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People commonly transmit the disease while asymptomatic. For example, speaking or singing can aerosolize virus which is transmitted to others within an enclosed indoor space potentially triggering super-spreader events.
Lower humidity might serve to promote transmission, as aerosols can dehydrate and remain aloft for longer duration.
Universal masking in the community preferably with surgical masks serves to reduce dispersal and inhalation of aerosols.
Physical distancing and adequate ventilation are extremely important. In a hospital context, negative pressure ventilation or HEPA filters may reduce the aerosol virus burden.
Modulation of temperature and humidity might provide additional avenues to limit spread of the virus. Zhao et al.
The number of aerosol-generating procedures has gradually been increased to encompass nearly any procedure involving the airway or mouth. However, this is probably a failed paradigm.
A better approach is to assume that patients with COVID are continually generating aerosols and act accordingly. More on this here.
Shoes Shoe covers aren't recommended, as removing them may increase exposure ANZICS guidelines.
Shoes that are easily cleaned and don't need to be touched might be preferable e. Removing soiled PPE is the most critical and difficult aspect.
Applying and removing PPE should ideally be practiced before patients arrive e. This video describes how to use PPE you may skip the first 5 minutes.
The gown should be tucked into the gloves leaving no gap in-between. Using gloves with extended cuffs facilitates this similar to sterile surgical gloves.
Gloves with long cuffs may facilitate removal of the gown and gloves as a single unit see in the above video if this doesn't make sense.
When removing PPE, always start by first applying alcohol-based hand sanitizer to your gloves.
After fully removing PPE, sanitize hands and wrists with alcohol-based hand sanitizer again. Create a step-wise protocol for PPE removal.
Two examples are shown below, but this may very depending on your exact gear. Follow the steps slowly. Consider doffing with someone watching you to ensure good technique.
If this isn't possible, doffing in a mirror may be helpful. Most patients will present with constitutional symptoms and lower respiratory symptoms e.
Absence of a fever does not exclude COVID This can lead to some unusual presentations e. Physical examination is generally nonspecific.
Rare patients may have a longer incubation, however graphed out nicely by Lauer et al. Typical evolution of severe disease based on analysis of multiple studies by Arnold Forest.
However, this timing may be variable some patients are stable for several days after admission, but subsequently deteriorate rapidly.
For more see the hematology section below. This seems to track with disease severity and prognosis. In a patient with severe respiratory failure and a normal CRP, consider non-COVID etiologies such as heart failure.
Young et al. Among patients with known COVID, an elevated procalcitonin is a poor prognostic sign likely reflecting of systemic inflammation Lippi et al.
RSV may be helpful. However, the rate of viral co-infection is dynamic, depending on the prevalence of other viruses in the community. Blood cultures should be performed as per usual indications.
However, obtaining these specimens may pose substantial risk of transmission. It's dubious whether these tests are beneficial if done for the sole purpose of evaluating for coronavirus see the section below on bronchoscopy.
Poor technique will cause the PCR assay to under-perform. Sicker patients with higher viral burden may be more likely to have a positive assay.
Likewise, sampling early in the disease course may reveal a lower sensitivity than sampling later on.
For example, in patients with positive CT scan and negative RT-PCR, it's murky whether these patients truly have COVID is this a false-positive CT scan, or a false-negative RT-PCR?
Convalescent serologies may help resolve this problem although they may to have their own limitations as well.
Sensitivity varies depending on assumptions made about patients with conflicting data e. Conversion from negative to positive PCR seemed to take a period of days, with CT scan often showing evidence of disease well before PCR positivity Ai et al.
Bottom line? A single negative RT-PCR doesn't exclude COVID especially if obtained from a nasopharyngeal source or if taken relatively early in the disease course.
If the RT-PCR is negative but suspicion for COVID remains, then ongoing isolation and re-sampling several days later should be considered.
The number of involved lung segments increases with more severe disease. Over time, patchy ground glass opacities may coalesce into more dense consolidation.
Infiltrates may be subtle on chest X-ray. COVID doesn't appear to cause masses, cavitation, or lymphadenopathy.
This probably reflects varying levels of exposure intensity and illness severity cohorts with higher exposure intensity and disease severity will be more likely to have radiologic changes.
Sensitivity of CT scanning? Sensitivity among patients with positive RT-PCR is high. CT scan abnormalities might emerge before symptoms?
Shi et al. Emergence of CT abnormality before symptoms explains the existence of an asymptomatic carrier state discussed above. Chest X-ray Sensitivity of chest X-ray is lower than CT scan for subtle opacities.
A linear probe may be preferable for obtaining high-resolution images of the pleural line to make the distinction between a smooth, normal pleural line versus a thickened and irregular pleural line.
COVID typically creates patchy abnormalities on CT scan. These will be missed unless ultrasonography is performed overlying the abnormal lung tissue.
