Just for fun —YouTube (~3 minute video): The Swish Machine: 70 Step Basketball Trickshot (Rube Goldberg Machine)
Full text —MR Larochelle. DOI: 10.1056/NEJMp2013413. NEJM: Is It Safe for Me to Go to Work?
I believe that a strategy to protect at-risk workers needs at least three components: a framework for counseling patients about the risks posed by continuing to work, urgent policy changes to ensure financial protections for people who are kept out of work, and a data-driven plan for safe reentry into the workforce…
The Occupational Safety and Health Administration has published guidance and proposed a scheme for classifying the risk of SARS-CoV-2 infection as high, medium, or low based on potential contact with persons who may or do have the virus (www.osha.gov/Publications/OSHA3990.pdf. opens in new tab). Low-, medium-, and high-risk categories of individual risk of death from Covid-19 are based on age and the presence of high-risk chronic conditions identified by the CDC…
As states move to reopen their economies, millions of nonessential employees will join essential employees in putting themselves at risk for contracting SARS-CoV-2 at work. Physicians should engage patients in individualized risk assessments. Our society has the moral imperative and means to provide vulnerable employees a financial safety net until we can better ensure their workplace safety.
Related blog post: @Atul_Gawande: How to Reopen
Full Text: KF Murray, BD Gold, R Shamir et al. JPGN 2020; 70: 720-6. Coronavirus Disease 2019 and the Pediatric Gastroenterologist. This article includes CME availability too!
- The latest global count updates can be found at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/.
- SARS-CoV-2 is a positive-sense, single-stranded RNA virus belonging to the genus Betacoronavirus, and phylogenetically related (88%–89% similarity) to the two bat-derived SARS-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21….
- Routine gastroenterology practice poses increased risk of exposure and potential viral transmission during ambulatory interaction, especially during endoscopic procedures…
- The use of telemedicine is now a critical tool for the pediatric gastroenterologists and their patients, whether in the academic setting or private practice…The recently published AAP guideline, entitled Telehealth Payer Policy in Response to COVID-19 (https://downloads.aap.org/DOPA/Telehealth_2_rev.pdf and https://www.aap.org/en-us/professional-resources/practice-transformation/telehealth/Pages/compendium.aspx), which outlines policy changes aiming to alleviate barriers to telehealth care, along with a webinar on telehealth and guidance on structuring your practice during the pandemic are tools that can be employed in both the academic and private practice pediatric gastroenterologist office to facilitate ongoing quality care of their patients
My take: This article provides a concise update and numerous resources. As the information about the coronavirus is rapidly changing, the recommendations will continue to evolve.
Also, JPGN has a large number of articles available on its COVID-19 page: Link: COVID-19 page This page includes articles related to endoscopy, PPE, telemedicine, and central line infections. Also, based on a personal communication, there will be a link to a recently published article soon on “Pediatric Crohn’s Disease and Multisystem Inflammatory Syndrome in Children (MIS-C) and COVID-19 Treated With Infliximab.”(Dolinger M T, Person H, Smith R, et al. Journal of Pediatric Gastroenterology & Nutrition 2020; PMID: 32452979 DOI: 10.1097/MPG.0000000000002809)
Interesting article: Full Text: SARS-CoV-2 RNA concentrations in primary municipal sewage sludge as a leading indicator of COVID-19 outbreak dynamics
M Sahin-Toth. Gastroenterology 2020; 158: 1538-40. Full Text Link: Channelopathy of the Pancreas Causes Chronic Pancreatitis
Excerpt from editorial:
In this issue of Gastroenterology, Masamune et al report a landmark discovery, the genetic association of functionally defective TRPV6 channel variants and chronic pancreatitis. The authors investigated the TRPV6 gene in Japanese and European patients with nonalcoholic chronic pancreatitis using targeted sequencing followed by functional analysis of the identified variants. In the Japanese discovery cohort, they found functionally defective variants in 4.3% of the patients and in 0.1% of the controls (odds ratio 48). In the European replication cohort, 2% of the patients carried a defective variant and none was found in controls.
