Omicron: Diagnosis and Outpatient Management

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Omicron: Diagnosis and Outpatient Management

18 Jan, 3:30 PM

[Music] good evening everyone and welcome to netflix i'm dr naveed and we have with us today uh dr tushar shah he's a consultant physician from advanced multi-speciality hospital and this is his first talk in our series um of where he'll be uh he'll be starting his covet update club so this is the first talk in that series and there'll be many more to come um and along with uh sir we have um our co-host a doctor mahadev desai who is also a senior consultant physician from ahmedabad and the topic you all know is omicron which is a hot topic and we'll be discussing about the diagnosis and management of covid in an outpatient setting omicron we know it's just six weeks baby but uh probably there is so much of information and when there is so much of information obviously the everyone would get confused which was which one to believe in which were not to believe so we are here to learn unlearn and we learn about omicron exactly what is and we know that it's a very very corvid has been a very dynamic pandemic that it keeps on changing so much so that we have to remain updated and there are only two class of clinicians updated or outdated so we want to remain updated and that's why it's very kind of few that in spite of a very busy schedule at mumbai in the advanced multi-specialty hospitals we not only manage the kovid patients but the other internal medicine patients also your spared our time and in fact we agreed to start a commit club and this being the first of its kind so sir well we welcome you we are very thankful to you and stage is all yours thank you doctor thank you so much um yeah we start with a few mistakes uh being rectified by me my own mistakes in late december i released a video in which i had stated that omicron is not lethal now that blanket statement was incorrect omicron can be lethal it is rarely lethal but it can be lethal and we have experienced that already in mumbai at least definitely so there was one mistake that i had made and the other mistake i had made is saying that omicron does not cause enosmia or dysjuisia and that is again something that i rectify humbly can cause these so don't base or your diagnosis of delta on the basis of uh presence of an osmium so let's let's start uh straight away with uh how is omicron different in presentation from delta that is the the first theme and then of course we'll discuss elaborately more symptoms in the question answer sessions so how is omicron different we all know that it began with the greater transmissibility of omicron the r naught or the r number of omicron is supposed to be around 10 our number means the number of people one patient can potentially infect if the surroundings are ideal for the virus 10 is the number given at its best i mean it is best for the virus 4 micron whereas 5 to 6 was the number for delta so omega is more transmissible secondly omicron has a greater uh i'm so sorry it is a lesser virulence lesser variance does mean that it has lesser capacity to cause lethal disease much lesser capacity because than delta third important thing is omicron has a shorter incubation period or the incubation period for delta was supposed to be four to five days and for omicron is probably less than three days we have seen patients get infected within 12 hours of coming in contact with an infected person why is this important it is important because you will have to make out clinically whether this is omicron or delta and therefore some features will clearly tell you that you are dealing with omicron and not delta the other important thing about omicron is not only is the incubation period shorter the duration of illness is short we used to say in delta and even before that in the gohan strain the ancestral stream that the duration of fear is usually seven days in omicron we can confidently state that the majority of patients will have deformations or complete disappearance of fever in 72 hours so the magic number for me when i talk to patients is 72 hours if your fear persists beyond 72 hours we will uh take more notice and we will investigate otherwise we have to we have to wait patiently for 72 hours to pass so that is a very very uh uniform thing amongst omicron questions very surprisingly uniform that the duration does not exceed of fever other symptoms may persist beyond simply water like cough but not fear so uh that was another difference from uh the presentation and osmia district are less common in omicron than in delta but they are they do occur one peculiar feature of an osmium and this juicier in delta and in omicron is that these symptoms can appear after deformations or after the fever has disappeared the difference between delta and omega i think is that the recovery of anasthmia is quicker and the duration of enos is shorter than in the previous strains but this is something that will be brought out by with more experience another important thing about omicron is that the rapid antigen test and the rtpcr sometimes is positive before clinical features appear and clinical features appear after lag period that was a very interesting observation you get a rapid antigen test positive on the 18th of january the patient is asymptomatic at that time they have done the rapid anagen test because the contact was having uh omicron and now they are asymptomatic but after four or five days the patient starts getting fever it's a very unusual feature and now you are wondering what should be counted as the first day the representation test positive or the first symptom positive i would say symptom would should be the counter as the first day for management purposes uh yeah so these are some presentation differences in the omicron the most important difference we will come to now we all have spoken about this before and it is universally now accept that omicron is a more is more of a upper respirator in a virus and delta was both upper and lower subtract with more serious symptoms in the lower respiratory tract in omicron what are the features of the operational tract and i go one by one with symptomatology of each first is there is rhinitis in vinyls the symptoms are as you know sneezing watery discharge nose block principle symbol no rhinitis these symptoms can persist far beyond the fever so these can stay on for several days sometimes more than a week then there is pharyngitis pharyngitis can be one of the most troubling symptoms of omicron we we can see tonsil or pharyngitis meaning the tonsils and the fines are both inflamed and this tonsillo pharyngetis causes severe throat pain sometimes odynophagia swallowing difficulty dysphagia and sometimes throat irritation which is constant patients have to clear the throat remember cough is not a symptom of tonsil pharyngitis cough is a symptom further lower down tonsil of aryan that is causes throat pain throat irritation