MALLIK QUESTIONS

PART 1

IN THE CONTEXT OF THE FEAR OF THE 3rd WAVE ,HERE ARE MY 57

STRAIGHT QUESTIONS TO THE GOVERNMENT SPOKESMEN, THE
POLITICAL LEADERS , and all the MEDICAL AUTHORITIES and DOCTORS
(I’m not any of the above mentioned)

MY INTENTION HERE IS NOT TO CHALLENGE, BUT IT IS ONLY TO

DEMAND TRANSPARENCY AND ACCOUNTABILITY FOR THE SAKE OF
THE PEOPLE

PLEASE ANSWER POINT BY POINT,ALONG WITH YOUR INDIVIDUAL

SIGNATURE SO THAT YOU ARE MAKING A COMMITMENT
—- —-MALLIK PARUCHURI

1. Can you tell in detail how masks , sanitization and social distancing exactly
work?
A) Reduces risk of transmission by over 90-95% when all the above mentioned
things are followed in combination.

2. Is there any medicine in allopathy as a preemptive?

A) For COVID 19? Then, none clinically proven at present. Follow COVID
appropriate behaviour. Refer Q1.

3. What is your exact prescription for home isolated patients?

A) Varies on case to case basis. For asymptomatic patients – nothing required.
For mild cases – symptomatic treatment. Monitor saturation and symptoms
progression.

4. Are you following DGHS, IMA , ICMR , AIIMS and WHO guidelines,or are you
following your own? If so please detail and explain your guidelines
A) ICMR, kindly refer to the official website for details, its publicly available.
5. Antibiotics are prescribed to treat only bacterial infections, Then why are you
prescribing them for covid,which is a virus.
A) Not all patients require antibiotics. Kindly refer to your treating doctor if for a
particular patient. When prescribed, it is to treat superadded bacterial infection.

6. Why are you prescribing antibiotics for home isolated patients?

A) Answered above. Varies on individual basis. You can’t generalize a treatment
protocol for everyone. Refer to doctor who has seen the patient.

7. Glycine is extremely sensitive to antibiotics which target folate and blood

glycine levels . They drop severely within a minute of an antibiotic injection.
Some antibiotics can defeat more than 90% of glycine within few minutes of
being administered…Do you disagree with this?
If glycine is inhibitory neuro transmitter in central nervous system, especially in
the spinal card , brain stem ,retina and olfactory, then If there is glycine
deficiency how would these neurotransmitters function?
A) Glycine is a non-essential amino acid, meaning the body can produce its own
glycine as long as it has the required ingredients. As your question mentions,
Glycine levels are affected by drugs which interefere with folate, i.e Folic Acid
Antagonists. Not all antibiotics work through the same pathway. Rest assured,
these drugs/antifolates are not prescribed as first line in general practice.
NOT ALL ANTIFOLATES ARE ANTIBIOTICS, NOT ALL ANTIBIOTICS ARE
ANTIFOLATES.

8. Have you noticed thrombocytopenia (low platelet count) in covid patients ?

Can you tell us what is the reason for this ?
A) There are numerous causes of thrombocytopenia, beyond the scope of this
questionnaire. In view of covid patients, in most patients it would be due to DIC
(Disseminated Intravascular Coagulation), or due to viral infection itself.

9. Do you think there is any effect of antibiotics on platelets ?

A) Kindly read about Drug induced thrombocytopenia. There are many drugs
which are associated with lowering platelet counts, most of which are not even
antibiotics. Doctors see benefit vs risk.

10. What have you studied about the drug induced thrombocytopenia (low
platelet count) ?
A) Wish I had scrolled down a bit earlier. Already answered above. I could write a
20 page essay on “What I have studied”, but its just going to waste my time and
not benefit anyone. Honestly, I have better things to do.

11. Is the covid virus increasing platelet consumption or not ?

A) Answered in question 8. Read about DIC.

12. What are you prescribing to increase platelet production to control internal
bleeding due to low platelet count ?
A) Not everyone with decreased platelets(mild-moderate) is likely to bleed
internally. In severe thrombocytopenia, platelet infusion is considered on a case-
to-case basis.

13. Are blood thinners further depleting platelets or not ?

A) Not in all patients. Heparin induced thrombocytopenia can happen, but still
anticoagulation needs to be considered as we are dealing with a prothrombotic
state. Withdrawal of anticoagulation is done in patients with significant
thrombocytopenia at risk of bleeding.

14. Please tell us about the relation between RTPCR Ct value (viral load) and
disease severity ?
A) The is no established correlation between Ct values and disease severity.

15. Why are you not prescribing any replication inhibitors to control the virus load
in home isolation( first week of infection) ?
A) There is no approved replication inhibitor to be prescribed in the first week of
infection.

