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MONKEY POX - the next pandemic ? DR. NILAKSHI GUPTA SENIOR RESIDENT LOK NAYAK HOSPITAL, NEW DELHI 2. HISTORY Monkeypox- Initial discovery in monkeys in a Danish laboratory in 1958. First human case- 9-year-old boy in the democratic republic of the Congo in 1970 3. Clade West african clade Congo basin clade Severity Less severe More severe Case fatality rate 3.6% 10.6% Transmissibility Less More CLADES OF MONKEYPOX VIRUS 4. VIROLOGY Enveloped double-stranded DNA virus Family: poxviridae Genus: orthopoxvirus . 5. EPIDEMIOLOGY Viral zoonosis Since 1970, human cases of monkeypox have been reported in 11 african countries The true burden of monkeypox is not known. 6. Monkeypox cases in non-endemic countries reported to WHO between 13 to 21 may 2022 7. MODE OF TRANSMISSION Virus enters body through broken skin, respiratory tract, or mucous membranes [eye, nose, mouth]. Direct contact close contact with lesions, body fluids, respiratory droplets Indirect contact contaminated materials such as bedding. Human to human Animal to human Bites Scratches Bush meat preparation 8. CLINICAL FEATURES Invasion period Lasts between 0â5 days Characterized by fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, myalgia (muscle aches) and intense asthenia (lack of energy). Lymphadenopathy is a distinctive feature of monkeypox compared to other diseases that may initially appear similar (chickenpox, measles, smallpox) Incubation period: 6 to 13 days but can range from 5 to 21 days. 9. Period of rash- within 1â3 days of appearance of fever. More on the face and extremities rather than on the trunk. It affects face (95%), and palms of the hands and soles of the feet (75%). Also affected are oral mucous membranes (70%), genitalia (30%), and conjunctivae & cornea (20%) The rash evolves sequentially from macules to papules vesicles pustules and crusts which dry up and fall off. The number of lesions varies from a few to several thousand. 10. Macules (lesions with a flat base) papules (slightly raised firm lesions) Vesicles (lesions filled with clear fluid) Pustules (lesions filled with yellowish fluid) scabs At the SAME STAGE of development over all affected areas of the body. Usually self-limiting Symptoms may last from 2-4 weeks. May be severe in some individuals, such as children, pregnant women or persons with immune suppression due to other health conditions. 11. LABORATORY DIAGNOSIS Optimal diagnostic samples: skin lesions â the roof or fluid from vesicles and pustules, and dry crusts. Where feasible, biopsy is an option. Lesion is swabbed vigorously, to ensure adequate viral DNA is collected. Both dry swabs and swabs placed in viral transport media (VTM) can be used. Two lesions of the same type should be collected in one single tube, preferably from different locations on the body and which differ in appearance. 12. All specimens being transported should have triple packaging, labelling and documentation. Specimens should be refrigerated or frozen within an hour of collection and transported to the laboratory as soon as possible. If transport exceeds 7 days, specimens should be stored at -20Âc or lower. Longer term specimen storage (>60 days from collection) is at -70ÂC. 13. DIAGNOSIS Confirmatory test: Polymerase chain reaction (PCR) is the preferred laboratory test Nucleic acid amplification testing (NAAT), using real-time or conventional polymerase chain reaction (PCR), for detection of unique sequences of viral DNA. PCR can be used alone, or in combination with sequencing. PCR protocols for the detection of OPXV and more specifically MPXV-With distinction of Congo basin and west African clades. 14. Some protocols involve two steps, in which the first PCR reaction detects OPXV, but does not identify which species. This can then be followed by a second step, which can be PCR-based or utilize sequencing, to specifically detect MPXV. Disposal of waste: All waste that may contain MPXV should be decontaminated before disposal by autoclaving or chemical disinfection. 15. OTHER METHODS Electron microscopy: Electron microscopy can be used this method is not routinely used for the diagnosis of poxviruses. Viral culture: Virus isolation is not recommended as a routine diagnostic procedure. 16. Antigen and antibody detection methods do not provide monkeypox- specific confirmation due to serological cross-reactivity Not recommended for diagnosis 17. INFECTION CONTROL Isolation of patient Use of personal protective equipment Proper hand hygiene and cleaning procedures Household disinfection 18. ISOLATION OF PATIENT Persons with extensive lesions should be isolated in a separate room. Household members should limit contact with the infected person. Infected people should also avoid contact with animals, including pets. 19. USE OF PERSONAL PROTECTIVE EQUIPMENT Persons with monkeypox should wear a surgical mask, Disposable gloves should be worn for direct contact with lesions and disposed of after use. Skin lesions should be covered to the best extent possible (Long sleeves, long pants) to minimize risk of contact with others. Contain and dispose of contaminated waste (such as dressings and bandages) should be done according to biomedical waste disposal. 20. PROPER HAND HYGIENE AND CLEANING PROCEDURES Hand hygiene- Hand washing with soap and water or use of an alcohol-based hand rub should be done. Hand hygiene is to be performed after touching lesion material, clothing, linens, or environmental surfaces. 21. HOUSEHOLD DISINFECTION Laundry: To be washed separately to avoid direct contact with contaminated material. Soiled dishes and utensils should be with warm water and soap. Contaminated surfaces should be cleaned and disinfected. Standard household cleaning/disinfectants may be used. 22. INFECTION CONTROL PRECAUTIONS By health workers- To implement standard, contact and droplet precautions Recommended personal protective equipment (PPE) includes gloves, gown, medical mask and eye protection â goggles or face shield Aerosol generating procedures should be done by taking proper precautions. Continue until all lesions have resolved and a fresh layer of skin has formed. 23. VACCINATION Data from Africa suggests that smallpox vaccine is at least 85% effective in preventing monkeypox. JynneosTm (also known as imvamune or imvanex), has been licensed in the united states to prevent monkeypox and smallpox. Acam2000, which contains a live vaccinia virus, is licensed for immunization in people who are at least 18 years old and at high risk for smallpox infection. It can be used in people exposed to monkeypox if used under an expanded access investigational new drug protocol. 24. TREATMENT An antiviral agent known as TECOVIRIMAT[ST-246] developed for smallpox was licensed by the European medical association (EMA) for monkeypox in 2022. Data is not available on the effectiveness of cidofovir and brincidofovir in treating human cases of monkeypox. However, both have proven activity against poxviruses in in vitro and animal studies. Currently, there is no proven, safe treatment for monkeypox virus infection. For purposes of controlling a monkeypox outbreak, smallpox vaccine, antivirals, and vaccinia immune globulin (vig) can be used 25. RECOMMENDED PUBLIC HEALTH ACTION- NCDC,MOHFW, MAY 2022 1. Health care facilities to keep heightened suspicion in people who; a. Present with otherwise unexplained rash and b. Who have travelled in the last 21 days to a country that has recently confirmed or suspected cases of monkeypox or c. Report contact with a person or people with confirmed or suspected monkeypox. 26. 2. All suspected cases to be isolated at designated healthcare facilities untill all lesions have resolved and a fresh layer of skin has formed OR until the treating physician decides to end isolation. 3. All such patients to be reported to the district surveillance officer of IDSP. 4. All infection control practices to be followed while treating such patients. 5. Laboratory samples consisting of fluid from vesicle ,blood, sputum etc to be sent to NIV pune for testing in case of suspicion 6. In case a positive case is detected, contact tracing has to be initiated immediately to identify the contacts of the patient in the last 21 days. 27. REFERENCES 1. Interim advisory for IDSP ssus in view of monkeypox cases reported from few countries. 2. https://www.who.int/news-room/fact-sheets/detail/monkeypox 3. www.cdc.gov/poxvirus/monkeypox. 28. WE THINK WE ARE DONE WITH THE PANDEMIC, BUT THE PANDEMIC IS NOT DONE WITH US. THANK YOU https://www.friendbookmark.com/videos/1260/monkeypox-virusMonkeyPox Virus 1. Is MonkeyPox the next pandemic ? Dr. Suresh Kumar Medical Director , Lok Nayak Hospital Director Professor & Head of Medicine, Maulana Azad Medical College, New Delhi. 2. Monkeypox â Monkeypox virus is an enveloped double‐stranded DNA virus with a genome size of around 190 kb. â Monkeypox is a viral zoonotic disease that occurs primarily in tropical rainforest areas of Central and West Africa and is occasionally exported to other regions. 3. Structure 4. Confirmed human monkeypox cases Africa, 1970-2021 5. Confirmed human monkeypox cases Worldwide,1970-2021 6. Monkeypox transmission â an overview 7. Monkeypox â modes of transmission â Unprotected contact with: â respiratory droplets â lesion material â body fluids â contaminated materials and surfaces The virus can enter through: â respiratory tract â mucous membranes (eyes and mouth) â broken skin (e.g. animal bites 8. Disease progression I â Incubation â Duration: 5-21 days â No symptoms â Virus present in bloodstream (viremia) at the end of the incubation period 9. Disease progression II â Febrile stage â 1-4 days â Fever + other symptoms: swollen lymph nodes (lymphadenopathy), headache, chills, sore throat, malaise, fatigue â Virus in the blood â Small lesions in the mouth (enanthem) appear towards the end 10. Disease progression III â Rash stage 11. Disease progression III â Rash stage â Virus may be in the blood early in this stage â Virus is present in skin lesions â Antibodies are produced and become detectable 12. Disease progression IV â Recovery â The patient has recovered â Specific antibodies are present in the blood â Scars may remain 13. Monkeypox symptoms â an overview 14. Monkeypox and other common rash illnesses 15. Clinical Symptoms â Monkeypox typically presents clinically with fever, rash and swollen lymph nodes and may lead to a range of medical complications. â Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. â Severe cases can occur. â In recent times, the case fatality ratio has been around 3-6%. â Monkeypox is transmitted to humans through close contact with an infected person or animal, or with material contaminated with the virus. â Monkeypox virus is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding. 16. Monkeypox: Clinical syndromes and possible treatment options 17. Prevention â Raising awareness of risk factors and educating people about the measures they can take to reduce exposure to the virus is the main prevention strategy for monkeypox. â Scientific studies are now underway to assess the feasibility and appropriateness of vaccination for the prevention and control of monkeypox. â Some countries have, or are developing, policies to offer vaccine to persons who may be at risk such as laboratory personnel, rapid response teams and health workers. 18. Treatment â At this time, there are no specific treatments available for monkeypox infection, but monkeypox outbreaks can be controlled. â Smallpox vaccine, cidofovir, ST-246, and vaccinia immune globulin (VIG) can be used to control a monkeypox outbreak. â CDC guidance was developed using the best available information about the benefits and risks of smallpox vaccination and drug use for the prevention and management of monkeypox and other orthopoxvirus infections. 19. Monkeypox and Smallpox Vaccine â One vaccine, JYNNEOSTM (also known as Imvamune or Imvanex), has been licensed in the United States to prevent monkeypox and smallpox. â Because monkeypox virus is closely related to the virus that causes smallpox, smallpox vaccine can also protect people from getting monkeypox. â Past data from Africa suggests that smallpox vaccine is at least 85% effective in preventing monkeypox. â The effectiveness of JYNNEOSTM against monkeypox was concluded from a clinical study on the immunogenicity of JYNNEOS and efficacy data from animal studies. â Experts also believe that vaccination after a monkeypox exposure may help prevent the disease or make it less severe. 20. THANK YOU https://www.friendbookmark.com/videos/1259/monkeypox-outbreak-2022Monkeypox Outbreak 2022 1. Monkeypox outbreak by/ Kholoud Mohamed Family Medicine Resident Under supervision of Dr/ Samar Osama Assistant lecturer at the Family Medicine Department 2. The Causative Agent: Monkeypox is an infectious disease caused by the Monkeypox virus which is a double-stranded DNA, zoonotic virus and a species of the genus Orthopoxvirus in the family Poxviridae. Other human orthopoxviruses include variola, cowpox , and vaccinia viruses. 3. â The virus is found mainly in tropical rainforest regions of Central and West Africa. â The virus is split into Congo Basin and West African clades. â The Central African clade is reported more frequently and more severely than the West African clade . â The case fatality rate for the West African clade is around 3.6 %, whereas for the Central African clade, it may be as high as 10.6 %. 4. Epidemiology: 5. 2003 U.S. outbreak: It was the first outbreak of monkeypox outside of Africa. In May 2003, a young child became ill with fever and rash after being bitten by a prairie dog. In total, 71 cases of monkeypox were reported & all cases were traced to Gambian pouched rats imported from Ghana. No deaths were reported. 2003 Midwest monkeypox outbreak 6. 2017 Nigeria outbreak: In 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality rate of approximately 3%. 2018 United Kingdom cases: In Sept 2018, the United Kingdom's first case of monkeypox was recorded. The person contracted monkeypox in Nigeria before travelling to the United Kingdom. Till December 2019, 3 cases were recorded, and 2 of them were travelling to the UK from Nigeria. One of them was a medical worker who cared for a case. 7. 2018 Israel case: In October 2018, one case occurred in a man who traveled from Nigeria to Israel. 2019 Singapore case: On May 2019, Singapore reported the first case of monkeypox who travelled from Nigeria. 2021 cases: On 24 May in the UK, three cases of monkeypox from a single household were reported. On 16 July in the US, an American returning from a trip in Nigeria was diagnosed with monkeypox. 8. Countries reporting confirmed human cases of monkeypox 1970 â 2021, WHO 9. 2022 UK outbreak: The index case: In late April 2022, the case was reported of a British resident who travelled to Nigeria. The patient developed symptoms of monkeypox on 29 April while still in Nigeria. On 4 May, the patient flew back to the UK, presented to hospital later the same day. The monkeypox infection was immediately suspected. The patient was hospitalized and isolated. 10. Extensive contact tracing of people who had been in contact with the index case both on the international flight from Nigeria to the United Kingdom and within the country following their arrival was carried out. The potential contacts were advised to remain aware of the symptoms of monkeypox and immediately isolate if any symptom develops within 21 days of the contact event. Monkeypox (West African clade) was laboratory confirmed by polymerase chain reaction (PCR) on a vesicular swab on 6 May by the United Kingdom Health Security Agency (UKHSA). 11. on 12 May, two new cases of monkeypox were confirmed by the UKHSA in London. There was no known link between either of them and the index case or travel to endemic regions. on 17 May, Four additional cases of monkeypox were confirmed by the UKHSA. None of these new cases had any known contact history with the previous three confirmed cases, suggesting wider community transmission of the virus in London. On 20 May, it was reported that another eleven cases had been confirmed in the UK, bringing the total number in the country to 20. 12. Europe, North America and Australia: On May 18 Portugal: 14 confirmed cases 20 suspected cases Spain: 7 confirmed cases 23 suspected cases The USA: confirmed single case Canada: 13 suspected cases 13. On May 19 On May 20 Sweden : the first confirmed case Belgium: the first confirmed case Italy: the first confirmed case France: a suspected case Australia : 2 confirmed cases Germany : first confirmed case 14. On May 20, the World Health Organization held an emergency meeting to discuss the outbreak. The WHO European chief expressed concern that infections could accelerate in Europe as people gather for parties and festivals over the summer. The WHO is expected to provide an update on sequencing of the virus genome from different cases to determine the cause. 