More on this from 5 minute sono here. C With more severe disease, small peripheral consolidations are seen on CT scan and ultrasound. D In the most severe form, the volume of consolidated lung increases.
Other features: Peripheral lung abnormalities can cause disruption and thickening of the pleural line. Areas of normal lung with an A-line pattern can be seen early in disease, or during recovery.
Tiny pleural effusions may be seen, but substantial pleural effusions are uncommon Peng For excellent examples of the correlation between CT scan and lung ultrasonography see Huang et al.
Sensitivity will depend on several factors most notably disease severity, presence of obesity, and thoroughness of scanning.
My guess is that a thorough ultrasound exam might have a sensitivity somewhere between CT scanning and chest X-ray e. Huang et al.
There isn't solid data yet, but it's probably reasonable to extrapolate from our experiences regarding other types of pneumonia.
Specificity is extremely low. A patchy B-line or consolidation pattern can be seen in any pneumonia or interstitial lung disease.
Thus, clinical correlation is necessary e. Note that supine, hospitalized patients may have B-lines and consolidation in a posterior and inferior distribution due to atelectasis.
Thus, the lung ultrasonography may have greatest sensitivity and specificity among ambulatory patients. Patchy ground-glass opacities may be caused by a broad range of disease processes e.
Ultimately, the imaging is only one bit of information which must be integrated into clinical context.
The temptation to get a CT scan in all of these patients should be resisted. In most cases, a CT scan will probably add little to chest X-ray and lung ultrasonography in terms of actionable data which affects patient management.
From a critical care perspective, CT scanning will likely add little to the management of these patients all of whom will have diffuse infiltrates.
Enormous risk of transmission to providers. Considerable resource allocation requires N95 respirators, physicians, respiratory therapists — all resources which will be in slim supply during an epidemic.
Benefits of bronchoscopy: Benefit of diagnosing COVID is dubious at this point given that treatment is primarily supportive. Bottom line on bronchoscopy?
Bronchoscopy might be considered in situations where it would otherwise be performed e. Bronchoscopy should usually not be done for the purpose of ruling COVID in or out Bouadma et al.
This approach is based on the availability of a PCR assay for COVID with a reasonably short turn-around time. This currently isn't a reality in most locations in the United States.
Hopefully it will be soon. Thus, a positive influenza PCR cannot exclude COVID. The rate of double-positivity may decrease over time, as the rate of influenza in the community decreases.
The largest challenge may be determining who needs to be ruled out for COVID i. Currently there is no simple answer for this — clinical judgement is required.
Ruling out too many patients will result in excessive consumption of masks in patients who don't have COVID. Additionally, placing patients under COVID precautions may impair their care e.
Ruling out too few patients may result in nosocomial transmission of COVID. Labs CBC with differential.
Electrolytes, coagulation studies. Blood cultures x2. Additional studies as clinically warranted EKG, POCUS, etc. CT chest Generally not needed solely for purpose of diagnosing COVID especially if there are characteristic abnormalities on CXR and POCUS.
For patients with a history of diarrhea and clinical evidence of hypovolemia, titrated fluid administration may be beneficial.
CPAP or BiPAP with high levels of end-expiratory pressure. This may be provided using a facial mask, or a helmet interface. When in doubt, err on the side of avoiding intubation.
For patients with hypoxemia, start dexamethasone 6 mg daily or an equivalent dose of another steroid, for example 40 mg prednisone or 32 mg IV methylprednisolone.
Treatment pathways are evolving rapidly — have a low threshold to consult with MICU to assess the patient and collaborate on plan i. The first sign of deterioration is often escalating oxygen requirement, rather than dyspnea.
Aggressively avoid all nephrotoxins especially NSAIDs and vancomycin. Note: Contrast dye probably isn't nephrotoic. If you need to get a scan with contrast, then just get it with contrast.
Avoid vancomycin if high index of suspicion for MRSA pneumonia consider linezolid or ceftaroline. Cardiac and lung ultrasonography may be performed as indicated for changes in clinical status.
Lung ultrasonography not ascultation is the preferred modality for evaluating pulmonary status. Avoid fluid boluses more on this here and here.
Avoid maintenance fluid infusions. Consider discontinuation of home antihypertensive agents especially ACE-inhibitors or ARBs.
The use of ACE inhibitors or ARBs among outpatients is controversial, but among ill inpatients these agents are potentially nephrotoxic and should be avoided.
The approach to respiratory support is discussed further below. Consult ICU early for deteriorating patients, as this can escalate rapidly.
Provide dexamethasone 6 mg daily for patients requiring oxygen or an equivalent dose of steroid — 40 mg prednisone daily or 32 mg IV methylprednisolone.
Avoid nebulized bronchodilators Only use bronchodilators if truly indicated. Instead of nebulizers, use a metered dose in haler puffs may be roughly equivalent to one nebulizer treatment.
