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26 Nov, 5 tweets, 2 min read
Editing a #COVID19 guidebook for doctors. It's intended for those with little or no experience treating coronavirus. What should it tell them about prone positioning? (Prone = the patient lies flat on their chest instead of their back). 1/
Prone positioning works for some diseases, but not all. It improves oxygenation in patients with severe acute respiratory distress syndrome (though more homogenous ventilation) & may decrease lung injury. Some suspect it might help patients with COVID. 2/ pubmed.ncbi.nlm.nih.gov/23688302/
But there aren't any randomized controlled COVID trials to answer this question (yet). Instead, we have smaller, cohort studies suggesting prone positioning could be helpful in certain patients. 3/ ncbi.nlm.nih.gov/pmc/articles/P…
Today the NYT examined the plummeting death rate for COVID and cites this paper, which credits prone positioning with potentially helping to improve mortality. That conclusion seems premature 4/: 
journalofhospitalmedicine.com/jhospmed/artic…
Randomized proning trials are in the works but we don't have data yet. Which brings me back to the question I've been wrestling with: In the absence of strong data, what do we tell doctors?
The default is to say: Don't do it.
But I suspect many are.
clinicaltrials.gov/ct2/show/NCT04…

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More from @DrMattMcCarthy

Matt McCarthy Profile picture
28 Nov
Vitamin D is in the news today because: 1) England is giving it out for free and 2) This article minimizes its role in the pandemic. But there are some very smart people who think it is not just important for #COVID19 but essential. Here's how the argument was presented to me: 1/
Many of the chronic diseases identified as #COVID19 risk factors (high blood pressure, diabetes) are potentially associated with vitamin D deficiency.
pubmed.ncbi.nlm.nih.gov/20031348/
D deficiency is associated with increased risk for some respiratory infections. In one study, people with low levels were more likely to have had a respiratory infection in the month before having their blood drawn compared to people with normal levels.  
pubmed.ncbi.nlm.nih.gov/25781219/
Read 8 tweets
Matt McCarthy Profile picture
27 Nov
You've heard the refrain: "We want to see the data." But what does that mean? Here are some of the things we'll be looking for when a federal advisory panel meets on December 10th to discuss emergency authorization of a #COVID19 vaccine: 1/
1. Are there assurances that subjects were not inadvertently unblinded? Participants & doctors shouldn't know who received placebo, but one can occasionally make an educated guess. (Unblinding occurred during an HIV trial when the drug changed red cells):
virusmyth.org/aids/hiv/jltri…
2. Tell us more about the patients who developed symptoms in each group: How many were hospitalized? Required oxygen? What's the age breakdown? How many had chronic medical conditions?
Read 5 tweets
Matt McCarthy Profile picture
24 Nov
Asked by an interviewer today if there's anything that haunts me from the first wave of #COVID & what lessons we can learn from it. Those who've heard my lectures know I could do an hour on this, but the thing I keep coming back to: It took a long time for us to use steroids. 1/
The problem: Doctors are trained to practice 'evidence-based medicine'. When the disease is new, there's an evidence vacuum. We didn't have *any* reliable data in early March. How do you make life-or-death decisions without evidence? 2/
One way to look at it: If the intervention is relatively harmless, it's not a big deal to go out on a limb. (Want to try zinc? Go for it!). But steroids aren't harmless. There was a genuine concern that they could make things worse for COVID patients based on our experiences...3/
Read 5 tweets
Matt McCarthy Profile picture
24 Nov
The best COVID questions I got yesterday: 
1. Why did AstraZeneca give volunteers a half dose of vaccine followed by a full dose a month later? And why did that group do so much better than those who receive two full doses? (90% effective vs. 62%) 1/
2. Should prior #COVID19 infection affect your place in line for a vaccine?
3. If a healthcare worker gets vaccinated and develops a fever, does that person stay home from work the next day?
Answer to #1: It was an accident. Researchers were confused when side effects were much milder than expected, so they checked & realized they'd mistakenly given volunteers half of the predicted dose. We don't know why that worked better, but it did. 
reuters.com/article/uk-hea…
Read 6 tweets
Matt McCarthy Profile picture
24 Nov
CDC's Advisory Committee on Immunization Practices proposes 4 groups for initial vaccine rollout: 1) healthcare workers (21 million people), 2) other essential workers (87 million), 3) adults with high-risk conditions (>100 million) & 4) adults age ≥65 years (53 million). 1/
The subtext here is that in an effort to mitigate health inequities, "other essential workers" (police, firefighters, teachers) will have access to vaccines before adults over age 65: cdc.gov/mmwr/volumes/6…
EUA of a vaccine is unusual--it's only been done once before (anthrax, 2005)--and some may be concerned about targeting certain high-risk, traditionally-marginalized groups with an experimental product. But CDC is going about this thoughtfully & should be lauded for their work.
Read 4 tweets
Matt McCarthy Profile picture
21 Nov
Common question: If I contract coronavirus tomorrow, what meds would I want? Short answer: Depends where I am. If you sift through all of the breathless #COVID press releases, the only "game-changer" is dexamethasone, a cheap & widely available steroid that saves lives. But... 1/
I would only want it if I'm really sick. Otherwise, it could actually make things worse. Drugs that work in some groups fail in others. Lilly's antibody, bamlanivimab, is weakly effective (maybe?) for patients outside of the hospital but makes things worse for sick patients. 2/
This matters as we think about the vaccine roll out: different groups may respond differently. For example, patients in longterm care facilities (nursing homes, assisted living facilities) may be quite different than the people who actually enrolled in #COVID vaccine trials. 3/
Read 5 tweets

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