Coronavirus Update 111: Masks; New Vitamin D Data and COVID 19; NAC

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Welcome to another MedCram COVID-19 update.
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If we look at daily new cases in the United  States, they seem to be on the slight uptrend   at this point, whereas daily new deaths seem to  be on the slight downtrend. Over in Europe, in the   United Kingdom, daily new cases are definitely on  the uptick, and this is week over week, so with the   same amount of testing that they’re doing, they’re  seeing an increase in the cases of SARS-CoV-2.   Now despite that huge uptick, we are seeing only a  minimal increase in the number of deaths. We talked   about that in update 109. It seems as though a  lot of the new cases are of a younger population,   and of course they’re doing much more testing  now than they did back in April. Spain recently   underwent some lockdown procedures and it seems as  though their daily new cases are on the downtrend, and they also are seeing a modest increase in  daily deaths that seems to have plateaued here.
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Recently France similarly also had an increase  and continues to have an increase in their daily   new cases again, only with a modest increase in  the daily death. We haven’t talked much about   Canada recently; they’ve also experienced a  significant uptick in the number of cases   and interestingly they did have an increase  in the number of daily deaths. That seems to   have abated, although it may just be a weekly  trend. We’ll have to see how things pan out.  We also haven’t talked much about India recently. They are the world’s largest democracy, and they   have a number of daily cases it seems  to have peaked though and is coming down, and fortunately the same can be said about the  daily deaths; they also seem to have peaked and   are trending down at this point. Let’s talk about  Hawaii, briefly. We see that the daily new cases had   reached a peak in mid-August, but have come down  precipitously here in October. However, the daily   deaths in Hawaii still remain modestly elevated. If we go back to the new cases in Hawaii, what’s   interesting about this is, at this time, anyone who  travels to Hawaii, whether they are a visitor or a   former resident or a resident even, must quarantine  for 14 days. Now the plan is is that on October   15th, if someone is flying into Hawaii and they  have a CLIA-approved test that shows that they   are COVID negative, they will be able to skip  that 14-day mandatory quarantine period, and   a number of the local airlines are offering this  testing as part of the package to flying to Hawaii, although there is an additional cost for that  testing. I think it’s going to be interesting to   see how that works out. Hawaii is the state ranked  number one in unemployment currently at this time.  I wanted to point out an interesting study in  terms of wearing masks and the concern by some   that lung diseases may be exacerbated by wearing  a mask, either decreasing oxygenation or increasing   carbon dioxide, and this study that was published  here at a Jackson Memorial Hospital in Miami, Florida goes to answering that question about  what is the effect of face masks on gas exchange   in healthy people and also in patients with  COPD? So, in this study they looked at two   different groups: they looked at healthy  house staff, which are the residents and   medical providers at this VA hospital, and then  they looked at 15 veterans with severe COPD.   And they looked at a number of different factors  here with the healthy health staff and the   subjects with severe COPD, which by the way they  had to have an FEV1 of less than 50% of predicted,  and for those that don’t know, that would put them  in the category of either “severe” or “very severe” COPD, so they looked at heart rate, respiratory  rate, the pulse oximetry percent, they looked at   end tidal CO2, and then in the veterans alone, they  looked at the blood gas results for PAO2 and PCO2, and as you can see here, the differences between  the baseline values without a mask on room air in   these healthy house staff and for instance looking  at the surgical mask at five minutes at rest   and then the surgical mask at 30 minutes at  rest, you can see here that the differences   were really insignificant. In fact, in the SPO2,  there was an increase in the oxygen saturation and   a very modest increase in end tidal CO2, which was  actually smaller than the variation in the numbers   when we looked at the subjects with severe COPD.  We can see here, we have some baseline values like, heart rate was 86, respiratory rate was 20.5,  the average saturation was 91.3, which is not   out of line for severe COPD patients on room air, and tidal CO2 was 36, which is within the normal   range, actually. PAO2 on blood gas was 77 and PCO2  was at 39. So in these patients, surgical mask at   five minutes at rest, we can see here that the  saturation actually went up slightly, and that   the end tidal CO2 actually went down, so these are  in opposite directions of what you would expect   for someone with a mask to wear. Also, here we  have a surgical mask at 30 minutes at rest and   before the six-minute walk test that’s what “6 MWT”  stands for, again we saw an increase in saturation   on average and a decrease here in end tidal CO2. iIt may be because the patients are breathing a   little faster with the mask being on. Of course, no surprise here when we get the patient up and   walking after the six-minute walk test, because  after somebody gets up and walks, regardless of   whether or not they’re wearing a mask, we’re gonna  expect to see their oxygen saturation drop. We   might expect to see their end tidal CO2 drop as  well since they’re ventilating more, although we   should see that drop by even more potentially in  a patient who doesn’t have COPD. Here we see that   the oxygen saturation did go down on the blood gas, which is probably a more accurate read and here we   saw the PCO2 go slightly up, which is also what we  would expect in someone with severe COPD, and while   this is what we would have expected, it would have  been nice if they would have done the six-minute   walk test for the severe COPD patients both with  and without the mask, just to clarify that issue.