Original research study: A Masamune et al. Gastroenterology 2020; 158: 1626-41. Full text: Variants That Affect Function of Calcium Channel TRPV6 Are Associated With Early-Onset Chronic Pancreatitis
TRPV6 variants are globally associated with early-onset nonalcoholic CP. To our knowledge, TRPV6 is a novel pancreatitis-associated gene beyond the pancreatic digestive enzyme/enzyme inhibitor system, and it is the first gene that directly regulates Ca2+ homeostasis. Our findings open a completely new avenue by emphasizing the potential role of ductal cells and, especially, calcium channels in the pathophysiology of pancreatitis, which might lead to the development of personalized medicine targeting TRPV6 channel activity.
Yesterday –E Schneider NEJM commentary (DOI: 10.1056/NEJMp2014836) on how the U.S. has lagged behind other countries in SARS-CoV-2 testing Full Text: Failing the Test
Tragically, the United States, unable to match other countries’ response, has tallied the most cases and deaths in the world — and recent data suggest that those tallies are underestimates. Why has the U.S. response been so ineffectual? One key answer is testing, which has been a cornerstone of Covid-19 control elsewhere…
Having failed to test early enough to contain outbreaks, the country has fallen back on two mitigation strategies: accelerating drug and vaccine development and an unprecedented strategy of nonpharmacologic interventions (NPIs) involving draconian school and business closures, stay-at-home orders, and physical distancing
T Lewis. Scientific American (May 12): How Coronavirus Spreads through the Air: What We Know So Far
According to the U.S. Centers for Disease Control and Prevention and the World Health Organization, the novel coronavirus is primarily spread by droplets from someone who is coughing, sneezing or even talking within a few feet away. But anecdotal reports hint that it could be transmissible through particles suspended in the air…
“There is not much convincing evidence that aerosol spread is a major part of transmission” of COVID-19, Perlman says. That assessment does not mean it is not occurring, however…
Cowling hypothesizes that many respiratory viruses can be spread through the airborne route—but that the degree of contagiousness is low…
Most researchers still think the new coronavirus is primarily spread via droplets and touching infected people or surfaces. So diligent hand washing and social distancing are still the most important measures people can take to avoid infection.
In the latest bungling of tracking data for the novel coronavirus, a recently posted bar chart on the Georgia Department of Public Health’s website appeared to show good news: new confirmed cases in the counties with the most infections had dropped every single day for the past two weeks.
In fact, there was no clear downward trend. The data is still preliminary, and cases have held steady or dropped slightly in the past two weeks.
DPH’s page has led readers to think that cases were dropping dramatically, even though lower case numbers were the result of a lag in data collection.
My take: Though, the number of reported cases has been fairly steady in Georgia, the amount of testing has increased; thus, even if the numbers hold steady, this likely reflects some improvement in the absolute number of infected individuals.
A recent terrific review on Alpha-1-Antitrypsin (A1AT) Deficiency: P Strnad et al. NEJM 2020; 382: 1443-55
- 95% of A1AT deficiency is due to homozygosity for the Z allele; prevalence of 1 in 2000 in those of European descent.
- A1AT protects the lung tissue against attack by the enzyme neutrophil elastase.
- The presence of A1AT genetic variants suggests that these mutations may confer a selective advantage, perhaps by amplifying the inflammatory response to invasive respiratory/gastrointestinal infections.
- Table 1 lists the key alleles/mutations associated with A1AT deficiency -17 deficiency/null listed including: F, I, Iners, King’s, M-malton, M-procida, Pittsburgh, Queen’s, S, S-iyama, Z, QO-bellingham, QO-granitefalls, QO-hongkong
- S allele deficiency often results in disease (emphysema, cirrhosis) in the setting of SZ heterozygotes. The disease is typically less severe than in ZZ disease. This allele is the most common deficiency variant (1 in 5 in Southern Europe, 1 in 30 in U.S.)
- Z allele deficiency is the most common severe deficiency variant. Carrier frequency: 1 in 27 persons in Northern Europe, 1 in 83 in the U.S. It is NOT seen in China, Japan, Korea, Malaysia, or Northern and Western Africa.
PI ZZ Genotype:
- 73% of infants with PI ZZ genotype had elevated ALT level in the 1st 12 months of life
- Cholestatic jaundice noted in 10% of infant; 15% of these infants progress to juvenile cirrhosis
- Only 15% with abnormal ALT values by 12 years of age
- 35% of adults with ZZ genotype show clinically-significant liver fibrosis. Risk factors for advanced fibrosis: male gender, metabolic syndrome/obesity, and alcohol consumption.
