CME INDIA Presentation by Prof. Dr. S. Arulrhaj, MD, PhD, FRCP(G), FRCP(L), MBA, National President, API, Head Acute Medicine, Sundaram Arulrhaj Hospitals & Research Foundation, Tuticorin.
Mask is the Vaccine.
Hand wash is the medicine.
Distancing is immunity.
Early Detection and Effective Treatment are Key.
Biography of SARS-CoV-2
| Family Name: | Corona viridae |
| Misnomers: | Manmade China-Virus |
| Date of Birth: | November or December 2019 |
| Place of Birth: | Wuhan, Hubei Province |
| China, Locality: | Huanan Seafood Wholesale Market |
| Birth Day in India: | 30th Jan 2020 |
| Profession: | Corona virus Disease 19, COVID-19 |
| Current Address: | Type-II Pneumocytes, Lung |
| Bar Code to Residence: | ACE2 |
| Roaming Address: | Rogue Virus, Globe trotter |
| Gen Bank Number: | MN908947 (NCBI) |
Define it
Acute Manageable Immunogenic Thrombogenic Inflammatory Viral Notifiable Disease.
Catch It
- Incubation period: 1-27 days
- Recovery time: 3 weeks to 6 weeks
- Frequently reported signs and symptoms of patients include:
- Fever, usually low grade (77%β98%)
- cough (46%β82%) Dry throat, Dry cough
- myalgia or fatigue (11%β52%)
- Loss of smell β Nose Corona
- Loss of taste β jaggery taste β Throat Corona
- shortness of breath (3%-31%) β Lung Corona
- Happy hypoxia (spo2)
- Low hand grip strength
- 6-minute walk test β plan 3-6 β 5% desaturation
- Any symptom with close contact.
- Any 1: symptom: taste, smell loss (partial or total), left red eye.
- Any 2: Fever, Throat irritation, SOB, Loose Motion.
- Any 3: Headache, Nausea, Vomiting, Rash, Pain Below Knees, Cystitis, Anorexia, Altered sensorium.
Confirm It
- Travel history to endemic areas.
- CBC.
- Chest X-Ray (cheaper & easier with 60% sensitivity).
- PCR (30%-70% sensitivity).
- Chest CT Scan (95% sensitivity, low specificity).
- IgM/IgG antibody test for COVID-19.
In Severe COVID-19
- Decrease lymphocyte count-Lymphopenia
- Decrease albumin
- Decrease haemoglobin levels
- Increase C-reactive protein (CRP)
- Increase Erythrocyte Sedimentation Rate Increase Lactate Dehydrogenase (LDH)
- Increase D-dimer
- Increase Ferritin
- Increase Neutrophil count
- Increase in NLR
- Increase Alanine Aminotransferase Increase Aspartate Aminotransferase
- Increase Cardiac biomarkers
- Increase Procalcitonin
Investigate It
- CBC, Neutrophil Lymphocyte Ratio 3:1 significant, >7 is severe.
- D-Dimer – more than 1.5-mcg/ml,>10 is severe
- S. Ferritin > than 400 nanogram /ml, severe > 1500
- CRP >2.5 mg/dl, severe >100
- Serum Procalcition – < 0.5 nanogram / ml
- LDH >220 IU/I, > 500 severe
- Serum IL6 levels: >8PCG/ml
Test it
1. RTPCR – gold standard, expensive, 6 hrs.
- Cycles threshold(Ct) number: 17-24 – high viral load.
- Cycles threshold(Ct) number: 24-31 – moderate.
- Cycles threshold(Ct) number: > 31 – low viral load.
2. CBNAAT – gene expert
- screening and confirmation
- result 2 hrs.
- ICMR – ICU & SARI
3. TRUENAT
- Detects genes
- result in 1 hr.
- ICMR – screening
4. Rapid antigen
- containment zones
- economic
- sensitivity moderate, specificity β high
5. Antibody test
- IgM: 3rd day β 22nd day
- IgG: 7th day β long period
Serology
CXR
6 patterns of COVID on chest X-Ray
Pattern 1 – Reverse Batwing
Pattern 2 – Multifocal lower lobe predominant consolidation
Pattern 3 – Peribronchial rounded consolidations
Pattern 4 – Multifocal bilateral consolidations
Pattern 5 – Ball pattern or round pneumonia
Pattern 6 – Bilateral symmetrical diffuse lung involvement
HRCT
All go in favour of Corona
- Peripheral lesions
- Ground Glass Haziness
- Consolidation patches
- Reverse Halosign
- Vaculation sign
- Air Bronchograms
- Prominent Pulmonary Vessels
- Crazy Pavement Patterns on CT-SCAN
RTPCR Negative CT Positive, what to do?
