RheumNow Podcast – The Beginning Of Something Else (4.10.20) Save
Dr Jack Cush reviews the news and journal reports from the past week on RheumNow.com
Transcription
It's the 04/10/2020. This is the RheumNow podcast, and I'm doctor Jack Cush, executive editor of roomnow.com. Today, we're gonna talk about the pandemic a little bit more. We're gonna start off by actually doing some other things. First, we want to congratulate Doctor.
Ken Saag, who's been named the new chief for the division of, rheumatology at the University of Alabama Birmingham. Very strong division over the years, going to be led even further into the future with strength from Doctor. Saag. Good luck, Ken. There's a study out about ITP and lupus, and I put it up because I thought, you know, everybody knows this, but do you know the numbers?
Well, this particular study was a population based study that looked at ITP cases over fifteen years or thirteen years, and showed that of those people diagnosed with ITP, you actually had a 25 fold increased risk, 25 fold, hazard ratio 25.1 of developing lupus. My goodness. We've always known about this association. It's not surprising to see data that backs it up. Risk factors, for developing lupus were being female and also having Sjogren's syndrome.
New England Journal has an interesting report that someone tweeted and I retweeted because I thought it was important. We'll cover it next week, in the room now, on head to head analysis of physical therapy versus glucocorticoid injections in knee osteoarthritis showing, guess what, physical therapy works. That's good news. More conservative always works. Next week, we're going to resume a lot of our rheumatologic reporting, maybe a little less emphasis on the coronavirus crisis.
We're gonna keep it going. We're gonna have another town hall meeting probably in the first two May after a lot of this has played out and we have some a new round of different questions that we can pose to an expert panel. So look for that. You'll notice this week, if you follow us on Twitter, that we've been beginning every day with a tweet from mister Rogers. Now, I've never been a big fan of mister Rogers.
A lot of people are, just not me. I didn't watch him growing up. But I saw this movie with Tom Hanks, A Beautiful Day in the Neighborhood. I was blown away by it. The man's philosophy, the way he lived was incredible.
So, I like the quote that says, often when you think you're at the end of something, you're at the beginning of something else. I think that we might wanna keep that in mind as we go forward. I tweeted at the beginning of the week some of the numbers from Sunday, April 5, the numbers on coronavirus infections in The United States. We've had the number was ninety six hundred deaths and over three hundred and thirty seven thousand confirmed infections. That was Sunday, April 5.
Today, shocking. The number of people infected in The United States has gone from three hundred and thirty seven to almost four hundred and ninety thousand infected. Deaths have gone from ninety six hundred and doubled to eighteen thousand five days. It doubled. It's shocking.
Worldwide, the numbers went from one point two million infected to today, one point six million infected and from worldwide deaths from sixty nine thousand to a hundred and one thousand worldwide. We're up against a really tough foe here. We do know the presentations for this virus and how it presents. There are other organ systems that are involved. I think many of you have already heard about there's a significant cardiac, component to this.
GI, I tweeted the GI information that's out there was covered recently in the journal Gut. The rates of diarrhea as a presenting finding is as low as three percent, as high as twenty four percent. Nausea in ten to eighteen percent. Very few people are vomiting when they present less than four percent, but LFT elevations are not uncommon seen in twenty to thirty percent of patients. It turns out that patients who have GI symptoms, most of them have the rest of the full house of symptoms, but you know what?
Twenty eight percent in one study did not have respiratory symptoms. So a lack of respiratory symptoms shouldn't preclude the diagnosis of coronavirus. Strangely enough, while they think you cannot get this through the GI tract, meaning if it's on a fruit that it's unlikely you're going to get it by eating any food that might be infected, they have found virus, and cultured virus stool samples of people who have proven infection. Likewise, brain involvement has been reported. You might have noticed today in RheumNow we put up the, findings of coagulopathy associated with IgA anti cardiolipin antibodies and beta-two glycoprotein IgG antibodies, and that was associated with limb ischemia and cerebral infarcts.
