2nd QOTD: Derek Lowe on #Hydroxychloroquine and #COVID19 #Coronavirus

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.

French Doctors Stop Hydroxychloroquine Treatment for One COVID-19 Patient Over Major Cardiac Risk

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.

Steve Parker MD, Advanced Mediterranean Diet

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Swedish Chloroquine trial stopped due to side effects

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

Steve Parker MD, Advanced Mediterranean Diet

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

QOTD: Israel Shamir on Fear of Death

This too shall pass

The seasonal madness overtook mankind. In years to pass, it will be remembered as a new Witch Hunt, but on a global scale. The Salem affair engulfed a small town in a remote British colony, while the Corona lockdown broke the back of the global economy, pauperised millions, imprisoned three billion people, caused uncounted suicides and misery. It could be compared with World War One, when the West at the peak of its historic achievement rushed towards its self-destruction for reasons so feeble that none of the contemporary actors was able to explain them convincingly.

The madness is fuelled by fear of death. Death, this normal occurrence for our ancestors, a peaceful transformation, when the discarded body is laid to rest in the churchyard after the soul has departed to its Creator, became the worst thing to happen to man, a disaster to be avoided at all costs, because there is no hereafter, no Creator for the soul to return to, but only here and now. They embarked on the War on Death, as our colleague CJ Hopkins observed. Trying to escape death, mankind inflicted upon itself a mortal wound.

Source: Fighting the Worldwide War on Death, by Israel Shamir – The Unz Review

 

From Aesop: Math Update And Ventilator Numbers #covid19 #coronavirus

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.

Steve Parker MD, Advanced Mediterranean Diet

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

Nurses, New York’s Offering a Major Pay Raise! #covid19 #coronavirus

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

Ongoing Debate: #Coronavirus Infection and Renin Angiotensin System Blocking Drugs #COVID19

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.

Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19

Self-portrait on a hospital shift in April 2020

From JAMA Network:

Recently developed protocols expressly call for the rationing and reallocation of ventilators, in a manner that aims to save the greatest number of lives. These protocols are broadly accepted by medical ethicists. But ethics aside, there are potential legal ramifications of either withholding or withdrawing a ventilator from a patient who would ordinarily receive such aid in the absence of a public health emergency.

In this Viewpoint, we assess the legal risks that physicians, other health care workers, and hospital systems confront in such scenarios and recommend that states explicitly and immediately adopt legal protections for health care workers, modeled on provisions in place in Maryland.

Source: Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19: Assessing the Risks and Identifying Needed Reforms | Critical Care Medicine | JAMA | JAMA Network

Physicians worry about our patients, but we also have to worry about gettin sued.

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.

Once again, what is the mortality rate of #COVID19 patients on ventilators? #Coronavirus

If the patient isn’t already on a mechanical ventilator when the “code blue” is called, he’s likely to be intubated during cardiopulmonary resuscitation. Is that reasonable for a COVID-19 patient?

SkepticalScalpel (a retired surgeon) is wondering the same as I:

What’s the survival rate of COVID-19 patients admitted to an ICU and given mechanical ventilation?

From Physician’s Weekly:

We have some early published data on percentages which vary widely. A paper from China involved 710 Covid-19 patients; 52 were admitted to an ICU. Of the 22 who eventually required mechanical ventilation, 19 (86%) died. Another early study reported 31 of 32 (97%) mechanically ventilated patients died.

I posed the following question on Twitter: “What is the mortality rate for [COVID-19] patients who require mechanical ventilation?” and received answers ranging from 25% to 70% from people who have personal knowledge of outcomes in their hospitals.

Probably the best published information we have so far is from the Intensive Care National Audit and Research Center (ICNARC) in the UK. Of 165 patients [apparent COVID-19 patients] admitted to ICUs, 79 (48%) died. Of the 98 patients who received advanced respiratory support—defined as invasive ventilation, BPAP or CPAP via endotracheal tube, or tracheostomy, or extracorporeal respiratory support—66% died.

Compare that to the 36% mortality rate of non-COVID patients receiving advanced respiratory support reported to ICNARC from 2017 to 2019.

***

We know nothing about the survival rate of COVID-19 patients who have undergone cardiopulmonary resuscitation.

Regarding that last sentence: Cardiopulmonary resuscitation probably puts lots of viruses into the air, likely increasing the risk of infection transmission to healthcare providers. So if CPR is futile, let’s not do it. Believe it or not, most healthcare providers did not sign up for a high risk of death when they leave for work in the morning.

Source: Mortality rate of COVID-19 patients on ventilators | Physician’s Weekly

Steve Parker, M.D.

PS: Contrary to what you may hear from the mainstream media, most experienced intensivists and hospitalists are comfortable deciding whether cardiopulmonary resuscitation is worthwhile or not. I fully expect that once a COVID-19 patient is on a ventilator and in intractable shock (hypotension), DNR status (do not resuscitate) is recommended to the responsible party. It’s over when the cardiac arrest finally comes.

Steve Parker MD, Advanced Mediterranean Diet

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

Stop Panicking: It’s Time to Resuscitate the U.S. Economy #Coronavirus #COVID19

 

Will we allow coronavirus to destroy the fabric of American life?