Virus enters through nose and throat.Β Will stay there 4 – 7 days in nose / throat.
- later descend to lung
- RTPCR taken for the swab from nose and throat
- hence RTPCR positive only in early days. When virus has moved in lungs, RTPCR is negative. BAL will help.
- Hence CT helps:
CORAD – COVID radiologist finding:
- CORADS 2-3: suspicious
- CORADS 4-5: confirmatory
Hence RTPCR may be negative
rtPCR, what you need to know?
Frequently asked questions:
1. What is the full form of RT PCR?
Ans: Reverse Transcription Polymerase Chain Reaction
2. Why test is only 67% specific & not 100%? What are the pitfalls?
Ans: Problem can be at 4 levels:
- very low viral load at the time of sample collection
- faulty sample collection
- improper transport of the sample &
- faulty laboratory technique.
So, test must be repeated in high clinical suspicion.
3. Is there any false positive result?
Ans: No false positives- positive is certainly positive. It can be false negative. (Repeat the Test- if high clinical suspicion).
4. How many types of antigen are present in COVID- 19 virus?
Ans: COVID-19 virus has 6(six) antigens – E, S, N, ORF 1a, ORF 1 b &, RDRP.
5. Which antigen is common to all corona viruses?
Ans: E antigen is common to all CORONAVIRUSES. If E is negative – No Corona. Other 5 are specific to COVID-19.
6. Do all countries test same antigens?
Ans: Testing of antigen differ from one country to another. In Singapore, chip machines check for N, ORF and S antigens at the airports.
7. Certified as Non-Infectious?
Ans: The patient demonstrates the presence of IgG antibodies with or without presence of antigens, the patient is asymptomatic after 10 days without doing antigen test, the patient is positive for 2 weeks, his ESR and CRP are normal.
Classification of COVID Patients Clinically
- Asymptomatic β RTPCR positive, no symptoms, X-ray β normal
- Mild – URI symptoms, Fatigue, fever, GI, CT Corad 1-2
- Moderate β Pneumonia, no hyposaturation, CT Positive Corad 2-3
- Severe β pneumonia with hypsaturation (SpO2 <92%) CT Positive Corad 4-5
- Critical β ARDS, shock, encephalopathy, HF, Coagulation dysfunction, AKI
Manage it Simply
OXYGEN β SUPER HERO
- Oxygen Therapy
- HFNO/ NIV/ Invasive
- Antibiotics
- Steroids
- Antivirals
- Heparin
- Monoclonal Antibodies
- Plasma Therapy
- ECMO
- Lung Transplant
Antibiotics in COVID
- Antibiotics act on Bacteria
- Bacteriostatic
- Bacteriocidal
- Antibiotics are not viricidal.
- Can be used to treat secondary infections
- They are for Off label use.
Why we are using in COVID?
Because of their:
- Non-Bactericidal Properties
- VIRISTATIC Properties
Effect on Virus
- Entry inhibition
- Inhibition of uncoating of virus
- Replication
- Post translational modification
Effect on Host
- Enhancing host immunity
- Preventing Cytokine Storm
DOXYCYCLINE, Why?
- Doxycycline showed its effect in
- Antiviral – Dengue
- Anti-Typhus
- Anti-Parasite β Malaria
- Doxycycline inhibited the post-infection replication in addition to reducing the virusβs ability to enter the cultured cells.
- Tetracyclines may act through their well-known anti-inflammatory capabilities including downregulation of the nuclear factorβk B pathway as well as a decrease in levels of inflammatory cytokines such as tumor necrosis factor-a, interleukin (IL)-1b, and IL-6 independent of its antibiotic mechanism.
- Two other studies showed that chemically modified tetracyclines can induce apoptosis of mast cells and activation of protein kinase C, thus decreasing levels of circulating inflammatory agents.