and difficulty in swallowing or painful swallowing now this is this is tonsiller pharyngitis and if you look at the patient's throat you will see completely red inflamed uh uvula palate tonsils pharynx in some patients and a patient actually um laughed at me once when when she said i heard a video of your sir and you called omega mild disease but you should exp i experienced this tonsil pharyngitis and then then call it a mild disease so it is in that sense very very symptomatic in some some patients then we have laryngitis a well-reported symptom of omicron patient's voice becomes horse and patients can hardly talk sometimes so laryngitis is a part of the upper airway disease of omicron and then there is strategy of bronchitis bronchitis refers to the inflammation of the trachea and of the main bronchitis the it's not in the intrapulmonary branches probably just the main bronchus right and left and the trachea tricu bronchitis the symptomatology is principally cough severe hacking cough and sometimes there is hyper reactive airway problems like bronchospasm and leaves patients who are already prone to bronchospasm are more likely to get broken spasm but even those who have never had bronchospasm before may experience bronchospasm now this is an interesting area for me because i think this will make differences in the therapeutics of omicron and i'll come to that later this bronchospasm may be responsible for earlier than usual hypoxia that we sometimes see in omicron omega surprised me sometimes by showing hypoxia on the third or fourth day and sometimes this hypoxia does not correspond well with the ct scan picture the cd scan is normal and the patient has marginal drop from 96 to 93 uh saturation now this hypoxia i am postulating as an upper airway bronchospasm related hypoxia so this is an interesting area and i think this is something that where knowledge is still evolving because management will completely change if we say that hypoxia due to tracheobronchial problems and not due to parenchymal problems so um would there be will there be more would there be more clinical findings than the x-ray findings in that events eventuality means more wrong kind of you would see more wrong in such a place patient if you will complain of vs which will say that i have sounds when i breathe so yes and so i think that is one area where we might uh kind of explore more clinically and see what is happening ah so this is the upper airway symptomatology that you will see how frequently are lower areas involved now in vaccinated people the only statistic i could get is that in vaccinated people omicron causes serious parenchymal lung disease in a study in switzerland in one in nineteen thousand patients genius parent one in nineteen thousand which seems to be very very low compared to what we see in um in delta but i i think i have seen uh i would say abnormal ct scans in about twenty or thirty patients on the ground abnormal ct scans with ggos ground glass opacities i have had under my care three omicron deaths where patients had deaths principally due to omicron not due to underlying disorder of course they were all 85 plus age group all three males all three with serious comorbidities all three vaccinated and yet all three died with severe parenchymal disease with ct scan scores of 15 plus so ah we are and how do i know they were omicron and not delta is the question that i asked myself why do i label everything as omega i will come to that also but in these patients all three of them there were multiple family members with uh with covet so i postulated that it had to be omicron and not delta so that is uh uh the parenchymal disease i'll come to that again we we are seeing less parent time we see you're seeing very mild parathyroid disease meaning the patient has seven days of fever on the seventh day you do a cd scan in a delta patient then you would get scores like 8 9 or 10 15. you know in a omicron patient on the seventh day of fever you might get a score of two three or four you get lower ct scan severity scores in omicron then you get in delta on a on the same day of temperature another feature of omega before i forget is the prolonged fever that we sometimes saw in delta in younger people i'll explain this in the young often we saw low grade 9900 fever lasting for four weeks two to four weeks was the range in young people but they would say 99.5 99. i would ask them to kindly ignore because many people would uh you know begin to take steroids some doctors will be came to your steroids and prolonged fear but low grade fever i would always tell them wait and watch your body will take care of the fever in three four weeks this is not happening significantly with overcome you're not getting prolonged low grade right i can count about two patients of the few hundreds that we have seen i can count two patients who have had 99.5 for running for 10 days or so so prolonged low grade fever can be uncommon less common than in delta so that is about symptomatology uh differences between delta and omega let's go to the investigation and how they can be different in homicide one very important difference and that i think is still not realized very easy very much is the crp in omicron in the first two three days is higher than the cr in delta this is surprising why are you saying that in a relatively milder disease the crp higher than the first two that it is remember if you get a tonsil of anxieties or procure bronchitis that inflammation is very likely to cause a higher crv than uh just parenthetical disease in the early phase so i think the severity of tricho bronchitis and of the tonsillophane that is is the reason why crb often and what kind of cf the upper limit of normal is 5 you'll often see 15 on day 2 12 on day 2 which we did not see in delta in delta we saw five or less the first two three days and then a gradual rise over the first week and a sharp price if there was a hyper immune response in the second week so i think uh one way to make out whether this is or delta omega is also this higher than usual crb on the second day itself not that i am doing crp in all questions i'll explain that to you too so d dimer labs are telling us that d dimers are much lesser in omicron than in delta i have stopped doing d diameters in opiate patients so my experience currently on d dimers is less lymphoma i am seeing less in omicron than in delta the reason lymphoma might be less is because the viremia the the affection in the bloodstream is probably less maybe that is the cause for i don't know the exact cause but maybe lymphoma is less because of that in omicron than in delta what are the blood tests that i usually ask for in omicron if a patient is young and in omicron my definition of young changes yeah in delta i used to call anybody below the age of 40 truly young 40 to 55 would be middle and 55 plus would be at high risk in india in delta in omicron the high risk age changes highest age now i am keeping a 75 plus so if the