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208: 4 Doctors, a Virus, and a Battered Economy: Part 1

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Buck: Welcome back to the show everyone. Today on Wealth Formula Podcast this is a very interesting, different sort of format we got here and you know I think you’ll find this useful. I have with me today, I have three of our listeners who also happen to be members of Wealth Formula Network and they’re also active members in Investor Club and they’re physicians all of them. And so we’ve got Ian Kurth who’s been on before is a neuroradiologist in Wisconsin. And we have Paresh Mehta who’s a GI gastroenterologist doctor in San Antonio. And then John Foley who’s a neurologist and who has a lot of experience actually in immunology and things like that too and he’s based in Utah. Guys first of all I want to thank you for joining us. I wanted to start out real quick and just for a little perspective this is kind of for each one of you maybe just getting to know kind of like you know what’s your specialty we already talked about that but maybe kind of like you know what’s going on with your work right now, how you’re handling it, and then you know also you know talk about what you do outside of medicine in terms of you know your investments and stuff like that you know just a high-level perspective so people know who’s actually talking. Why don’t we start with you John?

John: Sure so buck I’m a practicing neurologist specializing in clinical neurology which primarily involves taking care of patients with multiple sclerosis and related disorders. I’ve had a significant interest particularly in the coronavirus pandemic due to the fact we have a lot of immunocompromised patients primarily because of the medications that we’re using in multiple sclerosis so I’ve been following it pretty closely. Our practice right now is following the guidelines of the state of Utah so we are primarily doing telemedicine for follow-up patients we still do some infusions and emergent cases where we’ll see the patients directly. As far as investments go, I’m not real big on the general stock market. I have a lot of investments in real estate and some backup investments in precious metals in case the world falls apart which it’s proceeding to do.

Buck: I thought I saw some zombies in the backyard. They came for me first because I was the one making jokes about them. How about you Paresh?

Paresh: Yeah thanks Buck. My name is Paresh Mehta. I’m a practicing gastroenterologist down in San Antonio Texas. There’s about 25 of us in the group. What does a gastroenterologist do? Well we deal with all type of things such as acid reflux, ulcers, Crohn’s disease, colon cancer prevention and lots of other things in between. We also recently joined one of the largest groups in the country with about total of 350 GI Docs that’s sort of allowed us to grow and take into account some of the changes in medicine in regards to payers and other hospital systems Mar group currently you know we’re made up of surgical centers and outpatient office visits just like you saw in other states so most of our visits now have been sort of pushed to telehealth which is a video platform to kind of chat like this online in order to diagnose and get things done for patients. Our surgical centers have been closed over the last four weeks which means all of the procedures such as the endoscopies which are cameras going down and colonoscopies have been shut down but just recently the governor of Texas is gonna allow us to open back up so we’re slowly trying to figure out how to do that.

Buck: Got it. You’re also a guy who’s you know certainly got exposure to you know multiple real estate offerings and I know you do a lot of other things. Ian ,you’ve been on before but if you want to give us a brief reintroduction that’d be great.

Ian: Thank you so yeah I gave my earlier introduction but basically I’m a married father for I did my academic training at a variety of institutions including undergrad at the University of Michigan Medical School Michigan State and I did a diagnostic radiology residency and neuroradiology fellowship at Duke. For the past 13 years I’ve been in private practice with the same group here in northern Wisconsin and recently because of the current circumstances I’ve dusted off my old clinical reference books and have been forcing myself to explore some more clinical topics in an effort to remain informed in an effort to yeah be a resource to family and friends and community and so forth this so anything I say during this should be you know listened to through the lens of a radiologist.

Buck: Listen and Ian if you go by the way if you go back to the shows previously you get the whole story any it’s really interesting in many ways I’ve called him the Wealth Formula poster child because he’s you know quintessential high paid professional who’s really created you know this very elaborate investing I guess you would call an investing business right I mean he is looking at deals all the time and investing and deploying capital and thinking about this stuff so I would encourage you to listen that as well. Guys obviously you know the last I’ll just remind everybody that I that I actually am a physician although I haven’t practiced now for about four years so this is four physicians who are going to talk about the current situation and the reason I wanted to do this is because frankly there’s so much BS out there. There’s a lot of misinformation about this virus you know we call Covid-19 there’s a lot of information on potential therapies vaccines unfortunately we live in a world where there are often more than one set of facts which makes it really really difficult for people to understand what the truth or what you know what’s not true so John let’s start with you right now what is going on with the Covid-19 pandemic and maybe you can kind of give us a little bit of an idea from you know what you’re seeing in terms of you know the curves and also you know true advances or non advances in therapy.

