Frontiers in Emergency Medicine
Volume:4 Issue: 2, Spring 2020

COVID-19 is a highly contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an enveloped positive stranded RNA virus and the third member of the family Coronaviridae which has emerged as a zoonotic infection. The predecessor of this new pathogen caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Although corona viruses have been known since 1960’s, their familiar species were human pathogens and caused common cold and seasonal flu. SARS-CoV-2 is easily transmitted via respiratory secretions of an infected person, with a reproductive number (the average number of cases to which a single infected person will transmit the virus) of 1.4-2.5. Covid-19 has been estimated to have a case fatality rate of around 3%. As of today, asymptomatic transmission is assumed to be possible during the incubation period, which usually ranges from 2-14 days. The source of infection, animal host, and reservoir are currently unknown. In late December 2019, an outbreak of COVID-19 was reported from Wuhan city, China. The disease soon spread outside China borders and became rapidly prevalent all around the world. The pandemic announcement was officially made by World Health Organization (WHO) on 11 March 2020. Today COVID-19 has affected more than 212 countries and has made billions of people to be quarantined in their houses. Up to now, almost 1500000 confirmed cases of COVID-19 have been reported globally and the death toll has been declared to be 86000. In Iran, we are also facing this unprecedented global public health emergency, with about 65000 confirmed cases and 3993 deaths. This pandemic is beyond an expanding contagious disease and has influenced different features of life. Its enormous social, political, and specifically economic impacts all around the world are undeniable. In low- and middle-income countries this can potentially lead to a huge spike in poverty and collapse. Many vulnerable families have lost their income and access to the essential needs. Education systems have collapsed in many regions. The long-term effect of this global crisis has reduced economic growth even in developed countries. Economic effects of COVID-19 are estimated with dramatic variations. Orlik et al in Bloomberg hypothesized this cost to be $2.7 trillion. The political consequences are even harder to predict but quite significant and devastating, like the heated discussion, criticism and accusation flowing between the leaders of different countries. Since the pandemic is not yet over, the global influence will carry on to happen and make situation even more complicated. While the outbreak is evolving rapidly, health care systems across the world are actively fighting against the new virus. They have encountered many new challenges. Public health measures (such as active case finding, prompt isolation of cases and contacts tracing) to contain the spread of the disease in the society as well as provision of care for the unpredictably high number of people who are infected with the virus have stretched the healthcare system beyond its capacity. At the same time, protecting health care providers’ safety, which often requires provision of sufficient supplies of personal protective equipment, has definitely challenged the system. Societal demand for discovery of a definitive treatment and vaccine has also added to the complexity of the situation that the health care systems are facing. Studies about COVID-19 are increasingly being performed and published; many of them have not yet been fully reviewed and criticized by the academic community. Practitioners often find it difficult to find, appraise and apply the information they need amid the turbulence of their clinical practice. Furthermore, there are still many questions to be answered. The most efficient method for personal protection, methods of viral transmission, most accurate diagnostic approaches, and effective treatment options are yet to be determined. This special issue of the Advanced Journal of Emergency Medicine plans to specifically focus on COVID-19 by gathering the relevant scientific information available. We hope that by publishing high quality papers, this journal can provide its readers with further required information. Appropriate management of patients suffering COVID-19 as well as controlling this pandemic are our ultimate aspirations. We encourage further researches in this field by all scientists and physicians all across the world to be able to eradicate COVID-19 as soon as possible.

Emergency medical services (EMS) play a vital role in the management of public health emergencies such as epidemics of infectious diseases. Unique challenges, however, are expected under these circumstances beyond what occurs during normal conditions. EMS personnel often have limited information about their patients, work under uncontrolled conditions, and accompany their patients in enclosed spaces of the ambulance. They are at particular risk of contracting the infectious agent unless standard and transmission-based precautions are implemented. Appropriate use of personal protective equipment (PPE) by responding personnel is, therefore, of paramount importance. Since the report of the first cases of COVID-19 in late December 2019, the disease has spread beyond China. As of March 29th, a total of 634,835 confirmed cases have been reported globally and 29,975 people have died. The Center for Diseases Control (CDC) and other authorities and advisory agencies have prepared guidelines regarding safety precautions for EMS personnel, including appropriate selection and use of PPE .

