For the management of COVID-19 patients, the document outlines guidelines for treating mild, moderate and severe cases. It discusses criteria for hospital admission, oxygen support, antiviral and supportive treatments. It provides guidance on prone positioning, intubation, ICU admission for severe ARDS patients and ventilator management. It also covers anticoagulation, septic shock management and care of critically ill patients. The goal is to provide evidence-based recommendations for treating the varying severity levels of COVID-19.
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
COVID-19 (Coronavirus Disease 2019) is an infectious disease caused by the recently found virus known as SARS-CoV-2 (or coronavirus). Before the outbreak originated in Wuhan, China on December 2019, there was no information about this virus. Case Definition (India), Symptoms, Statistics, Preventive Measures, Management
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
COVID-19 (Coronavirus Disease 2019) is an infectious disease caused by the recently found virus known as SARS-CoV-2 (or coronavirus). Before the outbreak originated in Wuhan, China on December 2019, there was no information about this virus. Case Definition (India), Symptoms, Statistics, Preventive Measures, Management
DEFINITIONS:
• ILI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F) and
– cough
– with onset within last 10 days
• SARI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F),
– cough
– with onset within the last 10 days and
– requiring hospitalization
• Respiratory failure
– Represents the failure of the lung to maintain adequate gas exchange
– Characterized by ABG abnormalities: PaO2< 60 mmHg with or without hypercarbia PaCO2> 46 mmHg (with drop in pH<7.30)
DEFINITIONS:
• ILI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F) and
– cough
– with onset within last 10 days
• SARI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F),
– cough
– with onset within the last 10 days and
– requiring hospitalization
• Respiratory failure
– Represents the failure of the lung to maintain adequate gas exchange
– Characterized by ABG abnormalities: PaO2< 60 mmHg with or without hypercarbia PaCO2> 46 mmHg (with drop in pH<7.30)
Airway manipulations and intubation are the potential to cause a high level of aerosolization in the emergency department. This presentation is giving an overview of how to perform protected intubation in the emergency department. It has prepared by using the available latest data on COVID 19 protected Intubation
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. Management of mild cases
Mild cases are those with low grade
fever/cough/malaise/rhinorrhea/sore throat WITHOUT any
shortness of breath
Admission in COVID care centers
Contact and droplet precautions, strict hand hygiene
Symptomatic treatment
Tab Hydroxychloroquine 400 mg BD for 1 day followed by 400
mg OD for 4 days in patients
with high risk factors for severe disease may be considered
3. Indications for hospital admission(moderate case)
The following criteria may be applied to consider for admission (Any ONE of the
following):
1. Respiratory rate > 24/min
2. SpO2 < 94% on room air
3. Those at high risk for severe disease:
a. Age > 60 years
b. Cardiovascular disease including hypertension
c. Diabetes mellitus/other immunocompromised states
d. Chronic lung/liver/kidney disease
e. Cerebrovascular disease
4. Consider Tab HCQ** (400 mg BD x 1 day f/b 400 mg OD x
4 days) **
Oxygen Support:
Target SpO2: 92-96% (88-92% in patients with COPD)
Preferred device for oxygenation: preferably
nonrebreathing face mask ,venturimask, HFNC
Monitor for: Work of breathing
Fatigue
Hemodynamic instability
Change in oxygen requirement
5. • Assessment of severity of hypoxemia/shunt: If patient
achieves a SpO2 >95% at 15L/min O2 the shunt fraction is mild. Failure
to achieve this indicates a moderate-severe shunt fraction.
• If the target is not achieved/maintained with the above mentioned
devices,
cautious trials of CPAP via oro-nasal mask/NIV via helmet interface
maybe given.
• Try to achieve targets with lowest possible PEEP.