John: Well let me take just a few minutes I’m going to try and stay on the light side for a numeric data and such but there’s a few things that we have to do to just sort of level set the discussion I think one is what is the virus that we’re dealing with so this has an official name of SARS Covid-2 it has about 80% of the call homology or similarity to the original SARS virus which had a much higher mortality rate, probably around 10% we call that classic SARS and this family of viruses that coronaviruses for the most part we know them through the common cold there’s probably at least four strains of Coronavirus that produce the common cold. They’re large envelope single-stranded RNA viruses. This thing is extremely contagious we use a scale for infectivity and if you take a virus like measles which is probably has about 11 or 12 which means that for one person infected maybe 11 or 12 people will actually come down with the virus from that one contact this might be as high as six I mean official estimates have put it around three but that’s primarily using the number of known cases. And so a known case is a case that has been shown to be positive by a technique called polymerase chain reaction in this case reverse transcriptase polymerase chain reaction. So if you look at those numbers worldwide were about 2.6 million with a mortality of about a hundred and eighty three thousand and a case fatality rate of about seven percent. Now the problem with that case fatality rate is again it’s only measuring those people that actually tested positive by this basic test the PCR which amplifies little pieces of the virus. It’s looking more and more like there’s a very large percentage of the population who actually have been exposed to the virus, their innate immune system has handled it at the level of the nasopharynx and they produced antibodies and long term antibodies are called IgG and that rate is really unknown but probably is at least ten times the number of diagnosed cases which would put our fatality rates that’s called the infection fatality rate that would drop that dramatically probably under 1%. To give you an example flu mortalities are generally around point one percent so as far as where we’re at on the curve it looks like the US is coming close to peaking but the US a very large country’s got a lot of variability there are a number of states that really aren’t anywhere near peaking for instance in Utah we might not peak until July even June or July. So the virus it’s very interesting as well and I’m sure we’ll get to talking a little bit more about country variability and lock down and how tight the lock down is to change the numbers but anyway that’s a little basic overview before we get into the specifics.

Buck: Yeah you know and one of the things you pointed out I think are really important to just sort of people to know. This is different in that from the first SARS virus people might remember the first SARS virus and it was somebody else as a problem right it was in China it was never something that you know we saw in this country and the reason for that was that the first SARS virus was so damn deadly right and it also wasn’t something that you had so many asymptomatic carriers with. So the paradox of this virus is that it’s it’s you know not like it has a brain but it’s smarter it’s a smarter virus it doesn’t kill as much it infects a lot more and it kills you know it kills less but the pure volume of people who are getting infected it was what’s creating the you know then that the numbers game that’s resulting in all these deaths so that’s what’s making it so challenging. Paresh and Ian, either one of you have anything to add to that?

Paresh: Yeah I’ll just jump in and say if we come out of the medical knowledge and just thinking about the listeners of Wealth Formula, you know my thoughts are the current status is evolving and still progressing I mean if you really look at what we know today the evidence suggests that you know some areas appear to be peaking but around the you we’re still seeing increasing in areas really the ones that may have been a little bit less stringent with the social distancing you know one of the key issues we have and I’m sure we’ll get into this later is what’s been effective in other areas has been able to test and also then quarantine in social distance since we haven’t had that ability here in the US that’s why we’ve forced to the whole everybody socially distance and get away from each other and you can see some of the issues that’s causing so yeah my thoughts are right now it’s still evolving and we’re learning a lot more about exactly where it’s gonna land and then I think some new information is coming out also on what its gonna look like later this year when the flu Peaks again.

Ian: Yeah I’ll jump on that and just say that you know I will put this out there and say I humbly recognize we humbly recognize that today is April 23rd 2020 and anything that we say today in regard to the current knowledge of science and the situation could be proven ridiculously false the future and we’re all sort of navigating this in the best way that we can with the best data that we have access to and trying to convey that data to the population frankly we’re trying to translate that data and then and that’s what one of the challenges I found myself faced with recently is to do what we do every day a practicing physicians it’s to be a translator for people so take complex topics and themes and convey them and stories are now just to make them you know relatable and understandable and frankly actionable so kind of further upon that and one of the bIgGest themes that I find myself sort of trying to convey to people is that you know in my opinion that we’re not going back to how it was anytime soon. They people people yearn for that and they really just want to have it how it wasn’t in February when nobody knew about this but it that’s just not a reality and you know I’ve heard this description that what people want it to be as a corona blizzard it’s this big you know bad thing everybody goes into their homes let’s to pass and then we come all come out of hiding and it’s sunny and and and we can go about our day but that’s actually probably the wrong approach and and it should be you know basically we’re all you know likelihood facing kind of a corona winter, it’s gonna be a long protracted process where we’re just gonna you know attempt to buy yourself time with this isolation and then allow the scientific method to you know get us ahead on various therapies and knowledge about the about the virus and potentially a vaccine soon.