Overcrowding during pandemics, such as COVID-19 necessitates the separation of respiratory patients in different locations with special protective measures. Thus, we allocated space to such a purpose and named it "respiratory emergency” in our emergency department and started to triage the patients coming in with respiratory tract signs and symptoms apart from others. However, the most critical point for the triage of respiratory patients is differentiation between COVID-19 and non COVID-19 suspicious patients as well as decision-making in terms of self- quarantine and outpatient treatment or admission. Considering the lack of test kits and more importantly, the uncertainty revolving around the performance and efficacy of tests, we used computed tomography (CT) scan as a triage tool, yet our machines cannot scan all these patients because we had up to more than eight hundred patients per day. Meanwhile three of us - emergency attending physicians - were under the impression that lung ultrasound may help. Therefore, we started to use lung ultrasound in a limited fashion. Fortunately, typical cases had peripheral and sub-pleural lesions that could be seen by ultrasound. Parallel to these efforts, limited reports were published about the use of ultrasound for COVID-19 in other regions. Evidently, a screen test is expected to have high sensitivity rather than specificity and the ultrasound provides this opportunity. Also we know the findings are not specific and for example we had observed these patterns in other viral epidemics, such as severe acute respiratory syndrome (SARS) or middle East Respiratory Syndrome (MERS). To date, several triage systems have been developed. The Italian version used by Dr. Volpicelli first and developed further by others, like that of Liam Devonport can exemplify this case. Furthermore, a simple triage system has been developed by Dr. Mike Stone, based on the ultrasound of lungs plus oxygen need. This flowchart summarizes Dr. Stone’s idea with three elements for decision-making consisting of: a) O2 requirement, b) B lines and c) consolidation. Three categories are enrolled. All patients with cough, fever and dyspnea or patients coming in from high-risk areas or those having close contact with covid-19 patients are enrolled. After bedsides sampling for polymerase chain reaction (PCR) test, the O2 saturation is measured and lung ultrasound is also done and then according to the data obtained, four categories are created as follows: • Inpatients for whom supplementary O2 is not required. If lung ultrasound shows A profile, patients can be discharged to home quarantine. If lung shows profile B, patients should undergo quarantine plus follow-up. This quarantine can be at home or institutes considering the facilities available. • Patients, depending on supplementary oxygen, should be admitted according to the findings of lung ultrasound. If they have only B lines, they are admitted in the ward but if they have profile B plus consolidation, we should consider intensive care unit (ICU) beds for them. In essence, all these systems use lung ultrasound for decision-making, which is efficient in a majority of occasions, yet we have critically ill patients with dyspnea and decreased O2 saturation without proportionate changes in lungs even according to CT scanning. Thus, we could not justify their health status based on the findings of the imaging of respiratory system. To discover the cause of dyspnea in these patients, we included heart ultrasound in addition to lung ultrasound and witnessed a decline in ejection fraction and global hypokinesia, which can justify their unsatisfying health status. In the meantime, several case series about myocarditis in covid-19 reveal the prevalence of myocarditis between 7% and 20% among patients. Increased troponin and change of the electrocardiogram (ECG) in these patients confirm myocarditis and help us to calibrate our care for the heart complaints sooner and more effectively. This approach might provide better prognosis for these patients. Recommendation We suggest adding heart ultrasound to lung ultrasound in triaging the patients suspicious of COVID-19 or at least in the first doctor visit even if CT scan is available because myocarditis with pneumonia exists in some patients at the same time. Furthermore, we found that E-Point to Septal Separation (EPSS), as a reliable indicator of global hypokinesea in heart, can be used effectively instead of evaluating through eyeballing because eyeballing needs a high level of expertise and may be more operator-dependent and obtaining a four-chamber view in supine critically ill patients is difficult when the operator lacks expertise.

During COVID-19 pandemic, it seems that healthcare workers (HWs) are more prone to the infection than general population. Indeed, a high viral load atmosphere and infected medical equipment are sources for spreading the disease. Many HWs should care for patients in the intensive care units (ICUs) which are one of the most contaminated areas. However, despite the adequate protections, HWs are still exposed to the coronavirus. Moreover, some procedures such as tracheal intubation increase the risk of infection. Overall, the probability of contamination in HWs is three times more than that of other people. According to Keshavan et al., about 3300 Chinese HWs have been infected by COVID-19, with a mortality rate of 0.4%. In Iran, we have a large number of affected HWs, with 69 registered deaths until late March 2020. Most of them were young with no previous medical history. So we have to improve protection and plan additional arrangements against COVID-19.There are several mechanisms for the antiviral activity of hydroxychloroquine. This drug is a weak base that concentrates on the intracellular sections including endosome and lysosome; so, viral replication in the phase of fusion and uncoating will be stopped.  Also,hydroxychloroquine can change the ACE2 glycosylation and inhibits both S-protein binding and phagocytosis. The last mechanism would be the suppressing effect on cytokine production and the immunomodulatory effect of the drug. Based on in-vitro studies of chloroquine on SARS-CoV-1, its effective role as a prophylactic agent and a post-infection treatment has been raised. According to another cell-culture study, the preventive effect of the drug is estimated to be 24 hours before and 5 hours after the contamination. The weekly dose of 500 mg chloroquine, which is used for malaria prophylaxis, will result in a concentration below the EC50, which is not enough for inhibition of the novel coronavirus. But the minimum dosage, which is used for rheumatoid arthritis treatment (250mg daily) will result in plasma concentrations higher than EC50, which may be sufficient in this regard. Regarding this pharmacokinetics and in-vitro investigations a double-blind, randomized, placebo-controlled trial using chloroquine as a prophylactic agent for SARS-CoV-2 infection is ongoing. The recommended dose is a loading dose of 10 mg/kg from base drug followed by 150 mg daily (250 mg chloroquine phosphate salt). Subsequently, the number of infected patients will be assessed after 3 months. Another running clinical trial is a phase III triple blinded one employing hydroxychloroquine with 200mg daily dose for 60 days and the outcome as well as the rate of symptomatic infected patients will be evaluated. There is also another ongoing study on hydroxychloroquine as a COVID-19 post-exposure prophylactic agent prescribed within 3 days of either a HWs or household contact. The recommended dose is 800mg once, followed by 600 mg during 6 to 8 hours, then 600mg once a day for 4 consecutive days. Finally, the rate and severity of COVID-19 infections are compared. The study could probably show that 200-400mg of hydroxychloroquine per day is a reasonable prophylactic regimen for the exposed HWs.To be more precise, our experience on the rheumatologic patients who tool 200 mg per day hydroxychloroquine, as well as the medical workers who received the same dose for prophylaxis against the novel coronavirus showed that hydroxychloroquine with a 200 mg/day dose can have a relative prophylactic effect on COVID-19. According to our data, the few cases who received 200mg of hydroxychloroquine per day, showed mild to moderate symptoms with no severe manifestations. However, the prophylactic dose of 400mg per day may be accompanied by some drug interactions and adverse effects in the long term; so 200mg of hydroxychloroquine is a rational prophylactic dose for practitioners who are exposed to the high viral load environment.

