COVID-19 medical discussion

[triplehorn 2664]

33 minutes ago, GRHorn said:

The link is gone but I’m curious how they think “cytokine storm” can be modulated in the case of this virus. It’s just another name or iteration of SIRS. People’s immune systems react differently to infections. We don’t exactly know why some people get just sick, and some people go into shock and multi organ failure. This virus is rough because you can’t treat the underlying infection like you can a bacterial infection to get out of the woods. 

A good lay explanation of the role of an overactive immune system aka cytokine storm, how it relates to coronavirus, and existing interventions:

How doctors can potentially significantly reduce the number of deaths from Covid-19

We already have medicines for treating cytokine storm syndrome, the immune response that’s killing many who die of Covid-19.

Quote

During a cytokine storm, an excessive immune response ravages healthy lung tissue, leading to acute respiratory distress and multi-organ failure. Untreated, cytokine storm syndrome is usually fatal. Patients in other studies who developed cytokine storm syndrome after viral triggers often ironically possessed subtle genetic immune defects resulting in the uncontrolled immune response.

Over the past two decades, much has been learned about the diagnosis and treatment of cytokine storm syndromes. On the front lines of the Covid-19 response, it is critical that medical professionals are aware of the syndrome and prepared to identify and treat it.

This act of preparation could help to significantly reduce the number of deaths from Covid-19. In treating cytokine storms brought about by other illnesses, like other viral infections and autoimmune diseases, death rates among patients suffering a cytokine storm have been reduced to as low as 27 percent.

The link that disappeared above (which was not a scientific article) mentioned something about an autoimmune component with this coronavirus involving antibodies against the covid surface "S" spike which also cross-react with a similar antigen on the surface of healthy cells.  I haven't seen anything to substantiate that.

 

 

Edited March 17, 2020 by triplehorn

[triplehorn 2664]

The sooner we understand the dimensions of this bug well enough to significantly reduce morbidity and mortality in the minority of people who have a complicated course, the sooner we can return to normalcy while acknowledging that there will always be some risk factors we can't modify, like old age. At that point, the risks could more resemble the risks of getting influenza.  I suppose it's conceivable we already have the tools to accomplish that, we just don't yet have an integrated medical consensus for diagnosis and treatment of the full spectrum of the illness and complications.  It's also conceivable we could make major progress there well before a widely used vaccine is available.

[triplehorn 2664]

2 hours ago, Bruno Sardine said:

At some point when people were discussing this previously, the claim was made that zinc is only beneficial in lozenge form – that its palliative properties derive from the interaction between the zinc and the lining of the throat. In other words, zinc in pill form is ineffective against viruses. 

Would anyone in the know have an opinion? 

Think of swallowing a zinc supplement tablet vs using a zinc throat lozenge as similar to taking an oral steroid vs. getting a localized steroid injection.  In some cases you want the zinc (or steroid) to target a limited area quickly and don't need it to hit the whole body.  Normally we think of hitting a virus in the throat where it's attacking.  This coronavirus is infecting cells that bear the ACE2 receptor, and we know that's not limited to the respiratory tract.  Publications are already showing this virus attacking gut lining and causing limited nausea, vomiting, and diarrhea in about half the cases in one report out of China.  Those symptoms reportedly happen at the start and then respiratory symptoms follow in shortly after.

JMO, supplementing with oral zinc is probably best as a pre-emptive measure you should do well before you get infected.  It needs some time to distribute and equilibrate throughout your entire body and then find its way inside healthy cells.  Getting into cells, which is where it is thought to help shut down viral replication, is the rate limiting step (zinc has a positive electrical charge and cell membrane is lipid, i.e "oil and water").  But if you take oral zinc over days in advance, in principle you will slowly drive up or at least optimize intracellular zinc concentration throughout your body, which is the goal.  

In vitro studies have shown that Chloroquine in a zinc ionophore.  That means Chloroquine grabs zinc.  Chloroquine crosses the cell membrane far more easily than zinc alone.  So Chloroquine is thought to carry zinc into cells and quickly increase zinc levels inside cells to have an antiviral effect.  Again, no controlled human studies to demonstrate this.  China and other countries are reporting positive results.

Here's an article about a guy in NJ with covid who contacted Chinese docs in China to tell his US docs how to help.  They gave him choroquine:

New Jersey patient James Cai recovering from coronavirus

Quote

The New Jersey health care worker who was the state’s first coronavirus case says he’s on the mend — adding that he would be “dead and gone” had he not reached out to doctors in China about how to defeat the deadly bug.

James Cai, a 32-year-old physician’s assistant, remains hospitalized Thursday at Hackensack University Medical Center, where he’s now only experiencing a cough and fatigue after 11 days of battling the virus.

“Fortunately I have the resources and knowledge about it. I would be dead and gone already,” Cai told The Post in a text message.

He credited several Chinese doctors with helping his providers here better understand the infectious disease taking over his body.

“Most medical providers here don’t know about it,” Cai said. “Medical providers need to communicate with Chinese medical teams.”

Cai said he believes that he came down with the bug while at the Westin in Times Square for a medical conference from Feb. 28 to March 2.

During the final days of the conference, he started to experience bone pain, which was followed by a cough.

He then went to a local health clinic, where they determined that his heart rate was fast, he said.

Cai was instructed to go to the hospital, where CT scans showed that he lost 50 percent of his lung function.

Doctors started to treat him like he had bacterial pneumonia, but his family was unconvinced and reached out to five Chinese doctors who studied the virus that emerged in Wuhan.

It was only with the Chinese experts’ encouragement that they agreed to perform a coronavirus test, he said.

When it came back positive, they recommended he be treated with the antimalarial medicine chloroquine and the HIV drug Kaletra.

“Chinese experts suggest to treat with medicine to slow the virus first. Don’t wait,” he said. “Definitely I would not be here today [without them].”

Cai said since he was otherwise healthy, he fears how those who are older will fare fighting the virus.

“I am young. [People who are] 40 years and above [will] definitely not be making it,” Cai said.

His case is among the 23 people infected with the virus in New Jersey, where on Monday a state of emergency was declared.

FILED UNDER CORONAVIRUS ,  NEW JERSEY

If you have chloroquine on hand, you may not even need to supplement with zinc as typical zinc levels in people are adequate to boost intracellular zinc levels with addition of choroquine.

[naija 2854]

Blood banks to take a hit shortly.

[boknowstecmo 216]

Hey Surly docs, I talked to a doc over the phone using teledoc about my symptoms since Saturday night: mild headache, sore throat, minor chest tightness (feels like there's a couple pound weight on my chest, but no difficulty breathing.) He said he thinks it's allergies, even after I told him my allergies are usually always just runny nose and sneezing. He then prescribed me Prednisone.

