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: https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.15874 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.

Telemedicine

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.

Oncology

There is evolving guidance being generated as in all aspects of medicine during the pandemic. ( eg: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf ) 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. 

Upcoming: 

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



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