Regarding point of care / home testing most manufacturers report >95% accuracy, however there was hesitation to them being widely rolled out. This comes down to 2 main reasons;

False negatives – most tests have been validated on known COVID-19 patients that have been admitted into hospital. By default these patients will be quite unwell and have likely mounted a strong immune response so antibodies will be more easily detected.
In the community however some patients have mild symptoms or are even asymptomatic. These patients may produce lower antibody levels which may not be detectable by current point pf care tests.

False positives – there are other coronaviruses which have been circulating seasonally for many years – often causing mild cold / flu like symptoms. We are unsure whether these home testing kits are specific enough. So an individual may test as positive if they have been infected with a coronavirus that is not SARS-CoV-2, this is obviously a concern and can lead to individuals / families / companies making unwise decisions based on the assumption that they are immune. 

New Laboratory testing using methods such as ELISA is more promising. They can provide quantitive antibody levels, rather than a negative or positive reading, so are able to identify those patients that had mild symptoms with lower antibody levels in the community.

The body produces different antibodies to different parts of the SARS-CoV-2 virus. Some antibody responses are stronger than others. The better tests now look for more than 1 antibody which also increases sensitivity.

Also many of the lab based tests report better no cross reactivity to other coronaviruses which increases specificity, this should mean less false positives.

In fact, the latest laboratory based antibody tests have sensitivity and specificity values of over 99%.

The big question however remains, what does a positive antibody result mean? Does is guarantee protection from COVID19 or a less severe infection in the future – hopefully yes, but unfortunately we don’t yet know for sure.
For the time being we need to interpret with caution and those testing positive for antibodies still need to take precautions. 

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Pulse Oximetry in the fight against COVID-19 is proving vital.

These relatively simple medical devices provide valuable info when assessing patients with many respiratory conditions – especially COVID-19.

Given the importance of the data – our practice has been sending them out to our members for no charge.
Likewise, local NHS services have started to provide remote pulse oximetry for suspected COVID-19 cases.

In conditions like asthma and pneumonia, patients are usually significantly short of breath before oxygen levels start to fall. However, with COVID-19 we sometimes see oxygen levels drop before shortness of breath develops – termed silent hypoxia – for patients in the community it may be an early warning sign.

Similarly, some physicians stress patients by getting them to exercise whilst monitoring oxygen saturations. A significant drop in oxygen levels can indicate serious underlying lung pathology and can be used to identify those patients who need hospital admission and close monitoring (not something I would recommend doing remotely). 

I’ve remotely consulted with patients with COVID-19 in the NHS and private sector who were not short of breath but during regular follow up their oxygen levels were found to be low. They were admitted into hospital and treated with oxygen (did not require ventilation), made a good recovery and discharged after a few days.

Picking up low oxygen levels early into the illness may result in better outcomes. A pulse oximeter, together with a thermometer and blood pressure machine provide information that can potentially influence decision making in a particular case.

It’s not to say that 02 levels are the only factor, those with normal levels may also require hospital admission. A full clinical assessment is always necessary, but pulse oximeters provide a key piece of data.

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Up until now our main work with small to medium sized businesses was looking after executives as part of our Concierge Clinic membership, providing both acute and chronic medical care with a strong emphasis on bespoke health screening and preventative medicine in order to optimise health. 

However, in view of the recent coronavirus outbreak we have been asked to work with businesses to advise on safely gettingback to work. Though each business is different with specific requirements and solutions we focus on four main areas. 

– Reducing risk of exposure this can include strategies such as working remotely from home, having less people in the office with physical distancing measures and adequate office ventilation. It’s also important to look at the way individuals travel into work and the risk that that entails. In addition, there have been discussions around wearing of masks particularly in indoor working environments and daily temperature monitoring. 

– Containment involves each individual reporting any symptoms, no matter how mild, so that their case can be assessed and they can be advised to self-isolate as required. This can also extend to reporting symptoms of anyone who is unwell in the household. With the use of healthcaretechnology, we now have clients who monitor vitals such as temperature, pulse rate and blood pressure at home daily prior to going to work. These readings get automatically sent via an app to the physician who can assess real time data. Setting up alerts on the app so that temperatures above 37.5 result in an urgent push notification to the physician means the case can be assessed urgently. 

– Testing there are various ways of doing this and although there are limitations to all current testing methods, some organisations have requested antibody testing to assess whether employees / executives have previously been infected with COVID19. However, it’s important to note that even if this is the case, we are not yet sure whether this means they will not pick up the infection again. There are multitudes of antibody tests available with varying degrees of accuracy. The point of care test kits, although providing an instant result, is not specific or sensitive enough in the community for it to be reliedupon. The laboratory tests such as Abbott’s antibody test is significantly more accurate with more than 99% sensitivity and specificity. 

In addition to antibody testing there are also options for PCR testing (which tests for the actual virus) being trialled by organisations. This is usually recommended for workers who are symptomatic or if a member of their household is symptomatic. We still need to be cautious with negative tests as PCR swabs do have a false negative rate. Combining testing of SARS-CoV-2 with other respiratory viruses can give us further information. Notably, if another respiratory virus is showing as positive then we are less worried about a negative COVID-19 swab being a false negative (in saying that sometimes coexisting infections can also be present).

