Category Archives: Coronavirus

Are High Blood Pressure Drugs Making #Coronavirus Cases Worse? #COVID19

Are you tired of this pic yet?

Certain conditions are linked to the more serious cases of coronavirus infection, aka COVID-19. These include high blood pressure (hypertension), diabetes, and heart disease. Classes of drugs that are OFTEN used to treat ALL these conditions are ACEIs (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin receptor blockers.

I’ve never understood why or how hypertension would predispose to serious COVID-19 disease, especially if blood pressure is well controlled. A new theory suggests why that may be: The drugs used to treat hypertension—ACEIs and ARBs—allow the virus to flourish.

From JAMA Network:

The increased mortality and morbidity of COVID-19 in patients with hypertension is an association that has been observed in a number of initial epidemiological studies outlining the characteristics of the COVID-19 epidemic in China. Wu et al2 found hypertension to have a hazard ratio of 1.70 for death and 1.82 for acute respiratory distress syndrome in 201 patients with COVID-19. Zhou et al found hypertension to have a hazard ratio of 3.05 for in-hospital mortality in 191 patients with COVID-19.

Neither of these studies adjusted for confounding variables and thus it remains unclear if this association is related to the pathogenesis of hypertension or another associated comorbidity or treatment. There has been a growing concern that this association with hypertension is confounded by treatment with specific antihypertensive medications: angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

The link with ACEIs and ARBs is because of the known association between angiotensin-converting enzyme 2 (ACE2) and SARS-CoV-2. ACE2 has been shown4 to be a co-receptor for viral entry for SARS-CoV-2 with increasing evidence that it has a protracted role in the pathogenesis of COVID-19. ACE2 has a broad expression pattern in the human body with strong expression noted in the gastrointestinal system, heart, and kidney with more recent data identifying expression of ACE2 in type II alveolar cells in the lungs. The concern that ACEIs and ARBs affect the severity and mortality of COVID-19 is 2-fold. One suggestion is that ACEIs could directly inhibit ACE2; however, ACE2 functions as a carboxypeptidase and is not inhibited by clinically prescribed ACEIs.

In addition, there is concern that the use of ACEIs and ARBs will increase expression of ACE2 and increase patient susceptibility to viral host cell entry and propagation.

In response, the Council on Hypertension of the European Society of Cardiology, the American Heart Association, the Heart Failure Society of America, and the American College of Cardiology all recommend that patients continue their ACE inhibitors and ARBs until we have better evidence that they may be harmful in the setting of this coronavirus pandemic.

One of my patients with hypertension was concerned about his ACEI promoting serious COVID-19 illness, and I had no hesitation about switching him to another class of drug, chlorthalidone in this instance. Calcium channel blockers like amlodipine are another good choice for hypertension that requires just one drug.

As usual, we need more hard data.

Steve Parker, M.D.

Source: COVID-19 and Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: What Is the Evidence? | Pulmonary Medicine | JAMA | JAMA Network

PS: Loss of excess weight also helps control high blood pressure.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

Click pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

War Zone Report From Atlanta, GA #Coronavirus #COVID19

If you will be caring for critically ill COVID-19 patient in the near future, you’ll want to watch this interview by ZDoggMD of Barbara McLean, RN, NP. Sounds like she’s knee-deep in **** right now in an Atlanta ICU.

If you’re not a physician, nurse, hospital PCT, or respiratory therapist, this is not for you. Even I had never heard of a few of the therapies and concepts mentioned.

Here’s their current progression to being on a ventilator: nasal cannula oxygen up to 6-7 liter/minute, non-rebreather mask, then if still not adequate oxygenation, to to mechanical ventilation. No fooling around with CPAP or BIPAP.

I also agree fully with limiting the number of folks in the room handling a code blue (cardiac or pulmonary arrest) in a COVID-19 patient, or even COVID-19 PUI (person under investigation, not definite yet).

All their COVID-19 patients in the ICU get arterial and central lines.

Have We Been Mislead About the Protection Provided By Masks? #Coronavirus #COVID19

 

She may have the right idea

Infectious Disease Professor Kim Woo-joo from Korea University Guro Hospital has no doubt that the common use of face masks by the public in Korea and other Asian countries helps to reduce the spread of coronavirus and COVID-19. His pertinent comments start at 15:50 or so. If you’re fairly knowledgeable  about this pandemic, you can skip everything up until then.

He thinks the World Health Organization and DCD pooh-pooh face masks for the general public so that healthcare workers have enough.

Did you know you can increase the playback speed? I listened at speed 1.5 and had no trouble. Most of the video has subtitles in English.

Dr Woo-too stresses the importance of frequent hand-washing.

Also discussed is that the common street mask in Korea is the KF94, which I’d never heard of. Dr W says they’re nearly as good as the N95.

Dr W implies that smoking by itself is a risk factor for contracting COVID-19, regardless of any underlying diagnosis of emphysema or COPD.

Hospitals consider universal do-not-resuscitate orders for #coronavirus patients #COVID19

Not this hospital

The problem is two-fold. If a hospital is overwhelmed with critically ill patients, there won’t be enough equipment or staff to go around. So you’re forced to ration resources—there’s no alternative unless you can transfer the patient to another facility. The other issue is that it may be futile to do cardiopulmonary resuscitation on a certain subset of patients, because they all die anyway. Use your limited resources on patients who have a fair chance of eventually walking out of the hospital.