15. Cases of monkeypox in non-endemic countries reported to WHO between 13 to 21 May 2022 16. Geographical distribution of confirmed and suspected cases of monkeypox in non-endemic between 13 to 21 May 2022 17. Cases of monkeypox in endemic countries between 15 December 2021 to 1 May 2022 18. Cases of monkeypox in non-endemic countries till 27 May 2022 19. The current situation in Egypt: On May 20, Dr. Hossam Abdel Ghaffar, the spokesman of the Egyptian Ministry of Health and population confirmed that there are no cases of infection or suspected infection with the monkeypox virus so far. 20. Animal Reservoir: â Monkeys âDormice âGambian pouched rats âAfrican squirrels Monkeys dormouse Gambian pouched rat African squirrel 21. Mode of Transmission: The virus enters the body through: Broken skin (even if not visible). The mucous membranes (eyes, nose, or mouth). Respiratory tract. Animal-to-human transmission may occur by: Bite or scratch. Bushmeat preparation. Direct contact with body fluids or lesion material. Indirect contact with lesion material, such as contaminated bedding. 22. Human-to-human transmission occurs through: Large respiratory droplets. Direct contact with body fluids or lesion material. Indirect contact with lesion material, such as contaminated clothing or linens. Human-to-human transmission is occurring among people in close physical contact with cases who are symptomatic. 23. Is it a sexually transmitted disease??! Almost all of the case clusters include men aged 20â50, many of whom are gay, bisexual and have sex with men (GBMSM). Although monkeypox isnât known to be sexually transmitted, sexual activity certainly constitutes close contact. The most likely explanation is that the virus was coincidentally introduced into a GBMSM community, and the virus has continued circulating there. 24. Is the virus genetically mutated??! In Portugal, the first draft genome sequence of the monkeypox virus was obtained from a swab collected on May 4th from skin lesions from a male patient. The draft genome indicates that the 2022 virus belongs to the West African clade and is most closely related to viruses associated with the exportation of monkeypox virus from Nigeria to several countries in 2018 and 2019, namely the United Kingdom, Israel and Singapore. 25. The incubation period: usually 6-13 days but can range from 5-21 days. 26. History taking: Important clues: Recent travel to endemic areas. Interaction with wild animals imported from endemic areas. Providing care to an infected animal or human. 27. Clinical picture: Initial symptoms : Fever. Headache. Myalgia. Fatigue. Lymphadenopathy. (a key differentiating feature of monkeypox from smallpox) 28. Within 1 to 3 days after the fever, the patient develops a rash: â Begins on the face and extremities (including palms and soles). â Centrifugally concentrated. â The total number of lesions may vary from a small amount to thousands. Lesions progress through the following sequential stages before falling off: â Macules â Papules â Vesicles â Pustules â Scabs 29. Monkeypox lesions 30. Differential Diagnosis: Smallpox Chickenpox Disseminated zoster Eczema herpeticum Disseminated herpes simplex Syphilis Scabies Rickettsia Measles Bacterial skin infections Drug-associated eruption 31. Diagnosis: Clinically. Laboratory testing: â Polymerase chain reaction (PCR) testing of samples from skin lesions. â Specimens should be collected from at least 3 lesions and from different sites on the body. â Viral culture â Anti-orthopoxvirus IgM and IgG. WHO-Laboratory testing for the monkeypox virus: Interim guidance is available at: https://www.who.int/publications/i/item/WHO- MPX-laboratory-2022.1 32. Prevention: Avoid contact with animals that could harbor the virus Avoid contact with any materials of a sick animal. Isolate infected patients from others who could be at risk for infection. Practice good hand hygiene after contact with infected animals or humans. Use personal protective equipment (PPE) when caring for patients including gown, gloves and masks. 33. Vaccination: Smallpox vaccine (ACAM2000): â It contains live vaccinia virus, and it was approved by the Food and Drug Administration (FDA) on 31 August 2007. â It is administered by (scarification) using a bifurcated needle. â Following a successful inoculation, a lesion will develop at the site of the vaccination. The virus growing at the site of this inoculation lesion can be spread to other parts of the body or even to other people. 34. The vaccine is not routinely available for public. It is licensed for immunization in people who are at least 18 years old and at high risk for smallpox infection such as laboratorians working with certain orthopoxviruses and military personnel. The smallpox vaccine is thought to be at least 85% effective in preventing monkeypox. 35. JYNNEOS (also known as Imvamune or Imvanex) JYNNEOS is a live, attenuated vaccinia virus, incapable of replicating. On Sept 2019, it was approved by the U.S. Food and Drug Administration (FDA). It is administered as two subcutaneous injections four weeks apart. There is no visible âtakeâ and as a result, no risk of spread to other parts of the body or other people. 36. People who receive JYNNEOS are not considered vaccinated until they receive both doses of the vaccine. It is indicated for preventing smallpox and monkeypox disease in adults 18 years of age and older who are at high risk for smallpox or monkeypox infection. It can be used for patients with weakened immune systems or atopic dermatitis. 37. When to take the vaccine? â Vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox virus. â The vaccine can be given within 4 days from the date of exposure in order to prevent onset of the disease. â If given between 4â14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease. 38. Monkeypox Disease vs Vaccine Risks. In Central Africaâwhere people live in remote areas and are medically underservedâshowed that the monkeypox disease killed 1â10% of people infected. Complications of the vaccines include eczema vaccinatum, progressive vaccinia resulting in death, contact transmission of vaccine virus, and fetal vaccinia. Between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine 39. Ring Vaccination This would vaccinate the close contacts of people who have been infected with monkeypox to cut off any routes of transmission and contain the spread of monkeypox. 40. Treatment: Supportive care: â Antipyretic. â Treatment of fluid & electrolytes disturbance. â Oxygenation if needed. â Empirical antibiotic therapy if secondary bacterial infection is suspected. â Acyclovir if varicella zoster infection is suspected. 41. Tecovirimat (ST-246): â On 13 July 2018, it was approved the U.S. Food and Drug Administration (FDA) and was approved for medical use in the European Union in January 2022. â Animal Studies have shown that ST-246 is effective in treating orthopoxvirus-induced disease. â Human clinical trials indicated the drug was safe and tolerable with only minor side effects. 42. Brincidofovir & Cidofovir: â Cidofovir was approved for medical use in 1996. â Brincidofovir was approved for medical use in June 2021. Brincidofovir is a prodrug of cidofovir. â Brincidofovir may have an improved safety profile over Cidofovir. â It have proven activity against poxviruses in in vitro and animal studies. 43. Vaccinia Immune Globulin (VIG) â It has no proven benefit in the treatment of smallpox complications. â IVIG can be considered for prophylactic use in an exposed person with severe immunodeficiency in T-cell function for which smallpox vaccination following exposure to monkeypox is contraindicated. 44. Complications: Bacterial superinfection of skin Permanent skin scarring Hyperpigmentation or hypopigmentation Permanent corneal scarring (vision loss) Pneumonia Dehydration Sepsis Encephalitis Death 45. Complications among Pregnant Women With Human Monkeypox: In 2017, Mbala et al. reported the fetal outcomes of 4 pregnant women who were infected by monkeypox virus. Variable Case 1 Case 2 Case 3 Case 4 severity Moderate Severe Mild Moderate Age, y 20 25 29 22 Time of gestation, wk 6 6â7 14 18 Event Miscarriage Miscarriage Live birth Fetal death 46. Pathologic findings for the stillborn fetus from case 4: Diffuse cutaneous maculopapular lesions. Hydrops fetalis Marked hepatomegaly with peritoneal effusion. No congenital malformations or deformities. Postmortem autopsy was consistent with intrauterine fetal demise. Placental hemorrhages on the maternal surface. 47. Monkeypox is usually self-limiting. The condition resolves around 3 to 4 weeks after symptom onset in most cases. Patients are no longer considered infectious after all crusts fall off. The West African clade has a more favorable prognosis with a case fatality rate 3.6% . The Central Basin clade is more lethal, with a case fatality rate of up to 10.6% in unvaccinated children. 48. The role of Family Physicians: 49. Case and Contact Definitions: 50. CASE INVESTIGATIONS: â Once a suspected case is detected, the physician should notify health care authority to start intensified surveillance. CDC case Investigation Form available at: https://www.cdc.gov/poxvirus/monkeypox/pdf/Monkeypox-Exposure- Questionnaire.pdf â Referral to the isolation facility. â The patient should wear a surgical mask& skin lesions should be covered (e.g., long sleeves, long pants). 51. During hospitalization: â The patients should be isolated in a negative air pressure room as soon as possible. â If it is not available, place patients in a private examination room. â If neither option is feasible, these following precautions must be applied : a surgical mask over the patientâs nose and mouth and covering any of the patientâs exposed skin lesions with a sheet or gown. â Confirmation of the diagnosis with lab tests and proper treatment and follow up of the patient. 52. Personal protective measures : â PPE should be donned before entering the patientâs room. â All PPE should be disposed prior to leaving the patientâs room. Disposable gown. Gloves whenever in contact with the patient, and with the patient surroundings. NIOSH-certified N95 (or comparable) filtering disposable respirator. Eye protection (e.g., face shields or goggles). 53. In case of home isolation: â The patient should be isolated in a room or area separate from other family members when possible. â Persons with monkeypox should not leave the home except as required for follow-up medical care. â They also should avoid contact with wild or domestic animals. â Unexposed persons who do not have an essential need to be in the home should not visit. 54. â The patients should wear a surgical mask & if this is not feasible, other household members should wear a surgical mask when in the presence of the person with monkeypox. â Disposable gloves should be worn for direct contact with lesions and disposed of after use. â Skin lesions should be covered to the best extent possible (e.g., long sleeves, long pants). â Contain and dispose of contaminated waste after consultation with state or local health officials. Do not dispose of waste in landfills or dumps. 55. Duration of Isolation Procedures Isolation should be continued until all lesions have resolved and a fresh layer of skin has formed. Following the discontinuation of isolation, the patients should avoid close contact with immunocompromised persons until all crusts are gone. â Immunologic disorders. â Chronic diseases. â Immunosuppressive therapy. 56. Contact tracing: â Identification of all contacts of every suspected case during case investigation . â All contacts should be included in a line-list and the contact listing section of the MPX Case investigation form. â If the laboratory result of a suspected case comes back as negative, the contacts are immediately dropped from further follow-up. â The contacts of confirmed animals or humans and contacts of probable cases should be placed under symptom surveillance for 21 days calculated from the last day of exposure. 57. Case investigation form - U.S. Centers for Disease Control and Prevention 58. Contacts should be instructed to monitor their temperature twice daily. If fever or rash develop, contacts should self-isolate and contact their local health department immediately. If only chills or lymphadenopathy develop, the contact should remain at their residence and self-isolate for 24-hours. During this time, the individual should monitor their temperature for fever; if a fever or rash develop, the health department should be contacted immediately. If fever or rash do not develop and chills or lymphadenopathy persist, the contact should be evaluated by a clinician for potential cause. 59. â Contacts who remain asymptomatic can be permitted to continue routine daily activities (e.g., go to work, school). â Contacts should not donate blood, cells, tissue, breast milk, semen, or organs while they are under symptom surveillance. 60. Monitoring of the exposed healthcare workers: All healthcare worker should be alert to the symptoms and should notify the infection control department if develop any symptoms. Healthcare workers who have unprotected exposures do not need to be excluded from work duty if asymptomatic, but should undergo active surveillance, which includes measurement of temperature at least twice daily for 21 days following the exposure. Prior to reporting for work each day, the healthcare worker should be interviewed regarding evidence of fever or rash. 61. Could it be a new pandemic ??! â Unlike SARS-CoV-2, It is related to the smallpox virus, there are already treatments and vaccines on hand. â Unlike SARS-CoV-2, which spreads through tiny air-borne droplets, monkeypox spreads mainly through close contact with bodily fluids, and less extent through large respiratory droplets. 62. â Unlike SARS-CoV-2, RNA virus, monkeypox virus is a relatively large DNA virus. DNA viruses are better at detecting and repairing mutations than RNA viruses. â According to the World Health Organization (WHO), Monkeypox can be contained in countries outside of Africa where the virus is not usually detected. â The current outbreak probably wonât necessitate containment strategies beyond ring vaccination. âThis is a containable situationâ Maria Van Kerkhove, the WHO's emerging disease lead 63. References: â CDC. About Monkeypox | Monkeypox| Poxvirus | CDC [Internet]. 2018 [cited 2019 Oct 19]. Available from: https://www.cdc.gov/poxvirus/monkeypox/about.html â WHO. Monkeypox [Internet]. WHO. 2016 [cited 2019 Oct 19]. Available from: https://www.who.int/news-room/fact-sheets/detail/monkeypox â "Monkeypox," UK Health Security Agency, 18 May 2022. [Online]. Available: https://www.gov.uk/guidance/monkeypox#transmission. â https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest- updates â Durski KN, McCollum AM, Nakazawa Y, Petersen BW, Reynolds MG, Briand S, et al. Emergence of monkeypox â West and Central Africa, 1970â2017. Morb Mortal Wkly Rep. 2018 Mar 16;67(10):306â10. â NCDC. Nigeria Centre for Disease Control: Weekly Epidemiological Report [Internet]. 2017 [cited 2019 Oct 19]. Available from: https://ncdc.gov.ng/reports/101/2017-december- week-52 64. â "Epidemiological update: Monkeypox outbreak," European Centre for Disease Prevention and Control, 20 May 2022. [Online] â Placide K Mbala, John W Huggins, Therese Riu-Rovira, Steve M Ahuka, Prime Mulembakani, Anne W Rimoin, James W Martin, Jean-Jacques T Muyembe, Maternal and Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the Democratic Republic of Congo, The Journal of Infectious Diseases, Volume 216, Issue 7, 1 October 2017, Pages 824â828, https://doi.org/10.1093/infdis/jix260 â https://www.nature.com/articles/d41586-022- 014218?utm_source=Nature+Briefing&utm_campaign=722ea2a64d-briefing-wk- 20220520&utm_medium=email&utm_term=0_c9dfd39373-722ea2a64d-42456515 â https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1 https://www.friendbookmark.com/videos/1258/understanding-monkeypoxMonkeypox update 1. Epidemiology and laboratory diagnosis of Monkeypox virus in Africa Nikola Sklenovskà Master of Biomedical Sciences KU Leuven Supervisor: prof. dr. Marc VAN RANST Co-supervisor: dr. Piet MAES Instructor: Valentijn VERGOTE 2. 2 Content â Introduction â Epidemiological data, DRC 2014-2016 â Development of qPCR diagnostic assay â Conclusions â Future work 3. 