• Use of CPAP/NIV requires intensive monitoring for any increase in
work of breathing/large tidal volume breaths [to prevent self-inflicted
lung injury (SILI)] and hemodynamic instability
6. Awake proning may be used as a rescue therapy
All patients should have daily 12-lead ECG
Follow CRP, D-dimer, LDH, Trop I & Ferritin every 48-
72 hourly; CBC w/diff, KFT/LFT & coagulation parameters
daily Symptomatic and supportive treatment
(antipyretics,antibiotics, etc. as per existing protocol)
Anticoagulation
Prophylactic dose of LMWH(e.g., enoxaparin1mg/kg
per day SC)
7. #Prone positioning in COVID-19 pneumonitis:
Awake proning prior to intubation:
• May serve as an adjunct to use of non-invasive respiratory
support and should only be used as a rescue therapy
• The benefit is usually short lived and lies in redistribution of
perfusion
• Awake proning should only be considered if patient:
o Is Able to communicate and co-operate with the procedure
o Is Able to rotate to front and adjust position independently
o Has no anticipated airway issue
8. • If patients fulfils criteria for proning, ask the patient to switch
positions every 30 min to 2 hours ,while looking for
improvement in oxygenation, as follows:
o Lying on right side
o Sitting up (30-60 degrees) by adjusting head of the bed
o Lying on left side
o Lying prone again
9.
10. For patients with a PaO2/FiO2 ratio of less than 150, the next maneuver is proning the
patient, or placing them in the proned position, to improve oxygenation to the posterior
lungs. Proning the patient improves V/Q matching and allows the patient to have gas
exchange along the posterior aspects of the lungs
11. How to intubate:
Intubation trolley should be prepared and kept ready in ICU
Intubation checklist should be displayed inside ICU
The most skilled member of the team should be identified at the beginning of
each shift for performing intubation
Ensure proper fit of N95 mask and face shield before attempting intubation
Pre-oxygenate with 100% FiO2 for 3-5 minutes with closed circuit (preferably)
Try to avoid bag and mask ventilation (due to high risk of aerosol generation)
but can be used if required by connecting an HME between mask and AMBU bag
(or HME between
12. Use video laryngoscope and endotracheal tube with stylet for
intubation
Rapid sequence intubation (RSI) to be done using available
induction agents (preferably etomidate 0.3 mg/kg) and muscle
relaxants (Succinylcholine 1.5mg/kg or Rocuronium 1.2mg/kg)
Monitor for hemodynamic instability during induction
Use visible chest rise, end-tidal CO2 and subsequently X-ray chest to
confirm correct position of tube as auscultation may not be possible
with PPE
13. In unanticipated difficult airway when intubation is not
successful in two attempts, use 2nd generation laryngeal mask
airway (i-Gel or Proseal LMA) as rescue device for ventilation
and call for expert help
Insert nasogastric/orogastric tube at the same sitting to avoid
repeat exposure
Remove the outer most pair of gloves as early as possible to
avoid contamination to other surfaces
After intubation, appropriate cleaning/disinfection of
equipment and environment should be done
14. COVID ICU admission(severe case):
1. Moderate/Severe ARDS
2. Multi-organ dysfunction
3. Shock
4. Transfer from ward to ICU if needs mechanical
ventilation/closer monitoring
15. ARDS
The condition must be acute (< 7 days)
The findings are not solely explained by cardiogenic
pulmonary edema
The chest X-ray must have bilateral opacities
While on at least 5 cmH2O of positive pressure ventilation, the
ratio of PaO2 to FiO2 (expressed as a decimal, such as 0.7)
must be < 300
Mild ARDS is a PaO2/FiO2 ratio of 200-300
Moderate ARDS is 100-199
Severe ARDS is < 100
16.
17. This is the principle behind performing a recruitment maneuver and a
“BestPEEP” trial to find a PEEP that optimizes compliance – preventing both
atelectasis and overdistention
18.
19. Tidal Volume
4-8 ml/kg PBW, starting with 6
ml/kg
Respiratory Rate
Higher, often > 20 breaths per
minute
PEEP ≥ 8 cmH2O, avoiding overdistention
FiO2
Decrease as tolerated, SpO2 ≥ 92%
21. Antibiotics and antivirals as per clinician’s discretion (to cover
community acquired pneumonia including atypical pneumonia and
Influenza)
Patients with high risk factor should be transferred to
designated hospital without dely.