I definitely should not be taking Prednisone in the middle of this pandemic, should I? I've read several articles from sources like CDC, etc. that state patients taking Prednisone and other similar steroids are at an increased risk of developing more serious symptoms if they get Covid. Shouldn't I just ride this out instead of putting myself at risk for something far worse?

[TWHOOKEM 10]

On 3/14/2020 at 5:14 PM, triplehorn said:

on it.  I'm taking it daily though for presumptive active sars-cov-2 infection.

 

600 mg?

[triplehorn 2664]

That's a 500mg tab of chloroquine, also comes in 250mg.  Hydroxychloroquine comes in 200mg tabs, so x3 for 600mg/d is what was used in the French study that came out today.  They appear to both work by the same mechanism of increasing intracellular zinc to thwart viral replication.

This really could be it.  Or at least could knock this bug down to a point where morbidity and mortality levels become comparable to flu.  If that's the case we probably will rapidly establish stability in our health care system and form an acceptable compromise that lets us get back to normal routines.

Full court press to manufacture enough of this, even if it's only a part of the picture of full success.

[Hate 20108]

That's the first bit of good news in a while.  I hope this pans out.

[Anastasis 23469]

3 hours ago, boknowstecmo said:

 

I definitely should not be taking Prednisone in the middle of this pandemic, should I? I've read several articles from sources like CDC, etc. that state patients taking Prednisone and other similar steroids are at an increased risk of developing more serious symptoms if they get Covid. Shouldn't I just ride this out instead of putting myself at risk for something far worse?

That a big nope on the steroids. 

[wild_turkey 3159]

12 hours ago, boknowstecmo said:

Hey Surly docs, I talked to a doc over the phone using teledoc about my symptoms since Saturday night: mild headache, sore throat, minor chest tightness (feels like there's a couple pound weight on my chest, but no difficulty breathing.) He said he thinks it's allergies, even after I told him my allergies are usually always just runny nose and sneezing. He then prescribed me Prednisone.

I definitely should not be taking Prednisone in the middle of this pandemic, should I? I've read several articles from sources like CDC, etc. that state patients taking Prednisone and other similar steroids are at an increased risk of developing more serious symptoms if they get Covid. Shouldn't I just ride this out instead of putting myself at risk for something far worse?

Prednisone makes you immunocompromised and therefore more susceptible to infectious diseases. If your indication for prednisone is allergies and you can get by without it, then it's probably best to treat your allergies with other medications if at all possible.

At the same time, many people take steroids for more serious chronic health conditions (giant cell arteritis, ITP, rheumatoid, etc..) and stopping the prednisone could put you at serious health risk from your chronic disease.

The bottom line is consult with your doctor who prescribes prednisone to determine if the risk of prednisone use is justified during this time.

[wild_turkey 3159]

The WHO is launching the multinational SOLIDARITY trial to look at the effects of 4 different drugs:  remdesivir, lopinavir and ritonavir, and lopinavir and ritonavir plus interferon beta, and chloroquine. They are looking to see if any of the treatments reduce mortality, reduce hospitalization time, or reduce the need for ICU or ventilation.

https://www.statnews.com/2020/03/18/who-to-launch-multinational-trial-to-jumpstart-search-for-coronavirus-drugs/

 

WHO to launch multinational trial to jumpstart search for coronavirus drugs

The World Health Organization said Wednesday that it would launch a multiarm, multicountry clinical trial for potential coronavirus therapies, part of an aggressive effort to jumpstart the global search for drugs to treat Covid-19.

Four drugs or drug combinations already licensed and used for other illnesses will be tested, said WHO Director-General Tedros Adhanom Ghebreyesus. Ten countries have already indicated they will take part in the trial.

The mere fact the WHO is sponsoring the trial suggests that efforts in China to test these drugs may not have come up with enough data to indicate whether any were of use to prevent patients from developing severe disease or save those with severe disease from death.

The study, which Tedros said he hopes other countries will join, has been named the SOLIDARITY trial. Countries that have already signed on are: Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland, and Thailand.

“Multiple small trials with different methodologies may not give us the clear strong evidence we need about which treatments help to save lives,” he said during a briefing in Geneva.

Ana Maria Henao-Restrepo, unit head for the WHO’s research and development “blueprint” group, said the trial design was deliberately kept simple “to enable even hospitals that have been overloaded to participate.”

“This trial focuses on the key priority questions for the public. Do any of these drugs reduce mortality? Do any of these drugs reduce the time a patient is in hospital and whether or not the patients receiving any of the drugs needed ventilation or intensive care units,” Henao-Restrepo said.

The four drugs or combinations will be compared to what is called standard of care — the regular support hospitals treating these patients use now, such as supplementary oxygen when needed.

The drugs to be tested are the antiviral drug remdesivir; a combination of two HIV drugs, lopinavir and ritonavir; lopinavir and ritonavir plus interferon beta; and the antimalarial drug chloroquine. All show some evidence of effectiveness against the SARS-CoV 2 virus, which causes Covid-19, either in vitro and/or animal studies.

Remdesivir is made by Gilead. Lopinavir and ritonavir are combined and sold as Kaletra or Aluvia by AbbVie.

Later in the day, after close of business in Geneva, the New England Journal of Medicine published a study from China that reported finding that the lopinavir-ritonavir combination did not improve survival or speed recovery, though the authors noted that the very high death rates among patients who received the drugs and those who received only standard care suggest they had enrolled “a severely ill population.”

Of the 199 patients in the trial, 22% died, which was “substantially higher than the 11% to 14.5% mortality reported in initial descriptive studies of hospitalized patients with Covid-19,” they said. The trial was also not blinded — meaning the doctors knew which patients were receiving the drugs — which they acknowledge could have influenced their clinical decision making.

“These early data should inform future studies to assess this and other medication in the treatment of infection with SARS-CoV-2,” wrote the authors. “Whether combining lopinavir–ritonavir with other antiviral agents, as has been done in SARS and is being studied in MERS-CoV, might enhance antiviral effects and improve clinical outcomes remains to be determined.”

Henao-Restrepo said chloroquine — which is cheap and used regularly around the world — will be tested two ways. Some countries will test chloroquine against the standard of care while others will test hydroxychloroquine, a related drug.

“The good thing about the trial is … that the randomization could be adjusted to the drugs available in each individual hospital over time,” Henao-Restrepo said. “The other good thing … is that we can include additional arms or drop arms as our global data safety and monitoring committee advises we should do.”

Enrolling patients across a number of countries should speed the world to an answer about which drugs, if any could be effective in reducing the toll of Covid-19. The WHO launched a similar trial in the Democratic Republic of the Congo in November 2018 to test four therapies against Ebola.

