There is much uncertainty about the value of dietary advice and dietary supplements. If these interventions do anything at all, then surely this would show in malnourished patients. And if any effect can be demonstrated, then surely with a hard endpoint, such as survival. This study tested the hypothesis; it investigated the effect on survival after 6 months of treatment involving individual dietary advice and oral nutritional supplements in older malnourished adults after discharge from hospital.

This multicentre randomised controlled trial was supported by grants from Region Västmanland, Uppsala-Örebro Regional Research Foundation (RFR), and the Swedish National Board of Health and Welfare. It included 671 patients aged 65 years who were malnourished or at risk of malnutrition when admitted to hospital between 2010 and 2014, and followed up after 8.2 years (median 4.1 years). Patients were randomised to receive:

• dietary advice,
• oral nutritional supplements,
• a combination of both,
• routine care.

The intervention started at discharge from the hospital and continued for 6 months, with survival being the main outcome measure.

During the follow-up period 398 (59.3%) participants died. At follow-up, the survival rates were

• 36.9% for dietary advice,
• 42.4% for oral nutritional supplements,
• 40.2% for dietary advice combined with oral nutritional supplements,
• 43.3% for the control group.

After stratifying the participants according to nutritional status, survival still did not differ significantly between the treatment arms (log-rank test p = 0.480 and p = 0.298 for the 506 participants at risk of malnutrition and the 165 malnourished participants, respectively).

The authors concluded that oral nutritional supplements with or without dietary advice, or dietary advice alone, do not improve the survival of malnourished older adults. These results do not support the routine use of supplements in older malnourished adults, provided that survival is the aim of the treatment.

The findings of this trial seem perhaps counter-intuitive and they contradict the current Cochrane review on the subject. I nevertheless feel that this is an interesting, rigorous and important study. It deserves to be publicised widely – perhaps more widely than the ‘Upsala Journal of Medical Science’ would afford.

President Trump is not the only head of government who has discovered his talents as a scientist saving the world from the corona-virus pandemic. It has been reported that shipments of a herbal tea are being sent to neighbouring countries by the President of Madagascar, Andry Rajoelina (below having a sip of his herbal drink). He claims that his tea is a powerful remedy against the corona-virus and hopes to distribute across West Africa and beyond.

Baptised ‘Covid-Organics’, the tea is derived from artemisia, a plant containing artemisinin which has efficacy in malaria treatment. Artemisia is cultivated in Cameroon, Kenya, Ethiopia, South Africa, Mozambique, Tanzania, Uganda and Zambia – all in high-altitude regions and regions with a pronounced cool periods. The tea reportedly also contains other indigenous herbs, such as ravintsara. Ravintsara is derived from the Cinnamomum camphora tree which is a native of Madagascar. This species of tree is different from the Asian camphor species; its leaves have a very different chemical composition.

‘Covid-Organics’ is being marketed after being tested on fewer than 20 people over a period of three weeks.

After Equatorial Guinea on Thursday, Guinea-Bissau is the second country to take delivery of the potion that Andry Rajoelina claims cures Covid-19 patients within 10 days.

The World Health Organisation has said that the herbal tea’s effects have not been tested, and there are no published scientific studies of the potion.

Embalo’s chief of staff Califa Soares Cassama told reporters that part of Saturday’s shipment was to be passed along to the other 14 members of the Economic Community of West African States (Ecowas). He said that he will test the potion from Madagascar on leading government members, including the premier. (Some readers of this blog might feel that the same should have been done in the US when Trump seemed to promote disinfectant for the corona-virus infection.)

Back in Madagascar, unarmed soldiers have been going from door to door in the capital Antananarivo handing out Covid-Organics. When launching the distribution last month, Rajoelina said two people had already been cured thanks to the potion, and added: “We can change the history of the entire world.”

Personally, I wonder whether a potion against hubris would not also be needed in these desperate times.

Guest post by Christian Lehman

How I would have loved it if a brilliant genius, in the style of Jeff Goldblum in Jurassic Park, had discovered, on a corner of a grubby lab bench, THE miracle treatment for Sars-cov-2! How I would have clapped if, working fast, very fast, too fast for the eyes of mere mortals, this magnificent hero had blazed brilliantly ahead and saved millions of lives, so proving the accuracy of his hypothesis before an awestruck world. But we’re not in a Hollywood style blockbuster.

When Didier Raoult launched his first study on chloroquine he was basing it on three things: a verifiable fact, an assertion, and an intuition.

The verifiable fact is that in a test-tube (in vitro), and not in tests in humans (in vivo), chloroquine is active against SARS-cov-2 , the virus of Covid19. The fact that this in vitro action exists in a number of other viruses, without ever having given good results in humans, even increasing mortality in the case of chikungunya, would suggest the need for some degree of caution.

