Este es un blog medico que nunca podrá sustituir el buen juicio médico en la toma de decisiones.Intentamos compartir con los profesionales nuestras experiencias, conocimientos,lecturas,etc con la finalidad de mejorar la practica clinica.No es un blog para pacientes aunque no rechazamos sus comentarios
Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention
S.E.F.H (@sefh_) twitteó: Medidas dirigidas a prevención y control de la infección por #coronavirus 2019-nCoV ➡ Equipos de protección individual recomendados en caso de sospecha/confirmación de infección @GrupoGPS_sefh https://t.co/LvXEAL77k2
microBIO: CORONAVIRUS UPDATE Febrero 23: #COVID19 #SARSCoV2 El 97,5% de los casos confirmados siguen ocurriendo en China, el 83% en la región del Hubei, donde además se concent...
SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients
To the Editor:
Figure 1. Viral Load Detected in Nasal and Throat Swabs Obtained from Patients Infected with SARS-CoV-2.
The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, and has been declared a public health emergency of international concern by the World Health Organization, may progress to a pandemic associated with substantial morbidity and mortality. SARS-CoV-2 is genetically related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries in 2002–2003.1 The epidemic of SARS-CoV was successfully contained through public health interventions, including case detection and isolation. Transmission of SARS-CoV occurred mainly after days of illness2 and was associated with modest viral loads in the respiratory tract early in the illness, with viral loads peaking approximately 10 days after symptom onset.3 We monitored SARS-CoV-2 viral loads in upper respiratory specimens obtained from 18 patients (9 men and 9 women; median age, 59 years; range, 26 to 76) in Zhuhai, Guangdong, China, including 4 patients with secondary infections (1 of whom never had symptoms) within two family clusters (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The patient who never had symptoms was a close contact of a patient with a known case and was therefore monitored. A total of 72 nasal swabs (sampled from the mid-turbinate and nasopharynx) () and 72 throat swabs () were analyzed, with 1 to 9 sequential samples obtained from each patient. Polyester flock swabs were used for all the patients.
From January 7 through January 26, 2020, a total of 14 patients who had recently returned from Wuhan and had fever (≥37.3°C) received a diagnosis of Covid-19 (the illness caused by SARS-CoV-2) by means of reverse-transcriptase–polymerase-chain-reaction assay with primers and probes targeting the N and Orf1b genes of SARS-CoV-2; the assay was developed by the Chinese Center for Disease Control and Prevention. Samples were tested at the Guangdong Provincial Center for Disease Control and Prevention. Thirteen of 14 patients with imported cases had evidence of pneumonia on computed tomography (CT). None of them had visited the Huanan Seafood Wholesale Market in Wuhan within 14 days before symptom onset. Patients E, I, and P required admission to intensive care units, whereas the others had mild-to-moderate illness. Secondary infections were detected in close contacts of Patients E, I, and P. Patient E worked in Wuhan and visited his wife (Patient L), mother (Patient D), and a friend (Patient Z) in Zhuhai on January 17. Symptoms developed in Patients L and D on January 20 and January 23, respectively, with viral RNA detected in their nasal and throat swabs soon after symptom onset. Patient Z reported no clinical symptoms, but his nasal swabs (cycle threshold [Ct] values, 22 to 28) and throat swabs (Ct values, 30 to 32) tested positive on days 7, 10, and 11 after contact. A CT scan of Patient Z that was obtained on February 6 was unremarkable. Patients I and P lived in Wuhan and visited their daughter (Patient H) in Zhuhai on January 11 when their symptoms first developed. Fever developed in Patient H on January 17, with viral RNA detected in nasal and throat swabs on day 1 after symptom onset.