patient is below 75 i sometimes will not do any investigation unless the patient has many co-morbidities and has not had any recent blood test done then then the current omicron gives us an excuse to investigate a patient who has never been investigated in the last one or two years so below the age of say 40 50 i would not do any tests any tests in the first three days for 72 hours no investigations in almost every patient below 40 between 40 and say 75 i would say if they have co morbidities haven't tested them themselves no investigation uh in the first 72 hours remember my my thing is for 72 hours no investigations after 72 hours i would investigate these people everybody after someone i would investigate if you are is persistent otherwise i would not investigate about the age of 75 i would investigate on the day of presentation which might be day one or day two also the investigations in the senior people the very senior would be cbc crp renal profile and blood sugar and these will be my four investigations cbc for its lymphoma crb for it i would like to see the high crp because i want the baseline crp which can rise later uh renal profile the whole renal profile i like because in the elderly hyponatremia can be common dehydration induced diuretic induced so and in the elderly i would like to keep the baseline creatine and known because many people have a low gfr to begin with so i would do cbc crp renal profile and blood sugar random in everybody above the age of 75 irrespective of comorbidities in the very first presentation which may be first day or second day otherwise in all most other patients i would not investigate unless the fever goes beyond 72 hours that is the principle we were going beyond 72 hours on the 73rd hour investigate same blood investigations after 72 hours [Music] what would i do a ct scan and when would i do a cd scan as we know the utility of ct scan has diminished considerably as compared to delta uh in omicron we used to do ct scans for two reasons one is to get severity and one is to find the diagnosis if the rtpcr was negative those are two reasons why we used to do in delta now in omicron rtbc of negative rapid antigen test negative clinically like omicron what do you do how do you diagnose or label a patient or a scobid if in the whole family there is a lot of fever and even one person has tested positive on the rapid test or the artificial your answer is that this person even with a negative artificial negative rit is omicron so it was not difficult to diagnose in a given circumstance so i would not do ct scan usually for diagnosing covid in the omicron era the other utility of ct scan is what the is getting the severity of overcome now this um this something that we should do more often sometimes as i told you we will see sometimes in the very senior person worse than expected parent animal disease we should not miss that we should not miss that because in such patients with significant paranormal disease even before hypoxia has occurred we may be able to give a combination of remnant civil and steroids to save the patient i come to therapeutics later because therapeutics i think will be a little different in omicron than they were in delta so in the very elderly with persistent fever if a patient comes with persistent i would do a ct scan on the fifth day of your in a 75 plus individual that would be my protocol it is important to have a few set protocols because we get confused very easily with you know so many patients and now we have to make decisions for good decision making even if it is not perfect every time if we have a protocol we can be more uniform so first three days no investigations in most people blood tests in the elderly i'm so sorry i'll have to take a glass of water what's her say up till now is that what is most important the 72 hours of fever that is one thing that we have to keep in mind fever for the beyond three days is something that is a sign that we have to further investigate and there is no role of ferritine ldh d-dimer to begin with as far as omicron is concerned right sir yeah right sir right and i think the worst investigation to do on an opening is the worst when you do disservice to the patient is il-6 doing an is6 is a criminal offense you should be borrowed from practice if you send io6 il-6 is bad because il-6 methodology collection method and testing method is such that i6 is usually abnorm usually the normal upper limit is seven and uh usually you'll see higher than seven il-6 we have learned the hard way that up to 77 should be considered normal and above 77 we may consider normal in a hypoxic patient until the patient gets hypoxia il6 has no rule and patients panic very very easily i've seen patients getting admitted i've seen patients getting ct scan done i've seen patients getting more antibody cocktail just because the il6 is high so except in the moderate or severe category only we should go for this investigation here so how do we define mild moderate severe severe is hypoxia if hypoxia occurs or if the six minute walk test is abnormal then we classify the covalent as cbm that is the classification so only in severe because the patient will obviously be admitted only in indoor patients will we do il-6 and now even d diamond only in indoor patients should be done ferritin again in high input and in ielts is in the more important thing is not just indoor hypoxic patients in patients whose oxygen requirement is increasing is the patient in which you do io6 to be able to judge whether you want to give tocilius so that is about the uh ct scan i was telling you so the ct scan as i also said before the cd scan pictures sometimes are surprising they are either very mild or sometimes really they are severe and you get surprised and you start wondering whether this is delta that you missed initially and you start feeling guilty because if you if you diagnose delta early then you can give molecule antibody cocktail which is very effective in delta and useless in homicide so i'll come to that in a bit so that is about uh investigations uh i don't know if you missed any investigation something about rtpcr something about rtpcr so rapid angle so what what are the values of rapid antigen places what many people ask some people have raised doubts about whether artificial should be the only tester and not rapid i think rapid antigen test is a beautiful test i think abraham's test is the uh best thing that has happened in the omicron uh era with so many cases to do artificial for everybody if you imagine not there the labs would not be able to cope with artificial so rapid hydrogen test is useful a good la good rapid energy test is required there are a few that make good uh rabbit and tests i prefer one called pine bio by abbot but there are there must be few more which make good tests so rapid energies are useful and as you know if there are four family members with fever and coffin cold and you do rapidanium one and that comes positive then