The novel coronavirus (COVID-19) emerged for the first time in China and then rapidly spread and swept the entire world like a tornado killing thousands of patients around the planet. People were advised to stay in-doors to prevent the spread of this deadly disease, and this slogan helped to a greater extent in containing the spread of the virus. Unfortunately, there is no treatment for the disease at present, but extensive research is going on to find a definitive treatment. Regarding endotracheal intubation (ETI) of COVID-19 patients, data are scarce and no randomized clinical trials are available to develop and formulate succinct and acceptable guidelines in tackling the problem of ETI in these highly risky and vulnerable patients.

Health care workers (HCWs) are heavily involved in the fight against COVID-19 in all over the world. They have the vital role of treating patients and searching for the proper treatment for the disease, while supporting and protecting their families. It is imperative that the systems should try hard to keep them safe and healthy. World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have recently published guidelines for keeping HCWs safe and protected. The Personal Protective Equipment (PPE) is the cornerstone of recommendations and contains face mask (air purifying respirator), goggles or face shield, gown, and gloves. There is no doubt that a proper mask (e.g. N95) is the most important element of the protective gear when it comes to transmission of COVID-19.

Recently the pandemic of Covid-19 challenges countries’ medical health services systems. While some patients experience acute and devastating symptoms, others may only have mild myalgia and fever. Due to the high amounts of hospital referrals, some countries’ health systems have asked patients to stay at home and go to the hospital when they feel that the symptoms are severe. Some symptoms, such as fever, myalgia, diarrhea, and headache, have been offered as Covid-19 symptoms. However, is there any clinical test that helps patients themselves to detect the severity of symptoms? A six-minute walk test is a clinical test to investigate the function of the cardiorespiratory system. In this test, a physician asks a patient to walk for 6 minutes in a 30-meter walking course. Some studies have shown its relation with short term survival, especially in patients who complete less than 300 meters. Based on the walked distance, results can be used in the two following formats. First, the Vo2 max could be estimated via an equation; second, the distance can be compared at different times. Considering that Covid-19 affects the respiratory tract, it seems that it could affect 6-min walk test results. Due to the particular situation, the health system can ask people who have mild symptoms to check their 6-min walk test results for several consecutive days besides the other symptoms. If patients’ walking distance decreased due to breath shortness at this time, they should go to the hospital. Even if their walking distance is less than 300 meters, maybe they need a chest CT scan. With the application of this approach, we can decrease the load of referrals to the hospitals and also prevent patients with mild symptoms from being contacted to the high load of virus in the hospitals.

