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Tag: COVID-19

A big data COVID train wreck

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BY ANISH KOKA

If there was any doubt the academic research enterprise is completely broken, we have an absolute train wreck of a study in one of the many specialty journals of the Journal of the American Medical Association — JAMA Health.

I had no idea the journal even existed until today, but I now know to approach the words printed in this journal to the words printed in supermarket tabloids. You should too!

The paper that was brought to my attention is one that purports to examine the deleterious health effects of Long COVID. A sizable group of intellectuals who are still socially distancing and wearing n95s live in fear of a syndrome that persists long after a person recovers from COVID. There are any number of papers that argue a variety of putative mechanisms for how an acute COVID infection may result in long term health concerns. This particular piece of research that is amplified by the usual credentialed suspects on social media found “increased rates of adverse outcomes over a 1-year period for a PCC (post-COVID conditions) cohort surviving the acute phase of illness.”

In this case PCC (Post-COVID conditions), is the stand-in for Long COVID, and leading commentators use this paper to explicitly state that heart attacks, strokes and other major adverse outcomes doubled in people post-COVID at 1 year…

It is a crazy statement, and anyone regurgitating this has no business commenting on any scientific papers. Let me explain why.

In order to find out about the potential ravages of long COVID researchers need to be able to compare outcomes between those who were infected with COVID and now have long covid to those who were never infected with COVID. At this point finding a large enough group of people that never had covid is impossible, because everyone in the world will have been infected with COVID many, many times. It’s also really hard to define the nebulous long COVID because a study after study finds no clear objective markers of the disease.

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A COVID-19 vaccine exemption letter

BY ANISH KOKA

I recently saw a young man who came to see me because his place of future employment, a large health system was requiring him to complete the 1º series of his COVID-19 vaccination. He was concerned because he had chest pain after his first mRNA vaccine and was uncomfortable with the risks of a second mRNA dose. He attempted to get a Johnson and Johnson vaccine and was told by pharmacists he was not allowed to mix and match this particular vaccine as he had already received an mRNA dose. With no other option, he came to ask me whether I thought a vaccine exemption was reasonable in his case. He already had a family medicine physician sign an exemption that had been denied by his future employer’s vaccine exemption committee. The young man works on the “back end” of the health system remotely from home and he has no patient contact. The entire process has caused him to lose his health insurance from his former employer, and he was now paying out of pocket for an expensive COBRA health insurance plan. What follows is my letter to the vaccine exemption review committee regarding his case. (Published with permission, only the relevant names have been changed/redacted)


Dear Vaccine Exemption Review Committee,

I am writing this letter on behalf of John Smith DOB: xx/xx/xx in regard to a mandate from xxxx Health that Mr. Smith receive a second dose of an mRNA vaccine to complete his primary COVID-19 vaccine series.

Mr. Smith has asked me to render an opinion specifically related to his cardiac risk of receiving a second dose of an mRNA vaccine. I am a board-certified cardiologist in Philadelphia, Pennsylvania, and have been in active clinical practice for 13 years.

After reviewing the details of his case, I have grave concerns about compelling him to receive a second dose of an mRNA vaccine and would like to outline the reasons for my conclusion in this letter. I am going to specifically discuss his risk of an important, now well-recognized, adverse event: vaccine myocarditis.

What follows is some important background information about vaccine myocarditis that has been gleaned over the last 2 years before I discuss the particulars of Mr. Smith’s case.

It is relevant to note here that as a physician active clinically in both the inpatient and outpatient arenas, I am an eyewitness to the severe toll COVID-19 took on my patients in the Spring or 2020. I was impressed enough with the initial mRNA vaccine data to acquire the vaccine available from the Philadelphia Department of Health (Moderna) and ran multiple vaccine clinics in order to vaccinate my mostly high-risk patients.

What follows is data produced since the vaccine rollout that is relevant to Mr. Smith’s case.

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Last in Line: Hospitals Brace for a Chilly 2023

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BY JEFF GOLDSMITH

As they emerge from the COVID pandemic, US hospitals have a terrible case of Long COVID.  They experienced the worst financial performance in 2022 in this analyst’s 47 year memory.  As the nation recovers from the worst inflation in forty years, hospitals will find themselves locked in conflict with health insurers over contract renewals that would reset their rates to the actual delivered cost of care.  “Last in line” in the US battle with inflation, hospitals will be exposed to public criticism when they attempt to recover from pandemic-induced financial losses. 