16. Why are Hydroxychloroquine and azithromycin are being continued to be

prescribed in india even after the New york trials and WHO clearly concluded that
HCQ is associated with QT interval prolongation ?
A) HCQ is a long known drug even before COVID-19 and its safety and side
effects are established. QT Prolongation is a possible side effect, but can be
monitored, hence the drug is given to non cardiac patients. The demographic
chosen for WHO/Solidarity trial is different from the demographic and
indication/phase the drug is being prescribed to in India. It was initially
considered as an option due to good in vitro results against covid through its
action at ACE-2 receptor site. The efficacy or lack there-of of this drug in mild or
household contacts is yet to be proven/disproven, but given its safety in non
cardiac patients in the dose prescribed, ICMR might have given the benefit of
doubt for its usefulness. Maybe a medical authority involved in the decision
making would be better qualified to answer this, but safety wise, there is no
reason to worry.

17. Why are you prescribing emergency approval drug to a home isolation
patient?
A) Question needs elaboration.

18. Why is Favipiravir still being continued, Why do you feel it’s Emergency
approval still continues?
A) Favipiravir though initially considered in mild-moderate cases to reduce the
duration of illness, is no longer recommended in Indian guidelines.

19. Despite the former japan prime minister’s hype in may 2020 why did the
japan regulatory still not approve Favipiravir ?
A) I’m not really sure what Japan is upto.

20. Why is Favipiravir approved in india and why is this emergency approved
drug still being sold in medical shops ?
A) Addressed in Question 18. Studies have conflicting results with no definite
result. Needs a government medical authority/pharmaceuticals to address this.

21. Why did L and J hospital in Delhi stopped prescribing Favipiravir?

A) Because it is no longer recommended? Refer Q 18.

22. Why are you still prescribing favipiravir even after ICMR and DGHS removed
it from protocol ?
A) Me? No, I’m not. Please refer answer to Q18.

23. While giving plasma therapy are you matching patient and donor blood group
only or patient and donor variant also ? Please give reasons
A) Convalescent plasma therapy in no longer recommended for Covid 19.
24. Can you explain how without matching the variant how is plasma therapy
going to help the patient?
A) Please refer answer to above question.

25. Is cocktail antibody therapy effective against delta plus variant?

A) It is too early to say but current evidence doesn’t look good.

26. What is the protocol you follow to identify and match the variant ?
A) Current medical infrastructure in India doesn’t allow for genomic sequencing
of samples to identify the variant for each patient. Government medical body to
address the issue better.

27. Is Remdesivir helpful after viremia phase (first week of infection) ?

A) Best when used in replication phase, but there is limited evidence with regard
to usage of drug overall in any phase.

28. Are you monitoring AST / ALT after administering remdesvir on a daily
basis ?
A) Depending on patient condition, monitored anywhere between 24 hours to 72
hours.

29. What is the upper limit to discontinue the remdesivir if there is an abnormal
rise in AST and ALT?
A) We take it as 5 times the upper limit of normal for safety purposes.

30. What is the role of tocilizumab in covid ?

A) Has role in managing cytokine storm due to its antagonizing effect on IL-6
receptors.

31. What is the minimum value of IL6 to start tocilizumab in covid ?

A) IL6 is not the only parameter to look for before considering the drug. We take
it as 6 times the normal. There are many confounding factors, so false positives
should be looked for.

32. What is the role of glucocorticoids (steroids) in covid treatment ?

A) Covid causes a pro inflammatory state in the body, so steroids are used for
their anti inflammatory properties in moderate to severe cases.
33. What are the markers to be considered while starting steroid therapy and
what are the minimum values to start steroid treatment ?
A) Inflammatory markers are to be monitored (ESR, CRP, Ferritin, LDH etc)
along with patients clinical condition and comorbidities – preferred in moderate-
severe patients and those at high risk for progression of disease.

34. Are you not monitoring neutrophils to lymphocytes ratio (NLR) at the time of
steroid treatment ?
A) NLR is monitored not only at the time of steroid treatment, but also at the time
of admission of patient to assess severity and risk of disease progression.

35. Do you agree or not,that High neutrophils count results in NETtosois ?

A) Neutrophilia can be one factor associated with increased risk for “NETosis”,
but there are much more important factors at play. High neutrophil count as
factor alone, is inadequate for causing such a response.

36. How will you control spike in neutrophils after giving steroids?
A) Refer to answers above. The proinflammatory state of covid likely causes
Cytokine release syndrome/NETosis. Steroids are given for their anti-
inflammatory role.

37. Since Lymphocytes are the main defence in covid battle , if steroids are
reducing the lymphocytes then how will the patient’s immuno defend against the
virus ?
A) Hence, timing and duration is important. Do not self-prescribe. Steroids are
reserved for moderate to severe cases, to protect from host inflammatory
response.
To put it in your terms, some patients in their battle, enter a stage where their
“main defence” does more harm to the kingdom than the virus you are fighting
against. Steroids are given with the intention to help you recover from that
damage caused by your own immunity.