At the time of that launch, it was thought that the trial might need to draw data from several Ebola outbreaks before it could reach an answer. But the North Kivu outbreak, which could be declared over next month, was so large results were announced in August 2019. Given the high number of cases globally of Covid-19 and the number of countries participating, results should come faster with this trial.

Edited March 19, 2020 by wild_turkey

[boknowstecmo 216]

49 minutes ago, wild_turkey said:

The WHO is launching the multinational SOLIDARITY trial to look at the effects of 4 different drugs:  remdesivir, lopinavir and ritonavir, and lopinavir and ritonavir plus interferon beta, and chloroquine. They are looking to see if any of the treatments reduce mortality, reduce hospitalization time, or reduce the need for ICU or ventilation.

https://www.statnews.com/2020/03/18/who-to-launch-multinational-trial-to-jumpstart-search-for-coronavirus-drugs/

  Reveal hidden contents

WHO to launch multinational trial to jumpstart search for coronavirus drugs

The World Health Organization said Wednesday that it would launch a multiarm, multicountry clinical trial for potential coronavirus therapies, part of an aggressive effort to jumpstart the global search for drugs to treat Covid-19.

Four drugs or drug combinations already licensed and used for other illnesses will be tested, said WHO Director-General Tedros Adhanom Ghebreyesus. Ten countries have already indicated they will take part in the trial.

The mere fact the WHO is sponsoring the trial suggests that efforts in China to test these drugs may not have come up with enough data to indicate whether any were of use to prevent patients from developing severe disease or save those with severe disease from death.

The study, which Tedros said he hopes other countries will join, has been named the SOLIDARITY trial. Countries that have already signed on are: Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland, and Thailand.

“Multiple small trials with different methodologies may not give us the clear strong evidence we need about which treatments help to save lives,” he said during a briefing in Geneva.

Ana Maria Henao-Restrepo, unit head for the WHO’s research and development “blueprint” group, said the trial design was deliberately kept simple “to enable even hospitals that have been overloaded to participate.”

“This trial focuses on the key priority questions for the public. Do any of these drugs reduce mortality? Do any of these drugs reduce the time a patient is in hospital and whether or not the patients receiving any of the drugs needed ventilation or intensive care units,” Henao-Restrepo said.

The four drugs or combinations will be compared to what is called standard of care — the regular support hospitals treating these patients use now, such as supplementary oxygen when needed.

The drugs to be tested are the antiviral drug remdesivir; a combination of two HIV drugs, lopinavir and ritonavir; lopinavir and ritonavir plus interferon beta; and the antimalarial drug chloroquine. All show some evidence of effectiveness against the SARS-CoV 2 virus, which causes Covid-19, either in vitro and/or animal studies.

Remdesivir is made by Gilead. Lopinavir and ritonavir are combined and sold as Kaletra or Aluvia by AbbVie.

Later in the day, after close of business in Geneva, the New England Journal of Medicine published a study from China that reported finding that the lopinavir-ritonavir combination did not improve survival or speed recovery, though the authors noted that the very high death rates among patients who received the drugs and those who received only standard care suggest they had enrolled “a severely ill population.”

Of the 199 patients in the trial, 22% died, which was “substantially higher than the 11% to 14.5% mortality reported in initial descriptive studies of hospitalized patients with Covid-19,” they said. The trial was also not blinded — meaning the doctors knew which patients were receiving the drugs — which they acknowledge could have influenced their clinical decision making.

“These early data should inform future studies to assess this and other medication in the treatment of infection with SARS-CoV-2,” wrote the authors. “Whether combining lopinavir–ritonavir with other antiviral agents, as has been done in SARS and is being studied in MERS-CoV, might enhance antiviral effects and improve clinical outcomes remains to be determined.”

Henao-Restrepo said chloroquine — which is cheap and used regularly around the world — will be tested two ways. Some countries will test chloroquine against the standard of care while others will test hydroxychloroquine, a related drug.

“The good thing about the trial is … that the randomization could be adjusted to the drugs available in each individual hospital over time,” Henao-Restrepo said. “The other good thing … is that we can include additional arms or drop arms as our global data safety and monitoring committee advises we should do.”

Enrolling patients across a number of countries should speed the world to an answer about which drugs, if any could be effective in reducing the toll of Covid-19. The WHO launched a similar trial in the Democratic Republic of the Congo in November 2018 to test four therapies against Ebola.

At the time of that launch, it was thought that the trial might need to draw data from several Ebola outbreaks before it could reach an answer. But the North Kivu outbreak, which could be declared over next month, was so large results were announced in August 2019. Given the high number of cases globally of Covid-19 and the number of countries participating, results should come faster with this trial.

Good. 

[RayDog 682]

In the comment section of today's Peak Prosperity video someone mentioned that quercetin is another ionofore for zinc. It is available as a supplement and is in many foods including red onions.

Doed the surly medical Brain trust have any information on quercetin as a possible uncontrolled alternative to chloroquine?

 

[Anastasis 23469]

A pretty broad review, with information on dosing etc.

https://www.idstewardship.com/coronavirus-covid-19-resources-pharmacists/

 

Created: 14 March 2020

Last updated: 18 March 2020 PM

Many pharmacists across the world are working hard to keep up with therapeutic options for coronavirus / SARS-CoV-2 / COVID-19. This webpage was created to provide insights and resources for pharmacists helping to manage this pandemic. Take note that updates to the page will be made periodically as permitted and the content here may not be completely up-to-date as the situation is evolving quickly. Also beware that much of the data identified below is of relatively poor quality in terms of utility for determining what should be done in clinical practice.

Additionally, there are many potential COVID-19 therapies, I list several at the bottom, but do not discuss them in depth. Some of these can potentially lessen the cytokine storm associated with COVID-19 and help with managing acute respiratory distress syndrome (ARDS).

MOST IMPORTANTLY: Thus far no antiviral drug has been proven to work against COVID-19 in humans, although many randomized controlled trials are ongoing. Inclusion in this webpage is not an endorsement for use of any of these drugs for COVID-19.

If you have a resource that is helpful and reliable, but not posted here, send it to me: IDstewardship@gmail.com or @IDstewardship on Twitter.

