Advanced Mediterranean Diet

Are you tired of this pic yet?

One way our bodies prevent infection a second time by the same germ is to produce proteins called antibodies. The initial infection leads to antibody production that is specific to that infection. When the germ enters our body the next time, antibodies attack and neutralize it.

You’ve heard of vaccines. They work by inducing production of antibodies.

From South China Morning Post:

Researchers in Shanghai hope to determine whether some recovered coronavirus patients have a higher risk of reinfection after finding surprisingly low levels of Covid-19 antibodies in a number of people discharged from hospital.

A team from Fudan University analysed blood samples from 175 patients discharged from the Shanghai Public Health Clinical Centre and found that nearly a third had unexpectedly low levels of antibodies.

In some cases, antibodies could not be detected at all.

Source: Coronavirus: low antibody levels raise questions about reinfection risk | South China Morning Post

From National Geographic on April 10

If the past is any indicator, the world won’t have a coronavirus vaccine for more than a year, probably longer. The mumps vaccine—considered the fastest ever approved—took four years to go from collecting viral samples to licensing a drug in 1967. Clinical trials come with three phases, and the first stages of the current COVID-19 trials aren’t due for completion until this fall, spring 2021, or much later. And there are good reasons to allow time for safety checks. Some preliminary vaccines for the related coronavirus SARS, for instance, actually enhanced the disease in model experiments.

***

One major hitch in developing a COVID-19 vaccine is that no medically proven predecessor exists for any type of human coronavirus. This despite the fact that the 2002 SARS and 2012 MERS outbreaks, both caused by viral cousins of the new coronavirus, were warning shots that claimed about 1,600 lives.

Be skeptical about all the vaccine happytalk you hear from Trump, Birx, Fauci, et al.

Steve Parker, M.D.

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Why ruin her life her when her risk of serious illness is so low?

On April 2,2020, I proposed a four-point plan to resuscitate the U.S. economy.  Here ’tis:

1. Young and middle-aged healthy adults go back to work now.
2. Young and middle-aged healthy adults and children return to usual social interactions and school, using 6-foot distancing and face masks if desired.
3. Extreme social distancing for those at risk for serious illness from COVID-19 for the next 2–3 months, then re-evaluate the situation. The goal is NO EXPOSURE  to those who may transmit the virus to them. Protect the medically frail who are over 60, particularly if over 70 or 80.
4. Continued isolation of COVID-19 cases until they’re no longer infectious.

See a section below for details of extrema social distancing for those at risk for serious illness from COVID-19, the disease caused by coronavirus SARS CoV2. But first…

Background: Panic and Over-Reaction?

Around mid-March, federal and many state authorities recommended extreme social distancing for most of the U.S. population. Whether strongly recommended or “do this under penalty of law,” we were told to avoid groups of over 50 people, then it was 10 people, then close your restaurant, bolt the door to your bar, chain the doors to the gym, shutter your house of worship, and stay at home unless your job is considered “essential” by ONE person, usually a state governor. This looks like “house arrest,” with permission to go the grocery store and walk your dog (but no more than 100 yards from the house). (Admittedly, seven or eight states did not go on “lock-down.”) Municipal, state, and federal parks were declared off limits. Beaches were closed. A man in Colorado was arrested for playing ball with his daughter in an empty park. A paddle boarder was arrested at Malibu pier for asserting his right to pursue happiness. Walton County in Florida even closed some backyards. I’ve heard of fines for up to $1,000 in some jurisdictions if you get caught, and/or up to six months in jail (the paddle boarder). In some states, e.g., Rhode Island, these measures bordered on martial law. Whether these restrictions were constitutional is a question for another day.

How did our rulers justify these draconian measures? To “flatten the curve” of the epidemic so that medical resources (especially hospitals) wouldn’t be overwhelmed and, of course, to “save lives.” I understand those goals and agree with many of the measures taken early-on when we didn’t know much about this virus. We couldn’t trust information coming from China, where this pandemic started. When Italy became an apparent disaster, it really got my attention; that’s when my wife and I started prepping (a few days before I published prepping advice on March 20).

With restaurants, gyms, bars, and other service businesses being stifled, and hotel occupancy down by 70%, 17 million people lost their jobs and applied for unemployment benefits. And this was just in the first three weeks of “shelter in place” orders. The unemployment rate has exploded from 3.5% to an expected 15–20% almost overnight. Undoubtedly, thousands of businesses will be filing for bankruptcy within the next few months.

Both of these tribal elders are at risk due to age alone

What should we have done instead in early April or even earlier? Extreme social distancing for those at risk of serious illness. They are the ones who would overwhelm hospitals when they contract COVID-19. Yes, I know young, previously health folks have come down with the virus and tragically died, but they are a small minority of those needing ICU care (intensive care and a ventilator). When you peruse the list of those at risk of serious illness from coronavirus, be aware that risk increases as conditions stack up in an individual. The more risk factors you have, the more extreme must be your infection-prevention measures. I’m at risk myself, being 65 and having hypertension, but I’ve been blessed otherwise with good health (and work at it, too), so I’m going into the hospital to work my shifts, potentially exposing myself to the virus. I’m not worried even though Dr Anthony Fauci says I should stay home. (My wife and children worry.)