Hospital payment rates for commercial payers are backward looking. Commercial insurance contracts between hospitals and health insurers were multi-year contracts negotiated before the pandemic.  They continued in force during the pandemic, despite explosive rises in people and materials costs.    As a consequence, health costs were conspicuously missing from the main drivers of the 2021-22 inflation surge– food, housing, energy, durable goods, etc.    

Hospitals’ operating costs blew up during COVID due to a shortage of clinicians, the predations of temporary staff agencies, shortages of supplies and drugs and crippling cyberattacks that disabled their IT systems.   Hospital losses worsened during 2022 because they are unable to place patients who are no longer acutely ill but who cannot be placed in long term, psychiatric or home-based care (a problem shared by Britain’s disintegrating National Health Service).   Thousands of patients are stuck in limbo in hospital “observation” units, for which government and commercial payers do not compensate them adequately or at all.   

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COVID-19 myocarditis illusions: A new cardiac MRI study raises questions about the diagnosis

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BY ANISH KOKA

One of the hallmarks of the last two years has been the distance that frequently exists between published research and reality. I’m a cardiologist, and the first disconnect that became glaringly obvious very quickly was the impact COVID was having on the heart. As I walked through COVID rooms in the Spring of 2020 trying to hold my breath, I waited for a COVID cardiac tsunami. After all social media had been full of videos from Wuhan and Iran of people suddenly dropping in the streets. My hyperventilating colleagues made me hyperventilate. Could it be that Sars-COV2 had some predilection for heart damage?

Happily, I was destined for disappointment. There never was a cardiac tsunami from COVID.

There were, unhappily, lots of severely ill patients with lungs that were whited out who quickly developed multi-organ dysfunction while hospitalized. The lungs were where almost all the action was. Every other organ got hit hard because of the systemic illness that unfortunately often is a downstream result of a severe respiratory illness. Cardiac Cath labs waiting for some major influx of COVID heart damage not only didn’t see patients presenting with COVID heart attacks, but they idled as patients terrified of coming to the hospital stayed home rather than come to the hospital with chest pain. (Public health messaging about COVID appears to have kept people away from hospitals, and autopsy series of deaths during the pandemic found that reduced access to health care systems (for conditions such as myocardial infarction) was further likely to be identified as a contributory factor to death than undiagnosed COVID-19).

So imagine my surprise when I saw peer-reviewed research based on a cardiac MRI study come out in 2020 suggesting that 78% of patients who survived COVID may have significant heart damage. A more detailed read of the paper, of course, threw up massive problems. The article and authors were more suited as writers for Oprah and Dr. Phil than for a well-respected academic journal. But the damage was done, and the notion that COVID was attacking hearts spread via a social media influencer class that should have had the credentials and smarts to know better, but clearly didn’t.

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America, the intolerant

BY ANISH KOKA

Historically, the great tension between liberty and authority was between government as embodied by the ruling class and its subjects.  Marauding barbarians and warring city-states meant that society endowed a particular class within society with great powers to protect the weaker members of society.  It was quickly recognized that the ruling class could use these powers for its own benefit on the very people it was meant to protect, and so society moved to preserve individual liberties first by recognizing certain rights that rulers dare not breach lest they risk rebellion.  The natural next step was the establishment of a body of some sort that was meant to represent the interests of the ruled, which rulers sought agreement and counsel from, and became the precursor to the modern day English parliament and the American Congress.  Of course, progress in governance did not end with rulers imbued with a divine right to rule being held in check by third parties.  The right to rule eventually ceased to be a divine right, and instead came courtesy of a periodical choice of the ruled in the form of elections.  The power the ruled now wielded over those who would seek to rule lead some to wonder whether there was any reason left to limit the power of a government that was now an embodiment of the will of the people.

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The college football fans that beat COVID and the experts that couldn’t

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BY ANISH KOKA

The COVID pandemic was supposed to herald the end of the idea that a smaller government is a better government. The experts who desperately seek to be in charge of a sprawling bureaucratic state told us that it was only a powerful central authority that could do what was needed to safeguard individual liberties at a time when a highly contagious respiratory virus was spreading across the globe.

New Zealand may have imposed draconian policies that did not even allow its own citizens to return, but scenes of cheering unmasked New Zealanders stood in sharp contrast to empty seats in American stadiums when teams were allowed to play. If only US politicians possessed the iron will of New Zealand premier Jacinda Arden, Americans too could have ‘freedom’.