00:06:52
So their conclusions were that it is important to  inform the public that the discomfort associated   with mask use should not lead to unsubstantiated  safety concerns, as this may attenuate the   application of a practice proven to improve  public health as growing evidence indicates that   asymptomatic individuals can fuel the spread of  COVID-19. Universal mask use needs to be vigorously   enforced in community settings, particularly now  that we are facing a pandemic with minimal proven   therapeutic interventions. We believe our data  will help mitigate fears about the health risks of   surgical mask use and improve public confidence  for more widespread acceptance and use.   There can be associated psychological phenomena,  such as anxiety, claustrophobia, or effective   responses to perceive difficulty in breathing.  Now I want to make a very specific point and   that is that here they used surgical masks and  not the use of N-95 masks, which are not required   for use in a public setting, but are in  fact required for healthcare providers.  In those, it has been shown that there is an  increase in the PCO2, which can happen even in lung- healthy users. They say here, however, without major  physiological burden, and take it from me and other   healthcare providers like me who sometimes need  to wear an N-95 mask for 12 hours straight when we   take care of these patients in the hospital, and  you never know which patient really will have   COVID-19 retrospectively, so we wear it all the  time, regardless of who we see, and that goes for   the nurses and the respiratory therapists  and everybody else who’s seeing patients   in the hospital. I also want to talk about this  topic that was published in PLOS ONE, titled   “SARS-CoV-2 positivity rates associated with  circulating 25-hydroxyvitamin D levels,” and it   seems like a week doesn’t go by and there’s a new  article with some angle on COVID-19 and vitamin D.   So we’ve seen articles talking about retrospective  data; we’ve seen articles showing us that countries   with higher mortality rates have in general lower  vitamin D levels; we even discussed recently how   giving calcefidiol in a pilot study that was  randomized and controlled showed that there was an   improvement in the number of patients going to the  ISU. As it turns out this is a retrospective study   and here you can see the data, which is  pretty incredible, here they looked at   a hundred and ninety thousand patients  that were positive, and in terms of the   positive rates in the populations, they looked  at the circulating 25-hydroxyvitamin D levels   and what you can see here is that when you get 25-hydroxyvitamin D levels that are around 45 to 50   or even a little bit higher that you’ve reached  the lowest level of SARS-CoV-2 positivity. Now   again, this is just an association study; this  is not necessarily causation, but it does show   a pretty interesting relationship, and it also goes  for whether or not you’re in the northern portion   of the United States, the central portion, southern,  whether you’re black non-hispanic, hispanic,   white non-hispanic, this relationship seems to hold  true through all of these types of subpopulations:   that the higher the vitamin D levels are, the lower  the SARS-CoV-2 positive rate in that population.
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Here, we look at male versus female, or even in  those age greater than 60 and those younger   than 60, no matter what the population  was, that relationship seemed to hold true:   higher vitamin D levels was associated  with a lower SARS-CoV-2 positivity rate.   And you can see, this led the authors to  conclude that there was a strong and inverse   association between circulating 25- hydroxy D levels and SARS-CoV-2 positivity,   so definitely more research is needed here  in this field. So here’s a trial that I was   looking forward to seeing the results of. This  is looking at an acetylcysteine in the treatment   of severe acute respiratory syndrome caused by  COVID-19. Disappointingly, it’s a negative study.
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let’s take a look at it. They enrolled 135 patients  with severe COVID-19, either confirmed or suspected,   with saturations that were less than 94, and they  were randomized to pretty large doses of NAC — this   was 21 grams for 20 hours — and what they’re trying  to do is save them from mechanical ventilation, admission to the ICU, and dying. And the  results were: slightly less people ended   up with endotracheal intubation mechanical  ventilation in the intervention group at 20.6   versus the placebo group at 23.9 percent, but  that difference was small enough and the study   did not have enough participants in it to reach  statistical significance. So p-value was 0.675, which is above the 0.05 necessary to reach  statistical significance. So there was no   difference between these two groups and so the  conclusion was that administration of NAC in  high doses did not affect the evolution  of severe COVID-19. Now, I still take NAC   about 600 milligrams twice daily, and I probably  will still continue to take it, because this study   does not negate the possibility that this might  work in the early setting. We’re starting to find   out that COVID-19 is very different in the early  setting, where there is a reduction in innate   immunity, where there is a reduction in interferon, as opposed to later in the course where there is a   storm of cytokines and inflammation. And just  because something doesn’t work later in the   course, doesn’t mean that it won’t work earlier in  the course, and the reason for the NAC therapy   that I take myself was a study that was done  back in the 1990s that showed that patients who   were taking 600 milligrams twice daily of NAC  for a flu season didn’t get less flu infections, but actually came through the infections that they  got with significantly less symptoms. But this is   important to understand, because in the hospital  setting when a patient is very sick or ill   and getting close to being on a ventilator, it  may not be beneficial based on this study to   treat them with large amounts of NAC as they did  in this study. Well I think that’ll be it for now.   There are so many other things to talk about.  There are developments in the vaccines. There are   potentially new therapeutics that will be coming  out. We will keep track of it all and highlight the   things that we think are important. Please come and  see us at MedCram.com for clear explanations on   over 60 different medical topics. So  until next time, thanks for joining us. [Music] welcome to another medcram coveted 19 update if we look at daily new cases in the united states they seem to be on the slight uptrend at this point whereas daily new deaths seem to be on the slight downtrend over in europe in the united kingdom daily new cases are definitely on the uptick and this is week over week so with the same amount of testing that they’re doing they’re seeing an increase in the cases of sars kovi 2. now despite that huge uptick we are seeing only a minimal increase in the number of deaths we talked about that in update 109.
