リオオリンピックで銀メダルを獲得したマデリン・グルーブスさんは、子宮腺筋症と子宮内膜症と診断された
「子宮腺筋症の痛みは、子宮にナイフを刺され、そのナイフをゆっくりとねじ込まれているようなもの」と語っている
その後、スクリーニングで高度異形成も見つかり、切除した
マデリン・グルーブスさんのガーダシル接種歴は不明であるが、オーストラリアの接種率は80％となっている
子宮腺筋症はサーバリックス治験中の重篤副反応として報告されている
240人参加中1例の報告
オーストラリアでガーダシル導入後に子宮頸部の異形成が減少していると拡散している産婦人科医がいるようですが、
オーストラリアではガーダシル接種世代のスクリーニング参加率が減少しています
しかも、子宮頸がんは増えている
子宮頸がんは、2007年のガーダシル導入後、着実に増加中
ガーダシルやシルガード９にはアラムアジュバントが使用されています
アラムアジュバントはTh2応答を誘発します
もしBCGワクチンがTh1応答を誘発して新型コロナの軽症化に貢献していると考えるなら、
逆にガーダシルやシルガード９は新型コロナの重症化に貢献していると考えてよいでしょうか
Alum is the most commonly used adjuvant in human vaccination. It is found in numerous vaccines, including diphtheria-tetanus-pertussis, human papillomavirus and hepatitis vaccines [3]. Alum provokes a strong Th2 response, but is rather ineffective against pathogens that require Th1–cell-mediated immunity.
2020年3月13日VAERSで報告された症例
11歳少年が、シルガード９（米国名ガーダシル９）を接種後、失明した
2020年3月にVAERSに報告されたHPVワクチンの副反応は11件
16歳少女、13歳少年、23歳女性、25歳男性、15歳女性、20歳男性、17歳女性、11歳少年、年齢不明女性、35歳男性、11歳少年
男性6人
女性5人
精神遅延2人
視神経炎疑い2人（男性）
2012年シリアの戦禍から家族とトルコに逃れ、2014年英国にたどりついた若いシリア人医師
新型コロナウイルスの症状は、今までの人生に起きた様々な困難の中でも、一番つらいものだった
4月6日、病院で勤務中に体調の不良を感じ、同僚に体温を測定してもらったところ38.5度であった
上司に自宅で隔離するよう言われ、7日間自宅にいた。すぐに良くなると思っていたが、7日後の4月13日悪化し、倒れ、救急車で病院に運ばれた
症状が悪く、死を覚悟していた
7日間、自宅に待機し、5日間病院にいて、2週間後の4月20日に体温は平温に戻っているが、息切れの症状はまだ残っている
病院に到着したとき、自分の測定値はそんなに悪くなく、酸素飽和度も下がっていなかったが、体調はとても悪かった
担当医師は、アセトアミノフェンを静注し、帰宅させようとした
自分の経験では、若い人は酸素飽和度が低下しなくても、注意が必要であるとわかっていたので、医師にそう伝えた
若い人は、数値が良くても、突然倒れることがあり、一度そうなったら助ける時間がないと伝えた
医師は、入院を認めた
入院の1日目、コンサルタント医師は、新型コロナは熱が下がるのに14日かかるのでサポートすると言った
翌日、抗生物質を静注するよう頼んだ
12時間後、魔法のように、熱が下がり、胸痛が無くなった
生まれ変わったようだった
4日目、医師に、退院させるよう頼んだ
経口抗生物質を処方してもらった
若い人の場合、酸素飽和度や血圧の数値が悪くなくても、注意しなくてはいけない
数値が悪くなるのに、時間がかかることがあり、突然倒れることがある
最後に、すべての病院のスタッフ、救急車のスタッフ、病院で働いているクリーナーの人たちに感謝している
2次感染への注意はBBCの記事の中でも喚起されている
What saved my life perhaps was one male nurse who said to me: "If the doctors say you're medically fit to go home - go! Don't make the mistake of staying in hospital because you feel a bit weak. Believe me, I've seen it on this ward - every patient who's been told by doctors 'you can go home' and have argued saying they don't feel 100% and just want one more night in hospital - every one of them has contracted a secondary illness, because this is a high-risk Covid ward and they've all died."
