The COVID-19 pandemic has raised concern of viral transmission during otolaryngological procedures by means of droplets/saliva. The use of PPE and isolation settings are mandatory during surgery. This paper describes the development of the STAPID setting to reduce salivary spread during a sialendoscopy-assisted transfacial removal of a parotid stone.

Since December 2019, Coronavirus disease-19 (COVID-19) has spread rapidly across the world, leading to a global effort to develop vaccines and treatments. Despite extensive progress, there remains a need for treatments to bolster the immune responses in infected immunocompromised individuals, such as cancer patients who recently underwent a haematopoietic stem cell transplantation. Immunological protection against COVID-19 is mediated by both short-lived neutralising antibodies and long-lasting virus-reactive T cells. Therefore, we propose that T cell therapy may augment efficacy of current treatments. For the greatest efficacy with minimal adverse effects, it is important that any cellular therapy is designed to be as specific and directed as possible. Here, we identify T cells from COVID-19 patients with a potentially protective response to two major antigens of the SARS-CoV-2 virus, Spike and Nucleocapsid protein. By generating clones of highly virus-reactive CD4+ T cells, we were able to confirm a set of 9 immunodominant epitopes and characterise T cell responses against these. Accordingly, the sensitivity of T cell clones for their specific epitope, as well as the extent and focus of their cytokine response was examined. Moreover, by using an advanced T cell receptor (TCR) sequencing approach, we determined the paired TCR sequences of clones of interest. While these data on a limited population require further expansion for universal application, the results presented here form a crucial first step towards TCR-transgenic CD4+ T cell therapy of COVID-19.

Remote communication in ENT has been expanding, spurred by the COVID-19 pandemic. Conferences and teaching have moved online, enabling easier participation, and reducing financial and environmental costs. Online multi-disciplinary meetings have recently been instigated in Africa to discuss management of cases in head and neck cancer, or cochlear implantation, expanding access and enhancing patient care. Remote patient consultation has also seen an explosion, but existing literature suggests some caution, particularly because many patients in ENT need an examination to enable definitive diagnosis. Ongoing experience and more research is needed to better understand how remote communication will fit into our future working lives, both during and after the pandemic.

A document by kadir karkin, written on Authorea.

During the COVID-19 pandemic, many specialists doctors found themselves in a situation that they had not faced for a long time: treating patients out of their subarea of expertise. The possibilities of teaching and learning through the modalities of webinars brought to these days the urgent necessity for teamwork and interdisciplinary approach, taking advantage of different areas of expertise to the same patient. With the amount of papers published and the speed at which data are accessed, and analyzed it is impossible to be aware of new findings in all medical areas. The lesson that the COVID-19 pandemic brought to us was the urgent need for the interdisciplinary approach to treating better our patients, and not only each disease they present with. We must review our traditional approach to medical students, residents, colleagues, and patients in which we became stuck to distance and time obstacles. We must use the technology on our behalf to offer the best treatment and follow-up for patients. We live now in the Medicine 4.0 era. As Darwin a long time ago proved: we must evolve!

Objective To test the hypothesis that there is seasonal variation in the rates of gestational diabetes (GDM) diagnosed using a 2 hour oral glucose tolerance test. Design Monthly assessment of the percentage of women screened from 1st April 2016 to the 31st December 2020 who were diagnosed as having gestational diabetes Setting London Teaching Hospital Population 28,128 women receiving antenatal care between April 1st 2016 and 31 December 2020. Methods Retrospective study of prospectively collected data. Main Outcome Measures Proportion of women screened diagnosed as having gestational diabetes. Results The mean (SD) percentage of women diagnosed with GDM was 14.78 (2.24) in summer (June, July, August) compared with 11.23 (1.62) in winter (p < 0.001), 12.13 (1.94) in spring (p = 0.002), and 11.88 (2.67) in autumn (p = 0.003). There was a highly significant positive correlation of the percentage testing positive for GDM with the mean maximum monthly temperature (R2 = 0.248, p < 0.001). There was a statistically significant 33.8% increase in the proportion of GDM diagnoses from June 2020 onwards, possibly related to a reduction in exercise secondary to the Covid-19 pandemic. Conclusions There is a 23.3% higher rate of GDM diagnoses in the warmer summer months. There has been a 33.8% rise in GDM diagnoses associated with the Covid-19 pandemic.

