Susan's new post: You Are Not A Horse

[Luís Filipe Gomes]

	If you arrive at wording that says [Message clipped], make sure you click on “View entire message.” You Are Not A Horse On treatments, vaccines, American and Italian specials, health inequities, long COVID, the state of the pandemic, and crazies. Susan Levenstein May 7   READ IN APP   Treatment Carolyn Bramante’s metformin boosters have now published a paper saying it significantly lowers viral load, citing their earlier results as finding metformin reduced “ER visits/hospitalizations/death” by 42% and “hospitalizations/death” by 58%, though that paper’s conclusion read, “None of the three medications that were evaluated prevented the occurrence of hypoxemia, an emergency department visit, hospitalization, or death associated with COVID-19.” At least the viral load analyses, unlike their long COVID ones, adjusted for vaccination. Stanford University researchers have developed an oral protease inhibitor, ML2006a4, tested thus far only in mice. They hope it will work better than Paxlovid, without medication incompatibilities, and will resist new mutations. Another oral antiviral, ensitrelvir (Xocova), shortened symptom duration from 192 to 168 hours in a clinical trial, with almost no patients (mean age 35, few risk factors) requiring hospitalization. It might lower long COVID risk, and has been fast-tracked by the FDA for trials against both COVID-19 and long COVID. A new remdesivir prodrug, obeldesivir, performed well in mice, but Gilead stopped enrolling patients in one clinical trial because of low hospitalization rates, continuing another though the rates will be even lower because the subjects are low-risk. Patient impressions notwithstanding, there’s almost no evidence that Paxlovid shortens COVID-19 symptoms. Final results in the New England Journal of Medicine from the EPIC-SR trial among unvaccinated or undervaccinated low-risk adults, confirm. Vaccinated patients with risk factors (obesity, smoking, hypertension) were briefly included, but symptom duration was unaffected in either group, and Paxlovid didn’t significantly lower hospitalizations or deaths among low-risk patients. Subjects came one third each from the US, Europe, and the rest of the world. Oddly, the 1250 patients with efficacy data were scattered across 210 research groups. Paxlovid did bring high-risk patients significantly fewer urgent medical consultations and briefer hospitalizations, and the authors admit that real-world studies find Paxlovid to decrease progression in vaccinated high-risk patients: in Israel (78% vaccinated or previously infected, >65, hospitalizations fell by 73% and deaths by 79%), New England (all vaccinated, >50, 40% and 71%), Colorado (78% vaccinated, 55% and 85%), Southern California (94% vaccinated, progression fell 79.6%), and Hong Kong (40% vaccinated, 66% fewer deaths). The 59% reduction in high-risk EPIC-SR patients (from 2.2% to 0.9%) falls in that range. Jeremy Faust, who authored one paper confirming Paxlovid effectiveness in selected vaccinated adults, thinks vaccinated patients shouldn’t receive Paxlovid unless they’re extremely high-risk, e.g. immunocompromised. But editorialists suggest, with Paul Sax, that Paxlovid be used in high risk patients regardless of previous vaccination. Commentators now trashing Paxlovid include Matt Taibbi, citing Matt Bivens: “There’s not a lot of convincing evidence the drug does anything at all, much less proof that it saves lives.” Yes, the EPIC-HR trial in high-risk unvaccinated adults slashed disease progression by an astonishing 89%, but 53-80% in vaccinated patients is nothing to sneeze at. The FDA has, perhaps foolishly, settled a lawsuit about ill-advised social media posts aimed at discouraging misuse of ivermectin in COVID-19: “You are not a horse. You are not a cow. Seriously, y'all. Stop it” falsely suggested that ivermectin is never used in humans, and has been permanently removed. The FDA still advises against using ivermectin for COVID-19, though it can’t prevent off-label use. A sensible advisory, Why You Should Not Use Ivermectin to Treat or Prevent COVID-19 has also disappeared. Vaccines A new CDC report finds the XBB.1.5 vaccine less effective than expected. In one non-elderly cohort it reduced hospitalizations or urgent/emergent visits by 50% at 1-8 weeks and 45% at 8-16 weeks, in the elderly by 49% and 37% respectively. In another data set, risk fell by 43% among all adults, 48% in the elderly. Just a month earlier an MMWR had reported 54% effectiveness against symptomatic COVID-19; protection against hospitalization is usually higher, and was >70% in Denmark and The Netherlands. An FDA study said combining last year’s bivalent booster with a flu jab carried a risk of stroke in the very elderly. Now another finds 35% more ministrokes following combined Moderna/flu vaccination, and 20% more strokes after Pfizer/flu. XBB.1.5 vaccines are unlikely to be different, and