Until now, April 22, 2020, Covid-19 has been confirmed in 2471136 patients and 203 countries and territories with mortality rate over 169000 patients. Right now, there is no definite cure for it and developing treatments including vaccines and antiviral compounds are under evaluations for efficacy. Covid-19 infection can be mild, severe, or even critical. The symptoms may range from fever (the most common symptom), chills, fatigue and cough to decreased arterial oxygen saturation, changes in respiratory rate and dyspnea. The dyspnea in critically patients is more severe. In severe cases, respiratory failure, acute respiratory distress syndrome (ARDS) and septic shock have been reported. Septic shock is also associated with hypoxia and acidosis. ARDS is the most important cause of death in this group of patients. This feature of the disease may be caused by various factors, including inflammatory mediators and cytokine storm. The computed tomography (CT) imaging findings have shown that the lung with ARDS has a ground-glass appearance, in which white fluid-filled patches are seen inside the lung. The fluid inside these patches has a jelly state. Pathological samples obtained from lung tissue also indicate pulmonary damage, obvious destruction of pneumocytes and formation of a hyaluronan membrane, which more emphasized on ARDS occurrence. Cytokine storm caused by Covid-19 infection is a severe immune response. The occurrence of cytokine storm can lead to severe tissue damages. Pre-inflammatory factors are involved in this process and one of them is interleukin 6 (IL-6) which affects different cells. IL-6 performs various functions such as regulating body temperature, increasing the production of acute phase protein and differentiation of B cells. On the other hand, the production of interleukin 1 (IL-1) as an inflammatory mediator will be increased during cytokine storm, as well. IL-1 can cause fever and stimulating the production of hyaluronan which has been seen in fibrosis. Based on studies on SARS-CoV, rapid spread and proliferation of the virus as a result of delayed interferon-1 production and subsequent rapid accumulation of macrophages and monocytes may also be involved in tissue destructions and a similar mechanism might be seen in Covid-19 infection. When there is no proper immune system response, the virus causes extensive tissue damages, especially to organs where ACE2 is most commonly seen, such as the lungs. Therefore, since the lungs are damaged, efforts should be focused on suppressing the inflammation, managing the symptoms and theoretically any compounds that may help this inflammation subside could play an important role in reducing the incidence of ARDS and consequently the mortality rate. The use of corticosteroids in different phases of ARDS has been inconsistent with conflicting results. Corticosteroids exert their anti-inflammatory effects by regulating the signaling pathways on the membrane and inside the cells, stopping pre-inflammatory gene-related processes (genes responsible for producing pre-inflammatory factors). Furthermore, they are able to increase the production of anti-inflammatory mediators such as interleukin 10 (IL-10). Corticosteroids have been investigated in some clinical protocols for evaluation of their effectiveness in reducing inflammatory responses and cytokine storm. According to the guideline of World Health Organization (WHO), systemic corticosteroids should not be routinely used in viral pneumonia except in clinical trials. However, WHO has recommended that these compounds can be used in exacerbations of asthma and COPD, and septic shock, considering each patient's condition and assessing the benefits and risks. This guideline further states that the use of corticosteroids in similar conditions such as influenza may lead to secondary super infections and increase mortality rate. But in another study on SARS-CoV, the use of corticosteroids was associated with improvement in time to survival in severe patients and decrease in mortality rate. Delayed viral clearance is another concern. In a study on patients with MERS-CoV, the use of corticosteroids did not make a significant difference in mortality rate. However, its association with a delay in viral clearance from the lungs of patients was reported. Side effects are another limiting factors for use of corticosteroids in patients with Covid-19. A similar study in patients with SARS-CoV showed that use of higher doses of corticosteroids in such conditions could cause a corticosteroid-induced diabetes, with 36.3% of patients experiencing such complication. The guideline of Surviving Sepsis Campaign for the management of patients with Covid-19 has recommended the use of corticosteroids under the following conditions: 1) in patients with Covid-19 who are suffering from septic shock, the use of corticosteroids (low-dose) are preferred over not using it. The guideline notes that there is no difference in mortality rate and side effects. However, there is weak recommendation that using corticosteroids in these conditions can reduce the time of resolution of shock and ICU and hospital length of staying; 2) In cytokine storm, if the patient has not yet developed ARDS, corticosteroids are recommended in ways other than routine procedures, and if ARDS occurred, the use of these compounds is recommended over not using them. Lesser need of oxygen, improved radiographic findings and reduced length of staying in ICU and hospital are some of the advantages that this guideline has referred to. However, there is just a week recommendation over the use of these compounds in this guideline. Based on what has been discussed, it could be concluded that the use of corticosteroids in the current situation should be limited, since there are no significant benefits over their effectiveness. On the other hand, there is a risk in prolongation of viral clearance and secondary infections and mortality rate. The use of these compounds should be limited to clinical trials to further evaluate their effectiveness in this new found disease. The clinical conditions of patients should be carefully evaluated throughout the studies and close monitoring should be performed while discontinuing these drugs.

The COVID-19 pandemic in a matter of few months has wreaked havoc across the globe. However as per the WHO, the worst may not be over yet and COVID-19 is going to stay with us for a long time. The coronavirus is highly contagious, and in the current scenario containment measures in the form of lockdowns and curfew may only be useful in transiently flattening the curve and not disease elimination. The absence of an effective vaccine and/or treatment, means that morbidity and mortality associated with COVID-19 is going to increase in the foreseeable future. For the emergency physicians (EPs) working on the frontlines, the battle may have just begun. Any patient coming to emergency room (ER), with COVID-19 related symptoms or otherwise, could be a potential source for the spread of coronavirus infection in the hospital. With most of the ER’s being overcrowded, the place itself will act as amplifier which could lead to a catastrophe. Ever since the beginning of this pandemic, our focus has completely shifted to only COVID-19 related symptoms which is proving detrimental for the other non-COVID emergencies. We hereby put forth certain possible solutions which may be useful for the smooth functioning of our emergency departments (EDs).

In December 2019, a novel coronavirus (2019-nCoV) was detected in Wuhan Hubei province, China. The virus has caused a global concern because of its high potential for transmission, high morbidity and mortality. COVID-19 spreads so rapidly across an increasing number of countries worldwide that it has been found in more than 200 countries so far. The World Health Organization (WHO) has declared COVID-19 a pandemic and public health threat. In general, COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A case fatality rate of approximately 2.3% has been reported for COVID-19. New fever, cough, lymphopenia and bilateral lung infiltrations are characteristic but not diagnostic for COVID-19. Sore throat, dyspnea, myalgia, diarrhea, and abdominal pain are other presentations of COVID-19. We should also be attentive to the probability of atypical presentations in patients who are immunocompromised. While the majority of cases result in mild respiratory tract symptoms like acute bronchitis, severe cases might end in severe pneumonia, acute respiratory distress syndrome (ARDS), septic shock and death due to multiorgan damage, so early recognition of patients with suspected COVID-19 infection is crucial. The burden of the virus is not limited to physical damage, but it also has a significant impact on the mental health of the public. It can lead to generalized anxiety disorders and depression during COVID-19 pandemic. Now many countries are in a state of crisis worldwide. Whenever the living environment changes, people feel unsafe. People's fear of COVID-19 makes them refrain from going to medical centers, which significantly impacts their access to medical care while they require acute treatment. COVID-19 outbreak in countries has pulled essential medical resources away from regular procedures. This has caused complications for patients who need treatment for other medical conditions that require timely and appropriate care. Cancer patients especially still require attention in curative or palliative settings, and women will still be delivering their infants. How can we care for these patients without exposing them to COVID-19?