Objectives: This study aims to (i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post-extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort. Design: A multi-site prospective observational cohort study Participants: 100 adults with confirmed COVID-19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive. Main Outcome Measures: Oral intake status, level of diet modification and perceptual voice quality. Results: Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% unable for oral intake. Age (OR 1.064; 95% CI 1.018-1.112), proning (OR 3.671; 95% CI 1.128-11.943), and pre-existing respiratory disease (OR 5.863; 95% CI 1.521-11.599) were predictors of oral intake status post-extubation. Two-thirds (66%) presented with dysphonia post-extubation. Intubation injury (OR 10.471; 95% CI 1.060-103.466) and pre-existing respiratory disease (OR 24.196; 95% CI 1.609-363.78) were predictors of post-extubation voice quality. Thirty-seven percent required dysphagia rehabilitation post-extubation whereas 20% needed voice rehabilitation. Dysphagia and dysphonia persisted in 27% and 37% cases respectively at hospital discharge. Discussion: Post-extubation dysphagia and dysphonia were prevalent amongst adults with COVID-19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Introduction: Most patients with COVID-19 have mild or moderate manifestations, however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID-19. Objective: Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and to identify the main initial clinical manifestations in these cases. Methodology: We assessed triage times before and after the use of Smart Check in 11,466 patients. In this group, we identified 211 patients for the identification of COVID-19 clinical manifestations in a case-control analysis. Results: Smart Check was able to decrease the triage time by 33 seconds on average, with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID-19 initial manifestations. Those with the highest frequency were dry cough (46.8%), fever (41.3%), dyspnea (35.8%), and headache (32.1%). Loss of appetite, fever, and ageusia were the manifestations that had a statistically significant association with the SARS-CoV-2 presence. Conclusions: Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimize triage time for patients with and without COVID-19. In triage centers, a number of initial signs and symptoms should be cause for SARS-CoV-2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations. Keywords: new coronavirus, COVID-19, triage, clinical manifestations

Aims to evaluate the incidence of cardiac arrhythmias during a lockdown period due to COVID-19 pandemics in a population followed by remote monitoring through implanted cardiac defibrillators. Methods and results In this retrospective, multicentre cohort study, we included 574 remotely monitored automatic (AICD) and cardiac resynchronization devices (CRT-D) recipients implanted before January 1st 2019 at seven Hospitals of Campania Region, comparing the incidence of arrhythmias occurred during the lockdown period due to COVID-19 epidemics (from March 9th to May 1st 2020) with the arrhythmias rate of the corresponding period in 2019. An effective retrospective data collection was performed through remote monitoring, as this tool allows the direct transfer of the the information stored by the implantable devices to medical personnel. During the lockdown period, we observed ventricular tachyarrhythmias (ventricular tachycardia or fibrillation) in 25 (4.8%) patients as compared to 12 (2.3%) during the corresponding 2019 period (p < 0.04); new-onset atrial fibrillation was detected in 38 (8.2%) subjects during lockdown period and in 24 (5.2%) during the reference period (p < 0.004). Conclusion During pandemics lockdown period we observed an higher incidence of arrhythmic events in ICD/CRT-D patients followed up through device remote monitoring by seven hospitals of Campania region.

Objectives: This study investigated the relationship between viral load and the incidence and recovery of olfactory and gustatory dysfunction (OD and GD), incidence of respiratory and gastrointestinal symptoms in COVID-19 patients. Design: A Retrospective Cohort Study. Setting and Participants: In total 599 outpatients’ cases polymerase chain reaction (PCR)–confirmed COVID-19-positive patients in Golestan province were included in the study. Main Outcome Measures: The incidence of OD, GD, their severity and the time of recovery was determined. The association of these variables with cycle threshold (CT) values of SARS-CoV-2 polymerase chain reaction was assessed. Results: The mean age of patients was 38.27 ± 13.62 years. The incidence of general symptoms included myalgia 70.1%, headache 51.8%, fever 47.7%, and dyspnea 21.4%. 41.9% of patients had gastrointestinal symptoms, including abdominal pain 26.5%, diarrhea 25.2%, nausea 20.5%, and vomiting 12.9%. 12.2% of patients had comorbidity. The trimester recovery rates of OD and GD were 93.94% and 94.74%, respectively. The mean recovery time of OD and GD was 14.56±13.37 and 13.8±3.77 days, respectively. The mean CT value in all patients was 27.45±4.55. There were significant associations between CT value with headache (P=0.04), GD (P=0.002) and OD (P=0.001). Conclusions: The intensity and the recovery of OD and GD in Covid-19 patients may be affected by initial viral load. Unlike to respiratory and gastrointestinal symptoms, the OD and GD were associated with lower viral load. Therefore, it may be recommended to use these clinical symptoms as an indicator in the initial screening of patients during pandemics.