General COVID-19 Resources

• CDC information for healthcare professionals
• CDC clinical care information for healthcare professionals
• CDC COVID-19 cases in the U.S webpage
• UK Government COVID-19 guidance for healthcare professionals
• Johns Hopkins Coronavirus Tracker
• WHO COVID-19 Clinical Management Document
• University of Liverpool COVID-19 resources (drug interactions, information for patients with difficulty swallowing)
  • **THIS IS AN EXCELLENT RESOURCE**
  • University of Liverpool page on COVID-19 patients with difficulty swallowing
• ClinicalTrials.gov search page
• Internet Book of Critical Care (IBCC) COVID-19 Review
  • **THIS IS AN EXCELLENT RESOURCE**

Institutional & Society COVID-19 Treatment Guidelines

• Italian Society of Infectious Diseases and Tropical Diseases COVID-19 Guideline
  • Published in Italian
  • Tweet with link to google.doc that has the document translated into English
• Chinese Government’s New Coronavirus Pneumonia Diagnosis and Treatment Plan (Trial Version 7)
  • Published in Chinese
  • Translated into English
• University of Michigan: Inpatient Guidance for Diagnosis and Treatment of COVID-19 in Adults & Children
• University of Washington Resources (includes Treatment Guideline)
  • University of Washington Emergency Medicine ED/ICU COVID-19 Guide
     

General Notes

• Coronavirus 2019 (aka SARS-CoV-2) causes a diseases called COVID-19
• Corticosteroids are not recommended as part of treatment for COVID-19 unless other indications exist
  • They may prolong viral shedding
  • One recent article did recommend to consider a short course of glucocorticoids
• Nebulized bronchodilators may risk spread of the virus, in general meter dose inhalers (MDIs) are preferred
  • RE: Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!
• Antibiotics are generally NOT recommended
  • Pharmacotherapeutics for the New Coronavirus Pneumonia
• Co-infection with influenza and COVID-19 is expected to be unlikely, but possible
  • Co-infection with SARS-CoV-2 and Influenza A Virus in Patient with Pneumonia, China
• Lymphopenia is a common component of initial COVID-19 presentation
  • Clinical Characteristics of Coronavirus Disease 2019 in China
• COVID-19 does not appear to increase procalcitonin, but does appear to increase CRP
  • Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China
  • Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore
• Empiric neuraminidase (NMD) inhibitor therapy may be reasonable during flu season, but I am unable to identify any data to support NMD inhibitor use for COVID-19
  • Inhibition of SARS Coronavirus Infection In Vitro with Clinically Approved Antiviral Drugs
• People who die from COVID-19 usually have ARDS, beware the fluids may exacerbate this so aggressive fluid support is not generally appropriate
• COVID-19 commonly causes troponin elevations
• Patients with mild disease may not require hospitalization, but they may worsen with progression to lower respiratory tract disease
  • Risk factors for progression include: older age and underlying chronic medical conditions such as lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, diabetes, immunocompromising conditions, and pregnancy
  • Infection in pediatrics may not be as common or severe, but it is possible
    • A case report of neonatal COVID-19 infection in China
    • Laboratory Abnormalities in Children With Novel Coronavirus Disease 2019

Remdesivir Resources & Notes

• Remdesivir (GS-5734, RDV) is not FDA-approved and is available for investigational use only
  • Is a nucleotide analog antiviral
  • Has activity against Ebola virus, MERS, and SARS
  • Has drug-drug interactions via the liver, so would not be expected to be given with LPV/r
    • Guidance I received from Gilead was that once remdesivir is initiated, any experimental anti-COVID-19 therapies must be ceased
  • Available intravenous only
    • Study dose in adults: RDV 200 mg loading dose on day 1 is given, followed by 100 mg iv once-daily maintenance doses for 9 days
      • Review study protocols here
• In preparing to request investigational remdesivir, collecting the following information ahead of time may be helpful:
  • Prescriber name, address, email, and phone number associated with the treatment center
  • Professional designation (ie, MD) or qualifications of requester including medical license number
  • Institution/ hospital name, address, email, and phone number
  • Shipping information (including pharmacy hours)
  • Patient case information, including previous or current treatments and clinical status
• There are many exclusion criteria for remdesivir
  • Gilead website including key inclusion & exclusion criteria for remdesivir
• Remdesivir clinical trials
• Email to contact Gilead compassionate use: compassionateaccess@gilead.com

Lopinavir/ritonavir (Kaletra, LPV/r) Resources & Notes

• Data suggests LPV/r should not be used mono therapy for severe COVID-19
  • A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19
• LPV/r may be effective when used in combination with other drugs versus COVID-19, but more data on this is needed
• Beware drug-drug interactions as ritonavir is a CYP enzyme inhibitor (will increase levels of other drugs)
• Consider avoiding for patients with liver or cardiac disease
• LPV/r comes in an oral solution, but it may not be available during times of high demand, so people may consider crushing the capsules
  • Pharmacokinetics of Lopinavir/Ritonavir Crushed versus Whole Tablets in Children
    • Crushing LPV/r can reduce the AUC by 50%
    • Increasing the LPV/r dose by 50% to compensate would mean a considerable amount of ritonavir, which may cause considerable drug-drug interactions
      • Cushing LPV/r has shown to reduce exposure to both lopinavir and ritonavir, so the increase in ritonavir may not be clinically relevant
  • From a colleague (paraphrased):
    • We may be able to use information from venetoclax (Venclexta), which like LPV/r has a film coated tablet
      • For venetoclax we dissolve the tablet into a slurry in a syringe to reduce the risk of losing drug in a crusher or amber vial. It can take up to 20 mins (per patient report) to get the drug to dissolve. The ICU nurses have not had issues with getting ventoclax surry down NG tubes, but floor nurses did report issues (potential it was not administered immediately?). We also did the tablet slurry in a syringe to reduce exposure to compounding staff.
      • This approach can avoid the use of preservatives
        • This briefing includes  information on making a pediatric venetoclax solution, notes avoiding preservatives and potential issues with stability
      • Stability data is lacking, consider immediate use
        • From the above referenced article: “Disruption of the extrude matrix environment may adversely impact this formulation affect. The crushing of the pill leaves part of the drug(s) on the walls of the container or crushing device, and the transfer of the crushed substance to the food or liquid for mixing may also generate loss of the active drug.”
• The dose and duration I have seen recommended is LPV/r 400-100 mg BID x14 days
• The University of Michigan COVID-19 guidance document recommends:
  • Adult dosing: 400 mg-100 mg PO BID
  • Pediatric dosing:
    • 14 days to 6 months old: lopinavir component 16 mg/kg PO BID
    • 6 months to 18 years:
      • 15-25 kg: 200 mg-50 mg PO BID
      • 26-35 kg: 300 mg-75 mg PO BID
      • >35 kg: 400 mg-100 mg PO BID
• LPV/r oral solution has a high alcohol content and tastes terrible, which can be an issue for children in particular
• Consider HIV testing prior to initiating therapy
• Some clinicians are combing LPV/r with ribavirin
• Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore
  • Includes 5 patients treated with LPV/r for COVID-19
  • None died
  • 3 of 5 developed abnormal liver test results
• There are pre-SARS-CoV-2 publications supporting activity of LPV/r versus SARS
  • Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings
  • Treatment of severe acute respiratory syndrome with lopinavir/ritonavir: a multicentre retrospective matched cohort study
• Kaletra Package Insert (tablet & oral solution)