Although crises such as pandemic can inflict cascading disasters on a health care system, they can provide opportunities for the emergence of new types of potential and their optimal use and manifesting the best kinds of altruism and philanthropy. The COVID-19 crisis will undoubtedly entail great costs that are both economically and emotionally irretrievable; nevertheless, the present study seeks to highlight the new opportunities that are provided during this disaster and the optimal utilization of all capacities to alleviate this seemingly-terrible condition. This paper presents a brief report of the first weeks of the COVID-19 crisis in Imam Khomeini Hospital Complex (IKHC) affiliated to Tehran University of Medical Sciences as the largest hospital in Iran with approximately 1200 active beds. In addition to lots of problems during the battle for maintaining the treatment quality in this crisis, a strategy was devised to mitigate the challenges. The positive perspectives during the fight with the predicament of COVID-19 in this hospital are detailed in the following nine domains.

A highly contagious coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which was first identified in Wuhan, China in December 2019. The virus primarily affects the respiratory system of human beings and results in the symptoms of headache, fever, dry cough, sore throat, shortness of breath and fatigue with abnormal chest computed tomography (CT) scan. In some cases, nasal sputum discharge and diarrhea have been also reported. Up to the 26th of April 2020, more than three million laboratory confirmed cases of COVID-19 have been recorded worldwide with more than 220,000 confirmed deaths. In the Kurdistan region of Iraq, the first case of laboratory confirmed COVID-19 was recorded in March 1st, 2020 in Sulaymaniyah province.

As COVID-19 spreads all around the world, it indicates various side effects and complications. Currently, we know that, this disease can affect other organs like brain. The growing number of neurological complications from this disease suggests that, the coronavirus is a neurotropic virus, and this neurotropicity has been attributed to the expression and presence of receptors of angiotensin-converting enzyme 2 (ACE2) in central nervous system (CNS). Unlike ACE itself, ACE2 converts angiotensin 2 to 1, and is present in lung alveolar epithelial cells. In this regard, the coronavirus is likely to use ACE2 as a receptor to enter and infect human cells. The virus causes disease in some other areas such as pancreas and colon with the same mechanism as that of ACE2 receptor. Moreover, the high presence of the corresponding receptor in the CNS has increased the likelihood of neurological involvement in this virus. The binding of the virus to this receptor (Figure 1), which is present in different areas of the brain such as the glial cells, neurons and astrocytes spreads the virus to the CNS and this induces a variety of neurological symptoms. One of the most important areas of the brain that causes high expressions of ACE and ACE2, angiotensinogen, and angiotensin II secretion in the CNS, is perivascular astrocytes. Neuromyelitis optica spectrum disorder (NMOSD) is an astrocytopathy in which a high rate of astrocyte destruction occurs. Some studies have also shown that, these perivascular astrocytes are largely eliminated in multiple sclerosis (MS), especially at chronic stages. This destruction could justify the studies, which have demonstrated the low levels of ACE2 in the cerebrospinal fluid of these patients. Matsushita et al. revealed that, angiotensin II, ACE, and ACE2 levels were lower in the cerebrospinal fluid of the patients with seropositive NMOSD compared to healthy individuals. Accordingly, the same was true for ACE2 levels in MS patients. Another study confirmed the low level of ACE2 concentration in the cerebrospinal fluid of the patients with MS. The destruction of astrocytes and low level of ACE2 concentration could theoretically predict the ACE2 receptor deficiency which might reduce the chance of entering the virus into the CNS, and consequently, decrease the neurological complications. This may suggest that, neurological complications are less likely to occur in the patients with NMOSD and MS in case of developing COVID-19. However, as with all diseases, it is not possible to simply predict the lower degree of neurological complications in these patients on the basis of one factor such as a lower expression of ACE2 in these patients. Thereafter, further investigations are required to shed light on how MS and NMOSD patients develop infectious diseases related to the CNS.

COVID-19 is a zoonotic viral infection that first emerged in Wuhan, China, the source of which is thought to be a seafood market, and then spread rapidly from China to the world. 

The aim of this observational study was to analyze cases with COVID-19 admitted to a single secondary care center in Turkey. 

This is a descriptive study performed during the period from March 22 to 30, 2020, in Kars Harakani State Hospital, Kars, Turkey. We evaluated all patients with reverse transcription polymerase chain reaction (RT-PCR) to confirm COVID-19. Demographic characteristics, clinical signs and symptoms, comorbidities, blood tests results, chest computed tomography (CT) scan findings and outcomes including hospitalization, intensive care unit (ICU) admission and survival of the patients were recorded. 

