Saturday, 30 May 2020

The 11th WACEM-ACAIM Joint Special Global Web Conference on "Living with COVIFLU"


In this 11th WACEM-ACAIM Joint Working Group, we venture into furthering work we have already commenced and introducing the topic of supply chain dynamics in the COVID-19 era. Today we were joined by President-Elect of the American Academy of Emergency Medicine (AAEM), Dr. Lisa Moreno, with whom we hope to establish a long and fruitful collaborative relationship.

Situation in Greater Mumbai

We learnt of the further worsening situation in Greater Mumbai, particularly focussing on the severely inadequate ventilator to patient ratios. Our leaders are working hard on applying the algorithms we have jointly developed on the ground level, and gathering data derived from the practical application. Our prayers and well wishes go out to the healthcare workers and people of they city and country. 

Urban and Rural Pandemic in India

Though it started out an urban disease, as things stand with migration, and the natural course of spread, we will see two very different scenarios playing out - the urban pandemic struggling even with all its amenities and man-power, and the rural pandemic, which will be heavily reliant upon primary care, with very little scope of using tertiary care as their safety net due to an overwhelming of resources already in play. 

AAEM Collaboration

We were joined by Dr. Lisa Moreno, President-Elect of the American Academy of Emergency Medicine, who gave us a short overview on their excellent democratic model seeking to create a culture of fairness and equality for emergency physicians so they can in turn deliver the highest quality of patient care. We hope to develop a fruitful working relationship between ACAIM/WACEM and AAEM going forward in the realm of global emergency medicine.

Education Design

We hope to develop our work, papers and presentations into a structured educational course to benefit all physicians everywhere. For these purposes, we had an excellent presentation of developing a sound educational model based on successfully applied existing courses. 

Developing a Culture of Telemedicine

As discussed in previous meetings, and reiterated with good reason, the joint group is working on developing a paper that will encompass the topic of moving from crisis telemedicine to a culture of telemedicine. The paper will hope to answer the why, what, how and when questions, and hopefully provide a robust system that is practically applicable and medically sound.

Pathophysiology Hypothesis

Extensive work done by the immunologists in our working group is coming to fruition. We hope to soon publish the detailed work on the pathophysiology of the coronavirus infection, rooted in the workings of the immunology system - direct and indirect pathways, hopefully paving the way to a better understanding of the disease, and consequently developing immune-modulating treatments. 

Supply Chain Model to Restore the Economy

Understandably, the medical fraternity has been keenly focussing on the medical impact of the disease - either to patients, hospitals or healthcare workers. However, we need to expand this focus to the greater picture and work on reviving the economy as a whole, and medical care dynamics by creating a workable supply chain model. From the well off - focussing on safety, amenities, and the finest private medical care, to the socioeconomically deprived - worried about living hand to mouth, and the food reaching their plate, let alone a high standard of medical care, an operational supply chain is the basis of biosecurity. Again, we are working on developing the model and sharing our accumulative knowledge. 

More to come...

It's been 11 weeks since the commencement of these weekly meetings, and from abstract visions and undeveloped ideas, we have now reached the stage of creation, implementation, publications and expanding collaboration. No doubt there is more to come.


Sunday, 24 May 2020

The 10th WACEM-ACAIM Joint Special Global Web Conference on “Living with COVIFLU”.




The 10th  in the series of WACEM-ACAIM Joint Group Meeting was packed with presentations of important work being done by the group. Our continued gratitude to all presenters and panelists.

The leaders Celebrated 10 weeks of Academic Leadership across the World with our Web Conference crossing record registrations from all around the world.

Immunotherapeutic Combinations   

COVIFLU immunology was discussed with Therapeutic targets encompassing anti-viral and immune antibodies. The upcoming Publication was discussed in Detail.

Telemedicine
A working Group was created to work on building the science of TeleMedicine.
The group discussed the Four Pillars of TeleMedicine Sciences:
1. Recording of Audio Visual Data as Health Record
2. Reimbursements and Accountability
3. Telemedicine Metrics / Analytics / Reforms
4. Patient Safety & Confidentiality

Kerala COVID Control Model
A detail discussion was held on the success of the Kerala Model.
Contact Tracing, Transformational Leadership and a Strict Chain of Command with open communication with the citizens were found to be major success behind the COVID Control.
Detail discussion was held on each of the above aspects.

