What do I need to know about coronavirus?

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Birdstrike said:
Hydroxychloroquine + Azithromycin is already standard of care for high risk outpatient COVID-19 and should be widely available and promoted immediately for physicians to prescribe, according to a peer reviewed article in American Journal of Epidemiology.


Abstract

Full text
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Mostly garbage.

Zelenko is a family doctor who previously claimed a 100% success rate with his drug cocktail. There is no way that's remotely true.

The French study with a 50-fold benefit? With only 46 patients, 6 of whom dropped out?

The second French study I can't find much detail about to critique one way or another.

The only one that may have merit is the Brazilian one but it leaves out mortality and includes asthma as a high risk condition, which I thought was not the case: I thought it was data you linked here several weeks ago in fact.
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I really wonder if the ID wonks are saying that the death number is going to end up being "extra".
Remember, a large chunk of the NH pop in many states has now died.
That means that those people clearly won't die this fall of flu or pneumonia. Or any other year.
While the are some young people dying and having complications, we know this isn't the majority. And now I'm stuck wondering if the spike is even relevant with regard to 5 year mortality at NH.
 
Dr.McNinja said:
I really wonder if the ID wonks are saying that the death number is going to end up being "extra".
Remember, a large chunk of the NH pop in many states has now died.
That means that those people clearly won't die this fall of flu or pneumonia. Or any other year.
While the are some young people dying and having complications, we know this isn't the majority. And now I'm stuck wondering if the spike is even relevant with regard to 5 year mortality at NH.
Click to expand...

What? Source on that? I think you're really underestimating how many people live in nursing homes. I'd be surprised if any state hit even like 2-5%.
 
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VA Hopeful Dr said:
Mostly garbage.

Zelenko is a family doctor who previously claimed a 100% success rate with his drug cocktail. There is no way that's remotely true.

The French study with a 50-fold benefit? With only 46 patients, 6 of whom dropped out?

The second French study I can't find much detail about to critique one way or another.

The only one that may have merit is the Brazilian one but it leaves out mortality and includes asthma as a high risk condition, which I thought was not the case: I thought it was data you linked here several weeks ago in fact.
Click to expand...

Lots of problems with that paper, some of which you point out. With the Brazilian paper, their control group was comprised of those who were offered H+A but didn't want it (doh).

This paper is quackery quackadoodle medicine.

That being said....
I follow my COVID patients in the hospital and they all seemingly get Hydroxychloroquine (without azithromycin). This is recommended by our infectious disease doctor in his notes.

I will not be prescribing H&A, or just H, to anyone with COVID that I'm sending home until major, reputable societies recommend it's use. And I suspect that will be never.
 
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VA Hopeful Dr said:
Zelenko is a family doctor who previously claimed a 100% success rate with his drug cocktail. There is no way that's remotely true.
Click to expand...
It's not very hard to find a sample where a random sample of 99 or 100% COVID patients live, hydroxychloroqhine or not. It's a disease with 99% (or greater) survival rate with no treatment at all. In fact, you could have a 3-man committee of the local dog catcher, shaman and post lobotomy patient treat a random sample of 100 COVID-19 patients and they'd "cure" 99% or more of them.
 
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Birdstrike said:
It's not very hard to find a sample where a random sample of 100% COVID patients live. It's a disease with 99% (or greater) survival rate with no treatment at all. In fact, you could have a 3-man committee of the local dog catcher, shaman and post lobotomy patient treat a random sample of 100 COVID-19 patients and they'd "cure" 99% or more of them.
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That's fair, so you agree that including that in the manuscript you linked shows poor judgement or an agenda that isn't just good science?
 
VA Hopeful Dr said:
That's fair, so you agree that including that in the manuscript you linked shows poor judgement or an agenda that isn't just good science?
Click to expand...
It doesn't matter what I think about this. I don't have a strong opinion about HCQ/Zmax in COVID. I'm just issuing a warning. When I start seeing the term "standard of care" appearing in the literature about a controversial topic that's not settled, it gets my attention. It's something that requires action, or at least awareness. That's unless you want to let the med-mal attorneys stay two steps ahead of you, like they usually do with physicians.