you have diagnosed all four so in that sense the sensitivity of rapid energy is about 50 is not 200 it is 400 percent the sensitivity so i think it's a beautiful test and it must be used every person should learn how to do the rapid energy testing uh sensitivity i suppose there is no false and i suppose there is no false positive it is positive it is positive is that what recificity is 99 approximately whereas sensitivity may be less of 50 percent or so uh one important thing about rapid interest is that on the first day of symptoms it is usually negative and sensitivity lesser than 50 though if you are asking a patient to do a rapid antigen try to do it on the second day on the second day the sense will be very high uh not very high but higher than the first day so what do you do on the first day when the patient presents with symptoms you tell them resume code isolate and do the rapid antigen to what is what would be a good thing to tell a patient or if they can afford it they can do it on the first day and repeat it if negative on the second day that might be done so often you will find rapid engine coming positive after a day sometimes even after two three days uh if the rapid antigen is negative maybe two or three conjugate times and if you wish to confirm because sometimes you know it is important for the patient to go to the clinic if the patient is a doctor etc then you might order an idbcr asking for rtbcrs for me become very very uncommon i'm asking for very few patients to understand one of the most important reasons for asking for artificial besides travel where it is required if you travel abroad another important reason is if a patient is being hospitalized or likely to be hospitalized rdbc sometimes is better than rapid energy test in you know getting received in getting solution operator in getting uh medically so i think artificial may be useful for those things rather than just for diagnosis but yes artificial of course is a better more sensitive test several seventy maybe eighty percent sensitivity and uh we probably uh should do it in some cases on self testing there has been a lot of talk about rapid engineers through the nostril through the mouth throat saliva etc i don't know what is the correct thing to do nasal swab is still remains the method or recommended by all manufacturers but i think that if you have a patient who has a lot of tonsil or pharynges then maybe you could use a swab there if you're wasting a lot of rhinitis maybe you could use a swab in the nose that that is something that you can uh take a call on patients can do it one day in one area and the secondary another area if negative so yeah so that is about rapid engine test uh yeah so these are the investigations that we we wanted to talk about now what is the most important thing in omicron for the outpatient manager besides giving treatment what is the most important thing it is when to hospitalize the fish this is probably the most crucial thing and i think it is though you will be admitting if you see 100 cases maybe you'll admit one but though you'll be admitting just one or two cases uh you should know who to admit now the most obvious indication of admission is is hypoxia that you know under six minute walk rest fall of three percent or more or frank hypoxia rest are obvious indications for admission but you have to probably admit the patient before the patient becomes hypoxic and that is when you decide so what do i do what is what is what do i do is this i have decided that everybody above the age of 75 is definitely going to need more care if fear persists beyond three days in a patient with 75 plus on the fourth day of fever i will tell the patient i want to give you remedy and for that either you get hospitalized or i'll give you on the opening basis i can do both if the patient wants medical insurance then the patient gets hospitalized if the patient doesn't need medical insurance then the patient gets on an obviously basis remedy on an opd basis or even at home is now approved in the us now uh so i the fourth day i would give reducing i want to give the antiviral as soon as possible so this is one reason for one indication for hospitalization hospitalization for rem decision therapy hypoxia of course one number two is reminiscent the number three uh indication for hospitalization is just the co-morbid condition of the patient which is uncontrolled or the severe weakness of the patient or dehydration of the patient there is one more reason to admit a patient for example if a diabetic patient who already was relatively uncontrolled now has sugars of 400 i would rather have that patient of kovaid in the hospital than at home similarly a patient was vomiting because covet can cause omega especially can cause severe nausea and vomiting then i would have the patient in the hospital rather than at home even if the patient has maybe low grade fever no fever or relatively normal blood reports so those are of course general indications for hospitalization so again i'm going to say uh the indication hospital is fairly clear the protocol should be clearly clear to us when where we would like to hospitalize the patient that will bring me to therapy yes one of the one of the viewers wanted to know if the rapid engine test is positive but rtpc are the next day is negative how do you go about it so that is the coroner that you will not be able to solve you there can there are two possibilities one is that the rapid engine test kit was not good second is the person who collected the rtpc did not do a good job in collecting proper swaps uh but this would be rare and i i would say that rely on the positive test so if the rapid engine test is positive you consider this patient if clinically correlation is there you consider the patient positive one important thing about omega about omicron and uh rapid iron intestines you have the clinical correlation to do the patient has smile cough cold also mild cough cold no fever and the rapid engineers shows just a failed second line the test line is faint as compared to the control line even then you should consider it positive because a faint line with symptoms present confirm the positivity of the test so i think positive tests are more important than negative tests even the negative articles here there were some claims that there were some claims that the flu also can be positive falsely positive with the representation even rt pcr how far is it true so there was a claim during the wuhan stream that vidal can be positive so yeah these claims will keep them keep coming and going but no uh flow will not cause a rabbit even the other or there are seven coronaviruses out of which three or four cause the common cold even the common cold causing coronaviruses will not cause a false positive rtbc then i am fairly certain so i think you can you can rely on the artificial and the rapid engine test if they are positive uh yeah that brings us to the management and now this is the most uh crucial