Agenda for Next Meeting
·       Education Framework
·       Translational Research Framework
·       TeleMedicine Systems Framework


Our COVID Publications:



Chauhan V, Galwankar SC, Yellapu V, Perez-Figueroa IJ, Stawicki SP. State of the globe: The trials and tribulations of the COVID-19 pandemic: Separated but together, telemedicine revolution, frontline struggle against “Silent Hypoxia,” the relentless search for novel therapeutics and vaccines, and the daunting prospect of “COVIFLU”. J Global Infect Dis 2020;12:39-43


Thakur S, Chauhan V, Galwankar S, Kelkar D, Vedhagiri K, Aggarwal P, Bhoi S. Covid-19 testing strategy of India – Current status and the way forward. J Global Infect Dis 2020;12:44-6

Stawicki SP, Jeanmonod R, Miller AC, Paladino L, Gaieski DF, Yaffee AQ, De Wulf A, Grover J, Papadimos TJ, Bloem C, Galwankar SC, Chauhan V, Firstenberg MS, Di Somma S, Jeanmonod D, Garg SM, Tucci V, Anderson HL, Fatimah L, Worlton TJ, Dubhashi SP, Glaze KS, Sinha S, Opara IN, Yellapu V, Kelkar D, El-Menyar A, Krishnan V, Venkataramanaiah S, Leyfman Y, Saoud Al Thani HA, B Nanayakkara PW, Nanda S, Cioè-Peña E, Sardesai I, Chandra S, Munasinghe A, Dutta V, Dal Ponte ST, Izurieta R, Asensio JA, Garg M. The 2019–2020 novel coronavirus (severe acute respiratory syndrome coronavirus 2) pandemic: A joint american college of academic international medicine-world academic council of emergency medicine multidisciplinary COVID-19 working group consensus paper. J Global Infect Dis 2020;12:47-93





Sunday, 17 May 2020

The 9th WACEM-ACAIM Joint Special Global Web Conference on Advance therapeutics in COVID19: Opinions from Experts around the World.



The 9th in the series of WACEM-ACAIM Joint Group Meeting was packed with presentations of important work being done by the group. Our continued gratitude to all presenters and panelists.


COVID19 ~Multi-System Dysfunction Syndrome also called Multi-System Inflammatory Syndrome in Children & Adolescents

We have in detail discussed that COVID is an Immunological Syndrome like HIV and our thought process was further validated by The World Health Organization.


We further profess that there is a strong possibility that COVID will be a chronic immunological disease which will need immunological and anti-viral intervention in combinations rather than individually.

Personalized COVID Therapy Options will need to be devised as COVID generates a personalized reaction in every patient.

The Term “Multi-System Dysfunction” was a term, which was apt for COVID and the personalized response it generates in humans at different ages.

Immunotherapeutic Anti-Virals

COVID and Flu are going to have a devastating effect on population. The synergistic antigenicity will be highlighted by the heightened immune response both by the direct and indirect pathway. IL6 will play a major role and will emerge as a target for therapy.

Immunotherapy Options will need to be addressed aggressively as we near the Flu Season. A detail discussion was held on the role of plasma therapy as well early cell therapy in acute viral diseases with multi-organ failure and shock.

ECMO in COVID

The role of cardiothoracic surgeons supersedes intensivist in the provision of ECMO in COVID. Discussion as regards induction and phase out criteria for ECMO was done.

Supply Chains BioSecurity

Presentations were done on Biosecurity of Medical and Survival supply chains.
It was deducted that a clear focus was to be laid on creating benchmarks to evaluate the security standards of all medical and survival supplies as a part of healthcare and public health.

POC Biomarkers in COVIFLU

Aggressive use of Point of Care Testing was found to be crucial for COVID patient care. Troponin, BNP, ABG and Bedside Chem 8 and lactates were found to not only decrease time but also fasten effective care. New Emerging biomarkers were discussed in detail including immunological markers.

