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  • welcome to another MedCram COVID-19 update we'll do some updates and also

  • talk about preparation from a prevention standpoint here we have our Johns

  • Hopkins dashboard at ninety four thousand total confirmed cases total

  • deaths thirty two hundred total recovered fifty one thousand South Korea

  • has the most confirmed outside of China and we're talking about aggressive

  • testing in South Korea Iran quickly shot up we can see here that's a pretty large

  • red dot we go to the world ometer website active cases are actually on the

  • decline probably because we are leaving a epidemic in China but there are small

  • epidemics relatively outside of China that are rapidly growing and that's why

  • this is not continuing to go down if we look at total cases we can see that the

  • inflection point has started to turn upwards let's look at the latest updates

  • a number of countries are reporting single digits cases and in some cases

  • some deaths interestingly here there's 586 new cases in Iran but they're also

  • starting the show recoveries as well we knew there would be recoveries but we're

  • just not seeing a lot at this point we see that there are 10 new cases in

  • Belgium nine of which came from northern Italy and that seems to be a hotspot of

  • spread throughout Europe remember that in Europe there are free borders because

  • of the European Union so it's not as if this is unregulated constrain travel at

  • least as of a couple of weeks ago four new cases in the United States all of

  • them being in California which is a hot spot there's one in Los Angeles County

  • two who had recently traveled to countries that have had cava 19 and

  • there's one new case in Contra Costa County in Northern California that

  • second case of corona virus in Los Angeles was reported by Fox 11 News that

  • patient is being taken care of at home in self isolation and being treated on

  • an outpatient basis the purpose of May cram and what we're doing here is to

  • talk about the data the raw numbers to talk about the medical aspects of this

  • virus and what we know is going but of course there are things that are

  • out there that are emerging that seemed to have evidence but don't quite fit

  • with coronavirus at this point because we don't have the data at this point

  • let's face it we have no randomized controlled trials for coronavirus Cove

  • at 19 they just haven't been performed so we're forced to look at things that

  • may work vitamin D is one of those things we don't have any randomized

  • control trials that show that supplement with vitamin D works in kovat 19 but we

  • do have data about vitamin D specifically and so I think it's

  • interesting to go over I've gotten a lot of comments from people about vitamin D

  • and the potential use for the corona virus and even though this paper here is

  • for the influenza virus vitamin D is not actually having an effect on the virus

  • itself as far as we know it's affecting the hosts us our bodies our immune

  • system and how they deal with the virus so potentially might be something that

  • is applicable to other viruses and in this case the corona virus and if you've

  • thought about this you'll notice that there's a lot of talk about what will

  • happen in the summertime to the virus and a lot of the talk has been about

  • heat and humidity versus dryness and I'm wondering if there's another angle on

  • this because vitamin D could be acknowledged as a quote seasonal

  • stimulus as defined by our Edgar Hope Simpson it would be crucial to prove it

  • from a potential easy and cheap prophylaxis or therapy support

  • perspective as far as influenza infections are concerned now this paper

  • talks about how first of all vitamin D is absorbed into the body and how it is

  • metabolized the fact that it is a vitamin you have to understand that we

  • cannot generate or make vitamin D in our own body but in fact we need ultraviolet

  • radiation from the Sun to convert the inactive form to the active form I've

  • always had a special place in my heart for vitamin D because that's what I did

  • in terms of my undergraduate research working in organic chemistry and so

  • you'll know that vitamin D for those of you studied the structure is a lipid

  • soluble vitamin and so it's possible to overdose on vitamin D so you have to be

  • very careful with it because it is fat soluble now there's a lot of talk about

  • vitamin D in the immune system and how it bolsters it but something that's also