Chloroquine Resources & Notes

• Chloroquine is best known for it’s use versus malaria, but apparently has activity versus some coronaviruses
• Beware liver toxicity
• Consider avoiding in patients with heart failure, recent myocardial infarction, G6PD deficiency, epilepsy, or porphyria
• Oral tablets can be crushed, but it is not preferable
  • A chloroquine oral syrup may be available for purchase
  • Stability of Alprazolam, Chloroquine Phosphate, Cisapride, Enalapril Maleate, and Hydralazine Hydrochloride in Extemporaneously Compounded Oral Liquids
    • Found chloroquine phosphate 15 mg/mL was  stable in extemporaneously compounded oral liquids for 60 days at 5 and 25 degrees C
• Expert Consensus on Chloroquine Phosphate for the Treatment of Novel Coronavirus Pneumonia
  • Recommends chloroquine 500 mg PO BID x10 days for treatment of COVID-19 pneumonia of mild, moderate, or severe disease
• Breakthrough: Chloroquine Phosphate Has Shown Apparent Efficacy in Treatment of COVID-19 Associated Pneumonia in Clinical Studies
  • These authors reported that information from a news briefing stated more than 100 patients given chloroquine phosphate did better than the control patients when it came to exacerbation of pneumonia, improving lung imaging findings, and promoting a virus-negative conversion, and shortening the disease.
• Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro
  • Favorable findings on activity of chloroquine and remdesivir versus SARS-CoV-2
• Screening of an FDA-approved Compound Library Identifies Four Small-Molecule Inhibitors of Middle East Respiratory Syndrome Coronavirus Replication in Cell Culture
  • Suggests chloroquine may be a therapeutic option
• New Insights on the Antiviral Effects of Chloroquine Against Coronavirus: What to Expect for COVID-19?
  • Discusses chloroquine’s potential mechanisms against SARS-CoV-2
• Chloroquine Package Insert

Hydroxychloroquine (Plaquenil) Resources & Notes

• Hydroxychloroquine is generally better tolerated than chloroquine and has the same mechanism of action
• On crushing hydroxychloroquine tablets:
  • Stability of Extemporaneously Prepared Hydroxychloroquine Sulfate 25-mg/mL Suspensions in Plastic Bottles and Syringes
    • Describes preparation of hydroxychloroquine sulfate and concludes it is stable for at least 90 days in Medisca Oral Mix or Oral Mix SF suspension media at 25°C and 4°C
  • Hydroxychloroquine suspension instructions:
    • Nationwide Children’s Pharmacy
    • Stanford Children’s Recipe (screenshot in a Tweet)
  • Nuffield Orthopaedic Centre NHS Trust and Oxfordshire Primary Care Trust Shared Care Protocol and Information for GPs
    • Recommends dispersing tablets in water after crushing
  • This article is referenced in some references, but I cannot find a link to it:
    • Pesko LJ. Compounding: Hydroxychloroquine. Am Druggist. 1993; 207-257.
• In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
  • This study found that hydroxychloroquine was 3x more potent than chloroquine phosphate in vitro
  • The study recommends hydroxychloroquine 400 mg BID load, then 200 mg BID for 4 days
    • Note this is a shorter course than the 10 day chloroquine course noted above
• The University of Michigan COVID-19 guidance document recommends:
  • Adult dosing: 600 mg PO BID x2 doses (load), then 200 mg PO TID
  • Pediatric dosing (<18 years): 10 mg/kg (max: 600 mg/dose) PO BID x2 (load), then 3 mg/kg PO TID (max: 200 mg/dose)
• Plaquenil (hydroxychloroquine) Package Insert

Tocilizumab (Actemra) Resources & Notes

• Tocilizumab is an inteurlukin-6 (IL-6) inhibitor that may be helpful for cytokine storm associated with severe COVID-19 disease
  • Cytokine storm may be a complicating factor for patients with severe COVID-19 disease
• Reserve for patients with severe disease who have failed other therapies, consider dose capping and limiting the number of doses
• Novel Coronavirus Pneumonia Diagnosis and Treatment Plan (Provisional 7th Edition) states:
  • For patients with extensive and bilateral lung disease and severely ill patients with elevated IL-6 levels, treatment with tocilizumab may be attempted
  • The initial dose should be 4-8mg/kg, with the recommended dosage being 400mg
  • Dilute with 0.9% saline to 100ml and infuse over the course of more than 1 hour
  • Repeat once after 12 hours (same dosage) if the response to the first dose was poor, mximum two cumulative doses
  • Single maximum dose is 800mg
  • Pay attention to allergic reactions
  • Prohibited in patients with active infections such as tuberculosis
• One article (not peer reviewed) reports on 20 patients with severe or critical COVID-19 disease treated with tocilizumab and having good outcomes
  • Effective Treatment of Severe COVID-19 Patients with Tocilizumab
• Concern exists that the long-term effects of this drug may predispose patients to future infections
  • Some providers are looking to IL-1 inhibitors for this reason
• This medication is very expensive
• Tocilizumab (Actemra) Package Insert

