Before I say anything,
I just want to say
that if you are squeamish
you might not want to watch this video
because there will be some pictures
of lungs that have a blood clot in them
and other organs of the body.
In my opinion it's nothing that bad
but I wanted to give you a warning,
regardless.
This video is a follow-up
to my last video which was called,
"What Doctors Are Learning From Autopsy
Findings of COVID Patients. "
Just after I published that video,
not even a day later, this study came out,
published in the
Annals of Internal Medicine
which I'll put a link in to the description below.
And what makes this study such a big deal
is that it's the first study that
looked at this many autopsies of
patients who died of COVID.
Not only do they do complete autopsies,
but they use CT scans
to scan the entire body for blood clots.
All 12 of the deceased had tested
positive for SARS Coronavirus-2
by means of RT-PCR.
Now, I want to say something.
Not everyone on this planet is
going to get COVID.
For those who do get the virus,
80% of them will either have mild
or no symptoms.
Roughly 15%-20% of them will
have pneumonia.
Roughly 4% will develop ARDS, or Acute
Respiratory Distress Syndrome
and/or shock with
multi-organ failure.
And about 1% will die of
the infection.
When I'm in the ICU and
someone dies it's obviously horrible.
Sometimes autopsies have to be done
irrespective of family consent
when it's a legal matter.
Rarely, depending on the
circumstances,
we ask familys' permission to
do an autopsy.
Most families decline the option for
autopsy,
but during this pandemic, it's especially
important for autopsies to be done
because they often provide
incredibly valuable information,
especially when we still know so little
about COVID.
Especially when it can present in so many
different ways.
So in this study that was
done in Germany,
autopsies were mandated for patients
who died of COVID.
And to the families of those victims
of COVID, my condolences.
And we're still trying to figure out
why some people do so poorly
when they get the virus,
while others do just fine
and then there's everyone in between.
So, the point of this video
is not to scare people.
The point is to learn about
the disease,
and to ultimately benefit from that
learning
with the hope of developing treatment
options
and ultimately reduce morbidity and mortality in other
words to save lives and by making this video the
goal is to educate myself and others about what
we're learning and getting the medical truth out
there to the public so in this study there were
12 patients total nine men three women and the
median age was 73 all patients had some type of
pre-existing medical condition most of them had
obesity and/or underlying heart disease such as
coronary heart disease some had type 2 diabetes
hypertension peripheral artery disease asthma
COPD initial lab tests revealed elevated levels
of d-dimer lactate dehydrogenase meaning LD H
and C reactive protein or CRP all of these are
nonspecific markers of inflammation there is also
mild thrombocytopenia in some patients meaning low
platelet counts this isn't an unusual finding in
patients who are critically ill they also looked
at levels of viral RNA using rt-pcr studies all
twelve patients had the SARS-CONORA-VIRUS 2
RNA in their lungs nine out of the twelve had it
in their throat and six had in their bloodstream
in five patients they had viral RNA in other
tissues like heart liver brain and kidney not
only did they have the virus there but the levels
were higher in those tissues compared to the blood
here's a picture from a different autopsy that
was not part of this study where the virus was
actually visualized in the kidney using electron
microscopy so what is this telling us it tells us
that the virus is binding to those h2 receptors
in those organs so in some people who die of COVID
they had the virus in other organs besides the
lungs. But, and this is a big BUT, they did not die
as a result of that virus being in those different
organs they died as a result of lung complications
also an important takeaway from this is that all
twelve had in their lungs and nine out of the 12
had it in their throat so when you go to do a throat
swab with someone who has COVID the virus might
not even be there and that's just another reason
why you can get a false negative test okay so they
also did post-mortem CT scans of these patients
which demonstrated mixed patterns of reticular
infiltrations in severe dense consolidations in
both lungs this CT scan is a patient with covid
pneumonia in ARDS not from this study
that we're talking about now but basically
demonstrating the exact same thing both lungs have
extensive consolidations ground-glass opacities
which represent an extensive inflammation these
are also known as pulmonary infiltrates and you
can see the difference compared to a normal
CT scan of the chest which doesn't have any
pulmonary infiltrates in four cases out of the 12
massive pulmonary embolism meaning massive blood
clots in the pulmonary arteries was the cause of
death in another three cases out of the 12 they
had blood clots in their large veins of their legs
meaning DVT without having pulmonary embolism so
in six of the nine men they had clots in the veins
that surround the prostate gland in all 12 cases
the cause of death was found within the lungs or
the pulmonary vascular system meaning within the
pulmonary arteries for the ones who didn't die of
having a large pulmonary emboli they died of the
extensive inflammation within the lungs meaning
pneumonia with ARDS in these cases the lungs were
wet and heavy much like a sponge that is saturated
with water. The surfaces of the lung often had
a distinct patchy pattern with pale areas
alternating with slightly protruding and firm
deep reddish blue hyper capitalized areas this
is indicative of areas of intense inflammation
with endothelial dysfunction that can be seen at
the microscopic level. When they look at slices
of the lungs under the microscope they found
diffuse alveolar damage in eight cases out of 12
specifically they saw hyaline membrane formation
tiny clots in the capillaries and capillaries
that were engorged with red blood cells and
other inflammatory findings. All these findings
represent ARDS they also found lymphocytes
a type of a white blood cell that infiltrated
these specific tissues this fits the picture of a
viral pathogen ASIS. They also look at the pharynx
of these patients meaning the throat. The lining of
the throat where the mucosa was hyperemic meaning
very red and irritated and at the microscopic
level they saw lymphocytes invading there as well
again which is consistent with a viral infection
in one case a patient had lymphocytes invade his
heart muscle findings that are consistent with
what we call viral myocarditis. In other words the
heart muscle had evidence of viral infection more
than half the patients in this study had large
blood clots. 1/3 of the patients had pulmonary
embolism as the direct cause of death. All the
others died of intense inflammation in their lungs
related to pneumonia and ARDS. Recently there's
been studies showing that about 1/3 of patients
with severe COVID have blood clots. Another study
of 191 patients with Covid 19, half of those who
died had clots compared with 7% of the survivors
and levels of d-dimer that were greater than
1,000 were associated with a fatal outcome so
it's pretty clear now that sars-covid-2 virus
is causing a lot of clots to form and moderate
to severe COVID disease. But how is this happening?