During the one week study period, we took 435 nasopharyngeal swabs from suspicious cases and found 22 patients (4 females, 18 males) whose COVID-19 infection was confirmed via RT-PCR. Their ages ranged from 18 to 86 years, with an average of 45.59±25.02. Ten (45%) of the cases were current smokers. The body temperature of the cases ranged from 36.1 to 38.4 oC, with an average of 36.78 ± 0.65. Four cases were asymptomatic and the most common complaint was cough (82%). Hypertension (23%) and chronic obstructive pulmonary disease (COPD) (23%) were the most common coexisting diseases. In chest CT scan, ground glass densities were detected in 7 (32%) patients and infiltration was observed in 8 (36.3%). The mortality rate of the cases was 9% (n=2). 

The most common complaint of patients was cough. Hypertension and COPD were the most prevalent comorbidities among patients.

Since the outbreak of Coronavirus on December 31, 2019 in Wuhan, Hubei Province, People’s Republic of China, the number of cases from China that have been imported into more than 180 countries and regions around the world. 

The goal of this study is to flatten the curve of new infection, through nosocomial transmission by health care system along with early identification of asymptomatic COVID-19 cases. 

A Survey was conducted over a period of 35 days. A total of 1709 individuals were screened (647 patients and 1062 patient attendees) coming to emergency Department. The waiting area of Emergency Care was divided into 3 screening zones and a separate second triage is established. The individuals entering are ensured that they are screened at all the 3 zones. Individuals were divided into two Groups after screening: Group A (suspected COVID-19) and Group B (unsuspected COVID-19). In Acute emergencies, the patient was directly treated at second triage. 

A total of 1709 individuals, 247 in Group A (Suspected COVID-19) and 1462 in Group B (Unsuspected COVID-19). Among 247 individuals, 141 were males and 106 were females. Age ranged from 14-72 years with a mean age of 46.7years. Among 247 individuals (Group A), 81 were patients, of which one case was found to be COVID-19 Positive. Two Health care workers (HCW’s) found to be positive. 

Challenges from the widespread pandemic underscores the importance of early implementation of a second triage and vigorous screening for all the individuals to minimize the spread of infection, failing which pandemic infection may turn into an epidemic.

Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard. 

This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment. 

This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients. 

In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge. 

Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients.

COVID-19 is an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a strain of coronavirus. The first cases were reported in Wuhan, China, in December 2019, later was officially recognized as a pandemic on March 11th, 2020. 

Here we report five trauma cases admitted to our hospital, not for COVID-19 related symptoms, but chest computed tomography (CT) scan findings were suspicious of COVID-19 infection. Real-time reverse-transcription polymerase chain reaction (RT-PCR) assays for COVID-19 were reported as positive in these cases. 

COVID-19 usually manifests with mild respiratory and constitutional symptoms, even some cases are asymptomatic.

Coronavirus disease 2019 (Covid-19) is caused by the novel coronavirus resulting in a highly contagious respiratory tract infection with an increased risk of acute respiratory distress syndrome (ARDS), which was first seen in Wuhan, China. Thus far, this virus has spread to many countries worldwide, including Iran. Multiple studies have assessed disease characteristics, viral genetics, and complications of Covid-19 in the Chinese population. However, there is limited data regarding patient characteristics and outcomes of infected cases outside of China. Besides, risk factors of adverse outcomes are poorly identified in different populations. Due to limited data in the Iranian population affected by the virus, we aimed to design a registry of patients with Covid-19 at Sina Hospital in Tehran, Iran [Sina Hospital Covid-19 Registry (SHCo-19R)] in this regard, to assess patient characteristics, imaging features, laboratory findings, management strategies, and adverse outcomes of Iranian patients with Covid-19 and their differences with other populations.

It is likely that high rate of healthcare workers (HCWs) infection has occurred in Iran, but there is not any proof yet. 

This study was conducted to highlight the rate of Iranian HCWs infected by COVID-19 and some of its surrounding points. 

This cross-sectional study was conducted in Tehran, Iran. Using web-based applications including WhatsApp, Telegram, Instagram and Facebook, the link to the questionnaire was sent and exposed to the eligible ones. The target population of the study was HCWs who were diagnosed as approved cases of COVID-19. They were asked about their baseline characteristics and also possible source of infection, symptoms onset, hospitalization and etc. All findings presented by frequency and percent. 

From March 29, 2020 to April 5, 2020, a total of 452 HCWs had completed the online questionnaire of whom 50.9% were women; mostly were in the age range of 25-29 years old. Among the participants, physicians had the largest population with 312 people (69.0%). The most frequent clinical symptoms were fatigue, fever and myalgia, respectively. The highest frequency with 85 cases (18.8%) was reported their symptoms onset within 20-24th February, 2020. The most commonly used piece of equipment was gloves, which was used in 57.3% of the cases, followed by simple surgical mask, which was used by 47.1% of the participants. In 21.9% cases no personal protective equipment was used. Totally, 348 cases (91.6%) were treated in an outpatient setting and only 36 cases (9.5%) needed to be hospitalized. In 160 cases (35.4%), at least one other person was infected with COVID-19 in their household. 

Considerable number of participants that declared their infection in this study, emphasizes on the considerable rate of Iranian HCWs infected by COVID-19.