Rather than arguing about the studies themselves, what I'm more interested in, is how people feel about the fact that a major journal of epidemiology has used the term "standard of care," in relation to HCQ and COVID-19. From the full text:

"Hydroxychloroquine+azithromycin has been used as standard-of-care ...These medications need to be widely available and promoted immediately for physicians to prescribe."

Once something gets the label "standard of care," particularly in peer reviewed journals, it has consequences, whether it's right or wrong, or whether a particular individual thinks it's right or wrong, or not.

Somewhere right now, a med-mal attorney has printed out this exact article, highlighted the bolded wording above and set it aside, waiting for the distraught, tearful 30-year-old widow of the young dentist with 4 kids, who died of COVID, "Because the doctor refused to give him the 'standard of care!'" Pain & suffering plus $200K per year lost wages x 50 years which don't apply to the cap is a helluva carrot, when that wording starts popping up in our own literature. Extrapolate that the any of the 100,000+ dead that didn't recieve what is, according the the American Journal of Epidemiology, the "standard of care" and the attorneys can easily extract untold millions of dollars from physicians and their insurance carriers.
 
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Birdstrike said:
I'm not interested in any of that. What I'm more interested in, is how people feel about the fact that a major journal of epidemiology has used the term "standard of care," in relation to HCQ and COVID-19. From the full text:

"Hydroxychloroquine+azithromycin has been used as standard-of-care ...These medications need to be widely available and promoted immediately for physicians to prescribe."

Once something gets the label "standard of care," particularly in peer reviewed journals, it has consequences, whether it's right or wrong, or whether a particular individual thinks it's right or wrong, or not. I doesn't matter what I think about the article and it's conclusions.

Somewhere right now, a med-mal attorney has printed out this exact article, highlighted the bolded wording above and set it aside, waiting for the distraught, tearful 30-year-old widow of the young dentist with 4 kids, who died of COVID, "Because the doctor refused to give him the 'standard of care!'" Pain & suffering plus $200K per year lost wages x 50 years which don't apply to the cap is a helluva carrot, when that wording starts popping up in our own literature.

It doesn't matter what I think about this. I don't have a strong opinion about HCQ/Zmax in COVID. I'm just issuing a warning. When I start seeing the term "standard of care" appearing in the literature about a controversial topic that's not settled it gets my attention. It's something that requires action. That's unless you want to let the med-mal attorneys stay two steps ahead of you, like they usually do with physicians.
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Except its an epidemiology journal. To the best of my knowledge, the CDC and our respective societies haven't said its standard of care. Don't think the IDSA has either. Haven't heard the CC journals saying that either.

I don't really want to be sued ever, but this is not at all a lawsuit I fear in the slightest. Their lawyer will bring this up, my lawyer will bring up this:
What's new | Coronavirus Disease COVID-19

And this: FDA cautions use of hydroxychloroquine/chloroquine for COVID-19

And this: Management of Patients With COVID-19
 
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Yeah, if one is worried about malpractice, it would probably the side of prescribing the combination of medications with known increased mortality, which the IDSA does not recommend except in clinical trials. Anyone can write anything in a yahoo paper, and writing "standard of care" does not make it so.
 
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pkwraith said:
Yeah, if one is worried about malpractice, it would probably the side of prescribing the combination of medications with known increased mortality, which the IDSA does not recommend except in clinical trials. Anyone can write anything in a yahoo paper, and writing "standard of care" does not make it so.
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In your opinion, what defines "standard of care"? I'm curious as to how you personally define it.
 
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I don't think HCQ is undisputed standard of care. I do think it's worth being aware when journals say it is. I post both articles I agree or disagree with.

I don't treat COVID-19 patients. I don't own stock in HCQ or remdesivir. I don't care which drug ends up proving to work as long as something does. I also realize that it often take years to settle the science on certain things, like steroids in spinal cord injury, tPA for stroke, how much volume to give traumas. Consensus on standard of care for COVID will also take years.
 
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Rekt said:
What? Source on that? I think you're really underestimating how many people live in nursing homes. I'd be surprised if any state hit even like 2-5%.
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Not the number that lives in nursing homes, the percentages of them that die that live in NH.
Based on this admittedly unscientific sample, ~40% of the deaths in many states are NH patients.
www.forbes.com

The Most Important Coronavirus Statistic: 42% Of U.S. Deaths Are From 0.6% Of The Population

A single statistic may hold the key to resolving the ongoing debate over COVID-19 lockdowns: the astounding share of deaths occurring in nursing homes and assisted living facilities.
www.forbes.com www.forbes.com
And since a large number of our pneumonia patients, as well as our sepsis/urosepsis patients are from NH, that number will be significantly lower for the next few years.
 