Sepsis causes multi-organ dysfunction and is a major cause of death in intensive care units, but there are no treatments that reverse the pathophysiological effects of sepsis. Vitamin C has antioxidant, anti-inflammatory, anticoagulant and immune modulatory actions, so is a potential treatment for sepsis. Recent clinical trials of high-doses of intravenous vitamin C (6-16 g/day) had variable effects. Since much higher doses are without side-effects in cancer and burns patients, we studied the effects of a mega-dose of intravenous sodium ascorbate (150 g/40 kg) in a clinically relevant ovine model of sepsis. This treatment dramatically improved the clinical state and over 3-7-h improved cardiovascular, pulmonary, hepatic and renal function and reduced body temperature. In a critically ill COVID-19 patient, intravenous sodium ascorbate (60 g) restored arterial pressure, improved renal function and increased arterial blood oxygen levels. Clinical trials are testing the effectiveness of mega-dose vitamin C in septic patients.

We present in this report case of a-19-year-old teenager who had presented in her near term, infected with COVID-19 and delivered in rural part of Nepal. She is probably one of the first COVID-19 infected case in this country to be delivered normally.

A document by Indrani Roy, written on Authorea.

critically ill patient critically ill patient critically ill patient

The massive raise of COVID-19 cases all over the world is leading to unprecedented pressures on healthcare services. Growing evidence is highlighting that COVID-19 is a systemic condition that requires doctors with multiple expertise. Paediatricians are trained in these skills. Considering the issue of staff shortage that is facing every country in the world, and the complexity of COVID-19, paediatricians may represent an important source of ready and skilled specialists that can quickly translate the paediatric practice in the COVID-19 care. We report our experience of paediatricians engaged in the fight against COVID-19 within adult COVID-19 wards. In particular, we focus on the importance of a skill of some paediatricians in their clinical practice, namely the use of lung ultrasound which has also become fundamental in the management of adult patients with COVID-19, especially for some categories such as pregnant women.

Background: Despite numerous prior interventions to reduce unnecessary visits to the emergency department (ED), overutilization and overreliance on EDs continue to negatively impact quality of care and cost. Objective: Motivated by finding solutions to ED overuse, we evaluated the effect of COVID19 on pediatric ED utilization, specifically focusing on patients with pulmonary diagnoses. Methods: A retrospective study was conducted to review visits to the pediatric ED at Phoenix Children’s Hospital. The baseline pre-COVID19 period ranged from 01/01/2016 to 03/14/2019. Post-COVID19 data were collected from 03/15/2020 to 07/31/2020. Study subjects included all patients between 0-18 years of age. Data was collected biweekly for the number of ED visits, admission to hospital from ED, presenting diagnosis and pulmonary consults. Results: The average number of biweekly ED visits decreased significantly from 3437 during baseline to 2061 post-COVID19, while the percent of hospital admissions increased from 0.14% to 0.18% (p< 0.01). A significant decrease was also observed in the biweekly average number of pulmonology consults (527 to 250), and the percent of pulmonology consults (0.15% to 0.11%), presenting diagnosis of asthma (130 to 59), tracheostomy (7 to 6), cystic fibrosis (7 to 5), cough/wheeze (66 to 41) and bronchiolitis/upper and lower respiratory tract infections (300 to 126). No changes were detected in chronic respiratory failure, respiratory distress or hypoxemia. Conclusion: Many factors including telehealth, improved infection control measures, social responsibility, and fear of getting sick may have played a role in the reduction in our ED visits during the COVID pandemic.

Introduction: Due to the high mortality of coronavirus disease 2019 (COVID-19), there are difficulties in the managing emergency department. We investigated whether the d-dimer/albumin ratio (DAR) and fibrinogen/albumin ratio (FAR) predicts mortality in the COVID-19 patients.Methods: A total of 717 COVID-19 patients who were brought to the emergency department from March to October 2020 were included in the study. Levels of d-dimer, fibrinogen, and albumin, as well as DAR, FAR, age, gender, and in-hospital mortality status of the patients were recorded. The patients were grouped by in-hospital mortality. Statistical comparison was conducted between the groups.Results: Of the patients included in the study, 371(51.7%) were male, and their median age was 64 years (50–74). There was in-hospital mortality in 126 (17.6%) patients. The area-under-the-curve (AUC) and odds ratio values obtained by DAR to predict in-hospital mortality were higher than the values obtained by the all other parameters (AUC of DAR, albumin, d-dimer, FAR, and fibrinogen: 0.773, 0.766, 0.757, 0.703, and 0.637, respectively; odds ratio of DAR>56.36, albumin<4.015, d-dimer>292.5, FAR>112.33, and fibrinogen>423: 7.898, 6.216, 6.058, 4.437, and 2.794, respectively). In addition; patients with concurrent DAR>56.36 and FAR>112.33 had an odds ratio of 21.879 with respect to patients with concurrent DAR<56.36 and FAR<112.33.Conclusion: DAR may be used as a new marker to predict mortality in COVID-19 patients. In addition the concurrent high DARs and FARs were found to be more valuable in predicting in-hospital mortality than either separately.Keywords: Covid-19, D-dimer, Fibrinogen, Serum Albumin, in-Hospital Mortality