This was seen in three patients in China, And I'm hearing a number of reports about encephalopathy that's been described. There's another report in the Journal of Radiology of acute necrotizing encephalopathy that they think is either from the bug itself, the virus, leading to vasculopathic changes, or from the cytokine storm that may happen in those who are severely affected. The radiology report detailed multifocal lesions in the brainstem, cerebral white matter, cerebellum thalamus, but a lot of them are around the thalamus and central, and there was a hemorrhagic component to some of those. Children, you know, children, are children affected? Yes, they are.
The Journal of Pediatrics says that children thankfully are less frequently affected and that, less of the people that are affected, of those let's see, the numbers 19 is less than one percent of all people infected. So the younger you are, the less likely you are. Most a lot of those, ones that were infected were between the ages of 10 and 19. But, there were very few deaths in, and and not quite zero, but there were very few deaths in those 19. There is a report of, no deaths amongst a US cohort of forty two hundred patients that were coronavirus, proven under the age of 19 that none of those had died, but there have been worldwide reports of death in kids.
But again, kids seem to be less affected. The other interesting thing came out, Paul Peter Tack put out an interesting post, on on LinkedIn and Twitter, that comes from a report out of China that where they analyze their patients, they found that the, rate of hospitalization since severe respiratory failure was much higher in obese men who are infected with the coronavirus. In that study, they compared, you know, normal weight, underweight, usual weight, and those that were overweight and obese, there was as much as a two to two point five fold increased risk of severe respiratory outcomes in men who are obese, but not women who are obese. This kind of conforms to one of my observations. I don't know if you're seeing the same thing.
Seems like the ones who do really bad here are 50 and 60 year old men. And, I don't know whether they're obese or not, but this would say just suggest an addition and they don't always have to have comorbidity. You know, lot of these 50, 60 year old men who develop rapid respiratory failure and death, don't have preexisting conditions in many cases. Maybe obesity is the is another one that we should worry about. The overall hospitalization rate for the COVID-nineteen infection is four point six per one hundred thousand.
This is about the rate that you see in nineteen to fifty year old individuals. The rate was higher when you were over the age of 65. It's thirteen point eight, almost a threefold higher rate, and almost a doubling in the fifty to sixty five year old group at seven point four per one hundred thousand. So age is a factor in whether or not you're going to get, have a risk of hospitalization. And we did report last week about the influence of coronary disease, diabetes, hypertension also being a factor.
The discussion that we had on our town hall was we're not seeing a lot of our patients with autoimmune disease taking either biologics or methotrexate, azathioprine, hydroxychloroquine, etc. We're not seeing a lot of these patients infected nor going into the hospital. And the question is, are our patients protected somehow? And that's why we need to aggressively enroll patients in the global, Rheumatology Alliance Registry COVID, roomcovid.org. If you have a patient of yours who has the coronavirus infection, enroll the patient.
They'll collect data prospectively from you. It's very, very important. As of yesterday, they had two twelve patients in the registry. Most of them were rheumatoid, half of them more than half of them were on DMARDs. There were 32 patients on a quarter of them were on hydroxychloroquine.
I think the number is about fifteen percent with lupus here. A quarter of all patients reported were on hydroxychloroquine, and I think there are thirty two patients who were hospitalized on hydroxychloroquine, two of whom died. So the idea that hydroxychloroquine is protective here has been quickly dispelled by just observational reporting from you and your colleagues. We need to collect data and get some big numbers that the experts can rely upon when developing a public health strategy for this infection. The CDC, as you know, at the beginning of the week, put out a directive that everyone should wear a cloth face covering in public.
They should cover your mouth and nose and nose. It's not here. It's gotta be both the nose and mouth when you're out in public. Part of it, it really is so that if I wear a mask, I'm protecting everyone else from me rather than me being protected from everyone else. So if everyone's wearing a mask, we're all good.
If only half of us are wearing a mask, well, it really doesn't work. It's like it's sort of like not paying attention to social distancing. And that, I think, is the take home message behind the small advantage afforded by everyone wearing masks. Do not you should use them when you're out in public. Do not use in children under age two, and do not use, N95 masks, which really should be reserved for a health care worker when they're doing their job.