Ref: Doxycycline as a potential partner of COVID-19 therapies
Author links open overlay panel AlexandreE.MalekBrunoP.GranwehrDimitriosP.Kontoyiannis
HYDROXYQUINOLINE: Still Live, may be on backbench
- The effect of hydroxychloroquine and chloroquine on viral replication goes beyond cytokine inhibition.
- These medications are weak bases that can affect acid vesicles and inhibit several enzymes. This characteristic allows them to inhibit the viral entry to the cell when the endocytosis is pH dependent.
- It also inhibits glycosyl-transferases, viral post-translational modifications and replication of some viral families.
- The antiretroviral effect has been considered to be caused by the inhibition of viral glycosylation, a major antiviral mechanism of these drugs.
Prophylactic & Therapeutics
- Recovery Trial September 2020
Ref: https://pmj.bmj.com/content/early/2020/05/28/postgradmedj-2020-137785
IVERMECTIN Emerged as SHAKTIMAN?
- Inhibition of importin Ξ±/Ξ²1 mediated transport of viral proteins in and out of the nucleus
Bangladesh Study – observational study:
- No: 60 positive cases treated with
- Ivermectin Single dose and Doxycycline 200 mg day 1 & 100 mg BD X 7
- 19 cases Negative and symptom free
ICMR Started Ivermectin Schedule September 2020
API study is on
Monash University-led collaborative study
Prophylactic & Therapeutics
Ref: Gupta D, Sahoo AK, Singh A. Ivermectin: potential candidate for the treatment of COVID 19 [published online ahead of print, 2020 Jun 28]. Braz J Infect Dis. 2020; S1413-8670(20)30081-7. doi: 10.1016/j.bjid.2020.06.002
How you start?
- Protocol Based OXYGEN THERAPY.
- Document hypoxia by noninvasive or invasive methods.
- Start 2 therapy assessing SPO2 and deciding low flow system or high flow system.
- O2 therapy to be initiated if SPO2 less than 95%.
- Target SPO2 more than 94%.
- Titrate up or down based on monitoring spo2 and clinical assessment of hypoxia.
- For patients with normal rate and depth of breathing, each liter per minute of nasal O2 therapy increase the FIO2 by 4%.
Nocturnal oxygen therapy as an option for early COVID-19; Know itβ¦
Highlights:
- Oxygen supplementation may disrupt virus replication.
- Oxygen therapy can improve the antiviral immune response.
- An oxygen-rich environment may down-regulate ACE2 expression.
- Nocturnal oxygen therapy may delay the progression of COVID-19.HTS
Ref. International Journal of Infectious Diseases Volume 98, September 2020, Pages 176-179 By Chongxing Shena et al.
Mantra in COVID:
- Once diagnosed or suspect, on Day I, do baseline minimum, Quantitative CRP, CBC, Blood sugar, ESR, 6MWT, (Ferritin, D Dimer, IL6, tnf Alpha, RDW, LDH, Fibrinogen levels may add in deciding the clinical severity).
- On Day I, consider starting azithromycein: ivermectin: vitamin Lmelatonin, favipiravir, famotidine
- In health care workers or high-risk individuals with base line CRP>1MG/L start blood thinner Dabigatran 110 mg BID or Rivaroxaban 10mg OD or Abeiximab 2.5 mg BID or Enoxaparin SC (if hospitalized). Aspirin may not be helpful in big viral load.
- If high risk with comorbid condition, start low dose Steroids on Day 3(if there is an evidence of pneumonia as evident by fever>101 F, CRP>10MG/L, cough starting on day 3 or fall in SPO2 saturation by 4% or CT proven)
- Do 6MWT AND CRP daily on days 1-5.
- Treat fever with mefemic acid if not contraindicated (indomethacin/naproxen are other options). (Pareek Rp. Use of mefenamic acid as a supportive treatment or COVID-19: a repurposing drug. International Journal of science and Research(IJSR).2020:9(6):69
- Do not miss MI or CVA as the first presentation. (SiddamreddyS,et.al.Corona virus disease 20 (COVID-19)presenting as acute ST elevation myocardial infarction. Cureus.2020;12(4):e7782 Avula A,et.al.COVID-19 presenting as stroke. Brain Behav Immam 2020; 87:115-9).