This article reports an association of thrombotic thrombocytopenic purpura(TTP) with COVID-19. A 49-year old male presented with fever, diarrhea and altered mentation, was found to have COVID-19. On sixth hospital day, he developed thrombocytopenia, microangiopathic hemolytic anemia with schistocytes on peripheral blood film and worsening renal function signifying TTP.

BACKGROUND: Despite SARS-CoV-2 immunizations have started in most countries, children are not currently included in the vaccination programs, thus it remains crucial to define their anti-SARS-CoV-2 immune response in order to minimize the risk for other epidemic waves. This study seeks to provide a description of the virology ad anti-SARS-CoV-2 immunity in children with distinct symptomatology. METHODS: Between March and July 2020, we recruited 15 SARS-CoV-2 asymptomatic (AS) and 51 symptomatic children (SY), stratified according to WHO clinical classification. We measured SARS-CoV-2 viral load using ddPCR and qPCR in longitudinally collected nasopharyngeal swabs samples. To define anti-SARS-CoV-2 antibodies we measured neutralization activity and total IgG load (Diasorin). We also evaluated antigen-specific B and CD8+T-cells, using a labelled S1+S2 protein and ICAM expression, respectively. Plasma protein profiling was performed with Olink. RESULTS: Virological profiling showed that AS had lower viral load at diagnosis (p=0.004) and faster virus clearance (p=0.0002) compared to SY. Anti-SARS CoV-2 humoral and cellular response did not appear to be associated with the presence of symptoms. AS and SY showed similar titers of SARS-CoV-2 IgG, levels of neutralizing activity, and frequency of Ag-specific B and CD8+T-cells. Whereas pro-inflammatory plasma protein profile was associated to symptomatology. CONCLUSION: We demonstrated the development of anti-SARS-CoV-2 humoral and cellular response with any regards to symptomatology, suggesting the ability of both SY and AS to contribute towards herd immunity. The virological profiling of AS suggested that they have lower virus load associated with faster virus clearance.

Post renal transplant patients are generally immunosuppressed and remain at a higher risk for getting bacterial and viral infections. Most of these patients are taking immunosuppressive medications, including steroids. This case series highlights the clinical outcomes and characteristics of 8 post renal transplant patients who acquired COVID-19.

COVID-19 IgM/IgG false-positivity in a rheumatoid arthritis patient negative for RF and ACPA: exist of other serological interference?To the editor:The outbreak of coronavirus disease 2019 (COVID-19) which rapidly spread throughout the world is still threatening the global health safety. Diagnostic tests for COVID-19 divided into two main categories: detection of viral RNA and serological detection of anti-SARS-CoV-2 immunoglobulins including specific IgM and IgG[1].Recently, we came up with an 89-year-old RA patient. She was diagnosed of rheumatoid arthritis for interphalangeal joint pain and rheumatic factor (RF) positive over 15 years ago and had been taking prednisone 5mg per day. Since the spread of COVID-19, we gave her the test of SARS-Cov-2 IgM/IgG and nucleic acid routinely. The confusing results showed IgM and IgG positive and nucleic acid negative. This old woman had no epidemiological history due to poor lung function. To further clarify the diagnosis, we retest SARS-Cov-2 nucleic acid from throat, nasopharyngeal and anal swab specimen and got negative results again. Diagnosis of COVID-19 was eliminated. 6 months later, this lady was readmitted with persistent positive result of specific IgM and IgG and negative result of nucleic acid. Serological test of RF and anti-cyclic citrullinated peptide antibody (ACPA) showed negative.According current reports, serum IgM arrived peak need 16-30 days and rapid decayed, while IgG remained relatively stable up to 105 days post-symptoms onset[2,3]. In our reported case, the IgM and IgG had persisted for more than 6 months.Recent study reported that no cross-reactivity was observed between autoantibodies in autoimmune disease and SARS-CoV-2 antibodies[4]. Controversially, the false-positivity of anti-SARS-CoV-2 IgM was reported in RF IgM-positive serum[5]. Considering this case, some unknown factors besides RF IgM and ACPA may exist in serum of RA patients which cause persist false positivity of anti-SARS-CoV-2 immunoglobulin.In conclusion, medical history combined with nucleic acid tests still played the key role in diagnosis of COVID-19 when come with positive result of SARS-Cov-2 IgM and IgG. The false positivity could involve either IgM or IgG which may be caused by other cross-reactive factors besides RF antibody and ACPA. The potential mechanism remained further explored.

