YouTube Videos Demonstrating the Nasopharyngeal Swab Technique for SARS-CoV-2 Specimen Collection: Content Analysis.

BACKGROUND: Real-time polymerase chain reaction using nasopharyngeal swabs is currently the most widely used diagnostic test for SARS-CoV-2 detection. However, false negatives and the sensitivity of this mode of testing have posed challenges in the accurate estimation of the prevalence of SARS-CoV-2 infection rates. OBJECTIVE: The purpose of this study was to evaluate whether technical and, therefore, correctable errors were being made with regard to nasopharyngeal swab procedures. METHODS: We searched a web-based video database (YouTube) for videos demonstrating SARS-CoV-2 nasopharyngeal swab tests, posted from January 1 to May 15, 2020. Videos were rated by 3 blinded rhinologists for accuracy of swab angle and depth. The overall score for swab angle and swab depth for each nasopharyngeal swab demonstration video was determined based on the majority score with agreement between at least 2 of the 3 reviewers. We then comparatively evaluated video data collected from YouTube videos demonstrating the correct nasopharyngeal swab technique with data from videos demonstrating an incorrect nasopharyngeal swab technique. Multiple linear regression analysis with statistical significance set at P=.05 was performed to determine video data variables associated with the correct nasopharyngeal swab technique. RESULTS: In all, 126 videos met the study inclusion and exclusion criteria. Of these, 52.3% (66/126) of all videos demonstrated the correct swab angle, and 46% (58/126) of the videos demonstrated an appropriate swab depth. Moreover, 45.2% (57/126) of the videos demonstrated both correct nasopharyngeal swab angle and appropriate depth, whereas 46.8% (59/126) of the videos demonstrated both incorrect nasopharyngeal swab angle and inappropriate depth. Videos with correct nasopharyngeal swab technique were associated with the swab operators identifying themselves as a medical professional or as an Ear, Nose, Throat-related medical professional. We also found an association between correct nasopharyngeal swab techniques and recency of video publication date (relative to May 15, 2020). CONCLUSIONS: Our findings show that over half of the videos documenting the nasopharyngeal swab test showed an incorrect technique, which could elevate false-negative test rates. Therefore, greater attention needs to be provided toward educating frontline health care workers who routinely perform nasopharyngeal swab procedures.

The utility of digital pathology in improving the diagnostic skills of pathology trainees in commonly encountered pigmented cutaneous lesions during the COVID-19 pandemic: A single academic institution experience.

Digital pathology has become an integral part of pathology education in recent years, particularly during the COVID-19 pandemic, for its potential utility as a teaching tool that augments the traditional 1-to-1 sign-out experience. Herein, we evaluate the utility of whole slide imaging (WSI) in reducing diagnostic errors in pigmented cutaneous lesions by pathology fellows without subspecialty training in dermatopathology. Ten cases of 4 pigmented cutaneous lesions commonly encountered by general pathologists were selected. Corresponding whole slide images were distributed to our fellows, along with two sets of online surveys, each composed of 10 multiple-choice questions with 4 answers. Identical cases were used for both surveys to minimize variability in trainees' scores depending on the perceived level of difficulty, with the second set being distributed after random shuffling. Brief image-based teaching slides as self-assessment tool were provided to trainees between each survey. Pre- and post-self-assessment scores were analyzed. 61% (17/28) and 39% (11/28) of fellows completed the first and second surveys, respectively. The mean score in the first survey was 5.2/10. The mean score in the second survey following self-assessment increased to 7.2/10. 64% (7/11) of trainees showed an improvement in their scores, with 1 trainee improving his/her score by 8 points. No fellow scored less post-self-assessment than on the initial assessment. The difference in individual scores between two surveys was statistically significant (p = 0.003). Our study demonstrates the utility of WSI-based self-assessment learning as a source of improving diagnostic skills of pathology trainees in a short period of time.

Managing the risks of making the wrong diagnosis: First, do no harm.

The appropriate use of diagnostics is important as misdiagnosis may have serious consequences. Confidence in a diagnostic test result depends on the test's accuracy (sensitivity and specificity) in the context of the use-case (who is tested and why) and the prevalence of the condition investigated. Here, we offer an approach to diagnostics focused on the risks and effects of making the wrong diagnosis. We propose 'fitness brackets' for a given test to define the range within which the test is fit-for-purpose, based on the use-case and risk-management principles. We use as exemplars tests for dengue pre-vaccination screening and tests for diagnosing Covid-19 in different settings.

Effects of a Serum Heating Procedure for Inactivating COVID-19 on Common Biochemical Tests.

