Todd C. Lee
@DrToddLee
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Clinician-scientist at McGill Fellow of the Infectious Diseases Society of America. Co-inventor of https://t.co/IlHagSloQ3 Immortal-time Lord. Legacy verified.
Montréal, Québec
Joined November 2015
@edschenck @jpogue1 @boulware_dr @ABsteward So you are NNT under 250 and I'm over 250. $530 to charity. Overall result. Needs to be statistically significant (e.g can't be NNT 250 with CI including an NNH). Trial needs to complete. Consider it done.
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Why are we not offering, with consent, the AZ vaccine to younger people in the very hot zones, particularly >=40 year old men?. Let people choose between some small risk of AE vs their benefit vs how long estimated delay for mRNA in age group.
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Urgently quadrupling your inpatient covid capacity is probably a sign that things are not moving in the correct direction.
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@VPrasadMDMPH But don't worry if you are at a restaurant enjoying a meal. Laugh and be merry, with mask off. But for god's sake, mask up to go to toilet. I'm pro public health. I'm on board for masking as a bridge to normal, but no one can pretend there are not numerous amusing contradictions.
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To whom it may concern. Please stop doing procalcitonin in nearly all patients.
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@VincentRK @zchagla From a meta analysis of all steroid RCTs. 93% chance of increase mortality if given when pt does not require oxygen.
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@US_FDA I have had 3 doses of vaccine and BA2. Please share with me the controlled, experimental, human evidence that I have benefit with further doses. I'm a 40s male, in good health, who values distance running. Thanks in advance.
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People would still get covid-19 unless they ate and drank alone.
Imagine N95s were accessible to everyone and we wore them (properly) for a minimum of two weeks at the same time 🤔.
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@theBSinBSN Have I seen patients die of encephalitis because someone with lesser diagnostic acumen called it "urosepsis" ?. Yes. Too many times.
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Oh CT contrast nephropathy. They myth that won't die? Still blocking optimal care in 2022. @PulmCrit.
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@cafreeland @DFisman We need normal Canadians to be able to buy homes for their families to live in without competing against corporations and people running short term hotels. @nrmaharaj.
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@VPrasadMDMPH I have taken my last COVID vaccine without RCT level evidence it will reduce my risk of severe disease. I would volunteer for the RCT. 3 doses + omicron recovered and otherwise healthy 40s man.
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With cases spiking, oral antivirals unaccessible, and limited access to monoclonal antibodies which work for Omicron -- fluvoxamine looks like reasonable choice to prevent hospitalization. Preprinted to make it available immediately for consideration.
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Congratulations to @remap_cap for taking on oseltamivir vs no oseltamivir in hospitalized patients with influenza. 13 years after pandemic h1n1 and billions of drug dollars later and we finally start the journey to know if it works or move on to find better drugs.
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@VPrasadMDMPH Oh, and the company "removed" vaccinated and recovered patients from the ongoing trial, with knowledge of results, and presumably with the FDAs blessing. Totally normal.
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Sadly, when we ran our fluvoxamine trial in Quebec we were denied coverage by government insurance agency and couldn't get public health to agree to give us the list of patients - instead they gave list to another centre to run a pharma sponsored phase 2 trial. @DrEmilyMcD.
Inexpensive anti-depressant could be best COVID treatment yet, Canadian-led trial finds
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Another week, another example of premature diagnostic closure for "UTI" causing a near miss for something else. If anything needs to be better taught in hospital medicine, it is UTI (or lack thereof).
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Just because a patient with methicillin sensitive S. Aureus bacteremia is sick enough to be in the ICU doesn't mean they need to be treated with pip-tazo and vanco. .
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I am all for masking and safety. But rules which state I need to wear a mask while outside tobogganing with my children feel pretty silly.
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If I see another note saying physical exam deferred due to the pandemic, I'm gonna lose my cookies.
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Teachers are really trying but wow, zoom kindergarten is kind of a gong show.
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Fell sick this week with a non covid contagious resp illness. The amount of self imposed guilt about asking a colleague to cover and the pressure from some others to just "ibuprofen and go anyways" makes we feel like there's a real pathology in medicine. We should not work sick.
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Today someone received a transfer from a nursing home. The patient was dehydrated. The reason for transfer was allegedly "sorry, we have run out of IV fluid".
