SARS-CoV-2 detection in human milk: a systematic review.

PURPOSE: To synthesize the current evidence for the presence of SARS-CoV-2 RNA in the human milk of mothers with confirmed COVID-19 and its potential role in neonatal SARS-CoV-2 infection. MATERIALS AND METHODS: Using terms related to novel coronavirus 2019 and human milk, a systematic search was performed in three electronic databases (PubMed, EMBASE, and Web of Science) for studies published between December 2019 and 15 October 2020. Published peer-reviewed studies reporting the results of RT-PCR for SARS-CoV-2 RNA in human milk in mothers with confirmed COVID-19 were included. Proportion meta-analysis of case series and prospective cohort studies was performed using STATA version 14.2 (StataCorp, College Station, TX) and pooled estimate (with 95% confidence interval) of overall incidence of SARS-CoV-2 transmission was calculated. RESULTS: We identified 936 records, of which 34 studies (24 case-reports, 10 cohort studies) were eligible for this systematic review. A total of 116 confirmed COVID-19 lactating women (88 in cohort and 28 in case-reports) underwent RT-PCR testing in human milk, and 10 (six in case reports) were detected to have SARS-CoV-2 RNA. The overall pooled proportion (from cohort studies) for SARS-CoV-2 RNA detection in human milk was 2.16% (95% CI: 0.0-8.81%, I2: 0%). Four studies (six patients) also reported the presence of SARS-CoV-2 specific antibodies (along with RT-PCR) in human milk. CONCLUSIONS: The limited low-quality evidence suggests that SARS-CoV-2 RNA is detected in human milk in an extremely low proportion, however, based on current evidence no conclusion can be drawn about its infectivity and impact on the infants. In concordance with World Health Organization recommendations, exclusive breastfeeding should be considered in all cases unless any other contraindication exists.

A Correlation Analysis of Peripheral Oxygen Saturation and Arterial Oxygen Saturation Among COVID-19 Patients.

Background and objective It has been observed that peripheral oxygen saturation (SpO2) measured by pulse oximeter is consistently lower than arterial oxygen saturation (SaO2) measured directly by blood gas analysis. In this study, we aimed to evaluate the correlation between SpO2 and SaO2, and SpO2 and partial pressure of oxygen (PaO2), and compare the SpO2/FiO2 (SF) and PaO2/FiO2 (PF) ratios in patients with coronavirus disease 2019 (COVID-19). Methods In this observational study, SpO2 was recorded and arterial blood gas analysis was performed among 70 COVID-19 patients presenting on room air (FiO2 = 0.21). SaO2 and PaO2 were recorded from arterial blood gas analysis. The SF and PF ratios were then calculated. Results The strength of correlations between SpO2 and SaO2, and SpO2 and PaO2, were significant (p<0.001) and moderately positive [Pearson coefficient (r) = 0.68, 0.53]. SpO2 value (85%), i.e., SF ratio (404.7 or below), was the best estimate for mild ARDS (acute respiratory distress syndrome) [PF ratio (300 or below)] with a sensitivity of 80.6% and specificity of 53%. Conclusion A pulse oximeter is a vital tool in the diagnosis and management of COVID-19. In our study, SpO2 was found to have a positive correlation with SaO2 and PaO2 with acceptable sensitivity but low specificity in estimating mild ARDS. Therefore, pulse oximetry can be used as a tool for the early diagnosis of mild COVID-19 ARDS as per the given considerations and clinical correlation.

Airway management, procedural data, and in-hospital mortality records of patients undergoing surgery for mucormycosis associated with coronavirus disease (COVID-19).

PURPOSE: Although unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse. METHODS: In this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and in-hospital mortality records. RESULTS: Forty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27-74) days. The median (range) time to hospital discharge was 53.5 (10-85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03). CONCLUSION: In patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

Comparison between C-MAC and King Vision video laryngoscope (channelled blade) for tracheal intubation in aerosol-prevention intubation box for COVID-19 patients: A manikin-based study.

Background and Aims: The risk of contracting infection while intubating a coronavirus disease 2019 (COVID-19)-positive patient can be reduced by the use of personal protective equipment (PPE), video laryngoscope (VL) and aerosol-preventing intubation box. We compared two VLs (C-MAC and King Vision laryngoscope [KVL]) for ease of intubation and time taken to intubate the manikin using an intubation box. Methods: This randomised study involved healthcare workers having experience in using both C-MAC and KVL. After explaining the study and five practice sessions, a total of 63 volunteers were included; 61 participants gave consent and were enroled. The participants were allowed to intubate initially with one VL as per random sequence. Each participant performed three tracheal intubations with each device (C-MAC VL and KVL) on a manikin using an aerosol-prevention box over the head end at the time of intubation. Results: Time taken, percentage of glottic opening (POGO) score and the number of attempts taken for successful intubation with C-MAC and KVL were comparable in any of the three attempts (P > 0.05). The participants reported more difficulty in using KVL compared to C-MAC, and insertion of laryngoscope blade into the mouth of manikin for intubation was easy in group C-MAC compared to KVL in all three intubations (P < 0.01). Conclusion: C-MAC and KVL take comparable time for successful intubation under COVID-19 simulation conditions. But C-MAC is more user-friendly.