3 Zoonotic diseases MIEF zoonosis conference 2015 7,5 billion people on earth 2,4 billion affected/year 2,3 million death/year Introduction 4. 4 Monkeypox Family Poxviridae Subfamily Chordopoxvirinae Genus Orthopoxvirus Species Camelpox virus Cowpox virus Ecromelia virus Monkeypox virus Raccoonpox virus Skunkpox virus Taterapox virus Vaccinia virus Variola virus Volepox virus Introduction 5. 5 6. 6 7. 7 8. 8 Introduction 9. 9 1. Assess epidemiological characteristics of the most recent monkeypox data. 2. Develop a diagnostic assay for differentiation of MPXV and VZV suitable for field conditions. Aims 10. 10 Democratic Republic of Congo â Provided by prof. dr. Muyembe â September 2014 â February 2016 â Passive surveillance â 223 laboratory confirmed monkeypox cases Materials and Methods 11. 11 Results and Discussion 1981 - 1986 2014 - 2016 17 months72 months 223 cases338 cases Geographical distribution 12. 12 Gender 42% 58% 41% 59% 1981 - 1986 2014 - 2016 ResultsResults and Discussion 13. 13 14. 14 Age ResultsResults and Discussion 0 2 4 6 8 10 12 14 16 0 5 10 15 20 25 30 35 40 45 50 55 60 Cases Age (years) 0 20 40 60 80 100 0-2 3-4 5-6 7-9 10-14 â 15 Cases Age (years) 87% 71% 1981 - 1986 2014 - 2016 Likely vaccinated Likely vaccinated 15. 15 Increase of MPX incidence 20-fold increase between 2005 - 2007 compared to 1981 - 1986 Rimoin et al 2010 1981-1986 (cases/month) 2014-2016 (cases/month) DRC 4,7 13,7 Equateur 3,2 11,3 ResultsResults and Discussion 3-fold 223 cases338 cases 16. 16 17. 17 neither 587 suspected VZVMPX 223 40 78 339 tested Results and Discussion Monkeypox misdiagnosed 18. 18 19. 19 1. Assess epidemiological characteristics of the most recent monkeypox data. 2. Develop a diagnostic assay for differentiation of MPXV and VZV suitable for field conditions. Aims 20. 20 Materials and Methods Diagnostic tools 21. 21 Assay development â Multiplex assay for VZV and MPXV detection â Validated with  10 VZV-positive samples  5 MPXV-positive samples 22. 22 Results and Discussion 107 copies 107 copies 102 copies 101 copies 102 - 107 copies 101 - 107 copies VZV standards MPX standards Sensitivity of the assay 23. 23 Results and Discussion VZV MPXV VZV coinfection in MPXV samples 24. 24 Results and Discussion VZV coinfection in MPXV samples 25. 25 VZV MPX Results and Discussion Simultaneous infection 26. 26 VZV MPX Simultaneous infection Results and Discussion Latent VZV 27. 27 Conclusions â Monkeypox incidence is increasing  need for effective interventions, surveillance and research â Multiplex qPCR diagnostic assay suitable for field conditions was developed â VZV and MPX coinfections are not rare events? 28. 28 Future work â Prior DNA extraction â Lyophilization of reagents (cold chain) â Testing cidofovir as treatment for monkeypox in humans (clinical trial) 29. âThis virus, we are sure, cannot infect humansâ Zhengli Shi 30. 30 31. 31 32. 32 https://www.friendbookmark.com/videos/1146/secondary-dyslipidemiaInformation covered in this presentation slides: 1. Secondary Dyslipidemia By : Ahmed Mohsen Ammar Yasser Heba Sadek Marwa Khalifa 2. Dyslipidemia â Definition : Dyslipidemias are disorders of lipoprotein metabolism, including lipoprotein overproduction or deficiency. These disorders may be manifested by elevation of the serum total cholesterol, low-density lipoprotein (LDL) cholesterol and triglyceride concentrations, and a decrease in the high-density lipoprotein (HDL) cholesterol concentration. 3. Classification Etiological classification 1- Primary Hyperlipidemia. 2- Secondary Hyperlipidemia. 4. Secondary hyperlipidemia Causes: â Type 2 diabetes mellitus â Cholestatic liver diseases â Nephrotic syndrome â Chronic renal failure â Hypothyroidism â Cigarette smoking â Obesity & Anorexia nervosa â Drugs : such as thiazides, Î-blockers, retinoids, highly active antiretroviral agents, estrogen and progestins, and glucocorticoids. 5. Increased triglyceride level â Alcoholism â Diabetes mellitus â Hypothyroidism â Obesity â Renal insufficiency â Drugs: Beta-adrenergic blockers ,Bile acidâbinding resins, Estrogens ,Ticlopidine â Acute hepatitis â Systemic lupus â Ileal bypass surgery â Monoclonal gammopathy :myeloma â Sepsis â Pregnancy 6. Decreased HDL cholesterol level â Cigarette smoking â Diabetes mellitus â Hypertriglyceridemia â Menopause â Obesity â Puberty (in males) â Uremia â Drugs: Anabolic steroids,Beta-adrenergic blockers ,Progestins 7. Increased LDL cholesterol level âDiabetes mellitus âHypothyroidism âNephrotic syndrome âObstructive liver disease âDrugs: Anabolic steroids, Progestins ,Beta- adrenergic blockers ,Thiazides âAnorexia nervosa âAcute intermittent porphyria 8. Type 2 Diabetes mellitus Diabetes is an especially significant secondary cause because patients tend to have an atherogenic combination of high TGs; high small, dense LDL fractions; and low HDL (diabetic dyslipidemia) Diabetes mellitus 9. The combination may be a consequence of obesity, poor control of diabetes, or both, which may increase circulating free fatty acids (FFAs), leading to increased hepatic very-low- density lipoprotein (VLDL) production. TG-rich VLDL then transfers TG and cholesterol to LDL and HDL, promoting formation of TG-rich, small, dense LDL and clearance of TG-rich HDL. 10. Diabetic dyslipidemia is often exacerbated by the increased caloric intake and physical inactivity that characterize the lifestyles of some patients with type 2 diabetes. 11. Cholestatic Liver Disease Primary biliary cirrhosis and similar disorders may be accompanied by marked hypercholesterolemia that results from an accumulation of lipoprotein-X. Clinical stigmata include xanthomata striata palmare that may appear when the serum cholesterol concentration is 1400 mg/dL or higher. 12. Xanthomata striata palmare 13. Xanthomata appear on the extremities as well. Marked elevations in lipoprotein X has been associated with the hyperviscosity syndrome, but no clear association with coronary heart disease (CHD) has been established. 14. Nephrotic Syndrome Marked hyperlipidemia can occur in the nephrotic syndrome due primarily to high serum total and low-density lipoprotein (LDL) cholesterol concentrations. Increased hepatic production of lipoproteins, induced by part by the fall in plasma oncotic pressure is the major abnormality, but diminished lipid catabolism may play a contributory role. 15. Chronic Renal Failure Dyslipidemia is less prominent in chronic renal failure, but hypertriglyceridemia occurs in 30 to 50 percent of cases. Chronic renal failure 16. Hypothyroidism Hypothyroidism is frequently associated with and is a common cause of hyperlipidemia. This relationship was illustrated in a study of patients with primary hypothyroidism. Hypercholesterolemia was present in 56 percent, hypercholesterolemia and hypertriglyceridemia in 34 percent, and hypertriglyceridemia in 1.5 percent; only 8.5 percent had a normal lipid profile. 17. Reversal of the hypothyroidism with thyroid hormone replacement leads to correction of hyperlipidemia. Serum TSH should be measured in all patients with dyslipidemia. 18. Smoking Smoking modestly lowers the serum HDL cholesterol concentrations and may induce insulin resistance. These effects are reversible within one to two months after smoking cessation. 19. Obesity Obesity is associated with a number of deleterious changes in lipid metabolism, including high serum concentrations of total cholesterol, LDL cholesterol, VLDL cholesterol, and triglycerides, and a reduction in serum HDL cholesterol concentration of about 5 percent. Loss of body fat can reverse the hypercholesterolemia and hypertriglyceridemia. 20. Anorexia nervosa â Hypercholesterolemia has long been known to be associated with anorexia nervosa. Typically total cholesterol and LDL are elevated; HDL may be high also. With refeeding, cholesterol levels return to baseline. Other forms of malnutrition are not usually associated with high cholesterol. However, until recently the underlying mechanism has not been clearly delineated 21. Clinical Presentation â Dyslipidemia itself usually causes no symptoms but can lead to symptomatic vascular disease, including coronary artery disease (CAD) and peripheral arterial disease. â High levels of TGs (> 1000 mg/dL) can cause acute pancreatitis. â High levels of LDL can cause eyelid xanthelasmas; arcus corneae; and tendinous xanthomas at the Achilles, elbow, and knee tendons and over metacarpophalangeal joints. 22. â Patients with severe elevations of TGs can have eruptive xanthomas over the trunk, back, elbows, buttocks, knees, hands, and feet. â Extremely high lipid levels also give a lactescent (milky) appearance to blood plasma. 23. Eyelid xanthelasmas 24. Arcus corneae 25. Tendinous xanthomas 26. Tendinous xanthoma 27. â Serum lipid profile (measured total cholesterol, TG, and HDL cholesterol and calculated LDL cholesterol and VLDL) â Tests for secondary causes of dyslipidemiaâ including measurements of fasting glucose, liver enzymes, creatinine, thyroid-stimulating hormone (TSH), and urinary proteinâshould be done in most patients with newly diagnosed dyslipidemia. Diagnosis 28. Treatment â Treatment of the cause. â Lifestyle changes (eg, exercise, dietary modification) â For high LDL cholesterol, statins, sometimes bile acid sequestrants. â For high TG or low HDL cholesterol, niacin , fibrates, and sometimes other measures. https://www.friendbookmark.com/videos/1145/causes-of-malnutrition 1. Causes and Disease of Malnutrition 2. Poor Diet - One of the most common causes of malnutrition is the lack of nutritious and balanced diet. -Not having enough of the healthy foods we need each day, or consuming too many types of food and drink. 3. Illness and Medical Conditions Illness and medical conditions can have a great impact on oneâs nutrition. Digestive disorders and stomach conditions may upset the ability to digest food and absorb the necessary nutrients that may help in the growth and development of the body. Taking lotâs of medicine may affect the bodyâs capacity to break down nutrients. 4. Mental Health Problems Anorexia Nervosa Is an eating disorder and metabolic condition that results in excessive weight-loss and extreme thinness caused by self- starvation. Bulimia Is a psychological eating disorder in which youâve consuming a large quantity of foods in one sitting. 5. Physical Factor Persons with disability or impairment have difficulty choosing the right kind of food. Poor dental hygiene, badly fitting dentures, and painful gums may prevent people from eating properly which may result in inadequacy of the required nutrients. 6. Protein Energy Malnutrition - Protein serves as the building block of the body. It helps maintaining, developing, and repairing body tissues. It also helps in providing energy for the body. - if the consumption of protein is insufficient, protein energy malnutrition (PEM) occurs. Protein Energy Malnutrition causes diseases such as marasmus, and kwashiorkor. - Protein hastes the creation of hormones. These hormones helps controlling bodily functions. It is also responsible in forming antibodies which prevent infectious, illness and disease. Protein helps in destroying bacteria and viruses. 7. Marasmus - Occurs when there is a sever deficiency of essential nutrients such as protein and carbohydrates. It is characterized by loss of muscle mass and body fat, mental and intellectual impairment, and stunted growth. 8. Kwashiorkor - It is also called wet protein energy malnutrition. It is primarily characterized by fluid retention or swelling of the stomach. Children suffering from kwashiorkor often develop of bulging belly and extremely thin arms and legs. Their immune system becomes weak and they show behavioural defect and mental retardation. 9. Micro Nutrient Deficiencies Micronutrients are composed of vitamins and minerals which are needed by the body in small amounts to ensure normal metabolism as well as growth and development. Insufficient dosage of these nutrients in the body may lead to different kinds of micronutrient deficiencies. https://www.friendbookmark.com/videos/1144/antihyperlipidemic-agents 1. ANTIHYPERLIPIDEMIC AGENTS BY SWATHI KENCHA 2. INTRODUCTION â What is hyperlipidemia? â A condition in which there are high levels of fat particles(lipids) deposited in the blood. â Elevated plasma levels of lipids are deposited in the form of lipoproteins. Eg: lipids like cholesterol and triglycerides. â These lipids can deposit in blood vessel walls and restrict blood flow. â This creates a risk of heart attack & stroke. 3. CAUSES OF HYPERLIPIDEMIAS â Diet & Hereditary factors â Hypothyroidism â Nephrotic syndrome â Anorexia nervosa â Systemic lupus erythematousus â Obesity,Alcohol consumption & smoking â Diabetes â Pregnancy â Obstructive liver disease, Acute hepatitis 4. SYMPTOMS OF HYPERLIPIDMIA 5. ANTIHYPERLIPIDEMICS â The clinically important lipoproteins are HDL,LDL and VLDL . â Antihyperlipidemics are the drugs used to reduce the deposited levels of cholesterol and other lipoproteins from the blood plasma . 6. CLASSIFICATION â HMG CoA Inhibitors â Lovastatin,Atorvastatin â Fibrates â Clofibrate,Fenofibrate â Bile acid sequesterants â Cholestyramine,colestipol â LDL Oxidation inhibitors âProbucol â Pyridine derivatives âNicotinamide,Nicotinic acid â Cholesterol absorption inhibitors âEzetimibe â Miscellaneous âÎ-sitosterol,Dextrothyroxine 7. LOVASTATIN Uses:HMG CoA reductase inhibitor Side effects â Headache,Myositis,nausea,sleep disturbance, contraindications in pregnancy 8. ATORVASTATIN Uses:HMG CoA reductase inhibitor It prevents ischemia by inhibiting both deposition of lipids and decreases inflammation 9. CLOFIBRATE Uses:Reduces VLDL To treat hyperlipoproteinemia. 10. FENOFIBRATE Uses:Reduces the fatty substances like Cholesterol and VLDL Increases the amounts of HDL 11. CHOLESTYRAMINE Uses: To treat type II a hyperlipoproteinemia. 12. COLESTIPOL Uses:Reduces cholesterol levels To treat Type II hyperlipoproteinemias. 13. PROBUCOL Uses:It is used to treat high cholesterol levels in the blood Anticholesteremic drug with antioxidant and anti- inflammatory properties. 14. Nicotinamide & Nicotinic acid Uses:In high doses reduces low density lipoprotein,cholesterol and increases the amount of HDL in blood 15. EZETIMIBE Uses:It inhibits the cholesterol absorption in the body So it reduces the amount of cholesterol 16. Î-Sitosterol & Dextrothyroxine Uses:Dextrothyroxine is a thyroid hormone having antihyperlipidemic activity. Î-Sitosterol reduces cholesterol levels 17. MECHANISMS â Lovastatin regulates cholesterol synthesis in the liver by inhibiting microsomal reduction of 3-hydroxy 3-methyl glutaryl CoA (HMG Co A) catalyzed by HMGCoA reductase. â Colestyramine & Colestepol â The reduction in the amounts of reabsorbed bile acids results in increased catabolism of cholesterol in bile acids in the liver.Then it decreases concentration of bile acids. 18. â Fibrates inhibit triglyceride synthesis ,reduces VLDL release into circulation.This drug increases lipoprotein lipase activity,which catabolises the chylomicrons and VLDL. 19. â Probucol lowers the levels of cholesterol in the blood by increasing the rate of LDL catabolism.Probucol is a powerful antioxidant which inhibits the oxidation of cholesterol. â Nicotinic acid and Nicotinamide inhibits a hormone- sensitive lipase in adipose tissue which reduces the breakdown of triglycerides to free fatty acids,and the transport of free fatty acids to the liver. â Ezetimibe reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine. 20. THANK YOU ALL https://www.friendbookmark.com/videos/1143/steps-to-recover-from-bulimia-nervosaEllern Mede Eating Disorder Services is widely regarded as the UKâs most specialist provider of intensive inpatient and outpatient treatment for children and young people since 2000. We are specialists in eating disorder treatment like Bulimia Nervosa very effectively and efficiently. 