Advanced Mediterranean Diet

Hey now, be careful!

It’s no wonder that this work [use of hydroxychloroquine for COVID-19] has set off so many arguments: statistically, it’s like a funhouse mirror. Here, though, is where some of the folks pinging me on Twitter and sending me emails tend to get more worked up, especially to that point about anecdotal data. I can see where they’re coming from: if you haven’t done this stuff, you can look at a report of people responding to such a treatment and figure that the answer is here – right here, and anyone who doesn’t see it must have some ulterior motives in ignoring what’s in front of their face. But that’s not how it works.

It’s weird and startling, though, if you haven’t had the opportunity to go back through clinical research (and even patient treatment) and seen how many things looked like they worked and really didn’t. It happens again and again. Alzheimer’s drugs, obesity drugs, cardiovascular drugs, osteoporosis drugs: over and over there have been what looked like positive results that evaporated on closer inspection. After you’ve experienced this a few times, you take the lesson to heart that the only way to be sure about these things is to run sufficiently powered controlled trials. No short cuts, no gut feelings – just data.

You get that good data via double-blind randomized controlled trials.

David also referenced a worrisome study. The combo of hydroxychloroquine and metformin in mice caused 30% mortality. Many human type 2 diabetics take metformin.

Source: Hydroxychloroquine Update For April 6 | In the Pipeline

Steve Parker, M.D.

Old heart patients like this often have long QT intervals

From Newsweek:

A hospital in France has had to stop an experimental treatment using hydroxychloroquine on at least one coronavirus patient after it became a “major risk” to their cardiac health.

The University Hospital Center of Nice (CHU de Nice) is one of many hospitals trialing hydroxychloroquine in COVID-19 patients. It announced it had been selected for the trial on March 22. A statement from the hospital said it was testing four experimental treatments, one of which included hydroxychloroquine. It hoped to establish its effectiveness and side effects of this and the other treatments being tested.

In an interview with the French daily newspaper Nice-Matin, Professor Émile Ferrari, the head of the cardiology department at the Pasteur hospital in Nice, said the side effects had already been identified, with some patients having to stop treatment because of the risk posed.

The drug was stopped probably due to an abnormality on a heart tracing —EKG, or picture of electrical activity in the heart—called QT prolongation that developed during treatment with hydroxychloroquine. Prolonged QT interval is thought to be a risk factor for life-threatening heart rhythm disturbances like ventricular fibrillation and torsade de pointe.

The original French study of hydroxychloroquine treatment for COVID-19 included a few folks that also got azithromycin, an antibiotic that also tends to prolong the QT interval.

When I first read the Newsweek headline, I thought they halted the entire clinical trial. Not so.

Source: French Hospital Stops Hydroxychloroquine Treatment for COVID-19 Patient Over Major Cardiac Risk

Steve Parker, M.D.

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Would hydroxychloroquine ruin her vision?

From DailyMail in UK:

Hospital[s?] in Sweden have stopped using the malaria drug chloroquine [?] on coronavirus patients after reports it was causing blinding headaches and vision loss.

Doctors in the Vastra Gotaland region, 200miles west of Stockholm, are no longer administering the medication, touted as a ‘miracle drug’ by Donald Trump. A number of patients at hospitals in the county reported suffering cramps, peripheral vision loss and migraines within days of being prescribed the tablets.

For one in 100 people, chloroquine can also cause the heart to beat too fast or slow, which can lead to a fatal heart attack.

The authors of the article admit they don’t know if the drug in question was chloroquine or hydroxychloroquine. MedicineNet has an article comparing the two drugs. A 1985 journal article says hydroxychloroquine is much safer than chloroquine in terms of retinal (eye) toxicity. A March 31, 2020, article at Annals of Internal Medicine cautions clinicians against use of these drugs for COVID-19, noting that 10 clinical trials are underway, with results available within weeks.

Source: Coronavirus Sweden: Chloroquine trials stop due to side effects | Daily Mail Online

On the other hand, heme-one doctor Ray Page says thinks hydroxychloroquine is pretty darn safe:

Steve Parker, M.D.