Detection of three pandemic causing coronaviruses from non-respiratory samples: systematic review and meta-analysis.

SARS-CoV-2 has posed an unprecedented challenge to the world. Pandemics have been caused previously by viruses of this family like Middle East Respiratory Corona Virus (MERS CoV), Severe Acute Respiratory Syndrome Corona Virus (SARS CoV). Although these viruses are primarily respiratory viruses, but they have been isolated from non-respiratory samples as well. Presently, the detection rate of SARS-CoV-2 RNA from different clinical specimens using Real Time Reverse Transcriptase Polymerized Chain Reaction (qRT-PCR) after onset of symptoms is not yet well established. Therefore, the aim of this systematic review was to establish the profile of detecting SARS-CoV-2, MERS CoV, SARS CoV from different types of clinical specimens other than the respiratory using a standard diagnostic test (qRT-PCR). A total of 3429 non-respiratory specimens were recorded: SARS CoV (total sample-802), MERS CoV (total sample-155), SARS CoV-2 (total sample-2347). Out of all the samples studied high positive rate was seen for saliva with 96.7% (14/14; 95% CI 87.6-100.0%) for SARS CoV and 57.5% (58/250; 95% CI - 1.2 to 116.2%) for SARS CoV-2, while low detection rate in urine samples for SARS CoV-2 with 2.2% (8/318; 95% CI 0.6-3.7%) and 9.6% (12/61; 95% CI - 0.9 to 20.1%) for SARS CoV but there was relatively higher positivity in urine samples for MERS CoV with detection rate of 32.4% (2/38; 95% CI - 37.3 to 102.1%). In Stool sample positivity was 54.9% (396/779; 95% CI 41.0-68.8%), 45.2% (180/430; 95% CI 28.1-62.3%) and 34.7% (4/38; 95% CI - 29.5 to 98.9%) for SARS CoV-2, MERS CoV, and SARS CoV, respectively. In blood sample the positivity was 33.3% (7/21; 95% CI 13.2-53.5%), 23.7% (42/277; 95% CI 10.5-36.9%) and 2.5% (2/81; 95% CI 0.00-5.8%) for MERS CoV, SARS CoV-2 and SARS CoV respectively. SARS-CoV-2 along with previous two pandemic causing viruses from this family, were highly detected stool and saliva. A low positive rate was recorded in blood samples. Viruses were also detected in fluids along with unusual samples like semen and vaginal secretions thus highlighting unique pathogenic potential of SARS-CoV-2.

Comparison of Mc Grath-MAC and C-MAC video laryngoscopes for intubation in a COVID simulated mannequin by novice users wearing face protective gear: A randomized crossover trial.

INTRODUCTION: Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices. METHODOLOGY: This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over. RESULTS: The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes. CONCLUSION: The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.

Efficacy and safety of hydroxychloroquine/chloroquine against SARS-CoV-2 infection: A systematic review and meta-analysis.

INTRODUCTION: Hydroxychloroquine (HCQ)/Chloroquine (CQ) has been evaluated for treatment and prophylaxis against SARS-CoV-2 infection in various studies with conflicting results. We performed a systematic review to synthesize the currently available evidence over the efficacy and safety of HCQ/CQ therapy alone against SARS-CoV-2 infection. METHODS: We searched Embase, PubMed, Web of Science, and Cochrane central for randomized controlled trials (RCTs) and prospective cohort studies published until October 15, 2020 and assessing the efficacy of HCQ alone against SARS-CoV-2 infection. We included studies evaluating HCQ/CQ alone as intervention and placebo/standard care as a control group. Retrospective studies and studies using other drugs (namely azithromycin, corticosteroids, immunomodulators, etc.) we excluded. Thirteen RCTs and three prospective cohort studies were included in this review. We pooled data using a random-effect model. RESULTS: Pooled data from 12 studies (9917 participants) showed that HCQs increase mortality as compared to placebo/standard of care (RR 1.10; 95% CI:1.00-1.20). Hydroxychloroquine did not reduce the need for hospitalization in out-patients (RR 0.57; 95% CI 0.31-1.02). HCQ group has a significantly higher rate of any adverse event (RR 2.68; 95% CI 1.55-4.64), as compared to the control group. Also, using HCQ for prophylaxis against SARS-CoV-2 infection did not reduce the risk of acquiring SARS-CoV-2 infection (RR 1.04; 95% CI 0.58-1.88). CONCLUSIONS: HCQ therapy for COVID-19 is associated with an increase in mortality and other adverse events. The negative effects are more pronounced in hospitalized patients. Therefore, with the available evidence, HCQ should not be used in prophylaxis or treatment of patients with COVID-19.