From The Washington Post:

Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

“They made us do all kinds of mandatory education and fittings and made it sound like they are prepared,” he said. “But when it hits the fan, they don’t have the supplies so the plans they had in place aren’t working.

”Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital’s policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

“By the time you get all gowned up and double-gloved the patient is going to be dead,” he said. “We are going to be coding dead people. It is a nightmare.”

Source: Doctors consider universal do-not-resuscitate orders for coronavirus patients – The Washington Post

I hadn’t thought about it before, but that last sentence has some truth to it. If someone is circling the drain toward cardiac or pulmonary arrest, it’s best to do it before they actually “code.”

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

Cut the Politicians’ Pay? #Coronavirus #COVID19

Post-viral apocalypse? Raccoon City?

Wise words from economist Brian Wesbury:

The government-mandated shutdown of business, and the massive drop in economic activity it is causing, may actually do more harm to the United States than the coronavirus itself.  Early estimates suggest the U.S. economy will contract at a staggering 20% annualized rate in the second quarter, and the number may move even higher.  Despite multiple recessions, global wars, the avian flu, SARS, 9/11, and natural disasters, the U.S. hasn’t experienced a quarterly drop in activity like this since the Great Depression.

The unemployment rate is likely to double from 3.5% to 7% in the coming months, representing a loss of more than 5 million jobs.  And the longer the shutdown lasts, the further that number is likely to rise.  Few businesses have cash hoards that can tide them over for this drastic a decline in activity.  People are coming up with creative solutions, stopping rent and loan payments, but there isn’t enough money in most business coffers to survive a trillion-dollar drop in economic production.  The greater the number of businesses that don’t survive, the slower the path to recovery when this global tragedy passes.

Tax payments to federal, state and local governments will fall precipitously, and many government entities will face serious financial challenges (if they didn’t already).  Illinois, for example, still has billions of dollars of unpaid bills, not to mention a severely underfunded pension system.  A 10%-to-20% drop in tax revenue makes these problems that much worse.  And every extra day the shutdown continues, the deeper the hole is dug.

Source: Cut the Politicians’ Pay

RTWT for Wesbury’s proposed solution.

Once Again, I Ask WHO Is to Get the Limited Ventilators? #coronavirus #COVID19

Are you tired of this pic yet?

Physicians in New York City, Los Angeles, and Seattle may soon need to answer the question, if they haven’t already.

From a Perspective article in the New England Journal of Medicine:

But though approaches vary even within a single hospital, I sensed that age was often given the most weight. I heard one story, for instance, about an 80-year-old who was “perfect physically” until he developed Covid-19–related respiratory failure. He died because mechanical ventilation could not be offered. Though Lombardy’s richly resourced health care system has expanded critical care capacity as much as possible, there simply were not enough ventilators for all patients who needed them. “There is no way to find an exception,” Dr. L. told me. “We have to decide who must die and whom we shall keep alive.”

Contributing to the resource scarcity is the prolonged intubation many of these patients require as they recover from pneumonia — often 15 to 20 days of mechanical ventilation, with several hours spent in the prone position and then, typically, a very slow weaning. In the midst of the outbreak’s peak in northern Italy, as physicians struggled to wean patients off ventilators while others developed severe respiratory decompensation, hospitals had to lower the age cutoff — from 80 to 75 at one hospital, for instance. Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence — or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. “This is not a nice thing to say,” he told me. “You will just scare a lot of people.”

Dr. S. was hardly alone. The agony of these decisions prompted several of the region’s physicians to seek ethical counsel. In response, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations under the direction of Marco Vergano, an anesthesiologist and chair of the SIAARTI’s Ethics Section.2 Vergano, who worked on the recommendations between caring for critically ill patients in the ICU, said that the committee urged “clinical reasonableness” as well as what he called a “soft utilitarian” approach in the face of resource scarcity. Though the guidelines did not suggest that age should be the only factor determining resource allocation, the committee acknowledged that an age limit for ICU admission may ultimately need to be set.

It would be easier to make this life-and-death decision if the experienced Italian physicians would share their ventilator survival rates—i.e., how many and what kind of patients were successfully weaned off the ventilator and walked out of the hospital—and who were the patients in which ventilator care was futile. As far as I know, 97% of ventilator patients in China died.

Source: Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line | NEJM

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

 

CDC Leaders May Be Lying to Trump About #Coronavirus #COVID19

Deliberate sabotage of Trump’s presidency?

From ABC3340:

WASHINGTON (SBG) – As the coronavirus spread to all fifty states over the last two months, the Trump administration faced mounting criticism for the lack of reliable, widely accessible test kits. Now, a former senior federal health official nominated to his post by President Trump, alleges that the delays in testing occurred because leaders at the Centers for Disease Control “lied” to the president, and to Health and Human Services Secretary Alex Azar, about the center’s ability to produce the kits.

Source: EXCLUSIVE: Former HHS official claims CDC leaders “lied” to Trump over coronavirus testing | WBMA

Who knows?!