Follow microbiologic studies. For patients with marked D-dimer elevation, consider higher doses of enoxaparin such as 0.
Melatonin 5 mg QHS for sleep. Zhang et al , Zhou et al. Confirm ETT depth at the upper teeth ensure no migration of the tube.
Tighten connections between ETT, connecting tubing, and ventilator to prevent accidental disconnection. Neurologic status. Thirdly, Allied bombing made it extremely difficult to transport food in bulk, since Allied bombers could not distinguish German military and civilian shipments.
As the south-eastern the Maas valley and the south-western part of the Netherlands Walcheren and Beveland became one of the main western battlefields, these conditions combined to make the transport of existing food stocks in large enough quantities nearly impossible.
The areas affected were home to 4. Butter disappeared after October , shortly after railway transport to the western parts of the Netherlands had stopped in September due to the railway strike.
The supply of vegetable fats dwindled to a minuscule seven-month supply of 1. Together with one kilogram of potatoes, this then formed the entire weekly ration.
The black market increasingly ran out of food as well, and with the gas and electricity and heat turned off, everyone was very cold and very hungry.
Tulip bulbs and sugar beets were commonly consumed. Furniture and houses were dismantled to provide fuel for heating. In the last months of , in anticipation of the coming famine, tens of thousands of children were brought from the cities to rural areas where many remained until the end of the war.
Deaths in the three big cities of the Western Netherlands The Hague, Rotterdam, and Amsterdam started in earnest in December , reaching a peak in March ,  but remained very high in April and May In early summer the famine was brought quickly under control.
From September until May the deaths of 18, Dutch people were attributed to malnutrition as the primary cause and in many more as a contributing factor.
Shortly before that, some relief had come from "Swedish bread", which was baked in the Netherlands from flour shipped in from Sweden.
The Germans agreed not to shoot at the planes flying the mercy missions, and the Allies agreed not to bomb German positions.
Operation Faust also trucked in food to Rhenen beginning on 2 May, utilizing vehicles. Rhenen was also occupied by the Germans. The Dutch famine of —45 was a rare case of a famine which took place in a modern, developed, and literate country, albeit one suffering under the privations of occupation and war.
The well-documented experience has helped scientists to measure the effects of famine on human health.
The Dutch Famine Birth Cohort Study  found that the children of pregnant women exposed to famine were more susceptible to diabetes , obesity , cardiovascular disease, microalbuminuria and other health problems.
Moreover, the children of the women who were pregnant during the famine were smaller, as expected. However, surprisingly, when these children grew up and had children those children were thought to also be smaller than average.
Despite this, a subsequent study by the same author failed to find a correlation between maternal exposure to famine and birth weight of the next generation.
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Szenen einer Kindheit" Hamburg verarbeitet. A decade ago, when the grandchildren of men and women exposed to the famine were here, they, too, were reported to have had higher rates of illness.
Archived from the original on 23 July Company Credits. Russischer Offizier Ulrike Knobloch Some 4. Furniture and houses were dismantled to provide ridremont patrick for heating.
Angeklagte Frau Alexander Häusser This section does read more cite any sources. Ende lag die vorgesehene Tagesration für erwachsene Normalverbraucher bei lediglich This web page.
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Handball-Bundestrainer Christian Prokop hat sich einen Spielertausch in seinem Kader vor dem Start in die Hauptrunde der Europameisterschaft offen gehalten.
Er könne das bis zum Donnerstagmorgen um 9 Uhr entscheiden, sagte Prokop in Wien. Spieler bei der deutschen Mannschaft weilt, ins Aufgebot rücken.
Der Zeitpunkt, überraschend. Vergessen der Treueschwur, öffentlichkeitswirksam ausgesprochen von …. Eines der wichtigsten Utensilien beim Handball ist das Tape.
Haben zwei oder mehrere Teams nach Abschluss der Gruppenphase gleich viele Punkte, entscheiden diese Kriterien in der Reihenfolge absteigend über das Weiterkommen:.
Bis zum 8. Januar muss Bundestrainer Christian Prokop diesen auf 16 Akteure reduzieren. Während der Europameisterschaft kann Prokop mehrfach Wechsel mit Spielern aus dem erweiterten Kader vornehmen.
In Deutschlands Kader stehen natürlich viele bekannte Spieler der vergangenen Turniere. Bei der Handball-EM gibt es nicht den einen Favoriten.
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Archived from the original on 30 September Retrieved 1 July Home Office. Archived from the original on 26 September Raphael Honigstein forecasts another frustrating year for Arsenal and Mesut Ozil.
But it's a blow for Tottenham and Wolves Bournemouth would consider appointing Jason Tindall as successor to Eddie Howe should the assistant manager want the vacant managerial role.
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