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it seems as though a lot of the new cases are of a younger population and of course they’re doing much more testing now than they did back in april spain recently underwent some lockdown procedures and it seems as though their daily new cases are on the downtrend and they also are seeing a modest increase in daily deaths that seems to have plateaued here recently france similarly also had an increase and continues to have an increase in their daily new cases again only with a modest increase in the daily deaths we haven’t talked much about canada recently they’ve also experienced a significant uptick in the number of cases and interestingly they did have an increase in the number of daily deaths that seems to have abated although it may just be a weekly trend we’ll have to see how things pan out we also haven’t talked much about india recently they are the world’s largest democracy and they have a number of daily cases it seems to have peaked though and is coming down and fortunately the same can be said about the daily deaths they also seem to have peaked and are trending down at this point let’s talk about hawaii briefly we see that the daily new cases had reached a peak in mid-august but have come down precipitously here in october however the daily deaths in hawaii still remain modestly elevated if we go back to the new cases in hawaii what’s interesting about this is at this time anyone who travels to hawaii whether they are a visitor or a former resident or a resident even must quarantine for 14 days now the plan is is that on october 15th if someone is flying into hawaii and they have a clia approved test that shows that they are coveted negative they will be able to skip that 14-day mandatory quarantine period and a number of the local airlines are offering this testing as part of the package to flying to hawaii although there is an additional cost for that testing i think it’s going to be interesting to see how that works out hawaii is the state ranked number one in unemployment currently at this time i wanted to point out an interesting study in terms of wearing masks and the concern by some that lung diseases may be exacerbated by wearing a mask either decreasing oxygenation or increasing carbon dioxide and this study that was published here at a jackson memorial hospital in miami florida goes to answering that question about what is the effect of face masks on gas exchange in healthy people and also in patients with copd so in this study they looked at two different groups they looked at healthy house staff which are the residents and medical providers at this va hospital and then they looked at 15 veterans with severe copd and they looked at a number of different factors here with the healthy health staff and the subjects with severe copd which by the way they had to have an fev1 of less than 50 of predicted and for those that don’t know that would put them in the category of either severe or very severe copd so they looked at heart rate respiratory rate the pulse oximetry percent they looked at end tidal co2 and then in the veterans alone they looked at the blood gas results for pao2 and pco2 and as you can see here the differences between the baseline values without a mask on room air in these healthy house staff and for instance looking at the surgical mask at five minutes at rest and then the surgical mask at 30 minutes at rest you can see here that the differences were really insignificant in fact in the spo2 there was an increase in the oxygen saturation and a very modest increase in end tidal co2 which was actually smaller than the variation in the numbers when we looked at the subjects with severe copd we can see here we have some baseline values like heart rate was 86 respiratory rate was 20.5 the average saturation was 91.3 which is not out of line for severe copd patients on room air and tidal co2 was 36 which is within the normal range actually pao2 on blood gas was 77 and pco2 was at 39. so in these patients surgical mask at five minutes at rest we can see here that the saturation actually went up slightly and that the end tidal co2 actually went down so these are in opposite directions of what you would expect for someone with a mask to wear also here we have a surgical mask at 30 minutes at rest and before the six minute walk test that’s what 6 mwt stands for again we saw an increase in saturation on average and a decrease here in end tidal co2 it may be because the patients are breathing a little faster with the mask being on of course no surprise here when we get the patient up and walking after the six-minute walk test because after somebody gets up and walks regardless of whether or not they’re wearing a mask we’re gonna expect to see their oxygen saturation drop we might expect to see their end tidal co2 drop as well since they’re ventilating more although we should see that drop by even more potentially in a patient who doesn’t have copd here we see that the oxygen saturation did go down on the blood gas which is probably a more accurate read and here we saw the pco2 go slightly up which is also what we would expect in someone with severe copd and while this is what we would have expected it would have been nice if they would have done the six minute walk test for the severe copd patients both with and without the mass just to clarify that issue so their conclusions were that it is important to inform the public that the discomfort associated with mask use should not lead to unsubstantiated safety concerns as this may attenuate the application of a practice proven to improve public health as growing evidence indicates that asymptomatic individuals can fuel the spread of covet 19 universal mask use needs to be vigorously enforced in community settings particularly now that we are facing a pandemic