22. Symptomatic treatment
Maintain euvolemia
Work of breathing:
o Excessive inspiratory efforts (requiring accessory muscles of respiration, large
volume tidal breaths, air hunger)
o Esophageal pressure monitoring (if available)
Oxygen requirement
Vital signs
Laboratory:
Routine: CBC with differentials, LFT, KFT, coagulation profile, Urine R/M
Predictive and prognostic markers: CRP, LDH, Ferritin, D-Dimer, Troponin
I
23. Anticoagulation
• All hospitalized patients should be started on prophylactic LMWH (e.g.,
Enoxaparin 1mg/kg per day Subcutaneously) if not contraindicated, and no high
risk factors for bleeding are present
• Bleeding risk should be estimated with well validated risk scores (e.g. HAS-BLED
score of ≥3
signifies a higher bleeding risk)
• In patient with a HAS-BLED score of 3, a risk benefit analysis should be done
considering the risk of thrombosis based on level of D-dimer and SIC score ( ≥4
suggests high risk of thrombosis)
• In patients who are admitted to ICU, consideration should be given to
therapeutic dose LMWH
(e.g., enoxaparin 1mg/kg SC BD), if not at high risk of bleeding
24. Specific therapy:
NO SPECIFIC ANTIVIRALS have been definitively proven to be
effective as per currently available data.
Drugs which have been tried in clinical trial settings include:
a) Hydroxychloroquine/Chloroquine b) Lopinavir/ritonavir c)
Remdesivir d) Nitazoxanide e) Ivermectin
Steroids may be considered in a defined subgroup of patients
including:
o Patients with critical disease (admitted in the ICU)
Given the potential for delayed viral clearance, the duration of
steroid use should be limited to 3 to 5 days (with no tapering) in low to
moderate doses (1-2mg/kg/day)
25. Adjunctive therapy (may be considered):
Inj. Vit C 100mg/kg IV in 4 divided doses plus
Inj. Thiamine 200mg IV Q12 hourly
26. Supportive treatment in critically ill patients:
Head end elevation (30 to 45 degrees)
Oral hygiene with mouthwash
Glycemic control to maintain blood sugar between
140 to 180 mg/dl
Ulcer prophylaxis with proton pump inhibitors
Foley’s catheter and Ryle’s tube placement
Central venous catheter (CVC) insertion
Pressure ulcer prevention by position change every 2 hourly
27.
28. Care of ventilated patient:
Fresh ventilator circuit to be used for every new patient
Change circuit only when visibly soiled (not routinely)
Use two HME filters- one at the patient end close to ETT and
another at the ventilator end of expiratory limb of circuit. Do not
use heated humidifiers
HME-F to be changed only when visibly soiled
Use closed inline suction system(avoid open suctioning)
Use the same closed suction system to collect ET aspirate
sample in a mucus trap chamberfor RT-PCR
29. Do not disconnect the circuit- push twist all connections
In case disconnection is unavoidable (like patient transport) use
deep sedation/muscle relaxation, put the ventilator on standby mode
and clamp the ET tube just before disconnection
Avoid nebulization (use MDI instead)
Tracheostomy should preferably be delayed by the end of two
weeks- possibility of decreased viral load
Alternative ventilation strategy like APRV (Airway pressure release
ventilation) and ECMO(extracorporeal membrane oxygenation) to be
considered if indicated
30. Septic shock:
Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors
are needed to maintain mean arterial pressure ≥ 65 mmHg AND lactate is ≥ 2 mmol/L in
absence of hypovolemia.
Recognize septic shock in children with any hypotension or two or more of the following:
altered mental state; bradycardia or tachycardia (Heart rate < 90/min or > 160/min in infants
and < 70/min or > 150/min in children); prolonged capillary refill (> 2 sec) or feeble pulses;
tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria;
hyperthermia or hypothermia.
Management should be as per surviving sepsis campaign guidelines
Choice of antibiotics: as per indication (community acquired vs hospital acquired) and local
antibiogram
31. When to do dialysis:
Urine output < 400 ml/24 hours
Uremic encephalopathy
Severe metabolic acidosis
Uremic pericarditis
Refractory hyperkalemia
Fluid overload
Keep low threshold for dialysis as fluid overload and
acidosis are detrimental in ARDS.
Bedside dialysis to be preferred.
32. Pregnant patients:
Testing to be prioritized
Steroids may be given for fetal indications as per
obstetrician’s advice
Obstetrician to monitor fetal well-being daily
Breastfeeding patients:
Currently there is no data suggestive of viral
transmission via breast milk. However, due to close
contact and risk of droplet transmission,
breastfeeding should be avoided in COVID-19
confirmed mothers
34. Discharge Criteria:
Suspected case – if the laboratory results for COVID-19 are
negative, discharge is to be decided as per discretion of the
treating physician based on his provisional/confirmed
diagnosis
Confirmed case – resolution of symptoms, radiological
improvement with a documented virological clearance in 2
samples at least 24 hours apart