There is little data on direct medical costs and how to overcome the shock introduced by the novel Coronavirus (COVID-19) which emerged in Wuhan, China. The aim of this report is to present the methodology of an observational study for analyzing the resource utilization and direct medical costs of hospitalization. A multicenter retrospective observational study will be conducted on hospitalized patients with COVID-19 in selected hospitals of Tehran University Medical Sciences from February 2020 to June 2020. Cost calculations will be based on micro-costing approaches according to the health insurance perspective. Demographic, clinical, and cost data for the aforementioned patients will be collected through reviews of medical and financial records using a self-made questionnaire categorized in three parts (Form No. 1). The first part consists of demographic characteristics, the second part includes clinical information (e.g., symptoms, comorbidities, and complications), and the third part consists of resource utilization and cost data. Descriptive statistics (means, frequencies, percentages, and 95% confidence intervals) will be used to report data. With this report we sought to provide a valuable framework for estimating the direct medical costs of COVID-19 for hospitalized-patients basis on the severity of presentation. This will be the core for an assessment of the economic burden of COVID-19 in different presentations of the disease.

There is not enough and comprehensive evidence on signs and symptoms of COVID-19; therefore, it seems too early to provide an appropriate clinical decision-making rule for this newly emerged pandemic viral disease. 

We tried to categorize patients’ signs and symptoms from very highly suspected to non-suspected, regarding having COVID-19. 

Most recently published English-language articles on COVID-19, were reviewed by the researchers. We considered each complaint, separately, and gathered available data, such as percentage of involved patients and their crude number. Then we considered the pooled and collected results as the final percentage of the occurrence of every specific symptom. We categorized patients’ complaints into six types, based on the data obtained. All extracted complaints were categorized and scored. 

Twenty-seven articles were reviewed, of which, 12 considered for analysis. The selected papers had reported various numbers of patients, ranging from 16 to 1,099 patients (mean=229 patients per study). In total, nineteen different complaints, with an average of nine complaints per article, had been reported (IQR= 8-11). In terms of overall prevalence, based on the total number of patients, fever and dry cough were reported in more than half of the referred patients. The complaints were categorized in six types with and scored. 

The patients with score ≥17 are very highly suspected to COVID-19; However, patients with score <5 could be considered as non-suspected to COVID-19.

 Due to their availability and rapid turnaround time, the supplemental role of chest computed tomography (CT) scan and real-time polymerase chain reaction (RT-PCR) is growing for early diagnosis of patients with COVID-19. However, due to the low efficiency of viral nucleic acid detection as well as low specificity of chest CT scan for detecting COVID-19 pneumonia, both methods show incomplete clinical performance for proper COVID-19 disease diagnosis. The purpose of this review was to compare the clinical performance of two methods and to evaluate the diagnostic values of chest CT scan and RT-PCR for suspected COVID-19 patients.

We systemically searched PubMed, Cochrane, from December 2019 to the end of April 2020. Clinical research papers in goal fields that reviewed COVID-19 patients, whom chest CT scan, and PCR testing were performed together were included. 

In total, we found 536 studies; and finally168 studies were shortlisted. Following title and abstract screening, we reached 83 studies based on the inclusion and exclusion criteria. Conducted screen by the full text covered 28 studies, which led to data extraction. By the full-text assessment of 28 included studies, we found 4486 assessed patients. Totally, 3164 patients had positive chest CT scans, and 3014 patients had positive PCR results. The finding showed that recent studies on the diagnostic performance of RT-PCR and chest CT scan have commonly been reported from China. 

The results from this review indicate that the chest CT scan should be used for symptomatic and hospitalized patients. Moreover, chest CT scan should not be used as a primary screening tool for diagnosing COVID-19. Application of RT-PCR as the first line diagnosis is still recommended.

The ongoing global pandemic of the Coronavirus disease 2019 (COVID-19) is a public health emergency. It has not only affected the general population, but has also caused psychological distress in the frontline health care workers (HCWs). It is crucial to understand the psychological impact of the COVID-19 on the frontline HCWs. The overall well-being and resilience of HCWs are key determinants to maintain an optimal healthcare response for appropriate patient management as well as to achieve good patient outcomes. This article summarizes the various risk factors as well as strategies that can be adopted to reduce the impact of stress on these frontline HCWs. This will help guide institutional as well as national policies and interventions to maintain their psychological well-being.

 There is a significant burden on all emergency services in the management and prevention of the novel COVID-19 transmission. The effects are felt right across the World with certain geographical areas being most affected, it has affected all countries irrespective of their healthcare infrastructure. It has been suggested that certain parts of World that are prone to natural disasters are better prepared for pandemics. However, this is completely unfound as major economies are overwhelmed with the effects of the COVID-19 and it becomes completely irrelevant of any past experiences as these have been in never seen before scale.

The national fight against COVID-19 has been dubbed as the greatest fight for the National Health Service (NHS) with the entire United Kingdom under lockdown and the unfamiliar situation not seen before in peacetime. The general understanding of the disease process is that it has profound effects on the elderly and those with significant underlying health conditions such as cardiovascular, respiratory amongst others. However, it has surfaced from time to time that the very young are being affected and at times unfortunately been fatal. Results/Measures: The United Kingdom has been in a lockdown just like several nations across the globe in a desperate measure to limit the spread of the virus. There have been weeks of planning at every level for all possible eventualities with regards to the ongoing COVID-19 pandemic. All routine operations and procedures have been cancelled only procedures that emergency life and limb saving and cancer surgery continue to take place in hospitals all across the hospitals in the NHS. Widespread measures such as social distancing, calling a dedicated helpline for information and advice rather than attending the nearest Emergency Department have led to a significant number of presentations to the Emergency Department.

