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wathe

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Posts posted by wathe

  1. GP is right.  Statin therapy is standard of care for secondary prevention of ischemic stroke/TIA.  The benefits outweigh the risks

    American guideline, Canadian Guideline, SPRCL trial.

    Aggressive lipid management is indicated post ischemic stroke/TIA, but statin therapy also seems to reduce risk of recurrent TIA/ischemic stroke independently from its lipid lowering effect; there is some thought that this is through antithrombotic and antiinflammatory mechanisms. (People on statins do better than people on other classes of lipid lowering drugs, even with the same absolute change in lipid levels)

     Regular blood work to monitor for muscle and liver injury is standard.  If liver enzymes or CK start to climb, then statin is discontinued.  Liver and muscle injury is generally completely reversible with discontinuation of statin therapy; I've never seen a case that wasn't.  (Conversely, stoke is often irreversible)

    My husband is on one, no issues.

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  2. 18 hours ago, BeachGal said:

    Oh no! You managed to escape it for quite a few years. I hope it’s short and mild.

    Did you see this Medcram video from about a month ago?

    https://youtu.be/ZdiUnmpOgqE

    Dr. Seheult discusses an RCT using near infrared light as an adjunct treatment and the effect it had on biomarkers, outcome and hospital stay. He recommends increasing melatonin by finding a way to get more near-infrared light exposure as well as sleeping in a dark room. Melatonin mops up the bad reactive oxygen species caused by Covid.

    Around the 15-16” mark, Seheult discusses how the small clots are forming.

    Around the 26” mark is a good summary of how NIR light exposure causes mitochondria to produce magnitudes more melatonin than the pineal gland.

    Anyway, I hope you and your daughter feel much better very soon.

     

    In case anyone is wondering how to get more NIR light in winter months where it’s dark and cold, you can buy NIR light devices. Hooga, a Wisconsin company, makes a sturdy one that is easy to use and priced around $270 (might have a coupon online to get it for less). The linked model has both red and NIR light. Place it close to or directly on skin on chest area and then on the back for about 10 minutes, doing one session in the morning and one in the evening. Don’t get too bogged down by the techy stuff. The expert on these, Michael Hamblin, says a wide range of red and near infrared light works fairly well. He began his research decades ago using red garage lights. NIR light also tamps down the inflammation after the initial infection. Medcram did a video on that also.

     

    16 hours ago, Corraleno said:

    I've been following your posts on NIR light and I watched the MedCram video (love Dr. Seheult!). I do have a red light/NIR device —  many thanks for your previous posts on that!

    I've also upped my melatonin intake, and I gave some NAC and melatonin to DD (who doesn't normally take melatonin). She said her throat is still extremely sore (can't swallow), but the headache and fever aren't as bad as yesterday, so I hope she's on an upward trajectory.

    Do either of you have a link to the trial itself?  I can't find the reference (and I'd rather not sit through a video - not my fave medium).

  3. 2 hours ago, KSera said:

    At this point, the only people I know who still haven’t had Covid are full-time maskers in public. I realize no conclusions about masks can be drawn from that, since that’s going to be a self selected group who is likely doing other things as well, but these are all people who are out and about in public, they’re just always wearing a good mask when doing so. It’s hard for me to imagine that a good portion of those would not had Covid by now had they not been masking, though. 

    Yes.  Individual masking clearly works.  My family and I have still haven't had acute covid (yet trying to hold out as long as we can, understanding that it's inevitable eventually).

    Two way masking works even better.  And more masking is better:  twice as many people masking, in theory, should be better than twice as good wrt to transmission because masking works in both directions, and as masked and unmasked populations mix, the masked are also protecting the unmasked too.  I saw a math simulation on this, I wish I could remember where.

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  4. Yes, the Bangladesh study is one of the ones included in the Cochrane review that the article @mommyoffive posted is referring to.    Scroll down to Table 1 for a list of the studies included and their main features.  Many were HCW trials, looking at mask use while at work, some were trials of masking in home for sick contacts, and some seem to be trials of handing out masks rather than actual mask-wearing.  One had a duration of masking for only 5 days.

