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.


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. 


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.

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                                                                                                                                              

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.

Saturday 11 April 2020

The WACEM-ACAIM Joint 4th Special Global Web Conference on Case Based Lessons from COVID19 patients across the World

Transplant recipients in COVID-19

It is still early for statistical data on the prognosis of transplant recipients with COVID-19, however anecdotally kidney transplant patients are showing poorer outcomes. 

Linked is an open access case study: which also suggests having a lower threshold for suspicion of COVID-19 in kidney transplant patients with non-specific or atypical symptoms.

Differing treatment for immunocompromised individuals?

General global consensus is that the initial algorithm of management in patients with and without immunocompromise remains the same, though data suggests that outcomes are worse in immunocompromised individuals, putting them in a higher risk bracket. There is benefit to be had in conducting early transparent discussions with immunocompromised individuals about available modalities of treatment, and regular review of ceiling of care based on expected outcomes tailored to individual cases.


As evident from this point being regularly reiterating during these meetings, telemedicine is playing a major role during this pandemic. There was some advocacy for use of telemedicine before the COVID-19 era, however several different models of care have unintentionally found the impetus needed to take off from a hypothetical to practical stage. There are advocates who hope to see telemedicine continue where appropriate to reduce unnecessary risk and/or need for physical clinical visits.


There is evolving guidance being generated as in all aspects of medicine during the pandemic. ( eg: ) Oncologists are stopping cancer therapies with the goal to minimize harm where appropriate, or stopping immunocompromising medications. This requires regular review and consideration by oncologists on an individual patient basis. 

Stem Cell Trial

Placental stem cell trial was brought up as another emerging modality of treatment currently in trial phases. Unfortunately I could find limited information about this. 

However expect more articles to emerge.

Transfer procedures

The presence of both symptomatic and asymptomatic COVID-19 cases generates the important question of safe transfers. Transfer guidance differs in various institutions, and perhaps has some inter-institution variability, but developing set criteria during this period is critical to maintain in-hospital and inter-hospital safety of both patients and providers. 

Some hospitals are conducting "box-transfers" and in other cases, have protective plastic covers. PPE guidance for transferring team varies by institution and case. There must be due consideration for the safety of, and clear communication to the team receiving the transfer/referral.

Test Value

Though there is value to positive tests, there are several reports of delayed positive testing. Thus a negative test in a symptomatic patient carries little value and onus of decision making must rest upon the clinical picture. 

Bottom-line is: guided testing is carried out for symptomatic individuals (whether mild or otherwise), therefore regardless of the test results, the individual must follow self-isolation advice.

Another point of discussion, was the purchase and use of commercial testing by private companies outside the remit of hospital based or clinician based management. Commercial tests lack standardisation both in the kind of tests available as well as their legitimacy and accountability.

Pooled PCR

Theoretically, this is the collection of multiple samples, pooled together for PCR testing. If none of the samples contain the virus, then the result of the test is negative. If the result is positive, then further testing on an individual level can be conducted. This is of particular benefit in resource-limited and/or population dense areas. 

Medical Ethics during the pandemic

Every hospital/clinical establishment should have an ethic and medicolegal team to provide guidance and support at all times, but especially during a pandemic. In the context of COVID-19, ethics come into play on both an individual patient basis, as well as institutional basis. If there aren't already, then there will be high stakes decisions in emotionally charged situations that can impact provider and patients, and these must not be dismissed. 


Discussions involving anticoagulation in COVID-19, ACAIM/WACEM multidisciplinary working group statement, and more.

Saturday 4 April 2020

The WACEM-ACAIM Joint 3rd Special Global Web Conference on Case Based Lessons from COVID19 patients across the World

4th April 2020


Telemedicine for home monitoring of discharged patients and other complaints is in full use as numbers in Italy start to trend south.


Point of Care Pulse Ox assessment at triage should identify silent Hypoxia Assessment via rest and stress check after one-minute walk.

Order Labs and X-ray Chest.

An inconclusive chest X-ray should prompt plain CT of the chest. If the CT is positive then the patient is admitted.

Negative CT Chest should prompt an evaluation to rule out COVID Myocarditis / PE as COVID has shown to have cardiac effects and thrombotic tendencies.

CTA is done when there is a high suspicion for PE. Additional POCUS Cardiac exam is done. D-Dimer routinely is high in COVID patients.

The PE algorithm should be followed keeping in mind that AKI and dehydration can be present.

Kidney Dysfunction

GFR and trending the creatinine in last 7 weeks is good enough to evaluate the kidney status in addition to creatinine.

High Sensitivity Troponin is an efficient marker to r/o myocarditis.

Non-COVID Pathologies:
The emphasis was that other pathologies do exist and we have to keep that in mind as we evaluate COVID patients and vice versa.

Hematological / Metabolic Markers
Neutropenia, Lymphopenia, Hypokalemia and High Fibrinogen levels have been found in COVID19 patients.

Routine dosing that the experts recommended for patients admitted.

Extra-Pulmonary manifestations of COVID19
AMS / Seizures / Delirium / Encephalopathy / Myocarditis / N / V/ D / Rhabdomyolysis / AKI / Thrombosis / Embolism were the major manifestations mentioned by experts.