We analyzed the viral load in nasal and throat swabs obtained from the 17 symptomatic patients in relation to day of onset of any symptoms (). Higher viral loads (inversely related to Ct value) were detected soon after symptom onset, with higher viral loads detected in the nose than in the throat. Our analysis suggests that the viral nucleic acid shedding pattern of patients infected with SARS-CoV-2 resembles that of patients with influenza4 and appears different from that seen in patients infected with SARS-CoV.3 The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients. These findings are in concordance with reports that transmission may occur early in the course of infection5 and suggest that case detection and isolation may require strategies different from those required for the control of SARS-CoV. How SARS-CoV-2 viral load correlates with culturable virus needs to be determined. Identification of patients with few or no symptoms and with modest levels of detectable viral RNA in the oropharynx for at least 5 days suggests that we need better data to determine transmission dynamics and inform our screening practices.
Lirong Zou, M.Sc. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
Feng Ruan, M.Med. Zhuhai Center for Disease Control and Prevention, Zhuhai, China
Mingxing Huang, Ph.D. Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
Lijun Liang, Ph.D. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
Huitao Huang, B.Sc. Zhuhai Center for Disease Control and Prevention, Zhuhai, China
Zhongsi Hong, M.D. Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
Jianxiang Yu, B.Sc. Min Kang, M.Sc. Yingchao Song, B.Sc. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
Jinyu Xia, M.D. Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
Qianfang Guo, M.Sc. Tie Song, M.Sc. Jianfeng He, B.Sc. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
Hui-Ling Yen, Ph.D. Malik Peiris, Ph.D. University of Hong Kong, Hong Kong, China
Jie Wu, Ph.D. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China 771276998@qq.com
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on February 19, 2020, at NEJM.org.
Ms. Zou, Mr. Ruan, and Dr. Huang contributed equally to this letter.
3. Peiris JSM, Chu CM, Cheng VCC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-1772.
5. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med. DOI: 10.1056/NEJMc2001468.
Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate
The novel coronavirus that has so far spread from China to 26 countries around the world does not seem to be as "deadly as other coronaviruses including SARS and MERS," the World Health Organization has said.
At a briefing on 17 February WHO's director general, Tedros Adhanom Ghebreyesus, said that more than 80% of patients with covid-19 have a "mild disease and will recover" and that it is fatal in 2% of reported cases. In comparison, the 2003 outbreak of severe acute respiratory syndrome (SARS) had a case fatality rate of around 10% (8098 cases and 774 deaths), while Middle East respiratory syndrome (MERS) killed 34% of people with the illness between 2012 and 2019 (2494 cases and 858 deaths).12
However, despite the lower case fatality rate, covid-19 has so far resulted in more deaths (1871) than SARS and MERS combined (1632).
The latest update from China's National Health Commission said that as at 17 February there had been 72 436 confirmed cases of the infection and 1868 deaths in the country. More than 12 500 patients have recovered and been discharged from hospital, while around 58 000 patients with confirmed cases (including 11 741 in a serious condition) and 6242 with suspected cases remain.
Outside China, WHO has reported 794 cases across 26 countries and three deaths.
Referencing a new paper from China that was based on 44 000 confirmed cases, Tedros said that 14% of cases of covid-19 were severe, causing pneumonia and shortness of breath, and that about 5% of patients had critical disease, including respiratory failure, septic shock, and multiorgan failure.
"As more data comes in from China, we're starting to get a clearer picture of the outbreak, how it's developing, and where it could be headed," Tedros said. He added that while the data seemed to show a decline in the rate of new cases, the trend could change as new populations became affected.
This comment came after the first case of covid-19 was confirmed in Africa (in Egypt). Commenting on this milestone in the outbreak, Trudie Lang, director of the Global Health Network at the University of Oxford, said it was "important but not unexpected." She highlighted the fact that WHO had declared the outbreak a "public health emergency" to "support less well resourced nations in responding and preparing for cases."
Lang praised the response of the Africa Centres for Disease Control and Prevention, which is based in Ethiopia and supports countries with surveillance, emergency responses, and prevention of infectious disease. She said that the patient had been isolated, and all contacts had been found and tested (all negative). However, she added that a "key challenge" would be to ensure that countries across Africa had diagnostic capacity.