My Advice on Extreme Social Distancing for those at risk of Serious Illness From COVID-19

Essentially, don’t let other people bring the virus to you and don’t go out and expose yourself to virus carriers who may look and feel healthy.

Give the virus time to “burn itself out” in the healthy population. Allow time for “herd immunity”: increasing numbers of people who have been infected and beat the virus will no longer carry the virus and transmit it to you. Viruses are not alive; they propagate only in living organisms that pass the virus from one organism to another. Don’t be that viral host. People can be “infected” with the  virus and have no, or minimal, symptoms. That tends to be young healthy folks. After 2–3 months, we’ll re-evaluate the situation. For now:

• Isolate yourself. As much as possible, stay in your residence and don’t let others in. Have groceries and other supplies delivered to the front door.  Don’t invite deliverers in, and don’t shake hands.
• If you have to go out, wear a surgical mask and stay at least six feet away from others.
• If you have to go out and you are in proximity to someone coughing and/or sneezing, move far away immediately. Even if they’re wearing a mask.
• If you need to see your friends or relatives, use iPhone face-time, Skype, Zoom, WebEx, or similar internet options.
• If you’re in a nursing home, skilled nursing facility, or other sort of senior living facility, insist that they abide by these restrictions. They need to severely restrict who enters the facility.
• If you’re mostly independent but need a little assistance, consider moving in temporarily with someone who’s in your same situation, needing a little help. Help each other.
• If over 60–65 and still working, consider quitting your job temporarily, or retiring. Let a younger, healthier person take over. Unemployed Gen X, millennials, and Gen Z folks are looking for opportunity! Millions of them are now unemployed.
• If you live with others or live in a multi-generational household, spend more time in your room, wear a surgical mask, stop hugging and kissing, practice social-distancing within the home. Housemates who are younger and/or healthier than you are going out into the community, potentially picking up the virus. You can’t know if these symptom-free housemates are carriers and transmitters of the virus.
• If you need medical care, see if your physician is willing to practice “telemedicine”: talk by phone or examine and chat via Doxy.me, WebEx, Zoom, Skype, iPhone face-time, etc. Note: these options may not be HIPAA-compliant, which will inhibit your doctor.

I get it now, doc

A Few More Things to Get You Through This Crisis

• Endeavor to ensure your chronic medical condition is being optimally managed and under as good control as possible.
• While isolating yourself, don’t do anything that will worsen or exacerbate your underlying conditions. E.g., if you have lung or heart disease, don’t smoke. Liver disease? Don’t drink alcohol or take too much acetaminophen. Kidney disease? Don’t take NSAIDs.
• Maintain or improve your level of physical fitness via exercise.
• Eat healthful foods, not junk.
• Of course, practice frequent hand-washing and don’t touch your face after contact with anyone or anything that might transmit the virus.

Hang in there! This is a temporary situation and we’ll get through it. Remember the H1N1 Swine Flu pandemic of 2009? Very few do. But that virus  infected roughly 100 million Americans, killing about 75,000, the CDC estimates. As of early AM April 10, 2020, the U.S. death toll from COVID-19 is a little under 17, 000.

The history of this pandemic will be written a couple years from now. If truth be told, it will be a story of panic and over-reaction.

Steve Parker, M.D.

PS: The governor of South Dakota agrees with me that folks over 65 or with serious health conditions should stay at home for now.

PPS: I strongly disagree with Dr Ezekiel Emanuel that we have no choice. Emanuel was an architect of the Affordable Care Act, aka Obamacare. From Dr E:

Realistically, COVID-19 will be here for the next 18 months or more. We will not be able to return to normalcy until we find a vaccine or effective medications. I know that’s dreadful news to hear. How are people supposed to find work if this goes on in some form for a year and a half? Is all that economic pain worth trying to stop COVID-19? The truth is we have no choice.

PPPS: It turns out that northern Italy isn’t very similar to the U.S., given the severe air pollution in Lombardy, the many Chinese living there, the very old population, and mis-coding of causes of death.

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I’m getting worried, doc

Only 6% of the COVID-19 fatalities in Israel are under 60 years old, similar to global averages. And 64% of the deceased are male, in other countries. As of the date of the article below, Israel had only 34 total COVID-19 deaths. There are bound to be more; 83 cases are on ventilators and I suspect 50–90% of them will not make it.

From The Times of Israel on April 2, 2020:

Most of Israel’s coronavirus fatalities have been elderly men with underlying medical conditions, in line with global averages.

The average age of Israel’s dead was 79.8 years old as of Thursday afternoon. Of the 34 dead, 21, or 64 percent, were men, and 13 were women.

Ninety-four percent of Israel’s fatalities — all but two — are over the age of 60, in line with the average in Europe of 95%.

The vast majority of Israel’s dead had underlying medical conditions, as do most senior citizens. Israeli medical authorities rarely specify which preexisting conditions the fatalities had.

I’ve never seen a breakdown at to how many seriously ill COVID-19 patients have morbid obesity.

Source: Israeli coronavirus fatalities are mostly elderly men, average age 79.8 | The Times of Israel

Steve Parker, M.D.

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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…

https://twitter.com/steveparkermd/status/1247866157551570945?s=20

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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