Oxygen Therapeutics

The Group had a detail discussion on the collective wisdom being applied in developing diagnostic, therapeutic as well as home monitoring benchmarks in Oxygenation Therapy.

Our COVID Publications:

Detailed CORONAVIRUS Primer

Silent Hypoxia Algorithm


Crisis TeleMedicine





Wednesday, 13 May 2020

The 8th WACEM-ACAIM Joint Special Global Web Conference on Advance therapeutics in COVID19: Opinions from Experts around the World.

The 8th in the series of WACEM-ACAIM Joint Group Meeting was packed with presentations of important work being done by the group. Focus on Immunotherapy and discussion of upcoming publications was the highlight of the meeting.

Our continued gratitude to all presenters and panelists.


Pediatric COVID

A lot of discussion was done about the cases of Pediatric COVID. Immunological syndrome simulating Kawasaki disease / vasculitis is being seen in children. It was emphasized that different strains of COVID19 are in circulation and every strain reacts differently in every human being. Response to a foreign organism is always “Personalized”. Hence, therapies need to be personalized.

The Term “Multi-System Dysfunction” was a term, which was apt for COVID and the personalized response it generates in humans at different ages.

Immunotherapy in COVIFLU

The group discussed in detail about human body response when COVID pandemic mixes with the annual FLU outbreaks. The immunological pathway found a common ground on generating an IL6 Response. Monitoring IL6 levels and blocking them relative to the existing levels rather than a 100% blockade could be a possibility. This will need to be looked at carefully.

Additionally aggressive treatment of Flu will be important, as neutralizing the virus is key.

Herd Immunity V/S Herd Infectivity

The group discussed the theory of “Herd Infectivity” which is the complete opposite of Herd Immunity. The spread of Herd Immunity is rapid and effective and from the data at hand, it is very clear that COVID has a “Herd Infectivity” pathway.

Density of people, viral volume of exposure, time / length of exposure are all profound factors in the spread of COVID.

Publications

The group will be soon publishing a Primer on COVID19, The Hypoxia Assessment Pathway, Oxygen and Ventilation Algorithm for COVID Respiratory Distress as well as Home Oxygen Monitoring Guidelines.

Transition to “TeleMedicine Culture” from “Crisis TeleMedicine”

The group confirmed the Four Pillars of TeleMedicine Sciences:
1. Recording of Audio Visual Data as Health Record
2. Reimbursements and Accountability
3. Telemedicine Metrics / Analytics / Reforms
4. Patient Safety & Confidentiality

A working group was created to lead the 4 Pillars.

BioEconomics and BioSecure Supply Chains


Tremendous Discussion was done about the New World of BioSecurity in terms of Food Water and Health Supplies. Stockpiles and Delivery to end users will need more security and testing. Cues from the Cold Chain for Vaccines will serve as a starting point to work on BioSecurity. A new era of BioEconomics are been thrust upon us and we have to work on improvising to respond to the same.

Saturday, 2 May 2020

The 7th WACEM-ACAIM Joint Special Global Web Conference on Advance therapeutics in COVID19: Opinions from Experts around the World.


The 7th in the series of WACEM-ACAIM Joint Group Meeting was packed with presentations of important work being done by the group. For this meeting, we were graced by the presence of our first speaker, the honorable Secretary of State at the Ministry of Internal Affairs, Romania, Dr. Raed Arafat, who shared an enlightening glimpse into the Romanian model in this COVID era.

Our continued gratitude to all presenters and panellists.

Romanian Model 

There were a lot of enlightening insights about the successes seen from the Romanian working model for the pandemic, as well as a look into the challenges they faced, as a nation, and on the healthcare front. 

Of particular interest, Dr. Arafat shared that they had conducted table-top exercises geared towards a projected response to biothreat issues, just within a year preceding the pandemic. These exercises highlighted theoretical issues which indeed reflect the challenges being faced now. 

Disaster Preparedness in any place, and at every level (institutional/national/international) is of paramount importance. 