38. Does glucocorticoid (steroid) affect B cell antibody production are not ?
A) Not all steroids are glucocorticoids, but yes, glucocorticoids have
immunosuppressive activity.
39. If Glucocorticoid(steroid) spikes glucose level, then why is glucocorticoid
being prescribed to a diabetic patinent ? is there any alternative ?
A) The purpose of using steroids has been answered above. That host
inflammatory response for a diabetic patient and the role of glucocorticoids in
diabetics remains the same. Such patients are advised admission to a hospital,
regular blood sugar level monitoring and insulin as required if uncontrolled.

40. Isn’t steroid treatment the root cause of different fungal infections ?
A) Fungal infections in patients who previously were treated for Covid are being
increasingly observed in those who have received steroids for a particularly long
time, and also had Diabetes. But a short course of steroids is still indicated in
patients who are oxygen dependent and show evidence of inflammation. The
best practice would be to control the blood sugar levels along with following
hygiene.

41. What is the dosage of steroid to be administered for a particular range of

IL6 ?
A) There is no such formula for dosage of steroid to be administered at a
particular IL-6 level. The false positives of IL 6 have already been mentioned in
one of the answers above. The weight-based dosage of steroid in indicated
cases can be easily referred to from the ICMR website publicly available, but I
would refrain from mentioning it here as I don’t want people self-medicating.

42. Why are allopathic doctors reluctant in integrating allopathic and herbal
medicine ?
A) I cannot speak for everyone. Herbal medicine is not without side effects, we
have seen patients land up in fulminant hepatic failure. No one would be against
anything/reluctant if there are enough properly conducted studies on such
alternative forms of medicine, their efficacy, side effects and complications.

43. Why are so many allopathic doctors reluctant to replace ambroxol with
bromhexine syrup?
A) Because, currently there is no evidence to support that bromhexine has any
prophylactic or therapeutic benefit.And public aren’t guinea pigs to test out our theories on. Weird, right?

44. Why are doctors reluctant to replace low dose steroid with GOUTNILL?
A) Colchicine was studied for its possible benefit in patients with Covid 19.
Studies so far have failed to show significant benefit, where as steroids have
been effective.

45. Are you aware of the press release on February 4th 2021 by ivermectin
manufacturer MERCK ?
A) Yes.

MY ADDITIONAL QUESTIONNAIRE FOR DOCTORS REGARDING

THIRD WAVE / DELTA PLUS THREAT

46.Do you or not anticipate that third wave may hit India ?
A) Would be better answered by an epidemiologist.

47.Which variant would trigger and will be the dominant variant during third
wave?
A) It is too early to tell which variant, when the 2nd wave hasn’t ended. Better
answered by an epidemiologist.

48.There is an anticipation that third wave may affect kids on a large scale, what
is your opinion on this?
A) Third wave, if & when occurs, can affect anybody. Vulnerable groups, those
not vaccinated or those not previously affected by the disease are likely to be
affected the most.

49.What are the major factors that will make kids more vulnerable in third wave ?
Can you tell us about your supporting studies regarding this ?
A) Kindly refer to the answer above.

50.Do you think it is their ignorance that so many different countries are
panicking about delta plus variant ?
A) Would be better answered by an epidemiologist/government body.

51.Can you tell us the mutations in delta plus variant, and what the clinical
significance of those mutations are?
A) Delta plus variant has K417N mutation in its spike protein, hypothesized to
contribute to its immune escape.
52.Have you studied any autopsy report of a delta variant patient ? what are your
findings ?
A) Honestly, no. Autopsy reports are not made available to us as far as I know.

53.P681R mutation in delta plus variant increased syncytia and lympho

elimination in Japanese study ..How will you address this issue?
A) This is not unique just to P681R and delta plus, but covid in general.

54.Is delta plus variant reporting or not low RTPCR Ct value ( high viral load) ?
A) I’m unsure of any such thing, we are currently not giving emphasis to ct values
for treatment. Also, the variant reporting/genomic sequencing is inadequate to
establish a correlation.

55.What is your treatment protocol for delta plus variant?

A) As already stated, genomic sequencing in inadequate to establish a variant
and give variant targeted treatment. The treatment protocol for covid has not
changed for now and is what is being followed. The best practice is to prevent
transmission through covid appropriate behaviour, refer question 1.

56.What replication inhibitors are recommended to manage viral load in kids and
adults?
A) Treatment with replication inhibitors or any drug for that matter is currently
based on clinical severity of the disease and not on viral load. Viral load does not
correspond to disease severity.

57.Are steroids recommended for delta plus variant which consist of P681R
mutation causing lympho elimination?
A) Already answered in two of the questions above and also in the question
about when steroids are indicated.

THE ABOVE ARE MY QUESTIONS FOR NOW..WILL KEEP ASKING AS

SITUATION CHANGES