the high-dose adjuvanted flu vaccines intended for the elderly often cause days of fatigue, muscle aches and headache. I’d leave a couple of weeks between COVID-19 and influenza vaccines, especially if you’re over 65. Paul Offit claims the bivalent booster wasn’t any better than the monovalent one. However: it restored previous protection to Californian adults, cut COVID-19 in half in elderly Koreans and both adult and school-age Americans, and added 28% protection against outpatient encounters in the US, 39% against hospital admission, and 50% against critical illness, for up to seven months. Japanese researchers found 78% effectiveness against hospitalization in older people. And a Korean study found that, compared with bivalent vaccinees, monovalent vaccinees had increased risk of infection (x3), critical infection (x9), and death (x11). After much chatter about intranasal/inhaled vaccines, an Imperial College London consortium is planning a study, using human challenge methodology: young healthy volunteers will first be given vaccine or placebo, then deliberately exposed to SARS-CoV-2. This may be ethically acceptable, because there’s currently too little SARS-CoV-2 circulating in the community to allow for standard methodology. New data say the XBB.1.5 vaccines protect immunosuppressed individuals somewhat against hospitalization. Not much (34-38% for four months), less than the 45-76% in healthy people, or among the immunocompromised during the Delta wave: 69% for two doses, 88% for three. It's claimed young people drop dead after mRNA vaccines. Do they? A CDC study investigated 40 possible cardiac deaths over 18 months in 16-30-year-old Oregonians. Only three occurred soon after vaccination (4, 21, and 45 days), including two with severe underlying medical conditions. Thirty were attributed to COVID-19. Unsurprisingly, 98%of investigated claims of vaccine damage have been rejected. “Everytime we record a death as 'Sudden Adult Death Syndrome', an elephant appears in the room” said one doctor! Pregnant women should get COVID-19 vaccines because of their high risk for severe disease. Babies of vaccinated women also have fewer breathing problems and less developmental delay. Now a large Swedish study reports lower risks of intracranial bleeding (22%), hypoxic-ischemic encephalopathy (27%), and neonatal death (32%). Second trimester vaccination seemed the best, with Pfizer perhaps outperforming Moderna. The CDC, backtracking on previous advice, is suggesting Americans over 65 get another XBB.1.5 vaccine dose this spring. As of April 20th only 22.6% of adults, 42.2% of >75s, and 14.0% of children have received one. The US is the only major nation to vaccinate healthy kids and babies. Paul Offit and I agree that’s questionable. Recovery, responsibility, and retreat Andrew Cuomo Among US COVID-19 deaths, 15% or more are among nursing home residents, partly because algorithms abet understaffing. Ex-NY governor Andrew Cuomo is now being called to account, subpoenaed by a House committee about a notorious memo requiring nursing homes to admit COVID-19 patients. By May 2022 more than 17,000 New York nursing home residents had died, without apologies. Something very similar happened in England. Amid a COVID-19 surge, all but 48 American institutions of higher education have scrapped student vaccine mandates. Holdouts include Rutgers, until March 26th Johns Hopkins, and small colleges like Swarthmore, Wellesley, Reed, Oberlin, and Bryn Mawr. Yes, young people rarely die of COVID-19, and I think 16-30-year-old males should get only one dose due to myocarditis risk. But contrary to claims that vaccination is useless for young people, during Omicron BA.4-5 unvaccinated 18-49-year-olds had 3.2 times more infections and 4.5 times more deaths. From January 2020 through September 2023 7,030 Americans ages 18-29 died of COVID-19, versus 329 from influenza, but Johns Hopkins currently requires vaccination against flu but not COVID-19. At the pandemic’s peak in Massachusetts there were fewer Emergency Room visits than previous years, but patients were sicker: 28% needed hospital admission, versus 20% pre-pandemic. Rates fell by mid-2021, but are creeping back up now, possibly due to healthcare catchup (screening resumed, cancers were detected). Leana Wen believes the COVID-19 pandemic positively impacted American public health infrastructure, and NIH Director Monica Bertagnolli thinks the US is preparing well for the next one. The Washington Post Editorial Board summarizes important proposals. Medicaid unwinding: states have now reviewed two-thirds of 94 million Medicaid recipients. Over 20 million were “unwound,” while 43.4 million had their coverage renewed. Utah expelled 56%, with MT, SD, OK, ID, and GA also over 50%, Texas 49% (two-thirds children), California 21%, Maine 12%. Most (69%) lost coverage not for ineligibility but for procedural reasons, ranging from 22% in Maine to over 90% in Nevada, Utah, and