- Do not miss COVID cystitis (pus cells with culture negative and no bacteria)
- High CRP can cause sudden reduction of LDL; be on the alert
- Consider high dose statins for low grade inflammation (CRP 1-3 mg% and high LDL>80 mg%
- On day 0, if CRP is 1-3 mg/L and LDL is high, there is high risk of acute thrombosis.
- Most antenatal cases (50%)will be asymptomatic. (Allotey J,et.al.(Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ.2020 sep 1; 370: m3320. doi:10.1136/bmj.m3320).
- Consider preoperative RTPCR in elective surgeries along with pooled RTCPR of family. (somashekhar SP, et.al.ASIβS Consenus Guidelines: ABCs of what Do and what not during COVID-19 Pandemic. Indian J surg, 2020 Jan 9:1-11).
- Isolation, quarantine and monitoring: you should isolate, quarantine and all family members and close contacts should monitor themselves.
Never Forget:
- We can reduce mortality if we monitor each case properly from day 6 to 12. PCR after 4 days.
- Start antivirals early and judiciously. Favipiravir is comparatively less effective than remdesmivir. Mild cases start favipiravir. Moderate to severe start remdesivir. If pt not improving clinically on favipiravir shift pt to remdesivir early.
- Don’t use Dexa with remdedivir. Use methylprednosolone inj with remdesivir.
- ABG is important in milder and severe cases. Prolonged high FiO2 is harmful, so manage Fi02 to maintain P02 around 60.
- When pt is on HFNO with flow more than 35lit per min, take precautions while giving DC shock in ICU. chances/ cases of fire are seen.
- Changing positions while ventilator helps to improve oxygenation.
- Patients with positive 6 min walk test should not go to washroom. He should use bed pan. Mortality is high in washroom while straining in hypoxic cases.
- Risk of mortality is high in relatives where any one has died due to COVID infection. (Genetic reason) so other positive relatives should be closely monitored.
- To reduce chances of pulmonary fibrosis, cases. with CT score, more than 15 should undergo repeat scan and should be on warfarin, oral steroids, and antifibrotic drugs like perfinidine etc. for minimum 6 wks. Then tapering of steroid.
- If COVID Pt develops AKI with good urine output but high creatinine and urea. All COVID cases needs adequate hydration.
- COVID patient can’t spread active virus after day 12 to 14.
- All home quarantine cases use surgical masks at home also. Use of hot flush or use of sodiumhypochliride for toilets is important to avoid spread at home. Virus spreads through fecal matter also.
- Now many paediatric cases are coming with bad COVID infection and mortality.
- No role of antivirals after day 14 of disease.
- Role of steroid from day 4/5 to day 18 to 20. (Judiciously used.)
What with Comorbidities?
- Age > 60
- Diabetes
- HTN
- CAD
- CKD
- Smoker
- Alcoholic CLD
- Cancer
- Immunocompromised
Watch for complications:
A. Immediate:
- Sepsis & Septic shock
- ARDS 7 Refractory Hypoxemia
- Happy Hypoxia
- ACS, HF, Myocarditis, Dysrhythmias HTN & Thrombo Embolism
- Diabetes; New onset & aggravation DKA
- GI, AKI, CNS & Skin
- The virus is present in skin. The Lancet has published a case report where RT PCR was negative, but the skin biopsy samples from rash, were positive for the virus.
B. Delayed:
- Pulmonary Fibrosis, Stroke, & ACS
- Reinfection
Wait for 2021
HOPE is there
CME INDIA Learning Points
- Swab negative, CT positive, high inflammatory markers- runs sick in ICU β Outcome bad
- Past CAD and autoimmune disorder on proper treatment has good outcome.
- Pt on aspirin, clopidogrel have mild disease – come out well.
- No emergency to correct hypoxia in high inflammatory markers. Patient tolerate hypoxia well.
- Chronic hypoxia in COVID does not cause more problem as we expect.
- Oxygen, statins, anticoagulant do good.
- COVID aggravates and cause hyperglycaemia. Glycemic control must be adequate with insulin.
- HTN control with ACEi and CCB is good
- DM stiffly controlled wit Insulin β Short & long acting
- Lung involvement and ischemic CVA is common. Use anticoagulant – They come out well.
- At discharge recommend aspirin 75mg Atrovastatin to be continued for 3 months.
- Radiological resolution takes 3 months.