Buck: Yeah I saw a study recently I think it was yesterday I saw a study about about how many people if all of the quarantine stuff was taken off today how many people would actually go on a plane you know and how many people would actually feel comfortable going to like a football game and the numbers were staggering right it was like 80% in every category from these major things were No and so we’ll get into this later but there’s a in enormous economic consequence to this that that we haven’t even gotten close to yet. John I want to go with go to you again because I know you’ve been following some of the studies we’ve been talking about that talking about them a little bit on even in Wealth Formula Network. You know until a month ago hydrochloric win or or chloroquine or Plaquenil all these are the sort of the same drug in one way or another they’re they’re they’re old malarial drugs and and they were kind of you know they’ve been around for 50 years maybe Plaquenil is used to treat lupus now and you know it actually showed some benefits in some studies particularly out of France for Covid-19 in terms of at least decreasing death maybe decree you know decreasing the amount of time to clear the virus etc. And then I think based on that I think that became a trump mantra you know to hit Plaquenil and you know the A-pak the Azithromycin etc but then we’ve had mixed studies, we’ve had really confusing stuff out there in some studies actually showing increases in mortality and patients that were given a Plaquenil. John can you give us you know specifically and more generally about what’s what do we really know about the Hydroxychloroquine and in Z-pak without the political sauce on it and also you know if there any other drugs that really are showing some promise.

John: Sure so this really is a way Buck that just amazing how science can get interpreted in ways that really can be extremely detrimental I think to understand hydroxychloroquine you have to understand a couple of other things one is its relationship to zinc and what zinc does and also where in the disease process you really place the drug name. So hydroxychloroquine so let’s just talk about the progression of the disease in my mind it kind of boils down into three stages. In the first week generally you become symptomatic get right around the five to six date can be out to 14 days after exposure especially in older people seems to take longer for the virus to build up but essentially and pre-symptomatic people can be infectious for probably at least a couple of days which further complicates, we’ll be talking later about social distancing and looking actually at contact tracing and such but essentially you have a first week in which viral replication is going crazy, your body’s throwing a little bit of nonspecific IGM antibodies added in that first week but it doesn’t really work that well by day 10 you pretty much have started to build IgG antibodies to epitopes or locations inside the virus that can be attached by antibody. So that viral increase in load really is occurring in that first week week-and-a-half once you move into the second week you either stabilize the IgG works reasonably well your viral loads start to decline and you you can still be very sick for a number of days but but you don’t start entering the respiratory distress stages where you drop your saturations and you start to where you’re taking a lot of breaths that’s the stage where you need to be probably in the hospital watched very carefully because you can go move to AR D s and and respiratory support very very quickly within less than a day and then there’s that third stage which is really characterized by cytokine storm which is a bunch of proteins in your body especially one protein interleukin 6 which kind of goes crazy and reacts dramatically to the virus being in your lower lungs. So I really feel that hydroxychloroquine doesn’t do much in those later stage hydroxychloroquine is really you want to use day one through five day one through seven maybe and most of the studies have concentrated on hospitalized patients so hydroxychloroquine is less toxic than chloroquine what it seems to do is it increases the pH and so it interferes with things like viral fusion to the cell and the membranes. Most antivirals work best given very early and the other thing that hydroxychloroquine does is it helps transport it’s called an ionafore it helps transport zinc from the circulation into the cell and zinc really has a toxic effect on viruses. Most of the studies to date have been pretty late have not necessarily included zinc or zinc levels we know that people most at risk for this disease are the elderly and diabetics and obese, they tend to be zinc deficient. There have been a few small studies and there have been a number of just empiric sort of announcements of what clinical practice has yielded. The French study you alluded to Buck showed showed significant reduction in progression to the more severe stages there was an early actually this was a had a control group the Chen study 31 patients in each group and they found that fever cough and pneumonia improved an 81 percent of the of the treated group and these people were treated with 200 milligrams bi di hydroxy chloroquine for five days no zinc added not much in the way of Studies on as if through Meissen many people are using hydroxychloroquine in addition do as if for Meissen right now because of the potential risk of adding multiple QT prolong the heart interval that’s been discussed quite a bit I’m not sure I would use azythro in combination but I sure would use hydroxychloroquine and zinc early on.

