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The Reply

Published:December 17, 2021DOI:https://doi.org/10.1016/j.amjmed.2021.10.034
      We have read Dr Mohapatra's remarks on our commentary.
      • Mardikar H
      • Mardikar M
      • Deshpande N
      • Deshpande M
      • Admane P.
      COVID-19 second wave in India - wait or act?.
      We would like to respond point by point:
      During the coronavirus disease 2019 (COVID-19) pandemic, many international organizations and even local authorities came up with treatment guidelines. We firmly believe that the pandemic was a war-like situation, and guidelines needed to be taken with a pinch of salt.
      An interesting letter was published in Lancet in 2007 titled “Guidelines on Guidelines.” We quote the author: “This profusion of guidelines from multiple sources illustrates well the current obsession with guidelines, particularly from multiple tiers of bureaucracy at the expense of service delivery, unless something is done to curb this fixation, we will need a set of guidelines on the management of guidelines”.
      • Townend JN
      Guidelines on guidelines.
      A good clinician's challenge is not to generalize everything like an epidemiologist but to individualize therapy for the patient in front of him or her.
      Mohapatra has criticized what we did but ignored the study quoted in our commentary “Multiple Biomarker Approach to Risk Stratification in COVID-19”.
      • Smilowitz NR
      • Nguy V
      • Aphinyanaphongs Y
      • et al.
      Multiple biomarker approach to risk stratification in COVID-19.
      This was a retrospective analysis suggesting a multimarker strategy in which patients were categorized based on number of elevated biomarkers and was effective in identifying patients at high risk for in-hospital adverse cardiac events. Patients we treated had raised biomarkers that possibly pushed them from mild to moderate risk.
      The aim was not to do a randomized trial but to bring forward some observations in an outpatient department in a fully equipped cardiology hospital. Hopefully there will be no third wave, but in case we have a problem, this approach is the one that could be studied in larger trials. This is not the place to write stories of patients and their sufferings under various guidelines in government committees.

      Mascarenas A. COVID patients overcharged in private hospitals, finds state-wide survey. The Indian Express. Available at:https://indianexpress.com/article/cities/pune/covid-patients-overcharged-in-private-hospitals-finds-state-wide-survey-7542619/. Accessed October 3, 2021.

      Now that the issue of ethics has been raised, it is worth mentioning that every single patient we treated was on a humanitarian basis and without any charges.
      This is a story of patients treated amid during a pandemic in which there were scarce resources available.
      The author mentions that we diverted the supply of Remdesivir; this is absolutely false. Different states had different policies for injectable Remdesivir therapy and the policies kept changing.
      Finally, the author suggests that this is misleading information and urges an evidence-based approach with a randomized trial. In this small observation, we followed the Hippocratic principle: first do no harm to patient (ie, primum non nocere); Remdesivir is a reasonably safe injection with few side effects with short five day therapy. The alternative option was to wait for the clinical condition to deteriorate or improve automatically. Waiting could have had grave consequences because hospitals were short of beds. As mentioned in our commentary, patients were encouraged to be admitted.
      The data published to date showed that those older than the age of 60 years with comorbidities suffered the most; that was the subset we treated.

      References

        • Mardikar H
        • Mardikar M
        • Deshpande N
        • Deshpande M
        • Admane P.
        COVID-19 second wave in India - wait or act?.
        Am J Med. 2021; 134: 1309https://doi.org/10.1016/j.amjmed.2021.06.002
        • Townend JN
        Guidelines on guidelines.
        Lancet. 2007; 9589: 740https://doi.org/10.1016/S0140-6736(07)61376-2
        • Smilowitz NR
        • Nguy V
        • Aphinyanaphongs Y
        • et al.
        Multiple biomarker approach to risk stratification in COVID-19.
        Circulation. 2021; 143: 1338-1340https://doi.org/10.1161/CIRCULATIONAHA.120.053311
      1. Mascarenas A. COVID patients overcharged in private hospitals, finds state-wide survey. The Indian Express. Available at:https://indianexpress.com/article/cities/pune/covid-patients-overcharged-in-private-hospitals-finds-state-wide-survey-7542619/. Accessed October 3, 2021.