    Epidemiological studies like the NEJM Boston schools one I linked above, are a much more robust type of evidence for this sort of intervention.

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  5. 1 hour ago, mommyoffive said:

    Key sentence from the Cochrane Review that the article is talking about, "The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions"

      I haven't looked at the individual studies.  I strongly suspect  that when I do I will likely find that this is a case of GIGO (garbage in, garbage out).

    Physical intervention studies are methodogically different than drug trials.  RCT's aren't necessarily gold standard when we are talking physics or epidemiology (rather than physiology).  There is  very good non-trial evidence that suggests that community masking is actually very effective in decreasing the spread of COVID - like this very elegant study published in NEJM in November 2022

     

    Edited: I was mistaken about pre-2016.  Many of the studies reviewed are more current

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  6. 25 minutes ago, KSera said:

    I’ve seen study results indicating Paxlovid decreases the chance of long Covid, but haven’t read the study to see how they came to that conclusion. It’s the one reason I would consider it though, but I don’t know if the effect is strong enough to warrant taking it. 

    Observational studies.

    I would rephrase: that there are some study result that show Paxlovid is associated with a lower rate of long covid - because it's all observational data, with all the same confounders that I listed in my recent previous post about paxlovid for acute covid.  The people who seek paxlovid very well may be people who were going to do better anyway.  Must interpret with caution.

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  7. 8 hours ago, Acadie said:

    Thank you so much for this explanation of the data on Pax (or lack thereof). 

    Any observations on patients with immune compromise receiving Paxlovid?

    Dd has Long Covid, gets frequent respiratory infections, and her doctor recommends Pax for patients with LC who get reinfected. Thankfully dd hasn't had another bout yet but just wondering if you have any thoughts on Pax for people with immune compromise or LC based on what you're seeing clinically. 

    I think it's reasonable to extrapolate EPIC-HR to immune-compromised people.  But, that's just an extrapolation based on a plausible mechanism; there is no actual  hard evidence for pax in IC people.

    There is no evidence that I am aware of to support use of paxlovid for long covid, or any evidence to specially recommend its use for re-infections. I work at an acute covid clinic though; I don't treat long covid.  I am very much not a long-covid expert.  (And really, neither is anyone, I don't think, at this early stage -- though obviously some are more knowledgeable than others).  LC is still very poorly understood and there is no standard treatment as far as I know; treatment protocols are all pretty much still experimental, I think.

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  8. Adding that both RTC's above were pharma funded and pharma run.

    We really need for EPIC-SR to be published.  But, I strongly suspect that it really does show that the drug was ineffective.  Which would not be good for Pfizer.  So quite it's self-serving for them to not publish it.

    Infuriating indeed.

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  9. 11 hours ago, mommyoffive said:

     

    Paxlovid, which has been shown to be nearly 90% effective in reducing the risk of a severe COVID disease, will also no longer be free. A course of the drug currently costs the US government $530, according to Kaiser Health News, but that's at a bulk discount. 

    Pfizer, which manufactures Paxlovid, has not said what the retail price would be.

     

    This bit is infuriating. It is so very misleading, bordering on misinformation.

    Paxlovid showed 89% RRR in unvaccinated, covid-naive people with risk factors, in a trial that was methodologically tweaked to favour benefit.  That population doesn't even really exist anymore.  That's the study from which the oft quoted "90% effective" number comes from.  EPIC-HR

    The only other RTC that we have was done in vaccinated with risk factors or unvaccinated without, was halted for futility.  Results were by press release only.  The study was never published or per reviewed, and likely never will be. EPIC-SR

    All other data is based on observational association.  Which must be interpreted with extreme caution:  People aged 60+ who get paxlovid do better than people who don't in these studies.  But that's not necessarily causal:  the population who seek out paxlovid might have done better anyway - perhaps they take better care of their health, are better supported, have social determinants of health in their favour.  This matches my clinical experience:  the people who come to clinic seeking paxlovid were mostly going to do well anyway.  Our highest risk pts*(homeless, or no supports, or multiple co-morbidities that are poorly controlled, or disorganized, or chaotic lives, social determinants of health not in their favour, or all of these) do not get paxlovid because they do not present for it, and were mostly going to do worse anyway.   It is not possible to magic away every possible confounder with statistical wizardry in observational studies (though they try). The only way to tease out the difference is with an RTC, which, at this stage, we will never get.  

