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      Smartphone-enabled wireless otoscope-assisted online telemedicine during the COVID-19 outbreak

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      American Journal of Otolaryngology

      Elsevier Inc.

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          Abstract

          Dear Editor: Coronavirus disease 2019 (COVID-19), a new infectious disease in humans, is characterized by respiratory symptoms and human-to-human transmission [1]. The number of the confirmed cases of COVID-19 is rising sharply, and the World Health Organization (WHO) has declared that it can be considered as a pandemic on March 1, 2020 [2]. COVID-19 epidemic has caused disastrous consequences all over the world. As of March 30, 2020, WHO reports that 693,224 people have been diagnosed with COVID-19 worldwide, with 33,106 deaths, including 200 countries and territories, and 82,447 of these cases in China [3]. As an integral part of the respiratory system, the nasal cavity and throat may become susceptible to the virus infection. Swabs sampled from the mid-turbinate, nasopharyngeal, and throat of the COVID-19 patients have been detected the 2019 novel coronavirus, with a higher viral load in the nose [4]. Therefore, the department of otolaryngology is considered to be a high-risk department for COVID-19 [5]. Disasters and pandemics present extraordinary challenges for the healthcare system [6]. During the rampant spread of COVID-19, most hospitals have suspended routine otolaryngology outpatient services in China, retaining only emergency services. Some clinics also shuttered their doors and delivering services only via the non-contact method in the USA [7]. Local health authorities recommend medical care online to meet people's medical needs. The current COVID-19 pandemic reminds us of the importance of telemedicine to prevent cross-contamination [8]. Telemedicine in otolaryngology has a long history [9]. However, otolaryngology is under a complicated anatomical structure. Lacking specialized medical expertise, many patients cannot clarify their clinical signs and symptoms accurately. As a result, otolaryngologists sometimes have to make a diagnosis online or even give therapeutic advice in minimal information, resulting in an inadequate diagnosis. With the increased popularity of smartphones, the smartphone application is increasing in otolaryngology clinical practice [10]. The smartphone-enabled otoscope (SEO) is emerging a new electronic device in recent years. Using this device with a dedicated application, doctors can quickly investigate the patient's external auditory canal and tympanic membrane. Previous studies have shown the value of the portable devices not only as a convenient diagnostic aid but also as a teaching adjunct for the pre-clinical medical students [11,12]. However, smartphone-enabled wireless otoscope-assisted online telemedicine (SEWOAOT) has not been explored during the COVID-19 outbreak. To contain an epidemic, most people like to stay at home and try to minimize going out. Also, a proportion of people have quarantined in an isolation centre or their home for medical observation. In these situations, SEWOAOT can provide an excellent solution, delivering online otolaryngology services. We encouraged patients to be involved in the SEWOAOT via two avenues. On one side, our department delivered online outpatient services to respond to the patients' questions. If the patient seeking medical consultation has chronic ear symptoms with a long medical history, we recommend that the patient involves this project. On the other hand, part of emergency patients participated in an online follow-up. For instance, a 5-year-old boy visited our hospital complaining of ear pain in the middle of the night. This patient was diagnosed with acute otitis media, and was treated with orally administered antibiotics, and was told to take part in voluntary online revisiting at home without exceptional circumstances. Mebird M9pro wireless otoscope (Black Bee Intelligent Manufacturing (Shenzhen) Technology Co., Ltd.) can be adapted to any smartphone using wireless fidelity. The smartphone needs to download a dedicated app according to the operating system from the app store. The built-in 3-megapixel camera can offer a picture with 2048 × 1536 pixels resolution and a 480 × 480P video (Fig. 1 .). The device can be purchased for 250 RMB ($35) from multiple e-commerce websites, which can be delivered by courier to customers except for Hubei Province from one to three days. Depending on the instruction manual, the patient can smoothly perform the otoscope to examine the ears by oneself (Fig. 2 .). The children need their parents' help for examination. The patient sent the images or video taken by the smartphone via WeChat group to doctors. After got the images data, the otolaryngologists made a diagnosis and provided real-time feedback. WeChat, the most popular social media in China, plays a critical role in telemedicine services. Since February 15, 2020, we have preliminary serviced 12 patients via SEWOAOT. There were 5 males and 7 females, with an average age of 28 years (range 4–58 years). Among them, 3 cases of acute otitis media, 2 cases of traumatic tympanic membrane perforation, 2 cases of mycotic otitis externa, 2 cases of cerumen impaction, 1 case of acute external auditory canalitis, 1 case of external auditory canal trauma, and 1 case of post-operation of external auditory canal cholesteatoma. We ask patients to rate their satisfaction with SEWOAOT ranging from dissatisfied, somewhat satisfied, and very satisfied. They were dissatisfied (0, 0%), somewhat satisfied (2, 16.7%), and very satisfied (10, 83.3%). Overall, we have received excellent feedback for participation. Fig. 1 Photograph showing the edited image of the tympanic membrane taken by the patient's smartphone with the wireless otoscope. A: Normal tympanic membrane (right ear); B: post-operation of external auditory canal cholesteatoma (right ear); C: cerumen impaction (right ear); D: traumatic tympanic membrane perforation (right ear). Fig. 1 Fig. 2 A woman examined the tympanic membrane of the right ear with a smartphone-enabled wireless otoscope. Fig. 2 Mandavia et al. performed a cross-sectional study, screening ear disease in Nepal,and concluded that an SEO is a potent tool in the diagnosis of ear disease and the decision for onward referral [11]. Hakimi et al. used SEO for training medical students instead of the traditional otoscope [12]. They found that the students were more confident in identifying the anatomical landmarks of the middle ear. However, a recent study had shown that it had not proved the effectiveness of SEO when local health care workers were examining the children. It potentially relates to insufficient training and education of local medical personnel [13]. SEO in this paper offers a better imaging quality than the previous product. The device also has a directional gyroscope which can keep a constant view angle when the machine body rotates unstably. The technological progress makes it possible to perform a self-examining. However, SEWOAOT also has disadvantages. In some remote rural areas of China, smartphone and internet use remains restricted. SEO is not convenient enough for older people. Nevertheless, SEWOAOT has great significance for preventing human cross-infection during the infectious disease outbreaks. Funding The authors have no funding, financial relationships to disclose. Declaration of competing interest The authors declare that they have no conflict of interest.