More COVID-19 Articles

• First 12 patients with coronavirus disease 2019 (COVID-19) in the United States
  • This is essentially a case series and given the limited amount of data here it is hard to take much away from it
• 2019-Novel Coronavirus (2019-nCoV): estimating the case fatality rate – a word of caution
  • Case fatality rate may vary by region
• Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China
  • Found older age is associated with death
• Detection of SARS-CoV-2 in Different Types of Clinical Specimens
  • Virus may be spread via feces and testing multiple sites of the body may be helpful
• Involving Antimicrobial Stewardship Programs in COVID-19 Response Efforts: All Hands on Deck
  • Discusses opportunities for antimicrobial stewardship programs to help out, including managing drug shortages, developing treatment guidelines, assisting with acquisition of investigational drugs, and monitoring
• On the origin and continuing evolution of SARS-CoV-2
  • This article discusses the L type and S type of SARS-CoV-2 and how the frequency of each may be shifting as the pandemic progresses
• Re: Preventing a covid-19 pandemic: ACE inhibitors as a potential risk factor for fatal Covid-19
  • This article suggests use of ACE-inhibitors (ACE-Is)/ angiotensin-receptor blockers (ARBs) may increase the risk for severe COVID-19 disease and increase transmissibility, due to increased expression of ACE2 receptor
    • However, this article suggests the opposite in that ARBs may be protective against COVID-19:
      • Angiotensin receptor blockers as tentative SARS‐CoV‐2 therapeutics
  • On the topic: Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?
    • This article suggests patients with cardiac diseases, hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection and, therefore, should be monitored for ACE2-modulating medications, such as ACE inhibitors or ARBs.
      • However, the European Society of Cardiology notes: “speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it.”
        • Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers
    • This article also notes that ibuprofen and thiazolidinediones can increase ACE2
      • On the topic: The French Minister suggested to avoid NSAIDs, take acetaminophen instead
        • Anti-inflammatories may aggravate Covid-19, France advises
      • Now there are multiple groups recommending against NSAIDs for patients with COVID-19
        • Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists
      • It is being reported as of March 16th, WHO is recommending to avoid ibuprofen for as a self-medication for COVID-19
• Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1
  • This article found SARS-CoV-2 (HCoV-19) could be found in aerosols up to 3 hours post-aerosolation, on cardboard up to 24 hours, and on plastic or stainless steel for 2-3 days
  • The inoculum required to cause infection is an important factor to consider when reading this article
• How will country-based mitigation measures influence the course of the COVID-19 epidemic?
  • This article has the famous figure showing how flattening the initial wave can help the healthcare systems cope with the influx of COVID-19 cases
• COVID-19: An Update on the Epidemiological, Clinical, Preventive and Therapeutic Evidence and Guidelines of Integrative Chinese-Western Medicine for the Management of 2019 Novel Coronavirus Disease

List of Other Potential Therapies

• Probably the best place for a full list and ongoing studies related to these: clinicaltrials.gov
• Intravenous Immunoglobulin
• Thalidomide
• Fingolamid (FTY720)
• Carrimycin
• Bromhexine HCl
• Ecluzumab (Soliris)
• Bevacizumab (Avastin)
• Nitrous oxide gas
• Nitazoxanide
• Tiecoplanin
• ASC09F
• Xainping
• Ascorbic acid (vitamin C)
• Arbidol
  • Arbidol Combined With LPV/r Versus LPV/r Alone Against Corona Virus Disease 2019: a Retrospective Cohort Study
    • Supports LPV/r therapy but not LPV/r + arbidol therapy
• Darunavir/ cobicistat (Prezcobix)
• Danoprevir (Ganovo)
• Pirfrenidone (Esbriet)
• Ribavirin
  • Stability of Extemporaneous Oral Ribavirin Liquid Preparation
• Interferon alfa 2b
• Indomethacin
  • Indomethacin Has a Potent Antiviral Activity Against SARS Coronavirus
• Zinc
  • Zn²⁺ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture
  • Chloroquine Is a Zinc Ionophore

Other COVID-19 Resource Centers

• IDSA COVID-19 Resource Center
• SCCM COVID-19 Resource Center
• ASM COVID-19 Resource Center
• The LANCET COVID-19 Resource Center
• CIDRAP COVID-19 Resource Center
• UW Medicine COVID-19 Resource Site
• UNMC COVID-19 Resource Center
  • UNMC COVID-19 Resources for Providers

More COVID-19 Webpages

• Contagion Live coronavirus page
• Shoreland travax coronavirus 2019 page
• FL DOH COVID-19 Tracking Map

Miscellaneous Things That May be Helpful

• UCSF COVID-19 Clinical Evaluation Guide (via Twitter)
• Medcram COVID-19 video update (includes discussion on Zinc)
• YouTube video from Italian MD Dr. Stefano Aliberti (March 17) providing insights on his experience
  • Related: On the Front Lines of Coronavirus: The Italian Response to covid-19
• Controversies in Hospital Infection Prevention article: COVID-19: Deep Thoughts and a Little Therapy

And Even More COVID-19 Literature

• Under the Epidemic Situation of COVID-19, Should Special Attention to Pregnant Women Be Given?
  • Provides considerations for pregnant patients
• Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy
  • Provides a summary of the response of the COVID-19 Lombardy ICU network and a forecast of estimated ICU demand over the coming weeks
• A Novel Approach for a Novel Pathogen: using a home assessment team to evaluate patients for 2019 novel coronavirus (SARS-CoV-2)
  • Describes an effective mechanism for testing outside of the healthcare setting
• A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias
  • Suggests CT scan may be a reliable test for screening NCOVID-19 cases, liver function damage is more frequent in NCOVID-19 than NON-NCOVID-19 patients, and LDH as well as α-HBDH may be considerable markers for evaluation of NCOVID-19
• Dysregulation of immune response in patients with COVID-19 in Wuhan, China
  • Suggests surveillance of neutrophil-lymphocyte-ratio and lymphocyte subsets can be helpful in the early screening of critical illness, diagnosis and treatment of COVID-19

[Newdoc 3440]

13 hours ago, wild_turkey said:

Prednisone makes you immunocompromised and therefore more susceptible to infectious diseases.

Actually no. This is a myth. It does not work that way. It can cause other problems. And it looks to be ineffective in critical Covid infections.

[Newdoc 3440]

16 minutes ago, Newdoc said:

Actually no. This is a myth. It does not work that way. It can cause other problems. And it looks to be ineffective in critical Covid infections.

I should clarify. Short term use (less than one week) does not suppress the immune system like long term use and is relatively safe. I wouldn’t use it in the face of a serious infectious disease unless all other treatments have been exhausted however. 

[TWHOOKEM 10]

Maybe a dumb question, but are you still developing antibodies to this if you basically eliminate it in 6 days with Chloroquine? 

[triplehorn 2664]

Yes.  Exactly what we need to be doing right now.  I expect there will be a sense of which way this is going to break within a couple weeks.

 

 

Edited March 20, 2020 by triplehorn

[Sbbruin 21853]

This explanation of how the virus works is both fascinating and disturbing.

https://nymag.com/intelligencer/2020/03/the-story-of-a-coronavirus-infection.html?fbclid=IwAR14jR2mNZpLBhJZX29m9tRe8PTNM-pmsOmu5Mij6tFJt2we5QvkgIlvDuU

[Skipper 6135]

1 hour ago, Sbbruin said:

This explanation of how the virus works is both fascinating and disturbing.

https://nymag.com/intelligencer/2020/03/the-story-of-a-coronavirus-infection.html?fbclid=IwAR14jR2mNZpLBhJZX29m9tRe8PTNM-pmsOmu5Mij6tFJt2we5QvkgIlvDuU

Well that's a fucking terrifying read.  Maybe I need to find one describing someone completely asymptomatic to even it out.   And I still don't understand the spread of this virus.  It's clearly pretty damn contagious but if it were as easy as stated in that article you would think the RO would be 10+.   The fact you have both "super spreaders" on one hand while in other cases, spouses never even get sick, and then asymptomatic 70 year olds with 8 pre-existing conditions vs. ICU or death in 20's/30's is just bizarre to me.  I don't understand it medically or logically.