As you know, there's gonna be a serious shortage of n 95 masks and other PPEs out there. The CDC and MMWR did report on its study of the first report of COVID infection in Seattle at a nursing home. It was a study of 142 individuals, patients and staff, and found that three residents and two staff to develop positive tests had positive tests but had no symptoms, suggesting that a number of the individuals involved in this infection are those who are just carriers and not those who became infected with symptoms. They, upon finding the problem, they quickly implemented a number of the hygienic measures and social distancing that are required that include social distancing, visitor restriction, testing of everyone, current hygiene practices, hand washing, not touching your face, etcetera. And they confirm the value of these hygienic practices, especially social distancing.
It's very, very important to underscore the proven value of that intervention. There is an Annals of Internal Medicine report this week that looks at the incubation period. This is looking at, a 181 well described cases where they have all the data they need. And from those individuals, they calculated a median incubation period here of five point one days ranging from four to six, and that, almost everyone developed symptoms within eleven point five days. These estimates suggest that for every one hundred thousand cases, there would only be a hundred who would develop symptoms after fourteen days of active quarantine, suggesting some of the numbers and days and limits on quarantine that you've heard out there right now.
I'll close with a review of the NICE guidelines on rheumatologic care and care of your patients who have rheumatic conditions, during this COVID nineteen epidemic. They released this on April 3. The ACR has a task force that's finalizing its recommendations. You'll see those shortly, probably, this upcoming week. And I'll just give to you a few highlights that you probably may know about, but may wanna tell others about.
Obviously, everyone should be minimizing face to face contact, and we should be doing remote visits as much as possible. Who should you see? They don't go into that. I went into that with a blog yesterday called Urgent or Not. I put out there who are the urgent conditions that need to be seen, and that's for you to consider as a guideline during the COVID crisis.
For patients who actually are infected, and this really applies to those who are not infected, everyone should continue their hydroxychloroquine, their sulfasalazine, their nonsteroidals, and their prednisone or prednisolone. Do not stop these medicines. There's no good reason to do that. You should probably not stop any DMARDs or biologic if you're not infected and you're just worrying about it. They do say that if you're infected that you should stop, other DMARTs, and that would include methotrexate and JAK inhibitors, and biologic therapies.
I don't know that I agree with that, but, we'll see what the ACR, committee is gonna come up with. They say that you should not be doing in general intra articular steroid injections at this period, and that you would only do it in a COVID infected person if there was a significant degree of disease activity and there were no other alternatives. Then it could be done. Otherwise, you really shouldn't be doing joint injections, should manage this with other medicines, outpatient, oral meds, etc. They did remind everyone that patients on immunosuppressive therapies may have atypical presentations with regard to the COVID-nineteen infection.
That goes to the point I made earlier, something different about our patients maybe not getting infected. My crazy theory, not based on any fact, is that our patients who have hyperimmune status, overactive, inflammatory arms, and B cell activity and whatnot, we control those and control them so the patients are disease controlled and doing well. But maybe their immune system being turned up a little might be enough to protect them from either infection or severe infection. You heard it here first. Blame me when it's wrong.
Congratulate me. Nominate me for the Nobel Prize when I'm right. Maybe soon. Anyway, they say do not stop bisphosphonates and denosumab during this period. You should give them as scheduled, and that you could hold off, reclass as olendronic acid for another six months if need be, that they tell you to consider or reconsider the use of routine laboratory testing every three months, especially a patient who has had such testing in the last two years with no abnormalities that you could space consider spacing out the therapies for a little longer.
They want you they end with two really important points. One is to support your staff, as keep in touch with them as much as possible, really for their mental well-being. You know a lot. You know more. People wanna be led.
They need you to lead. Provide your staff with leadership. Give them messaging if you're not in meeting with them on a regular basing basis and maintain morale during what is a very difficult period for healthcare providers. That's it for this week. You can go to the website and find the links to these reports and more.