Some organisations prefer to test their employees on a regular basis even if they are not showing symptoms to pick up asymptomatic carriers and those in the incubation period. Whilst this is possible, there is not any evidenced based guidelines into how effective this strategy is and how frequently testing should occur. 

– Personal Risk Stratificationcan be overlooked but is certainly a vital part of any back to work strategy. Patients that fall under the shielding category need to continue following the relevant Public Health England guidance. However, those with medical conditions and other risk factors falling into the moderate risk group also need to take extra precautions.

The challenge is the moderate risk group covers a very broad spectrum of risk and a one size fits all approach is simply not safe. Calculating an individual’srisk / probability of developing COVID-19 complications is important before deciding on further steps. There are various risk calculations tools available and these should be used to guide decisions but it’s also important to note many risk calculators are not validated and they will likely become more accurate and sophisticated as further evidence becomes available  -continuous review is important.

In summary, during what is likely to be an uncertain few months ahead of us, a bespoke and flexible plan is required for most businesses to get safely back to work. It’s important that any plan is regularly reviewed, particularly in light of any new developments as the pandemic progresses.

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Here’s a summary of the 2 main tests available:

PCR tests – throat / nose swab that test for presence of the actual virus. They are usually accurate when you first start developing symptoms (likely withing the first 7 days) but this is dependent on taking the swab correctly. An incorrect swabbing technique can certainly give a false negative result. 

This test can also be positive in those with no symptoms – so called asymptomatic carriers who are still able to spread the virus. 

The PCR swab may show as positive in the incubation period, possibly 1 or 2 days before developing symptoms in some cases but this is not completely reliable and therefore despite a negative test you may still be a carrier and able to infect others. 

We are unsure how long the test will remain positive for, as once symptoms develop individuals will clear the virus at different rates. Another interesting development is that some people test positive even 4-5 weeks after becoming symptomatic – currently the consensus is they are not infectious at this stage but the swab is being overly sensitive and picking up inactive viral genetic material.

Serology – generally a blood test which looks at the immune response specifically to the SARS-CoV2 virus. Serological tests can look for for both short term (IgM) and long-term (IgG) antibodies. In essence it looks for previous COVID19 infection but is not ideal for assessing acute current symptoms. 

Timing of the test is important. The antibodies may not show up as positive in the first few days of having the illness so if tested too early you may get a false result. Most manufacturers state tests are accurate after day 7 – 14 of having symptoms. 

The IgG antibody is likely to remain positive for at least a few months. It can show if you had COVID19 in the past but we are unsure if this means future protection and immunity. As with most tests there are also limitations (discussed in next update) – this is especially the case with point of care / home tests.

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There is emerging information regarding risk factors – some non-modifiable such as age, ethnicity and male gender. However, in terms of modifiable risk factors, obesity, cardiovascular disease, diabetes, hypertension and lung disease infer an increased risk.

The anxiety around coronavirus is partly due to the uncertainty. Hand washing and maintaining distance from those with flu like symptoms in addition to wider social distancing measures will help reduce infection rates. In addition, although the evidence about wearing masks is not conclusive there appears to be some benefit and many countries have adopted rules for wearing masks in public. 

But there’s more we can all do to get our immune systems primed to give us the best chance of fighting infections and a sense of some control. In general: 

– getting enough sleep (there are many entrepreneurs that live on 4 hours sleep, which may not cause too much of an issue in the short term but it’s not a good sustainable long term plan!)

–  moderate exercise for approximately 20 mins most days (over exercising can have a negative impact)

– Eating well (whole grains, nuts, seeds, fruit, vegetables)

– Avoiding excessive alcohol

– Avoiding smoking – although there are some reports that nicotine may have a protective effect, the other chemicals present in cigarettes damage the lungs and put you at risk of a more severe infection.

On a more personal level for those with other health conditions it’s important to optimise the numbers. A preventative and proactive approach to healthcare is vital. 

Focus on getting parameters such as HbA1c (average sugar levels), cholesterol, blood pressure and weight to target.
This can be done through a combination of lifestyle measures and / or medication. 
Optimising medications for other conditions such as asthma and COPD are also important.

There’s not enough evidence yet to say that this will translate in fewer complications / deaths, however it will improve overall health and logically that should lead to fewer complications.

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Routine, Routine, Routine…
We all generally function better when we have a set routine and your bowels are no different – especially when you have IBS.
It’s important to eat your meals at approximately the same time each day – this includes weekends!
Slowing down is also important. Many of us have busy schedules and often meal times are rushed. This tends to cause more stress on the bowel and aggravates IBS symptoms. Take enough time with meals, chew properly and don’t rush.