Lung Disease Due to A1AT Deficiency:
- The clinical features of lung disease due to A1AT deficiency are “mainly indistinguishable from those of nonhereditary emphysema…this is partly why severe A1AT deficiency remains undiagnosed in approximately 90% of case, with an interval of 5 to 7 years from the onset of symptoms to diagnosis.” When the diagnosis is late, lung disease has become irreversible.
- Early diagnosis allows lifestyle changes (eg. smoking cessation), reduction in occupational risks, and access to therapies.
PI MZ genotype is more susceptible to multiple disorders, including a predisposition to COPD (at least among smokers) with odds ratio of 1.4. Other conditions with increased risk: NAFLD-related cirrhosis (OR 3-7), Alcoholic cirrhosis, and CF-associated liver disease
- Smoking cessation
- Plasma-purified A1AT infusions. “Randomized, controlled trials have focused on decreased loss of lung density as the primary efficacy outcome;” however, augmentation therapy has not been to shown to effect other measures, “such as FEV1, quality of life, or exacerbation of COPD.”
Related blog posts:
Also, this study was previously alluded to by this blog, but now is in print:
Briefly noted: X Lu et al. SARS-CoV-2 Infection in Children (NEJM 2020; 382: 1663-5). In 171 Chinese children with confirmed SARS-CoV-2 infection, 41.5% had fever during illness; 27 (15.8%) had no symptoms of infection or radiographic findings. Three required ICU/ventilator support; all had coexisting conditions. One 10 month old child with intussusception died.
Recent data show why experts were concerned about SARS-CoV-2 (COVID-19 Virus) several months ago, due to its potential for exponential spread. Even now many question whether this infection is more significant than influenza.
Link: COVID-19 Daily Deaths
Between March 22 and April 4, 2020, a total of 215 pregnant women delivered infants at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center [NYC] …
Most of the patients who were positive for SARS-CoV-2 at delivery were asymptomatic, and more than one of eight asymptomatic patients who were admitted to the labor and delivery unit were positive for SARS-CoV-2. Although this prevalence has limited generalizability to geographic regions with lower rates of infection, it underscores the risk of Covid-19 among asymptomatic obstetrical patients. Moreover, the true prevalence of infection may be underreported because of false negative results of tests to detect SARS-CoV-2
My take: This study indicates that there are a lot of undetected cases of SARS-CoV-2.
Stony Brook Univeristy’s Innovations to manage COVID-19 Crisis -NEJM: Staying Ahead of the Wave
- To minimize direct contact with patients and to conserve PPE, we rapidly deployed a telehealth solution that involves giving patients iPads to communicate with health care staff and consultants.
- Our engineers and chemists have been producing face shields, masks, a prototype ventilator, and hand sanitizer (https://news.stonybrook.edu/sb_medicine/stony-brook-ingenuity-takes-on-coronavirus/. opens in new tab).
- We have found a safe and effective way to sterilize used N95 respirators to further conserve PPE (www.battelle.org/newsroom/news-details/battelle-cleared-to-sterilize-n95-masks-at-max-capacity-operate-in-other-states-to-fight-coronavirus-ppe-shortage. opens in new tab).
Related blog posts:
- NY Times: How Will We Know When to Reopen the Country? & Timely Tweets
- COVID-19 Projections –IHME Data & IBD Infusion RecommendationsHow to Do a Colonoscopic Polypectomy and U.S. COVID-19 Tracker NPR: Map: Tracking The Spread Of The Coronavirus In The U.S This tracker details the pandemic in every state.
- How to Protect Healthcare Workers from COVID-19 -Lessons from Hong Kong and Singapore Atul Gawande has a very pertinent article in the New Yorker: Keeping the Coronavirus from Infecting Health-Care Workers
- What is the Current Standard of Care for PPE and Endoscopy Cases? Link to manuscript: COVID-19 in Endoscopy: Time to do more?