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          Most cited references 11

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          Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia

           Qun Li,  Xuhua Guan,  Peng Wu (2020)
          Abstract Background The initial cases of novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) occurred in Wuhan, Hubei Province, China, in December 2019 and January 2020. We analyzed data on the first 425 confirmed cases in Wuhan to determine the epidemiologic characteristics of NCIP. Methods We collected information on demographic characteristics, exposure history, and illness timelines of laboratory-confirmed cases of NCIP that had been reported by January 22, 2020. We described characteristics of the cases and estimated the key epidemiologic time-delay distributions. In the early period of exponential growth, we estimated the epidemic doubling time and the basic reproductive number. Results Among the first 425 patients with confirmed NCIP, the median age was 59 years and 56% were male. The majority of cases (55%) with onset before January 1, 2020, were linked to the Huanan Seafood Wholesale Market, as compared with 8.6% of the subsequent cases. The mean incubation period was 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days. In its early stages, the epidemic doubled in size every 7.4 days. With a mean serial interval of 7.5 days (95% CI, 5.3 to 19), the basic reproductive number was estimated to be 2.2 (95% CI, 1.4 to 3.9). Conclusions On the basis of this information, there is evidence that human-to-human transmission has occurred among close contacts since the middle of December 2019. Considerable efforts to reduce transmission will be required to control outbreaks if similar dynamics apply elsewhere. Measures to prevent or reduce transmission should be implemented in populations at risk. (Funded by the Ministry of Science and Technology of China and others.)
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            SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients

            To the Editor: The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, and has been declared a public health emergency of international concern by the World Health Organization, may progress to a pandemic associated with substantial morbidity and mortality. SARS-CoV-2 is genetically related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries in 2002–2003. 1 The epidemic of SARS-CoV was successfully contained through public health interventions, including case detection and isolation. Transmission of SARS-CoV occurred mainly after days of illness 2 and was associated with modest viral loads in the respiratory tract early in the illness, with viral loads peaking approximately 10 days after symptom onset. 3 We monitored SARS-CoV-2 viral loads in upper respiratory specimens obtained from 18 patients (9 men and 9 women; median age, 59 years; range, 26 to 76) in Zhuhai, Guangdong, China, including 4 patients with secondary infections (1 of whom never had symptoms) within two family clusters (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The patient who never had symptoms was a close contact of a patient with a known case and was therefore monitored. A total of 72 nasal swabs (sampled from the mid-turbinate and nasopharynx) (Figure 1A) and 72 throat swabs (Figure 1B) were analyzed, with 1 to 9 sequential samples obtained from each patient. Polyester flock swabs were used for all the patients. From January 7 through January 26, 2020, a total of 14 patients who had recently returned from Wuhan and had fever (≥37.3°C) received a diagnosis of Covid-19 (the illness caused by SARS-CoV-2) by means of reverse-transcriptase–polymerase-chain-reaction assay with primers and probes targeting the N and Orf1b genes of SARS-CoV-2; the assay was developed by the Chinese Center for Disease Control and Prevention. Samples were tested at the Guangdong Provincial Center for Disease Control and Prevention. Thirteen of 14 patients with imported cases had evidence of pneumonia on computed tomography (CT). None of them had visited the Huanan Seafood Wholesale Market in Wuhan within 14 days before symptom onset. Patients E, I, and P required admission to intensive care units, whereas the others had mild-to-moderate illness. Secondary infections were detected in close contacts of Patients E, I, and P. Patient E worked in Wuhan and visited his wife (Patient L), mother (Patient D), and a friend (Patient Z) in Zhuhai on January 17. Symptoms developed in Patients L and D on January 20 and January 22, respectively, with viral RNA detected in their nasal and throat swabs soon after symptom onset. Patient Z reported no clinical symptoms, but his nasal swabs (cycle threshold [Ct] values, 22 to 28) and throat swabs (Ct values, 30 to 32) tested positive on days 7, 10, and 11 after contact. A CT scan of Patient Z that was obtained on February 6 was unremarkable. Patients I and P lived in Wuhan and visited their daughter (Patient H) in Zhuhai on January 11 when their symptoms first developed. Fever developed in Patient H on January 17, with viral RNA detected in nasal and throat swabs on day 1 after symptom onset. We analyzed the viral load in nasal and throat swabs obtained from the 17 symptomatic patients in relation to day of onset of any symptoms (Figure 1C). Higher viral loads (inversely related to Ct value) were detected soon after symptom onset, with higher viral loads detected in the nose than in the throat. Our analysis suggests that the viral nucleic acid shedding pattern of patients infected with SARS-CoV-2 resembles that of patients with influenza 4 and appears different from that seen in patients infected with SARS-CoV. 3 The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients. These findings are in concordance with reports that transmission may occur early in the course of infection 5 and suggest that case detection and isolation may require strategies different from those required for the control of SARS-CoV. How SARS-CoV-2 viral load correlates with culturable virus needs to be determined. Identification of patients with few or no symptoms and with modest levels of detectable viral RNA in the oropharynx for at least 5 days suggests that we need better data to determine transmission dynamics and inform our screening practices.
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              Virtually Perfect? Telemedicine for Covid-19

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                Author and article information

                Contributors
                Journal
                Am J Otolaryngol
                Am J Otolaryngol
                American Journal of Otolaryngology
                Elsevier Inc.
                0196-0709
                1532-818X
                4 April 2020
                4 April 2020
                Affiliations
                Department of Otolaryngology, Wuxi Huishan District People's Hospital, 2 Zhanqian North Rd, Luoshe Town, Huishan District, Wuxi 214187, PR China
                Author notes
                [* ]Corresponding author. xiangming_meng@ 123456hotmail.com
                Article
                S0196-0709(20)30158-7 102476
                10.1016/j.amjoto.2020.102476
                7128762
                © 2020 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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