- Reinfection is usually mild & numbers low, Reported in USA, Hong Kong & India
- Fit for Procedures & surgery: Asymptomatic, PCR Negative, IgG positive, Markers normal, ECHO & PFT normal. CT will take time.
RED FLAGS:
- Fever > 101ΒΊ F with drugs or > 103ΒΊF without anti-pyretics
- Persistent cough starting after day 3
- Sudden onset of shortness of breath (or exertional SOB)
- Rapid rise in CRP (>10 mg/L)
- More than 50% lung involvement on CT (13/25 score)
- Altered sensorium
CME INDIA Tail Piece
Decision Simplified:
- Corona is not a lung disease, a systemic Thrombo hyper inflammation Vasculitis Disease
- The Virus is non β replicating after Day 9. (Muge Cevik, et al. SARS β CoV-2, SARS- CoV-1 and MERS-CoV viral load dynamics, duration of viral shedding and infectiousness: a living systematic review and meta- analysis, MedRxiv, Posted July29, 2020)
- Fever > 101ΒΊ F, CRP > 10 mg/L, Rapid rise of CRP, Cough on Day 3 or fall of SPO2 on six-minutes walk test by 54% are suggestive of pneumonia.
- Day 5 is the THE day in critical phase (Fei Z,et.al.Lancet,2020;395 (10229):1054-62).
- Day 90 is THE day after which the word COVID ends (CDC Duration of isolation for adults with COVID-19. Updated sept.10,2020. Available at https://www.cdc.gov/coronavncov/bcp/duration-islation.btml
- Loss of Smell is THE symptom equal to RTPCR test (Hacbner A,et.al.ORL J Otorbinolaryngol Relat Spec.2020:82(4)175-80.
- 15 minutes THE time to get the infection (CDC Contact tracing for COVID -19. Available at: https://www.cde.gov/coronavirus/2019-ncov/plop/contact-tracing /contact βtracing-plan.
- Clinical Features, Serum Markers and CT scan of Chest are much better diagnostic tools than depending on PCR test
- RT PCR may remain positive up to 90 days, but Ct value should increase. (up-to-date)
- If RTPCR is positive after 3 months or becomes positive after two consecutive negatives, consider possible reinfection. (Gupta V, et al. Asymptomatic reinfection in two healthcare workers from India with genetically distinct SARS- CoV-2. Clin Infect Dis. 2020 Sep 23; ciaall 1451)
- Antibody test can be done once a month to check for exposure.
- RTPCR Ct is THE test for diagnosis (Tang YW,et.al.J Clin Microbial.2020;58(6)
- CRP is THE lab test for assessment of seriousness (Knight SR,et.al.BMJ.2020 Sep 9;370:m 3339)
- The six-minute walk test (6MWT) is now mandatory from Day 3-6. If the patient desaturates by 5% on walking, this is indicative of pneumonia with thrombosis and this is considered as an emergency.
- Toilets are recognized as a COVID chamber – Contact time from 30/10 minutes to 15/5 minutes in closed areas.
- Home Isolation is THE modality of Treatment (maria N,et.al.Int J Surg,2020;77:206-16)
- 12 years is THE age when the mortality starts (Gotzinger,et.al.Lancet child Adolese Health 2020;4(9):653-61).
- Remdesvir for all COVID 19 admitted pts irrespective of severity.
- Treatment is Anti coagulants and immune suppressants
- Steroids (high dose) for all hypoxic pts and shows mortality benefit.
- LMWH for pts with high D DIMER values.
- Tolicizumab more sepsis related complications, not much benefit.
- Starting treatment early even with Ivermectin and Doxycycline, followed by LMWH and dexamethasone at right time can reduce need of Remdesiver and Tocilizumab
- Anticoagulants may need to be given for 3weeks or more.
- Zinc is THE mineral (Wessels I, et.al. Front Immaunol, 2020;11;:1712); D is THE vita Z.et.al.PLoS One.2020;15(9):e0239799)
- People are developing Myocardial infarctions, Stroke, etc. few weeks after Corona infection – Thromboembolic phenomenon
- Oxygen is the superhero.
- Consider zero power eye glass for protection. (Maragakis LL. Eye protection and the risk of coronavirus disease 2019: does wearing eye protection mitigate risk in public, non- health care settings? JAMA Ophthalmol.2020 Sep 16 ) Glass provide partial barrier
- In OPD areas, consider screening for loss of taste and smell/ fever /SpO2 hand grip before entry
- Masking is THE prevention (Esposito S,et.al Enr Respir J.2020;55 (6):2001260).