Objectives: Coronavirus disease 2019 (COVID-19) is an infectious disease, that’s the reason for the currently ongoing pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Angiotensin-converting enzyme (ACE2) has been recognized as the specific receptor of the SARS-CoV-2 virus. Although the possible effect of ACE2 gene polymorphism remains unknown, human ACE2 receptor expression influences SARS-CoV-2 susceptibility and COVID-19 disease outcome. In this study, we aimed to investigate the relationship between ACE gene I/D polymorphism, ACE2 receptor gene polymorphism, and Covid-19 severity. Methods: ACE gene I/D polymorphism and ACE2 receptor gene rs2106809 and rs2285666 polymorphisms were determined using PCR and PCR-RFLP methods, respectively in 155 Covid19 patients who were divided into 3 groups (mild, moderate, and severe) according to clinical symptoms. Results: However, the distribution of genotype and allele frequencies of ACE gene I/D, ACE2 receptor gene rs2106809, and rs2285666 polymorphisms was not statistically significant in all groups. Conclusions: In conclusion, in the study population, ACE gene I/D, ACE2 receptor gene rs2106809, and rs2285666 polymorphisms were not associated with the severity of Covid-19 infection. Although, ACE2 receptor gene expression may affect the susceptibility to Covid-19, there is no existing evidence that the ACE or ACE2 gene polymorphisms are directly associated with Covid-19 severity. Interindividual differences in covid-19 severity might be related to epigenetic mechanisms of ACE2 receptor gene expression or variations in other genes suggested to have critical role in COVID-19 pathogenesis such as proinflammatory cytokines, coagulation indicators. Keywords: COVID-19 , ACE , ACE2, rs2106809, rs2285666

Background: Seasonal influenza is a burden for emergency departments. The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures. Methods: Using a cross-over design, the cobas® Liat® Influenza A/B POC PCR test (Liat) was compared to standard clinical practice during the 2019/2020 influenza season. All adult patients (aged ≥18 years) with fever (≥38°C) and respiratory symptoms were included. Primary endpoints were prevalence of influenza infections in the ED and staff sick days. Secondary endpoints were frequency of antiviral and antibacterial therapy, time between admission and test result or treatment initiation, patient disposition, ED length of stay (LOS) and for in-patients mortality and LOS. Nurses were interviewed about handling and integration of POC testing. The occurrence of SARS-CoV-2 infections coincided with the second half of the study. Results: A total of 828 patients were enrolled in the study. All 375 patients of the intervention group were tested with Liat, 103 of them (27.6%) tested positive. During the intervention period staff sick days were reduced by 34.4% (p=0.023). Significantly more patients in the intervention group received antiviral therapy with neuraminidase-inhibitors (7.2% vs. 3.8%, p=0.028) and tested patients received antibiotics more frequently (40.0% vs. 31.6%, p=0.033). Patients with POC test were transferred to external hospitals significantly more often (5.6% vs. 1.3%, p=0.01). Conclusion: We conclude that POC testing for influenza is useful in the ED, especially if it is heavily frequented by patients with respiratory symptoms.

Vaccination against the COVID-19 virus began in December 2020 in the UK and is now running at 5% population/week. High Levels of social restrictions were implemented for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education outcomes and provision of non-Covid-19 healthcare. Weekly and monthly officially published values in 2020/21 were used to estimate the impact of seasonality and social restrictions on the spread of COVID-19 by age group, on the economy and healthcare services. These factors were combined with the estimated impact of vaccinations and immunity from past infections into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. It was applied prospectively to the next 6 months to evaluate the impact of different speeds of easing social restrictions. The results show vaccinations are significantly reducing the number of hospitalisations and deaths. The central estimate is that relative to a rapid easing, the avoided loss of 57,000 life years from a strategy of relatively slow easing over the next 4 months comes at a cost in terms of GDP reduction of around £0.4 million/life-year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting give significantly different trade-offs between costs and benefits of different speeds of easing. Disruption of non-Covid-19 Healthcare provision also increases in times of higher levels of social restrictions. In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies.