Peaceful life

Mackerel was boiled with soy sauce, sugar and sake. Green onions and ginger were added to it. We are trying to have sea grown but not artificially reared fish. The former is rich with omega 3 unsaturated fatty acid which is beneficial to avoid arteriosclerosis. Even though we should have been more conscious of this long before. Maybe, better than nothing. Pretty good taste. It is a kind of typical family dish in Japan. 

The dish below is salad featuring broccoli harvested in the garden farm. Some of them are already flowering. I have planted 3 of broccoli in the garden farm.

There is another japanese plum tree fully blooming at the eastern end of the property. In total, we have 3 of japanese plum trees. Two of them, including this one, have been planted by my father while the newest one by myself. Japanese plum requires partner tree to bear fruits in early summer. To enhance bearing fruits, a small one has been planted in between the other old two. The photo below is a close up view of the new one.

It has been a peaceful day. On the other hand, the news tells the number of infected people has increased abruptly after the Olympic games was postponed. The governor of Tokyo even warned that we might had been in the beginning of overshoot. I still suspect they have limited the tests in order to show less infected people than real. Politics is inclined to utilize such a crisis to get more power. Wondering if people could notice that or not. 

I should not take it granted to have such a peaceful day. Peaceful and tranquil life is being threatened by things going on. 

Anti-inflammatory drugs for COVID19

It is well known anti-inflammatory drugs so called NSAID are not indicated for any viral infection, including COVID19. Ibuprofen, one of the common NSAIDs, is told to exacerbate pneumonia in COVID19. It is not proved medically yet but is quite probable such an anti-inflammatory drug as Ibuprofen delays recovery or even aggravate the course.

https://www.bmj.com/content/368/bmj.m1086

NSAID could cause Reye syndrome, fatal liver/brain dysfunction syndrome, when given to the case of Influenza, especially type B. It is not clinically possible to tell COVID19 from Influenza or other common cold due to viruses. Knowing of the possibility to cause Reye syndrome with NSAID, we should not give any anti-inflammatory drugs, even including acetoaminophene, to viral infections. Even though some doctors may prescribe the latter one, which has less adverse effects than the other NSAID.

In rare cases with COVID19 or the other viral infections, a very serious condition named cytokine storm could occur and lead to multiple organ failure. It is a generalized too aggressive immune response to the pathogen. In that case, anti-inflammatory drugs should be tried. But in such a case, the patient is always so serious that he/she should be under the management by doctors at hospital.

Anti-inflammatory drugs give us only symptomatic relief. They should not be used for viral infections including COVID19.

PS;After writing this post, I have noticed this article on this issue. The effect of NSAID on COVID19 is not scientifically elucidated yet. At least, it is not advisable to give this kind of medicine to the patient of COVID19 at present. This article also mentions that ACE blocker has not been proved to deteriorate the course of COVID19.

https://science.sciencemag.org/content/early/2020/03/20/science.abb8034

Prediction of the peaked outbreak

In Japan, PCR tests are limited only for those in close contact with an infected person as already reiterated in this blog. Only 5% of requests for tests are allowed to be tested. That is told the main reason why the number of infected people remains rather small compared with the other countries.

Researchers of Imperial College London has published prediction of the infected cases in UK and USA. It is a horrible forecast. Without considering the overwhelmed healthcare especially for severe respiratory failure, the peak of the outbreak comes from May to June. Eighty one % of the population is expected to be infected. The expected deaths are 2.2 millions in US and 0.51 millions in UK in total.  

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf?fbclid=IwAR2pHXimauFMaS0MiA2tGlial7ed8tfCxR7K3HzvU420nYAAxLpUHwajvbs

The non pharmaceutical interventions could reduce the death rate. They include case isolation, household quarantine, social distancing especially of elderly and closing schools/universities. Among them case isolation seems to work best.

Case isolation depends on the right diagnosis. We should depend it on PCR tests result however the test's sensitivity is not ideal and could yield false negatives/positives if it is done as a screening test. History taking and examination by doctors may enhance accuracy of the diagnosis.

There are a lot of people insisting that PCR test is of limited value to mitigate the outbreak. They forget the fact we need to make case isolation by any means. We may utilize such as LAMP method for gene detection or immunochromatographic method for antibodies. PCR should be improved as well. Despite of the test defect at present, we should diagnose infected cases and put them in isolation as soon as possible.

Needless to say we should get ready for respiratory care intensive facilities to do with the peaked outbreak or overshoots coming up soon. 

Boiled chicken wings

Chicken wings boiled with soy sauce, sake and sugar. Cooked for an hour, the meat is soft and tasty. 

I would have cooked pork spareribs. But it was not sold at the supermarket I always go for shopping. Whether it was not very popular or the supermarket is not doing with common people like me.

This was pretty successful. Honestly, most of the dish is not the meat but the bone. Bone could be a source of stock. But not suitable for commoners' dinner.

I have purchased a bit more of foods than usual. I am afraid the viral infection could overshoot very soon and it could be difficult to go for shopping then. I have heard of the difficult situation in the West Coast from a few friends this morning. I hope the situation might be settled down soon. The professional committee of the government announces only that the infection is under control not telling any actual data. I am afraid they have very few epidemiological data if any. How could they announce that way without any definite epidemiological data? 

Another candidate drug for COVID19

Researchers of Institute of Medical Science, Tokyo University, announced that they had found another promising candidate drug for SARS CoV2. It is Nafamostat Mesilate, a protease inhibitor, which has been used for treatment of pancreatitis. SARS CoV2 requires a serine protease to invade into the cell. Nafamostat Mesilate seems to inhibit that process working as a protease. A derivative of this substance has been given to COVID19 patients in Germany with certain success. But it should be given at large dose. Nafamostat Mesilate seems to work at rather smaller dose.

Among depressing news regarding this disease in pandemic inundating in the mass media, this is a news of hope. The researchers told they had not published on this drug as a paper yet but, considering its importance for COVID19 treatment, they decided to publish it as an announcement. I was impressed at their conscience and passion as researchers in medical science. All the knowledge and experience should serve for the patients who need help.

Let's hope this drug turns out to be effective for the cases of COVID19. 

Favipiravir as a treatment choice for COVID19

A good news has been come out of a Chinese site as I already posted in Facebook.

Favipiravir turned out to be effective for SARS CoV2, the pathogen of the novel Corona virus infection, as they say. No notable side effects. They are including it to the treatment protocol.

http://www.xinhuanet.com/english/2020-03/17/c_138887971.htm

Favipiravir is a potent antiviral agent discovered by Toyama Chemical Co. in 2014, presently FUJIFILM Toyama Chemical Co. It inhibits RNA dependent RNA polymerase and is shown to be effective against wide range of RNA viruses. Working on the gene itself, it is expected to develop less chances of treatment resistance not like the most preceding anti Inluenza drugs. It has been deemed a key medicine for bird Influenza viruses, another example of RNA viruses. Since SARS CoV2 belongs to RNA virus group, they have started using it to COVID19 cases in China. A Chinese Pharmaceutical Co. seemed to have obtained the production license from FUJIFILM Toyama Chemical Co.

I would emphasize that early diagnosis, as the general rule in infectious disease treatment says, is mandatory to get a good result from this drug. It is surprising there are a number of "professionals" still insisting the RT PCR tests are of limited value so that they should not give it even to the suspicious cases. Of course, the government and MHLW are the source of such wrong opinion. They would pretend to have the number of infected cases much lower than real. In Japan, only 5% of the suspected cases could be tested for diagnosis. It is a non sense and even inhumane. It is irrational from the epidemiological stand point. Since this drug turns out to be a curative one, those test denial people have lost their standpoint. 

I hope this drug will be given to many patients in early stage. Hopefully, the other candidates for the treatment will bring good results in the very near future as well. 

Test, test and test

Our government is intending to limit the number of the test for COVID19. I could not help feeling they will have the outbreak progress and have those elderly and with underlying illnesses pass away. They just hide and falsify the facts. It is a willful negligence by the authority.

They have got through a lot of scandals through that evil way. The outbreak is not a political matter itself but is a phenomenon of nature which could never be hidden or never be falsified. It is an urgent issue if the healthcare system could do with the explosive outbreak or would be collapsed with too many patients.

In our country, the rule of funeral has been changed and those corpus died from unknown cause of pneumonia should be cremated in 24 hours after death. They are regarded as infectious with COVID19. The authority may be conscious that certain number of people are dying from COVID19.

No, it is not my intention to induce panic among people. But we should understand what is going on with the outbreak and should calmly deal with it step by step. People should be informed right and accurate facts. It is the first step for us to manage the ongoing crisis.

https://www.cnbc.com/2020/03/16/who-says-some-nations-arent-running-enough-coronavirus-tests-test-every-suspected-case.html

Further increase of the infected cases

Further increase of the infected cases with COVID19 in various countries.

It is more obvious that Japan still goes on increasing the cases in exponential manner while S. Korea is reaching plateau of the cases. S. Korea seems successful to control the infection.

This graph shows thorough testing as S. Korea has done is mandatory to control the infection. Our government is still failing without adequate number of the tests performed. It has made miserable failure not only in quarantine but also in controlling the infection. 

There have been so called "professionals" who approved and even actively supported the maneuver or, exactly, the willful negligence by the government. Both of them have committed crime.　

What the transitive graph of the number of the infected cases tells us

This graph shows the increase of SARS CoV2 infected people in each western country. I have quoted the same kind of graph in a previous post. This shows problems in Japan in more clear-cut manner.

The caption on the curve of the infected cases in Japan timidly says the increase could be really slowed or the slow increase could be due to limiting the tests. In our country, the tests are done only in limited number of cases. The number in Japan is one tenth or even less of the numbers in the other countries. The proverb of "No tests, no patients" could be applied to our country. As told in the previous post, the government tries to pretend that infection control has been successful resulting in the less number of infected cases here. It is in order to hold the Olympic games this summer, which is already quite unlikely to happen. 

In this graph, I noticed the curve of Japan goes up straight, that is, in exponential way while the other countries of major outbreak like Iran or S. Korea reaches plateau or lessening of increase in 3 or 4 weeks. If maneuver of infection control is successful and/or the society reaches plateau of immunity against this virus, the curve should be like those of Iran or S. Korea. The data is still preliminary and could not let us conclude definitely. But it should be concerned that the curve of the infected cases in Japan is straightly increasing. It might mean the infection control measures are not sufficient in Japan.

Being an amateur in epidemiology and sociology, I may not be appropriate for commenting the consequences of this pandemic. But if I am allowed to comment a bit about it, I should say it could result in collapsed health care system and the economic regression.

Without making definite diagnosis to the suspected cases, they will be in close contact with their households and may visit health care facilities. Sure they will become epicenters of the cluster. And health care facilities suffer much, infection to the high risked inpatients and to the medical staff, from them. Being labor intensive industries, health care facilities could be easily collapsed with such a cluster epidemic. Like in Italy etc, the intensive care for respiratory failure should be overloaded easily. They say the intensive care beds for infectious diseases are almost fully occupied for now. The ventilators or ECMO for respiratory failure patients should be no vacancy very soon once the outbreak explodes.

It seems the government fears of the panic among people when they know what is really going on. I believe they are wrong. Knowing the disease in outbreak properly is the first step to do with the outbreak. Knowing that 80% of the cases are mild or even asymptomatic especially for young adult and children, they could stay home carefully observing themselves of possible progression to pneumonia. It will spare the reserve of the healthcare system. I am afraid the government is going the opposite way at present. 

Needless to say this outbreak would result in drastic regression of the economy. In Japan, the government has directly controlled the stock market through investment by the Bank of Japan and the annuity funds. The latter may result in reduction of the annuity which depresses the domestic demand. Increased number of the people may get even poorer. It will shrink the economy. The BOJ already got a few trillion JPY loss by the drop of ETF. It might have to print more money to balance the deficit. BOJ has enforced as much the low interest rate policy as possible. The banks, especially the local banks, are suffering much with it. Actually, some of them have have undergone business failure even if not bankruptcy for the outlook. Those banks have invested much for such high risk bonds as CLO. In the world economy in recession, such CLO or CoCo bonds would be collapsed. They say the extent of credit failure might be much worse than that in Lehman Bro. Holdings bankruptcy in 2008.