1. Ellern Mede follows NICE guidelines in treating Bulimia, the treatment of choice being cognitive behavioural therapy (CBT). Outpatient Care Plans are patient-centred to suit the lifestyle circumstances of the patient. Ellern Mede outpatient treatment consultations for psychiatry, psychology and dietetics may be found to help post discharge from other providersâ inpatient care. Other treatments are medications, nutrition education and hospitalization. Ellern Mede Eating Disorder Services is regarded as the UKâs most specialist provider of intensive inpatient and outpatient treatment for children and young people since 2000. Ellern Mede is a specialists in eating disorder treatment like Bulimia Nervosa very effectively and efficiently. Email - info@ellernmede.org Phone - +44 (0)20 3209 7900 Address - Ellern Mede Ridgeway Holcombe Hill The Ridgeway, Mill Hill London NW7 4HX Website - https://ellernmede.org Stop the Binge-Purge Cycle Start Healing Your Relationship with Food Manage Your Anxiety Start Healing Your Relationship with Your Body Develop a Support System STEPS TO RECOVER FROM BULIMIA NERVOSA Bulimia Nervosa is a dangerous eating disorder where the individual goes through cycles of binging and purging. It is an eating disorder that can wreak havoc on your body, relationships, and life. Bulimics typically have low self- esteem and distorted views of their body image. ABOUT ELLERN MEDE STEPS TO RECOVER FROM BULIMIA NERVOSA CONTACT INFORMATION WHAT IS BULIMIA NERVOSA? BULIMIA NERVOSA TREATMENT BY ELLERN MEDE The effects of Bulimia, which worsen the longer the condition persists, include mental disorders such as depression and anxiety, but also physical damage to the heart, kidneys, digestive system and teeth. EFFECTS OF BULIMIA NERVOSA https://www.friendbookmark.com/videos/1142/side-effects-of-anorexia-nervosa-on-teenagersAnorexia is a disastrous way to start out in life as it will affect all aspects of the young personâs future - physical, psychological and social. If your adolescent son or daughter is suffering from anorexia, consult Ellern Mede Eating Disorder Services today. 1. SIDE EFFECTS OF ANOREXIA NERVOSA ON TEENAGERS 2. Starvation, over-exercising and an unhealthy attitude towards body image will, as you can imagine, have numerous side effects on younger anorexics. If your teenage son or daughter is suffering from anorexia, you must seek eating disorder treatment in London immediately to prevent the complications and life-long health problems which could arise from this eating disorder. 3. Although being young means the sufferers are still growing, a false perception of their body image will force them to lose weight even if they are already severely underweight. This is especially tragic for the young. During adolescence, the body needs plenty of food to grow and reach adulthood, but anorexics will experience unnatural side effects during this phase of development. Here are some of the most common side effects of anorexia on young adults: 4. Women will not gain a normal and regular menstrual cycle, which could lead to serious problems later in life regarding pregnancy. There can also be a loss of brain tissue and muscle tissue. Young people typically have the energy to be active, taking up sports and outdoor activities. That said, an energetic lifestyle does not fit in with deteriorating muscles. Not only that, but the brain is constantly being tested during school, through exams and homework. Anorexia causes brain tissue to atrophy, so a normal education will prove difficult, not to forget the serious long-term complications arising from failure at school. 5. All sufferers of anorexia will experience over-exhaustion as the body simply wonât be able to function properly without enough food. It is like trying to run a car without any gas; it will just stop. As the body shuts down, the anorexic will experience lethargy and drowsiness. Day to day activities will become a chore and working - whether at school or in a job - will become ever more difficult. Low blood pressure is another side effect of the disorder from undernourishment and the ensuing lack of sleep, both causing the body to be in a state of shock. Concentration is severely affected, due to the mind being overcome with tiredness and hunger. 6. Other physical side effects can be the sign of deeper internal complications. Brittle yellow nails are a sign of kidney problems brought about by dehydration. And a lack of essential minerals such as sodium and potassium bring rise to heart problems. Physical appearance will also deteriorate. Although the individual thinks they are working towards a âperfectâ body by losing weight, the reality is they are creating a frail and unhealthy body. Hair that falls out, pallid skin, discoloured nails and swelling arms and legs are some obvious side effects to name a few. Anorexics will work at hiding these physical side effects, but the psychological complications and internal side effects are long-lasting without any treatment. 7. Social problems can also occur, as sufferers tend to judge others negatively who do not share the same distorted view of body image. This can lead to social exclusion resulting in a deeper depression. Anorexia is a disastrous way to start out in life as it will affect all aspects of the young personâs future - physical, psychological and social. If your adolescent son or daughter is suffering from anorexia, consult Ellern Mede Eating Disorder Services today. As one of the UKâs leading providers of intensive outpatient and inpatient eating disorder treatment for young people, they will be able to help your child overcome the negative impact of anorexia and improve their quality of life. https://www.friendbookmark.com/videos/1141/long-term-health-consequences-of-anorexia-nervosaEllern Mede Eating Disorder Services is widely regarded as the UKâs most specialist provider of intensive inpatient and outpatient treatment for children and young people. We are a specialist in Anorexia Nervosa Treatment to recovered patients from Anorexia which was the major eating disorder facing people today. 1. LONG TERM HEALTH CONSEQUENCES OF ANOREXIA NERVOSA 2. WHATIS ANOREXIA NERVOSA? Anorexia Nervosa is the most serious eating disorder in the world and has a higher death rate than any mental illness. Individuals suffering from anorexia often think they are fat when they are slim. But whether that is the reason or not, a person with this condition refuses to eat or restricts what they eat to such an extent they put themselves in danger. It is often (but not always) linked to a deliberate and conscious will to be as thin as possible without regard to their health. 3. LONG TERM HEALTH CONSEQUENCESOF ANOREXIA â Seizures â Brain Abscesses â Stroke â Heart Failure â Pancreatitis â Osteoporosis â Kidney Failure 4. ABOUTELLERN MEDE Ellern Mede Eating Disorder Services is widely regarded as the UKâs most specialist provider of intensive inpatient and outpatient treatment for children and young people. We are specialist in Anorexia Nervosa Treatment to recovered patients from Anorexia which was the major eating disorder facing people today. We have two hospitals, both based in North London, the first is at Ridgeway and is registered for 28 patients and the second is at Barnet is registered for up to 16 patients. 5. ANOREXIA NERVOSA TREATMENT BY ELLERN MEDE Ellern Medeâs experienced physicians, specialist doctors, psychiatrists and psychologists provide regular physical monitoring during both inpatient and outpatient weight restoration. We follow NICE recommended family therapy as the treatment of choice for young people with Anorexia Nervosa. We offers eating disorder therapies such as Motivational Enhancement Therapy (MET) and Cognitive Remediation Therapy (CRT) as well as Cognitive Behavioural Therapy (CBT). 6. CONTACTINFORMATION Email â info@ellernmede.org Phone â +44 (0)20 3209 7900 Address â Ellern Mede Ridgeway Holcombe Hill The Ridgeway Mill Hill London NW7 4HX Website â https://ellernmede.org https://www.friendbookmark.com/videos/1140/anorexia-nervosa-eating-disorderInformation covered in this presentation slides: 1. Christopher Nirmal 2. - Definition: Anorexia nervosa is an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain as well as a distorted body self-perception. - It typically involves excessive weight loss and is diagnosed approximately nine times more often in females than in males 3. - A DSM-5 diagnosis of anorexia nervosa requires each of the following criteria : - ●Restriction of energy intake that leads to a low body weight, given the patientâs age, sex, developmental trajectory, and physical health - ●Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight - Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of oneâs low body weight 4. - ●Mild â BMI 17 to 18.49 kg/m2 - ●Moderate â BMI 16 to 16.99 kg/m2 - ●Severe â BMI 15 to 15.99 kg/m2 - ●Extreme â BMI < 15 kg/m2 5. - Anxiety disorders - Obsessive-compulsive disorder - Body dysmorphic disorder - Posttraumatic stress disorder - Mood disorders - Substance use disorders - Disruptive, impulse control, and conduct disorders 6. - ●Obsessive-compulsive - (15 percent of patients with anorexia nervosa) - ●Avoidant (14 percent) - ●Dependent (7 percent) - ●Narcissistic (6 percent) - ●Paranoid (4 percent) - ●Borderline (3 percent) 7. - ●Perfectionism â pursuing unrealistically high standards despite the occurrence of adverse consequences - ●Compulsivity â insisting upon order, symmetry, exactness, and control - ●Narcissism â craving admiration and external validation from others; excessive concern with physical appearance 8. - ●Amenorrhea - ●Infertility - ●Exertional fatigue - ●Weakness - ●Cold intolerance - ●Palpitations - ●Dizziness - ●Abdominal pain and bloating - ●Early satiety - ●Constipation - ●Swelling of the feet - Irritability is often present as well. 9. - ●Low body mass index (< 17.5 kg/m2) - ●Emaciation (body weight less than 70 percent of ideal body weight) - ●Hypothermia (core temperature < 35ÂC or 95ÂF) - ●Bradycardia (pulse < 60 beats per minute) - ●Hypotension (systolic blood pressure < 90 mmHg and/or a diastolic blood pressure < 50 mmHg) - ●Hypoactive bowel sounds - ●Xerosis (dry, scaly skin) - ●Brittle hair and hair loss 10. - ●Serum electrolytes - ●Blood urea nitrogen - ●Serum creatinine - ●Serum glucose - ●Serum calcium, phosphorous, and magnesium - ●Serum albumin and prealbumin - ●Liver function tests (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase) 11. - ●Internationalized Normalized Ratio (INR) - ●Complete blood count (CBC) including differential - ●Thyroid stimulating hormone (TSH) - ●20-OH Vitamin D - ●Electrocardiogram (ECG) - ●Urinalysis for specific gravity 12. - ●Neoplasm - ●Chronic infections (eg, tuberculosis or acquired immunodeficiency syndrome) - ●Uncontrolled diabetes mellitus - ●Hyperthyroidism - ●Malabsorption syndromes (eg, celiac disease) - ●Inflammatory bowel disease (eg, Crohn disease) - ●Pregnancy - ●Primary ovarian failure - ●Polycystic ovary disease - ●Pituitary prolactinoma 13. -Cardiovascular (structural) - Decreased cardiac mass - Decreased cardiac chamber volumes - Mitral valve prolapse (20%) - Myocardial fibrosis - Pericardial effusion - Improve with weight gain 14. -Cardiovascular (functional) : - Bradycardia - Hypotension - QT dispersion - Occasionally QT prolongation - Decreased heart rate variability - ST,T changes AV block Vent.arrhythmias 15. - Gastroparesis with bloating - Constipation - Severe pancreatitis - Mild rise in LFTS - Superior mesentric artery syndrome (rare) 16. - Anaemia 83% - Leucopenia 79% - Thrombocytopenia 25% -Bone marrow: - Normal 11% - Aplastic or Hypoplastic 39% - Gelatinous degeneration with serous fat atrophy 50% 17. -Decreased GFR -Decreased concentration -Electrolyte abnormalities - (Purging > Restrictive) 18. - Dyspnoea - (weakness and wasting of resp. muscles) - Pneumothorax /Pneumomediastinum - (weakening of alveolar walls) - Aspiration pneumonia - PFTS: - decreased maximal inspiratory pressures (59% of predicted) - expiratory pressures (35%), and - increased residual volume (162%). - Diffusion capacity (98.1 +/- 16.2%) and transfer coefficient (98.4 +/- 16.2%) were also normal 19. - Hypoglycemia - Hypothalamus and pituitary: - Decreased GRH - Increased activation of HPA axis> Raised Cortisol - Increased GH and decreased IGF-1 - Decreased ADH levels - Abnormalities of thermoregulation - Osteoporosis: In 30% (multifactorial) - (BMI < 15 and Amenorrhoea > 6months) 20. - Euthyroid hypothyroxinemia may develop in anorexia nervosa, marked by - normal to decreased serum levels of thyroxine (T4) and triiodothyronine (T3) levels, - - a normal level of thyroid stimulating hormone (TSH), - and an increased level of reverse T3 21. - ●Xerosis (dry, scaly skin) - ●Lanugo-like body hair (fine, downy, dark hair) - ●Telogen effluvium (hair loss) - ●Carotenoderma (yellowing) - ●Acne - ●Hyperpigmentation - ●Seborrheic dermatitis (erythema and greasy scales) - ●Acrocyanosis (cold, blue, and occasionally sweaty hands or feet) 22. - ●Perniosis (painful or pruritic erythema) - ●Petechiae - ●Livedo reticularis (reddish-cyanotic circular patches) - ●Paronychia (inflamed lateral and posterior nail folds) - ●Pruritus - ●Striae distensae (erythematous or hypopigmented linear patches) - ●Slower wound healing 23. - Nutritional rehabilitation - Psychotherapy - Nutritional rehabilitation: - Supervised meals - Proscribing binge eating and purging - Expected weight gain: 0.9 to 1.4 kg/week (in pts) - 0.2 to 0.5kg/week (out pts) - 1000 to 1600 kcal /day gradually stepped up - ( 30 to 40 kcal/kg) 24. -Psychotherapy: - Cognitive Behavioural Therapy - Specialist supportive clinical management - Motivational interviewing - Family therapy - Maintenance Psychotherapy 25. -Pharmacotherapy: - Olanzapine (2.5 to 10mg/day) - Lorazepam 0.5mg/day - SSRIs - Deep Brain Stimulation for chronic and treatment refractory Anorexia nervosa - (Sub callosal singulate gyrus) - DBS was associated with improvements in mood, anxiety, affective regulation, and anorexia nervosa-related obsessions and compulsions. Seems to be safe 26. - American Psychiatric Association suggest hospitalization for adults, adolescents, and children who meet one or more of the following criteria - ●Medical instability (eg, bradycardia near 40 beats per minute; blood pressure < 80/50 mmHg; dehydration; or compromised cardiac, hepatic, or renal functioning) - ●Weight < 85 percent normal body weight, or rapid weight decline with food refusal despite outpatient treatment or partial hospitalization - ●Suicidal ideation with high lethality plan or suicide attempt - ●Poor motivation that necessitates supervision with meals, or cooperation with treatment that is contingent upon a highly structured environment - ●Comorbid psychiatric conditions (eg, depressive, substance use, or anxiety disorders) that require hospitalization 27. - Practice guidelines from the Society for Adolescent Medicine suggest hospitalization for adolescents with eating disorders who meet one or more of the following criteria : - ●Failure of outpatient or partial hospital treatment - ●Acute food refusal - ●Uncontrollable binging and purging - ●Severe malnutrition (eg, rapid weight loss and/or weight at a medically concerning level) - ●Dehydration - ●Cardiac dysrrhythmia 28. - ●Vital signs unstable - âSevere bradycardia (eg, heart rate < 50 beats per minute during the day or < 45 at night) - âHypotension (eg, blood pressure < 90/50 mmHg) - âHypothermia (eg, < 96ÂF) - âOrthostatic changes in pulse (> 20 beats per minute) or blood pressure (> 10 mmHg) - Electrolyte disturbances (hypokalemia, hyponatremia, or hypophosphatemia) 29. - Acute medical complication of malnutrition (eg, syncope, seizures, cardiac failure, or pancreatitis) - ●Arrested growth and development - ●Acute psychiatric emergencies (eg, suicidal ideation or behavior, or acute psychosis) - ●Comorbid diagnosis that interferes with the treatment of eating disorders (eg, moderate to severe depression, obsessive compulsive disorder, concurrent substance abuse, or family dysfunction) 30. - The refeeding syndrome is defined as the clinical complications that occur as a result of fluid and electrolyte shifts during nutritional rehabilitation of malnourished patients - ●Hypophosphatemia - ●Hypokalemia - ●Vitamin (eg, thiamine) deficiencies - ●Congestive heart failure - ●Peripheral oedema 31. - Cardiovascular: Heart failure / Arrhythmias - Pulmonary : Dyspnoea and impaired respiratory function - Muscular: Myalgia / Weakness / Tetany - Gastrointestinal: Impaired LFTS / Nausea, vomiting, diarrhoea - Neurological: Tremors / Paraesthesias / Delirium / Seizures 32. - ●Available dietary and nutritional support staff should be consulted to determine the initial daily calories to be ingested - ●Patients should be fed according to a standard protocol that includes a limited intake of sodium and fluids. The amount of daily calories should be raised by 300 to 400 kcal every three to four days. - Electrolyte deficiencies that are present in patients with anorexia nervosa should be corrected prior to initiating the refeeding process - The goal for weight gain should be limited to one kilogram per week. - ●Vital signs and weight should be monitored each day - ●The daily physical examination should focus upon the cardiovascular and pulmonary systems, and upon signs of edema 33. - Reduce nutritional support - Correct hypophosphatemia, hypokalemia, and hypomagnesemia. - Moderately to severely ill patients with marked edema or a low serum phosphate level should be hospitalized to intravenously correct electrolyte deficiencies and for close monitoring. - Continuous telemetry may be needed to monitor cardiopulmonary physiology. 