WHO is calling for donations to help it help countries prepare. It said that $675m was needed, and that though some contributions had been made, they "have not seen the urgency in funding that we need."
WHO has been providing countries with testing kits, personal protective equipment, and training for health workers, as well as advice on how to do screening, testing, contact tracing, and treatment.
Tedros said, "We have a window of opportunity now. We need resources now to ensure countries are prepared now. We don't know how long this window of opportunity will remain open. Let's not squander it."
Había una vez una consulta de atención primaria a la que acudían pacientes, con diversas y variadas quejas, problemas y algunos, incluso, enfermedade. Entre estas últimas había de las más diversas clases y condición. Difieren sobre todo en la gravedad.
Un día llegó un paciente con un cuadro con síntomas, a mi parecer importantes. Estos síntomas, a veces se dan en procesos que requerían atención urgente, en otros, aunque sin dejarlos, podía ser evaluado con más calma y sosiego por el especialista correspondiente. Este fue el caso que nos ocupa, el paciente fue derivado para que fuera atendido, sin urgencia pero con cierta premura, utilizado un sofisticado pero engañoso sistema, al que llamaban de valoración previa por especialista (VPE) o algo así.
Este sistema a modo de algoritmo "inteligente" se autorregulaba y daba inicialmente una cita tentativa al derivador, de tal forma que si estaba conforme con la fecha no hacía falta utilizarlo. En nuestro caso, el derivador no estuvo conforme ya que la cita se dilataba más de un mes. Optó por el procedimiento rápido es decir VPE. ¡Oh sorpresa!, días más tarde recibió la fecha de cita, y comprobó que la fecha asignada era la misma que el sistema le había ofrecido previamente.
El derivador con tal de no sobrecargar el sistema, optó de nuevo por una espera activa y vigilante del proceso hasta la cita, fue adelantando pruebas y haciendo todo lo que estuvo en su mano hasta ese momento.
Pero los pacientes tienen preocupaciones, familia, amigos, vecinos, etc. que opinan y sentencian sobre lo que debe hacer. El paciente no puede resistir las presiones y aunque confía en su médico, cede y se va al servicio de urgencias.En urgencias, le hacen un TAC y le dan cita con el especialista al día siguiente.
Moraleja: Los pacientes la próxima vez en caso similares, o incluso menos graves, optarán por la vía de urgencias. Lo malo es que el médico derivador también
No olvidemos el cuentecito clasico del gatekeeper (medico de Familia) and the wizard(medico hospitalario).
La resolucion de problemas via urgencia desprestigia totalmente la comunicacion Primaria-Hospitalaria.
A todo esto existe al menos dos visiones altervativas a lo que debe de ser la derivación:
1. una que dependa exclusivamente del gatekeeper: todo lo que envio debe de ser estudiado y valorado presencialmente
2. otra que conlleve una valoración por the wizard que decida si el paciente debe de verse ó no. Evidentemente debe de existir medios de colaboracion para resolver dudas en ambos sentidos.
Si el gatekeeper hace su tarea adecuadamente defiendo la primera via. Aunque es poco probable que se cumpla la premisa de adecuadamente en la mayoria de los casos...
Un trabajito nuestro muestra que a mas consultas mas derivaciones.
La pregunta original del usuario era "En un paciente con enfermedad de Alzheimer en tratamiento con memantina o inhibidores de la acetilcolinesterasa, ¿cuándo estaría indicada su retirada?" http://www.murciasalud.es/preevid/23454#
Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study
Despite these concerns, all four patients who were seen in Munich have had mild cases and were hospitalized primarily for public health purposes. Since hospital capacities are limited — in particular, given the concurrent peak of the influenza season in the northern hemisphere — research is needed to determine whether such patients can be treated with appropriate guidance and oversight outside the hospital.
Viral Load Detected in Nasal and Throat Swabs Obtained from Patients Infected with SARS-CoV-2.
