RheumNow Podcast - COVID Kids And Men (5.15.20) Save

It's the 05/15/2020. This is the RheumNow podcast. Hi, I'm doctor Jack Cush with roomnow.com. So how are you doing? It's kinda difficult out there, isn't it?

This is seemingly like a bad party or a never ending visit to your in laws, this COVID thing, but, you know, we're gonna get by, we're gonna persevere, and you have to. People are looking to you to lead, because you're the ones who know. I'm staying interested by just watching the news. I mean, I'm not talking about the television, that's kind of beat down. You know, you can't stay positive when you see all that negativity.

When I say the news, I'm talking about the medical news and the general reports about the coronavirus and what's changing and how our drugs are still in the news and still, hogging the limelight. We're gonna cover a number of these items today on the podcast. I don't know when this is going to end, you know, this focus on the coronavirus. As long as it's interesting, I'm gonna keep reporting it. If you're tired of it, let me know.

I'm gonna try to mix in, you know, the good news in rheumatology with a lot of the news in COVID, and keep it interesting in the weeks to come. So I'll first point you to the website, roomnow.com, and a bunch of interesting videos we put up this week. One, maybe my first, is God bless the nurses. And, you know, it is Nurses Week, and I have been thinking about this and what I can do more than write a card and give some, flowers to our nurses. But, this was my sort of video testimonial as to what I think about nurses and yes, I put everything in there that I do truly think.

I want you to look at it and share it with your nurses, and tell me what you tell them what you think about nurses. There's a great video by Barry Gruber from, Long Island. Barry talked about why you can't stop denosumab, and why there's a significant rebound with increased fracture rates if you try to space that out during this COVID era. Not a good idea. This past Tuesday, Joan Merrill gave a great grand rounds on Tuesday night rheumatology as to what COVID nineteen has to do with lupus.

Spoiler alert, it actually has quite a bit due to lupus, even though she said nothing at the start of her lecture. She talks a lot about the vascular disease that's now, becoming part of the COVID damage syndrome and how that fits into what we know about lupus and catastrophic lupus and complementopathies. Interesting video, a lot of good questions. And then lastly is a really good video from, what I call the practice guys, Doctor. Danny Ricciardi in Brooklyn, Doctor.

Herb Baraff in DC, Maryland area. I just sat them down, asked them a bunch of questions about life, practice, challenges, the future, a funny discussion and, actually interesting answers. It looks like nobody's going back to normal anytime soon, and most people think they're gonna continue doing this telemedicine thing for quite some time and long into the future. Maybe the highlight of this week are the new ACR guidelines on gout management. Now, do we really need them?

I think we always need guidelines out there that we can wave at people and say, here, read this, you'll learn something about managing gout. And it's a fairly long document. I think there was like 47 or 50 PICO questions and a total of 42 guidelines. I tried to make it short and I didn't. It's really kind of long.

So, I'll thank, Doctor. Mike Putman at Northwestern at EB Room, evidence based rheumatology, if you don't listen to his podcast, you should. He sort of distilled it on Twitter by saying a few things that he liked. One, don't treat asymptomatic hyperuricemia. Two, it's okay to start urate lowering therapy during a flare.

Three, yes, everyone should still be treat to target with, an SUA of less than six. And and that lastly, allopurinol should be your first line therapy. A few other notes that are in there is that they do suggest that we limit our patients in their alcohol intake, their intake of purines, which I found surprising, the intake of high fructose corn syrup and its derivatives, but didn't support the use of vitamin C in gout management. It's worth a read and it's worth being aware of that. There's an interesting report that looks at, what are the associations with non alcoholic fatty liver disease or NASH or basically severe liver disease.

A meta analysis of many patients shows that type two diabetes was associated with a greater than two fold risk hazard ratio of two point two five, and then obesity, associated with a twenty percent increased risk of, severe liver disease. And this is not just in our patients, this is across the board. Other risk factors are low HDL, high triglycerides, hypertension, were all independent variables in predicting those who will develop, NAFLD, non alcoholic fatty liver disease. A Hungarian cohort of whom, I think it was like nine thousand patients, looked at incident lupus and treated lupus patients and, looked at their mortality rates and showed that yes, both groups have an increased standardized mortality ratio of an SMR of one point six three or two point zero nine respectively. But when they looked at the deaths, the deaths in the lupus populations were just like the deaths in a lot of other populations.