Next week, a lot of reporting on good old rheumatology. Next week, Tuesday night rheumatology grand rounds on the evaluation of febrile patients in rheumatic patients. That is going to be done by me. I'm going talk about auto inflammatory diseases, Still's disease, the diagnosis of such diseases by either clinical grounds or by genetic testing. We'll talk to you next week.
Take care.
Ken Saag, who's been named the new chief for the division of, rheumatology at the University of Alabama Birmingham. Very strong division over the years, going to be led even further into the future with strength from Doctor. Saag. Good luck, Ken. There's a study out about ITP and lupus, and I put it up because I thought, you know, everybody knows this, but do you know the numbers?
Well, this particular study was a population based study that looked at ITP cases over fifteen years or thirteen years, and showed that of those people diagnosed with ITP, you actually had a 25 fold increased risk, 25 fold, hazard ratio 25.1 of developing lupus. My goodness. We've always known about this association. It's not surprising to see data that backs it up. Risk factors, for developing lupus were being female and also having Sjogren's syndrome.
New England Journal has an interesting report that someone tweeted and I retweeted because I thought it was important. We'll cover it next week, in the room now, on head to head analysis of physical therapy versus glucocorticoid injections in knee osteoarthritis showing, guess what, physical therapy works. That's good news. More conservative always works. Next week, we're going to resume a lot of our rheumatologic reporting, maybe a little less emphasis on the coronavirus crisis.
We're gonna keep it going. We're gonna have another town hall meeting probably in the first two May after a lot of this has played out and we have some a new round of different questions that we can pose to an expert panel. So look for that. You'll notice this week, if you follow us on Twitter, that we've been beginning every day with a tweet from mister Rogers. Now, I've never been a big fan of mister Rogers.
A lot of people are, just not me. I didn't watch him growing up. But I saw this movie with Tom Hanks, A Beautiful Day in the Neighborhood. I was blown away by it. The man's philosophy, the way he lived was incredible.
So, I like the quote that says, often when you think you're at the end of something, you're at the beginning of something else. I think that we might wanna keep that in mind as we go forward. I tweeted at the beginning of the week some of the numbers from Sunday, April 5, the numbers on coronavirus infections in The United States. We've had the number was ninety six hundred deaths and over three hundred and thirty seven thousand confirmed infections. That was Sunday, April 5.
Today, shocking. The number of people infected in The United States has gone from three hundred and thirty seven to almost four hundred and ninety thousand infected. Deaths have gone from ninety six hundred and doubled to eighteen thousand five days. It doubled. It's shocking.
Worldwide, the numbers went from one point two million infected to today, one point six million infected and from worldwide deaths from sixty nine thousand to a hundred and one thousand worldwide. We're up against a really tough foe here. We do know the presentations for this virus and how it presents. There are other organ systems that are involved. I think many of you have already heard about there's a significant cardiac, component to this.
GI, I tweeted the GI information that's out there was covered recently in the journal Gut. The rates of diarrhea as a presenting finding is as low as three percent, as high as twenty four percent. Nausea in ten to eighteen percent. Very few people are vomiting when they present less than four percent, but LFT elevations are not uncommon seen in twenty to thirty percent of patients. It turns out that patients who have GI symptoms, most of them have the rest of the full house of symptoms, but you know what?
Twenty eight percent in one study did not have respiratory symptoms. So a lack of respiratory symptoms shouldn't preclude the diagnosis of coronavirus. Strangely enough, while they think you cannot get this through the GI tract, meaning if it's on a fruit that it's unlikely you're going to get it by eating any food that might be infected, they have found virus, and cultured virus stool samples of people who have proven infection. Likewise, brain involvement has been reported. You might have noticed today in RheumNow we put up the, findings of coagulopathy associated with IgA anti cardiolipin antibodies and beta-two glycoprotein IgG antibodies, and that was associated with limb ischemia and cerebral infarcts.
This was seen in three patients in China, And I'm hearing a number of reports about encephalopathy that's been described. There's another report in the Journal of Radiology of acute necrotizing encephalopathy that they think is either from the bug itself, the virus, leading to vasculopathic changes, or from the cytokine storm that may happen in those who are severely affected. The radiology report detailed multifocal lesions in the brainstem, cerebral white matter, cerebellum thalamus, but a lot of them are around the thalamus and central, and there was a hemorrhagic component to some of those. Children, you know, children, are children affected? Yes, they are.