[G650 14256]

10 minutes ago, Skipper said:

Well that's a fucking terrifying read.  Maybe I need to find one describing someone completely asymptomatic to even it out.   And I still don't understand the spread of this virus.  It's clearly pretty damn contagious but if it were as easy as stated in that article you would think the RO would be 10+.   The fact you have both "super spreaders" on one hand while in other cases, spouses never even get sick, and then asymptomatic 70 year olds with 8 pre-existing conditions vs. ICU or death in 20's/30's is just bizarre to me.  I don't understand it medically or logically.

There is obviously a ton about this virus we don't know. There's a huge spread in how it affects people, and with family clusters obviously some sort of genetic component at play. At lot doesn't make sense yet.

[triplehorn 2664]

21 hours ago, TWHOOKEM said:

Maybe a dumb question, but are you still developing antibodies to this if you basically eliminate it in 6 days with Chloroquine? 

Cross posting from CFH on another thread - good overview of timelines and other considerations related to the immune response (doesn't speak to any medication effects).  I think generally if you have enough virus for an infection that triggers the onset of symptoms, you have enough to trigger an immune response even if you knock it out with some medication in short order, though strength and types of response vary.

thread VVV

As the thread notes, other countries have already produced post-infection antibody detection tests.  Having those available here as soon as possible is very important and will help our country get past this and back to normal work and routines. 

 

Edited March 21, 2020 by triplehorn

[triplehorn 2664]

SoKo already has an antibody test packaged and ready to go.  The US having a version of this right now is essential.  Recovery starts even before the peak hits.

 

 

 

[crimsonlonghorn 2306]

8 minutes ago, triplehorn said:

SoKo already has an antibody test packaged and ready to go.  The US having a version of this right now is essential.  Recovery starts even before the peak hits.

 

 

 

I just posted about testing in the other thread. 

I don't understand at all what the utility of testing already sick people is and just publishing the positives since that doesn't provide any sort of statistical information about the actual prevalence of spread in the general population. 

If and when we have an antibody test, that DEFINITELY needs to be deployed randomly to get an idea of the distribution of the disease. 

The way we are doing tests right now just makes no sense at all to me, especially since the treatment is more or less the same no matter what the underlying cause may be. 

[triplehorn 2664]

6 minutes ago, crimsonlonghorn said:

I just posted about testing in the other thread. 

I don't understand at all what the utility of testing already sick people is and just publishing the positives since that doesn't provide any sort of statistical information about the actual prevalence of spread in the general population. 

If and when we have an antibody test, that DEFINITELY needs to be deployed randomly to get an idea of the distribution of the disease. 

The way we are doing tests right now just makes no sense at all to me, especially since the treatment is more or less the same no matter what the underlying cause may be. 

Mass testing will be most useful if and when there's a consensus on medication applications, especially for early detection and intervention before pneumonia sets in.  Otherwise, you're right.  If you're not in acute respiratory distress, you stay home whether you have it or not.

[Newdoc 3440]

8 minutes ago, crimsonlonghorn said:

I don't understand at all what the utility of testing already sick people

It looks like SK used it as a tool to isolate more strictly. It can also give us an idea of community spread by extrapolation.  There is no good way to do this clinically. For most people this thing looks like the flu or a rhinovirus infection among others.

[Newdoc 3440]

I would also like to know how many deceased in the CFR would be dead anyways in the next, say 3 months. It is a callous question but how many hospice, critically ill, etc. patients is Covid just tipping over the edge? It could give us a better idea of virulence of this disease.

[crimsonlonghorn 2306]

13 minutes ago, Newdoc said:

It looks like SK used it as a tool to isolate more strictly. It can also give us an idea of community spread by extrapolation.  There is no good way to do this clinically. For most people this thing looks like the flu or a rhinovirus infection among others.

Agreed, but why not just tell everyone who is sick to quarantine, regardless of what the illness is? 

If we had an unlimited number of tests, then sure. That's a good use for an individual test. But if the number is limited, which appears to be the case, then I think we would benefit more from getting a population-level estimate of the prevalence rather than confirming the need for quarantine on an individual level. 

[Newdoc 3440]

45 minutes ago, crimsonlonghorn said:

But if the number is limited, which appears to be the case, then I think we would benefit more from getting a population-level estimate of the prevalence rather than confirming the need for quarantine on an individual level. 

That’s where we are at. We had loosened the testing last week then tightened it back up due to supplies. The problem with 14 day quarantine is that it is killing the economy and it’s hard to tell the guy with no savings to sit home for two weeks BUT we are doing that.

[triplehorn 2664]

We're hearing some (premature) hints about the combination of chloroquine and the antibiotic azithromycin.  Interesting info on the antibiotic:

Azithromycin induces anti-viral effects in cultured bronchial epithelial cells from COPD patients

Quote

Abstract

Rhinovirus infection is a major cause of chronic obstructive pulmonary disease (COPD) exacerbations and may contribute to the development into severe stages of COPD. The macrolide antibiotic azithromycin may exert anti-viral actions and has been reported to reduce exacerbations in COPD. However, little is known about its anti-viral actions on bronchial epithelial cells at clinically relevant concentrations. Primary bronchial epithelial cells from COPD donors and healthy individuals were treated continuously with azithromycin starting 24 h before infection with rhinovirus RV16. Expression of interferons, RIG-I like helicases, pro-inflammatory cytokines and viral load were analysed. Azithromycin transiently increased expression of IFNβ and IFNλ1 and RIG-I like helicases in un-infected COPD cells. Further, azithromycin augmented RV16-induced expression of interferons and RIG-I like helicases in COPD cells but not in healthy epithelial cells. Azithromycin also decreased viral load. However, it only modestly altered RV16-induced pro-inflammatory cytokine expression. Adding budesonide did not reduce interferon-inducing effects of azithromycin. Possibly by inducing expression of RIG-I like helicases, azithromycin increased rhinovirus-induced expression of interferons in COPD but not in healthy bronchial epithelium. These effects would reduce bronchial viral load, supporting azithromycin’s emerging role in prevention of exacerbations of COPD.

 

The part at the end of the abstract about Azithromycin increasing expression of interferons in affected tissue is interesting.  There's been anecdotal accounts from other parts of the world about interferon inducing meds having an effect fighting this coronavirus, Russia touting it in particular with its own "Cycloferon".

