Jon-Emile S. Kenny MD [@heart_lung] “… but prejudices, like odorous bodies, have a double existence, both solid and subtle – solid as the pyramids, subtle as the twentieth echo of an echo, or as the memory of hyacinths which once scented the darkness.” -Mary Ann Evans Background As previously described, the SARS-CoV-2 main protease inhibitor [Mpro] [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “When she smiles without her teeth in place she looks like a witch. But with them in her mouth she’s very pretty.” -Judy Blume Basic Biology The SARS-CoV-2 genome encodes structural proteins [i.e., spike, envelope, membrane, nucleocapsid] and polyproteins [i.e., pp1a and pp1ab]. When the guts of SARS-CoV-2 spew into a [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I find real life challenging enough. If I get to the dry cleaners without having a huge fight, that’s challenging enough.” -Fran Lebowitz Background Quite recently, the BaSICS investigators evaluated the infusion rate of a fluid bolus on patient outcome. As considered, however, contrast should be made between a fluid bolus, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “If you’re afraid of butter, use cream.” -Julia Child Background Early observational studies and the RECOVERY collaborative group initially demonstrated the benefit of corticosteroid therapy in oxygen-requiring, COVID-19-patients; additional randomized studies as well as a meta-analysis of these reports corroborated this. Yet the dosing of corticosteroids across the above studies was [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “… Sartre tells us that man makes himself this lack of being in order that there might be being.” -Simone de Beauvoir Background Like many early, proposed therapies for COVID-19, inhaled corticosteroids [ICS] had suggestive, conflicting evidence. For example, in a very large observational investigation – the OpenSAFELY platform – patients with both [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “In those years, truth was elusive – as was my own faith that I could recognize and contain it.” -Mary Oliver Previously, the very basic underpinnings of fluvoxamine as a pharmacological method to quell cytokine unruliness was outlined. In brief, fluvoxamine is a sigma-1-receptor [S1R] agonist – an effect that opposes [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The left ventricular ejection fraction [LVEF] is a commonly-sought cardiac measure. With the explosion of bedside ultrasound and automated methods to capture LVEF, the ejection fraction will grow in clinical prominence and affect decisions for the acutely-ill. Asked the meaning of the LVEF, many clinicians might describe it as a ‘measure [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Apocalypse is played out now on a personal scale; it is not in the sky above us, but in our bed.” -Mark Doty Introduction With a proposed pathway coupling pathogen-associated molecular patterns to the elaboration of pro-inflammatory cytokines, sketched lightly in part 1, this segment ties murine biomolecular theory to human [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “You see, we have a kind of allergy to the past; it’s our national disease, and the very assurance with which you insist that the past is within the present is likely to seem quite repellent, even offensive, to these new readers.” -Richard Howard Introduction Early in the COVID-19 pandemic, the [… read more]
Jon-Emile S. Kenny MD [@heart_lung] When we model the circulation at the bedside, we resort to generalizations. While these mechanistic heuristics don’t completely capture the complexity of hemodynamics, they do help us think quickly when confronted by clinical urgency. For example, distilling ‘venous return’ into an upstream pressure and downstream pressure separated by a single resistance, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “As human beings, don’t we need questions without answers as well as questions with answers?” -Alan Lightman With the publication of REMAP-CAP, CAPE-COVID and CoDEX, the World Health Organization [WHO] Rapid Evidence Appraisal for COVID-19 Therapies [REACT] Working Group combined these results with 4 other randomized trials of corticosteroids in COVID-19. [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Let us try to assume our fundamental ambiguity.” -Simone de Beauvoir When the pre-peer review RECOVERY trial was released in mid-June of this year, clinicians lost equipoise to enroll hospitalized patients receiving at least oxygen for COVID-19 into trials including a treatment arm without corticosteroids. This brought to an early-halt three [… read more]
A combination of vitamins C and B1 with corticosteroids didn’t prevent organ failure in septic shock, the ACTS trial showed. The intervention improved the Sequential Organ Failure Assessment (SOFA) score 4.7 points compared with a 4.1-point improvement with placebo over the 72 hours after enrollment, which was not significant at P=0.12 for interaction, reported Michael Donnino, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “ This is the way the world ends Not with a bang but with a whimper.” -T.S. Eliot As lightly discussed a few months ago, deploying corticosteroids in COVID-19 began, expectedly, with controversy. Russell and colleagues submitted a letter arguing against wholesale administration of corticosteroids in patients infected with SARS-CoV-2. They [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “This whole thing is not about heroism. It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency.” -Albert Camus Background In 2013, Dünser and colleagues communicated a rogue viewpoint in shock resuscitation – let us do away with strict macro-hemodynamic goals [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…fires had been put out by volunteers using brickmason’s ladders and buckets of water carried in from wherever it could be found, and methods so disorderly that they sometimes caused more damage than the fires.” – Gabriel García Márquez In this second primer [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “…but they all had an evasive tremor in their voices and an uncertainty in their eyes that belied their words.” – Gabriel García Márquez Background With early data illustrating upwards of 1 in 5 COVID-19 patients developing acute respiratory distress syndrome [ARDS], there is [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “He found a glimmer of hope in the ruins of disaster …” – Gabriel García Márquez Background The coronavirus moniker originates from the appearance of the virus under the electron microscope – protein peplomers radiating from the viral envelope like a crown. Prior [… read more]
A new randomized trial showed no benefit from intravenous vitamin C in patients with sepsis, but delays in treatment baked into the trial design will keep hope alive for true believers in the novel therapy. Vitamin C, hydrocortisone, and thiamine have been promoted as a lifesaving adjunctive therapy for septic shock, based on anecdotal data [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Sich regen bringt Segen” -German proverb Background It is an overcast day in Bern, Switzerland. I have recently left Zermatt, having had the honour and pleasure of speaking at ‘The Big Sick’ conference. I spent the day roaming the narrowed passages of this old, beautiful city. In the midst of my [… read more]
Get PulmCCM’s Weekly Email Update
Stay up-to-date in pulmonary and critical care. No spam.