Link to the podcast:
http://www.microbe.tv/twiv/twiv-595/
In episode 595, they bring back Daniel Griffin, MD PhD who works in New York at the Northwell/LIJ Valley Stream system and is an infectious disease doc to talk about what he is seeing on the frontlines in New York and the latest developments.
Here are some highlights for discussion:
http://www.microbe.tv/twiv/twiv-595/
In episode 595, they bring back Daniel Griffin, MD PhD who works in New York at the Northwell/LIJ Valley Stream system and is an infectious disease doc to talk about what he is seeing on the frontlines in New York and the latest developments.
Here are some highlights for discussion:
- Certain clinical characteristics of presentation, based off 500 patient study in Washington state -- 25% do not present with shortness of breath (lower risk), fatigue + headache + abdominal pain symptoms seem to be high risk patients. 2nd week after symptom onset (7-14 days after first symptoms) is when this will hit you hardest (already established)
- Validation of risk profiles from Chinese data there in New York -- Age (60+ higher risk), diabetes, cardiovascular disease, asthma, lung disease, active cancer and those on immune suppressants are comorbidities and those with the highest risk
- % Saturation of blood oxygen in 80s is high risk, 92 or above low risk
- Respiratory rate (potential for telemedicine with this) below 20 low risk, >24 high risk
- Neutrophil / Lymphocyte ratio (NLR) (this one is really interesting to me) < 3 you do well, > 6 worry about, > 10 likely ICU, > 20 no recorded survivors to date locally or from Chinese data
- Other risk stratifiers being used like D-dimer levels and ferritin
- Prepping people for oxygen / ventilator based on that neutrophil / lymphocyte ratio and oxygen saturation levels
- they are discharging and people are going home
- IgM sensitivity comes up diagnostically by day 7-10 of symptom onset (80% of patients)
- Test of swabbing just front of nose vs all the way back into sinuses -- 95% sensitivity to front swab vs deep swab for PCR test (people should be able to sample themselves in the future)
- Hospital where he is at is overwhelmed. Have people laying on the floors, with old ventilators he was never seen used before
- Survival rate of ventilator use for patients is 50%, but they are taking people off who are recovering and sending them too. Survival rate off ventilator may become better in time.
- Steroid usage -- starting to be used again for those patients that might be going on a ventilator soon to get their oxygen up
- NSAIDS -- little bit of use is okay, but not 4 pills every 4 hours. Only 2 before bed
- Hydroxychloroquine + Azithromycin -- they are not using it as much as originally, seeing little benefit
- Using anti-IL6 (Tocilizumab) to try and save patients with the highest neutrophil / lymphocyte ratios
- Case study of 30 year old Irish male with NLR > 20, really bad oxygenation even with 100% on ventilator, they proned him (laid on belly) and that increased oxygen saturation. Gave man Tocilizumab to decrease NLR, and seems to be working. Now down to 70% oxygen on ventilator and NLR decreasing. May be first recovery of patient with NLR > 20
- How does it work? Cytokine storm IL-6, IL-10 driven, called it 'maladaptive immune storm'
- High neutrophil count occurring after viral load is decreasing and adaptive immunity should be taking over, instead not seeing lymphocyte come up like they are supposed to: possible cell lysis issue
- Once NLR comes down and oxygen requirement comes down, unless there is a secondary infection, patients do 'quite well'
- 2nd week goes bad -- related to immunology and beginning of adaptive immune response. Managing should save patients but have to be careful in immune suppression
- Number of admissions is still increasing and hospital system is close to capacity
- okay to use low dose aspirin if you were already on, does not recommend taking a lot