However, in their cohort, it was infection that was much higher in the lupus population compared to others. And that's an important note, that infection in lupus could be a really severe, if not, final, endpoint. A financial analysis of what's happening during the COVID era shows that overall hospitalizations are down over fifty percent, fifty five percent on average. Last week we talked about that hospitals are going to lose $50,000,000,000 a month beginning in March, April, May, June. They don't know what's going to happen after July 1.

That's $200,000,000,000 in the first four months of COVID. And again, this is clearly shown up by hospitalization rates are way down, especially for things like ophthalmology and ENT, ninety one and seventy two percent. Even rheumatology is down two thirds by sixty six percent. So again, everything's being affected. Think we're going to look forward in the future to other analyses that are going to tell us what's the financial impact of this COVID era on practice and practice incomes.

I know that institutions like mine and medical schools are sorely hurting, but boy, that's not nearly as much as what's happening to you guys that are in private practice, where many people are getting by, they're not making the income that they were even by working hard at doing telemedicine, televideo, telephone visits, that, you know, overall incomes are gonna be down at least 30% or more. So we'll be looking at that and try to get some numbers for you in the future. I know you might've heard of this, but I think it's good to put it on record. There is this thing out there called COVID toes And, you know, it looks like chill blains. It looks like bad libido.

It looks like vasculitis, you know, modeled, ecchymonic or erythematous toes, a little, asymmetric in their distribution. It's not like all toes or whatnot, it's a few toes here and there. It looks like an ischemic and or vasculitic stage. Toes, heels, and soles appear to be affected. When they do happen, they tend they can resolve with the, as the infection resolves, taking up to three weeks to do so.

So look for COVID toes, it kind of goes along with what Joan Merrill was talking about in her talk about, thrombotic microangiopathy being one of the downstream damage events that seems to be happening in COVID that could be complement mediated. Obviously, there's a lot of vascular effects that can affect organs, including brain, kidney, skin, which is what we're seeing here at COVID toes. JAMA Lancet, no, I'm sorry, not JAMA Lancet, there's no such journal, I just made that up. Lancet Rheumatology republished, at the end of last week on an anakinra study. You know, there are a number of IL-one studies in progress with anakinra and with canakinumab in treating the, COVID positive patients.

I I think we'd like to see trials looking at that drugs, those drugs in patients with a cytokine storm syndrome, because we don't believe that IL-six is the only option there. But this particular study looked at twenty nine patients treated with high dose anakinra, that's two hundred milligrams given, once a day, and they compared that to a control group, a semi control group of 17 patients not on anakinra. These patients were, had ARDS, lung involvement, but they were not, in the ICU. They had to have high CRPs and high ferritins to get in the study. The endpoint was what were they doing at day 21.

There was greater survival with the Anakinra treated patients, ninety percent versus fifty six percent in the non anakinra or control group, and the anakinra treated patients had more resolution of CRP and respiratory function than control seventy two versus fifty percent. Two more reports. Plaquenil does not protect lupus patients from COVID-nineteen. This was in Annals of Rheumatic Disease article that was, a published, I guess, early report from the Global Rheumatology Alliance that's looking at, you know, all of your patients who developed COVID-nineteen being entered into this registry. They talk about the first eighty lupus patients with the coronavirus.

These eighty lupus patients were largely young women or women 65, who are, about 80% of the population were women, 80% were 65. I think two thirds of them were on antimalarials, and they were taking routine doses of hydroxychloroquine. When they looked at patients who were, treated with hydroxychloroquine versus those that were not, there was no protection from, what happened with COVID, meaning hospitalization, severe outcomes, etcetera, were not any different. So being on hydroxychloroquine, at least in this unselected, sort of registry generated dataset looks like it's not necessarily protective. That kind of falls in line with many of the trials that we've seen recently where either hydroxychloroquine, especially in high doses, had either had no effect or may even be associated with more cardiac effects, and even more deaths.

And lastly, maybe the big report of the week well, I didn't put in this point out here. Oh, yeah. Here's a big report. I thought this is I led the week with this report about why men are more severely affected with COVID, and are they? Now, I don't know about you.

Men and women are affected here, but there are more men and probably of those who go into the ICU and or who die or require mechanical ventilation, it looks like men are outnumbering women, by a significant margin. And the really, there's no good reason. I was thinking that, you know, why is it that middle aged men, 50 and 60, who have no risk factors are the ones who get severe COVID get intubated and die, you know, either right away not usually right away, actually, usually after two, three, four weeks. You know, elderly people who get this tend to die earlier, and I think it's because they have comorbidities that will take them to death more quickly. But why is it that these middle aged men are in the ICU on the respirator?