The Journal of Pediatrics says that children thankfully are less frequently affected and that, less of the people that are affected, of those let's see, the numbers 19 is less than one percent of all people infected. So the younger you are, the less likely you are. Most a lot of those, ones that were infected were between the ages of 10 and 19. But, there were very few deaths in, and and not quite zero, but there were very few deaths in those 19. There is a report of, no deaths amongst a US cohort of forty two hundred patients that were coronavirus, proven under the age of 19 that none of those had died, but there have been worldwide reports of death in kids.
But again, kids seem to be less affected. The other interesting thing came out, Paul Peter Tack put out an interesting post, on on LinkedIn and Twitter, that comes from a report out of China that where they analyze their patients, they found that the, rate of hospitalization since severe respiratory failure was much higher in obese men who are infected with the coronavirus. In that study, they compared, you know, normal weight, underweight, usual weight, and those that were overweight and obese, there was as much as a two to two point five fold increased risk of severe respiratory outcomes in men who are obese, but not women who are obese. This kind of conforms to one of my observations. I don't know if you're seeing the same thing.
Seems like the ones who do really bad here are 50 and 60 year old men. And, I don't know whether they're obese or not, but this would say just suggest an addition and they don't always have to have comorbidity. You know, lot of these 50, 60 year old men who develop rapid respiratory failure and death, don't have preexisting conditions in many cases. Maybe obesity is the is another one that we should worry about. The overall hospitalization rate for the COVID-nineteen infection is four point six per one hundred thousand.
This is about the rate that you see in nineteen to fifty year old individuals. The rate was higher when you were over the age of 65. It's thirteen point eight, almost a threefold higher rate, and almost a doubling in the fifty to sixty five year old group at seven point four per one hundred thousand. So age is a factor in whether or not you're going to get, have a risk of hospitalization. And we did report last week about the influence of coronary disease, diabetes, hypertension also being a factor.
The discussion that we had on our town hall was we're not seeing a lot of our patients with autoimmune disease taking either biologics or methotrexate, azathioprine, hydroxychloroquine, etc. We're not seeing a lot of these patients infected nor going into the hospital. And the question is, are our patients protected somehow? And that's why we need to aggressively enroll patients in the global, Rheumatology Alliance Registry COVID, roomcovid.org. If you have a patient of yours who has the coronavirus infection, enroll the patient.
They'll collect data prospectively from you. It's very, very important. As of yesterday, they had two twelve patients in the registry. Most of them were rheumatoid, half of them more than half of them were on DMARDs. There were 32 patients on a quarter of them were on hydroxychloroquine.
I think the number is about fifteen percent with lupus here. A quarter of all patients reported were on hydroxychloroquine, and I think there are thirty two patients who were hospitalized on hydroxychloroquine, two of whom died. So the idea that hydroxychloroquine is protective here has been quickly dispelled by just observational reporting from you and your colleagues. We need to collect data and get some big numbers that the experts can rely upon when developing a public health strategy for this infection. The CDC, as you know, at the beginning of the week, put out a directive that everyone should wear a cloth face covering in public.
They should cover your mouth and nose and nose. It's not here. It's gotta be both the nose and mouth when you're out in public. Part of it, it really is so that if I wear a mask, I'm protecting everyone else from me rather than me being protected from everyone else. So if everyone's wearing a mask, we're all good.
If only half of us are wearing a mask, well, it really doesn't work. It's like it's sort of like not paying attention to social distancing. And that, I think, is the take home message behind the small advantage afforded by everyone wearing masks. Do not you should use them when you're out in public. Do not use in children under age two, and do not use, N95 masks, which really should be reserved for a health care worker when they're doing their job.