BACKGROUND: COVID-19 has recently been declared an epidemic by the WHO, and there is an urgent need for affected countries and laboratories to assess and treat people at risk of COVID-19. A heat procedure has been suggested for specimen inactivation. This study was designed to evaluate the effect of serum heating on biochemical indexes, and providing a basis for accurate detection results of the COVID-19 patients. METHODS: We collected 29 normal cases of two tubes of 5 mL whole blood. One tube was analyzed directly, and the other was analyzed after heating at 56°C 30 minutes. RESULTS: A total of 34 serum biochemical index quantitative results were obtained, 28/34 indexes were not significantly affected by the heat inactivation and remained clinically interpretable. As the thermal inactivation for these indexes showed good correlation, ALB (p = 0.04, Pearson R = 0.91, 2.6% mean increase), CysC (p = 0.03, Pearson R = 0.98, 9.9% mean increase), CO2CP (p < 0.001, Pearson R = 0.96, 13% mean decrease), they were still inter-pretable. Four biochemical indexes ALP, CK, CK-MB, and insulin were inactivated and showed significant statistical differences (p < 0.001). CONCLUSIONS: Our study showed CK, CK-MB, ALP, and insulin were sensitive to heat and will be inhibited or degrade after heating, indicating that the rapid decrease of this indexes in the COVID-19 patients may be caused by sample heat inactivation. For safety and diagnostic accuracy, we recommend the use of a point-of-care device for blood gases, electrolytes, troponin, and liver and renal function tests within a ISL 2 or above biosafety cabinet with level 3 or above biosafety laboratory practice.

Unmatched Virus Preservation Solution may Impede One-Step Reagent for Detection of 2019-nCoV RNA.

BACKGROUND AND METHODS: 2019 Corona Virus Disease (COVID-19) caused by SARS-CoV-2 is still pandemic now. RT-qPCR detection was the most common method for the diagnosis of SARS-CoV-2 infection, facilitated by amounts of nucleic acid testing kits. However, the accuracy of nucleic acid detection is affected by various factors such as specimen collection, specimen preparation, reagents deficiency, and personnel quality. RESULTS: In this study, we found that unmatched virus preservation solution will inhibit N gene and OFR-1ab gene (two independent genes of SARS-CoV-2) amplification in one-step detection reagent. CONCLUSIONS: Despite just being a particular phenomenon we found in our work to fight 2019-nCoV, we concluded that unmatched virus preservation solution may have an inhibitory effect on SARS-CoV-2 nucleic acid detection which may lead to incorrect clinical diagnosis.

Risk of misdiagnosis and delayed diagnosis with COVID-19: A Syndemic Approach.

ABSTRACT: Misdiagnosis and delayed diagnosis are common problems in healthcare and are typically related to patient, provider, and socioeconomic factors. A syndemics model of COVID-19 is used to analyze the synergistic relationship between diseases and influences that impact patients' living conditions and health. NPs can use this approach to promote patient safety and equitable healthcare.

Retinal imaging study diagnoses in COVID-19: a case report.

BACKGROUND: Hyperreflective lesions at the level of ganglion cell (GCL) and inner plexiform retinal layers (IPL) by optical coherence tomography (OCT) and cotton wool spots in the examination of the eye fundus have recently been described as findings in patients with COVID-19 infection. CASE REPORT: We report the case of a 42-year-old healthy Caucasian male anesthetist who had treated COVID-19 patients during the previous 5 weeks and suddenly presented with a temporal relative scotoma in his left eye. Best-corrected visual acuity was 20/20 for the left eye, and no discromatopsy or afferent pupillary defect was present. Visual field test was performed, with no significant findings associated with the focal loss of sensitivity described by the patient. The anterior segment was unremarkable on slit lamp examination in both eyes. Fundus examination of the left eye showed no significant findings. A placoid, hyperreflective band at the level of the GCL and IPL was visible in OCT which spared the outer retina, at the time of diagnosis and 1 month later. An oropharyngeal swab test was performed for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ribonucleic acid (RNA), immunoglobulin G (IgG) and immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) determination. Real-time reverse-transcriptase polymerase chain reaction (RT-PCR) was negative. ELISA testing and a third rapid antibody detection test performed 7 days after the onset of symptoms were positive. CONCLUSIONS: Ocular signs and symptoms in COVID-19 cases are rarely reported, but may be underestimated, especially those that affect the retina and occur in asymptomatic or paucisymptomatic cases. We present a case of COVID-19 diagnosis based on retinal ophthalmic examination.

Patterns of repeated diagnostic testing for COVID-19 in relation to patient characteristics and outcomes.

BACKGROUND: Whilst the COVID-19 diagnostic test has a high false-negative rate, not everyone initially negative is re-tested. Michigan Medicine, a primary regional centre, provided an ideal setting for studying testing patterns during the first wave of the pandemic. OBJECTIVES: To identify the characteristics of patients who underwent repeated testing for COVID-19 and determine if repeated testing was associated with downstream outcomes amongst positive cases. METHODS: Characteristics, test results, and health outcomes for patients presenting for a COVID-19 diagnostic test were collected. We examined whether patient characteristics differed with repeated testing and estimated a false-negative rate for the test. We then studied repeated testing patterns in patients with severe COVID-19-related outcomes. RESULTS: Patient age, sex, body mass index, neighbourhood poverty levels, pre-existing type 2 diabetes, circulatory, kidney, and liver diseases, and cough, fever/chills, and pain symptoms 14 days prior to a first test were associated with repeated testing. Amongst patients with a positive result, age (OR: 1.17; 95% CI: (1.05, 1.34)) and pre-existing kidney diseases (OR: 2.26; 95% CI: (1.41, 3.68)) remained significant. Hospitalization (OR: 7.88; 95% CI: (5.15, 12.26)) and ICU-level care (OR: 6.93; 95% CI: (4.44, 10.92)) were associated with repeated testing. The estimated false-negative rate was 23.8% (95% CI: (19.5%, 28.5%)). CONCLUSIONS: Whilst most patients were tested once and received a negative result, a meaningful subset underwent multiple rounds of testing. These results shed light on testing patterns and have important implications for understanding the variation of repeated testing results within and between patients.

