Hydroxychloroquine-Azithromycin and COVID-19
 

New observational study by French DR Raoult shows good results,

Note: This is not the same as a clinical trial but is good news

Clinical and microbiological effect of a combination of hydroxychloroquine and
azithromycin in 80 COVID-19 patients with at least a six-day follow up: an
observational study

Abstract

We need an effective treatment to cure COVID-19 patients and to decrease the virus carriage duration. In 80 in-patients receiving a combination of hydroxychloroquine and azithromycin we noted a clinical improvement in all but one 86 year-old patient who died, and one 74 yearold patient still in intensive care unit. A rapid fall of nasopharyngeal viral load tested by qPCR was noted, with 83% negative at Day7, and 93% at Day8. Virus cultures from patient respiratory samples were negative in 97.5% patients at Day5. This allowed patients to rapidly de discharge from highly contagious wards with a mean length of stay of five days. We believe other teams should urgently evaluate this cost-effective therapeutic strategy, to both avoid the spread of the disease and treat patients as soon as possible before severe respiratory
irreversible complications take hold.

https://www.mediterranee-infection.c...ID-IHU-2-1.pdf

I have rheumatoid arthritis and my dr. put me on hydroxychloroquine over a year ago. I'd heard of this news on my social media sites (support for my disease) maybe 3 or 4 weeks ago. People with immuno-suppressed diseases such as mine often have multiple ones with it, such as Lupus, M.S. and many others---for some reason they sort of "dove-tail" together. Anyway, it was part of their conversation---some were freaking out that the medications would become scarce due to hoarding (have heard that's happening now) or that this protocol would offer hope and then not work. It does sound like a promising protocol. I've also read that some places are doing Vitamin C via intravenous in high doses with some success as well. But back to the OP---have heard stories of using those 2 medications together has done miraculous things for patients. One man even said he was very close to death and they brought him back from the brink with them. Praying ALL this is true!!

There are lots of clinical trials going on testing this protocol, if it's proven to work there may be temporary shortages but production can be ramped up quickly. Just keep a 90 day supply and you should be fine.

in the event these drugs should ultimately be recommended, A new level of availability will need to be determined such that those who are currently on the drug are not compromised due to a rush on the existing availability.

I am confident that the companies that currently make these drugs already have implemented increases in production due to all the publicity.

This is a valuable addition to the discussion. This report is from the same French group as the previous combination treatment study and includes some of the same patients. Their results are interesting but careful review of their patient selection should be done.

While these are hospitalized patients I believe that the great majority of them would not be hospitalized in this country. The authors used a severity of disease score on admission.
You can see the scoring system HERENovel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in Sichuan Province, China
92% of their patients were in the low risk [NEWS 0 to 4] category. Only 15% of the patients had a fever. Only 15% ever needed oxygen.

So this is a much less ill group of patients than we would hospitalize. The authors compare their results to reports out of China noting that the Chinese patients took a median of 12 days to resolve fever. In these French patients hardly any had fever.

Additionally there is this sentence
So the sicker patients got an additional potent antibiotic. There was no control group. The clearance of virus both by RNA detection by PCR and by direct viral culture was impressive. But again this is clearance in a low grade illness group. This data needs to be replicated in a sicker population and it must have a control group.

If you are trying to prove that mildly ill Covid patients get better more quickly with a particular treatment, take the time to randomize similar mildly ill Covid patients to not get treatment. It is unclear why these doctors didn't do that as they had plenty of patients and plenty of time. Perhaps they felt it was unethical to withhold treatment as they clearly believe they have a tool to improve outcome. But their failure to include a control group will certainly cloud their conclusions and thus slow the adoption of this therapy. A properly done study would have been a much more powerful proof or refutation of their treatment approach. The plural of anecdote is not evidence. It is anecdotes.

It was clearly noted this was an observational study, plenty or more rigorous clinical studies are underway now. Thanks for detailed reply.

That is an interesting comment. So I present to you an ethics question. For the question accept that there is a shortage of hydroxychloroquine. It has been shown to improve Covid patients in terms of deaths, severity of acute illness, needs for ventilators, and length of contagiousness. [none of this has been shown, just the givens for my question]

The drug is also useful for reducing the pain of patients with multiple rheumatological illnesses. But it is not critical to saving their lives nor prevent spreading of disease. Should the manufacturers not be able to crank up production by millions of doses a day as would be needed to combat Covid who should get the drug? In 2017 there were only 5.6 million scripts for hydroxychloroquine in the US.