aspect of omega because there's so much controversy and so much recommendation differences between icmr maharashtra sports gujarat task force so let us try to get around the uh basics first is customers under symptomatic therapy the most important parasitomol and symptomatic treatment is the treatment for 99 or 100 patients what symptomatic treatment you decide because uh i still have not been able to fathom how to treat the cough of omega the the persistent stevia of whom we people have given inhalers or steroids and uh bronchodilators people have given oral bronchodilators people have given cough suppressants people have given nebulizers people have given healthy and things like that home remedies people everyone's multitude of syrups i love to think non-allopathic syrups uh i don't know what works frankly i don't know what works in the everybody has a favorite concoction everybody after this i will have one i will have one or two everybody have so we will take your opinion all of you all the viewers will take your opinion as to what you think has worked well everybody will have some but i think still that everybody's experiences will be counted as only anecdotal and we will be still struggling with and that brings me to the most important area of therapeutics that we might have to might have to develop we are saying that the cough is due to tricho bronchitis we are so saying that it's an inflammatory lesion not a secondary bacterial infection an inflammatory lesion causing the cough inflammation of the trachea and bronchus will steroids help is the main question here will steroids help symptomatically and if steroids helps implementing this severe cough will they worsen the viral disease we have always said in delta that in the first week of viremia we should not give steroids steroids will actually increase mortality which is true in delta it was it was a crime that we used to give steroids in the first week in delta and this used to happen rampantly all across india uh we we are allowed backs have a kind of love affection for steroids and that affection caused a lot of harm during the delta wave or even the gohan virus now in this uh i'm wondering if without hypoxia in a patient who has severe brachiobronchial symptomatology beezing or off incessant cough even after the fever has disappeared this fashion i think deserves oral steroids i'll repeat this and i don't please don't misuse steroids just because we are saying that give oral steroids in a non-hypoxic patient of omicron if the patient has severe cough but the fever has disappeared why is the fever disappearance important when the fever disappears you know that the viral load has come down in general and by giving steroids you will probably not worsen the viremia if at all there is some idea by giving steroids the risk will be less of aggravating the disease but the patient is symptomatic severely symptomatic needs relief from the packing cough give oral steroids and my recommendation is give half the dose of what we used to give in delta in delta for example the approved dose of steroids 40 milligrams of pregnancy loan per day whatever the body weight of the patient here give 20 milligrams of redness alone per day or 16 milligrams of methyl prednisone per day or three milligrams of dexamethasone per day and give it for half the duration we used to give for 10 days in delta give it for five days in omicron or give it till the symptoms are really relieved just give it for symptomatic treatment of the hacking cough that is in a non hyper in a hypoxic patient treat the hypoxic patient with steroids as you would treat in delta with the full dose of 40 million pregnancies per day in the hospital for 10 days they don't have to go on in a in a hypoxic omega that is that is hypoxic outpatient non-hypoxic severe cough use steroids after fever has gone so i i hope i am not misquoted on this in future that dr tushar recommended non-hypoxic equation getting steroids you know omicron please understand we are treating symptomatic brachiobronchitis with severe cough after fever goes i i'm repeating this because i just don't want misuse of steroids to happen so yeah so that is about symptomatic treatment of cough will be left to you otherwise you can you can use whatever but i do think the most effective treatment of symptomatic cough is codeine unfortunately codeine is not freely available as a serum so the other way i think codeine works works better than almost anything i know yeah so that gluten health corticosteroids boolean health corticosteroids help in this track your bronchitis i have tried it i have tried nebulization in indoor patients i have tried inhaled steroids as you know has been recommended as a treatment yeah before also and high dose 800 micrograms twice a day has been recommended i have not found much relief in the cough but i think that i think we have to experience this more i have not actually garnered enough experience with individual therapies to be able to ask you what is your experience of inheritance are you have you used it for cough symptoms we haven't seen honestly so many patients admitted with this kind of tracheal bronchitis opd basis yes we do use inhale corticosteroids and they are fine just fine you are happy with that but not many patients that we have encountered okay so uh symptomatic treatment of nose is with steam inhalation now stimulation and gargling i have been against in in delta and in the gohan strain first we have secondly i have a vehemently opposed steam and garlic and as you know india is traditional hub for steven gargling it does kadas demon gargling across all sections of the society and i was i was kind of criticized for saying no to steam but we do did realize later on even wj realized very late aerosols are important and therefore steam and gargling can worsen the uh spread of delta or of the one stream now my my mind is changing in omicron as you said it's unlearning and new learning in omicron i am advising in favor of steam for nose block for throat and gargling with betadine or whatever goggles you like tantrums in uh for symptom relief and i tell them to do it in their closed bathroom uh with the closed room doors with an exhaust fan open if they can do that will be the best thing to happen now we also know that if we cause aerosolization of the virus by gargling or steaming we now know that the virus survives this particular omicron virus survives in the air for five to ten minutes and it rapidly diminishes in the intensity in the air so i think i am now okay with steam and garlic in omicron so uh yeah so that is about omicron symptomatic therapy of the nose throat some people have given uh lignocaine as a gargle uh so many things have been tried now for the throat pain like no game garbage nuclear gel which also has some local anesthetic beta goggles displaying so many things have been right for throat pain and throat irritation i think the best thing that works for throat pain with odynophagia