[Newdoc 3440]

Don’t know if this has been posted but it’s a great physician level pathophys discussion of Covid 19. The guy looks like someone who should be slamming a beer bong on spring break but he’s got a good mastery of the material and good presentation skills.

[triplehorn 2664]

Man, that guy would have earned an A++ with mega gold stars in Dr. Dee Silverthorn's UT undergrad physiology course.  Gawd she loved having you do those hand drawn diagrams on exams.  Some here may have had her back in the day.  Davis over in Welch for inorg chem as well.

 

[Damor 1236]

Absolutely watching that when I get home from my shift tonight.

Silverthorne was awesome.

[Murfdogg21 4412]

Posted this peer reviewed study in the main thread. 

The cloth masks do virtually nothing

[UTGrad98 2273]

1 hour ago, triplehorn said:

Man, that guy would have earned an A++ with mega gold stars in Dr. Dee Silverthorn's UT undergrad physiology course.  Gawd she loved having you do those hand drawn diagrams on exams.  Some here may have had her back in the day.  Davis over in Welch for inorg chem as well.

 

HAHA. I remember that class. She had us all stand up when she was talking about what the average person was. She first had all the women sit down, then all the minorities, then anyone who wasnt 5'9'', then anyone who wasnt 150 lbs. At the end I was the only one standing. Ill never forget that.

[Bruno Sardine 147]

I have a question about coughing. I have always been told by physicians that coughing is good because it helps clear mucous. But a coronavirus cough is a dry cough. 

Does coughing exacerbate inflammation in the lungs? Because if it does, then it seems like the act of coughing itself could worsen the course of this disease.  

Edited March 22, 2020 by Bruno Sardine

[Lhorn 4913]

I have a question about coughing. I have always been told by physicians that coughing is good because it helps clear mucous. But a coronavirus cough is a dry cough. 

Does coughing exacerbate inflammation in the lungs? Because if it does, then it seems like the act of coughing itself could worsen the course of this disease.  

Within reason, coughing is not a bad thing. Getting rid of phlegm is good and it helps somewhat in opening up airways deep in the lungs which might not be used in shallow breathing.

 

Coughing should not appreciably affect the inflammation in your lung. Take some robitussin if you want for comfort but suppressing your cough won’t help you get better faster.

 

+another Silverthorn alumni

[Damor 1236]

13 hours ago, Newdoc said:

Don’t know if this has been posted but it’s a great physician level pathophys discussion of Covid 19. The guy looks like someone who should be slamming a beer bong on spring break but he’s got a good mastery of the material and good presentation skills.

Who the fuck is this guy???

Yeah, he's not quoting literature and shit, but he's doing a pretty fucking amazing job explaining all this shit on an understandable yet sophisticated level.  I'll take exception with some of things he says, but overall, he's as good as my best basic sciences profs (albeit not as dirty or quite as outlandishingly entertaining as Frank Kretzer). 

What a great educator.

But for fuck's sake, turn yer damn hat around!

[Newdoc 3440]

17 hours ago, Murfdogg21 said:

Posted this peer reviewed study in the main thread. 

The cloth masks do virtually nothing

Yes that is my worry as well. I have seen some literature that shows maybe 50% reduction. They could be effective on ambulatory patients with disease to prevent major droplet expulsion??

[Murfdogg21 4412]

47 minutes ago, Newdoc said:

Yes that is my worry as well. I have seen some literature that shows maybe 50% reduction. They could be effective on ambulatory patients with disease to prevent major droplet expulsion??

Yes but I think nurses are running into the fire with these hand sewn masks in pretty Joann fabric prints with a false sense of security. 

[triplehorn 2664]

90 Tons of broth

 

 

[RayDog 682]

ECGC is another proven zinc ionophore in vitro. Anything on that?  I actually have a bottle and drink green tea most mornings.

I read a dissertation by Dabbagh-Bazarbachi and he found it was a better ionophore than quercetin  but less effective than clioquinol. I have not read anything about studies with clioquinol against covid19 either. Clioquinol is readily available for topical use and has been used for treating cancer.

Edited March 23, 2020 by RayDog

[Newdoc 3440]

This is a pretty great N-95 work around and reusable for hospital based folks. 

 

[Newdoc 3440]

I will share a go to website for supplemental information with good EBM digestion of studies. They have a specific Covid page.

https://examine.com/topics/coronavirus/

[F250 28776]

On 3/22/2020 at 8:35 PM, triplehorn said:

90 Tons of broth

 

 

That is going to be a lot of Lemon Chicken.

[F250 28776]

8 hours ago, Newdoc said:

I will share a go to website for supplemental information with good EBM digestion of studies. They have a specific Covid page.

https://examine.com/topics/coronavirus/

Well, after reading that it seems like a healthy diet, exercise and being outdoors is the best preventative steps to take.

My concern is that access to fresh produce is getting difficult to find.

[Newdoc 3440]

20 minutes ago, F250 said:

Well, after reading that it seems like a healthy diet, exercise and being outdoors is the best preventative steps to take.

My concern is that access to fresh produce is getting difficult to find.

Ultimately yes healthy living is absolutely better than anything we could hope to supplement in our body. Ideally that process would have been happening for years prior to this outbreak but anything you can do now will help some. The body is amazing at cleansing itself if we stop poisoning it with crappy food and the couch (which I have been guilty of sometimes). Make sure y'all are drinking lots of water. Your metabolism and immune system runs much better on it. Speaking of immune system - exercise is a great benefit in the short and long term for fighting off disease and its complications.

[Anastasis 23469]

6 minutes ago, Newdoc said:

Ultimately yes healthy living is absolutely better than anything we could hope to supplement in our body. Ideally that process would have been happening for years prior to this outbreak but anything you can do now will help some. The body is amazing at cleansing itself if we stop poisoning it with crappy food and the couch (which I have been guilty of sometimes). Make sure y'all are drinking lots of water. Your metabolism and immune system runs much better on it. Speaking of immune system - exercise is a great benefit in the short and long term for fighting off disease and its complications.

fuck that shit that requires effort.  can you package it up in a pill?

[F250 28776]

11 minutes ago, Anastasis said:

fuck that shit that requires effort.  can you package it up in a pill?

I was going to mention that in addition to keeping you healthy good cardiovascular health gives you dick power but there is a pill for that.

[Hmbre97 6308]

I wonder if they have the data to look at people who have been on hydroxychloroquine for a long period of time to see what their response to the virus is? My father has been on Plaquenil (which is name brand hydroxychloroquine) for rheumatoid arthritis for the last 25 years. I'd be curious to see how someone who has it in their system prior to being exposed would react.