ACP Internist Blog

Monday, June 1, 2020

Hydroxychloroquine for COVID-19 is dead

Physicians and scientists everywhere, led by Anthony Fauci, MD, MACP, have been saying “Let's wait for the data on hydroxychloroquine as a treatment for COVID-19”. Well, we now have that data and it is irrefutable that hydroxycholorquine and cloroquine, with or without a macrolide antibiotic (azithromycin), does not work for COVID-19 and, in fact, causes increased death.

In case you are wondering about the guy who says, “Hey, my uncle has been evertaking it and he got better in six hours,” or “Hey, I know lots of people who take it every day and they are just fine,” let me explain this Lancent study for you. The researchers studied 671 hospitals on six continents involving 92,036 patients. They looked at hospitalizations from Dec. 20, 2019 through April 14, 2020. Patients who were given remdesivir were excluded. The mean patient age was 53.8.

They formed two groups, a control group given standard treatment, and a hydroxychloroquine or chloroquine group with and without receiving azithromycin. In every single group, the mortality was higher in the hydroxychloroquine/chloroquine/azithromycin groups. Every. Single. Group.

This is the scientific method. Anecdotes are fine but they don't really give us safety or efficacy information. Not only does hydroxychloroquine not work, it caused decreased survival. That is the final nail in the coffin and we don't need to speculate that this is a “game changer” anymore.

People are free to do what they want as long as it doesn't hurt others. They can believe the liberals are blocking doctors from giving life-saving treatments. They can believe something they read online instead. All we can do is give valid information, backed by rigorous science.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Friday, May 29, 2020

Placing one pebble on another

I finished a few evening shifts in the hospital (I asked for more, but we'll see what I get assigned). I felt very lucky that they went all right. The roughest edges of the COVID-19 pandemic are felt in the emergency room, the intensive care units. There the doctors and nurses, the techs and janitors and sitters and nursing assistants, are accompanied by death and near-death. The typical hospital ward, on other hand, is usually (now as in non-COVID-19 times) marked by large stretches of rhythmic tedium punctuated by frantic activity.

The “bio” wards (as the containment units for COVID-19 patients are called) do have a different feel, a churchlike hush, a procession of hooded figures, anterooms to don protective equipment and chambers to doff them. But even there, it was such a comfort for me to participate in the ordinary rituals of seeing patients in the hospital: low-wattage pleasantries and jokes exchanged with people at the nurses' station; rumors of snacks; gossip about which hospital executive did what to whom and why.

Yes, there is death all around these days. There is the woman almost ready for discharge, whose husband is dying in another hospital's ICU. [Identifying details changed.] There are the dashboards with the latest COVID-19 statistics, which I and other doctors check obsessively to no great benefit. There is the vast gulf between models and statistics, on the one hand, and lived experience, on the other. R-naught (R0)is simulated. Fear is palpable.

To be an embodied human being and to fill a role (a small role, piling pebble on pebble as Newton had it), was a true joy. Working in health care can be joyful. That it's scary and dangerous for so many right now is a product of the disease, but also born of our rapacious institution.

Wearing the face shield felt like bearing a priestly breastplate. As insufficient as I am, I felt like a healer when I leaned close to a man who was hoarse from the breathing tube that was removed from his throat just yesterday. “Thank you so much doctor,” he rasped. “It was nice to meet you.”

It was nice to meet him, too. And I squeezed his hand just because I could.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Thursday, May 28, 2020

We are wrong to pin our hopes on a COVID-19 vaccine

Much of the strategy that is being used for the lockdown and other social distancing measures, is done with the expectation that we are perhaps a year or two away from an effective COVID-19 vaccine that will be the end to all our woes. Is it only 12 months away? Or maybe 18 months away? I definitely like to be an optimist in life, and hate to be a Debbie Downer on this topic, but this expectation is at best unrealistic, and at worst misleading.

As big pharmaceutical companies and research institutions across the world race to be the first to come up with a vaccine and expedite clinical trials, not enough people are looking ahead realistically as to how this may pan out. So let me paint a scenario.

A vaccine does eventually come out next year that has passed through the expedited trials (that usually take several years) and shows promise. It starts being rolled out. Within a few days, we start hearing some sporadic accounts of reactions, side-effects and medical syndromes that people claim is directly from their jab. This is bound to happen with any vaccine that is being administered to millions of people.

In this social media age, these stories gain traction online—as we give disproportionate coverage to these few cases (which may or may not be genuine reactions) compared to the hundreds of thousands who don't have any problems. This news spreads like wildfire, lawsuits start to be filed, and all this makes more people reluctant to get the vaccine so soon after its release with no long-term safety data. Are we going to mandate everyone get the vaccine, or give people individual choice, like with other vaccines? If everyone isn't going to get it, then won't that defy the whole logic of eradicating this virus, because plenty of people will still be acting as vectors and spreading it?

And then, will the vaccine even be completely effective? The flu vaccine is administered every year to millions of people, who still go on to get the flu. That's because viruses mutate, and new strains arise all the time.

Finally, while we all wait for a COVID-19 vaccine and pins our hopes of resuming life on that milestone, what about all the other festering illnesses that may just kill people first? Statistics show that people are now afraid of going to hospital with their ailments for fear of contracting the virus. Emergency rooms across the country are reporting that heart attacks and strokes are, for some reason, dramatically declining. Does this mean that millions of people are suddenly healthier, or that these issues are boiling just below the surface or worse still, they are dying at home? Add to this mix the inevitable effects of poor eating and exercise habits during a lockdown (obesity and diabetes rates are going to skyrocket) and the depression that stems from millions out of work—we are sitting on a health ticking time bomb. Try getting a vaccine for those things. The medical community has rightly been entirely focused on coronavirus for the last several weeks, but we must now plan on getting back to addressing all the other deadly chronic diseases out there.

We can pin our hopes of a better future post-coronavirus crisis on many things, but a vaccine shouldn't be one of them.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Friday, May 22, 2020

'We called and called'

Last night on my shift I was assigned a woman in her 50s who had been transferred from another hospital with diarrhea, cough, and fever, diagnosed with COVID-19. She was now off any supplemental oxygen, ready to move to a less intensive unit in the hospital. [Identifying details changed in this story.]

She was lying in bed, sweaty, stiff and uncomfortable. “Where are you from?” “In Ecuador.” Why'd you come here? “To make a better future,” she says, turning her face away. They were only living five to a room, she tells me. Her roommate was diagnosed positive. She's still coughing. She was working in construction.

She had a son. The patient was from Ecuador but various Hopkins people were under different impressions about where the son was living. Someone had written “Honduras” with a Sharpie next to their number on the see-through sliding room door. It said “Guatemala” in a couple of notes in the chart. I think people were mixing up Spanish-speaking countries. “No, my son's in Ecuador,” she said, confused. “Why would they be anywhere else?”

I called her son. I gave the international number to the hospital operator and before I finished giving the digits the operator finished the sequence for me. I guess other people had tried to call. There was a foreign-sounding ringing on the other end. “Alo?”

“Thank God for you,” he said. “We've called and called but no one picked up. We were so worried. She's out of danger?”

“Not entirely. But she's better.”

“God bless you and your work. We would like to send her something. Can we do that?”

“From Ecuador to the U.S.?”

“Why not?”

Yes, why not.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.