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Primary Care and COVID-19

As in a war when the battle is over, sentries and the guards remain at their posts . They not only would have fought the battles alongside others but they will remain and become part of the reconstruction team. That is how to appreciate the place of primary care providers in a pandemic or any outbreak . That said, primary care providers can only be most effective in a country that has built its systems with the crucial role they play in mind. 

"Strong primary care systems are the exception rather than the rule, but they're also a best buy in healthcare. They're crucially important, and they're going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care."


COVID-19: The bitter and sweet turns of June 2020

By mid month, COVID-19 global fatality surpassed 440,000 lives. These deaths are no longer foreign or of mere statistical significance to a lot of us and many families. The US, six months into the pandemic still features some of the most infectious centers in the world, accounting for a disproportionately higher number of deaths. The month was filled with daily commentary of bad news and hard facts about COVID-19 virus ravaging communities. Incidents of police brutality and the protests that soon followed made the need to social distance, even among those willing to comply, a tall order. Local and regional variabilities in public health responses are yielding variable outcomes that will only ensure that the pandemic lasts as much as the virus would like. The unfolding rate of new infections tell the rest of the story as some cold spots turn hot in the second half of the month. In June, the US Food and Drug Administration (FDA) at the request of the US Biomedical Advanced Research and Development (BARDA) dealt a death blow to what was left of hope around chloroquine and hydoxychloroquine (CHQ/hCHQ) as COVID-19 therapeutic agents. Revoking the emergency-use authorization (EUA) for CHQ/hCHQ , the FDA noted that data shows the drug unlikely to be effective and said "Additionally, in light of ongoing serious cardiac adverse events  and other potential serious side effects, the known and potential benefits of chloroquone and hydoxychloroquine no longer outweigh the known potential risks for the authorized use". It based its decision on some of the already known scientific data citing that the observation of reported decrease in viral shedding with chloroquine and hydroxychloroquine as a mechanism of action could not be replicated reliably in large controlled studies. Even more alarming in the report, was that the co-administration with remdesvir, another drug that enjoys an EUA status, in COVID-19 patients reduces remdesvir's antiviral efficacy. It warned that in vitro data shows the two drugs are antagonistic.The agency, however, did not recommend the cessation of use of the drugs in hospitalized patients for whom the drug was already in use or for whom it had been authorized.

Providers of care and the public remained apprehensive as everyone waited for some clarification from the scientific community as soon as some US politicians started advocating for the drugs and self-medicating against doctors' advice. Never had there been so much side talk, suspicion towards, and motives ascribed to an agency's pronouncements for or against a drug as we saw with CHQ/hCHQ. CHQ/hCHQ nevertheless remains a staple as part of the anti-COVID cocktail in some countries. The preceding non-scientific messaging around the agents could not have happened at a worse time and was unfortunate because so many lives depended on good information. Doctors and most importantly those they treat needed to have absolute confidence that they have the best and scientifically vetted information about the tools available to them .

Various agents are under investigation for treatment of COVID-19 infection at the same time that there is a scramble to develop a protective vaccine.  Three months ago in March of 2020, the RECOVERY trial was established as a randomized clinical trial to test a range of potential treatments for COVID-19, including low-dose dexamethasone (a steroid treatment). Over 11,500 patients were enrolled from over 175 NHS hospitals in the UK.Some of the agents under clinical trials include:

  • Lopinavir-Ritonavir (commonly used to treat HIV)
  • Dexamethasone (a type of steroid, which typically used to reduce inflammation)
  • Hydroxychloroquine (which has now been stopped due to lack of efficacy)
  • Azithromycin (a commonly used antibiotic)
  • Tocilizumab (an anti-inflammatory treatment given by injection)
  • Convalescent plasma (collected from donors who have recovered from COVID-19 and contains antibodies against the SARS-CoV-2 virus). 

Some good news though came when on June 16, 2020., the University of Oxford published preliminary results of its RECOVERY (Randomized Evaluation of COVid-19 thERapY) trial which show that low dose dexamethasone decreased mortality in seriously ill ventilator requiring COVID-19 patients by as much as a third compared to those who received usual care.

COVID-19: Too many lives at stake, no room for misleading data.

The Lancet retracted a highly cited study that suggested hydroxychloroquine may cause more harm than benefit in patients with COVID-19 and hours following that, the New England Journal of Medicine retracted a second article by some of the same authors, also on heart disease. The issue relating to the unreliability of data on which recent recommendations were made about the dangers of the use of hydroxychloroquine and chloroquine phosphate in the this pandemic could not have come at the worst time. Surgisphere Corporation and its founder and co-author, Sapan Desai, citing client rights, confidentiality agreements, could not transfer for peer review the full dataset, client contracts, and the full ISO audit report for analysis, the report says. 

Primary Care Tips- Blood Pressure.

Diagnosis of hypertension before the age of 40 years increased the rate of cardiovascular disease ( stroke and heart failure) by as much as 3.5 times compared to those who have normal blood pressure, a study, the CARDIA trial shows. In a similar Korean study this increase is as much as 85 %. Two seperate studies a world apart with similar findings give those of us in primary care reason for pause. Blood pressure in young adults age 18-30 years need to be addressed, treated and controlled. A reasonable primary prevention strategy for cardiovascular disease (CVD) will be to use the new but somewhat controversial American College of Cardiology (ACC)/American Heart Association (AHA) 2017 guideline for diagnosis of stage 1 hypertension to identify persons with hypertension in this age group. These group of patients stand to benefit from timely identification, intervention and treatment of hypertension. The American College of Cardiology (ACC)/American Heart Association (AHA) 2017 hypertension classification update reduced the threshold for hypertension from 140/90 mmHg to 130/80 mmHg, with stage 1 hypertension defined as a systolic BP (SBP) of 130 to 139 mmHg or a diastolic BP (DBP) of 80 to 89 mmHg.

Reference: https://jamanetwork.com/journals/jama/article-abstract/2712542

Related Articles : http://chikeonyenso.com/posts/154-targeting-hypertension

COVID-19: The Many Hurdles in Black and Brown Communities.

Right in the middle of a pandemic caused by a killer virus that loves groups and people in close quarters, there is an outbreak of protests in response to a broad daylight public display asphyxiation murder of George Floyd, a black man by four Minnesota white policemen. The streets are flooded by sheets of outraged protesters. Epidemiologists brace up for an imminent uptick in transmission and cases of COVID-19 infection. The struggles and history of ethnic minorities and persons of color have always been told, but never has it been so downright draped on ones consciousness, especially for the generations that did not witness the civil rights movement past, the gaping wounds left behind by a long unrelenting history of disparity that is so evident in a society. The link has never begged to be made that always has existed of a not-so-novel a "virus" of disparities, of social and economic inequities, pervasive injustices, inequalities in educational opportunities. These social ills leave in their wake a roadmap for the lethal effectiveness and pathogenesis of COVID-19, the real novel virus that followed . A disease, a new enemy virus, that seemed to have earmarked whom, where and how it would hit the hardest, communities of color, knowing how those have been forced to live, breathe, eat and the work in America, a nation that once boasted a promise of greater life for those who set foot on its shores.

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