    Tamiflu, tamiflu, tamiflu.  History rhymes.

    *excluding immune-compromise

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  10. 8 hours ago, WildflowerMom said:

    Re: bolded.   How does that work if you're admitted in midst of a massive stroke?   Do you mean that every time she was discharged, she'd have to write a new one for next time?

    Resuscitation/code status has to be re-ordered by MD with each new admission - the orders (just like orders for meds or anything else) do not carry. over from one admission to the next.  The history of resusc orders from past admissions is available in the EMR, but they are not active until re-ordered.

    As for what happens when pts who can't speak for themselves arrive in ED requiring resuscitation with no SDU immediately available:  The ED MD has to make the decision in the moment (and take responsibility for it)

    Sometimes patients come with clear, formal DNR orders (my province has a DNR confirmation form especially meant to direct EMS and fire; ED MDs also use them to to make resusc decisions. Pt's are instructed to leave them on the fridge.)  Sometimes it's very clear in the EMR of a recent past visit that the pt has a terminal diagnosis and that the plan is strictly palliative.  Sometimes it's clear that resusc is futile.  

    Otherwise, though, ED MD's are going to err on the side of resuscitation.

     

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  11. "DNR" can mean different things.  One must specify some details.

    My hospital had a lovely tool that divided resusc decisions into 4 broad categories:

    • Full resus.  Do everything.
    • Limited resus.  NO CPR, but would accept bipap, pressors, cardioversion, ICU level care. (Do everything except CPR)
    • DNR supportive.  No CPR, no pressers, no ICU.  But yes to antbiotics, IV fluids, and other non-ICU interventions to reverse reversible causes and extend life
    • DNR comfort care.  End of life care.  No CPR.  Comfort measures/symptom management only.   No antiobiotics, blood work, IV's, or other interventions meant to reverse reversable causes or extend life.

    It was very helpful for walking SDU's through goals of care.  

    (These categories are not fixed in stone; interventions would be tailored to the unique circumstances of each pt, but medical interventions tend to be a package deal and SDU's sometimes want to choose a la carte in ways that do not make medical sense - having broad categories helps guide decisions.)

    We got rid of it because it was not supported by the almighty new EMR.  What we have now is much worse. I am mad about it.

     

     

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  12. 10 minutes ago, Pawz4me said:

    Having BTDT as a decision maker I feel like the word "extremely" is woefully inadequate. You want someone who can make very, very difficult decisions if the need arises. You also want someone whose mental health can withstand the consequences of having to make those decisions. It's a lot to ask of someone.

     

     

    Agreed.  Traumatic, futile CPR and the emotional tension between HCW and unprepared SDU's is a significant contributor to HCW burnout and PTSD.

     

    ETA:  of course it's terrible for families too.  For HCW, it happens over and over and over and over ---  cumulative trauma.

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  13. 8 minutes ago, cjzimmer1 said:

    As a family we decided that being suffocated was not what she had in mind when she asked for no medical interventions and overrode that and had her placed on oxygen. 

    This is very common.  SDU's override AD's, so long as it is clear that they are making decisions based on what they feel the pt would have wanted in the specific circumstances that actually happen.

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  14. 11 minutes ago, WildflowerMom said:

    How can I figure out the most likely scenarios and “what ifs”?    I need to do some googling.  Sorry for so many questions.  Just a little overwhelmed thinking of all of it.  

    Go through the workbook  from the page I linked in a previous post.