Birdstrike said:
It's not very hard to find a sample where a random sample of 99 or 100% COVID patients live, hydroxychloroqhine or not. It's a disease with 99% (or greater) survival rate with no treatment at all. In fact, you could have a 3-man committee of the local dog catcher, shaman and post lobotomy patient treat a random sample of 100 COVID-19 patients and they'd "cure" 99% or more of them.
Click to expand...

There are not too many people who die from COVID at home without ever seeking medical care.

Unless you are in a nursing home, get a fever, then a cardiac arrest overnight or something.

Treating outpatient COVID with medicines will likely require a huge sample population, like ten's of thousands, for it to be powered properly to detect a difference. And probably not worth the money or time to do so.
 
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VA Hopeful Dr said:
Except its an epidemiology journal. To the best of my knowledge, the CDC and our respective societies haven't said its standard of care. Don't think the IDSA has either. Haven't heard the CC journals saying that either.

I don't really want to be sued ever, but this is not at all a lawsuit I fear in the slightest. Their lawyer will bring this up, my lawyer will bring up this:
What's new | Coronavirus Disease COVID-19

And this: FDA cautions use of hydroxychloroquine/chloroquine for COVID-19

And this: Management of Patients With COVID-19
Click to expand...

You won't get sued if you don't prescribe H&A on an outpatient basis. The paper is nonsense.
 
thegenius said:
Treating outpatient COVID with medicines will likely require a huge sample population, like ten's of thousands, for it to be powered properly to detect a difference. And probably not worth the money or time to do so.
Click to expand...
I agree. Most treatments we have for diseases can't get to anywhere near a 99% success rate. COVID-19 is already better than than itself, without any help from you or me.
 
Birdstrike said:
In your opinion, what defines "standard of care"? I'm curious as to how you personally define it.
Click to expand...

It is a vague term, but like porn, you know it when you see it.

Although you didn’t ask me, I would say my closest definition is the regional practice that most physicians in a given area say is expected for the care of a given condition.

It doesn’t mean there’s any evidence behind it at all (see c collars). But it also certainly doesn’t mean it’s some academic dipshi* in an unrelated field yammering about plaquenil.

I will not lose sleep over this.
 
We are close to our normal volumes at work. In the summer we have anywhere from 30-40 patients in the ED from 12p - 12a, and we had that today. Lots of stupid **** too and people unwilling to make appts with their primary. Which is the usual.

Me: "sorry you came here, we don't take care of this kind of problem. You came to the wrong place. You need to see your own doctor"

Now...chose your own adventure:
Response 1: "I don't have a doctor"

Response 2: "My doctor is only doing phone visits due to coronavirus"

Response 3: "I talked to my doctor over the phone as she is not seeing patient due to coronavirus, and told me to come to the ER."

..
..
..
..

My response to Response 1: "The ER is a place you come to when you are dying. Like you are in a major car accident. Or you are unconscious. Or you can't breathe. Or you have massive bleeding. You don't have any of these and I'll be happy to tell you where to go for follow-up. Fortunately there are doctors out there who want to take care of you. Unfortunately you will have to do a little bit of work and call to make an appointment. But that is OK because they want to help you. All you have to do is put in some effort and make an appointment! It's real easy."

My response to Response 2: "The ER is a place you come to when you are dying. Like you are in a major car accident. Or you are unconscious. Or you can't breathe. Or you have massive bleeding. You don't have any of these and I'll be happy to tell you where to go for follow-up. Fortunately there are doctors out there who want to take care of you. Unfortunately you will have to do a little bit of work and call to make an appointment. But that is OK because they want to help you. All you have to do is put in some effort and make an appointment! It's real easy."

My response to Response 3: "The ER is a place you come to when you are dying. Like you are in a major car accident. Or you are unconscious. Or you can't breathe. Or you have massive bleeding. You don't have any of these and I'll be happy to tell you where to go for follow-up. Fortunately there are doctors out there who want to take care of you. Unfortunately you will have to do a little bit of work and call to make an appointment. But that is OK because they want to help you. All you have to do is put in some effort and make an appointment! It's real easy."
 