The main concerns that remains for the NHS and other countries that have been affected is that once the lockdown restrictions are slowly eased will lead to a significant resurgence of cases that will overwhelm their respective healthcare infrastructures. From a clinician perspective, the main concern is the potential late presentations of the acutely unwell patients. This is the sentiment that is likely to be felt by many of my critical care colleagues working across NHS hospitals.

At present, the biggest challenge to health and economic systems around the world is the emergence of COVID-19 pandemic. Several ethical questions have been raised at the macro-, meso- and micro-levels with respect to proper management and control of this pandemic. The most important factor in creating fear and public anxiety and disturbances of social functions is the fatalities caused by the epidemic by an unknown pathogen in most countries. Decisions for epidemic control measures are made among many uncertainties, and prioritize public health over individual rights. People's trust and compliance with recommendations play a decisive role in public actions. Therefore, during an epidemic, necessities such as adherence to the values of honesty, respect, human dignity, solidarity, justice, reciprocity, transparency, and responsiveness in the response system need to be considered. The major ethical considerations in macro and micro levels of decision-making responding to the COVID-19 will be reviewed in this paper. Ethical dilemmas arise in different domains of a pandemic such as restriction on freedom of movement, individual’s refusal of preventive or therapeutic interventions, health care workers’ rights and duty to care, the allocation of scarce resources, off-label use of diagnostic and therapeutic measures and research. The purpose of this article is to pay attention to ethical principles in solving these challenges and does not necessarily respond to all ethical problems; however, it draws the reader's attention and moral sensitivity to the issues raised in this area.

 The World Health Organization (WHO) declared a pandemic state as the coronavirus spread across the world. Personal protective equipment (PPE) has become a critical subject during the COVID-19 outbreak. It is necessary to prevent coronavirus transmission to healthcare workers (HCWs) as providing care. They are at high risk of exposure to coronavirus. The aim of this study was to provide a brief review of some routes of transmission of COVID-19, what, when and why PPE is recommended base on the route of transmission.

In this review, articles were extracted from the Google Scholar, Scopus, Web of Science, and PubMed search engines. The main keywords for search were coronavirus, COVID-19, personal protective PPE, healthcare, transmission, contact, and protect. 

Findings showed the COVID-19 transmission rate in the HCWs that wore PPE significantly decreased. All HCWs must use appropriate and adequate PPE in order to minimize the COVID-19 transmission. 

Although still uncertainty remains around COVID-19 transmission and it is early to have conclusion on its prevention, most of recommendations and guidance have emphasized to apply the PPE during COVID-19 outbreak among HCWs.

COVID-19 is a new pandemic in the world and data in the various aspect of this disease are evolving. In this review, the authors try to cover different aspects of clinical manifestations and the natural course of the disease.

For data gathering, the authors searched through MEDLINE, Cochrane library, google scholar and Scopus. The key phrases for search were "clinical presentation of COVID-19", "clinical features of COVID-19", "natural course of COVID-19", "neurologic manifestation of COVID-19", "cardiovascular manifestation of COVID-19" and "gastrointestinal manifestation of COVID-19". 

After screening of titles and abstracts, the authors finally enrolled 55 articles. Then the full texts of the selected articles were read carefully to determine eligibility and extracting relevant information. 

The most common presentations of COVID-19 patients were fever, non-producing cough and dyspnea but a considerable amount of patients may seek heath care without these complaints. Asymptomatic patients and patients with only gastrointestinal and neurologic symptoms remain a significant challenge for medical practitioners.

In late 2019, the COVID-19 epidemic began in Wuhan, China, which quickly spread around the world, becoming an international concern and pandemic. As with previous SARS and Influenza H1N1 pandemics, medical staffs providing services to patients are exposed to increased levels of mental stress. This review article introduces these symptoms based on the experience of previous pandemics and the data available on COVID-19 pandemic, introducing the underlying and protective factors against mental distress. Evidence suggests that levels of stress, depression and anxiety symptoms increase in health care providers. Moreover, these symptoms are more common in women, nurses, and people who are at the frontline of providing health care services for COVID-19 patients. Given the need to pay attention to maintain and promote the mental health of medical workers to provide effective services, this review offers suggestions to the effective management of these conditions at the individual and organizational levels.

As the number of patients infected by COVID-19 increases worldwide, and in the absence of appropriate therapeutic drugs or vaccines, it is essential to detect patients with COVID-19 pneumonia at its early stages, in order to isolate the patients from healthy population. Computed tomography (CT) scan seems to be promising in detection of COVID-19 as shown in some studies.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus, and its infection, coronavirus disease 2019 (COVID-19), have quickly become a worldwide threat. It is essential for clinicians to learn about this pandemic to manage patients. Among different aspects of the condition, is the treatment of this disease. Unfortunately, currently there is no effective treatment option that can be supported by evidence-based medicine. This review analyzes information from literature on treatments.