- Bill Gates: What We Need to Do Now for COVID-19, False-negative testing & Article Describing 3 Stages of Infection From NY Times: If You Have Coronavirus Symptoms, Assume You Have the Illness, Even if You Test Negative Bill Gates: Here’s how to make up for lost time on covid-19 & article describing 3 stages of infection: COVD-19 Illness in Native and Immunosuppressed States: A Clinical-Therapeutic Staging Proposal
- Allocating Scarce Resources During COVID-19 Pandemic Links CDC Link: Testing for COVID-19 Full Link NEJM 2020 (Ezekial J Emmanuel et al): Fair Allocation of Scarce Medical Resources in the Time of Covid-19. This post also displays some data on sensitivity/specificity of testing
- Iron Injectables Links Financial Times: Coronavirus tracked: the latest figures as the pandemic spreads | Free to read & from Johns Hopkins: COVID19 Caseload & Outcomes Worldwide
- COVID-19: Veneto vs. Lombardy and Georgia’s Part of this Pandemic Link: Harvard Business Review: Lessons from Italy’s Response to Coronavirus & Georgia DPH: COVID-19 Daily Status Report
- “Crushing It” Two More Pediatric Hepatitis C studies Full link from NY Times: How Long Will Coronavirus Live on Surfaces or in the Air Around You? and blog post shows how to properly place PPE
- Ethical Dilemmas and Digestive Symptoms –Common with COVID-19 Full link: NEJM: Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line & digestive symptoms ACG: Full Link: ACG Media Statement
- More Advice on Coronavirus for Pediatric GIs: NASPGHAN and CCFA CCFA Guidance for Pediatric Caregivers and Patients —Updates on COVID-19 and IBD
- Autoimmune Hepatitis Outcomes, Grand Rounds on Splenomegaly, Hydroxychloroquine for SARS-CoV-2 & Zantac Warning
- Liver Shorts and COVID-19 Screenshots This post includes Fauci donuts, AJG reference on COVID-19 digestive symptoms, and technology to sterilized used PPE
- New: NEJM link to video demonstrating need for PPE during intubation -see picture at bottom of post. Fluorescent Spray During Intubation and at the bottom -there is an image showing how hydroxychloroquine and azithromycin could increase risk for life-threatening arrhythmias
Here’s a commentary explaining why hydroxychloroquine is NOT proven effective:
Annals of Internal Medicine -Link: A Rush to Judgment? Rapid Reporting and Dissemination of Results and Its Consequences Regarding the Use of Hydroxychloroquine for COVID-19
Some of the key points:
- While the study suggested more rapid clearance of SARS-CoV-2 virus at day 6 in those treated with hydroxychloroquine/azathioprine (n=20), the authors excluded 6 from the treatment group including one patient who died and three who were transferrred to the ICU. In addition, the treatment group had a lower viral load at the start of treatment.
- Other viral infections, including influenza, have also had in vitro data suggesting efficacy with hydroxychloroquine but this did not translate into clinical efficacy in clinical trials.
- “The hydroxychloroquine shortage not only will limit availability to patients with COVID-19 if efficacy is truly established but also represents a real risk to patients with rheumatic diseases who depend on HCQ for their survival.”
A Di Giorgio et al (J Pediatr 2020; 218: 121-9) provide long-term data (median f/u of 14.5 years) from a retrospective review on 83 children with autoimmune hepatitis (AIH, n=54)/autoimmune sclerosing cholangitis (ASC, n=29). Median age at presentation, between 2000-2004 was 12.1 years
- 29% had histologic evidence of cirrhosis at diagnosis
- At a median followup of 14.5 years, 99% were alive, 11 underwent transplantation. In those who underwent transplantation, 5-year and 10-year survival was 95% and 88% respectively.
- ASC was associated with IBD in 73% of cases, compared to 33% of AIH patients.
- Treatment: 95% of all patients had normalization with transaminases with immunosuppressive treatment (most commonly azathioprine with prednisone 2.5-5 mg/day). ASC patients also received ursodeoxycholic acid 15-20 mg/kg/day.
- Immunologic remission: 47% achieved immunologic remission which required normal IgG levels and negative/low ANA/SMA <1:20 in addition to normal transaminases.
- Liver transplantation was needed in 28% of ASC compared to 9% of AIH patients; overall, 83% experienced 15-year transplant-free survival. Median age of those needing a liver transplant was 19.3 years.
- Immunosuppression withdrawal was attempted in 12 patients after a median of 4.5 years of treatment. 9 were able to stay off immunosuppression.