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Lawper said:
retractionwatch.com

NEJM, Lancet place expressions of concern on controversial studies of drugs for COVID-19

[See update on this story.] As controversy swirls around two papers that used data from Surgisphere, the New England Journal of Medicine and The Lancet have placed expression of concerns on the rel…
retractionwatch.com retractionwatch.com
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Good.

We know very little about remdesivir and patients should still be told "we don't know if this is going to help you or not."

My bet is there is a certain cohort of patients, whom we don't know yet, that would benefit from remdesivir as it might decrease mortality, but we need more study.
 
Lawper said:
retractionwatch.com

NEJM, Lancet place expressions of concern on controversial studies of drugs for COVID-19

[See update on this story.] As controversy swirls around two papers that used data from Surgisphere, the New England Journal of Medicine and The Lancet have placed expression of concerns on the rel…
retractionwatch.com retractionwatch.com
Click to expand...
It's pretty amazing that Lancet is now implying the negative study they published on HCQ was at best biased, and at worst, falsified. I have no idea if HCQ/Azith/Zinc workds for COVID or not. I have no bias for or against HCQ, but some have wondered if these guys purposefully tanked the data to make HCQ look ineffective dangerous, for political reasons. That's a pretty cynical and conspiratorial-minded stretch. But damn, left wing MDs and media types who normally react with a yawn to any scientific publication sure did react with bizzare giddiness, when this came out. Either common incompetence, or financial connections to drug companies with competing on-patent drugs, seem more likely.

Interestingly, the liberal opinion and the conservative opinion on this, are not that different. Both agree with Lancet, that the negative HCQ data they published, now appears highly questionable, and is teetering on being retracted. That doesn't mean HCQ works, just that you have another piece of garbage-science to throw out.
 
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Birdstrike said:
It's pretty amazing that Lancet is now implying the negative study they published on HCQ was at best biased, and at worst, falsified. I have no idea if HCQ/Azith/Zinc workds for COVID or not. I have no bias for or against HCQ, but some have wondered if these guys purposefully tanked the data to make HCQ look ineffective dangerous, for political reasons. That's a pretty cynical and conspiratorial-minded stretch. But damn, left wing MDs and media types who normally react with a yawn to any scientific publication sure did react with bizzare giddiness, when this came out. Either common incompetence, or financial connections to drug companies with competing on-patent drugs, seem more likely.

Liberal opinion on the impending retraction.

Conservative opinion on it.

Interestingly, the two opinions, are not that different. Both agree with Lancet, that the negative HCQ data they published, now appears highly questionable, and teetering on being retracted.
Click to expand...

I tend to go with money being more likely than politics as the motivation, but it’s irrelevant, they delivered a political win for trump if he’s bright enough to leverage it. His base would love an example of “the scientists being wrong (or better yet, conspiring against him)”

There is a body of other negative data against plaquenil, but I suspect that will be ignored as well.
 
dadaddadaBATMAN said:
I tend to go with money being more likely than politics as the motivation, but it’s irrelevant, they delivered a political win for trump if he’s bright enough to leverage it. His base would love an example of “the scientists being wrong (or better yet, conspiring against him)”

There is a body of other negative data against plaquenil, but I suspect that will be ignored as well.
Click to expand...
In an ideal world, politics should have no place in Medicine at all. Unfortunately, we don't live in that kind of world.

My personal opinion is that we're unlikely to find any game changing antiviral to make a major difference against COVID-19, anytime soon. The first reason is that historically, the great majority of attempts to come up with anti-viral cures have failed miserably, due to the inherent nature of viruses. The second reason is that >99% of COVID patients live without any drug. And those that die from it, die from the hosts response to the virus. I'm not sure killing the virus makes much difference once your lungs are 70% full of mucous and inflammatory material, due to ARDS, SIRS and/or whatever other host response COVID is causing, that we're not even aware of yet. Finding an effective treatment for ARDS and sepsis might be more effective. Unfortuantely, both have historically been as hard to find effective treatments for, as viruses. I'm optimistic we'll have an effective treatment for COVID-19 in the long term. I don't suspect that will happen in the short term.
 
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Birdstrike said:
In an ideal world, politics should have no place in Medicine at all. Unfortunately, we don't live in that kind of world.

