Hughesair (Inflection Point)

Retired physician and air taxi operator, science writer and part time assistant professor, these editorials cover a wide range of topics. Mostly non political, mostly true, I write more from experience than from research and more from science than convention. Subjects cover medicine, Alaska aviation, economics, technology and an occasional book review. The Floatplane book is out there. I am currently working on Hippocrates a History of Medicine and Globalism. Enjoy!

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Wednesday, May 20, 2020

COVID19 Diagnosis and Treatment

Early diagnosis is confounded by the fact that the contagious condition of this virus precedes symptoms. Therefore, temperature and symptom screening yields false negatives at the point of maximum spread. The PCR test while giving accurate results in the early stage, requires often days for the result. By then it’s irrelevant. The antibody test while the results are quickly available, only tells whether the patient already had the virus and is producing immune antibodies. The on-site, immediate result PCR test is a US new invention needing time for manufacture and distribution.

More important, is the quick staging of this fast moving infection. Stay home and recover from mild cases, risks getting behind on more sever cases, in that sever lung damage is already there by the time the patient recognizes shortness of breath. ICU and a respirator offer only desperate measures with poor efficacy.

The challenge of early diagnosis, monitoring-progression and staging, leading to early drug therapies before the respirator, offers a better promise. However, there are so many mild cases not requiring any treatment, some asymptomatic, that the monitoring will have to be limited to contacts and known explosions. Monitoring might consist of a simple finger pulse oximeter that you have probable seen used in your doctors office to detect sudden drop in O2 saturation.

From JAMA  May 12 , 323 #18 P1825
Of the several antiviral drugs being tested, one works at the entry level, a couple at the attachment level and several at the viral reproductive level. Only three are available in any quantity, the chloroquines and the 2 ACE inhibitors. The specific antivirals are: available in limited quantities from previous or other viral disease outbreaks, imported with questionable or over burdened supply chains, in research only and or extremely expensive.

Another factor inhibits treatment, and that is the FDA and the evidence based medical bureaucracy. In the old days, every physician would have thrown many drug combinations at the problem. limited only by his or her own knowledge, circumstances and bravery. Not today, drugs must be proven by best evidence and approved by treatment guidelines and the FDA. Dealing with massive numbers of desperately ill patients in over crowded ICUs does not lend itself to the rigid stepwise approval, one size fits all, modern system. Better the on-site multiplicity of individual trials limited only by rationality and “Do no harm.” A working combination, or "cocktail," would rapidly emerge. Such might be more scientific as well considering the infinite multiplicity of combinations -- not to discount the systematized in vitro search through millions of drugs done in advanced laboratories and the gold-standard, double blind clinical trials.

The results of clinical trials are about to be released. We will know more for the next outbreak if it’s the same virus and not mutated to another form of drug resistance. Watch out for drug company studies touting  their own expensive drug candidate and the study that somehow belittles any available affordable alternative.
Click the JAMA illustration for the full free summary.



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