I propose a four-point plan to prevent a prolonged economic recession or depression in the U.S. caused by unjustified fear and panic about coronavirus:

  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.

My presuppositions:

  • A large majority of the COVID-19 deaths and serious illness will be in the elderly (over 60-65) and/or those with risk factors for serious illness, as we’ve seen in Italy, China, and South Korea.
  • Those under 60-65 will have less severe illness and be much less likely to require hospitalization.
  • The pandemic in the U.S. is not going to be as bad as predictions you may have heard or read (e.g., 500,000 to 2.2 million deaths), in part due to actions already taken: isolation of cases, self-quarantine or mandated quarantine, social distancing, education on infection prevention, etc).
  • The recent $2 trillion relief package passed by Congress is unlikely to be very effective, particularly after the bureaucrats, politicians, major banks, and Big Business take their usual lions share. There won’t be much left for little guys like you and me.
  • “Relief packages” passed by politicians are not the answer. Government is more of a problem than a solution.
  • GM and Ford, et al, can’t make 50,000 ventilators in 3–4 weeks. By the time they’re ready, they won’t be needed.
  • The situation is quite fluid and helpful medical information arrives daily. So we need to stay light on our feet and ready to incorporate it.
  • The role of quarantine isn’t clear even now. We need more information. If a nurse treats a COVID-19 patient at the hospital, should she be on quarantine for two weeks or can she keep working? At what point do folks without symptoms start shedding virus that can infect others?
  • We’re seeing a power grab by federal and state governments that is unjustified and unprecedented in our lifetimes. For instance, a Florida pastor was arrested for holding a church service in violation of social distancing. Doesn’t the first amendment to the U.S. Constitution give us the right to peaceably assemble and freely exercise our religion? Once grabbed, government does not readily relinquish power. For more on this issue, read Peter Grant’s April 1 blog post.
  • Behavior of those living in COVID-19 hot spots like New Orleans or New York city may need to be different from those living elsewhere.
  • Extreme social distancing of those at risk or serious illness from COVID-19 may well require them to withdraw from the workforce for several months (or longer), but that’s much less harmful than what is essentially “house arrest” of 80–90% of the population.
  • Our list of conditions that increase serious risk from COVID-19 may well change over time as we learn more.
  • Increased testing to identify those infected with coronavirus will help us devise better containment measures. Containment will also be easier when we can identify—via antibody testing—those who have already been infected and are cured and (hopefully) immune to the current strain of the virus.

The problem with state-mandated or encouraged social distancing is that it’s strangling our economy.

Physicians, virologists, and epidemiologists who are advising our politicians are typically focused on medical aspects of the coronavirus epidemic. Economics is on the back burner, naturally, since that’s not their area of expertise. But the economy matters!

Post-viral apocalypse? Raccoon City?

In the U.S. in February 2020, 165 million people were in the labor force. For the week ended March 21, 2020, the U.S. set a record for unemployment benefits applications: 3.3 million. The following week, a new record was set: 6.6 million. Economists are predicting a drop in 2nd quarter Gross Domestic Product of at least 20%.

In good times, most folk don’t apprehend the web of connections among various parts of the economy. They will soon find out.

From LexisNexis:

Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment. Such findings have been reported from many industrialized nations and, with some minor variations, apply to workers of both sexes and all ages.

Research regarding the consequences of unemployment may be confounded by a commensurate loss of income in subjects being studied. However, some studies try to account for this phenomenon of drop in socioeconomic status. Although an alert health care system may provide some needed assistance, resolution of the problem lies outside the field of medicine.

For example regarding suicide, among the unemployed aged 26 to 64 suicide was two-and-a-half times more likely than those who had jobs. Worldwide, one in five suicides is linked to unemployment. In 2017, suicide was the 10th leading cause of death in the U.S., with over 47,000 victims. At the time of this posting, the U.S. has reported 5,137 deaths from COVID-19.

Bankruptcies and unemployment will lead to an epidemic of despair.

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Honey, we’ll be able to see the grandkids in few months. It’s just too dangerous right now.”

Additionally, the stock markets in the U.S—S&P 500 and Dow Jones Industrial Average—are already down by 20–30%, depending on the day you check. I wouldn’t be surprised if it drops another 20% or more from here. Imagine how that affects folks approaching retirement, or in it already, who are depending on their 401k’s to live.

Laid-off workers without a paycheck can’t pay their mortgages or car payments or other loans. In most jurisdictions, unemployment benefits are woefully inadequate: in Arizona it’s $240/week. This is a set-up for massive loan defaults. One silver lining: If you have cash, it may soon be buyer’s market for homes and new or used cars.

Panicking is rarely good. Let’s stop.

Expect more from me on Extreme Social Distancing in a future post.

Steve Parker, M.D.

PS: A few other sources that question the mainstream media’s and government narratives…

PPS: The history of the Coronavirus Pandemic will be written in the the next few years. I have no doubt it will look different than what we’re seeing now.

Updated at 0933 hrs April 4, 2020.

Steve Parker MD, Advanced Mediterranean Diet

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