And I think an interesting report showed up this week where it was a large study of heart failure patients, a biobank study of fourteen hundred eighty five men, five hundred thirty seven women. And they looked at circulating ACE2 levels as a predictor or variable in heart failure outcomes. Well, since they had the stuff biobanked, you know, they looked at a number of different things. Found that ACE two levels are actually much higher in men, with the the with the cohort that they looked at. And then ACE two levels were unrelated to being on either an ARB or an ACE two, an ACE inhibitor.

ACE two is found on lungs, heart, kidneys, and blood vessels and testes. It is the receptor that the coronavirus binds to, and maybe having more of these, receptors, might actually lend to more severe infection. That's a latter part is a hypothesis. And then maybe the other big report of the week came out just yesterday, the CDC issued a warning or an alert about the pediatric multisystem inflammatory syndrome or PMIS. It's a new thing.

You've been hearing about it a lot in the news, and there are hundreds of reports, over a 100 in New York City alone. These have cropped up in in England and Greece and Italy. There have been reports and, basically, we're told, gee, it looks like either toxic shock or something like Kawasaki's, but not Kawasaki's, and a lot of vagueness and scaring the heck out of moms and, parents who are worried about their kids getting this. You know, previously said that kids, they are less likely to get the coronavirus infection. If they do, they have less severe manifestations.

And then boom, starting two, three weeks ago, we get all these reports now of these kids not doing well, many of them in the ICU, a few of them dying, and it's a little scary. There was a New York City, health department report of fifteen cases. Those cases actually all had fever, half had rash, abdominal pain, nausea, vomiting, diarrhea. Only ten of the fifteen actually had, evidence, and the kids were ages two to 15. The, Lancet last week, or actually this week came up with 10 cases with Kawasaki like disease that have been collected in Italy after the February 18 and up till April 20.

And they compare those to their historic cases, and they basically show that these kids, had more of a risk of macrophage activation syndrome or shock or cardiac manifestations than do usual Kawasaki's disease. You know, as you know, Kawasaki's disease is a an acute febrile illness of children. It's an acute syndrome with fever, you know, the strawberry tongue, mucosal lesions, desquamative or erythematous lesions on the trunks, palms, and soles, conjunctivitis, cervical adenopathy. They have inflammatory markers, and, you know, and cardiac abnormalities, including the aneurysms. Well, in these kids, they don't, half of the the London group, the, I'm sorry, the the Lancet report actually met criteria for the Kawasaki syndrome.

Others did not. Many of them had conjunctivitis. Half of them had cardiac manifestations. Let's see. They had, six with diarrhea, five with CNS, four with pneumonia on chest X-ray.

Echoes were abnormal. In six of ten, only one had aneurysms. SED rates were high in seven out of the eight that were measured, usually fifty to over a hundred. They were all treated with IVIG either with aspirin or with methylprednisolone. And they and they have, you know, evidence of troponin and d dimers and whatnot.

Again, this seems to, differ from a COVID in adults in that the presentations are different. They're less likely to be pulmonary. They're more likely to have conjunctivitis and GI, presentations. And then the other thing that seems like, it's not well spelled out, but it looks like they get this, syndrome, this Kawasaki like syndrome, PMIS, Pediatric Multisystem Inflammatory Syndrome, they get it weeks after the onset of symptoms or after exposure to the bug. Again, the criteria by the CDC are age less than 21 with evidence of inflammation and multisystem illness as I just described.

They can get, more than, two or more organs involved including cardiac, renal, respiratory, hematologic, GI, derm, and CNS. There's no alternative diagnosis, so these patients have to be worked up for other causes. It could also be Kawasaki's. And they need to have a positive or current test for the SARS CoV-two infection either by PCR, serology, or antigen test. Again, the CDC wants these cases to be identified, and and if you find them, you should report them, to your state society, local officials so these can get into literature and we can get a better understanding of this particular disorder.

So that's it for this week on the podcast. The next week's gonna be a big week on RheumNow. Our Tuesday night rheumatology guests are going to be Philip Roger Philip Robinson from Queensland. Philip is one of the, instigators behind the Global Rheumatology Alliance and the COVID Room Registry. He's going to talk about that.

And then Peter Nash, also from Down Under, is going to talk about COVID in Oz. That means Australia to those of us who don't know about Oz. We might call Peter and Philip next week the Wizards of Oz. Tune in next week. Take care of yourselves.

Take care of your family. Bye.