- All HCPs (Care takers) while on duty (clinical and non- clinical areas) should wear N95/FF2P/Surgical, three- Layered Mask (correct and consistent use.) Transmission risk is < 0.5% with N95 mask. Y Qian, ei al. Performance of N95 respirators: filtration efficiency for airborne microbial and inert particles. Am Ind Hyg Assoc J.1998:59(2):128-32
- In India HCWs (care takers) in practice may consider ICMR recommendation and take HCQ 400mg per week, If not contraindicated. (Revised advisory on the use of Hydroxychloroquine (HCQ) as prophylaxis for SARS-CoV-2 infection, ICMR, 22/05/2020) I May change from country/state to country / state or as per WHO)
- In India if HCQ is contraindicated or by choice, may consider Ivermectin 12 mg once a week (UP protocol 1,7,30, days and then once a month).
- Vaccine will be ready by January 2021.
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Simply superb, one stop destination for knowing everything and anything about Covid19. Thanks a ton Sir.
Beautiful message depicting all parameter of the disease…
One of best write up of covid. Extremely informative.. Very well narrated
Very useful and updated information superb hats off to you sir
Excellent, exhaustive, all inclusive, practical, to the point.
Hats off to all who contributed.
Excellent exhaustive compilation of all information on COVID-19.Hats off to all the contributors.Thanks a lot.
By far the best narrative about COVID 19. Thanks alot Sir
Now with passage of time, observation and experience you need to modify this excellent presentation,which will benefit everyone.
Succint summary & a great presentation . Thank you.Dr Y.J.Visweswara Reddy
Very nicely summarised Covid 19 scenario
Great summary.
Includes everything.
Appreciate.
Beautifully covered almost all aspects of COVID 19.Thanks for your efforts.
Simply excellent
Excellent information very precise and accurate with lots of help to the treating physician.
Superb π
Excellent and simplified
Full and very useful information. Cestigivation on each point. Substantiated with evidences .
Almost all in one about COVID 19 .A referal document.Thanks a lot cmeindia.
Excellent exposure of present pandemic. All medical practitioners must read again and again.
I have become knowledgeable.
Brilliant presentation.
Exhaustive coverage.
Thanq.
One of the best documents read about COVID 19.. EXCELLENT INFORMATION- short and crisp
Excellent overview of COVID 19. Very precise and practical. VERY USEFUL FOR ALL CONGRATULATIONS
Excellent, thoroughly informative. Need of the hour.
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What a way to simplify such a treacherous disease! Salute !!ππ
An excellent and simply superb
explanation about Covid-19, till today.Thanks alot
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Superb, Complete information in one go.πππ
Covered everything
In a simple language
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beautiful presentations. Good job. Everything explained.
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Very Precise,
Highly Simplified,
Most informative,
Extremely useful,
Excellent Article.
Excellent way of Presentation
Mastach
Like this Post
Very informative and covering all aspects of covid-19
Nn
Excellent
Simply superb. Just felt like reading a Covid chapter in Davidsonβs.
Exhaustive and very clear. I don’t think you missed out on anything. This should serve as a Bible for all doctors.
Thanks and regards.
Very useful π
Thanks a lotπππ
veryinformative. well explained about everything
Very well managed review of the covid .kudos to writer
Very useful
All sector IMA local branches should hv CME n aware medical fraternity.
rch.shyamssidana@gmail.com
Superb every issue covered
Well researched and well compiled. Wonderful
Great analysis very good information Thank you very much sir
All necessary medical knowlege regarding covid 19 viral disease:Etiology Pathogenesis Concious care and Management along with Investigatio approach: Nice Lucid Presentation and fully useful for all Medicalites at any discipline.Thanks a lot dear.
Too gud n very essential knowledge.
Compact , comprehensive information on covid 19 excellent review
Very precisely described COVID-19 infection from sign and symptoms to management
Dr Vijay Kulshreshtha
Associate professor
Thank you very much Sir for all the efforts taken to put all the possible information in a single article
Commendable efforts
Thanks a million again
Great effort. Thank you
Quite informative, simple, comprehensive but elaborate enough for doctors and patients.