As you know, there's gonna be a serious shortage of n 95 masks and other PPEs out there. The CDC and MMWR did report on its study of the first report of COVID infection in Seattle at a nursing home. It was a study of 142 individuals, patients and staff, and found that three residents and two staff to develop positive tests had positive tests but had no symptoms, suggesting that a number of the individuals involved in this infection are those who are just carriers and not those who became infected with symptoms. They, upon finding the problem, they quickly implemented a number of the hygienic measures and social distancing that are required that include social distancing, visitor restriction, testing of everyone, current hygiene practices, hand washing, not touching your face, etcetera. And they confirm the value of these hygienic practices, especially social distancing.
It's very, very important to underscore the proven value of that intervention. There is an Annals of Internal Medicine report this week that looks at the incubation period. This is looking at, a 181 well described cases where they have all the data they need. And from those individuals, they calculated a median incubation period here of five point one days ranging from four to six, and that, almost everyone developed symptoms within eleven point five days. These estimates suggest that for every one hundred thousand cases, there would only be a hundred who would develop symptoms after fourteen days of active quarantine, suggesting some of the numbers and days and limits on quarantine that you've heard out there right now.
I'll close with a review of the NICE guidelines on rheumatologic care and care of your patients who have rheumatic conditions, during this COVID nineteen epidemic. They released this on April 3. The ACR has a task force that's finalizing its recommendations. You'll see those shortly, probably, this upcoming week. And I'll just give to you a few highlights that you probably may know about, but may wanna tell others about.
Obviously, everyone should be minimizing face to face contact, and we should be doing remote visits as much as possible. Who should you see? They don't go into that. I went into that with a blog yesterday called Urgent or Not. I put out there who are the urgent conditions that need to be seen, and that's for you to consider as a guideline during the COVID crisis.
For patients who actually are infected, and this really applies to those who are not infected, everyone should continue their hydroxychloroquine, their sulfasalazine, their nonsteroidals, and their prednisone or prednisolone. Do not stop these medicines. There's no good reason to do that. You should probably not stop any DMARDs or biologic if you're not infected and you're just worrying about it. They do say that if you're infected that you should stop, other DMARTs, and that would include methotrexate and JAK inhibitors, and biologic therapies.
I don't know that I agree with that, but, we'll see what the ACR, committee is gonna come up with. They say that you should not be doing in general intra articular steroid injections at this period, and that you would only do it in a COVID infected person if there was a significant degree of disease activity and there were no other alternatives. Then it could be done. Otherwise, you really shouldn't be doing joint injections, should manage this with other medicines, outpatient, oral meds, etc. They did remind everyone that patients on immunosuppressive therapies may have atypical presentations with regard to the COVID-nineteen infection.
That goes to the point I made earlier, something different about our patients maybe not getting infected. My crazy theory, not based on any fact, is that our patients who have hyperimmune status, overactive, inflammatory arms, and B cell activity and whatnot, we control those and control them so the patients are disease controlled and doing well. But maybe their immune system being turned up a little might be enough to protect them from either infection or severe infection. You heard it here first. Blame me when it's wrong.
Congratulate me. Nominate me for the Nobel Prize when I'm right. Maybe soon. Anyway, they say do not stop bisphosphonates and denosumab during this period. You should give them as scheduled, and that you could hold off, reclass as olendronic acid for another six months if need be, that they tell you to consider or reconsider the use of routine laboratory testing every three months, especially a patient who has had such testing in the last two years with no abnormalities that you could space consider spacing out the therapies for a little longer.
They want you they end with two really important points. One is to support your staff, as keep in touch with them as much as possible, really for their mental well-being. You know a lot. You know more. People wanna be led.
They need you to lead. Provide your staff with leadership. Give them messaging if you're not in meeting with them on a regular basing basis and maintain morale during what is a very difficult period for healthcare providers. That's it for this week. You can go to the website and find the links to these reports and more.
Next week, a lot of reporting on good old rheumatology. Next week, Tuesday night rheumatology grand rounds on the evaluation of febrile patients in rheumatic patients. That is going to be done by me. I'm going talk about auto inflammatory diseases, Still's disease, the diagnosis of such diseases by either clinical grounds or by genetic testing. We'll talk to you next week.
Take care.
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