Drinking
Maintaining good hydration levels is important with IBS – ensure you are drinking at least 2 litres per day of mainly water (unless you have any other medical condition which requires you to restrict your fluid intake).
In patients that are constipated the fluid works with fibre in the diet to help relieve constipation. In individuals who have diarrhoea predominant IBS the fluid intake is important in recouping the fluid loss through loose motions.
Caffeine should be limited to no more than 2-3 cups of tea / coffee per day. This is due to caffeine stimulating bowel movements which can worsen symptoms. Furthermore, alcohol and carbonated drinks should also be minimised as both can worsen symptoms of diarrhoea. Low sugar drinks and those with added sweetener should also be avoided as they contain sorbitol which can lead to bloating and diarrhoea.

Probiotics
Probiotics are now readily available and can come in the form of capsules, drinks and yoghurts. They help to replace the “bad” bacteria in our bowels with “good” bacteria. Some studies have shown an improvement in IBS symptoms (abdominal pain and bloating) when using probiotics, however they do not seem to work for everyone.
The consensus is to try a particular probiotic for at least 4 weeks to assess response.

Not all fibre is equal
We are often told that having fibre is an important aspect of our diet but in patients with IBS it can exacerbate symptoms.
There are two main types of fibre – soluble and insoluble.
In patients with diarrhoea predominant IBS it is advisable to reduce insoluble fibre. This type of fibre does not easily dissolve in water and is found in whole-wheat bread, brown rice, and cereals. It adds more bulk to the stools which can make bloating and diarrhoea symptoms worse.
Soluble fibre is found in oats, barley, fruit and vegetables. It dissolves in water and forms a soft gel which can help aid the passage of stool. Increasing soluble fibre can help relieve symptoms in patients with constipation predominant IBS.

What are FODMAPs?
FODMAP stands for fermentable oligo-saccharides, di-saccharides, mono-saccharides and polyols.
These are essentially carbohydrates that are not well digested and enter the large bowel. Once there they draw in water in the large bowel and are fermented by gut bacteria leading to production of excess gases. This in turn can cause bloating and abdominal pain.
Having a low FODMAP diet has been shown to improve IBS symptoms in up to 80 % of patients. Examples of foods that are high in FODMAPs are numerous, including apples, pears, sweeteners, milk, cheese and cabbage. It is important to attempt a low FODMAP diet in conjunction with your doctor and a dietician.

For more information or a comprehensive consultation with a bespoke management plan please contact us at the GP Clinic London.

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Do I have IBS?
IBS symptoms include the following:
Bloating
Abdominal pain
Diarrhoea
Constipation
Urgency to open bowels
Feeling of incomplete bowel emptying

The symptoms need to be present for at least 6 months in order to positively diagnose IBS. Stress and anxiety can trigger the symptoms or make them worse. Typically, the bloating and abdominal pain is worse after eating and better after opening the bowels. The bowel habits may be altered in different ways, some patients have diarrhoea, others constipation and some with a mixed / alternating pattern.

Other Causes
Seeing a doctor is important if you feel you may have IBS – the symptoms are non-specific and other conditions can cause similar symptoms.
It is important for a clinician to take a thorough history and examination to rule out inflammatory bowel disease (ulcerative colitis and Crohn’s) and coeliac disease. Other less frequently encountered conditions also need to be excluded depending on risk factors, age and symptoms. For instance, bowel cancer may present with a change in bowel habit and ovarian cancer can present with symptoms of bloating.
Blood tests are usually recommended as a first line investigation, but other tests may be required such as stool tests, abdominal / pelvis ultrasound and colonoscopy.
It is only if these tests come back as negative that a diagnosis of IBS can be made.

Red flags
If you have any of the following symptoms it is worth seeing a doctor as soon as possible to rule out any other causes. Sometimes these symptoms can be associated with potentially sinister conditions:
Blood in the stools
Weight loss
New onset symptoms after the age of 40

What Treatment is available?
It is important to tackle IBS symptoms with a holistic approach. We know that stress is linked closely with IBS symptoms so this is an important area to focus on. Exercise and relaxation practices such as yoga and meditation can be hugely beneficial. There is also some evidence that acupuncture can help. In some cases, psychological therapies like CBT (cognitive behavioural therapy) and hypnotherapy have been shown to be effective.
Diet is an important aspect of IBS management. Ensuring you eat meals at approximately the same time each day and at regular intervals can help with symptoms. Also maintaining good hydration throughout the day and cutting down on tea, coffee and alcohol can help.
Specific dietary changes can also result in improved symptoms – this includes changing the type of fibre that you consume and low FODMAP diets – see article “5 dietary changes for IBS patients” for more information.
There are different types of medication that can help:
For abdominal pain and bloating – antispasmodic medications that relax the bowel (such as hyoscine and mebeverine) can be helpful. Also peppermint oil capsules can significantly reduce bloating.
In patients with diarrhoea predominant symptoms the use of loperamide can settle loose stools. Bulk-forming laxatives can be used in constipation predominant IBS.
Second line treatments include the use of antidepressant medications (both tricyclic antidepressants and selective serotonin reuptake inhibitors) – they are used in lower starting doses than those used for depression. These medications require monitoring and follow up and can often result in a significant reduction in symptoms.

For more information or a comprehensive consultation and a bespoke management plan please contact us at the GP Clinic London.

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