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How Covid-19 is impacting multiple organs

Dr Naveen Bhamri

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2020 is the year most of the world would like to forget and wish that on one is exposed to such a situation ever. Our understanding of Covid-19 and its impact is limited still and the treatment is based more on symptoms rather than targeting the virus itself. The route of infection is mainly through mouth, nose and eyes and the latest WHO information suggests that this virus can spread through the air. Therefore, it is advised to wear masks to protect us and others around.

When we see the patients around us, most fatalities due to Covid-19 is happening to elderly and those with comorbidities, indicating that the virus impacts multiple organs and can cause damage through various parts of the body. It’s a known fact that Covid-19 is mainly characterised by symptoms such as fever, dry cough, fatigue and sore throat and as per the current understanding, the primary organ targeted is lungs.

 Covid-19 has demonstrated a wide spectrum of clinical manifestations from asymptomatic or paucisymptomatic forms to severe viral pneumonia with respiratory failure, multi-organ and systemic dysfunctions in terms of sepsis and septic shock and death.

 Low oxygen, breathing difficulty

The virus enters the cells by binding to receptors Angiotensin-converting enzyme 2 or ACE2 which are found on it. These receptors act as the site of entry and are found in the cells of multiple organs, making it easy for the virus to enter. For instance, the human lungs contain tiny air sacs known as alveoli. These are responsible for the exchange of oxygen between lungs and blood vessels. These alveoli are rich in the ACE2 receptors. When the virus enters these cells, the immune system mounts an all-out battle against the virus. This disrupts oxygen transfer and makes breathing difficult, accompanied by cough.

The most frequent, serious manifestation of Covid-19 infection seems to be pneumonia, which is characterised by cough, fever, dyspnea and bilateral infiltrates displayed on radiographic chest imaging. Unfortunately, there are no specific clinical features that discern Covid-19 from other viral respiratory illnesses. Although most patients will only experience mild symptoms of the disease, some patients will experience rapid progression of their symptoms over a week.

ARDS is a cause of concern

One study found that 17% of their patients developed Acute Respiratory Distress Syndrome (ARDS) and among these, 65% rapidly worsened and died from multiple organ failure. In a study focusing on the associated risk factors, it was reported that ARDS was greatly associated with older age (over 65 years old), diabetes mellitus, and hypertension. For most cases, bilateral lower zone consolidation (identified through chest x-ray) peaked at 10-12 days from symptom onset.

Patients with CVD at greater risk

Patients with existing cardiovascular disease (CVD) are at a greater risk of suffering from severe Covid-19 and having poorer prognosis. A meta-analysis comprising 46,248 patients who were Covid-positive found that the most common co-morbidities were hypertension (17%), diabetes (8%) and CVD (5%). CVD and hypertension have also been more prevalent in the severe patient group as compared to non-severe cases. Existing CVD is also associated with higher mortality. On the other hand, it is widely agreed that coronavirus can also have adverse effects on cardiovascular health itself, causing or aggravating damage to the heart. There are reports of cardiogenic involvement in patients without known CVD as well as cases with solely cardiac presentations.

A significant number of patients reported GI symptoms such as diarrhoea, nausea, vomiting and abdominal pain, with some reporting these symptoms as their sole presenting complaint. The incidence of GI symptoms, alongside the detection of SARS-CoV-2 RNA in stool samples of infected patients, suggest that ACE2 receptors highly expressed in the GI tract are another target for SARS-CoV-2 infection.

Liver injury in corona patients

Mild and transient liver injury, as well as severe liver damage, can occur in Covid-19. Wong et al indicated that 14.8to 53.1% of Covid-19 patients had abnormal levels of alanine aminotransferase, aspartate aminotransferase and bilirubin during the course of the disease, with bilirubin showing the smallest elevation. Furthermore, they reported that the severity of liver damage is proportional to that of Covid-19. Gamma-glutamyltransferase was elevated in 54% of patients in one cohort study that included 56 Covid-19 patients. 

There have been reports of strokes among patients. As blood vessels are present all over our body, any effects on them are not restricted to a specific organ such as lungs, kidneys and intestines. So if Covid-19 directly affects the blood vessels of a patient, they will cause blood clots more easily as they are damaged.

 In autopsies done on deceased Covid-19 patients, blood clots are apparent throughout many organs in their bodies. This suggests that many blood vessels and organs are affected. Once you have blood clots, you may have complications like stroke where blood clots travel to the arteries of the brain and clog them up. Doctors have also observed patients with dizziness, confusion, delirium, altered mental state and muscle weakness. Blood clots can lead to a heart attack or a pulmonary embolism when a clot gets into your lungs.

We need to look into this pandemic in a detailed way and the studies will pave way for the right treatment options and more inside information about the virus and its treatment. We cannot just rely on temperature reading to be Covid-positive or negative. The community needs to take this pandemic seriously and continue practising social distancing and other preventive measures.