with minimal proven therapeutic interventions we believe our data will help mitigate fears about the health risks of surgical mask use and improve public confidence for more widespread acceptance and use there can be associated psychological phenomena such as anxiety claustrophobia or effective responses to perceive difficulty in breathing now i want to make a very specific point and that is that here they used surgical masks and not the use of n95 masks which are not required for use in a public setting but in fact required for healthcare providers in those it has been shown that there is an increase in the pco2 which can happen even in lung healthy users they say here however without major physiological burden and take it from me and other healthcare providers like me who sometimes need to wear an n95 mask for 12 hours straight when we take care of these patients in the hospital and you never know which patient really will have covet 19 retrospectively so we wear it all the time regardless of who we see and that goes for the nurses and the respiratory therapists and everybody else who’s seeing patients in the hospital i also want to talk about this topic that was published in plos one titled sars cov2 positivity rates associated with circulating 25 hydroxy vitamin d levels and it seems like a week doesn’t go by and there’s a new article with some angle on covid19 and vitamin d so we’ve seen articles talking about retrospective data we’ve seen articles showing us that countries with higher mortality rates have in general lower vitamin d levels we even discussed recently how giving calcified dial in a pilot study that was randomized and controlled showed that there was an improvement in the number of patients going to the icu as it turns out this is a retrospective study and here you can see the data which is pretty incredible here they looked at a hundred and ninety thousand patients that were positive and in terms of the positive rates in the populations they looked at the circulating 25 hydroxy vitamin d levels and what you can see here is that when you get 25 hydroxy vitamin d levels that are around 45 to 50 or even a little bit higher that you’ve reached the lowest level of sars kobe 2 positivity now again this is just an association study this is not necessarily causation but it does show a pretty interesting relationship and it also goes for whether or not you’re in the northern portion of the united states the central portion southern whether you’re black non-hispanic hispanic white non-hispanic this relationship seems to hold true through all of these types of subpopulations that the higher the vitamin d levels are the lower the sars cov2 positive rate in that population here we look at male versus female or even in those age greater than 60 and those younger than 60 no matter what the population was that relationship seemed to hold true higher vitamin d levels was associated with a lower sars cov2 positivity rate and you can see this led the authors to conclude that there was a strong and inverse association between circulating 25 hydroxyd levels and sars kovi ii positivity so definitely more research is needed here in this field so here’s a trial that i was looking forward to seeing the results of this is looking at an acetylcysteine in the treatment of severe acute respiratory syndrome caused by coven 19. disappointingly it’s a negative study let’s take a look at it they enrolled 135 patients with severe coven 19 either confirmed or suspected with saturations that were less than 94 and they were randomized to pretty large doses of neck this was 21 grams for 20 hours and what they’re trying to do is save them for mechanical ventilation admission to the icu and dying and the results were slightly less people ended up with endotracheal intubation mechanical ventilation in the intervention group at 20.6 versus the placebo group at 23.9 percent but that difference was small enough and the study did not have enough participants in it to reach statistical significance so p-value was 0.675 which is above the 0.05 necessary to reach statistical significance so there was no difference between these two groups and so the conclusion was that administration of knack and high doses did not affect the evolution of severe coven 19. now i still take nac about 600 milligrams twice daily and i probably will still continue to take it because this study does not negate the possibility that this might work in the early setting we’re starting to find out that covid 19 is very different in the early setting where there is a reduction in innate immunity where there is a reduction in interferon as opposed to later in the course where there is a storm of cytokines and inflammation and just because something doesn’t work later in the course doesn’t mean that it won’t work earlier in the course and the reason for the knack therapy that i take myself was a study that was done back in the 1990s that showed that patients who were taking 600 milligrams twice daily of knack for a flu season didn’t get less flu infections but actually came through the infections that they got with significantly less symptoms but this is important to understand because in the hospital setting when a patient is very sick or ill and getting close to being on a ventilator it may not be beneficial based on this study to treat them with large amounts of knack as they did in this study well i think that’ll be it for now there are so many other things to talk about there are developments in the vaccines there are potentially new therapeutics that will be coming out we will keep track of it all and highlight the things that we think are important please come and see us at medcram.com for clear explanations on over 60 different medical topics so until next time thanks for joining us
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