This group hopes that we, collectively around the world, do not have a short-term memory regarding this period of time, and hope to see some constructive and lasting changes emerge amidst the other long-term impacts bound to come. 

Among the challenges they faced were an early closure of the export industry, supply of counterfeit equipment, high rate of HCA infections due to poor preparation and/or compliance with protective protocols. 

They tackled with these challenges very early, in fact having meetings quickly after news of infection first emerged from China. Military personnel were deployed to some areas to assist; there was no institution of a full lockdown, but good general compliance of sensible measures installed early into the local incidence of the disease. 

They learned quickly after instituting the model of: COVID-19 hospitals, Support Hospitals, and Clean Hospitals, that a "clean" hospital would not be an achievable concept practically.

They were able to overcome the hurdle of "admission only after testing for COVID", thus eliminating delays in clinical care of patients, and preventing bottle-necking in the ED. 

Their whole approach to the pandemic saw to the fact that they did not face overwhelming of their critical care units, which was and remains a major problem in the worst affected areas around the globe. 

There is, as there is bound to be, some public unrest, however a good overall compliance. This includes the forethought of delaying re-opening of schools till September: which has been well received by authorities, public, and concerned parents.


We, at WACEM-ACAIM, are looking forward to working together with global leaders in finding successful (and unsuccessful) models, applying lessons learnt from them on an international scale towards the betterment of health sectors globally, and improving disaster preparedness responses.
It has never been more apparent, that the wealth of a country relies heavily on its health.

Silent Hypoxia

It has been a recurring feature in this blog, and in our weekly meetings. Our joint group is in the process of developing a Silent Hypoxia Algorithm, that we hope to share soon. 

A stand-out point today, was the importance of recognizing a subtle minimal-exertional or stress-induced hypoxia in otherwise well-appearing, or imaging-negative patients. It should serve to act as a Red Flag and these patients should be considered for admission, and prophylactic LMWH due to increased thrombogenic potential.


Algorithm

To continue to highlight the importance of the above, and integrate it into practice, 'Silent Hypoxia Algorithm' is in development. 

The group is working on developing a ventilation algorithm to simplify and standardize approach to respiratory management of COVID-19 patients, integrating with the silent hypoxia algorithm.

We are also looking into a biotriage tool. 

COVIFLU 

While we continue to look into the pathophysiology and immune mediated response in COVID-19, we are also hypothesising potential co-infection responses. There is no current evidence of an amnestic response, however, studies are still ongoing.

Policy-making 

The health care sector and governmental response sectors go hand in hand in deciding the outcome of any crisis situation, as is evidenced by varying responses by different nations. 

A close working relationship needs to be developed now, and nurtured going forward, in preparedness, acute crisis response, and crisis recovery phases. 

Suggested model of Home based monitoring

In conjunction with telecommunication and community-based models of care, we suggest developing a model so as to reduce burden of hospitalization and also reduce risk of exposure for the patient where these are preventable.


Saturday, 25 April 2020

The 6th WACEM-ACAIM Joint Special Global Web Conference on Advance therapeutics in COVID19: Opinions from Experts around the World.




The 6th in the series of WACEM-ACAIM Joint Group meeting was a very productive conversation that included protocol-sharing, current data sharing, development of algorithms and standards, and expanding our thinking to the future of not just COVID-19, but beyond.

We continue to express our gratitude to all presenters and panellists.

Resource Conscious Approach

We need to be wary when generating data or developing guidelines of the resource-rich and resource-limited environments and institutions of healthcare.

As an example, idealistic practice of medicine would involve the monitoring of P/F ratio (PaO2/FiO2) but a resource-limited institution or patient-centric approach may consider monitoring of S/F ratio (SpO2/FiO2) in prognostication of respiratory optimization.

Standardization and Quantification

Because of limited data and gradual evidence emergence in a new disease, there is a common-sense approach and individualistic approach to monitoring and management of COVID-19. However 5 months into wide knowledge of existence of the disease, and 2 months into declaration of a pandemic, the need of the hour is to develop standardized and quantifiable methods of management of the disease. 

We discussed the use of a modification of the CURB-65 criteria as a clinical prognosticator, with concurrent use of the ROX index when considering invasive ventilation. 