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@DrCaliff_FDA @CDCgov In confounded observational studies which have major issues with immortal time bias. If I get the vaccine tomorrow - am I guaranteed not to have anything bad happen to be for 7-14 days? No. So why analyze the observational data that way?.
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@VicLeungIDdoc . Sending thoughts and prayers for good outcomes for the ream of upcoming nosocomial infections.
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Why consult if you're just gonna do what you want regardless of what the consultant says?.
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I guess. Though they hid the cure for decades so it could be advantageous for the US military and the military was later going to drop an incendiary device on a US town until the pilots disregarded orders from their commanding officer b/c of speech by Dustin Hoffman character.
Movies like Outbreak nailed it when they imagined a global disease-fighting team who is ready to respond to a crisis on a moment’s notice. Now we need to make it a reality.
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The disease took you from us long ago but having you leave forever makes it real. Thank you for being an amazing mother and forever an inspiration of how to treat other people. I'm still trying my best, mom. @robyn_s_lee
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The first @snap_trial patient in Canada has been randomized today! Several years in the making this 7000 patient RCT will redefine the care of S. Aureus bacteremia by answering many questions!. @RIMUHC1 @cusm_muhc @MatthewPCheng @syctong @Josh_S_Davis .
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Tonight, at bedtime, my five year old son told me that he didn't want me to get coronavirus and die. I didn't know what to say. Hit pretty hard and all the last weeks of pressure came right to the surface.
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Recurring theme:. Just cause a patient is very sick with S aureus bacteremia, it doesn't mean pip-tazo is the right antibiotic or any better than clox/naf/cefazolin. If anything, it's a worse choice.
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Once again, I am pleading for pillows for the patients boarded for days on stretchers in the ER.
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@ABsteward @DrEmilyMcD @BradSpellberg . Balance results will be presented Friday at ID week. 7 days NI to 14 for most uncomplicated bacteremia (powered on *mortality*).
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"the usefulness of nirmatrelvir–ritonavir in patients who are not at high risk for severe Covid-19 has not been established.". Oops. Guess that should have happened before 20+ billion dollars were spent.
Finally published .🔥EPIC-SR🔥 .The time to sustained alleviation of all signs and symptoms of Covid-19 did not differ significantly between participants who received Paxlovid nirmatrelvir–ritonavir and those who received placebo #IDXposts.
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I taught about HECK-yes today. First time. Exciting. @OncIDPharmd . Clinically relevant ampC induction potential:.Hafnea.Enterobacter cloacae.Citrobacter freundii.Klebsiella aerogenes. YErSinia enterocolitica.
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@VPrasadMDMPH Pay close attention to note this isn't anti-vax sentiment. This is "provide hsrd evidence of benefit to justify ongoing use" which is very different. It is only fair for a 30 billion dollar a year product given to hundreds of millions.
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If I have another person tell me that we can't use contrast for a clinically indicated scan where contrast is necessary to answer the question because of fear of "contrast nephropathy" I am going to explode. @PulmCrit.
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No, it is not the enterococcus in the (asymptomatic) urine causing fatigue and altered mental status. It is the s aureus in the blood. No, you don't need to cover both. #abxstewardship.
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Clinical trials that may change your practice about to begin. Going to live tweet sitting beside @Cortes_Penfield. (Can that be on the ID WEEK bingo). @IDWeek2022
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Perhaps explains why I've seen very immunocompromised patients who are doing fine until about 7-10 days post infusion and then decompensate.
Data show persistence of viable SARS-CoV-2 in patients after sotrovimab infusions and the rapid development of spike gene mutations associated with sotrovimab resistance. These findings underscore the importance of stewardship of monoclonal antibodies.
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@POTUS That 90% number was epic-hr trial (unvaccinated pts only) covid hospitalization rate. The all cause hospitalization decrease in the trial was 76%. The Epic-SR trial in vaccinated pts (like you) was unable to demonstrate a significant decrease & has not yet been published.
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@venkmurthy @VPrasadMDMPH We had a curfew at 8pm. Eventually pushed to later. For months. Not allowed outside. Initially couldn't even walk your dog outside in winter. Health care workers were issued a letter to show the police if we were pulled over going to the hospital after hours so wouldn't be fined.