    I will argue that it's more important to document your over-arching goals of care.  Once that's known, you SDU and care team can tailor care depending on specific, unique circumstances.  It is , thought, important specifically document interventions that will never be acceptable to you under any circumstances (ie blood products for JW's).

    Advanced directives that are too specific often don't actually make medical sense.  

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  15. Also, it's important to make sure that your substitute decision makers know what your goals of care are.  In a crisis situation where resuscitation is imminent, there isn't time to fetch documents from the lawyer or safety deposit box etc or review documents.  Please make sure that your SDM is empowered to make immediate emergency decisions that are consistent with your wishes.

    We do a lot of CPR that we really shouldn't because SDM wasn't prepared to make resusc decisions.  It's extremely traumatic for everyone:  patient, SDM, family, and care team.

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  16. On 1/24/2023 at 12:23 PM, TCB said:

    I am so frustrated and angry at our complete lack of ability, as a community/society, to realize, that in order to get out of this intact with good health, we must do everything we can to improve ventilation and air quality in our public areas!

    There is so much information available now, about the possible medium term, and long term affects of Covid. If we think longer term, even if some of these things turn out not to be correct, we can only improve our health anyway, by improving shared air.

    My frustration is increased right now because my dd is working in a preschool as part of her SLP grad course, and she tells me that almost all the kids there are sick. The students can’t wear masks because of the therapy they have to do with the kids. 

    I should put a JAWM on this post because I am really not in the mood to hear a bunch of minimizing crap. How we can think that it is ok for small children to be virtually continuously sick I don’t know.

    100%

    Here's my prediction: Clean indoor air will eventually become standard in public indoor spaces - a kind of expected public good.   Just like clean water, toilet facilities, fire suppression systems, food safety practices, etc.  There is momentum already: Belgium and France have already passed legislation.

    It will start with government spaces (schools, libraries, city hall, government offices etc).  Then be pushed to privately-owned publicly accessible spaces (stores, gyms, movie theatres, restaurants).  There will be government subsidies to help cover the cost of re-fitting ventilation systems.  Occupancy permits and capacity will be tied ventilation capacity.  Inspections (like current fire or food safety inspections).  Mandated real-time display of clean air metrics (CO2, and maybe also PM2.5, PM10) to keep businesses honest (to ensure the ventilations system is turned on).  New ventilation standards for new construction.

    I really believe that all of this will come to pass.  More socialist countries will get it done first.  Capitalist countries will have to follow in order to keep up -- the economic cost of a constantly sick population will be too high.

    It's only a matter of time.  More time than I'd like, but inevitable, I think.

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  17. Psychiatrists are 100% state funded in my province, and cannot legally charge privately for services covered by the state.

    Access to PCP mental health care and, with referral, psychiatrist care that is 100% funded care, with no out-of-pocket cost is a big deal.  

    Canadians love to complain about their healthcare (and it's not perfect!), but 100% state funded primary and specialist care and hospital care is actually a very big deal that our nation tends to take for granted.  

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  18. 3 hours ago, maize said:

    Do people have access to treatments like TMS? If primary care providers are mostly just dispensing SSRI's and calling it good I'd see that as a major concern.

    PCP's here do not dispense.  They assess, diagnose, formulate treatment plans, manage, and prescribe.  Treatment plans often include meds, but not always.  Some PCP's do psychotherapy (state funded 100%).

    TMS is not (yet!) covered by the provincial plan in my province, but is available through teaching hospitals (funded, ie UHN in Toronto.). Would require referral to a psychiatrist to access this way. In Canada, IIRC, it is approved only for treatment-resistant depression and OCD. It is covered in some other provinces.  I think that state funding for TMS in my province will happen in time, but we are not there yet.  (There are private TMS clinics, though, based on their websites, the ones I've seen seem very commercial/profit driven and shady to me.)

     

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  19. I'll be contrary and suggest that medical mental health care in Canada is actually pretty good  -- at least in my part of the country. (I acknowledge that access to care is not the same everywhere, and that rural and remote communities are under-serviced).  Managing social determinants of health s more challenging.