New Mexico. A KFF survey of people kicked off Medicaid finds that 23% remain uninsured, 56% skip medical care, and 50% of those with other insurance worry about affording their premiums. Community health centers, which serve about 15% of all Medicaid patients, are suffering. Medicaid covered 40% of their patients. Nearly a quarter are now gone, bringing income losses averaging $600,000. Some are cutting services, eliminating such “frills” as mental health support and dental care. Other pandemic programs going bye-bye: -       The Affordable Connectivity Program, helping poor and rural families access the internet by cutting their monthly bills, is already winding down. -       The Test to Treat program providing un-or-underinsured adults with free COVID tests, flu tests, and telehealth services ended this month. American specials Asthma/COPD inhalers Medicare price negotiations are proceeding. After their lawsuit against the government was dismissed in February, manufacturers of all 10 drugs in the first tranche submitted counteroffers to HHS proposals,. Bernie Sanders couldn’t convince drug company CEOs to price-match, but he did persuade GlaxoSmithKline, which makes asthma/COPD inhalers Advair, Breo, Arnuity, Flovent, Serevent, and Ventolin, to cap out-of-pocket costs at $35 a month, instead of $182-$537. But the cap doesn’t apply to expensive generics, or to products used, with “spacers,” by small children. In Italy generic Advair costs nothing on the National Health Service, $28 off it; branded “Aliflus” is $9 and $40 respectively. The drug companies’ claim their prices are high to drive innovation. Don't believe it. Guns are now the leading cause of death among American children, and the US has 57 times as many school shootings as all other major industrialized nations combined (more than doubling in 2021-22). Emergency Room visits for gun injuries soared in 2020/2021, especially among children (nearly tripling for girls), draining doctors. The US declared measles eliminated in 2000, but it’s having a comeback. In 18 states including Florida, 97 cases were reported in the first quarter of 2024, versus a previous average of five; 91% were unvaccinated. Most were imported, but home-grown vaccine hesitancy is to blame; 20 states and D.C. have measles vaccination rates below 92%, well under the 95% herd immunity threshold. Measles is surging worldwide too, with 2024 threatening 11% more deaths than 2023, when there were 5% more than 2022, when there were 43% more than 2021, reflecting fewer well-baby visits early in the pandemic. Italian specials Professor Gianfranco Gualdi Trump University Italian style. A Bosnian-Sicilian medical school that churned out some 1000 online degrees turns out to be a fake. The “Jean Monnet Department” of Gorazde University charged students up to €20,000 a year for useless degrees in medicine, physical therapy, nursing, and osteopathy. The swindler-in-chief was previously arrestedfor a similar €9 million scam. He beat an eight-year jail sentence that time by running out the statute of limitations, but now he’s up on fraud, money laundering, and tax evasion charges, with two cronies. Gianfranco Gualdi, “The Pope’s radiologist,” department chief at one of Rome’s top private hospitals, is under investigation for a mistaken diagnosis of brain metastases. Unnecessary radiation therapy for the nonexistent metastases somehow caused a prominent journalist’s death from bacterial pericarditis – his cardiologist is also being charged. The Italian National Health Service has many limitations – see Dottoressa: An American Doctor in Rome – but two giant strengths. First universality, covering all Italians and legal residents. Second, even expensive cutting-edge therapies such as biologics for autoimmune disease and immunotherapies for cancer cost nothing out-of-pocket. Both these strengths are now being challenged. Everybody has the right to a General Practitioner, but between relatively low GP pay (as little as $56,000), an aging workforce, and the dual temptations of expatriation and the private sector, more than 3% of Italians currently have none, which could soar to 8% in 2025. The system’s gross underfunding is also coming home to roost. As a percentage of 2022 GDP Italy spent less on healthcare (6.8%) than France (10.3%), Germany (10.9%), or the UK (9.3%), with few EU countries spending less. The US spent 17.3% of GDP in 2022, getting much less bang for its buck, with 2024 life expectancy 79.3 years versus Italy’s 84.1, plus numerous other worse outcomes Italian health spending shrank further in 2024, to 6.3% of GDP, as demand grows, waiting lists stretch into months, and patients turn to private care. Italian hospitals are aging, with one in three dating from before World War II, and even more violating fire regulations. In early April, 14 of Italy’s most prominent scientists and physicians signed a letter denouncing the drift toward private medicine and demanding