But in so many ways, the New Zealand example demonstrates the utter foolishness and shortsightedness of the central planners that seized control globally. A year after New Zealand took their victory lap COVID arrived in New Zealand and a very much masked Prime Minister noted that “very soon we will all know people who have Covid-19 or we will potentially get it ourselves”

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Vaccine Myocarditis Update

BY ANISH KOKA

The European Medicines Agency decided on July 19, 2021 that myocarditis and pericarditis be added to the list of adverse effects of both messenger RNA (mRNA) based vaccines (BNT162b2 [Pfizer-BioNTech] and mrna-1273 [Moderna]) against COVID-19. This advice was based on numerous reports of myocarditis that followed a clinical pattern that strongly suggested a causal link between these particular vaccines and myocarditis/pericarditis. The adverse events that appeared to be predominantly in young men typically occurred within a week after injection, and were clustered after the second dose of the vaccine series. A recent national database from France sheds some light on the approximate rates of mrna vaccine related myocarditis.

Between May 12, 2021 and October 31, 2021 within a population of 32 million persons aged 12-50 years, 21 million first doses of the BNT162b2 (Pfizer) vaccine and 2.86 million first doses of the mrna-1273 (Moderna) vaccine. In the same period, 1612 cases of myocarditis and 1613 cases of pericarditis with myocarditis were recorded in France. Compared to matched control subjects, the risk of myocarditis was markedly increased after 1st and 2nd doses of the vaccine. For the Pfizer vaccine, the odds of myocarditis were 1.8 times the expected background rate for the 1st dose and 8 times the expected background rate for the 2nd dose. The Moderna vaccine, which delivers about three times the dose of the Pfizer vaccine has an even higher risk of myocarditis — a stunning 30 times the expected background rate after the second dose. A prior history of myocarditis was associated with an odds-ratio of 160.

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Pharmacists Can Now Prescribe Paxlovid. Good idea?

BY ANISH KOKA

Apparently, the US Food and Drug Administration (FDA), that has long been charged with the safety and efficacy of drugs and devices now also controls who can prescribe drugs.

I was under the mistaken impression that in our highly rule based society you would need to pass a law to allow that to happen. Passing laws , of course, can be a long, messy, process that involves having to convince constituencies, and ruling by executive order is just way more efficient apparently.

So by decree of the FDA patients can now get Paxlovid, an anti-viral for the virus that causes COVID19, “directly from their state licensed pharmacist” if they so choose. Apparently, someone in government decided that there wasn’t enough Paxlovid being prescribed, and the major rate limiting step for many patients is not having access to a provider to prescribe the drug. I have to say provider now because physicians long ago lost the monopoly they enjoyed for prescribing medications to nurses with advanced degrees and physician assistants. The next obvious step is to cut out the ‘clinicians’ completely by allowing patients to get medications from a pharmacist without a prescription.

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Rural America is a Fertile Field for Digital Health

BY ERIC LARSEN and TOMMY IBRAHIM

Eric Larsen
Tommy Ibrahim

Our rural health care system has suffered badly during the COVID-19 pandemic. It entered the pandemic with severe structural weaknesses, including magnified health disparities and inequities, lower rates of vaccination in the general population, and high risk of rural hospital closures. Beginning with these challenges, rural providers have been harder hit by the pandemic than just about any other health care sector. 

Juxtaposed against this struggle is the optimism for digital health – one of the few bright spots of the pandemic. We have witnessed a veritable digital health revolution – record capital infusions of $37.9 billion to digital health companies in 2021, a proliferation of digital health companies (11,000 by some estimates), a wave of healthtech IPOs (29), and an unprecedented talent migration of Silicon Valley programmers, technologists, and engineers into health care. With this investment and talent boom comes staggering growth in new digital health tools. From telemedicine to remote diagnostics to the delivery of medications directly to a patient’s home, it seems that for every health care access need there is a digital solution.

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Long COVID cardiac studies: More questions than answers.

BY ANISH KOKA

The NIH recently announced $1.2 billion dollars in funding for research on Long COVID. This is in part because of a faction of scientists that have mined electronic health record databases to find evidence that the long term impacts of COVID on a variety of different organ systems is significant.

I have some concerns when it comes to the cardiac complications discussed related to Long COVID.

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