私の命を救ったのは、多分、1人の男性看護師が「医師が退院しても良いといったら、すぐに帰宅して。ちょっと弱っているからと入院を延ばす間違いを犯してはいけない。私を信じて。この病室で、医師に退院してもいいと言われて、まだ100％良くなっていないのでもう一晩入院していたいと言った人は、2次感染し、すべて亡くなっている、ここはリスクの高い新型コロナの病棟だ。」と言った。
2014年CDCでウイルスの漏出事故があったため、ゲイン・オブ・ファンクションの遺伝子操作を禁止した米国は、武漢ウイルス研究所に資金提供しコウモリウイルスの実験を続行していた
現場の医師は、ヒドロキシクロロキンとアジスロマイシン（＋亜鉛）で治療に成功していることをツイッターで拡散している
早期に治療を開始することが重要
1450人以上治療した
リスクの高い患者405人を、早期に投与し治療、そのうち死亡２人、4人が人工呼吸器後回復、残りは回復している
日本からの症例報告
日本感染症学会のページには、上記以外4例報告されている
内1例はネガティブな結果（慈恵医大）
日本では小児の特発性間質性肺炎の治療で使用されている
2. ハイドロキシクロロキン
ステロイドで十分な効果が得られない場合に使用する。実際にはステロイドとの併用療法で開始することが多い。投与量は10mg/kg/day、分2が一般的で、治療効果発現には、2-4週以上が必要である。
日本では網膜症のために承認が取り消された薬剤なので、適応を慎重に判断し、患者・家族の同意を得てから使用する。定期的な眼科診察で、網膜症の早期発見に努める。日本小児呼吸器疾患学会が平成17-19年に行った全国調査では、承認取り消しの事由となった網膜症の報告はなかった。低血糖の関連が疑われる症例報告があるので、注意する（特にステロイド併用例において、ステロイドを減量していく過程では注意が必要である）。
ステロイドで十分な効果が得られない場合に使用する。実際にはステロイドとの併用療法で開始することが多い。投与量は10mg/kg/day、分2が一般的で、治療効果発現には、2-4週以上が必要である。
日本では網膜症のために承認が取り消された薬剤なので、適応を慎重に判断し、患者・家族の同意を得てから使用する。定期的な眼科診察で、網膜症の早期発見に努める。日本小児呼吸器疾患学会が平成17-19年に行った全国調査では、承認取り消しの事由となった網膜症の報告はなかった。低血糖の関連が疑われる症例報告があるので、注意する（特にステロイド併用例において、ステロイドを減量していく過程では注意が必要である）。
クロロキンが有効であつた特発性間質性肺炎の１例
国立療養所南福岡病院小児科
（＊皮膚の色が濃いためのビタミンD欠乏という意見もあり）
英国で亡くなった医療従事者の方たち、男性はほとんどが中東、アフリカ系
最初に亡くなった医師二人はスーダン人だった
（白人女性の死亡者は極度の肥満が目立っている）
アフリカのベニンで亡くなった最初の患者さんは、鎌状赤血球症だった
ベルギーで亡くなった最年少の少女は、ガーナ出身だった
Black people in NYC twice as likely to die from COVID as white people: Data
ニューヨークの黒人の死亡リスクは白人の2倍である
（貧困が原因ではないかという意見があるが、英国では裕福な医師が多数なくなっている）
鎌状赤血球症患者は特に呼吸器系ウイルスに注意する必要があるという記事
世界の鎌状赤血球症新生児分布
2015年の新生児における鎌状赤血球症の数
米国医師から
酸素吸入だけしている人も、時々うつ伏せになったり、横になったりして、ベッドの上で体を回転させ、最も苦しくない姿勢を探すこと
肺は背中の側にあり、末端の肺胞まで空気が届くようにする
Webinar on Avoiding Intubation and Initial Ventilation in COVID19
45,740 views •Apr 4, 2020
おたふく風邪は、子どもが罹患すれば重症化しない
子どもの場合、無症候感染も多い
大人が罹患すると重症化する
男性成人が罹患すると不妊の原因になる
右のボックスの中
無症候暴露歴
・感染した患者は症状が現れる1～2日前に最も感染力が強い
・感染した人の15から27％は無症候
患者を新型コロナと診断すると米国医師は１人につき130万円受取り、その患者に人工呼吸器を装着すると更に390万円の支払いを受けることができる。
がんと診断すると、いくら支払われると思うか？１人につき5000万円の純益。
It's very interesting I came across this post at the same time I got this email from my British colleagues that I'll share in full below (happy for dissemination).
“Dear All,
I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases.
The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton.
Ventilation
- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness.
- Avoid spontaneous ventilation early in ICU admission as also may be harmful.
- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.
- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related.
- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation.
- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT.
- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier.
- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting.
- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days.