    Most medical mental health care is provided by primary care physicians (and sometimes NP's).  They are well trained and can competently manage most cases.  Funded by the state.  Out-of-pocket for PCP care is $0 - no co-pays, no deductibles, nothing.  The biggest benefit of primary care mental health delivery model is excellent accessibility.

    Complex cases get referred to psychiatrists, who mostly use a consulting model:  assessment and recommendations back to the PCP.  Some complex cases will be followed by a psychiatrist long-term.  Funded by the state.  Out-of-pocket cost $0

    Emergency assessments (generally in emergency departments) in mod-large hospitals are usually multidiscplinary.  Crisis intervention team (social work, mental health nurse) and ED MD both available 24/7/365.  Psychiatrist consultation at EDMD discretion.  Involuntary admissions are assessed by a psychiatrist.  All voluntary admits in my hospital are also seen by a psychiatrist.  Very small hospitals would tend to transfer care to a larger centre with a multidisc team.  Funded by the state, out-of-pocket cost 0$.  Cases that are not admitted are discharged to some sort of followup - multidisc crisis team, urgent outpt psychiatrist, community orgs or family doctor.  all of these are funded by the state, out-of-pocket cost $0.

    Talk-therapy and other therapies with non-MD's is not as easily available, and generally not funded by the state.  This is generally where private insurance provided by employers comes in.

    There are no private psychiatrists or family doctors in my province.  In my province, It is illegal for MD's to bill privately for services that are covered by the state, or to extra-bill (charge an extra fee beyond state funding) for these same services.  

    We do not have universal pharmacare.  Pharmacare varies by province.  In by province, those under-25, over-65, those on state disability benefits and welfare benefits, and first nations people with status cards have meds paid for by the state. 

    Part of judging how good a country delivers mental health care depends on how we define mental health and what we mean by mental health care --- western medicine cannot fix social determinants of health.  Homelessness, poverty, abuse, addiction, food insecurity... the list is endless.   Sometimes, when I hear people complain about access to mental health care, what they actually seem to be doing is medicalizing social issues --- seeking medical solutions to problems that are not solvable by western medicine.  Canada does pretty well with the medical aspects of mental health delivery.  Managing social determinants of health, on the other hand, not nearly as well as we should.

     

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  20. 10 hours ago, Corraleno said:

    The only person who should have the right to decide how "open and honest" they want to be about their personal history, and with whom, is the adoptee. It is their story to tell or not.

    The legal function of a birth certificate isn't to tell a child who his or her biological parents are, it's a government document confirming date and place of birth, along with the names of the legal parents, which also generally serves as proof of citizenship. Adopted children have two birth certificates, even when a child is immediately relinquished at birth; the birth mother signs the original birth certificate and then when the adoption is completed a second certificate is issued with the adoptive parents names. What possible justification can there be for insisting, against the wishes of many adoptees, that their birth certificate and proof of citizenship must inform everyone who reads it that this person's legal parents are not their biological parents? What purpose does that serve, other than to embarrass adoptees who may not feel like discussing their personal (often painful) history with some random DMV employee?

    It's a sad fact of life that people ask incredibly rude and inappropriate questions about adoption. DD has been asked why her mother "just threw her away," and how she feels about never knowing who her "real" parents are. I've been asked "where I got her from" and "how much I paid for her." People are stupid. 

    Imagine if marriage certificates were required to list prior marriages, and any time you wanted to apply for a joint mortgage or bank account or something, you had to show a marriage certificate that listed your ex-husband and listen to some nosy bank manager quiz you about your divorce. If your gut reaction is "that's none of their damn business," then you understand why adoptees should not be forced to include more than the names of their legal parents, just like your marriage certificate only needs to show the name of your current, legal spouse.

     

     

    Agree that BC is not about biology.  
    If it were, then paternity is wrong on BC quite often  - the BC names the person who claims paternity, which may have nothing to do with biological paternity.   Not a rare thing.

    (a bit of a tangent, since this nothing to do with adoption, but still a relevant point, I think)

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