A reservation swept aside by Raoult’s following assertion: a Chinese study has just emerged which demonstrates that chloroquine brings about spectacular improvement and is recommended for all clinically positive infections involving the Chinese corona virus. Unfortunately, nearly two months after this scoop the world still awaits the slightest corroboration of what seems more and more like an elaborate media bluff.

Finally, intuition is what Didier Raoult is still defending today, stubbornly, in ever weirder videos. The idea that a researcher outside the select Parisian elite, who has been knocking around for a long time, a practical man, can see at once straight to the heart of the matter, while a horde of followers bogged down in their standard procedures would take months to get going.

So Didier Raoult launches studies, raising great hopes by his attitude of complete certainty, his media facility. Hopes so great that nobody, in the media or at the heart of politics, thinks of questioning him. Who would imagine that a respected scientist with an impressive CV would throw himself blindly into a con?

Didier Raoult’s studies follow one after another, piling up errors and approximations, crazily rigged.

Thus, in the first study, out of 42 patients, among those treated by the Didier Raoult procedure, one dies, and three are hospitalised because of deterioration in their condition. And by a wave of a magic wand (which in France and elsewhere should be called a fraud)… all four are excluded from the results when they should have been considered as failures of hydroxychloroquine.

Somewhere along the way Didier Raoult will add Azithromycine to Hydroxychloroquine, and will conclude that the combination is more efficacious than HCQ alone, though the difference, on six patients only, is not significant.

The criterion established to judge the success of the trial was to be a check for the virus in the nasal passages around 14 days. The study will be halted on the sixth day, and the diminution in the intranasal viral load will be treated as a proof of efficacity/effectiveness (without any knowledge of whether this disappearance might simply indicate the migration of the virus to the pulmonary level).

Children of 10 years old will be included in one of the extensions of the study, without their consent.

A second study will be launched as a follow-up, while the first will be published under doubtful conditions and immediately disowned by the International Society of Antibacterial Chemotherapy, and this second study in which Didier Raoult and his team choose which patients to treat (thus intervening in their therapy in an illness offering 95% of spontaneous recoveries) is declared as a simple observational study (without intervention by doctors on the development of events), instead of an interventional study. This means that obtaining the obligatory agreement from the Agence Nationale de Securite du Medicament can be avoided.

All this takes place as if, paralysed by the obvious shambles of the government’s management of the epidemic, nobody dares to utter an objection. Bypassing any requirement to seek the agreement of the ethical committee, the Marseille Institute awards itself a blessing and at the end of March treats 80 patients with Hydroxychloroquine, because “that is what we are told to do by the Hippocratic oath which we have taken”. So Didier Raoult, on a hunch, will prescribe potentially cardiotoxic and untested medicines to asymptomatic patients, in violation of the fundamental rules of ethics concerning the prescription of medicines.

There would be, there will be much to be said on the inaction of agencies, of institutions, of politicians, faced with the forward flight of a man who trails behind him tens of thousands of frightened people, thousands of conspiracy theorists and hundreds of hate-filled trolls who have turned themselves into virologists in a couple of hours spent on YouTube gobbling down the videos of their Guru.

But what most interests me in the first place is Didier Raoult’s rationale, that certainty that the Hippocratic oath (which at no point mentions the right to enter into freestyle experimentation on human beings), his medical degree, and personal intuition, constitute a sort of trump card. Let us remind ourselves one more time. Didier Raoult is a microbiologist, a specialist in viruses and bacteria. He has no experience of therapeutic research, and the gross errors which he commits in the development of his studies and in the analysis of his results and his publication procedures are not linked, as he would like us to believe, to the emergence of a new paradigm, but to the rancid re-emergence of something which we hoped had disappeared, the overweening power of untouchable and tyrannical “mandarins” , medical overlords incapable of allowing themselves to be called into question.

Coming in worldwide, the results of the first correctly executed studies carried out on Hydroxychloroquine, are globally negative. The only line of defence which appears to be left to Didier Raoult is the excuse of having acted in an emergency. Comparing himself one day to Clemenceau, the next to Foch, he sees himself as a fantasy wartime leader, alone capable of facing up to the situation, far from the prevarications of the dismal adherents to scientific method. All that the media seem to have retained from his recent video, entitled “The Lesson of Short Epidemics” is his assertion that Covid19 is a seasonal illness, destined to disappear, and that “in a month there will be no more new cases”. The work of all of us who wrote articles and posted warnings on social media: ordinary GPs, cardiologists, emergency and resuscitation specialists, would seem to have borne fruit. The assertion of the mighty soothsayer who in January scoffed as he told us “when three Chinese who die, that sparks off a world alert” will not wash any longer. But how many people realise that, if Didier Raoult is pushing his latest intuition, it is because only a short epidemic will allow him to justify a posteriori having acted brazenly in an emergency. If Covid19 settles in the long-term, he will not be able to escape a minutely detailed autopsy of his statements and his actions. And the result will be devastating.