I have been much concerned about what is going on in Japan and the world as a  ex MD having worked in healthcare facilities as well as a retiree living with the annuity as well as small amount of investment to some world bonds. 

Magnolia and camellia are coming out

Looking east from veranda, I found most of the magnolia flowers in the garden coming out. It has happened over a night. I knew the buds were bulging more day by day and thought it could bloom very soon. It was beyond my guess that they came out over a night yesterday. Sure surprising.

The view from veranda.

In my memory, it was early in April that this flower always had come out. It came out 3 or 4 weeks earlier than usual. It might have become earlier year by year without my acknowledging it. At least, it was early April 10 years ago.

Anyway, it is gorgeously beautiful. As I told it many times in the past, my mother used to love this flower and to tell me it came out when she noticed it in her latest years of life. The time we could enjoy it together has not lasted long.

A close up view. All the flowers seemed to have waited for arrival of spring. Having this flower come out in this way, spring always get full blown very soon. 

This camellia has started blooming for several days. Each flower gets matured at different pace. 

Magnified view. 

Finally hibernation is over with me. I will start planting various veggies very soon.

A magic on the increase of infected cases

This graph shows the number of cases with SARS CoV2 infection in different countries. The vertical axis is the number of cases while the horizontal is the days after reports have been made.

I could not help grinning at this graph. Because it clearly shows some intention has worked in the curve of Japan to pretend the number of infected cases is increasing slower than reality. Since the basic reproduction number of this virus is estimated 2.2, the number of cases should have increased in exponential way. In the sensitive societies, the increase of cases should be in the same way wherever it may be. Comparing it with those of the other countries, it is quite obvious. Of course, it is our government that has done it. In the beginning of the outbreak, the government hesitated to show the real number for China and Olympic Games. They might be optimistic for the expansion of the outbreak. They have not hold any meeting with professionals at the governmental office until the beginning of February even though there have been some cases and cases of death reported by the end of January. Their apparently legal but ethically wrong policy seemed to lessen, or limit the number of the test for diagnosis at clinical sites even though much more was possible. They pretended such as RT PCR test has not been of use for "screening" of the infected cases due to its marginal sensitivity as well as to the small number of infected cases in the society. In some cases, the test has been performed even in postmortem.

As stated before, the test RT PCR has been of use for the person tested, for the society and as the basic epidemiological data to evaluate certain administrative measures taken to do with the epidemic. 

But they still keep the test capability much lower than needed. At present, it seems they would like people not to know the truth in order to avoid panic among them. They might think this falsification of the data helps to hide the probable collapse of medical care system which is thought to happen with explosive outbreak of COVID19. This collapse is just a nightmare which is going on Northern Italy now.

The medical staff could be infected and won't be able to go on working to give medical service.

What the government is doing right now is to legislate to declare emergency in the country. It would limit private rights. I wonder what this authoritarianistic government is intending to do. No wonder, they would try to hide the reality of total failure for what they have done in the past. A nightmare is going on here in addition to COVID19 outbreak.

What makes me feel sad is that 40% or even more people in this country is still supportive to the government as for the measure they take for this outbreak. Wondering whether they are cast a spell, are indifferent to their own situation or have become dumb in the past years. The PM Abe is compared to a magician who finally fails his plot with this outbreak by NYT, though.

Farce of onion

Since my wife has purchased a lot of onions at one time, I have tried to cook farce with them. The name, farce, was not familiar to me until cooking this. But it is only onion stuffed with minched meat seasoned with bouillon.

So it will be a few days continued we take this dish for dinner.

Red ume and the outbreak of COVID19

Red ume or red plum is coming out in the garden.

The same kind photos have been uploaded here before. Yes, it happens at this time every year. I guess I have mentioned that my parents must had enjoyed watching these flowers in front of their house when they were alive. Things wag on in the same way every year. I often wonder who will enjoy these flowers when I quit this world. Who knows? 

I have started plowing the ground at a corner of the yard. I will plant potatoes  and tomatoes there later. The same gardening and farming still goes on as last year. I don't know how long I could do that. Being on the ground is a pleasure for me. I don't know why but feel I am a part of the flow of lives whenever standing on the ground. The soil is where lives were grown and where we are coming back when we leave the world. 

With the failure of the government to control the outbreak of COVID19, it seems to prevail all over in our country. The situation is worst in the big cities like Tokyo where crowds of people are in closed spaces like the commuter trains with the passengers packed like sardine. I have planned a practice of piano trio with the niece who plays piano and a violinist friend in Tokyo in the end of this month. But it was postponed after April. My nice, a nurse in chief at the National Cancer Center in Tokyo, said the hospital is messed up with a number of COVID19 suspected patients.   

So I would spend days at home playing cello and doing house chores in peaceful mind. COVID19 is not an illness which healthy adults won't need to be scared at. But it could be harmful to aged people or to those with underlying illnesses. Hopefully, every friend of mine won't get infected with it or won't get serious if infected. Keep away from crowds of people from whom you may get infected. 

N95 mask

N95 mask is to protect the wearer from inspiring small droplet containing pathogen or airborne one. The ordinary surgical masks are not able to do that. Even though this protection effect is sometimes questioned, this mask still remains one of the main stays for medical staff dealing with outbreak of viral infections.

My wife told me there were several dozens of the mask with her. I remembered in the outbreak of SARS in 2003, I had purchased a lot of the masks and had given some of them to her to use at her practice. Fortunately, she and the staff had no chance to use it and kept them in storage.

SARS was more virulent than COVID outbreaking now. About twenty % of the victims were thought to be medical staff. The authority has announced the people to consult to the local medical facilities when they had any complaints reminding them of SARS. It was a terrible announcement since we were not equipped against SARS at all. Purchasing boxes of those N95 masks was one of the coping strategies for a small medical facility like mine those days. This mask has reminded me of the situation driving us into a corner those days.

Fortunately, this SARS COV2 is not so virulent  for healthy adults as SARS virus those days as I said above, even though the case mortality rate is up to 20% for elderly people. But in case a few medical staff are infected with it and have to leave their office for a couple of weeks, small medical facilities may have much difficulty to carry it on. Actually, I don't think this kind of mask is very potent to prevent from infection. It might be, however, of some help, if any, to the staff working at such facilities. I would look for anyone who needs it for medical service and donate them to such a facility. 

Recent discussion at the Upper House in our country, MHLW has disclosed they had not investigated mortal cases with pneumonia at elderly care facilities since the outbreak of COVID occurred. Those cases may include death due to COVID. Our government seems to be negative to investigate and publish the basic data of this disease in outbreak. We must have another newly emerging infection in the future. To get ready for such an infection, basic epidemiological data should be highly required. Our government is quite unwilling to record what is going on now. It is not an attitude of the government of a civilized country.

Early diagnosis is mandatory for treatment of COVID

This review of diagnostics, therapeutics of new Corona Viruses' diseases in J. Clin. Med. is interesting.

file:///C:/Users/PCUser/Downloads/jcm-09-00623%20(1).pdf

I am dazzled to see how many researchers have been involved in this field of investigation. Presently ongoing epidemic of COVID may be settled down with their relentless efforts sooner or later. Combination of antivirals seems to be promising. And I am more convinced early diagnosis is necessary to control these emerging infections as the general rule of any infection tells.

It is also clear that early detection of virus genome is essential for the appropriate treatment. Serum antibody tests are not of use in that standpoint.

Our government has intended to make the number of infected people regarded less than real in the first step of administration against this COVID. Actually, as I posted in the other article in this blog, they have controlled and limited the availability of the only diagnostic test. Even though it has been not so sensitive and has limitations as a diagnostic tool, it is the only test available for early diagnosis at present. The authority has not let the test done for clinical demand. They seem to have been concerned only with the Olympic Games being planned in this summer. If our country goes on being contaminated with this virus for another few months, it might become impossible to hold it this summer. It would deprive them of much profit from the event. Some researchers and even doctors have falsely insisted that RT PCR test is of no use. However, early diagnosis as well as further investigation for more efficient diagnostic tests is mandatory to give chance for early intervention and/or treatment to the patients.