My personal opinion is that we're unlikely to find any game changing antiviral to make a major difference against COVID-19, anytime soon. The first reason is that historically, the great majority of attempts to come up with anti-viral cures have failed miserably, due to the inherent nature of viruses. The second reason is that >99% of COVID patients live without any drug. And those that die from it, die from the hosts response to the virus. I'm not sure killing the virus makes much difference once your lungs are 70% full of mucous and inflammatory material, due to ARDS, SIRS and/or whatever other host response COVID is causing, that we're not even aware of yet. Finding an effective treatment for ARDS and sepsis might be more effective. Unfortuantely, both have historically been as hard to find effective treatments for, as viruses. I'm optimistic we'll have an effective treatment for COVID-19 in the long term. I don't suspect that will happen in the short term.
Click to expand...

What are your thoughts on anti-IL6 and anticoagulants?
 
Lawper said:
What are your thoughts on anti-IL6 and anticoagulants?
Click to expand...
I'm not on the cutting edge of the research on these two topics, but I'll answer to the best of my ability.

Considering COVID-19 seems to have a pro-coagulant effect, it doesn't surprise me that anti-coagulation is showing promise in these patients. More study is needed, obviously, to determine if the effect is real, for which patients, when, what drug and what dose. The one paper in the Journal of American Cardiology did show a big enough mortality difference difference it can't be ignored (29% mortality, vented patients on anti-coagulation vs 62% mortality of vented patients not on anti-coagulation).

Interestingly, guess what else has an anti-coagulant effect? Hydroxychloroquine, through platelet inhibition. That's one of it's benefits in Lupus. So if it has a positive effect in COVID-19, it may be by this mechanism alone. Either way, it seems to me the use of anti-coagulants has to be looked at.

As far as IL-6, it's also an interesting approach. Like most everything with COVID-19 being so new, what do we have? A mix of small, non-controlled trials which yet don't prove anything one way or the other, yet, right? But I did read about a small study out of France with one of the IL-6 blockers which was positive and then a different one, with a different drug by a different maker, which showed negative results.

So, I don't know. It's all new, evolving and changing every day, isn't it? The only thing I know for sure about COVID-19, is that there's a lot to learn about COVID-19, by just about everybody, myself included.
 
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thegenius said:
Has anyone had any time to look over the dexamethasone for COVID-19 paper?
To critically appraise it?
Click to expand...
It hasn’t been published yet, just a press release.

NNT for death was 8 for ventilated patients and 25 for patients requiring oxygen.

No benefit for patients not requiring oxygen therapy. Which makes me think those people were sick AND COVID +, not sick because COVID +.
 
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So have we settled on a basic covid treatment regimen then?

--Admit if pulse ox < 94% or severe dyspnea
--5 day course of remdesivir for all admitted (but we know it's not a life-saver and since the benefit was decreased LOS, it would be ridiculous to advocate 'admitting for remdesivir therapy')
--dexamethasone, 6 mg daily for all admitted. Consider higher doses if intubated w/ ards
--Just say no to HCQ
--target eu- or slight hypovolemia
--prophylactic lovenox for all admitted. Consider therapeutic dosing if diagnosed VTE or markedly elevated and rising dimer
--NC->HFNC->CPAP->MV
--if intubated, standard ARDSnet, OLV or APRV
--Consider a dose of actemra? Trials hopefully out soon...
 
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gutonc said:
It hasn’t been published yet, just a press release.

NNT for death was 8 for ventilated patients and 25 for patients requiring oxygen.

No benefit for patients not requiring oxygen therapy. Which makes me think those people were sick AND COVID +, not sick because COVID +.
Click to expand...
Has there been a pathology yet, that didn't at some point show "initial promise" with steroids?
 
thegenius said:
Has anyone had any time to look over the dexamethasone for COVID-19 paper?
To critically appraise it?
Click to expand...
They've all read it but are waiting to see where Trump stands on it first before forming an opinion.

.


.

( :lol: Sorry, just slap me my wrist. Go ahead do it. Slap me. I couldn't resist. :laugh: )
 
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No data transparency on the dexamethasone paper yet.

Science-by-press-release is going to be the death of us.

