Overtreatment in Medicine

https://www.scientificamerican.com/article/covids-other-toll-unnecessary-tests-and-huge-hospital-bills/

Tracheostomy Care in the COVID era

Types of Tracheostomy Tubes

NHS different tracheostomy tubes

Respiratory Supplies 

Articles : see READCUBE

Massimo Technology in tracheostomy patient 

RIP-Laika

 Although this really doesn't belong as an entry in my blog, in a way it does as Laika and other animals contributed to exploring and recognizing our space in the cosmos . It also refers to the title of the blog. 

from WIRED :

Space Dogs uses archival footage to tell the story of the clever, docile, and doomed Moscow street dog Laika, the first mammal to go into orbit—and the first mammal to die there. In 1957, the Soviet Union sent Laika to space in the satellite Sputnik 2. Despite initial assurances to the public that the pup would come back unharmed, she was always intended as a sacrifice to scientific progress, as there was no way to return her to Earth at the time. For years, the party line from officials was that Laika had been humanely euthanized before the satellite reentered the atmosphere. In reality, she lasted less than a day before heat and stress killed her, turning the object of cosmic progress into her small coffin. The film doesn’t have footage of Laika suffering in space (thank God) but it does have plenty of clips of scientists putting Laika and a few other research dogs through a barrage of exercises—they spin in a centrifuge, dazed—and subjecting them to invasive, gruesome surgeries in order to rig them up with the necessary sensors to see how long they’d last alone above the planet’s atmosphere.

It is not a pleasant viewing experience. In fact, if I had to imagine the film I would least like to be forced to watch, Clockwork Orange-style, with my eyes pried open, it might be this one. It is a stylish and honest film—a rare combination!—but also merciless

Space Dogs from Icarus Films on Vimeo.

The ACTS Randomized Clinical Trial

Now we  got three decently-sized randomized controlled trials, all in agreement: vitamin C does not reverse organ failure in sepsis," commented critical care physician Robert Dickson, MD, of the University of Michigan School of Medicine in Ann Arbor.

The VITAMINS trial showed no advantage in recovery from septic shock and numerically higher mortality with a vitamin C-hydrocortisone-thiamine combination. The CITRIS-ALI trial showed no impact on SOFA scores from high-dose IV vitamin C.

"If the signal of benefit for vitamin C was anywhere near as strong as was initially suggested, it shouldn't be this hard to detect it in clinical trials," Dickson added.

The researchers noted that vitamin C has also been proposed for treating respiratory failure from COVID-19, as was seen in a recent case report.

However, Dickson said, "the data supporting use of vitamin C in sepsis were already weak. The data supporting its use in COVID-19 are non-existent."

Any excuses Paul Marick after belittling the primary investigator of the Vitamins Trial?

Ref: Kamagurka

Cytokine Storm Nothing but a Tempest in Teapot?

I have often asked myself if I ever saw a patient with cytokine storm syndrome (CSS)  in the COVID-19 population. The "infamous " H-score which has been proposed as a clinical tool to assess post-test probability for CSS, has never been tested in a  COVID-19 population. 

Manifestations of CSS include systemic inflammation including fever, tachycardia, tachypnea and hypotension . How is this different from systemic inflammatory response syndrome (SIRS).

In the attached article we will also see that inflammatory markers, particularly IL-6 are "MUCH, MUCH"  lower on  average compared to  patients with ARDS due to  other etiologies.

Giving tocilizumab for example , directed at the single inflammatory response cytokine, reminds me of the multiple trials we ran years ago, giving  patient's monoclonal antibodies directed against a single inflammatory marker and sepsis. All those trials were acute disappointments.

We have absolutely no data if tocilizumab or sarilumab , beneficially affects mortality. As a matter of fact, these mediators are needed in a complex cascade of immunomodulation. Do we know for sure  that we do not increase risk for secondary infections?  Immunomodulation is a complex mechanism with pleiotropic effects of various modulators.

A simpler concept to understand and we now  have data on is that  SARS CoV-2 with it S-proteins deregulates ( and invades actual cells) endothelial function and is associated with  arterial thrombosis and venous thrombosis, both intra- pulmonary and extrapulmonary. Although we have no outcome studies yet, treating patients with anticoagulation in COVID-19, biologically makes far more sense than chasing CSS.

The attached article questions if CSS is actually a real and separate syndrome in COVID-19.

Please send me some comments after reading the article. I quite frankly do not worry much about CSS. Identifying the need of anticoagulation is far more important, something we totally disregarded in the treatment package early on during the COVID-19 epidemic.  Yet we saw patient receiving tocilizumab all the time, based on zero data. 

From HCQ/AZ, no steroids and  tocilizumab........to  remdesivir ( I have serious doubts on its beneficial effect, Tamiflu 2.0 ), DXM and anticoagulation....

Severe COVID-19 is associated with deep and sustained multifaceted cellular immunosuppression https://t.co/CpbQRnVFAI

— Guy De Gent (@gdegent) July 4, 2020

9/5/2020. Here is  more data from theUniversiteit van Nijmegen in Holland that cytokine storm probably is not part of SARSCov2 infection, as already written earlier in this post, I can't recall ever seen one clinically. As a matter a fact we maybe doing the complete wrong intervention by suppressing the immune system .Tociluzimab is even given from day one by some institutions with Remdesivir, biologically that makes no sense. 

Their Conclusion :

 "In this study, critically ill patients with COVID-19 with ARDS had circulating cytokine levels that were lower compared with patients with bacterial sepsis and similar to other critically ill patients. These findings are in line with lower leukocyte counts observed in patients with COVID-19, and are possibly due to lower overall disease severity, despite the presence of severe pulmonary injury. The findings of this preliminary analysis suggest COVID-19 may not be characterized by cytokine storm. Whether anticytokine therapies will benefit patientswith COVID-19 remains to be determined."

Covid-19 deadlier than acute myocardial infarction

This figure (via @ScottGottliebMD) receiving a lot of attention

And folks rightly point out mortality rates lower for young than for elderly

But thats true for every disease

So as point of reference:

How do these rates compare to mortality for folks with heart attack?

Thread pic.twitter.com/Vw1mtCcXCE

— Ashish K. Jha (@ashishkjha) June 28, 2020

Anticoagulation for COVID-19 (correspondence in the European Heart Journal)