19): 10 Questions and Discussion Points for Diabetes and COVID-19
Get PDFThe COVID-19 pandemic is now an international concern. COVID-19 is first reported in Wuhan, China on 31 December 2019 and affects different people in different ways. Evidence suggests that people with underlying disease are at higher risk for more severe disease. People with diabetes are not only more likely than the general population to have COVID-19 but also they are among those high-risk categories that can have serious illness if they get the virus
Point of Care Ultrasound as a Triage Tool in Novel Coronavirus. Is It Necessary or Not?
Get PDFOvercrowding during pandemics, such as COVID-19 necessitates the separation of respiratory patients in different locations with special protective measures. Thus, we allocated space to such a purpose and named it "respiratory emergency” in our emergency department and started to triage the patients coming in with respiratory tract signs and symptoms apart from others. However, the most critical point for the triage of respiratory patients is differentiation between COVID-19 and non COVID-19 suspicious patients as well as decision-making in terms of self- quarantine and outpatient treatment or admission. Considering the lack of test kits and more importantly, the uncertainty revolving around the performance and efficacy of tests, we used computed tomography (CT) scan as a triage tool, yet our machines cannot scan all these patients because we had up to more than eight hundred patients per day. Meanwhile three of us - emergency attending physicians - were under the impression that lung ultrasound may help. Therefore, we started to use lung ultrasound in a limited fashion. Fortunately, typical cases had peripheral and sub-pleural lesions that could be seen by ultrasound. Parallel to these efforts, limited reports were published about the use of ultrasound for COVID-19 in other regions. Evidently, a screen test is expected to have high sensitivity rather than specificity and the ultrasound provides this opportunity. Also we know the findings are not specific and for example we had observed these patterns in other viral epidemics, such as severe acute respiratory syndrome (SARS) or middle East Respiratory Syndrome (MERS). To date, several triage systems have been developed. The Italian version used by Dr. Volpicelli first and developed further by others, like that of Liam Devonport can exemplify this case. Furthermore, a simple triage system has been developed by Dr. Mike Stone, based on the ultrasound of lungs plus oxygen need. This flowchart summarizes Dr. Stone’s idea with three elements for decision-making consisting of: a) O2 requirement, b) B lines and c) consolidation. Three categories are enrolled. All patients with cough, fever and dyspnea or patients coming in from high-risk areas or those having close contact with covid-19 patients are enrolled. After bedsides sampling for polymerase chain reaction (PCR) test, the O2 saturation is measured and lung ultrasound is also done and then according to the data obtained, four categories are created as follows:
Inpatients for whom supplementary O2 is not required. If lung ultrasound shows A profile, patients can be discharged to home quarantine. If lung shows profile B, patients should undergo quarantine plus follow-up. This quarantine can be at home or institutes considering the facilities available.
Patients, depending on supplementary oxygen, should be admitted according to the findings of lung ultrasound. If they have only B lines, they are admitted in the ward but if they have profile B plus consolidation, we should consider intensive care unit (ICU) beds for them.
In essence, all these systems use lung ultrasound for decision-making, which is efficient in a majority of occasions, yet we have critically ill patients with dyspnea and decreased O2 saturation without proportionate changes in lungs even according to CT scanning. Thus, we could not justify their health status based on the findings of the imaging of respiratory system. To discover the cause of dyspnea in these patients, we included heart ultrasound in addition to lung ultrasound and witnessed a decline in ejection fraction and global hypokinesia, which can justify their unsatisfying health status. In the meantime, several case series about myocarditis in covid-19 reveal the prevalence of myocarditis between 7% and 20% among patients. Increased troponin and change of the electrocardiogram (ECG) in these patients confirm myocarditis and help us to calibrate our care for the heart complaints sooner and more effectively. This approach might provide better prognosis for these patients.
Recommendation
We suggest adding heart ultrasound to lung ultrasound in triaging the patients suspicious of COVID-19 or at least in the first doctor visit even if CT scan is available because myocarditis with pneumonia exists in some patients at the same time. Furthermore, we found that E-Point to Septal Separation (EPSS), as a reliable indicator of global hypokinesea in heart, can be used effectively instead of evaluating through eyeballing because eyeballing needs a high level of expertise and may be more operator-dependent and obtaining a four-chamber view in supine critically ill patients is difficult when the operator lacks expertise