Clinical Features and Outcome of SARS-CoV-2 Infection in Neonates: A Systematic Review.

OBJECTIVE: The objective of this study is to systematically synthesize the currently available literature on various modes of transmission (congenital, intrapartum, and postpartum), clinical features and outcomes of SARS-CoV-2 infection in neonates. METHODS: We conducted a comprehensive literature search using PubMed, EMBASE, and Web of Science until 9 June 2020. A combination of keywords and MeSH terms, such as COVID-19, coronavirus, SARS-CoV-2, 2019-nCoV, severe acute respiratory syndrome coronavirus 2, neonates, newborn, infant, pregnancy, obstetrics, vertical transmission, maternal-foetal transmission and intrauterine transmission, were used in the search strategy. We included studies reporting neonatal outcomes of SARS-CoV-2 proven pregnancies or neonatal cases diagnosed with SARS-CoV-2 infection. RESULTS: Eighty-six publications (45 case series and 41 case reports) were included in this review. Forty-five case series reported 1992 pregnant women, of which 1125 (56.5%) gave birth to 1141 neonates. A total of 281 (25%) neonates were preterm, and caesarean section (66%) was the preferred mode of delivery. Forty-one case reports describe 43 mother-baby dyads of which 16 were preterm, 9 were low birth weight and 27 were born by caesarean section. Overall, 58 neonates were reported with SARS-CoV-2 infection (4 had a congenital infection), of which 29 (50%) were symptomatic (23 required ICU) with respiratory symptoms being the predominant manifestation (70%). No mortality was reported in SARS-CoV-2-positive neonates. CONCLUSION: The limited low-quality evidence suggests that the risk of SARS-CoV-2 infections in neonates is extremely low. Unlike children, most COVID-positive neonates were symptomatic and required intensive care. Postpartum acquisition was the commonest mode of infection in neonates, although a few cases of congenital infection have also been reported.

Radiological Findings of COVID-19 in Children: A Systematic Review and Meta-Analysis.

BACKGROUND: The majority of the children with SARS-CoV-2 infection present with respiratory symptoms, hence various chest imaging modalities have been used in the management. Knowledge about the radiological findings of coronavirus disease (COVID-19) in children is limited. Hence, we systematically synthesized the available data that will help in better management of COVID-19 in children. METHODS: Four different electronic databases (MEDLINE, EMBASE, Web of Science and CENTRAL) were searched for articles reporting radiological findings in children with COVID-19. Studies reporting thoracic radiological findings of COVID-19 in patients aged <19 years were included. A random-effect meta-analysis (wherever feasible) was performed to provide pooled estimates of various findings. RESULTS: A total of 1984 records were screened of which forty-six studies (923 patients) fulfilled the eligibility criteria and were included in this systematic review. A chest computed tomography (CT) scan was the most frequently used imaging modality. While one-third of the patients had normal scans, a significant proportion (19%) of clinically asymptomatic children had radiological abnormalities too. Unilateral lung involvement (55%) was frequent when compared with bilateral and ground-glass opacities were the most frequent (40%) definitive radiological findings. Other common radiological findings were non-specific patchy shadows (44%), consolidation (23%), halo sign (26%), pulmonary nodules and prominent bronchovascular marking. Interstitial infiltration being the most frequent lung ultrasound finding. CONCLUSION: CT scan is the most frequently used imaging modality for COVID-19 in children and can detect pneumonia before the appearance of clinical symptoms. Undefined patchy shadows, grand-glass opacities and consolidation are commonly observed imaging findings in COVID-19 pneumonia.

Clinical Features and Outcome of SARS-CoV-2 Infection in Children: A Systematic Review and Meta-analysis.

OBJECTIVE: Knowledge about COVID-19 in children is limited due to the paucity of reported data. The pediatric age group comprises only less than 5% of total COVID-19 worldwide, therefore, large studies in this population are unlikely in the immediate future. Hence, we planned to synthesize the current data that will help in a better understanding of COVID-19 in children. EVIDENCE ACQUISITION: Four different electronic databases (MEDLINE, EMBASE, Web of Science, and CENTRAL) were searched for articles related to COVID-19 in the pediatric population. We included studies reporting disease characteristics and outcomes of COVID-19 in patients aged less than 19 years. We performed a random-effect meta-analysis to provide pooled estimates of various disease characteristics. RESULTS: 27 studies (4857 patients) fulfilling the eligibility criteria were included in this systematic review, from a total of 883 records. About half of the patients had each of fever and cough, 11% (6-17%) had fast breathing, and 6-13% had gastrointestinal manifestations. Most of the patients had mild to moderate disease, and only 4% had a severe or critical illness. Leukopenia was the commonest reported laboratory abnormality. CONCLUSIONS: Even among the symptomatic COVID-19 cases, severe manifestations are seen in very few children. Though fever and respiratory symptoms are most common, many children also have gastrointestinal manifestations.