Guillain-Barré syndrome and COVID-19: association or coincidence.

COVID-19 is a novel disease best known to cause a cough, fever and respiratory failure. Recently, it has been recognised that COVID-19 may present in multi-systemic ways which can cause diagnostic uncertainty or error.We present a patient who attended hospital with features of Guillain-Barré syndrome (GBS) before developing clinical and radiological findings of COVID-19. While the authors recognise that neurological complications have been reported following COVID-19 infection, to their knowledge this report describes a unique presentation of GBS without preceding COVID-19 symptoms.Since these conditions may have considerable overlapping features including respiratory failure and (following prolonged critical care admission) profound weakness, it is possible that one diagnosis may be overlooked. Raising awareness of a possible association between these conditions is important so both are considered allowing appropriate investigations to be arranged to optimise the chance of neurological recovery and survival, while also protecting staff from potentially unrecognised COVID-19.

An Overview on the Common Laboratory Parameter Alterations and their Related Molecular Pathways in Screening for COVID-19 Patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an emerging global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 mainly affects the tissues expressing angiotensinconverting enzyme 2 (ACE2). ACE2 is used as a receptor for the virus to enter the cells. Once SARS-CoV-2 enters the cells, it leads to further events through signaling pathways. This pathophysiological condition can appear as changes in laboratory tests. METHOD: However, the lack of studies in this area is strongly felt. The present study was conducted to review the most common abnormalities in laboratory tests caused by COVID-19 and their related molecular pathways and outcomes. RESULTS: It showed that the levels of IL-6, CRP, PCT, AST/ALT, bilirubin, ALP, GGT, LDH, ferritin, D-dimer, and neutrophils increased. Conversely, the levels of albumin and lymphocytes decreased. Since most of these parameters were related to hepatic function, their alterations indicated liver injury. CONCLUSIONS: Overall, the parameters CRP, D-dimer, and CBC are more important in diagnosis. Moreover, it seems that MAPK and NF-κB are the most frequent signaling pathways in which alterations may contribute to the pathogenesis of the virus. Altogether, our review encourages researchers to study signaling pathways as potential molecular targets to achieve effective treatment.

Clinical Characteristics of Asymptomatic Patients with SARS-CoV-2 in Zhejiang: An Imperceptible Source of Infection.

Objective: Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, was first identified in December 2019 in Wuhan, China, and has since spread globally, resulting in an ongoing pandemic. However, the study of asymptomatic patients is still rare, and the understanding of its potential transmission risk is still insufficient. In this study, epidemiological investigations were conducted in the Zhejiang province to understand the epidemiology and clinical characteristics of asymptomatic patients with COVID-19. Methods: This retrospective study was carried out on 22 asymptomatic patients and 234 symptomatic patients with COVID-19 who were hospitalized in Zhejiang Duodi Hospital from January 21 to March 16, 2020. The characteristics of epidemiology, demography, clinical manifestations, and laboratory data of mild patients were compared and analyzed. Results: The median age was 28 years in asymptomatic patients and 48 years in symptomatic patients. The proportion who were female was 77.3% in asymptomatic patients and 36.3% in symptomatic patients (p < 0.001). The proportion of patients with coexisting diseases was 4.5% in asymptomatic patients and 38.0% in symptomatic patients (p=0.002). The proportion of patients with increased CRP was 13.6% in the asymptomatic group and 61.1% in the symptomatic group (p < 0.001). The proportion of patients received antiviral therapy was 45.5% in the asymptomatic group and 97.9% in the symptomatic group (p < 0.001). The proportion of patients received oxygen therapy was 22.7% in the asymptomatic group and 99.1% in symptomatic patients (p < 0.001). By March 16, 2020, all patients were discharged from the hospital, and no symptoms had appeared in the asymptomatic patients during hospitalization. The median course of infection to discharge was 21.5 days in asymptomatic patients and 22 days in symptomatic patients. Conclusions: Asymptomatic patients are also infectious; relying only on clinical symptoms, blood cell tests, and radiology examination will lead to misdiagnosis of most patients, leading to the spread of the virus. Investigation of medical history is the best strategy for screening asymptomatic patients, especially young people, women, and people without coexisting disease, who are more likely to be asymptomatic when infected. Although the prognosis is good, isolation is critical for asymptomatic patients, and it is important not to end isolation early before a nucleic acid test turns negative.