Ideally of course making a triage decision will never happen. The drug companies [anyone hating on Big Pharma at this point?] hopefully have the reagents and the plant capacity to greatly ramp up drug production. I don't know if that is true, nor how hard it is to make hydroxychloroquine, nor if there will be purity and safety issues if some new company jumps into the market. "Here is your medication. It was imported by Smith Company from a manufacturer I've never heard of. The FDA has not had time to test their product but under the National Emergency we are skipping that step to have enough medication for everyone who needs it"

But it seems to me that it is going to be a lot harder to make a medication in a big hurry than it would be to make masks, or gowns, or other PPE. And we have seen that there is a long delay in getting those paper products available. If I were a drug company I would not be spending millions or billions making a medication that if the better studies show is useless will have been a waste of my time. I'd be calling the administration and saying "We can make hydroxychloroquine but I need a financial guarantee that the government will pay me back my costs if it turns out there is no market" And as most of the drug manufacturing is done outside of the US, are we all ok with our government covering a foreign company's risk? Do we then demand that the increased supply be sent here? Tough questions

Good information and as another poster noted this was clearly defined as anectodical data.

I wonder, however, that since these are known drugs with known side effects and the fact there is not a better alternative available; why not try it? The next best option appears to be to wait for another potential solution and we need a solution NOW.

Mylan (NASDAQ:MYL) has restarted production of its hydroxychloroquine sulfate tablets at its West Virginia manufacturing facility as a potential treatment for COVID-19, the disease caused by the new coronavirus. The company plans to have product available by mid-April and thinks it can ramp up to 50 million tablets, which could treat more than 1.5 million people.

Mylan Ramps Up Production of Hydroxychloroquine as a Potential COVID-19 Treatment | The Motley Fool

2 Companies to Boost Production of Hydroxychloroquine to Fight CCP Virus

2 Companies to Boost Production of Hydroxychloroquine to Fight CCP Virus

Yes, I saw that in the original post. But I wanted to explain the weaknesses of this report that jumped out at me. I am also mystified as to why this group which clearly is trying to be helpful and is attempting to change the way the disease is managed, did not bother to do it the right way. That is very troubling to me. If you want a study to be believed, do it the right way. This is something that would require one week of their time. It is not a long term double blind study. Just do it the right way and people will be much more likely to take your work seriously. They already published an earlier observational study. Fortunately other groups are certainly doing studies and I hope their data will be forthcoming soon.

There is probably a reason China stopped using this rx. They won't say if people died, just said they had better drugs. Tough to believe China though on anything they say.

What stood out to was the selection bias. If you choose only those with mild cases of the virus and don’t include a control group similarly selected, you have no way of knowing if the recovery was due to the treatment or not. You could have treated them with Perrier and touted that as a potential cure. Bad science is worse than no science.

DR Faoult has an MD and PHD and specializes in infectious diseases.

You?

I agree with Mikeod. And I have a MD and a degree in microbiology. This is NOT a study, it is an anecdote

Yes and while you are playing golf 1000s of Drs all over the world who actually treat coronavirus patients are using these drugs and conducting more rigorous studies.

We will know for sure under what conditions these drugs work or not fairly soon.

Exactly. There are some good studies underway, and we should get early results soon.
As far as playing golf goes, I spent 44 years learning and practicing medicine, I paid my dues and I am retired. I helped/cured thousands along the way. You?

The one thing I did notice about the control group was the average age was less than the treated group (37 for the control group and 51 for the treated group). The sample size was small; treated group was 20 and the control group was 16 and they did have 6 dropouts. The average number of days between the onset of symptoms and the inclusion in the study was essentially the same for the treated group and the control group. They did present the numbers of patients who were asymptomatic, had upper respiratory symptom, and had lower respiratory symptoms for both the treated and control groups. There were more patients with upper respiratory symptoms than lower respiratory symptoms for both groups; about 60% of both groups had upper respiratory symptoms. I suspect that means that most of the patients in both groups were not very sick (yet?). They did do a statistical test for significant of the results. This was clearly a preliminary study and the authors did make suggestions for further studies.

I shot 69 last week, 5 birdies 2 bogies, 32 putts. Had 2 holes in one last year.

There's a reason lots of Drs prescribing these drugs and conducting trials, it's not because they are stupid.

nice round!!!

The reason they are conducting trials is to find out if this is reasonable treatment. Those that are prescribing it, off label, are probably premature (or visionaries)

Bonus points for either reading a study or perhaps a post online. But the information you are presenting here is not the report which is the topic of this thread. Rather the it is the data from an earlier report by the same group. This newer report had no control group and was much larger, without going back I believe it was 80 patients.

No one is questioning Faoult's qualifications. The question being raised is whether he did a convincing study when he had the opportunity to do one, or if he produced a larger anecdotal study which while interesting does not advance the science.

Quote from DR Faoult:

Our study concerns 80 patients, without a control group because we offer our protocol to all patients with no contraindication. This is what the Hippocratic Oath that we have taken dictates to us.

This guy is in the trenches fighting a horrific disease. I don't think he gives a damn right now about control groups if he can save some lives. Besides, we have Michigan as a control group since their idiotic governor says she will prosecute Drs who prescribe these medicines for coronavirus.