Congrats to tuticorin doctor Raj
Sir , Excellent disposition of the most confused and complicated deadly Corona .Treatment has been simplified according to stages with valid reasons.Please update it if you find anything new. Hearty Congratulations
Very nicely narrated program of covid 19.Easy to understand
For G.P.and health workers it will help in future to guide the patient
Very beautiful presentation of COVID-19
Lovely summary. Thanks.
Very Comprehensive.
Must read and update required as we come to know more about the disease.
Myocarditis is not uncommon.
Never before such masterpiece since the day one.
Very good indeed.
Nice compilation of all the symptoms diagnostic tools and management as well as prevention. Lovely presentation π
A complex subject explained in a simplified manner excellent
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Vry informative and crisp information about covid
Superb presentation, to the point explanation.
Appreciable work.
Complete comprehensive Covid picture!
Includes everything about corona related queries.
Great piece of scientific desimination. All relevant point on one place. Use of antiviral and HCQS is still debated and looks more of industry propaganda. Use of gargle and steam inhalation in early days must have positive role as in any viral illness. Adressing anxiety and depression must have some positive benefits.
Excellent
Comprehensive A to Z of COVID 19. Excellent presentation.
Vv good comprehensive. Thanks for excellent summary
A very clear,precise,summation.great explanation.much needed information.great work
Very detailed, perfect coverage of most aspect with understanding of stage, pathophysiology, molecule indications n reasons and response with watchful isolation at home is so good that this can be considered to be a most useful single source document for anyone treating Covid. The Patient guide can be made by treating Doctor eliminating technical things and emphasising the daywise steps to be followed. Good Medicine is more of protocol than experience alone as protocol has built-in experience but there has to be good indeapth understanding before the protocol is made and this article is rightly timed even if few things change in future.
All articles should be dated so that people do not consider reading a month old article for treating their patients today.
Heartiest congratulations for writing this to help all medical colleagues overworked with Corona who may not find time for each point in detail yet need to know. Keep it up.
Simple, concise.
Excellent presentation, steroid use well defined, starting on day 3 ,in high risk patients
Excellent presentation
Excellent description and most simplified presentation.
Superb presentation
Cleared all confusions and myths regarding treatment measures
Comprehensive compiling of all details πππππ
Excellent, holistic presentation on Covid19 current management. It can be used as a ready reference on any aspects Covid19 infection. Though therapeutic modalities may get modified in future, at present this is a complete guide. Salutes sir.
Excellent and useful handbook presentation
Very Comprehensive.
Must read and update required as we come to know more about the disease.
Myocarditis is not uncommon.
Perfect and outstanding description for all concerned.
Excellent presentation. Everything on one page.Thanks a lot .ps keep us updated with newer researches .
Place of birth ? Wuhan virology lab.with casualties.local spread contained.international spread allowed.in india some Chinese industries n markaz n madrasas .WHO silently abetted.Superb n extensive presentation.hats off.
Excellent presentation.
Very informative for Gen physicians and easy to treat asymptomatic and mild patients at home isolation
Nice
Very nice
Wow, such a nice holistic ,simplified representation of COVID 19, Especially for me, its very informative…
Exce
Superb info.
All in one place
Thanks for giving helpful information in
Excellent descriptive information
Excellent confirmative clear information ,regarding COVID-19 never before seen,… presented …..thank you sir…..
Excellent and concise information.
Very well explained. ππ
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Very well explained. Kudos
Simple excellent, detail very much informative
Very informative , A to Z information available about COVID 19 till today . Please keep updating , specially about the vaccine .
Excellent
All details at one place
Grt .thank u
Excellent
Remdesivir –> To be given Only in Hypoxaemic patients and not all patients. In ACTT-1 study published in NEJM, October 2020, it Shortens time of recovery, Decreases length of hospital stay and daily oxygen requirements, but slight reduction seen in mortality is non-significant.
Dexamethasone –> To be used only if patient requires oxygen. Early use leads to increased morbidity & mortality. Dexamethasone preffered , interaction with Remedesivir is clinically not significant.
A great comprehensive update in easy to follow bullet points. Well referenced. Many thanks to the authors.
Excellent details with treatment guidelines in a very simple way. Alerts and Risks explained nicely. CONGRATULATIONS .