or dysphagia is anti-inflammatory drugs insane so i have used nostril latitude drugs more commonly than i've used ever before in uh or in uh over again i was against nsaids but now i have in my prescription that is you take ibuprofen sos you decide the patient decides when to take ibuprofen i tell them to take it i tell patients of cardiac disease hypertension kidney disease not to take it uh otherwise take it sparingly and yeah they give good relief for a few hours and then the nature takes its course it's a self-limiting disease after all uh for laryngitis again i think steroids would work so oral steroids can be used for laryngitis if the patient voice is very horse and is horse for several days you can start steroids for such a patient so that is about uh symptomatic treatment of the rescue track the most crucial area the most painful area for me is the antiviral treatment now uh we know three things that we know there are no studies in omicron of antiviral therapy of any significance no studies except sutrovima which is a monopoly antibody which is known to work we don't have studies of remnant severe monopoly where fibropyruvate in omega uh i have used private pyramid very frequently in the first wave and found it useless i have stopped very well i think monopoly is a hoax and i'm not using it anymore any money i've never used it sorry i've never used monography and i do think that uh is an unfortunate molecule it is an unlucky molecule it was researched for delta developed for delta and as soon as it came out in the market delta disappeared the the target disappeared and one parable was left hanging uh without any target and therefore then you know how 13 companies in india making vulnerability they had to find a target and they said okay why not omicron useless drug in omicron never tested useless and please shun monument i can talk for an hour on monogamy then we come to the ram decision now remedy is not being tried as a there is no trial in orbicula or foreign but of the three antivirals uh or five viewers i would trust them receive definitely because my experience has been excellent in uh in the first year of the second excellent many people still do not believe in numbers which is fine uh i think experience counts for something especially if the volume of xp is very high and i think there has not been a good study till very recently in the delta wave on rem decibel in the non-hypoxic state if you remember in the first wave lambda c was approved in the usa in hypoxic patients logic defies this this divides logic meaning if monologue level is to be used in the first five days february in the first five days in the viral phase why was the remedy reserved for hypoxia when the wiring has already disappeared i think that was one fundamental flaw in their study of the design at that time now they have done a study in the delta wave of remedy severe in the first week and they have found good results with the lower dose of ram disease what is the lower dose the lower doses instead of 600 milligrams they give 400 milligrams meaning 200 milligrams will be 100 on day 203 intro venous membership i think if i have to use an antiviral in omicron for me there is only one choice reminiscent it may not be the perfect choice but it is something to go with what is the fourth antiviral drug that is available here and that is the monoclonal antibody cocktail called cassidy verma plus in devi mark that is the cocktail available here now the company doesn't work you know micron every there is no study where it works it fails in omicron and yet it is being randomly used and what is the reason why is used people take the crutch of not being able to differentiate between delta and omicron to make it an excuse to use the antibody pocket now let me get this very clear to you just yesterday i read a newspaper uh public a press release by the government of maharashtra saying that there were uh how many 13 or i'm sorry 11 000 some odd new cases of i'm so sorry 13 111 new cases of kovit in the whole state of maharashtra one day second sentence read there were 122 omicron cases detected in maharashtra in one day now what does this mean i'm repeating myself 13 000 odd cases total in maharashtra 122 omicron cases in maharashtra to any lay person and even to many doctors this would mean that after 13 000 only 122 or omicron and the rest were dealt and nothing can be further from the truth what they should have said is 120 ohmic 122 omicron detected out of 150 samples of genomic sequencing done something like that they should have given the total figures of genomic sequencing they should have given how many delta within that genome no even currently the government is secretive about releasing figures of genomic sequencing they are all praise for south africa having released their genomic sequence so quickly and we are hiding our biology uh information from the lay public and from doctors anyway so the point is this even doctors believe that there is still delta in a significant number they want to believe somehow because they want to use the antibody cocktail which works in that consider this as a simple logical thing so that you understand that delta is not important now in mumbai i'm just talking about mumbai because i know the figures here in mumbai around the 12th of december there were less than 200 total documented cases of oil all of them were delta because delta was the current uh at that time the uh variant at work 12th december 200 or less then came over gradually numbers started rising at the peak in january we had 21 000 cases of of government the government said that 95 or more are delta now anybody here knows math and can you tell me if ninety five percent is delta and five well sorry ninety five with an omegra and five percent is data of twenty one thousand what is the number of delta cases sir guanido if five percent or twenty one thousand are delta how many dead how many anybody okay so somebody said thousand so if five percent of twenty thousand that is thousand cases are of delta currently in mumbai at the peak does that mean that delta has been increasing from two hundred in december to thousand now can you can you even think of delta increasing in number while omacron is trying to overtake that no delta cannot increase from that 200 level we have to freeze delta at around 200 level in our minds also whatever the number of cases currently ten thousand five thousand fifteen thousand in mumbai you cannot have more than two hundred delta simply cannot have delta cannot increase in numbers delta was on a decline in december if there is no reason for it to go up again especially so basically what i'm trying to say and why i'm appearing frustrated is delta is not a significant player in the current covet season and therefore to give more loop away to a patient because volatility used to work in delta to a very small degree or to give antibody cocktail to the patient the current antibody cocktail available here is incorrect