The writer is director and HoD interventional cardiology at Max Super Speciality Hospital, Shalimar Bagh, Delhi.

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New blood test predicts which Covid patients at severe risk

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Amid the ongoing battle with Covid-19, scientists have developed a score that can accurately predict which patients will develop a severe form of coronavirus. The measurement, called the Dublin-Boston score, is designed to enable clinicians to make more informed decisions when identifying patients who may benefit from therapies, such as steroids, and admission to intensive care units. Until this study, no Covid-19-specific prognostic scores were available to guide clinical decision-making.

 According to the findings, published in the journal EBioMedicine, the DublinBoston score can now accurately predict how severe the infection will be on Day 7 after measuring the patient’s blood for the first four days.

 “The Dublin-Boston score is easily calculated and can be applied to all hospitalised Covid-19 patients,” said study author Gerry McElvaney from the RCSI University in Ireland. 

The blood test works by measuring the levels of two molecules that send messages to the body’s immune system and control inflammation.

 One of these molecules, interleukin (IL)-6, is pro-inflammatory, and a different one, called IL-10, is anti-inflammatory. The levels of both are altered in severe Covid-19 patients. 

Based on the changes in the ratio of these two molecules over time, the researchers developed a point system where each 1-point increase was associated with 5.6 times increased odds for a more severe outcome.

 “More informed prognosis could help determine when to escalate or de-escalate care, a key component of the efficient allocation of resources during the current pandemic,” McElvaney said.

 “The score may also have a role in evaluating whether new therapies designed to decrease inflammation in Covid-19 actually provide benefit,” McElvaney added.

 With IANS inputs

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Delhi to be quack-free in 2021: New DMC chief

Shalini Bhardwaj

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Dr Arun Gupta has been re-elected as president of the Delhi Medical Council (DMC) for a second fiveyear term. Dr Gupta, a practising paediatrician for the last 30 years, worked for digitising medical processes during his previous tenure.

 Speaking of the DMC’s current goals, he said, “One of the mandates is to eradicate quackery. We have decided that by the end of the year 2021, Delhi will become the first anti-quackery state in India. We are working on it in collaboration with the Delhi Government. We don’t have any authentic data yet but more than 20,000 quacks are in Delhi only.” 

The DMC is responsible for handling and settling medico-legal issues against doctors. Currently, there are over 72,000 doctors registered with the council.

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National Medical Commission starts its website

Shalini Bhardwaj

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The National Medical Commission (NMC), constituted by the National Medical Commission Act, 2019, which came into force on 25 September, 2020, has launched its website. Citizens wishing to know about the National Medical Commission and its current medical working rules and regulations can log on to https:// www.nmc.org.in/.

 The NMC website also has highlights about its autonomous boards, members and organisational structure. The chairman of NMC is Dr Suresh Chandra Sharma and the commission has 33 members including the chairman, 10 ex-officio members and 22 part-time members. It also has four boards, the Under Graduate Medical Education Board, Post Graduate Medical Education Board, Medical Assessment and Rating Board, and Ethics and Medical Registration Board. The commission has 84 members from all over India as members of the medical advisory council.

 Cow dung chip will protect against mobile radiation: RKA chairman Rashtriya Kamdhenu Aayog (RKA) chairman, Vallabhbhai Kathiria, has launched a “chip” made of cow dung, claiming that it reduces radiation from mobile phones significantly.

 The chip, named Gausatva Kavach, has been manufactured by Rajkotbased Shrijee Gaushala. “This is a radiation chip. You can keep it in your mobile and it will reduce radiation. It will also keep you away from diseases,” said Vallabhbhai Kathiria during the launch of a nationwide campaign, ‘Kamdhenu Deepawali Abhiyan’

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India’s syringe makers to increase Covid-19 vaccine stocks

Shalini Bhardwaj

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India is one of the largest syringe makers in the world when it comes to 0.5 ml auto-disable syringes for intramuscular vaccination. With the current race towards procuring and distributing a Covid-19 vaccine, syringe manufacturers in the country are ramping up their capacities further by over 30% to meet the expected rise in global demand.

ISCON, Becton Dickinson, and Hindustan Syringes and Medical Device (HMD) are the three major Indian medical device companies which manufacture the 0.5 ml auto-disable syringes which would be required to administer a Covid-19 vaccine. The companies together have planned to expand their capacities to manufacture 1.4 billion pieces per annum by June 2021 next year.

“We are planning to ramp up our capacity to a billion 0.5 ml AD syringes and offer 50% to the Government of India and 50% as exports, which amounts to 200-250 million by June 2021 and another 250 million from June to December 2021,” said Rajiv Nath, Managing Director of Hindustan Syringes and Medical Devices Ltd.

“We have 70 million AD syringes in stock against our orders of standard immunisation campaign and can offer 100 million to Government of India by end of 2020, if needed,” he added.