It’s here!
 

Couldn’t post story

I fear we have fallen into a world where twitter posts have taken on the authority of a well thought presentation. The reason Dr. Raoult took to twitter to defend himself is that he certainly has been hearing the same criticism of the lack of a control group from his peers. Every single proper study that is done is started with the hope that the treatment group will do better than the placebo group. And yet, hoping the treatment will help, a proper medical researcher includes a placebo group. Drug companies spend millions after basic research suggests an anti-cancer compound will help. And once it is ready for human testing, they don't give it to every cancer patient hoping it will save their lives. They do a placebo controlled study. And sadly even after the basic science and the early studies suggested they had a life saving medication, they often find that it doesn't work in the real world. The placebo controlled study provides the proof.

Dr Raoult surely knows this. And he knows that the overwhelming number of patients in his study were only mildly ill, not facing death. He had time to do it the way that his work would not be questioned.

I don't understand why you are so vigorously defending him. Is he a relative of yours? And the Hippocratic Oath says nothing about how to do a controlled study nor that a physician should give untested medications to everyone in the hope there will be a benefit. It does say you shall not operate on kidney stones.

Actually the dictum "First do no harm" suggests that before doing anything the doctor must weigh the possibility that the treatment is not more dangerous than allowing the natural course of the disease to occur. That has not yet been established in regards to these medications because he didn't do a proper study.

Yes, my comments were about the first paper and I did read the paper. I made my comments because while the 80 patient test did not have a control group, they did do the earlier study with a control group (as would typically be done in a scientific study with a statistical analysis). As they explained for the second paper, they were trying to save as many people as possible.

Oh please, both drugs are in wide circulation taken by millions. Only bad side effect seems to possible arrhythmia complications. Can you post some cites where patients have died from a short course of these drugs?

It's easy to pontificate from your couch. DR Faoult is risking his life every day treating coronavirus patients, doing what he thinks best based on considerable experience and expertise. That's admirable.

Let's start by getting his name right. It is Raoult not Faoult. And I have not criticized anything about his being in the trenches. Although I am not really sure he is in the trenches or not. I suspect he is in his office while those he employs are in the trenches. Do you want to know that he has been found to have submitted false data for publication? Do you know that he was banned from publishing for a period because of his sloppy work?

Chloroquine genius Didier Raoult to save the world from COVID-19 – For Better Science
I don't know how true all these allegations are, but there sure is a lot of smoke.

On the other hand he is one of the most recognized and honored persons in his field in Europe. He or his institution has published 2300 papers.
Didier Raoult - Wikipedia
He is a man who knows how to do a proper study for the advancement of medicine. He is not some local GP who is seeing his patients at the bedside and just trying something as a last resort.

Any attempt to paint Raoult as some Albert Schweitzer ministering to his critically ill patients simply fails. Saying he couldn't have his team of 200 do a placebo controlled study ignores his history of publishing huge numbers of papers and his being well aware of what kind of data was needed for his work to be accepted.

Here is a quote from Dr Raoult that may give some insight into his character.

"In my field, I am a star, worldwide," Raoult told the La Provence newspaper in France. "I don't give a damn what others think. I am not an outsider. I'm streaks ahead of the others."

As to your request I produce evidence of harm, if you read the papers you will see that Raoult excluded patients with cardiac risk factors. Why? Because he knows that both of these drugs but especially hydroxychloroquine can induce fatal events.

Here is a citation for you, the package insert for Plaquenil wherein it warns of sudden cardiac death.

And here is one for you on the risk of the same cardiac fatal events with azithromycin

Of course when you combine two meds both of which have known risks of cardiac events the potential to kill patients increases. And if the drug is useless, then any risk is unacceptable. Yes, I saw you knew that cardiac events could happen. I don't understand why you minimize that risk. And of course patients have died from this fatal rhythm disturbance. Otherwise that wouldn't be a known risk of the meds Sudden death

A small Chinese randomized study showed no benefit to using HCQ in 30 patients. The burden on Raoult is to prove the benefit outweighs the risk. I expect we will have good studies available within two weeks. I hope he is right.

Your google fu is not quite up to the task.

Plaquenil and Arrhythmias - from FDA reports

Summary:
Arrhythmias is found among people who take Plaquenil, especially for people who are female, 60+ old , have been taking the drug for 6-12 months , also take medication Methotrexate, and have Osteoporosis. This study is created by eHealthMe based on reports of 48,911 people who have side effects when taking Plaquenil from Food and Drug Administration (FDA)

See that part about taking it for 6-12 months? They are prescribing these drugs for 6 days.

Leonid Schnieder, who writes For Better Science blog, is a hack who is being sued by several doctors and hospitals. Sure is a lotta smoke there. Calls DR Raoult a climate change denier among other things.