- Generally people are using humidified circuits with HMEs.
- A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily.
- Leak test before extubation is crucial, others are also seeing airway swelling.
- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high.
My conclusions from this are:
- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning.
- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky.
- An extubation protocol is needed immediately.
- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.
Fluid balance
- All centres agreed that we are getting this wrong.
- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated.
- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF.
- Hypovolaemia leads to poor pulmonary perfusion and increased dead space.
- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure.
- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic.
[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]
- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance.
- Lung ‘leak’ not as prominent in this disease as classic ARDS
My conclusions from this are:
- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality.
- Avoid hypervolaemia
- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients.
- Echo patients to understand their volume status.
Renal
- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia.
- Microthrombi in kidneys probably also contributing to AKI.
- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps.
- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines.
My conclusions from this are:
- Aggressive anticoagulant strategy required for CVVHF, potentially systemic.
- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)
Workforce
- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients.
- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU.
- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job.
My conclusions from this are:
- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).
- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.
There were some brief discussion about CPAP:
- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.
- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU.
- Considerable oxygen supply issues with old school CPAP systems.
My conclusions from this are:
- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation.
- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation.
- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure.
OK, that’s all I have.
I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs.
My conclusions after each section are nothing more than suggestions to be discussed.
We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required.
Lastly, we desperately need to look at our own data to understand whether we are getting this right or not.
Good luck, stay stay safe and be kind to one another.
Dan
Daniel Martin OBE
Macintosh Professor of Anaesthesia
Intensive Care Lead for High Consequence Infectious Diseases
Royal Free Hospital
London
“Dear All,
I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases.
The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton.
Ventilation
- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness.
- Avoid spontaneous ventilation early in ICU admission as also may be harmful.
- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.
- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related.
- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation.
- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT.
- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier.
- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting.
- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days.
- Generally people are using humidified circuits with HMEs.
- A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily.
- Leak test before extubation is crucial, others are also seeing airway swelling.
- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high.
My conclusions from this are:
- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning.
- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky.
- An extubation protocol is needed immediately.
- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.
Fluid balance
- All centres agreed that we are getting this wrong.
- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated.
- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF.
- Hypovolaemia leads to poor pulmonary perfusion and increased dead space.
- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure.
- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic.
[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]
- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance.
- Lung ‘leak’ not as prominent in this disease as classic ARDS
My conclusions from this are:
- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality.
- Avoid hypervolaemia
- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients.
- Echo patients to understand their volume status.
Renal
- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia.
- Microthrombi in kidneys probably also contributing to AKI.
- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps.
- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines.
My conclusions from this are:
- Aggressive anticoagulant strategy required for CVVHF, potentially systemic.
- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)
Workforce
- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients.
- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU.
- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job.
My conclusions from this are:
- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).
- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.
There were some brief discussion about CPAP:
- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.
- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU.
- Considerable oxygen supply issues with old school CPAP systems.
My conclusions from this are:
- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation.
- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation.
- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure.
OK, that’s all I have.
I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs.
My conclusions after each section are nothing more than suggestions to be discussed.
We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required.
Lastly, we desperately need to look at our own data to understand whether we are getting this right or not.
Good luck, stay stay safe and be kind to one another.
Dan
Daniel Martin OBE
Macintosh Professor of Anaesthesia
Intensive Care Lead for High Consequence Infectious Diseases
Royal Free Hospital
London
米国で病人食としてよく知られている「チキン・スープ」が効果があった
「熱を下げたと思う」ということ
呼吸法を行っている
アメリカ料理 風邪に効くチキンスープの作り方 クックパッド
アメリカの風邪ごはん「チキンスープ」 ユーチューブ
BBCの料理サイト チキンスープが効果があるのか科学的に説明 英語
入院時及び観察全期間における臨床症状、所見、治療（酸素投与の有無）、重症度を表２に示す。無症候性陽性者の割合が高く、軽症例が41.3%、重症例は26.9%であった。入院時に有症状であった症例のうち最も多かった症状は発熱で全体の28.8%であった。全観察期間を通して最も多かった症状は咳嗽で全体の41.3%であった。酸素投与が必要となった症例は13.5%であり、そのうちの約半数がいわゆるネーザルハイフローやNPPVなどの高流量酸素投与を必要とした。気管挿管による人工呼吸管理を必要としたのは１例であった。観察期間を通して全く症状や所見を認めなかった症例は全体の31.7%で観察期間中の死亡はなかった。