34. - Anorexia is a serious, potentially life threatening mental illness. - A person with Anorexia Nervosa has not made a âlifestyle choiceâ, they are actually very unwell and need help. 35. - Thank you https://www.friendbookmark.com/videos/1139/anorexia-nervosaComplex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image Anorexia nervosa is typically characterized by voluntary restriction of food intake ,distorted body image and fear of gaining weight. 1. ANOREXIA NERVOSA Prepared by: Anish Dhakal (Aryan) 2. OBJECTIVES â To discuss about anorexia nervosa â Differences with bulimia nervosa â Management of anorexia nervosa 3. EATING DISORDERS IN ADOLESCENT â Concerns about body image and dieting are very common in modern society females â Among these dieters, 5-10% become abnormally preoccupied with dieting and slimness â Low self esteem, tend to be perfectionists with obsessive compulsive traits â Genetic vulnerability, temperament, psychological and environmental factors also mediate the illness â âGenes load the gun, environment pulls the triggerâ 4. ANOREXIA NERVOSA â Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image â Characterized by â voluntary restriction of food intake â distorted body image â fear of gaining weight 5. EPIDEMIOLOGY â Among women, lifetime prevalence is approximately 1%. â Less common in males (1:10) â Prevalent where food is plentiful and thinness viewed as attractive â Incidence increasing 6. ETIOLOGY â Probably genetic and environmental factors including social pressure to be thin and attractive â â Incidence in families with an affected member 7. CLINICAL FEATURES â Begins in early puberty, before menarche, but seldom begins after age 40 â Severe weight loss â Fear of gaining weight â Use of diuretics, laxatives â Excessive exercise 8. PHYSICAL FEATURES â Cardiac and skeletal systems are most affected â Constipation â Amenorrhea â Vital signs: bradycardia, hypotension, and mild hypothermia â Lanugo hair in back, forearm and cheeks â Salivary gland enlargement â Acrocyanosis of the digits â Peripheral edema 9. DIAGNOSIS â Diagnosis based on â pronounced fear of fatness despite being thin â absence of alternative causes of weight loss 10. EXAMINATION & INVESTIGATIONS â Physical exam â Laboratory tests â complete blood count (CBC) â electrolytes â protein â LFT, RFT, TFT â urinalysis â Psychological evaluation â thoughts, feelings and eating habits â Other studies â X-rays (broken bones, pneumonia) â Electrocardiograms (heart irregularities) â Bone density testing 11. MANAGEMENT â Aim â Ensure patientâs well-being by helping them gain weight through addressing beliefs and behaviors that maintain low weight â Usually done on OPD basis â Inpatient treatment â if weight < 75% of normal â if chances of death due to complications â if risk of suicide â if outpatient treatment fails 12. TREATMENT GOALS â Establish good and caring relationship with patient â Resolve underlying psychological difficulties â Restore weight between ideal and the patient concept of optimal weight â Provide a balanced diet of at least 3000 kcal/day 13. OUTPATIENT TREATMENT â Aim â Cognitive behavioral or interpersonal psychotherapies â Family therapy is more effective than individual psychotherapy in adolescents 14. INPATIENT TREATMENT â Aim â Establishing a therapeutic relationship with both the patient and her family â Restoring the weight to a level between the ideal body weight and the patientâs ideal weight â The provision of a balanced diet, aimed at gaining 0.5â1 kg weight per week â The elimination of purgative and/or laxative use and vomiting â If fails, insertion of NG tube and feeding 15. DIET â Calories â Start calorie intake by approximately 1200-1800 kcal/day and increase intake (3000 kcal/day at least) â Ideal weight gain 0.5 - 1 kg/week â Micronutrients â Zinc â Calcium (1500 md/day) â Vitamin D (400 IU/day) â Essential fatty acids â omega-3 fatty acids docosahexaenoic acid (DHA) â eicosapentaenoic acid (EPA) 16. PSYCHOTHERAPY â Counseling â Cognitive Behavioral Therapy â Family-based treatment â Medications â Antidepressants (SSRIs) â Olanzapine 17. BODY SHAMING: A CULTURAL EPIDEMIC 18. PROGNOSIS â About 20% of patient have good outcomes â Further 20% develop chronic intractable disorder â Remaining have intermediate outcomes â Mortality rate is 10-20% (complication of starvation or from suicide) â Suicide has been reported in 2-5% â Highest mortality and suicide rate of any psychiatry disorder 19. INDICATORS OF A POOR OUTCOME â A long initial illness â Severe weight loss â Older age at onset â Bingeing and purging â Personality difficulties â Difficulties in relationships 20. COMPLICATION â Anorexia nervosa starvation malnutrition protein deficiency and disruption of multiple organ systems. Cardiovascular Renal Gastrointestinal Neurological Endocrine, metabolic and reproductive Integumentary, skeletal and hematologic 21. EMR 1.Delayed puberty 2.Amenorrhoea 3.Anovulation 4.Low estrogen states 5.Increased growth hormones 6.Decreased ADH 7.Hypothermia 8.Hypokalemia, hyponatremia 9.Hyper cortisolism 10.Arrested growth and osteoporosis 11.Decreased gonadotropin levels 22. CVS 1.Cardiomyopathy 2.Mitral valve prolapse 3.Supraventricular and ventricular dysrhythmias 4.Long QT syndrome 5.Bradycardia 6.Orthostatic hypotension 7.Shock due to congestive heart failure 23. RENAL 1.Decreased glomerular filtration rate (GFR) 2.Elevated BUN 3.Edema 4.Acidosis with dehydration 5.Hypokalemia 6.Hypochloremic alkalosis with vomiting 7.Hyperaldosteronism 8.Renal calculi 24. GI 1.Constipation 2.Decreased intestinal mobility 3.Delayed gastric emptying 4.Gastric dilation and rupture(from binge eating and purging) can lead to pneumothorax and pneumoperitoneum 25. NEUROLOGIC 1.Peripheral neuropathy 2.Wernickeâs encephalopathy 3.Korsakkoff syndrome 4.Ventricular enlargement 26. INTEGUMENTARY 1.Dry skin and hair 2.Hair loss 3.Lanugo hair/hypertrichosis 27. HEMATOLOGY 1.Anemia 2.Leukopenia 3.Thrombocytopenia 28. REPRODUCTION 1.Infertility 2.Low-birth-weight 29. REFERENCES â Harrisonâs Principles of Internal Medicine, 19th ed. â Murtaghâs General Practice, 5th edition, Mc Graw Hill â Davidsonâs Principles and Practice of Medicine, 22nd edition â Kumar and Clark Clinical Medicine, 8th ed. https://www.friendbookmark.com/videos/1135/covid-19-respiratory 1. COVID 19: RESPIRATORY CONDITIONS www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr 2. Asthma â Asthmatics with mildâmoderate disease usually have normal lungs when well controlled. â Maintenance therapy will not require changing when they are well as as inhaled corticosteroids from used in asthma therapy have not been shown to be immunosuppressant and should be continued. â BTS guidelines on provision of a rescue pack for patients with a good understanding of their personalised asthma action plan may be sensible in the current health climate. Issue a peak flow meter so they can monitor at home. Rescue packs should be issued as acute and SHOULD NOT be on repeat as each exacerbation requires a review. â Acute exacerbations of asthma should be treated in the normal way, including oral steroids. www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr 3. Acute asthma vs. COVID-19 â Differentiating an acute exacerbation of asthma from COVID-19 may be difficult. Pragmatically, fever and change of taste/smell are unusual in asthma. Decide (as best you can) which is more likely. If COVID-19 suspected, remember: â Oral steroids are NOT a treatment for COVID-19. In practice, this means that if an asthmatic has mild COVID symptoms but with no significant asthma symptoms, we should not give prophylactic oral steroids. â However, if typical asthma exacerbation features are dominant (wheeze/bronchospasm), oral steroids should be used as per asthma guidelines. Use shortest duration. â Twice as much steroids when ill under the guidance of medical practitioner. www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr 4. ASTHMA www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr Concern Management Wheeze/Bronchospasm But NO fever Treat as an exacerbation. Possible COVID-19 ie SOB/Cough/fever - Fever: Paracetamol & oral fluids - Possible Secondary Bacterial Pneumonia: As per severity of symptoms choose: Moderate: Amoxicillin 500mg TDS+ Clarithromycin 500mg BD for 7 days OR Doxycycline 200mg stat and then 100mg OD for 6 days Moderately severe: Co-Amoxiclav 625mg TDS + Clarithromycin 500mg BD for 7 days OR Azithromycin 500mg OD for 5/7 Days (If no other option). - Wheezing/SOB: High dose of SABA (4-8 puffs via large volume spacer). Do not introduce nebules, only to be used if patient previously using nebules. 5. COPD â There is NO evidence for âjust in case antibioticsâ OR using prophylactic antibiotics. â Treat apparent exacerbations as you normally would, irrespective of possible organism, which means: â Use antibiotics if suspected bacterial infective exacerbations (more sputum/change in sputum colour). â Consider oral steroids for increased breathlessness: but first check that symptoms canât be managed with increasing bronchodilators, breathing exercises, pacing. Have a lower threshold to use steroids in those with asthmaâCOPD overlap or previous raised eosinophils as they are likely to get greater benefits. Do not use if patient has a fever. If using, offer 30mg prednisolone for 5 days. â Remember, anxiety can also drive breathlessness/tachycardia: a phone/video consultation can help reassure people. www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr 6. If oxygen sats are available, a significant change from baseline is: www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr Mild: < 2% below baseline Moderate: 3â 4% below baseline sats Severe: â5% below baseline sats 7. www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr COPD Worsening SOB But No Fever - Use high dose SABA (4-8 puffs via large volume spacer). Do not introduce nebules, however, if patient has already got nebules may step up the dose. - Oral steroids only to be considered if 1. Mixed COPD+ Asthma 2. COPD with h/o high Eosinophil â0.3 COPD Increase sputum amount/ Sputum discolouration BUT No chest pain No fever No loss of Activity of Daily Living (ADL) Treat as infective COPD Exacerbation Reminder (No oral steroids to be used) 8. COPD : POSSIBLE COVID 19 Possible COVID-19 with SOB/New continuous cough/ fever/ Chest tightness or pain/ Decline in ADL/Lethargy www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr - Fever: Paracetamol and oral fluids. - Secondary bacterial Pneumonia As per severity of symptoms choose: Moderate: Amoxicillin 500mg TDS+ Clarithromycin 500mg BD for 7 days OR Doxycycline 200mg stat and then 100mg OD for 6 days AND: Treat SOB using SABA high dose via large volume spacer. Patient may use nebules if has got them at home. Moderately severe: Co-Amoxiclav 625mg TDS + Clarithromycin 500mg BD for 7 days OR Azithromycin 500mg OD for 5/7 Days (If no other option). Please note this group may be appropriate for COVID-HOT hub assessment and management AND - Treat SOB using SABA high dose via large volume spacer. Patient may use nebules if has got them at home. 9. Interstitial Lung Disease www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr - Currently under Shielding (12 weeks) - Will not do well with intubation/ mechanical ventilation - Likely to become hypoxic very quickly - Mostly have advanced care plan in place If has developed symptoms of possible COVID-19 â - Admission will be guided by deterioration of SpO2 from baseline (up to 2% decline is mild, 2-4% is moderate and â5% decline from baseline is severe deterioration) - Consult Advanced care plan for management decisions - Antifibrotic Biologics can be paused for up to 8 weeks - Do not stop Long term Oral Steroids - DMARDs to be paused and re-initiated 2 weeks after recovery. - Elongate the shielding time (Beyond 12 weeks) 10. Obstructive Sleep Apnea www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr Have normal Lung function Should they develop COVID-19 symptoms (A new continuous cough/fever/chest tightness/SOB/lethargy/decline in ADL) follow the decision tree as for all members of public Should these patient need hospitalisation, advise to take CPAP machine with them to use at hospital 11. Bronchietasis Development of discoloured purulent sputum But No chest pain No fever No loss of Activity of Daily Living (ADL) Treat as an exacerbation with standard dose Amoxicillin or Doxycycline for 10-14 days Do not collect sputum samples If non-respondent to the above may consider Ciprofloxacin but seek specialist advice. 12. Bronchietasis: Possible COVID 19 www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr Possible COVID-19 i.e. â SOB/New continuous cough/ fever â Chest tightness or pain â Decline in ADL â Lethargy With/without purulent sputum Fever: Paracetamol and oral fluids + As per severity of symptoms choose: Moderate: Amoxicillin 500mg TDS+ Clarithromycin 500mg BD for 7 days OR Doxycycline 200mg stat and then 100mg OD for 6 days AND: Treat SOB using SABA high dose via large volume spacer. Patient may use nebules if has got them at home. Moderately severe: Co-Amoxiclav 625mg TDS + Clarithromycin 500mg BD for 7 days OR Azithromycin 500mg OD for 5/7 Days (If no other option). Please note this group may be appropriate for COVID-HOT hub assessment and management 13. References â References: â http://primarycarepathways.co.uk/covid-19/clinical- assessment/pathways/177-barnet-primary-care-pathway-during-covid19- v2-0-pdf/file â Accessed 03/04/2020 â http://primarycarepathways.co.uk/covid-19/clinical-assessment/241- primary-care-and-community-respiratory-resource-pack-during-covid-19- nhs-london-clinical-networks/file â Accessed 03/04/2020 â The above guidance is correct and up to date as of 03/04/2020. It is subject to amendment as the pandemic progresses. www.belmatt.co.uk. Prepared by Aneela Tehseen and Jeshni Amblum-AlmÃr https://www.friendbookmark.com/videos/1132/covid-19-ayurvedaCovid-19 & ayurveda 1. COVID 19 & AYURVEDA Dr. Poornima Chhajer B.A.M.S., M.S. (Shalakya Tantra â Netra Roga), CPK Assistant Professor, CAMC, Rajanadgaon Director, Shri Ayurved & Keraliya Panchkarma Centre, Durg 2. Introduction Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome corona virus (SARS-CoV- 2). It was first identified in December 2019 in Wuhan, China, and has resulted in an on going pandemic. 3. AYURVEDA Ayurveda, being the science of life, propagates the gifts of nature in maintaining healthy and happy living. Ayurvedaâs extensive knowledge base on preventive care, derives from the concepts of âDinacharyaâ - daily regimes and âRitucharyaâ- seasonal regimes to maintain healthy life. 4. Diet According To Ayurveda Ayurveda explain in detail 8 attributes related to the food - 1. Prakrti âQualitative characteristics of the food 2. Karana â Processing of food 3. Samyoga â Mixing 4. Rashi â The quantity 5. Desha â Habitat of the person 6. Kala â Time & seasonal variation 7. Upayoga Samstha â Variable digestibility of various food articles 8. Upayokta â The person who takes the food. 5. 1. Prakrti âQualitative characteristics of the food Moong Dal Urad Dal 6. 2. Karana â Processing of food Curd Butter Milk 7. 3. Samyoga â Mixing Honey with warm water 8. 4. Rashi â The quantity 9. 5. Desha â Habitat of the person 10. 7. Upayoga Samstha â Variable digestibility of various food articles 11. 8. Upayokta â The person who takes the food 12. Recommended Measures (Ministry of AYUSH) Warm Water Golden Milk Gandoosha Nasya Steam inhalation Kadha / Herbal Tea Chyawanprash 13. PANCHKARMA (Detoxification Therapies) 14. YOGASANA Anulom - Vilom Bhramari Bhastrika Kapal - Bhati 15. National Clinical Management Protocol Based on Ayurveda & Yoga For The Management Of COVID - 19 https://www.friendbookmark.com/videos/1131/covid-19-quantitative-researchCovid 19 Quantitative Research 1. PREPAREDNESSANDAWARENESSOF LOCALGOVERNMENTUNIT (LGU) CAGAYANDE OROAMIDSTTHE COVID-19PANDEMIC2020 JOSEPHINE BOND PHD Public Administration and Governance PHILIPPINES LUZON VISAYAS MINDANAO 2. INTRODUCTION The world today grapples with the health crisis caused by the novel COVID-19. Unfortunately, the Philippines, which was spared from the previous epidemics like Ebola and SARS, is now facing this major obstacle. The local government units of the country responded by issuing guidelines to mitigate the spread of infection. This multi- sectoral plan aims to ensure prevention of COVID-19 spread into the country, preparedness and readiness for a timely, consistent and coordinated response in the event of COVID-19 outbreak. 