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I kind of like Singapore's plan. Thoughts?. Any data on how this is performing in real life?
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Serotonin syndrome interaction risks from linezolid are way way way over called.
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Monoclonal whack-a-mole continues. "BA.2 also exhibited marked resistance to 17 of 19 neutralizing monoclonal antibodies tested, including S309 (sotrovimab)".
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@VPrasadMDMPH @US_FDA I can understand the White House promoting vaccination and the centers for disease control promoting vaccination but I don't understand why the regulator would promote products. Regulators role is to be more neutral, not a cheerleader.
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Speaking of S. aureus! @snap_trial passed 3500!. Writing papers:.cefazolin (MSSA) and penicillin (PSSA) vs (flu)clox . Recruiting:.Adj clinda vs not (all).Adj cefazolin vs not (MRSA).Oral switch vs IV (all).cefazolin +/- Erta/Placebo (MSSA).Dapto vs Vanco (MRSA, starts tomorrow!)
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You can hold me to this:. If I ever press release pre-print clinical trial results they will come with the absolute numbers, a confidence interval, and, if applicable, a draft kaplan meier curve.
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@VPrasadMDMPH Why spend 100 million on a trial when you can spend 10 billion on hopes and dreams.
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4 areas where HCQ might work:.Pre-exposure --> RCTs ongoing.Post-Exposure --> Negative RCT Early Community Treatment --> RCTs ongoing.Hospitalized Patients --> Negative RCT #idtwitter @DrEmilyMcD @GermHunterMD @boulware_dr.
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@VPrasadMDMPH Masks in restaurants when walking to the table or bathroom, but off during whole meal. My son wears a mask while standing in the class but not if seated at his table. Lest I be drummed out of the infectious diseases union, it isn't anti-public health to be anti pandemic theatre.
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@MaryFernando_ @CBC @BogochIsaac @joeolivermd COVID is endemic. You have a better chance of stopping the sun coming up than putting the genie back in the bottle. Humankind will have dozens of infections in their life. Like they do with rhinovirus and other coronaviridae.
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Thinking of prescribing fluvoxamine for covid 19? Ontario has a nice infographic.
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@MKIttlesonMD It sounds like the electronic fence for dogs. Except that gives a small electric shock if they ignore the noise and keep going. Probably not the kind of pavlovian conditioning we want to establish in our youth.
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@DGlaucomflecken The cosmetic plastic surgeons. You see, they need to have a nice looking face so they'll be afraid of being hit in the face and they also need to not break their hands, or they can't operate. Both in favor for the cognitive specialties who can keep working ugly and handless.
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No @cdube_sante this is not why the emergency rooms are full. Unless vaccination prevents cancer, dementia, sepsis from gram negative bacteria, falls. The problem is too little inpatient and post hospital capacity causes by decades of underplanning.
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Nevermind that the trial in vaccinated people was stopped for futility and didn't demonstrate benefit. And that was pre omicron, pre boosters, and excluded people previously recovered. Wasn't financially viable at $530. Laughable at $2500.
The price of Covid-19 antiviral drug Paxlovid is expected to rise by as much as 5x, to $2500/course, as US transitions to a commercial market. While it will still be free through an access program for govt-insured and uninsured, others will have a copay:
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This is a good example of why you do RCTs and don't just randomly give experimental drugs because theory says they work. Need to digest more in detail but congratulations to them for doing this. @NEJM
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In lieu of preprint in case target journal does not allow. A discussion of fidaxomicin as first line for CDAD. Devangi Patel, Julien Senécal, Brent Footer.@ABsteward @ASPphysician @DrEmilyMcD @AntibioticDoc @BradSpellberg.
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When did daily CRP become people's jam? @BradSpellberg . Patient better, crp a bit higher. Stop needless testing, friends.
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Trainee pro tip: never make up a result. I don't know.I didn't check.I don't remember.I didn't think to ask. Are all 1000x better than talking around the issue or fudging an answer.
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Years ago a mentor told me to get a box and put anything nice anyone (patients, learners, colleagues, bosses) sent to me about my work and put it in there. I did the same for email. If you question what you're doing. Go back to the box. Has been great advice!. @DrEmilyMcD.