Buck: So just to interrupt you I mean you know well I mean for the non physicians basically I think what John is is getting at is that there’s studies out there and they’re conflicting and they’re confusing and part of it simply could be that we you know we tend to look at a drugs in a in a vacuum right this works this doesn’t work but what John is saying is hey this disease has different phases to it you know and you have one phase at sort of the beginning and then the middle and then the end and the studies that if I’m if I’m hearing you’re right John the the studies that are they’re all anecdotal they’re not double you know the the the gold standard type of testing that we want to do but the studies out of France that we’re showing some promise they were showing that you know if you used it early on in disease I mean this things seem to you know really potentially have some benefit and the stuff were you saw mortality in other words people dying more because of it actually may have been because in people who were already in a later stage of disease is that is that what you’re saying.

John: Yeah there was one study that just came out that really got in the news and was just extremely irritating this is the VA study with 368 vets retrospectively and basically they there was a selection bias where they gave hydroxychloroquine at these patients who were on ventilators in the process of dying and then they came up and said that yeah more people on hydroxychloroquine died and that got in the mainstream news and was amplified without giving the details about the fact that they gave hydroxychloroquine to people that were worse so you know there’s there’s this kind of thing and it was at a very late stage it was basically in that what I would call phase 3 of disease progression and you wouldn’t expect hydroxychloroquine to work. The thing that kills you is primarily sort of a coagulation prop problem in conjunction with an ARDS.

Buck: So it’s your own immune system that gives them amounts of big reaction and it’s ultimately what kills you and in what you’re trying to do is prevent that stage. So Paresh and Ian jump in here any additional thoughts on what John is talking about or maybe just some specific thoughts that your own feeling about you know hydroxychloroquine at this point you know what yeah what I got to tell you one thing what I hate seeing is seeing this thing getting politicized, I would say that you know Trump probably shouldn’t be you know acting like the you know the public health director of the United States he really shouldn’t be doing that but on the other hand the problem is that there’s so much partisan stuff about this that there’s a real potential that you know this drug actually could be a benefit to people and instead of looking at it objectively has become a partisan issue which is just insane so what do you think Paresh, Ian?

Paresh: I’ll jump in and say you know John summarized that very nicely and I couldn’t agree with you more I think there is there’s definitely seems to be some potential benefit in the early stages of using hydroxychloroquine or some derivative of that you know a good analogy is in the real estate world as we all know and with alternative assets says put a team together let’s figure it out and put the best people on the team if you look at what came out of the NIH I think the last 24 hours is they did exactly that and said hey is there a benefit between hydroxychloroquine and azithromycin and people who have Covid-19 infection that included 50 to 50 different individuals including doctors pharmacists, CDC, FDA and basically they just came out and said at the end of it based on what they know today at least that they would not recommend doing that they actually say that you know the quote is they would not recommend using this with co19 patients and so the more definitive clinical trials are needed to really get the optimal outcome. So I think that says enough now. Is that enough to say that this will never be used or that we may not use it eventually maybe for early stages no but I do think it’s helpful to have that full team of experts together and give us those results.

Buck: How about you Ian?

Ian: Yeah no I appreciate those comments and these two colleagues here joining me are way more involved in the nuances of this then then I am in and I appreciate the context that they offer I mean my approach to this tends to be sort of higher level. I’m certainly not a biologist epidemiologist I know enough to be dangerous and I know that sort of the processes that need to occur for drugs to get the market for therapies to be effective for the standards that we need to abide by to keep our population safe and to treat them and in my opinion you know repurposing existing therapies is probably the fastest way to sort of manipulate the curve right now and to by ourself time to get additional information about how this is evolving and to buy ourselves time to yeah you know redirect and repurpose manufacturing to get you know personal protective gear to our front liners and so forth so I know that there’s other therapies that are looking to be repurposed I mean a lot of it talk about antibody therapy which seems to be promising but that’s also challenged by time and resource intensive processes and you know there’s a number of different drugs that are sort of being analyzed by artificial intelligence to further you know for the prospects of them being fruitful but ultimately it’s gonna take some time right it’s gonna take some time for these to evolve and I place my trust in the institutions that are that are performing that kind of research and I know and I also like to tell people this that there’s been really no point in recent history where the entire world’s scientific community is pulling the sled in the same direction like there’s some smart people working on this everybody is kind of working on this and ultimately we’re gonna we’re gonna figure something out that’s just gonna take some time.

John: Can I just make a quick comment just you know one thing that is a little frustrating is for experts and you know I’m not a virologist or an epidemiologist either but to say there’s no data that anything really makes a difference and that we need to wait for phase 3 clinical trials well those will occur they’ll be available probably in six months but it also is I mean those people in New York are in the trenches there’s at one point thousands of people dying every day and it is the art of medicine and I guess and I’d like to get an opinion from all my colleagues on the show whether they would use hydroxychloroquine if they developed a fever to 101 shortness of breath and cough.