3. STATEMENT OF THE PROBLEM This study determines the preparedness and awareness amid the COVID- 19 Pandemic in Local Government Unit (LGU) Cagayan de Oro City. The findings of the study serves as basis for a proposed recommendation. Furthermore, it seeks to answer the following questions: 1. What is the profile of the respondents in terms of: â age; â gender; â civil status; â educational level; and â job status? 4. 2. Research question 2: As perceived by the respondents, how effective the preparation and awareness of Local Government (LGU) about COVID-19 Pandemic in terms of: â knowledge; â preparedness; â information update; and â preventive measures? 3. Based on the finding of the study, what recommendations can be proposed. 5. Table 1 Research Respondents Job Title Frequency Percentage Administrative Officer 6 20.00 % Police Officer 5 16.66 % DSWD Employees 5 16.66 % Maintenance 7 23.33 % Market Vendor 7 23.33 % RESEARCH RESPONDENTS 6. A. Age Frequency Percentage 20-25 2 6.66 26-31 5 16.66 32-47 13 43.33 48-56 4 13.33 57- 63 6 20 B. Gender Frequency Percentage Male 6 20 Female 24 80 C. Civil Status Frequency Percentage Single 10 33.33 Married 16 53.33 Widowed 2 6.66 Separated 2 6.66 D. Educational level Frequency Percentage Postgraduate 3 10 Tertiary 18 60 Secondary 9 30 E. Job Status Frequency Percentage Employed 16 53.33 Self-employed 14 46.67 Table 2 PROFILE OF RESPONDENTS 7. Knowledge Mean Interpretation 1. LGU implements Enhanced Community Quarantine. 3.77 Highly Prepared 2. LGU implements social distancing. 3.7 Highly Prepared 3. LGU implements wearing face mask. 3.5 Highly Prepared 4. LGU implements quarantine pass. 3.63 Highly Prepared 5. LGU implements proper hygiene like proper handwashing and disinfection/sanitation activities within the area of responsibility 3.7 Highly Prepared Aggregate mean 3.66 Highly Prepared Table 3 Preparedness and Awareness amid the Covid-19 Pandemic as to Knowledge 8. Preparedness 1. LGU coordinates Department of Health (DOH) for the continous monitoring of suspected/reported patients under investigation and persons under monitoring 3.7 Highly Prepared 2. LGU coordinates Philippine National Police (PNP) and Brgy. Intelligence for the safety and security of the community. 3.63 Highly Prepared 3. LGU coordinates Department of Social Welfare and Development on the relief distributions and cash assitance program. 3.63 Highly Prepared 4. LGU conducts continuos disinfection/sanitation activities within the area of responsibility 3.63 Highly Prepared 5. LGU launches the molecular diagnostic and patholgy laboratory swab test. 3.6 Highly Prepared Aggregate mean 3.64 Highly Prepared Table 4 Preparedness and Awareness amid the Covid-19 Pandemic as to Preparedness 9. Information update 1. LGU together with the Department of Health (DOH) provide information updates about COVID -19 with symptomatic and positive case within the Municipal area. 3.6 Highly Prepared 2. LGU implements Executive Orders, Memorandum, Ordinances, and other related issuances in addressing COVID-19 with the Local DRRMC and created the Inter-Agency Task Force. 3.63 Highly Prepared 3. LGU executes strict implementation of one entrance and one exit way in Public Market, pharmacies, and other establishments, including wearing face masks of the vendors and clients and strict physical distancing. 3.63 Highly Prepared 4. LGU coordinates and participates concerned agencies re virtual meeting like "Strengthening the Front liners for LGU Preparedness and Response". 3.63 Highly Prepared 5. LGU implements drafted protocol for returning residents. 3.73 Highly Prepared Aggregate mean 3.65 Highly Prepared Table 5 Preparedness and Awareness amid the Covid-19 Pandemic as to information update 10. Preventive Measures 1. LGU together with the Brgy. Officials implements continuous mandatory quarantine for 14 days especially to those who are returning back from other country and city. 3.77 Highly Prepared 2. LGU together with the Department of Health (DOH) implements constant monitoring to those who have symptomatic case. 3.7 Highly Prepared 3. LGU implements continuous coordination about updates to Department of Health (DOH). 3.63 Highly Prepared 4. LGU implements proper isolation to those with positive cases. 3.7 Highly Prepared 5. LGU implements continuous preventive protocols the spread of COVID-19 . 3.63 Highly Prepared Aggregate mean 3.67 Highly Prepared Table 6 Preparedness and Awareness amid the Covid-19 Pandemic as to preventive measures 11. 1. Majority of the respondents belonged to the age group of 32-47 years old, female, married, College graduate or level and employed. 12. 2. Majority of the respondents considered that the preparedness and awareness in terms of knowledge, preparedness, information update and preventive measures were highly prepared because of the level of effectiveness of best preparation and administration of preparedness and awareness of Cagayan De Oro LGU amid the Covid-19 pandemic. In knowledge, LGU implements Enhanced Community Quarantine was the highest weighted mean with 3.77 interpreted as highly prepared. In preparedness, LGU based on their preparations as highly prepared in terms of preparedness. Respondents revealed that LGU coordinates Department of Health (DOH) for the continuous monitoring of suspected/reported patients under investigation and persons under monitoring was the highest weighted mean with 3.70 interpreted as highly prepared. In information update, LGU implements drafted protocol for returning residents was the highest weighted mean with 3.73 interpreted as highly prepared. Lastly, as to preventive measures, LGU together with the Brgy. Officials implements continuous mandatory quarantine for 14 days especially to those who are returning back from other country and city was the highest weighted mean with 3.77 interpreted as highly prepared. 13. RECOMMENDATION 1. The government must consider extending the enhance community quarantine beyond April 13, 2020. As shown above there had been gains with the restrictions put in place averting an Iran-like scenario. These gains should be sustained until such time that the country has mass tested and isolated infective cases. 2. Corollary to the need to extend the ECQ, the national government must scale up and proactively do testing for Covid-19, isolate infective patients in health care facilities and hospitals, and improve contact tracing such that cases are identified and isolated sooner. Under this scenario, if Covid-19 cases are identified and isolated within 12 days of contracting the virus, then even with the less optimistic transmission rate of 0.08, the effect is an immediate control of the spread of Covid-19. 14. 3. As a consequence of a push to mass testing, human and material resources need to be increased to support our already burdened national health system. The special powers of the President provided in Republic Act No. 11469 could muster these additional resources. These additional resources include but are not limited to more testing kits, incentives and provision for front liners including proper personal protective equipment, and dissemination of PhilHealthâs coverage for testing and hospitalization to encourage low-income households to seek medical attention. 4. Aside from the medical aspect of the pandemic, the economic needs of those whose incomes are adversely impacted should be provided by the national government especially among the poor. This is to ensure that the extension of the ECQ will not cause social unrest. The provision of cash and relief goods both by the national and local governments should be continued and should reflect the size of the household. Further, monitoring mechanisms should be put in place to ensure that the assistance is delivered to intended beneficiaries. 15. 5. Prospectively, the national government should invest more resources in institutions such as the University of the Philippines, which can do evidence- based research to improve policy and program formulation and evaluation. These researches should underpin national plans to bolster resilience of national institutions, e.g. distance education and blended learning in schools, telecommuting, telehealth, and other similar initiatives. https://www.friendbookmark.com/videos/1075/covid-19-risk-mitigationInformation covered in this presentation slides: 1. Covid-19 risk mitigation Prepared by Tengku Hanidza Tengku Ismail, PhD 2. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 2 3. Putting mitigation into practice is based on: â Emphasizing individual responsibility for taking recommended personal-level actions â Empowering businesses, schools, and community organizations to take recommended actions, particularly in ways that protect persons at increased risk of severe illness â Focusing on settings that provide critical infrastructure or services to individuals at increased risk of severe illness â Minimizing disruptions to daily life to the extent possible 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 3 4. Community Mitigation Community mitigation activities are actions that people and communities can take to slow the spread of infectious diseases, including COVID-19. Community mitigation is especially important before a vaccine or drug becomes widely available. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 4 5. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 5 6. âPeople with risk factors may be more likely to need hospitalization or intensive care if they have COVID-19, or they may be more likely to die of the infection âTake extra precautions to avoid exposure to the virus that causes COVID- 19 âReduce your risk for severe COVID- 19 illness by managing any conditions you have that are risk factors âIt is important to learn about risk factors for severe COVID-19 illness because it can help you Why Risk Factors Matter Pregnancy Race/Ethnicity Gender Underlying conditions Use of certain medications Poverty Overcrowding Certain occupations Age 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 6 7. COVID-19 Transmission in the air 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 7 8. Covid-19 spread in confined spaces: How 1 person infected 94 co-workers Attack rate is 43.5% No evidence of linked to other clusters Extensive contact tracing, testing all contacts, and early quarantine blocked further transmission and might be effective for containing rapid outbreaks in crowded work settings. Floor plan of the 11th floor of building X, site of a coronavirus disease outbreak, Seoul, South Korea, 2020. Blue coloring indicates the seating places of persons with confirmed cases. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 8 9. Covid-19 spread in confined spaces: 1 member spread to others in the choir group In a study yesterday in Morbidity and Mortality Weekly Report (MMWR), researchers describe a COVID-19 super-spreading event at a Washington state choir practice in March, which was attended by a symptomatic index patient and produced an attack rate of 53.3% to 86.7%. "The 2.5-hour singing practice provided several opportunities for droplet and fomite transmission, including members sitting close to one another, sharing snacks, and stacking chairs at the end of the practice," the authors, from Skagit County Public Health, said. "The act of singing, itself, might have contributed to transmission through emission of aerosols, which is affected by loudness of vocalization." (L. Hamner et al. Morb. Mortal Wkly. Rep. 69, 606â610; 2020).9/6/2020 Covid19 risk mitigate/Tengku Hanidza 9 10. Covid-19 spread in confined spaces: A combination of social distancing and mouth covering will break the COVID chain. Hereâs whyâ 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 10 11. (1) A human cough: saliva dropletâs disease-carrier particles cannot travel more than 2 m in space at approximately zero wind speed. A human cough: mechanisms of airborne saliva dropletâs transport, breakup, dispersion, and evaporation. This figure shows different cloud kinematics (elongation and rotation) depending on the wind shearing force; the gravitational or settling forces; and the evaporation rates. (2) A human cough: saliva dropletâs disease-carrier particles may travel in the air medium to unexpected considerable distances depending on the environmental conditions. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 11 12. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 12 13. Rather than falling to the ground, the microdroplets float in the air and drift about. The researchers estimate that a single cough or sneeze can produce 100,000 microdroplets 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 13 14. Created by Purdue University in 2014 based on the related SARS virus A cough can infect up to ten surrounding people Saliva droplets from one cough cause an initial plume of germs, which then spread throughout the plane in the air. Will COVID-19 fits into this scenario? 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 14 15. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 15 16. The rate of particle emission during normal human speech is positively correlated with the loudness (amplitude) of vocalization, ranging from approximately 1 to 50 particles per second (0.06 to 3 particles per cm3) for low to high amplitudes, regardless of the language spoken (English, Spanish, Mandarin, or Arabic). This findings (2019) help to explain the superspreading events during COVID-19 pandemic: â A choir practice in a church in Mount Vernon, Washington â 80 infections tied to live music venues in Osaka, Japan â 65 cases resulting from Zumba classes in South Korea 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 16 17. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 17 18. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 18 19. The decision was made after an observational study was published in the medical journal The Lancet on Friday, which described how seriously ill Covid-19 patients who were treated with hydroxychloroquine and chloroquine were more likely to die. Who do you want to believe? Science vs the President 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 19 20. (26/5) âBerdasarkan pengalaman dan pandangan pakar-pakar kesihatan mendapati ubat antiradang ini dapat membantutkan penyakit ini (COVID-19) pada peringkat awal bagi mencegah ia daripada melarat, namun ada kesan sampingan dari segi denyutan jantung dan mata. Jika pesakit itu didapati mempunyai denyutan jantung panjang, kami akan menghentikan terus penggunaan ubat itu bagi mengelakkan jantung berhenti dan sebagainya. Pakar-pakar masih lagi mengkaji bagaimana untuk mengelakkan kesan sampingan sedia ada dan bagaimana elakkan dos tinggi, dan tunggu literature review yang akan dikeluarkan oleh WHO pada pertengahan Jun ini (Pengarah KKM). 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 20 21. The science behind COVID-19 testing 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 21 22. False positive, false confidence A false positive will lead someone to believe they have been infected when in fact they have not been. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 22 23. Survey saysâ.. after President Trump publicly asked whether injecting such products could treat COVID-19 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 23 Washing food with bleach, using household cleaning or disinfectant products on bare skin, and intentionally inhaling or ingesting these products were some of the most commonly reported "high- risk" practices in a May 4 online survey of 502 U.S. adults, the Centers for Disease Control and Prevention (CDC) reported. 39% reported intentionally engaging in at least one high-risk practice not recommended by the CDC to prevent coronavirus infection, including using bleach to clean food or misting the body with a disinfectant spray. 4% drank or gargled with diluted bleach solutions, soapy water or disinfectants. 24. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 24 25. The risk of a spike in infections is clearly present as some countries scrambled to restart their economies after easing stringent COVID- 19 restrictions, a top health official has warned. Michael Ryan, executive director of the World Health Organization's (WHO) emergencies program, expressed his concerns on Monday over the lifting of certain lockdown conditions that he reckons may lead to a resurgence of coronavirus cases. "Shutting your eyes and trying to drive through this blind is about as silly an equation as I've seen. "And I'm really concerned that certain countries are setting themselves up for some seriously blind driving over the next few months," he added. His comments came as Germany, France, Spain, Italy, Belgium, the Netherlands and the UK relaxed restrictions in a bid to revive their almost stagnant economies. Ryan praised Germany and South Korea for putting in place robust measures that would be able to trace and stop virus clusters before they get out of control. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 25 26. Europe easing up lockdown mid May Coronavirus: How lockdown is being lifted across Europe https://www.bbc.com/news/explainers-52575313 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 26 27. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 27 25/5 UK easing up lockdown 28. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 28 29. May 11, 2020, 10:02 PM +08 (Reuters) SEOUL - South Korean officials scrambled on Monday to contain a new coronavirus outbreak, searching for thousands of people who may have been infected in a cluster of cases linked to nightclubs and bars in the capital Seoul. The education ministry put off the reopening of high schools, which was scheduled to begin on Wednesday, by one week in light of the new outbreak. In less than a week since a 29-year-old man was confirmed infected on Wednesday -- the first to be found linked to the infections in Itaewon, a Seoul neighborhood known for its nightlife -- at least 86 visitors of the nightclubs there had tested positive as of Monday. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 29 30. South Korea restarts schools after coronavirus spread slows (May 20) 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 30 31. What happen when a leader denies COVID-19? Who do you trust? Zimbabwean President Cambodian Prime Minister Mexican President Brazilian President North Korean leader Tanzanian President Turkmen President Belarusian President California congressman âThe Prime Minister doesnât wear a mask, so why do you?â âIf this virus is really spreading like some people say that it is, we donât have any data on that,â The sole Asian outlier, a virus-free haven Coronavirus cases in the Central Asian state of Turkmenistan is zero.âCorona is the devil and it cannot survive in the body of Jesus,â âIt will burn.â Released a Facebook video encouraging his people to go out for dinner. âNo one will die of coronavirus in our country. I publicly declare thisâ âNo one will hinder my right to come and go,â Held a political rally and gave a speech to several hundred people at a school blatantly violating his own decree. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 31 32. â Brazil has the highest rate of transmission (R0 of 2Â81). Large cities such as SÃo Paulo and Rio de Janeiro are the main hotspots. â The biggest threat to Brazil's COVID-19 response is its president, Jair Bolsonaro. â He openly flouting and discouraging physical distancing and lockdown brought in by state governors and city mayors. â The president compared COVID-19 to a âlittle coldâ, accused the media of spreading âhysteriaâ, and encouraged people to âgo back to normalityâ. â President Bolsonaro continues to dismiss the health crisis, saying the economic impacts will be far worse to what he's compared to a "little flu." Data May 17 9/6/2020 32 33. Cases spike in USA as communities reopen -53 -2 -6 +3 -1 -53 -3 -22 +15 +39 +15 -1 -18 -55 +25 -26 +27 -13 -1 +14 +45 +6 -12 -6 +2 -13 -14 -3 -17 +5 -17 -2 +11 +19 +12 -4 +41 +4 +14 -19 -15 -14 -19 +8 % â US guidelines call for 14 days decline in new cases opening â Some states are proceeding even without clearing that threshold. â The number of new cases will rise as a state performs more testing 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 33 34. WHO warns there could be a second peak, not a second wave: During a media briefing, Dr. Mike Ryan, executive director of WHOâs health emergencies program, said the world is âright in the middle of the first wave, globally." Ryan warned that a second peak or wave could come during the normal influenza season, âwhich will greatly complicate things for disease control.â Americans crowd public places as Covid-19 cases rise in some states: Crowds packed beaches in Florida, Maryland, Georgia, Virginia and Indiana over the Memorial Day weekend â many venturing out without masks and others failing to keep their distance even as officials highlighted the continued importance of both in order to prevent another surge of infections. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 34 35. Swedenâs Approach to COVID-19: No lockdown, advocate Herd Immunity. Failure or success? 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 35 Anders Tegnell, the countryâs state epidemiologist, told UK- based daily Financial Times last month that Sweden expects 40% of people in the capital Stockholm to be immune to COVID-19 by the end of May. In the autumn there will be a second wave. Sweden will have a high level of immunity and the number of cases will probably be quite low,â . Data compiled by the Swedenâs Public Health Agency, as of May 20, only 7.3% of blood samples collected from people in Stockholm had antibodies to SARS-CoV-2. At least 70% to 90% of a population needs to be immune to a virus to reach herd immunity. Swedenâs COVID-19 mortality rate tops all Nordic countries and is also among the highest in the world. Stockholm will not reach this milestone in May. Earlier this month, Tegnell admitted he is not sure Sweden's strategy was the right call. "I'm not convinced at all â we are constantly thinking about this," he told Swedish newspaper Aftonbladet. 36. Feeding the hungry during COVID pandemic: Poor nations vs. rich nations Food security: Will we be better prepared for the next epidemic? 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 36 37. COVID-19 Vs. FAITH 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 37 38. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 38 39. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 39 40. COVID-19 CLUSTERS (Source: MOH, update 1/6/20) 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 40 41. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 41 42. 9/6/2020 42 43. May 12 â June 9, 2020 MCO 5 (Conditional MCO) regulations replaced MCO 4 regulations 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 43 44. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 44 45. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 45 46. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 46 47. How are we doing with our fear level? 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 47 48. Normal life (?) resuming in Malaysia 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 48 49. Facts vs. Myth: Body Disinfection? (Source: WHO) 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 49 50. Financial Implication of testing non citizens to protect citizens: Risk (costs) vs. benefits (stop COVID spread) 5.95% infection Expected 60 people positive Cost 31,204 x rm 300= Rm 9,361,200 Cost of treatment 750 x rm ? = rm ? 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 50 51. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 51 52. Backâto-school: Post COVID Looking East Korea: Depending on the school district, schools will start on different days and students will alternate between attending classes and online instructions at home.Class times and lunch hours are also being staggered. No extracurricular activities will be allowed. Students attend half-days or every other day wearing masks and sitting farther apart. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 52 53. Challenges on social distancing: Classroom capacity: up to 17 per classroom Teaching capability Teaching periods Canteen setting 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 53 54. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 54 55. The New Normal? Personal bubble in the park Drive-in movie comeback Dentist in PPE Dining with dummies Sun tan box Lunch Japanese style Tete-a tete 2 m part Drive-through graduation Cutouts fans Driver in veil9/6/2020 Covid19 risk mitigate/Tengku Hanidza 55 56. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 56 Travelling Post Covid Travel should still be limited to circumstances in which it's absolutely necessary. People who are immunocompromised or at high risk of developing severe illnesses, it should be avoided as much as possible. 57. Informed Citizen: Continuous Community education 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 57 58. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 58 59. 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 59 Perintah Kawalan Pergerakan Diperketatkan (PKPD) Secara pentadbiran yang dilaksanakan di dua kawasan perumahan di Bukit Changgang, Kuala Langat sejak 2 Jun dijadualkan berakhir 16 Jun ini. Pelaksanaan PKPD secara pentadbiran di kawasan itu turut membabitkan seramai 9,000 penduduk. 60. End of MCO5 June 9, 2020 9/6/2020 Covid19 risk mitigate/Tengku Hanidza 60 https://www.friendbookmark.com/videos/1074/updates-on-covid-19-by-dr-monisha-yadavUpdated info from reliable source. It helps in understanding complications due to covid . It is handy for interns and postgraduates to act when cases come. Information covered in this presentation slides: 1. UPDATES ON COVID -19 MONISHA J YADAV GUIDANCE : TEAM B 2. CORONAVIRUS - FAMILY : Coronaviridae - It is spherical particle with crown like projection - Average diameter â 125nm - Viral envelope consists of lipid bilayer with anchored proteins - Nucleocapsid â N protein and positive sense single stranded RNA genome 3. REPLICATION CYCLE 1. ENTRY â S protein + ACE2 2. TRANSLATION : virus particle uncoated and attaches to ribosome  Host ribosome translates open reading frames ORF1a and ORF1b into polyproteins pp1a and pp1b .  Polyproteins are cleaved by PROTEASES into 16 nonstructural proteins 4. - Includes RNA dependent RNA polymerase , RNA helicase - Number of nspâs coalesce to form replicase transcriptase complex (RTC) - RdRp mediates replication of viral genome 3. TRANSCRIPTION â genomic RNA to mRNAs . - In host endoplasmic reticulum RNA translation to structural proteins happen. - In Golgi apparatus assembly of virions happen and forms secretory vesicles - Progeny virus are released by exocytosis . 5. PATHOGENESIS - Viral antigens presented to APC - Stimulates cellular and humoral immunity - IgM and IgG antibodies are formed . They are S and N protein specific . - CD4 and CD8 T cells are activated . - Overproduction of proinflammatory cytokines - IL-6 , IL-1Î, Tumour necrosis factor : CYTOKINE STORM 6. THREE PHASES - STAGE 1 : asymptomatic state - Nasal cavity epithelial cells are infected - Virus starts multiplying and propagating down - Innate immunity acts - Most infectious period - Nasal swabs detect virus - Mason rj et all , national jewishealth , USA 7. STAGE 2 - Upper airway and conducting airway response - Epithelial cells are infected - Beta and lamba interferons produced - CXCL 10 â interferon gamma induced protein 10 is a disease marker . - Disease will be mild . Symptomatic therapy is advised 8. STAGE 3 - 20% infected patients progress . - Viral particles infect type 2 cells of alveoli - Self replicating pulmonary toxin is released - Causes diffuse alveolar damage with fibrin rich hyaline membrane and multinucleated giant cells - Severe scarring and fibrosis - Wound healing is also impaired - Leads to severe ARDS . 9. CYTOKINE STORM - Leads to vascular hyperpermeability - Defective procoagulant â anticoagulant balance - Leads to formation of thrombin - Thrombin activates protease activated receptor 1 on platelets and leads to aggregation and microthrombosis 10. HYPERCOAGULABLE STATE - Endothelial injury : due to direct invasion by virus and cytokine storm . - Stasis : immobilization in critically ill patients . - Decrease in Antithrombin , Protein S and Protein C . - Elevated factor vш , Fibrinogen , VWF UPTODATE 11. INCUBATION PERIOD - 2-14 days - Mean is 5 days after exposure . - CDC 12. MODES OF TRANSMISSION - PERSON â PERSON : - DROPLET transmission - Infected person coughs , sneezes or talks - direct contact - Droplets donot travel more than 6 feet . - Indirect spread â touching an infected surface followed by eyes , nose or mouth International pulmonary consensus 13. - VIABILITY : - Aerosols â 3 hours - Plastic and stainless steel â 72 hours - Copper â 4 hours - Cardboard â 24 hours - Clothes â 8 hours CDC 14. RISK FACTORS - Asthma - Chronic lung diseases - Chronic kidney disease - Chronic liver disease - Diabetes mellitus - Hypertension - Cardiovascular disease - Obesity - People above 65 years old - People living in long term care facility - Thalasemmia - Sickle cell disease uptodate 15. CLINICAL PRESENTATION - Fever (83-99%) - Cough (59-82%) - Fatigue (44-77%) - Anorexia (4-84%) - Shortness of breath (31-40%) - Myalgias(11-35%) - Loss of smell ( anosmia ) - Loss of taste (ageusia ) - GI symptoms - Sore throat - nasal congestion WHO 16. COVID 19 DISEASE SEVERITY - MILD DISEASE : symptomatic patients without evidence of pneumonia or hypoxia. - MODERATE DISEASE : clinical signs of pneumonia but no signs of severe pneumonia . - SEVERE DISEASE :  Severe pneumonia : clinical signs of pneumonia plus one of the following  RR- > 30 breaths/min  Severe respiratory distress  Saturation < 90 % on room air WHO 17. CRITICAL DISEASE - 1. ARDS - ONEST : within 1 week of known pneumonia or worsening respiratory symptoms . - CHEST IMAGING : bilateral opacities , not fully explained by volume overload , nodules - MILD ARDS â PaO2 / FiO2 200-300 mmHg - MODERATE â PaO2 /FiO2 100-200 mmHg - SEVERE â PaO2/FiO2 < 100 mmHg 18. 2. SEPSIS - Acute life threatening organ dysfunction - Weak pulse , tachycardia , hypotension - Low oxygen saturation , difficulty in breathing - Altered mental status - Reduced urine output - Lab evidence of coagulopathy , thrombocytopenia , acidosis , high lactate , hyperbilirubinemia . 19. 3. SEPTIC SHOCK - Persistent hypotension despite volume resuscitation - Requiring vasopressors to maintain MAP > 65mmHG - Serum lactate level > 2 mmol/L. 20. CUTANEOUS MANIFESTATIONS 1. COVID toes : erythematous or purpuric macules on toes , lateral aspect of feet , fingers , elbows Pernio like lesions of acral surfaces Pathogenesis : ? Inflammatory cause New onset , pernio like lesions with no clear cause should be tested for covid 19 TREATMENT : topical corticosteroids to reduce discomfort . UPTODATE 21. - Livedo reticularis - Necrotic vascular lesions - Histopathology shows : thrombotic vasculopathy with laboratory coagulation alterations 22. - MORBILIFORM RASH : this rash involves trunk - Most common manifestation - Noted after recovery 23. - Urtiaria : acute urticaria with fever is presenting sign of covid infection - VARICELLA â like eruptions: small papules , vesicles , pustules appears 4-30 days after symptoms of covid - Resolves in about 10 days - Fluid from vesicle tested negative by RTPCR 24. COMPLICATIONS British cardiovascular society 25. NEUROLOGICAL MANIFESTATIONS Acute cerebrovascular disease : cerebrovascular hemorrhage. And ischemic stroke ( most common ) 1. Hypercoagulable state 2. Low platelet count 3. Elderly patients . Liu k et al , BMJ 26. INTRACRANIAL INFECTION WITH SARS-COV 2 - Headache - Disturbance in consciousness - Convulsions - First reported case in Beijing with covid encephalitis . - CSF postive for RTPCR . 27. - Peripheral nervous system : hypogeusia , hyposmia . - Deficit in visual function - Neuralgia . - MUSCLE DAMAGE RELATED : fatigue , muscle soreness . - Elevated muscle enzyme - Due to inflammation of muscles , 28. ICMR STRATEGY FOR TESTING COVID 19 - 1. symptomatic ILI individuals with history of international travel in last 14 days . 2. Symptomatic contacts of laboratory confirmed case . 3. Symptomatic health care workers 4. All patients of severe acute respiratory infections . 5 . Asymptomatic direct and high risk contacts of a confirmed case on day 5 and day 10 of exposure . 29. 6 .All symptomatic ILI within containment zones 7 . All hospitalised patients who develop ILI symptoms 8. All symptomatic ILI among returnees and migrants within 7 days of illness CLOSE CONTACT : Cohabiting family members of covid 19 patient . Atleast 15 minutes within 6 feet of a patient with confirmed covid . 