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Efficacy of three primary diets in drug-resistant epilepsy

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Epilepsy that fails to get controlled by two antiseizure drugs is unlikely to respond to the addition of other medications. These children are designated to have drugresistant epilepsy. The principal treatment options for these children include either surgery or starting them on a ketogenic diet.

 The choice of surgery cannot be exercised in all patients: Epilepsy surgery is curative in specific diseases, and in certain conditions, it may be associated with permanent disabilities. Also, the expertise for performing epilepsy surgery is available only in a few centres across the country. The other option includes initiating a ketogenic diet.

 There are three main methods of providing these diets. The classical ketogenic diet often requires the patient to get admitted to the hospital, strict adherence to protocol and weighing the food items. The modified Atkins diet is less severe than the ketogenic diet. The low glycemic index therapy diet requires only minor diet modifications. So far, there has been adequate evidence about the efficacy of the ketogenic diet and the modified Atkins diet.

 The child neurology division of the department of paediatrics, All India Institute of Medical Sciences, carried out a first-of-itskind trial (The DIET Trial). They compared the three primary dietary therapies. This research showed that the seizure burden reduced by more than 50% in 67% of children receiving a ketogenic diet, 52% receiving a modified Atkins diet, and 59% of patients receiving a low glycemic index therapy diet. Also, the side effects were least with a low glycemic index therapy diet. 

Thus, this study adds a modified Atkins diet and low glycemic index therapy diet to the armamentarium for the management of drugresistant epilepsy. The added benefit is that since the study has been conducted in India, it can benefit a large population of drug-resistant epilepsy with local dietary menus. 

The writer is chief, child neurology at AIIMS.

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What happens when corona meets toxic air? CSIR to detect soon, says Dr Shekhar Mande

CSIR labs in Hyderabad and Chandigarh have collected samples from different locations and are working
on research regarding the effects of air pollution on the Covid-19 pandemic, says the CSIR Director General.

Shalini Bhardwaj

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With experts saying that rising pollution levels can worsen the effects of Covid-19, the Council of Scientific and Industrial Research (CSIR) has started its own research on the matter at the National Environmental Engineering Research Institute (NEERI), Nagpur. Director General of CSIR, Dr Shekhar C. Mande, speaks on the subject and about other Covid-related developments like the “Feluda test”, in an exclusive interview with The Daily Guardian. Excerpts: 

Q. Is CSIR going to do research on the link between air pollution and Covid-19?

 A. Of course, but the research will take some time to accomplish. Our labs are working on it already and the National Environmental Engineering Research Institute (NEERI) in Nagpur has started some work too.

 Q. When is CSIR expected to complete its research on whether Covid-19 is air-borne or not?

 A. Researchers have started compiling the results of the airborne study. They are conducting this research at two centres in Hyderabad and Chandigarh. Samples for the study have been collected from various places of India, from places like ICUs, hospital corridors, waiting rooms, places where healthcare workers are most at risk, high rise structures, etc. We are detecting how far this virus can travel. We have taken samples multiple times and are still sampling from different locations with different distances from patients, 4ft, 8ft and 12ft. Now, we have to wait for the results which are expected to come in the next ten days. 

Q. CSIR has tied-up with the UP government. Which projects are the CSIR going to focus on? 

A. We are going to work with the UP government on the types of projects which are required. If they have some ambitious plans on agriculture, the pharma industry or the environment, we will work as a knowledge partner. We are proposing some documents along with the UP government on pharma and we will be doing many other projects too. 

Q. When will “Feluda” come to the market? How does it work? 

A. It’s almost ready to enter the market. Feluda stands for FnCas9 Editor Linked Uniform Detection Assay. It detects active Covid-19 infection by using a CRISPR CAS 9-based readout on a paper strip. Detection takes place in less than an hour. It doesn’t require a real-time PCR machine, will be cheap, and can be performed at the point of care settings where a simple PCR machine is present. The virus has regenetic material RNA and we need to detect that particular RNA. We first do a reaction called RT-PCR (Reverse Transcription Polymerase Chain Reaction) in which we make DNA from RNA and amplify those copies of DNA. Then there is an enzyme which actually tries to match with the virus. It goes to the correct site and identifies the sequence for Covid. A paper strip is dipped into a solution, and if it is Covid-19 RNA, then you get a band that can be seen. The test gives its results in 45 minutes.

 Q. What should be the comprehensive distribution and delivery mechanism for vaccines?

 A. The Government of India is coming up with a very comprehensive plan and will take very considered decisions as a high priority. Those plans are pretty much in place and the people who have drawn these plans are technical experts in their area and therefore it’s going to be very robust. 

Q. In your opinion, who should get the vaccine first?

 A. People who are at high risk should get the vaccine first because they are handling Covid-19 patients every day. They deserve to get the vaccine first.

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