- An increase in case frequency was noted during the last 4 decades at this center, from 3.6 cases/year to 5.4 case/year.
- Four patients had isolated infrequent autoantibodies of anti-SLA (n=3) nad antiLC-1 (n=1). SLA =liver soluble antigen, LC-1 =liver cytosol antibody type 1. Thus, in those with suspected AIH/ASC, testing for these autoantibodies is important in ~5%.
- Pathology: 18% did not have classical features of interface hepatitis. Instead, some had lymphocytic/lymphoplasmocytic infiltrate without spillover into the parenchyma.
- Progression from AIH to ASC occurred in 3 patients on followup cholangiography.
- ASC would have been overlooked in 41% if one relied on pathology alone -reaffirming need for biliary imaging.
My take: This article has a number of useful points and with an overarching message that long-term outcomes are good for children with AIH/ASC.
Related blog posts:
- Steroid-Free Approach in Autoimmune Hepatitis
- Azathioprine metabolite measurement for Autoimmune Hepatitis | gutsandgrowth
- Adult versus Pediatric Data: Autoimmune Hepatitis | gutsandgrowth
- Genetics of Autoimmune Hepatitis | gutsandgrowth
- Diagnosing autoimmune hepatitis
B Freiberg et al. 2020; 218: 221-31. This grand rounds describes the extensive workup of a 12 year old with splenomegaly ultimately due to splenic vein stenosis. The report provides a nice review of hepatologic, hematologic, infectious, and other causes of splenomegaly as well as a work-up algorithm. (look for everything).
Initial evaluation per algorithm should start with CBC/d, retic, blood smear, liver biochemistries, GGT, coags, EBV VCA IgM, CMV IgM, Parvovirus IgM, and complete abdominal ultrasound with doppler.
Hepatologic causes of splenomegaly include the following:
- cirrhosis with portal hypertension
- autoimmune hepatitis/autoimmune sclerosing cholangitis
- congenital hepatic fibrosis
- hepatoportal sclerosis
- nodular regenerative hyperplasia
- storage disease and inborn errors of metabolism which includes lipidosis (Gaucher, Niemann-Pick), mucopolysaccharidoses, defects in carbohydrate metabolism (galactosemis, hereditary fructose intolerance), sea-blue histiocyte syndrome
- anatomic disorders: portal/splenic thrombosis, Budd-Chiari, cysts, hamartomas, hemangiomas, hematoma, peliosis
Other causes of splenomegaly: infecions, hematologic-oncologic, and rheumatic disorders
Related blog posts:
|The U.S. Food and Drug Administration today announced it is requesting manufacturers withdraw all prescription and over-the-counter (OTC) ranitidine drugs from the market immediately. This is the latest step in an ongoing investigation of a contaminant known as N-Nitrosodimethylamine (NDMA) in ranitidine medications (commonly known by the brand name Zantac). The agency has determined that the impurity in some ranitidine products increases over time and when stored at higher than room temperatures and may result in consumer exposure to unacceptable levels of this impurity. As a result of this immediate market withdrawal request, ranitidine products will not be available for new or existing prescriptions or OTC use in the U.S.
New FDA testing and evaluation prompted by information from third-party laboratories confirmed that NDMA levels increase in ranitidine even under normal storage conditions, and NDMA has been found to increase significantly in samples stored at higher temperatures, including temperatures the product may be exposed to during distribution and handling by consumers. The testing also showed that the older a ranitidine product is, or the longer the length of time since it was manufactured, the greater the level of NDMA. These conditions may raise the level of NDMA in the ranitidine product above the acceptable daily intake limit.
CC Thompson et al. Gastointestinal Endoscopy (EPUB), in a letter to the editor, respond to two recent studies on SARS-CoV-2 virus/COVID-19 and provide recommendations for PPE use in this era of COVID-19.
Here’s a link to manuscript: COVID-19 in Endoscopy: Time to do more?
- Reduce non-urgent cases. “We have cut our daily endoscopy volume by over 80% and closed our ambulatory endoscopy practice.”
- Increase the use of telemedicine. “At present, telemedicine or virtual visits make up 91% of our upcoming clinic appointments.”