30. RT-PCR - Diagnosis of covid 19 is made by direct detection of SARS-CoV2 RNA by reverse transcription polymerase chain reaction - TARGET GENES : 1. nucleocapsid (N) 2. spike (S) 3. envelope (E) 4. RNA dependent RNA polymerase 31. COVID TESTING POSITIVITY RATES Sl no . TYPE OF SPECIMEN POSITIVE 1. Bronchoalveolar lavage fluid 93% 2. Sputum 72% 3. Nasopharyngeal swab 63% 4. Oropharyngeal swab 32% 5. Feces 29% 6. Blood 1% 7. Urine 0% International pulmonary consensus 2nd edition 32. FALSE NEGATIVE RATES - 100% on day of exposure - 38% on day 5 - 20 % at day 8 - 66% at day 21 CDC 33. SEROLOGIC ASSAY - It has Emergency Use Authorization(EUA) by U.S. FDA . - Detects past infection and measures host humoral immune response . - Plays important role in virus epidemiology - IgM and IgG antibodies arise within 2-3 weeks simultaneously . - Helps to establish diagnosis when patient presents with late complications - People presenting 9-14 days after illness onset this test supports clinical diagnosis . - Positive test qualifies a person to donate blood to manufacture covalescent plasma . CDC 34. BINDING ANTIBODY DETECTION - These tests use purified proteins of SARS-CoV-2 - Duration : < 30 minutes . - 1. point of care (POC) tests : detects antibodies using whole blood obtained by fingerstick . - 2. lab tests using ELISA .  Requires trained laboratrians , specialized instruments and reagents . CDC 35. ANTIGEN BASED - On MAY 9 2020 U.S. FDA issued emergency use authorization for antigen test . - Highly specific - Not sensitive as RTPCR. - It can detect active infection . - Helps prevent spread by identifying patients early . - Detects fragments of protein found on or within virus . - Samples : nasal cavity swab - Lower cost and test results within minutes - False negative rate is high , suspected cases must undergo RTPCR CDC 36. OTHER INVESTIGATIONS ABNORMALITY POSSIBLE THRESHOLD D-dimer > 1000 ng/ml ( normal < 500 ng/ml ) CRP > 100 mg /L ( normal < 8 mg/L ) LDH > 245 units /L ( 110-210 units /L) Troponin > 2 times upper limit Ferritin > 500 mcg/L ( 10-300 mcg/L) CPK > 2 times upper limit Neutrophil/lymphocyte ratio > 3.5 uptodate 37. RADIOLOGICAL - CHEST XRAY : includes bilateral lobar/multilobar consolidation . - CT CHEST : - EARLY STAGE (0-4 days ) ground glass opacities , subpleural distribution predominantly in lower lobes . - . PROGRESSIVE STAGE ( 5-8 days ) : rapidly involves both lungs , multi lobar distribution . Crazy paving pattern International pulmonary consensus 2nd edition 38. - . - PEAK STAGE ( 9-13 days ) : consolidation becomes denser - ABSORPTION STAGE ( > 14 days ) : no crazy paving pattern , GGO remains - LUNG ULTRASOUND : preferred as it is done bedside . - Subpleural areas of consolidation - Areas of white lung 39. MANAGEMENT - Isolation protocol - General measures - Specific therapy - Managing chronic conditions - Management guidelines approved by RGUHS 40. TYPES OF COVID DEDICATED FACILITIES - 1. COVID care center â hostel, hotels for mild suspected cases . - 2. Dedicated COVID health center â full hospital or a block for moderate suspect cases . - 3. Dedicated COVID hospital â for severe suspected cases till results are obtained admitted in ICU 41. GENERAL MEASURES - Empiric antibiotics if secondary bacterial pneumonia is suspected . - Avoid nebulized medications . - Glucocorticoids - according to WHO and CDC is not indicated . - Prevention of venous thromboembolism ;  Prophylactic dose : inj Enoxaparin 40 mg once a day .  Full dose : Enoxaparin 1 mg / kg every 12 hours . uptodate 42. EMERGENCY USE AUTHORIZATION MANAGEMENT FOR COVID 19 - 1. Chloroquine and Hydroxychloroquine . - 2. Remdesivir - 3 . Convalescent plasma - 4. Hyperimmune globulin . 43. REMDESIVIR - It is an adenosine nucleotide prodrug - Competes for incorporation into RNA chains - Delayed chain termination during viral RNA replication . - DOSING : I.V. 200 mg on day 1 - Followed by 100 mg OD for 5 or 10 days based on severity . 44. HYDROXYCHLOROQUINE / CHLOROQUINE - Changes pH at cell membrane surface - Inhibits viral fusion - Inhibits nucleic acid replication , viral assembly and release . - DOSE: as per FDA 1. 800 mg PO on day 1 2. 400 mg PO OD for 4-7 days . Baseline : ECG , RFT , electrolytes , LFT to be done . Repeat ECG 2-4 hours , 48 hours and 96 hours after 1st dose . 45. PLASMA THERAPY - It is a strategy of passive immunization . - Apheresis is the recommended procedure to obtain plasma - 1. neutralising antibodies â ANTIVIRAL EFFECTS . - 2. contains : antithrombotic factors , immunoglobulins , antibodies that block complement , inflammatory cytokines TNÎ and IL-1Î â IMMUNOMODULATORY EFFECTS . Manuel Rojas et al , Elsevier on April 11 2020 46. - PATIENT ELIGIBILITY : 1. Laboratory confirmed covid 19 2.Informed consent by patient or attenders 3.Severe and critical disease â as per WHO . DONOR ELIGIBILITY : 1. Evidence of covid â 19 documented by RTPCR or serology . 2. Complete resolution of symptoms atleast 14 days before donation . 3. Female donors who have not been pregnant or negative for HLA antibodies .. FDA 47. - Dose : 3 ml/kg body weight in divided doses. - Covid 19 â convalescent plasma should be frozen within 8 hours of collection - Stored at â 18 C . - Expiration date â 1 year from date of collection . FDA 48. CLINICAL MANAGEMENT AS PER RGUHS GROUP A : TREATMENT : 1 . Cap oseltamivir 75mg bd for 5 days 2. Tab azithromycin 500 mg od for 5 days 3. Tab hydroxychloroquinine 400mg OD for 1 day followed by 200 mg BD for 4 days 49. 4. Inj ENOXIPARIN 40 mg , s/c , OD for 7 days ( if D-dimer > 1000 ng/ml or CT thorax showing ground glass opacities ) SUPPORTIVE : Tab zinc 50 mg od for 7days Tab vitamin C 500 mg TID for 7 days 50. GROUP B ( MODERATELY SICK PATIENTS) - Same as GROUP A - IV antibiotics according local antibiogram - Tab N-acetyl cysteine TID in patients with cough - Continous monitorong of oxygen saturation is advised - If saturation < 94 % to start on oxygen â 5L/ min via face mask or nasal prongs . 51. GROUP C ( CRITICALLY SICK PATIENT ) - Oral medications same as GROUP A - IV antiobiotics can be escalated - Inj Enoxaparin 1 mg/kg body weight s/c BD for 7 days - NOVEL THERAPY : - 1. TOCILIZUMAB - 2. REMDESIVIR - 3. CONVALESCENT PLASMA Lopinavir / Ritonavir to be used when there is no response for primary treatment . 52. - High flow nasal oxygen to be given - If patient deteriorates early intubation to be considered ABG to be done regularly for monitoring of acidosis and hypoxemia . Ionotrophic support to maintain MAP > 65 mmHg Correction of electrolyte abnormalities and acidosis Maintain HB > 8 gm % Group C patient progresses to ARDS , SHOCK novel therapy can be started 53. AIRWAY MANAGEMENT - COVID 19 is a hypoxemic respiratory failure . - High flow oxygen through nasal cannula upto 60 L/min should be started - If low flow oxygen therapy fails - Since NIV works well with hypercapnic failure it is not beneficial compared to high flow oxygen therapy - In later stages intubation to be done following AHA protocol creating a closed set up with HEPA filters at expiratory end and in line suction catheter - Minium oxygen fraction should be given to maintain spo2 0f 90-96% - Fio2 â 0.6 ideal . 54. DISCHARGE POLICY FOR COVID 19 - Mild : after 10 days of symptom onset , afebrile - 3 days - Moderate : after 10 days of symptom onset , afebrile and off oxygen for 3 days . - Severe : clinical recovery . - Only severe patients need RTPCR negative test before discharge - Mild and moderate â 7 days of home isolation following discharge , RTPCR not required MOHFW on 8/5/2020 55. PROPHYLAXIS â HYDROXYCHLOROQUINE Sl no. Category of personnel DOSAGE 1. Asymptomatic household contacts of lab confirmed patient 400 mg BD on day 1 400 mg weekly * 3 weeks 2. a. All asymptomatic HCW b. asymptomatic frontliners , surveillance team , paramilitary / police personnel in containment zone 400 mg bd on day 1 400 mg weekly once * 7 weeks As per Icmr on 22/5/2020 56. VACCINE TRIALS - Beijing Institute of Biotechnology , China conducted first human trial with adenovirus type 5 vectored COVID 19 vaccine . - It is a single centre , open label, non randomised dose escalation phase 1 trial . 108 covid negative participants were recruited - Confirmed by negative results of serum specific IgM and IgG with rapid test . - Negative RTPCR for covid in pharyngeal swabs , anal swabs . - Clear CT image with no evidence of lesions in lungs at the time of screening Feng-CaiZhu et al , Beijing institute of biotech , lancet article , may 22 2020 57. divided into 3 groups with 36 participants in each group. 1st group received mild dose 5 *10 10 . 2nd group received moderate dose 1*10 11. 3rd group received high dose 1.5 * 10 11 . received intramuscularly . 58. primary outcome after 7 days was adverse events , common injection site reaction was pain. systemic adverse reactions were fever , fatigue , headache and muscular pain . these reactions occurred within 24 hours post vaccination and persisted not more than 48 hours . 59. - Rapid binding antibody responses to RBD were observed in all 3 groups from day 14 . - Four- fold increase of anti â RBD antibodies was noted . - Neutralising antibodies against live SARS-CoV-2 were all negative at day 0 , increased at day 14 , peaking at 28 days post â vaccination . 60. - The Ad5 vectored COVID 19 vaccine is immunogenic , inducing humoral and T- cell responses peaking at day 14 and antibodies peaking at day 28 . - In conclusion , Ad5 vectored COVID 19 vaccine is tolerable and immunogenic in healthy adults 61. 1253 STUDIES ARE ONGOING FOR MANAGEMENT OF COVID 19 . - Includes hydroxychloroquine . - Plasma based therapy - Lopinavir/ Ritonavir - Azithromycin - Remdesivir - Vaccine - Tocilizumab - Favipiravir - Sarilumab - Anakinra - Interferon therapy - Umifenovir - Corticosteroids - Steam cell therapy 62. INDIAN TRIALS LISTED IN NATIONAL INSTITUTES OF HEALTH - 1. efficacy of HCQ as post exposure prophylaxis for prevention of COVID â 19 . By post graduate institute of medical education , Chandigarh with 200 participants started on march 1 2020 . - 2. Ivermectin versus standard treament by Max super speciality hospital, new Delhi with 50 participants start date on april 5 2020 , primary outcome being eradication of virus . 63. - 3. Efficacy of convalescent plasma therapy in severely sick covid 19 patients . Conducted by Maulana Azad Medical college . New Delhi and Institute of Liver and Biliary sciences with 40 participants started on April 21 2020 , primary outcome being patients remaining free of mechanical ventlation . 64. - 4. Low dose radiation therapy with a dose of 70 cGy in one fraction radiation for COVID 19 pneumonia by AIIMS , New Delhi with 10 participants estimated to start in june 2020 , primary outcome being symptomatic improvement and to reduce length of hospital stay , and ICUadmissions . 65. - 5 . A clinical trial of Mycobacterium w in critically ill COVID 19 patients conducted by AIIMS , Bhopal , MP and PG medical college , Chandigarh . With 40 participants started on April 30 , 2020 . - Suspension of heat killed Mycobacterium w , 0.3 ml of intradermal injection for 3 consecutive days were given along with standard therapy . - Primary outcome : to study effect of Mw on recovery of organ failure . 66. RAAS INHIBITORS AND RISK OF COVID - Harmonay et al from New York University conducted this study , published on May 1 2020 at NEJM.  Total of 12,594 patients were tested for covid out of which 5894 were tested positive . 2573 patients had hypertension and were on - ACE inhibitors - ARBâs - Beta â blockers - Calcium channel blockers - Thiazide diuretic 67. - Previous treatment with medications acting on RAAS was not associated with higher risk of testing positive for covid 19 . - No high risk of severe Covid -19 associated with any of the medications studied.. - Medications can be continued unless contraindicated - Like: hypotension , hyperkalaemia , acute kidney injury . 68. COVID WITH DIABETES - Diabetes is a risk factor for development of severe pneumonia and sepsis , occurs in 20 % of patients . - ACUTE HYPERGLYCEMIA : upregulates ACE2 expression on cells facilitating virus cell entry . - ACE2 on pancreatic Î cell leads to damage causing insulin deficiency. - Hence monitoring for new onset diabetes is important . Stefan et al , Kingâs college , London UK , LANCET diabetology on april 23 69. THERAPEUTIC AIMS - Plasma glucose concentration : 72-180 mg/dl - HBA1C : < 7 % INSULIN THERAPY : - Subcutaneous insulin therapy with basal or intermediate acting insulin along with meal time bolus of short acting insulin is preffered . - DPP4 inhibitors may be continued due to low risk of hypoglycemia , 70. THERAPY WHEN USED IN COVID 19 SUGGESTIONS FOR PRACTICE METFORMIN Risk of lactic acidosis in hypoxia and acute illness Stop if severley ill with hypoxia and hemodynamic instability SGLT2 inhibitors Risk of dehyration and euglycaemic ketoacidosis Stop in severely ill patients GLP-1 RAs Gastrointestinal side effects and risk of aspiration Not advised in severe disease SULFONYLURE AS Risk of hypoglycaemia due to poor oral intake and with use of HCQâs Stop if poor oral intake or at risk of hypoglycaemia 71. THERAPEUTIC AGENT Adverse events Choloroquine/ HCQ 1.Hypoglycaemia . Caution with Insulin and Insulin secretagogues. 2. QT interval prolongation . Lopinavir / Ritonavir 1.Hyperglycaemia , Poor glycaemic control . 2. Interaction with statins , Increases risk of hepatotoxicity and muscle toxicity Glucocorticoids 1. Hyperglycaemia 2. susceptibility to secondary bacterial infection Remdesivir Caution with statins. Hepatotxicity 72. COVID AND PREGNANCY - Clinical characteristics of pregnant covid 19 positive patients are similar to non pregnant patients . - Risk of transmission to infant is very low . - There is no confirmed mother - to- child transmission , - no positive cord blood or vaginal samples 73. WHO GUIDELINES FOR PREGNANT WOMEN WITH COVID - Covid 19 positive status alone is not an indication for caesarean section . - Mode of birth should be individualized based on obstetric indications . - Mothers should not be separated from their infant unless mother is too sick to care for her baby - Breastfeeding to be initiated within 1 hour of birth . - Advised to follow strict hygienic measures while handling the baby . 74. GUIDANCE FOR STARTING AND CONTINUING RESUSCITATION . - Health care system should institute policies for front liners in determining the appropriateness of starting and terminating CPR . - Mortality of critically ill covid 19 patient is high - It is reasonable to consider age , co morbidities , severity of illness to start CPR - To balance the success against the risk of rescuers . - American Heart Association 75. GUIDELINES ON RATIONAL USE OF PPE - Out patient department â  Triage area , temperature recording area , waiting area , Doctorâs chamber with moderate risk  No aerosol generating procedure shall be allowed .  N95 mask and Gloves are the recommended PPE as per Ministry of Health and Family Welfare .  Icmr 76. IN- PATIENT SERVICES - Isolation rooms with moderate risk â N95 mask and gloves . - ICU with high risk aerosol generating activities performed â full component of PPE . - ICU â dead body packing full component PPE . 77. - Other services : - LABORATORY : sample collection and transportation â full component of PPE . - Sanitation , CSSD, Supportive staff only N95 mask and Gloves . - Other non â COVID treatment areas PPE as per hospital protocol . 78. REUSE OF N95 MASKS - Mask rotation : 5 masks as per CDC should be numbered , rotated every day - Allow them to dry > 72 hours - Store in clean paper bag . - Dispose the mask if exposed to aerosol producing procedures . - DECONTAMINATION : - Hydrogen peroxide vaporization . - UV treatment - Moist and Dry heat . - Baking , boiling , using bleach , alcohol , soapy water not approved . 79. INDIAN STATISTICS Confimed 2,17,187 Recovered 1,04,107 Deaths 6,088 Confimed Recovered Deaths 80. STATISTICS OF WORLD Confirmed 65,75,177 Recovered 31,71,783 Deaths 3,88,060 Confirmed Recovered Deaths 81. PROGNOSIS - INDIA : - Incidence per million : 132 - Recovery rate : 48.31 % - Case fatality rate : 2.82 % - 50 % death â senior citizens - 75% death â with co morbidities . 82. REFERANCES - UPTODATE - WHO guidelines on clinical management of covid 19 - International pulmonologistâs consensus on covid 19 - COVID 19 clinical management approved by RGUHS - Centers for disease control and prevention . - WORLD HEALTH ORGANIZATION - U.S Food and Drug Administration - ClinicalTrials.gov - Harmony et al RAAS inhibitors and risk of covid 19 from Grossman school of medicine , new york - Practical recommendations for management of diabetes in patients with Covid 19 by Stefan et al published in Lancet journal 83. THANK YOU