People are citing reports of declining #COVID cases or deaths after mass #ivermectin distribution.
This is the scientific equivalent of “the rain stopped after I bought an umbrella.”
A short thread about why these “studies” are NOT very compelling. 1/
As cases rise, schools & businesses close, people stay home, nursing homes restrict visitors, masks are mandated, etc
A few desperate governments worldwide distributed ivermectin too
In an uncontrolled situation, why should ivermectin get “credit” for reducing cases/deaths?
2/
This is a classic POST HOC ERGO PROPTER HOC ("after this therefore because of this") fallacy.
Ivermectin distribution is usually a last-ditch effort, like buying an umbrella as you are getting soaked.
But the natural history of pandemics is to peak, then decrease.
3/
This pattern of rapid peak followed by decline is what we saw in areas that are overwhelmed, such as during the tragedies in NY & Italy during the first wave of the pandemic.
Ivermectin wasn’t used in either of these cases, but mortality declined rapidly form a high peak. 4/
Now let’s turn to the dubious AJT paper
Honestly, there’s so much wrong with this paper: it’s a narrative review pretending to be a meta-analysis that
picks small, poorly designed studies & excludes better ones
The dubious paper shows mortality in 8 provinces.
Oddly, it only looks at mortality in people >60yo.
They claim that deaths went down after ivermectin distribution.
Though L & R axes are slightly different, their data show that the mortally rate is ≈ or even > case rate?🤷♂️ 6/
Let’s look at mortality using JHU data.
We see deaths before (🟨) & after (⬜️) ivermectin.
In some cases deaths rose despite ivermectin; in other cases mortality was already falling (& continued to). In no case did ivermectin distribution appear to prevent future waves
7/
Summary:
* beware post hoc ergo propter hoc arguments
* the claim that mass ivermectin prevents COVID mortality is not supported by clinical trials (see BMJ's living meta-analysis)
* the claim that ivermectin prevents disease spikes is not supported by population evidence
8/8
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A few years ago I wrote about the problem with vitamin C in sepsis.
It’s not that vitamin C is harmful (it probably isn’t) or that it’s ineffective (it almost certainly is) but that embracing pseudoscience undermines evidence based practice.
#INSPIRATION RCT comparing intermediate vs standard dose DVT prophylaxis, just published @jama:
-no benefit to additional anticoag in ICU patients w/ #COVID19:no reduction in mortality, MV, LOS or any 2° endpoint
-time to rethink COVID #anticoagulation? 1/ bit.ly/3vCluqK
INSPIRATION was a 10 site open-label RCT in 🇮🇷 comparing intermediate vs standard dose prophylaxis in ICU patients with PCR-confirmed #COVID19.
LMWH was the primary intervention (~40 mg vs 1mg/kg daily), dosed appropriately for weight; UFH was used if the GFR was too low.
2/
Overall the groups were balanced (total n=562) & were fairly representative of US ICU cohorts with COVID19.
The use of HFNC was very low (~3%) compared to in the US, which may reflect different practice patterns/availability.
Pre-print of the @remap_cap RCT of #anticoagulation for ICU patients w/ #COVID19 adds details but confirms what we learned from the press release:
- no improvement in survival or organ failure w/ therapeutic (TA) vs prophylactic anticoagulation (PA)
- medrxiv.org/content/10.110… 1/
This study is the amalgam of 3 large platform RCTs of TA in COVID19: @remap_cap@ACTIV4a & ATTACC.
Each trial was administered separately but as much as possible they harmonized the design so the results could be analyzed together. (a pragmatic way to enroll more pts faster) 2/
There were some differences:
-REMAP enrolled suspected & confirmed infxn; the others only enrolled confirmed
-choice of anticoagulant varied
-most importantly, the definition of prophylaxis: ~1/2 the sites used standard low-dose heparin, the remainder used “intermediate dose” 3/
Following @remap_cap & #RECOVERY#Tocilizumab results, @NIHCOVIDTxGuide has updated guidelines:
-#Toci + #Dexamethasone now recommended for all ICU pts on IMV, NIPPV, or HFNC
-Toci + Dex recommended for non-ICU pts w/ rapidly increasing O2 needs & elevated inflammatory markers 1/
There are some caveats:
-Toci must be combined with dexamethasone (not given alone; ? harm signal)
-It should be given early (w/i 3 days)
-Toci should NOT be given to people who are already immunosuppressed or who have “an uncontrolled” infxn (e.g. getting worse despite Abx) 3/
🚨Exciting results from the #RECOVERY trial #preprint of #Tocalizumab (Toci) in hospitalized people w/ #COVID19
-reduced 28-day mortality (29 vs 33%; NNT)
-decreased likelihood of requiring MV (33% vs 38%)
-shorter hospital stay (median 20 vs >28 days) medrxiv.org/content/10.110… 1/
They randomized 4116 pts to weight-based Toci vs usual care (UC):
-groups were balanced: mostly male (>65%), older (>60 yo), & w/ comorbidities (>55%)
-most patients (82%) also received dexamethasone
-they received Toci early in hospitalization but were 7-14 days after onset 2/
Notably, only 83% of patients in the Toci group actually received Toci (plus 2.6% randomized to the UC group got Toci); this would decrease the effect size and bias the towards null.
This means their ITT analysis is probably *underestimating* the true effect size somewhat.
It kinda irks me when someone describes a vital sign or lab value as “incompatible with life.”
Here’s a @tweetorial all about the extremes of physiology.
Case #1:
A 10 yo ____ presents with the following vital signs.
T 109F RR 30 HR 300 BP 142/116
Fill in the blank
Answer: 🐓
A chicken's "normal" Temp is 103-110F (w/ HR 220-360) & they live up to 11 yrs.
The Hummingbird would be quite bradycardia (“normal" HR 800-1200 when active)
The Desert ant (Cataglyphis bicolor) has a higher temp (up to 122F!) but doesn't live 10 yrs or have that BP
Case #2:
An *arterial* blood gas is obtained from a ___ showing
pH 7.37 / PCO2 50 / PaO2 20 / HCO3 26
(yup it really is arterial)