You "suspect" he is in his office while his employees treat the patients?. Allrighty then

You cite one Chinese study with no results, there are others that state good results. Personally I don't believe anything coming out of china, it appears they are selling bad covid tests and defective N95 masks all over the world.

Again, DRs in USA and all over the world are currently prescribing the 2 drugs for their coronavirus patients, they aren't stupid. Clinical trials all over the place. Dummies! Billion dollar drug companies are ramping up production of the drugs, I guess they are dummies too.

Why would you post this? There are people that will create their own cocktail and take it. This has already happened. These deaths are on your hands. Idiot

Please don't take any of these possible cures until YOUR doctor prescribes it. Taking any drug can have adverse reactions based on other meds a person is taking, their current health issues and dosages. Even when FDA approved drugs are used, take a look at all of the class action lawsuits out there because it was found out later that the drug caused other negative outcomes. For now, protect our healthcare workers with needed masks, gowns, shields and get ventilators to the hospitals. Stay home and wash your hands.

69 nice...what do you normally shoot when you play 18?

I had a good round last week too...came close to shooting par...that darn hole with the windmill is always a toughie for me and once again I lost my ball on the 18th to that whale that's just sitting there

Novel Coronavirus 19
 

[QUOTE=GoodLife;1735057]New observational study by French DR Raoult shows good results,



Thank you for forwarding the on line study..It provided reassurance and medical break through ...reading this article instilled hopeful prognosis!!😊..indeed good news!!

From Jim Sinclair's Mineset

Michigan’s Governor Is Practicing Medicine Without A License

This is beyond an overreach. The action by this Politician.…Whitmer….is putting the citizens of Michigan in harms way….it is disgusting and DANGEROUS !

I have reviewed a number of studies….the first of which from 2005….yes 2005…revealed chloroquine was found to have suppressed the SARS Virus….a kissing cousin ( no social distancing with that virus) to the current Corona Virus.

In addition, a series of studies and case reports from China, Italy, Poland and France have shown Hydroxychloroquine to be effective against the current Corona Virus. Specifically, a study from Marseilles, France revealed a combination of Hdroxychloroquine plus Zithromycin ( Zpack) within 6 days debilitated the Corona Virus. This was a small population studied but the experience of those in the field in a number of countries including the United States have confirmed those results. In fact, the FDA has fast tracked a study on this combination of medications. That is a very rare action taken by the FDA and speaks to the positive data they have accumulated on the treatment.

Enter ” FAKE Doc” Whitmer…… she has threatened REAL Docs and Pharmacists in Michigan with punitive actions if they use this potential life saving combination for a patient…. I kid you not. This is beyond unconscionable ! By her ignorant and Despicable totalitarian actions she has put thousands of Michigan citizens and health care providers in harm’s way. This is an egregious example of politics at it’s worst!

She ran on “Fixing the damn roads”….. she needs to stick with the “damn roads” and QUIT practicing medicine without a license! Thousands of people have been put in Harm’s way and providers who are already over worked and stressed to the max do not need a political HACK DICTATING punitive actions against them as they battle for people’s lives.

Dave Janda M.D.

Terrific if it works!
I read this morning a long letter on Facebook from an ER doctor in New Orleans to a friend who is a retired professor from a nursing school. It’s tough going if you don’t have a medical background, but in short, this doctor says that they are giving hydroxychloroquine and azithromycin to everyone, and it doesn’t seem to be helping. Also, he says that worldwide, 84% of those who are put on ventilators die rather than getting better! In that case, a shortage of ventilators hardly matters. Might as well die. (But I prefer to keep my distance.)

“ A former ER nurse in New Orleans shared this post from an MD regarding the front lines of treatment of COVID 19.

"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."”

Mylan
 

If Mylan is making this drug it will $2,000.00 a dose vs $20.00 from anyone else. Don't forget what happened with the Epipen. Joe Manchin's daughter owns Mylan and the EpiPens went from $100.00 to $600.00 when the Manchin family took control.

Of course.

Lots of companies make hydroxychloroquine/plaquenil, its been in use for 70 years and is made all over the world. Costs less than a dollar per pill. Stop spreading nonsense.

Excellent but very scary information. Especially about withholding fluids. We cannot appreciate the people on the front lines enough. Dear God, protect all of us.

Normal scores for me are low/mid 70s, been playing since I was 5 but don't break par as often as in the past, also don't play from the tips anymore. That 69 was 1 less than my age, one of the hardest things to do in golf. Youngest guy to shoot his age or better was Bob Hamilton who carded a 59 at age 59. Sam Snead shot 67-66 on PGA tour at age 67 in Quad cities open. There was a guy at my club age 93 that regularly shot mid 70s, unfortunately he recently had leg amputated due to diabetes.