  • very in interesting about vitamin D is its

  • possible role in infections and also it has a suppressive anti-inflammatory

  • process so in other words vitamin D can turn things on and it can also turn

  • things off it's not unimodal and that is something that could be very helpful

  • especially in the immune response that we see in kovat 19 remember that it's

  • the immune system that is going to suppress the virus which is good but

  • it's also the immune system that could cause this storm of cytokines that put

  • your lungs into a RDS and could potentially kill so what we want is a

  • smart immune system an immune system that takes care of the virus but doesn't

  • put us into an inflammatory condition that could put us on a ventilator

  • so is vitamin D the answer I have no financial relationships with any

  • pharmaceutical companies or companies that make nutritional supplements in any

  • way this study that was talked about here in the Harvard Gazette may be what

  • we are looking for here it says a new global collaborative study has confirmed

  • that vitamin D supplementation can help protect against acute respiratory

  • infections the study our participant data meta analysis so a meta analysis is

  • simply a study that looks at a whole bunch of other studies breaks down the

  • components and makes a super study out of it so they took actually 25

  • randomized controlled trials with an N number of 11,000 participants that's a

  • pretty sizable number this was published in the British Medical Journal I will

  • give you a link to that journal will actually look through that most people

  • understand that vitamin D is critical for bone and muscle health Cisco's

  • Camargo of the Department of Emergency Medicine at Mass General our analysis

  • has also found that it helps the body fight acute respiratory infection which

  • is responsible for millions of deaths globally each year

  • remember this article was published before coronavirus several observational

  • studies with track participants over time without assessing the specific

  • treatment have associated low vitamin D levels with greater susceptibility to

  • acute respiratory infections I don't have to tell you that living in high

  • latitudes especially in the wintertime exposes you to the least amount of

  • sunlight if you have the least amount of sunlight you would conclude a

  • corporately that your vitamin D levels are generally going to be on the lower

  • side while it's possible that the seasonal variation in the virus may

  • still have something to do with the survival of the virus outside the body

  • but it may have more than we think to do with the survival of the virus inside

  • the body it is a postulate but it's interesting the meta-analysis of these

  • trials which aggregate data from several studies that may have different designs

  • or participant qualifications also had conflicting results and this really has

  • been the issue for some period of time some studies showed that there is a

  • connection that makes vitamin D look good in terms of preventing infections

  • others not so good so to resolve these discrepancies this research team out of

  • Queen Mary University of London conducted an individual participant data

  • meta-analysis so what does that mean they grouped all of these studies

  • together and then they stripped it down to each particular individual and that

  • is very powerful producing what could be considered a higher resolution analysis

  • of the data from all the studies the investigators found that daily or weekly

  • supplementation had the greatest benefit for individuals number one there was a

  • benefit and number two it was the turtle not the hare what I mean by that is it

  • was the daily supplementation not the huge doses of vitamin D if you got sick

  • this makes sense the people who have the lowest levels are going to have the best

  • effect from supplementation and it cut their risk of respiratory infection get

  • this in half that is a significant number and could reduce the Arnott or

  • the replication number in viruses and maybe the reason why we see these

  • viruses disappear in the summer I say May don't have proof of that yet but

  • it's interesting all participants experience some beneficial effects from

  • regular vitamin D supplementation administering a high doses of vitamin C

  • did not produce significant benefits this study was not funded by some

  • nutraceutical company but was funded in fact by the British National Institute

  • of Health Research so let's actually go to that study it's open access we'll put

  • the link in the description below this is from the British Medical Journal

  • that's a very prestigious publication in the conclusion vitamin

  • supplementation was safe and it protected against acute respiratory

  • tract infection overall patients who were very vitamin D deficient and those

  • not receiving bolus doses experienced the most benefit so if you go down to

  • the raw data they have to come up with cutoff points and for those of you who

  • don't know how to read studies let me show you here a little bit what they're

  • looking at is how many respiratory tract infections they receive so one step'

  • individual participant data men analysis proportion of partisans experiencing at

  • least one acute respiratory tract infection first thing to do is to look

  • at the very top one and that's overall how many trials twenty-five proportion

  • with greater than one acute respiratory tract infection and proportion with

  • greater than one acute respiratory tract infection in the intervention group and

  • you can see that there was a difference and what was that difference the

  • adjusted odds ratio is where you want to look

  • there's another way of looking at to looking at p-values to see if there's a

  • difference between these two groups those in the control group those in the

  • intervention group and any p-value of less than point zero five is considered

  • to be statistically significant so you can see here that a bolus dose of

  • greater than thirty thousand international units given had a p-value

  • of 0.67 that's greater than point zero five therefore not statistically

  • significant in other words a bolus dose is not going to be helpful if the bolus

  • dose wasn't given you can see that was very statistically significant so the

  • question is how much should I take on a daily dose well here it is daily dose

  • equivalent if it was less than twenty micrograms highly statistically

  • significant if it was 2250 still statistically significant however if you

  • took more than 50 micrograms there was no difference between that group

  • indicating that a modest dose of vitamin D every single day would be the best

  • here's more research in the study showing all of the different individual

  • studies and the proportion with greater than one acute respiratory tract

  • infection and you can see here where they lined up relative to number one

  • remember one being no difference if it was less than number one with a 95%

  • confidence interval less than one then you could say that that was

  • statistically significant and it was weighted based on the number of patients

  • in that study and finally we come to the overall which is down here at the bottom

  • p-value a point zero zero one you can see that it lands less than one so if

  • you scroll down to the discussion it says vitamin D supplementation reduce

  • the risk of experiencing at least one acute respiratory tract infection and it

  • talks about the grade of the data which was very good the question though is why

  • would a bolus dose of vitamin D be ineffective and they talked about how

  • the wide fluctuations of circulating 25 hydroxy vitamin D concentrations which

  • is the starting material for the active form in the body could this right

  • activity of enzymes responsible for the synthesis and degradation of the active

  • vitamin D metabolite which is 125 dihydroxy vitamin d so my recommendation