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Can the authors of the nejm ace/arb corona paper and the lancet hcq paper to release the names of the Canadian hospitals they claim contributed to the dataset so that they can be independently verified? @TheLancet @NEJM.
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Is there any other anti infective drug as versatile as tmp-smx?. Treats:. bacteria gram positive and negative .Fungi (e.g. PCP).Parasites (e.g. toxo).
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@VPrasadMDMPH So, what's their exit strategy exactly? Or is the plan to mask for the rest of human existence?.
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Lots of excitement re #BLING3 RCT published today (and the accompanying meta-analysis). Amazing trial. ~7000 patients. Mortality outcome. Unbelievably hard to do. Papers:. RCT:. Meta-analysis:.
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What happens when a high impact journal published something which was subject to a high profile retraction? . Still cited months later -- and data is even used in secondary analyses. Need a systems approach to dealing with retracted work. @DrEmilyMcD.
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Could we please give our covid patients (who mostly cannot leave their rooms) free television? It must be tremendously boring and this might help @cusm_muhc @MUHCFoundation @Aaron_Derfel.
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Putting together a covid-free top papers in ID / year in review . 2021 Jan to 2022 May. Can I also crowd source some favs?. @ABsteward.
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@LapointeShaw It is quite something he curfewed effective tomorrow at 5pm and didn't push for the 1st. I think it's a more serious signal to have done that.
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Challenges and controversies in S. Aureus bacteremia. @IDWeek2022 . (When you're running trials, you need to know your enemy in terms of all the off trial things people will want to do).
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4 infectious mimics of non-responsive ulcerative colitis to consider (amongst others!). Strongyloides .Cmv colitis .Listeria.Histoplasmosis . Here someone reports 2 in the same patient!.
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@RimmerDax @VPrasadMDMPH @ryangerritsen Ontario has mandatory physician reporting for medical conditions which impact on safety to drive. By law. And the doctor gets paid for reporting to compensate for the time spent doing the form. Unthinkable idea to suggest reporting unvaccinated people to ministry of transport.
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Ivermectin pre-print is gone too. The circle is now complete.
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@DrCaliff_FDA @CDCgov This is a very legitimate question. And those at the FDA and CDC should have a fair understanding of immortal time bias in observational studies, shouldn't they?.
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Fascinating that it looks like the ATCC-1 Day 28 mortality results everyone has been pining for were dropped without press release, preprint, or publication. Just quietly put onto clinicaltrials dot gov on September 25th (a Friday). Credit to @FateAugmented for finding it.
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Ah. I am now blocked. Oh well. With that purported effect size and event rate you'd only need 2000 people to do it. Not a lot to ask of a 20 billion drug. (And epic-hr and epic-sr combine for over 2000, so had we wanted to know from those trials, we could have).
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I don't understand disagreement with changing from pip tazo to penicillin for severe group A strep bacteremia. You don't need the gram negative coverage . There's no evidence piperacillin is as good as penicillin for the causative organism. You're only risking harm.
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Colcorona preprint . @ABsteward @ASPphysician @DrEmilyMcD @MatthewPCheng @srinmurthy99 @GermHunterMD.
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@BogochIsaac Before embarking on a tens of billions of dollars annual booster vaccine plan we should have studies powered on hard clinical outcomes and not serologic endpoints. With adequate size for safety.
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@VPrasadMDMPH I have been begging Canadian authorities to deploy this drug as part of a controlled trial in vaccinated people -- to learn how it best works -- before it becomes the de facto go to for millions with little chance for study. Prepare for tamiflu 2.0 (but at $530usd instead of $21).
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@EricTopol @hmkyale @TheLancet Many people haven't had covid and months later feel a lot of fatigue, anxiety and depression. I'm not minimizing covid symptoms but this last year hasn't been good for a lot of people so it's tough to tease out what's due to covid infection and what's due to the covid era.
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@jeffgilchrist @Susanbartlett12 Still doesn't feel the same at all on the ground. Not at all. I can count on one hand the number of people with covid who needed oxygen I've seen since Feb/march. Will be back in ER at beginning of September and can recalibrate my opinion. But omicron + vaccines= huge difference.
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Just said no to doing yet another unpaid training module that I'd have to do on my evenings and weekends because my actual job is busy enough. Felt liberating!. Let's see what happens to me. Academic physicians of the world, unite!.
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