unjustified and i think it should be banned the use of monopoly over and or quantity of it should be banned the problem is also patients are asking for those medications and you have to just refer them to somebody who will give the give the cocktail and please do not use the cocktail yeah i think that is about the therapeutics uh vaccinating now to another anti-sir about the immune modulators to facitive and parasitic name as drugs again remember this they are adjuvants to steroids so hasidic ambassadors are given with steroids in a hypoxic patient of it and they have no evidence to to support them i have used uh medicine more than i've used to opposite them even though basically slightly more expensive but now there are generic versions available so i think uh they can be used with steroids with to enhance the effect in a hypoxia again but they are indoor i i would not use them in obd patients uh very simple and medicine i would not use what type of bronchitis like we use steroids i would use it in parent hormone hypoxic disease uh vaccination very quickly how to complete the yeah to complete the list that backslow which is not available in software vb which is not available here just to complete these two antiviral drugs that are approved by u.s uh authorities for emergency use uh are tax flow bid actually it is a combination drug which uh is not made for pfizer it is supposed to be a game changer in the true sense uh it it works even in omicron works in delta and it reduces hospitalization if given within three days it is hospital into the you know eighty ninety percent so bachelor would uh may not become very easily available here or we may be very very expensive here but i hope that it is uh many indian companies will uh probably make it i don't so do you know any indian company already in collaboration no so that's one after all and they'll be afraid of launching any new antiviral suppose so baxter and it's not a cocktail because it's just one drug so you don't call it a cocktail it's a molecular antibody so come up with efficacy against omicron so if that was to come and i think it will take a few more weeks to come but if that was to come it might become useful in the very elderly or severely co-morbidity patient who who in whom you can give it in the first maybe first five days or seven days and prevent hospitalization again as we know postulation itself is very uncommon in omicron even in the elderly patients so you would have to really really be very choosy in using social map yeah so i think uh vaccination very quick water maximum because we have i think overshot very quick word on vaccination is that uh vaccination you should uh remember one thing one thing very important i have to give one message is about boosters if you have had code in the first wave second or third wave count that as one vaccine shot if you have taken two shots for the regular vaccine and have had over it on one wave do not take the booster even if you are elderly with comorbidities healthcare workers whatever i that is my recommendation excessive vaccination may not be useful may be harmful so you should not take more than two shots if you are code that's one message that i have yeah what is your best case so the uh wave will peter out maybe by february in mumbai at least and the problem in india is a big country and we have a very strong urban rural divide in terms of infect infections and i do think the the whole population is a is a vulnerable population right so to the omicron has a lot of population to still infect and we know that even boosters are not preventing omega infection they might might be making the infection less severe and so there are a lot of unvaccinated people there are a lot of single vaccinated people there are a lot of people who have the immune escape is so common so i think we are not seeing the end of omicron very soon across the country the omega the virus is not go away very soon but uh and then it came and when we yeah when it came in when we realized it is then we were under the hope that truly is bringing the now disease to an endemic city but now we are talking about that this is not the last variant and now for last few days the talk is going on that probably this is not the last parent and we don't know what will be the next nature of the next uh variant of this our scovie yeah we have we have really realized that this kovi is a very very adaptive adaptable uh adaptive organism there's no reason to believe that there won't be mutations there have to be mutations somebody asked about antibiotics and ivermectin so i'll just answer that iomethine is something that i i do think we have researched very much we have read all everything that is available uh on ivermectin all studies everything has been read by us dr kumar is a very keen team member and we have uh scored through all the papers and i think iron man is a hoax it's a hoax of the um it's a very good hoax in that it has been you we have been made suckers many doctors have been made suckers into using ivermectin and i think because we know that some patients get better anyway uh our experience personal experience anecdotal experiences has been good in many situations and so i i i sympathize with people who use higher or making and i tell them keep using that uh but element is useless the problem with only this not the scientific drug i'm not bothered about the side effects this the problem is it makes you waste days it makes you waste valuable days when you give a three day or a five day course or american then you will just leave the patient at his own mercy and not pay attention to the patient for five days when you give him somebody as old antibiotics antibiotics are my favorite my favorite thing about antibiotics is this antibiotics um if somebody gives a patient antibiotics they must buy the antibiotic they must see the antibiotic twice a day after breakfast see the strip after dynasty they'll see the strip and the strip then has to be thrown into the dustbin antibodies shame on the country shame on the country that we have used so much as a termites in toxic cycling sifi site exam because we are responsible for causing antibiotic resistance in the future for having one antibody which is beautiful for typhoid and drink fever go waste i think it's a crime against humanity you use antibiotics so yeah that is my opinion on antibiotics so but unfortunately still going on even in this omicron era also people are receiving azithromycin our aim is much less but still yeah yes in mumbai a city known for its kind of science knowledge hospitals pulmonologists are using azithromycin and now that astromycin thoracic is disreputed they have started using claritamycin which is the potentially linked drug invasion acute prolongation or drug interactions they are using how can i argue against gps that when they are setting examples i think the and the most important organization is the government authority when they give us money review they