more funding for the public system. Their letter, “Health is a public good, health is not for sale,” gave America a shoutout: “If we don’t intervene, the risk is healthcare for pay, like in the United States.” One physician-scientist suggests raising doctors’ salaries by 30%, promoting telemedicine, reducing overdiagnosis and overtreatment, and prioritizing prevention. Others add reorganizing services into “community homes,” eliminating hiring freezes, and reducing private-public competition. The best way to finance these expensive policies would surely be to recuperate funds lost to tax evasion, for which Italy leads Europe. Wealthy Italians pay more taxes than Americans. Tax brackets reach 43% at just €50,000/year, while the top American one is 37%, at $609,000 – in the 1950s it was 91%, largely in theory. The 400 richest Americans pay 23% of their income in taxes. Long-term capital gains are taxed in Italy at 26%, in the US at 20%. Italian corporate taxes are 27.9%. Donald Trump slashed the US rate from 35% to 21%, though most major drug companies actually paid less than 12% in 2023, and Pfizer got a refund! Since 1978 abortion has been legal on demand in Italy until 12 weeks of pregnancy, and for cause until viability, though in practice abortions can be near-impossible to obtain – 70% of gynecologists are conscientious objectors. In 2020 only 31.9% of early abortions used mifepristone/misoprostol, vs. 54% in the US, 74% in France, and 90% in Norway, with medication abortion unavailable in most regions. But now Georgia Meloni’s post-fascist government is inviting antiabortion activists into family planning clinics. While demonizing same-sex marriage, Meloni previously refrained from attacking abortion. Now the gloves are coming off. The state of the pandemic In Italy COVID-19 hospitalizations keep falling, now to 7.4% of their December peak. American hospitalizations peaked later and dropped less, remaining 50% higher per capita than in Italy, with eight times more deaths. Italy’s COVID-19 mortality is slightly above the EU average, while Japan, China, and the UK report, improbably, zero deaths. US SARS-CoV-2 wastewater levels are now mostly low. Hospitalizations, though falling nationwide, are rising in 25% of counties. Ever wonder how the 1918-19 “Spanish flu” pandemic compared with COVID-19? About 1.1% of Europe’s population perished, versus 0.28% for COVID-19 (0.35% in the US); neither holds a candle to the Black Death, which killed 30-50% of Europeans. Italian researchers calculated mortality in the flu pandemic at eight times that of COVID-19, prevaccine. Dutch researchers found it only 70% higher, but ten times that after age adjustment, because flu is deadlier in the young and COVID-19 in the old. long COVID The Guardian recently published a foolish article: “Time to stop using term ‘long Covid’ as symptoms no worse than those after flu, Queensland’s chief health officer says.” This claim is based merely on a future conference presentation, but multiple research teams have already published about this question. Ziyad Al-Aly summarized his research: “Although COVID-19 showed a greater risk of health loss than seasonal influenza, infection with either virus carried significant risk of disability and disease… COVID-19 exhibited increased risk of 68% of health conditions examined across all organ systems (64 of 94 adverse outcomes), while the flu was associated with elevated risk of 6%, mostly in the respiratory system. Also, over 18 months, COVID-19 patients experienced an increased risk of hospital readmission as well as admission to an intensive care unit (ICU). For every 100 persons in each group, there were 20 more hospital admissions and nine more ICU admissions in COVID-19 than flu.” Oxford University researchers found some persistent symptoms twice as frequent after COVID-19 as after flu. Another British study, pre-vaccine and pre-antiviral, found far more cognitive difficulties, dizziness, cough, and shortness of breath 12 weeks after probable COVID-19 than after other respiratory infections, and analyses of American electronic medical records found long-term symptoms about 50% more frequent after COVID-19 than after flu. Bernie Sanders, agreeing with Zeynep Tufekci, has proposed a $10 billion “long COVID moonshot.” The RECOVERinitiative is getting a bit more juice, with NIH Director Monica Bertagnolli announcing $515 million in funding beyond the original $1.15 billion. Hardly a moonshot. There’s still no trace of the promised HHS Secretary’s Advisory Committee on Long COVID. Kids rarely get long COVID, and worse symptoms carry higher risk. But one US-Canadian study found that after three months six out of 77 asymptomatic infected children had long COVID. University of Virginia researchers attribute long COVID to SARS-CoV-2-prompted antibodies mimicking enzymes that regulate bodily functions, and suggest targetting these “abzymes” as treatment. In one article they say