FWIW, a large percentage of critically ill are already receiving some sort of steroids – usually methylprednisolone – in severe disease with inflammatory phenotype. A few observational studies have suggested it may be of value. Nice to have this to confirm something we're already doing. It has face validity as salvage, at least – whereas remdesivir is probably only useful in early disease, prior to fulminant lung inflammation.

Super high mortality in RECOVERY – way above the NIAID remdesivir. Bad for patients. Good for finding a mortality difference to a treatment. Uncertain re: generalizability.
 
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turkeyjerky said:
So have we settled on a basic covid treatment regimen then?

--Admit if pulse ox < 94% or severe dyspnea
--5 day course of remdesivir for all admitted (but we know it's not a life-saver and since the benefit was decreased LOS, it would be ridiculous to advocate 'admitting for remdesivir therapy')
--dexamethasone, 6 mg daily for all admitted. Consider higher doses if intubated w/ ards
--Just say no to HCQ
--target eu- or slight hypovolemia
--prophylactic lovenox for all admitted. Consider therapeutic dosing if diagnosed VTE or markedly elevated and rising dimer
--NC->HFNC->CPAP->MV
--if intubated, standard ARDSnet, OLV or APRV
--Consider a dose of actemra? Trials hopefully out soon...
Click to expand...

I would add proning to that list.
 
turkeyjerky said:
So have we settled on a basic covid treatment regimen then?

--Admit if pulse ox < 94% or severe dyspnea
--5 day course of remdesivir for all admitted (but we know it's not a life-saver and since the benefit was decreased LOS, it would be ridiculous to advocate 'admitting for remdesivir therapy')
--dexamethasone, 6 mg daily for all admitted. Consider higher doses if intubated w/ ards
--Just say no to HCQ
--target eu- or slight hypovolemia
--prophylactic lovenox for all admitted. Consider therapeutic dosing if diagnosed VTE or markedly elevated and rising dimer
--NC->HFNC->CPAP->MV
--if intubated, standard ARDSnet, OLV or APRV
--Consider a dose of actemra? Trials hopefully out soon...
Click to expand...

I think this all is OK...but most of it is inpatient stuff.

If I have a pt with COVID-19 and abnormal respiratory vitals I'll admit them and start antibiotics (presuming the xray has pneumonia on it).
Otherwise most of the things above are inpatient mgmt.

I think most patients get prophylactic lovenox anyway, right?

Everything else makes sense. I don't think I'll be starting dexamethasone until I read the paper or the hospital forces me to start it.
 
thegenius said:
There are news articles today that the journal Nature Medicine has published a paper about variable immunologic response to COVID-19. Has anybody found it? I want to read it.

This is one of the articles...
Click to expand...
It's linked in the article you posted.
www.nature.com

Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections - Nature Medicine

A cohort of asymptomatic patients infected with SARS-CoV-2 had significantly lower levels of virus-specific IgG antibodies compared to a cohort of age- and sex-matched symptomatic infected patients.
www.nature.com www.nature.com
 
What are your thoughts on:

Dexamethasone:

blogs.jwatch.org

Dexamethasone Improves Survival in COVID-19 -- Why This Should Be Practice Changing Even Before the Paper is Published

When the news broke last week that the dexamethasone component of the RECOVERY randomized clinical trial was halted because those receiving the drug were significantly more likely to survive, I posted the following: – Very welcome news, dex is cheap, widely available!– Demonstrates the power of...
blogs.jwatch.org blogs.jwatch.org

Prone positioning:

jamanetwork.com

Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

This cohort study investigates whether the prone position is associated with improved oxygenation and decreased risk for intubation in spontaneously breathing patients with severe COVID-19 hypoxemic respiratory failure.
jamanetwork.com jamanetwork.com
 
Lawper said:
What are your thoughts on:

Dexamethasone:

blogs.jwatch.org

Dexamethasone Improves Survival in COVID-19 -- Why This Should Be Practice Changing Even Before the Paper is Published

When the news broke last week that the dexamethasone component of the RECOVERY randomized clinical trial was halted because those receiving the drug were significantly more likely to survive, I posted the following: – Very welcome news, dex is cheap, widely available!– Demonstrates the power of...
blogs.jwatch.org blogs.jwatch.org

Prone positioning:

jamanetwork.com

Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure

This cohort study investigates whether the prone position is associated with improved oxygenation and decreased risk for intubation in spontaneously breathing patients with severe COVID-19 hypoxemic respiratory failure.
jamanetwork.com jamanetwork.com
Click to expand...

