CME INDIA Presentation by Admin.

CME INDIA raises the curtain.

  • Understand it and tackle it wisely.
  • Very Grave Situation – We need to put on our thinking caps.
  • These observational points could save the life. Do not rely on traditional way of Covid Management.

Mysteries of Second Wave – COVID 2.0

CME INDIA Discussion:

Dr Vasanth Kumar, President Elect RSSDI (Research Society for study of Diabetes in India), Hyderabad Ponders:

  • There is something that is bothering me.
  • Young people are developing Covid-19 at significant rates—and hundreds have died.
  • According to an analysis of state data by the Washington Post, at least 759 people under the age of 50 in the United States died from Covid-19 as of Wednesday. The Post identified at least 45 deaths among patients in their 20s, at least 190 deaths among patients in their 30s, and at least 413 deaths among patients in their 40s. The Post noted that the actual number of Covid-19 deaths among people younger than 50 is likely higher, as not all states report Covid-19 deaths by age.
  • CDC data on more than 1,400 hospitalizations related to Covid-19 shows people under the age of 50 accounted for about 25% of the hospitalizations.
  • I have been observing that many younger individuals below 50 are becoming sick and needing Oxygen more often than the older.
  • We have been concentrating on older and those with comorbidities and stressing that they are more vulnerable.
  • Is this really true?
  • I have observed that most of the people in 80s even with Diabetes had only mild symptoms.
  • How do we account for this?
  • Do we need to rethink about the disease?

Dr S C Jha, Internist, Darbhanga:

It remains an enigma why younger people with supposedly stronger immune system are more vulnerable?

Dr N K Singh, Diabetologist Physician, Dhanbad:

Millions dollar question. But no clear answer exists. Definitely, present mutated virus is something different, behaving in different pattern. Everything depends on type of strain. Please see this comment by Dr Meenakshi Bhattacharya (made previously on…

Dr Meenakshi Bhattacharya, Aurangabad, Maharashtra (Observation A to K):

A. Rapid worsening of pulmonary phase is observed.
B. Younger population is also presenting with severe pulmonary phase (Cytokine markers are not very high which was observed during first phase)
C. Mortality is high in younger population and patient without having any comorbidity also.
D. Disease progression and outcome is becoming unpredictable. During first wave we could tell relatives that which patients are likely to improve. Now due to rapid worsening it is becoming unpredictable.
E. It was easier to tackle severe cytokine storm and we had predictable disease outcome. But now it is more severe pulmonary phase occurring at earlier stage of disease.
F. There are four groups in the admitted patients:

[G-1] Moderate disease group responding to Inj. Remdesivir getting discharged on 9th to 15th day of admission.

[G-2] Rapidly worsening pulmonary phase presenting with severe to critical disease and dying within first three to five days of admission (may be 7th to 9th day of illness).

[G-3] Patients fighting through the severe COVID pulmonary phase but losing the fight on 15th to 20th day of illness (we were able to save many of these patients during last phase).

[G-4] Fourth group is patients getting admitted with good oxygen saturation of 96-97%. Require low flow o2 start worsening irrespective of third day of Inj. Remdesivir oxygen requirement worsen very fast get intubated on 4th day and losing fight within 5-6 days of admission.
G. Home isolation is giving false sense of security to upper middle-class patients. Getting admitted late and losing lives.
H. Fifth day of fever, or severe body ache, persistent cough, malaise or severe weakness having mildly raised cytokine markers but having normal oxygen saturation even after a 6-minute walk test are getting rapid recovery after Inj. Remdesivir.
I. During first phase we had a special step down ward where there were 15-20 recovering patients either on NIV or on reservoir bag 10-15 litres of oxygen/min or low flow oxygen in the 4th -6th week of admission. This time survival after third to fourth week is reduced.
J. Shifting of patients from one place to another cause worsening of general condition and worsening oxygen saturation during travel. – multiple pulmonary thromboembolism??? Need to study D Dimer before and after shifting of moderate to severe patients.
K. Many critical patients could be discharged during first phase.

Dr Vasanth Kumar President Elect RSSDI, Hyderabad:

  • Then why are we not concentrating on this issue? Why are we repeatedly talking about old people?
  • Diabetes is highlighted as killer in Covid, which I am not prepared to believe. I have seen many Uncontrolled Diabetics doing well. I don’t agree to give credit to Remdesivir for recovery in peoples with mild disease, who are any way recovering.
  • I feel any young person whose fever does not come down at the end of 5 or 6 days is at high risk of developing complications and we need to closely monitor them, check their CRP and start them on steroids even if their saturations are good.