abzymes less powerful than real enzymes have been detected in patients with HIV and autoimmune diseases. If I’ve understood their results correctly, among 67 hospitalized COVID-19 patients (39 in ICUs, 26 intubated, eight fatal), 11 had abzymes related to blood pressure regulation. This could be relevant to long COVID, which often involves POTS(postural orthostatic tachycardia syndrome) or orthostatic hypotension. University College London researchers blame long COVID on “cytokine release syndrome,” apparently a slow-burn version of severe COVID-19’s cytokine storm. An Australian group found immune dysregulation to persist eight months after infection but to resolve by two years, along with most symptoms. Imperial College London researchers also favor immune mechanisms: complement activation and myeloid inflammation, and suggest treatment trials of steroids, IL-1 antagonists, JAK inhibitors, naltrexone and colchicine. Colchicine is in the UK’s STIMULATE-ICP trial. Steroids have been tried, with some promising results and at least one ongoing trial. Some say the US RECOVER Initiative is testing “immunosuppressants, immune enhancing drugs, and corticosteroids” as well as ivabradine, Paxlovid, and intravenous immunoglobulin. JAK inhibitors have been proposed in acute COVID-19 but not, to my knowledge, in long COVID. Naltrexone is supported by small studies in Ireland and California. IL-1 antagonists like anakinra are powerful medications with scary side effects such as pneumonia, even possibly cancer. Health inequities A heart waiting to be transplanted Black Americans are more susceptible to heart failure than Whites and twice as likely to reach its end stage. But they are 40%-50% less likely to receive heart transplants, suggesting racial bias in the decision-making process. Women, interestingly, beat men. Kidney transplants are more frequent and more successful, thus arguably more important. American Blacks develop end-stage renal failure 3-4 times more than Whites, but those under age 55 are one-quarter as likely to have received a transplant a year later. For years, creatinine norms were erroneously higher for Blacks than for Whites, overestimating their kidney function by up to 16% and kicking them way down transplant waiting lists. Since January 2023 this injustice is being remedied, with 14,300 Black patients having two years average lopped off their waiting time, and 2,800 already receiving transplants. Similarly flawed algorithms have led to overestimates of Black patients’ lung function and risk of heart disease, and to Black women not being offered a trial of labor following Caesarian section. A Commonwealth Fund report on health inequities proposes several solutions: ensuring universal, affordable, and equitable coverage, strengthening primary care, reducing inequitable administrative burdens, and increasing investment in social services. US News and World Report reveals the least and most equitable states. The World Bank’s latest goal: bringing affordable healthcare to 1.5 billion people by 2030. Ironic, when the United States, its chief funder, is the only developed country lacking universal healthcare, with more than 11% of nonelderly adults uninsured and a third of adults carrying medical debt. Check out Bernie Sanders’ thoughts in a recent speech at the Harvard School of Public Health. Systemic racism is so ubiquitous that the Lown Institute offers highly practical advice to Black patients: 1) Press for lower prices. 2) Don’t expect unbiased care, but fight for it. 3) Go to the best hospital around. Over the top The Supreme Court is debating whether the Biden Administration illegitimately sought to combat pandemic misinformation about vaccines, lockdowns, treatments, herd immunity, and masking. A Louisiana federal judge and a 5th circuit appeals panel ruled it had violated First Amendment free speech rights, citing false 2020 election fraud claims in their rulings. Fortunately, SCOTUS seems likely to disagree. Robert Kennedy Jr. joined other no-vaxxers and ivermectinites rallying outside the courthouse against a “new authoritarianism.” One speaker suggested that failure to protect speech questioning the safety of COVID vaccines and the integrity of the 2020 election was the road to “concentration camps.” Scary shit, because failure to vaccinate kills: 232,000 COVID-19 deaths among American adults would have been saved in one 15-month stretch if everybody eligible had been vaccinated, and 319,000 (half of all deaths) in another 15-month period. TV actor Forrie J. Smith claims he was kicked off a plane for refusing to sit next to someone wearing a mask. He hates vaccines so much that he doesn't vaccinate his dogs or his horse. Extra: From the Audiobook of Dottoressa: An American Doctor in Rome Listen now · 3:19 All posts and archives will always be free to all subscribers. But if you'd like to support me, please consider upgrading to a paid subscription.. Upgrade to paid Share