- Physical distancing as advocated recently by WHO throughout a patient’s time in the endoscopy unit is stressed in the papers, with a 6-foot minimum between individuals.
- Suggests “the need for a separate toilet as part of the isolation to minimize spread of infection due to bioaerosols from the toilet plume”
- Our hospital system has recently changed policy to mandate that all employees wear surgical masks at all times while in the hospital and attest to their wellness online before reporting to work.
- We suggest labeling each computer so the same provider uses that computer and chair for the entire day, and separating by at least 6 feet.
- All endoscopic procedures (upper endoscopy, colonoscopy, EUS, ERCP) are aerosol-generating, referencing studies that show contamination of the endoscopist’s face during routine procedures. This makes all endoscopic procedures high risk from an infectious standpoint, and appropriate PPE is
recommended… It makes little sense for healthcare providers to perform
aerosolizing procedures, with patients coughing or passing gas on them, while not wearing an N95 mask or better
- “It is important to use full PPE for all endoscopic procedures while in a pandemic such as this especially in areas with community spread, because no one is truly low risk given our ongoing difficulties with testing.”
- “The mask can be reused as long as it is functional, not soiled, and not used in a suspected or COVIDpositive patient. It is important to cover the N95 to prevent soiling.”
- “A study from China showed that no medical staff working in high-risk departments who wore N95s and practiced strict hand hygiene regardless of patient’s infection status became infected.”
- “Testing all patients before high-risk procedures such as endoscopy is likely the best approach; however, this will depend on significant expansion of testing capabilities. Hopefully, the development of point-of-care testing with rapid results and increasing testing availability will make this a reality soon”
My take (in part from authors): “We are living through an unprecedented time and are all trying our best to protect our patients and ourselves under suboptimal conditions of limited PPE, limited testing, and limited data. ” The recommendations in this article are based mainly on expert opinion and may need modifications based on new data and circumstances.
IOIBD (International Organization for the Study of Iinflammatory Bowel Disease) Recommendations (#76) for IBD Patients with Regard to COVID-19:
Full link: IOIBD Update on COVID19 for Patients with Crohn’s Disease and Ulcerative Colitis (3/26/20)
Atul Gawande has a very pertinent article in the New Yorker: Keeping the Coronavirus from Infecting Health-Care Workers
There are lessons to be learned from two places that saw the new coronavirus before we did and that have had success in controlling its spread. Hong Kong and Singapore…
All health-care workers are expected to wear regular surgical masks for all patient interactions, to use gloves and proper hand hygiene, and to disinfect all surfaces in between patient consults. Patients with suspicious symptoms (a low-grade fever coupled with a cough, respiratory complaints, fatigue, or muscle aches) or exposures (travel to places with viral spread or contact with someone who tested positive) are separated from the rest of the patient population, and treated—wherever possible—in separate respiratory wards and clinics, in separate locations, with separate teams. Social distancing is practiced within clinics and hospitals: waiting-room chairs are placed six feet apart; direct interactions among staff members are conducted at a distance; doctors and patients stay six feet apart except during examinations.
What’s equally interesting is what they don’t do. The use of N95 masks, face-protectors, goggles, and gowns are reserved for procedures where respiratory secretions can be aerosolized. Their quarantine policies are more nuanced, too. What happens when someone unexpectedly tests positive—say, a hospital co-worker or a patient in a primary-care office or an emergency room? In Hong Kong and Singapore, they don’t shut the place down or put everyone under home quarantine. They do their best to trace every contact and then quarantine only those who had close contact with the infected person. In Hong Kong, “close contact” means fifteen minutes at a distance of less than six feet and without the use of a surgical mask; in Singapore, thirty minutes. If the exposure is shorter than the prescribed limit but within six feet for more than two minutes, workers can stay on the job if they wear a surgical mask and have twice-daily temperature checks. People who have had brief, incidental contact are just asked to monitor themselves for symptoms…
Transmission seems to occur primarily through sustained exposure in the absence of basic protection or through the lack of hand hygiene after contact with secretions…
Singapore so far appears not to have had a single recorded health-care-related transmission of the coronavirus, despite the hundreds of cases that its medical system has had to deal with…
For those who cannot stay home, the lesson is that it is feasible to work and stay coronavirus-free, despite the risks….a greater likelihood of staff picking up infections at home than at work.