Dr Shashank Joshi, DM Endo, Mumbai:

Pick the vulnerable early. Remember 3 issues here:

1. In home care, Covid has a 14 days’ time table and they dip on day 5 to 10. Many do not do 6 min walk test or red flag desaturation and come late or dead. So, in this phase Covid home care has to have 12 hours medical connectivity with a doctor to assess and treat.
2. Delayed pulmonary phase needs prompt steroid and oxygen, which can be useful life saving.
3. The key is to pick up cytokine storm early in this group.
Focus on simple things from CBC and CRP, rising CRP and simple RDW above 14.5 and NLR if high or lymphocytopenia is reasonable to red flag them and institutionalize them if needed.
This strain has 2 unusual challenges:

a) Myocarditis which may have sudden arrhythmia which can lead to death; need for simple LMWH.
b) Gut involvement is also seen.

Dr Noni G Singha, Physician, Dibrugarh, Assam:

  • One need to act early as people are getting early pulmonary phase, cytokine strom and dying in 4-5 days’ time in this second wave.
  • One should not wait for SpO2 level to fall and start treatment. So, clinical finding CXR and severity markers at diagnosis and every 2 days for initial 8-10 days is most important to guide the treatment.

Dr Ambrish Mithal DM Endo, Delhi:

  • There is clearly a change in pattern from last year.

Dr (Prof) Sidhartha Das, Cuttack:

  • The situation in India is a bit different as conveyed by Dr. Bhargav DG, ICMR & Secy. Health Research GOI.
  • There has been hardly any statistical difference in rate of infection in the age groups of 0 to 19, 20 to 40 yrs. in India as compared to last year. Yes, the death rate is higher in the second wave.
  • After October 2020, we allowed teaching institutions to open in a phased manner and so also residential accommodation for students. Thus, since March 2021, many clusters of positive cases were detected in such places. This could be one of the plausible explanations to relatively more Covid-19 infection in younger age groups in India.
  • Still 70% or more affected are from above 40yrs age group. Detection in children often takes time as both parents and paediatricians were not appropriately conditioned for such exigencies.

Dr Vijay Viswanathan, Diabetologist, Chennai:

  • The virus causing the second wave seems to be more virulent and transmissible Even those with relatively milder CT scan score of 7 / 25 are needing Oxygen.
  • If One family member becomes positive most of others in the family are also becoming positive.
  • A stricter Home Quarantine is needed.
  • We are witnessing many RT PCR negative patients with lung opacities, dyspnea, higher D Dimer, CRP etc. …Our diagnostic kits are not detecting mutant strains.

CME INDIA Innovative Thought

Very Grave Situation – Time to put on our thinking caps.

Dr H D Sharan Sr Cardiologist, Ranchi:

  • When faced with unprecedented challenges, one must deviate from the normal and think out of a hat.
  • We are faced with such a situation. With the sharp surge in number of cases, we will have to think different and act differently.
  • In 2019, several hospitals in Ranchi were fined for having their own oxygen plants. It seems that one has to take proper permission from the government to have his own oxygen plant which was not done. Just think. If every hospital had an oxygen plant today, the oxygen cylinders would be available to those who are in home isolation because of not getting a bed.
  • The government now should make it compulsory for all big hospitals to have their own oxygen plants. Give a deadline of 6mths. For small Nursing Homes, less than 50 beds may be exempted from this.
  • There are no beds for many who really need hospitalisation because many beds are occupied by those who are receiving Remdesivir. The full course takes 5 days.
  • One word about Remdesivir. It is not a specific anti-viral agent against the SARS CoV2 virus. There is theoretical justification in using it as lab studies have shown that it interferes with replication of Virus. But many studies have shown no benefit with Remdesivir in preventing serious disease and deaths. Some studies do show its capability of shortening the hospital stay. We give it because we do not have any other anti-Viral agent to give and hoping that it will probably do some good to the patient. So, let us not panic if it is not available. This panic helps hoarding and black marketing of the drug.
  • Coming back to the beds being occupied by those receiving Remdesivir. How do we create more beds available to those patients who really need them?
  • Have a day care unit. Give 90 mints slots to each patient. The patient comes to the day-care daily for 5 days. He receives oxygen too if required. Gets Remdesivir in 100 ml of Saline, I/V Dexa 6 mg, and S/C Clexane 40 to 60 units and goes back home. You sanitize the bed and makes it ready to receive the next patient. Only thing required is right selection of patients. With 1 bed day care, you release 16 beds for those who need hospitalization. Was informed that Remdesivir can only be given to hospitalised patients. I wonder why?
  • I don’t know whether that’s feasible on technical grounds. Like cooking gas, can government supply oxygen by pipeline as we do it in hospital with big central cylinders from a common plant or plants area-wise to all clinics?

CME INDIA Tail Piece

“I was in the library of a home that felt centuries old. It was cozy and safe in the library but I knew that outside, a terrible plague was ravaging the world. It felt much more like Europe during the Black Plague than modern COVID-19 times,” – Barrett (who used the image of a plague doctor wandering a landscape of COVID-19 particles to represent her dream.)

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