Buck: I think they would do that that’s a great question 

John: I think we have to get that question answer but one thing is you know there is a point where you look and you just say okay clinically what’s the risk benefit ratio of intervening we give hydroxychloroquine to thousands of people who going on trips as an anti-malarial yep and and to me the risk benefit equation of doing this is well within the bounds that I would be comfortable with.

Buck: I would just I would just echo something there and I think that what from what I’ve seen from the literature and I haven’t dove as deep as John but I’ve been trying to to read the more significant studies but for me anecdotally and again this is not medical advice at all and just because you know when I think about you know the stays that most reflects somebody who’s in early disease and who you know doesn’t have an underlying heart problem which you know I don’t think I do. If I had a strong suspicion of you know that I that I was infected I would probably opt to to take the Plaquenil when and again it’s because I don’t think the data is clear but I think that you know the French studies out there are they’re not perfect but there there’s some there’s better than you know a little bit of evidence there I think so I would do it. Paresh, I’m guessing you’re a no on that.

Paresh: No it’s not a zero sum game at all. If the evidence was there and suggested that I had exposure or it seemed like it was higher than higher than average chance that I contracted the Covid-19 infection definitely would be on my list I’m definitely not a hard no. We run into this issue all the time in medicine and this is just one that happens to get international spotlight rightfully so is what do you do boots on the ground and what do you do with what a clinical trial says and it’s a very difficult decision.

Buck: How about you Ian would you do it?

Ian: I think it’s situational dependent yeah I mean I know I don’t have a strong opinion yet I probably I would probably lean towards considering it based on what we see and based on and this is just coming from where I am health-wise you know I don’t have an own heart problem I’m fairly healthy and I would like to you know be in the cohort that survives us and that seems to be a low-risk way to maybe add an incremental benefit.

John: There is one little other data point Buck. Costa Rica has six hundred and eighty-one cases so you heard you know we’re net internationally around five to seven percent on our case fatality rate which remembers only be the clearly diagnosed cases. Costa Rica started using this hydroxychloroquine regimen very early in their curve and their case fatality rate not infection fatality rate is still below one percent they’ve had six deaths doing that so you know kind of indirect population data but still interesting.

Buck: One other question I have for any of you is obviously you know Plaquenil is used for patients with lupus so are we seeing people with lupus dying? Do we know? I mean if there’s a lower incidence of infection, I mean obviously lupus is not something you probably can get a huge amount of data in a short period of time but has anybody heard about that?

Paresh: You’re right you know the Lupus spectrum is wide and and the degree of patients that are using front-line or mild to moderate level treatment like hydroxychloroquine versus some of the other patients were using more significant immunosuppressants it’s kind of hard to tell. I’ve not seen anything but I have not look forward either.

Buck: Got it. John?

John: I just have an anecdotal report of one patient who was on 200 milligrams of Plaquenil a day for discoid lupus she was hospitalized with worsening Covid-2 we in discussion talked to her hospitalist increased her dose from 200 to 600 and added azithromycin and the next day she started to reverse her oxygen needs and dropped from 4 liters down to 1 in about 24 hours but you know again a single anecdotal yeah so not sure what to make of that.

Buck: Is there any other drugs that I think you know just briefly I mean obviously we can we’ve got it some other things I want to talk about but any other really promising drugs here that anybody knows about?

John: Yeah I think the ILsix story is very interesting Buck, so that’s interleukin 6 it’s probably the lead cytokine or a little tiny protein that gets excited in cytokine form. There’s two drugs undergoing trial right now and they’re both very interesting. There’s a German study that showed that if you’re IL-6 level got higher than 80 pica grams per ml you are 22 times more likely to need a ventilator so you know that’s something that all the critical care Doc’s are following now in the ICU and these two drugs are potent inhibitors of IL-6. So we have a little bit of preliminary data that suggests that it works in more severe cases but big studies are this drug these drugs really need these major phase 3 trials and they’re ongoing and they started in the beginning of April. The only other drug that I would want to say something about is Remdesivir. This morning they accidentally released the results of their early Chinese study which looks like it didn’t help all that much it is a drug that binds to viral RNA polymerase.

Buck: That’s the Ebola drug.

John: That was the old drug that didn’t work but what fairly well in SARS and MERS so I don’t know we’ll have to wait and see what the American Studies on that look like but again it’s a drug that mainly impacts the virus and you’re talking about late-stage people you know it’s a good question whether impacting the virus is going to matter at that point.