We discussed using awake proning as a rescue therapy or indeed a temporizing measure while making an informed and well-thought decision for invasive ventilation. 

We are working on creating a standardised algorithm.

Immunology and Pathogenesis

A key factor in generating therapeutic regimens and working vaccines is to first understand the immunology and pathogenesis of the disease.

There was a thought-provoking discussion which is beyond the scope of this blog, however to elaborate two take-home messages: 

1) Not every presentation is that of a cytokine storm, there is in fact a preceding step of cytokine release syndrome (CRS). 

2) The goal for management would be to develop an IL-6 immune-modulation treatment rather than suppressing IL-6 altogether, as IL-6 is an expected and needed part of the body's normal immune response.

Crisis Telemedicine

This has to be treated differently to non-crisis telemedicine, especially when considering its role in the future of healthcare management. 

Development of a good model should consider the principles of confidentiality, patient safety, reimbursement, and data storage.

Testing

Antibody testing involves IgG or IgM or a combination of both.
The at-home tests/finger-prick tests utilize lateral assays.

These are not diagnostic, rather their main use is in understanding disease burden. 

The presence of antibodies to a disease does not necessitate the development of immunity to ii. 

Vaccine trials rely on studying both the antibody generation response, as well as immunity-conferred. 

Reinfection

It is important to understand, especially in the era where it is easy to share anecdotal medicine, that there is no known data about re-infection, re-activation, or resurgence of this disease. Studies are ongoing. 

Transformational biosafety in healthcare

Wider experiences shared by this global group led to the observation that this pandemic highlighted compromising of parameters and the onus going forward rests on improving these parameters instead. 

There in ongoing work to elaborate on this. 

Coming up next...

Our next meeting will recap on the work currently in development by the WACEM-ACAIM team, more on telemedicine, immunology and COVIFLU - anticipating and preparing for concurrent infection. 


Monday, 20 April 2020

The 5th WACEM-ACAIM Joint Special Global Web Conference on Advance therapeutics in COVID19: Opinions from Experts around the World.



Date: 18th April 2020

Inter Facility and In-Hospital Patient Transfers:
A detail discussion was held based on the HMC Qatar model about strict protocols for donning and doffing of protective clothing and gadgets when conducting COVID19 Patient Transfers. 

Various Videos are shared:

Lung Management Algorithms
Currently there are no objective recommendations / criteria about prone ventilation. There are no directives as regards duration, and monitoring and when does one intubate. There is no recommendation about ventilation settings. The WACEM Task force will soon come up with the recommendations, which will be a consensus document.

Telemedicine
One aspect, which stood out, clearly was that there was a stark difference between Crisis Telemedicine and Culture of Telemedicine. 
Patient Confidentiality, Patient Safety, Care Reimbursements and Tele medical records will need to be addressed very technically and systematically as Telemedicine becomes the new norm. 
In Crisis allied tools and platforms are used with very little recording of summaries of communication. If Crisis Telemedicine proceeds to be cultural telemedicine then a lot of thought will have to be put in to the four pillars of confidentiality, safety , records and reimbursements.

Immunology of COVID
Data on Immune Mechanisms of COVID was presented and on  discussion it was hypothesized that COVID Storm was a hyper immune reaction where there was some role played by IL-6. A detail discussion on Immunotherapy will be done in the Next Conference.

Anti COVID Therapeutics:
Currently some drugs are showing hope and so is the vaccine development. The data is enough to suggest compassionate use only. The group could not mention anything about Definitive EBM use of any therapy.

WACEM-ACAIM Survey Research

Leaders of WACEM have undertaken Path breaking Research and present surveys for open participation.

EMERGE Study: 


University of South Alabama Study 



HCQ Study                                                                                                                                                        https://docs.google.com/forms/d/e/1FAIpQLScCCZNNUbcDH_7-V7d-TV522CwgXV5HNg8Qf5ra_KErAYqMtA/viewform?usp=sf_link


Post COVID Era

If Post COVID becomes the New Norm Process of Medical Care will change. Detail discussion on the above area will be done in the next meeting.