PS: On a related note…

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The ventilator is out of sight, attached to the tubing

I have tremendous respect for respiratory therapists (RTs) like Dave, Sean, Walter, and the others I work with daily. I’m always having to remind the medical Residents I supervise that RTs know more than the Residents do regarding respiration, oxygen delivery, and ventilation.

Raconteur Report is right:

Nurses don’t run ventilators.

Respiratory therapists do that.

It takes 2 years to train one, and another year of OJT [on the job training] to get them good at it.

Each RT can manage 4 vents, if you want it done right.

If you don’t care about killing people, maybe you can surge that, short-term, to 6 or 8.

***

And if somebody, anybody, thinks we’re good if we just crank out 100,000 or 1,000,000 ventilators, because “‘Murica!”, then please, tell me how you plan to squat, grunt, and shit out the 25,000 to 250,000 trained respiratory therapists you’ll need to run that many vents, which you don’t have now just sitting around playing cards and waiting to come to your Pandemic Party in ICU or the ER.

You’re not hearing that from Dr Fauci and President Trump, are you?

But it’s true.

Source: Raconteur Report: Math Update And Ventilator Numbers

From another Aesop post:

Nawlins ER Doc’s laxative-substitute (because it’ll make you sh*t yourself) field clinical report is pointing towards what I’m afraid will become standard protocol: no one’s worried about 100,000 ventilators, or any such nonsense, because the survival rate once you’re intubated (for the 3-5% of everyone who get that sick) is from 30-14%. From about 1 chance in 3, to 1 chance in 7. Which, I suspect, is going to lead to standard of care to become “If they need intubation, don’t bother. Medicate for pain, and move to hospice tent.” It’s a futile intervention, and it generates more aerosol viral load, so it isn’t worth the risk to practitioners to intubate, and we cannot justify the effort and expenditure of staff time and resources, for something that’s 70-86% fatal anyways. In short, practice will be to let you die, because you’re going to anyways. If possible, in a narcotic haze to ease the pain of the transition.

Steve Parker, M.D.

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Are you tired of this pic yet?

The free market at work! From New York Post:

Hundreds of nurses are pouring into New York City from across the country drawn by a desire to save lives — and paychecks reaching $100 an hour.

Michael Fazio, the head of the Prime Staffing agency, said he was trying to fill 3,000 nursing slots for New York-Presbyterian, Mount Sinai, NYU Langone and Bellevue, along with hospitals in New Jersey.

“They’re all crisis needs. We’re just trying to get them the support,” he said. “The focus right now is in the emergency department and ICU.

”The hospitals have upped their pay rates, with the most experienced nurses getting top dollar.Fazio said some of the nurses are tripling their salaries.

“I spoke to some nurses in the south. Their hourly rate was like $29 an hour. They’re literally saying ‘Man, I gotta do it for my own family.’ One woman said to me, ‘I’ve got a kid going to college. I’m coming!’ “ Fazio said.

Source: Nurses flock to NYC to help with coronavirus outbreak

From JAMA Network:

Several professional societies have put forward their guidance regarding the use of ACEIs/ARBs in patients with COVID-19. In summary, all guidelines recommend continuing ACEIs/ARBs in patients with COVID-19 unless clinically indicated (Table). Furthermore, they do not suggest initiation of ACEIs/ARBs in those without another clinical indication (eg, hypertension, heart failure, diabetes), given the lack of strong evidence showing benefit of these medications in COVID-19. We agree with these recommendations, given the current state of evidence.

However, the biological plausibility of salutary effects of ACEIs/ARBs in those with COVID-19 is intriguing. A multicenter, double-blind, placebo-controlled phase 2 randomized clinical trial of starting losartan in patients with COVID-19 in outpatient settings (ClinicalTrials.gov identifier: NCT04311177) and in in-patient settings (ClinicalTrials.gov identifier: NCT04312009) is currently being planned. Accordingly, further epidemiological studies and prospective trials are urgently needed to investigate if use of ACEIs/ARBs can reduce the incidence or mortality associated with COVID-19–associated ALI or ARDS, both in patients with and without additional clinical indications for ACEIs/ARBs.

Source: Coronavirus Disease 2019 (COVID-19) Infection and Renin Angiotensin System Blockers | Global Health | JAMA Cardiology | JAMA Network

Clearly, we need real-world data.

Steve Parker, M.D.