Great effort to keep all points on one platform
Superb info.
All in one place
Thanks for giving helpful information
Very nice great information given
Excellent details and guidelines
All points covered must be read by all doctors. Great efforts and trouble taken. Thankyou very much
Superb A to Z of covid19 perfect guide nicely audited and managed just superb!!!!!
Extraordinary and simplified version like a chapter in text book. Great efforts to make it. Though CoViD19 is a new disease and medical fraternity is learning, the data are true guidance as on today. Tomorrow things might change but I am sure CME India will come out with new tips. Proud to be an Indian medico.
Excellent summary.
Very useful for treating physicians.
No words stunning article keep updating with recent research
What about Plasma therapy status.
IL6
Excellant compilation of Covid 19… Great efforts….Thanks
Very informative article. Keep updating.
Excellent
TruNAT can be used a diagnostic test if it is used as a 2 step procedure. The first step involves identification of the E gene, the presence of which is used as a screening test. In the second step, the identification of RdRp gene makes it confirmatory for COVID-19
Very well simplified
Excellent.Very precisely put and informative.Thank you Sir.
Excellent,Very precisely put and very informative.Thank you Sir.
Scientifically compiled details about COVID19 in simplest words coverings all aspects of the disease .
It will be very helpful for all practitioners.
Thanks a lot for the authors .
Excellent, detailed and very lucid information about Covid.
Thanks π
Great knowledge sharing help many lives , itβs just incredible explanation about COVID-19
A very good summary covering all aspects. Thanks Doctor for the efforts made
Superb sir
Excellent ready reckoner
Excellent coverage regarding COVID 19.
Very nice information . and guide about covid 19.
Pan coverage of Covid 19 in a nutshell highlighted and easily assmilable to all
Highly informative, pocket book reference for daily pt.care
Excellent presentation
Almost all in one about COVID 19 .A referal document.Thanks a lot cmeindia.
Very well depicted thank u very much for the efforts to enlighten
Very professionally done. Excellent, concise and foolproof advice. The most interesting thing is the demystification for widest application and utility.
Simple, but very informative.
Superb sir , very well explained,, all information at one place ,
Sincere Thanks,
Very simple and precise to read and assimilate (for an Orthopaedic Surgeon) Thank You very much.
Consize, crisp, covering all aspects, best article on covid
Excellent
Thanks
Very nice π
All necessary medical knowlege regarding covid 19 viral disease:Etiology Pathogenesis Concious care and Management along with Investigatio approach: Nice Lucid Presentation and fully useful for all Medicalites at any discipline.Thanks a lot dear.
Very very important and useful for all doctor and patient
Comprehensive yet concise.
It’s very informative and still simple to understand mystery of Covid 19 Thanks for great efforts and I highly appreciate
very nice comprehensive presentation sir!
Very nice
Very nice
Nice
Very simple and AtoZ informations about COVID-19 as of now. Atypical presentation like neurological manifestations would have been included in this sir- M.A.Aleem Neurologist Trichy Tamilnadu India
informative as well as easy to understand about COVID19 .. Thanks for sincere efforts…
Dr. J. K. Arora..
Jodhpur
Very Comprehensive & elaborate info on Covid-19.
Thank you dr Aralhaj.
Such a marvelous informative each n every aspect of mysterious deadly Chinese novel Corona virus Covid 19 will surely n certainly help medical fraternity at large. Congratulations to Authors by giving extract of deep routed study .
Very Precise,
Highly Simplified,
Most informative,
Extremely useful,
Excellent Article.
One stop encyclopedia on Covid19 A must read for all doctors
Great work, much needed at these times
Comprehensive yet focused
The format is extraordinary simple yet all encompassing
Such compact and thorough info and straight guidelines
Simply superb for comprehensive covid-19 coverage of infection.
Exellent explained in a single article.. only other causes why some race more mortality and and why other are more recovery and role of govt protocol , the governance and medicolegal aspect need to elaborate….pls prepare part two…..
Very useful presentation for the treating physician.
Thanks for taking efforts.
Excellent
FANTASTIC. PLEASE KEEP UPDATING
Nice and simple presentation for every medical fraternity. Difficult and controversial protocall simplified. Thanks dr
Complete information in one article superb
ππ
Master piece, all in one article on covid. Beautiful presentation.
Congratulations.