Anecdotally I tell some patients selectively to self prone. Usually the ones with reasonable body habitus. They say they feel better and sometimes improves numbers. As for dex, I don't think they've released the data but it is a relatively "benign" medicine, although with how long these people are in the hospital I worry about potential adrenal insufficiency.
 
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I still haven’t had a sick COVID patient yet. Don’t know about proning.

What is the decadron dosing? I don’t know if it was this study or some other, but I recall it being a piddly dose like 6 mg daily.

I agree that it’s fairly benign and i would probably use it (at those doses, say) but kind of makes you wonder why decadron and steroids are not effective with other pro-inflammatory septic conditions.

We still need to see the study. And it needs to be replicated. Should be fairly easy to do. 1) in the next 2-6 weeks have more than enough patients to enroll and 2) it’s already a well known drug. I would be MUCH more skeptical if a company invented a new novel drug that never has been seen before with these kinds of mortality benefit claims.
 
We've been following the EMCrit/IBCC recommendation with Dex 4mg TID since early on. The concern regarding steroids was in regards to viral shedding... which is something I don't care about in the unit.
 
Siggy said:
We've been following the EMCrit/IBCC recommendation with Dex 4mg TID since early on. The concern regarding steroids was in regards to viral shedding... which is something I don't care about in the unit.
Click to expand...

Yeah, the promising thing about dexamethasone is precisely the fact that the 'pretest probability' of it being modestly effective for covid pneumonia was already reasonable high, so this trial is likely to be more confirmatory than hypothesis generating. This stands in stark contrast to most of the prior BS "published" about treatment for this condition. We already knew steroids were modestly beneficial for run of the mill CAP and probably beneficial for ARDS.

For a lot of us, this trial isn't really practice-changing, just practice-reinforcing, so I don't really have major qualms about the press release.
 
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I read part of it. One of the takeaways is that people who did NOT require O2 support did WORSE while taking dexamethasone. It did not reach statistical significance, but there was a significant trend in that direction. One guess is the virus is probably still in the viremic stage, and suppressing the immune system during viral replication will make the patient worse.

It's a small dose, 6mg daily.

So, does this generally follow other experiences that steroids are beneficial for acute lung injury?
 
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So I heard there's apparently two major strains of virus, Wuhan and Italian? Apparently the Italian strain is deadlier, and that's what hit NYC initially? Can anyone confirm this?
 
bravotwozero said:
So I heard there's apparently two major strains of virus, Wuhan and Italian? Apparently the Italian strain is deadlier, and that's what hit NYC initially? Can anyone confirm this?
Click to expand...
I read that as well. I can't remember where I read it. If I can dig it up, I'll post it. If true, it might at least partially explain rising cases with a commensurate rise in deaths, wouldn't it?
 
I remember reading about the L and S types back in March from this paper:
academic.oup.com

On the origin and continuing evolution of SARS-CoV-2

Abstract. The SARS-CoV-2 epidemic started in late December 2019 in Wuhan, China, and has since impacted a large portion of China and raised major global concern
academic.oup.com academic.oup.com

Which had a fairly quick rebuttal via an editorial letter a couple days later (warning, the back and forth gets intensely nerdy as there are evolutionary virologists involved)
virological.org

Response to “On the origin and continuing evolution of SARS-CoV-2”

Response to “On the origin and continuing evolution of SARS-CoV-2” Oscar A. MacLean*, Richard Orton, Joshua B. Singer, David L. Robertson. MRC-University of Glasgow Centre for Virus Research (CVR). *To whom correspondence should be addressed: [email protected]. Introduction An...
virological.org virological.org

And then a more recent piece (not an article, more an informational site from the UK) says that there appear to be multiple random mutations without a true difference in strains.
coronavirusexplained.ukri.org

Are there different strains of the SARS-CoV-2 virus circulating?

There have been several recent reports of new “strains” of SARS-CoV-2 arising through mutation that have the potential to increase the severity of the pandemic. However, further analysis has shown these conclusions were premature and there is currently no robust evidence that any of the...
coronavirusexplained.ukri.org coronavirusexplained.ukri.org

Sooooooo... doesn't seem like anyone knows and there is no consensus opinion. Kinda par for the course eh?
 
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