give us heavy pilgrimage they give us etc etc then at no point has icmr declared in large bold letters fatwa against prescription of antibiotics they should have done that indian medical association one of the most important organizations i think that where it has done nothing in in government to educate and do make corrections because the president in many organizations are using antibiotics how we can talk so it is a very frustrating thing that we have not been able to do good science we are scientists we have failed our public yeah sorry for granted right sir no that's true yeah good evening dr it was an excellent talk by you as usual are we missing you at bangalore yeah i want your uh part of prediction for the other states like bangalore and your views on antenatal or micron in an antenatal a lady who is pregnant and during the delivery what precautions and you have suggested kovacson after kobe shield but the government is not giving the certificate so can we how do we go about it thank you sir so two three questions here so first the most important question is about the pregnancy and omicron i do not hear we do not have yet um you know figures or statistics about what happens in pregnancy i believe that this is purely my personal belief is that omicron is not going to cause the kind of problems that third trimester ladies used to have in delta we know that we used to get pre-term labor premature deliveries and that i don't think will happen with omicron generally because it's less virulence as as we know we are getting less with pneumonia we are hardly seeing any deep vein thrombosis or pulmonary thrombosis pulmonary venous thrombosis and um i don't think we'll see much longer with omicron and similarly i don't think we say we see pregnancy related problem so in fact if a person becomes pregnant don't give a booster because i don't think booster does much to prevent omicron and in a pregnant lady i am not because the lady must be young i am not worried about morbidity with omicron in fact i'm telling everybody even if you're if you're offered booster if you're below the age of 40 like in the u.s they are giving third doses below in college going students if they're below the age of 40 even if you're offered boosters please don't take boosters the second point about kobe shield one covaxian i have believed that mixing vaccines even in india should be good there are no studies of cohesion and coaxing mixing in india but i would say that probably it's a better choice uh having said that the government has offered only commission to those who have taken cove shield so if you now is a certificate important is the question you will have to ask the certificate of the vaccines will never become a mandate for travel ever i think okay so in india definitely no abroad i don't think will become mandate for travel generally mandates for travel are going to reduce after omicron because people have realized that travelling will occur and transition and about the uh non-metropolis cities uh of uh kovid i think every city is going to see a wave of omicron and uh you will have to just wait and we have to have delhi and mumbai as the principal cities currently with omicron i think every city will gradually have bear the brand yeah okay thank you very much yeah hi doctor hi doctor i should go ahead yeah please go ahead yeah good evening doctors thank you for such valuable information so my question is what is uh your opinion on this core vaccine being advised for all the kids below 18 years because i'm from bangalore and as i'm seeing all the schools over here they are making it though you know two days back the supreme court has actually said that you cannot force anybody to have a vaccine but even then uh as far as i'm seeing everywhere here uh all school students below like 18 all are all uh you know they have made it mandatory to come with the covida i mean with the vaccination what is your take on this so the first i'll give you the take of the indian association of pediatrics iap the indian associate pediatrics says that they must take the vaccine even younger children if they are offered they should take the vaccine that is their take i think we have to differentiate between the delta and the omicron wave if this was the delta wave still going on i would be very keen on vaccination in omicron wave because omega has such immune escape that children who are starting vaccination now are not going to be protected even after two doses you need three doses to protect against nobicon you will not do anything to spread you is to reduce the spread of omicron by vaccinating children whether the current vaccination of children will help against the future variant is a question open to debate so i would say a making it compulsory is a crime schools cannot make it compulsory it is a crime because the supreme court has declared [Music] you should have the choice if you have a 90 year old grandparent at home and you want to protect the guide parent made but i'm telling you even two doses are not going to protect against omega maybe you can try to take the vaccine but otherwise i would not expose the child to the vaccine i'm glad koishi is not approved covaxine is a much less effective vaccine but much less harmful vaccine so if you have to give something give the less harmful thing that i don't mind and one more thing is uh nobody has like the way the uh the very information that i got from you is if you are already have got covet then more than two doses are not recommended this has not been told to anybody sure i mean most of the people don't know about me and in the hospitals they are making it mandatory to take the booster shots the problem there is logistics how do you prove that you have those most of us all of us have got covered at least once in this last year we all have got it even then they are making us to take a business where there have been criminals there have been legal cases where people have defended themselves for not taking action because they have had proven they have won cases in supreme court in the u.s for not taking the vaccine but it is difficult with the previous rtpcr report yeah so people manufacture my artificial reports that is the problem in india you can get artificial course people get vaccine certificates which are fake everything happens so you know how how do you control it yeah yeah so thank you so much we'll get in touch with you for your next session and thank you everyone for joining in this was a wonderful sessio

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Is it possible for delta and omicron to co-infect? Although the Omicron image is generally asymptomatic, what is the red flag here? When should monoclonal antibody infusions begin? What is the recommended line of intervention for those who are experiencing symptoms? Get answers to all of these key questions in the first session of Dr. Tushar Shah's 'COVID Updates' Forum!

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