it's likely a combination of reasons they have
to do with down regulation of the h2 receptor in
the lung alveoli with a subsequent shift towards
having more angiotensin 2 in the lungs and less
angiotensin 1:7 and less in angiotensin 1:9 in
the lungs and when this happens this leads to
more cytokine storm with more inflammation more
constriction of pulmonary arteries and more
clots that develop. That in turn leads to more
endothelial dysfunction in the capillaries that
surround the alveoli. Also there's evidence that
the virus attaches to the ACE 2 receptors of the
endothelial cells that line those capillaries
which further propagates inflammation in clotting
and in the cytokine storm that develops there
Randy's Okemo kine bind to the ccr5 receptor
of cd4 and cd8 lymphocytes and that causes
those lymphocytes to infiltrate those areas of
inflammation and in doing so further contributes
towards the inflammatory reaction. This is why
we're seeing low levels of cd4 and cd8 lymphocytes
and severe COVID. Endothelial damage can also lead
to the development of antiphospholipid antibodies
and these antibodies are bad because they trigger
the formation of blood clots and that's why
patients who have clots with the diagnosis
of antiphospholipid antibody syndrome they
need to be on blood thinners also 11 out of the 12
patients in the study had underlying heart disease
and were obese these are known risk factors not
just for cardiovascular disease but also known
risk factors for endothelial dysfunction, and are
known risk factors for COVID the endothelium is
more susceptible to damage based on cardiovascular
risk factors such as men aged 45 or older, women
age 55 or older, smoking, high blood pressure, high
cholesterol, diabetes, obesity, and lack of physical
activity. So the big takeaways from the findings
in this study is that most people who die of Covid
it's primarily a lung problem either related to
inflammation with ARDS and/or blood clots even
though blood thinners are not a cure for Covid per
se they do have the potential to save lives. The
hard part is figuring out who is likely to develop
clots and who should we give blood thinners to and
which blood thinners should we give and should
we give high doses of blood thinners or just the
low-dose prophylactic doses? To further complicate
matters it's often hard to diagnose blood clots in
hospitalized patients even before COVID came along
usually it's easy to diagnose large blood clots in
the veins of the legs, meaning DVT by doing an
ultrasound of the legs even though ultrasound
isn't a hundred percent accurate. The way we
typically diagnose pulmonary emboli is by getting
a CT scan of the chest while at the same time
giving IV contrast and this is called a CT angio
or CT A of the chest the downsides of doing this,
well there's several. One, you have to transport a
patient to the CT scanner and sometimes patients
aren't stable enough to do that. Two, you risk
spreading the virus to others in the hospital by
transporting that patient. And this will also require
more PPE use. Three, CT scans require larger doses of
radiation. Four giving someone IV contrast has some
risks such as the risk of serious allergic
reaction and the risk of causing some kidney
damage. On top of that the CTA of the chest can
only visualize bigger clots so you might not see
the small clots that are there. Right now more and
more hospitals are giving high-dose blood thinners
to COVID patients who have severe disease even
if they haven't been diagnosed as having blood
clots. But what about patients without moderate or
severe Covid, should they take a blood thinner or
maybe a low dose blood thinner, or should they take
an antiplatelet medication like aspirin either 81
milligrams of aspirin or 162 milligram dose or 325
milligrams dose, or should the general public take
a low dose aspirin like 81 milligrams in order to
help prevent blood clots from forming if they do
get COVID or should it just be certain people in
the population who are at higher risk of getting
severe COVID should they take aspirin? These are
the questions we don't know the answers to at
this point. It's going to take a lot of studies
to answer these questions because not only do
we need to know that there's a benefit in doing so,
we have to know that these benefits will outweigh
the risks such as the risk of bleeding and then
there's all the other drugs that are being looked
at right now and randomized control trials we
should start seeing some of these results pretty
soon. What we do know is that in order to improve
the capillary endothelium and also to minimize
your chances of having severe disease if you
were to get COVID you want to do several things.
This includes exercise, eating healthy, getting
good sleep, minimizing stress, not smoking, what
about vaping? generally not good either but not as
bad as smoking. too much alcohol not good either
have your medical conditions under control
whether that's diabetes, high blood pressure,
COPD, asthma, allergies, whatever the case may be.
Now what about vitamin D? probably a good thing
but that's a whole another topic which I should
make my next video on because there's a lot to
say about that and possibly other vitamins too
if you're deficient in certain vitamins. Anyway
to catch that video subscribe to this channel and
hit that bell notification so you know when I post
here on YouTube so many topics I want to cover in
so little time but I will see you in the next one