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Post by matt@IAA on Apr 9, 2020 20:54:42 GMT -6
Except that it really doesn't (not with this disease, anyway). Which is why the CDC has (quietly, I guess they're embarassed) withdrawn all support for its use against Covid-19 And what "proposed methods of action" means, translated into English, is that they're really just guessing, they don't know, and there's no proof. Incidentally, IL6 IS interleukin 6. IL6 is just an abbreviation. What part of anything that I wrote makes you think that I don't know that IL6 is an abbreviation for interleukin 6? We don't know the method of action for a TON of drugs that we use regularly with success. Proposed method of action means - why it might work. I agree there's no proof, but there's anecdotal evidence, and we have a few clinical trials done now (randomized, not the initial one which was garbage). So far it looks like it helps clear up pneumonia faster on CT, but all of the finished studies have been small sample size. My guess is that it will be useful (if at all) for prophylaxis and to speed recovery of minor cases, but no effect on mortality. Anecdotally it doesn't help with severe cases. Anyway, here's a third method of action. i.imgur.com/aKYMFfJ.jpgThis curve shows how O2 binds to hemoglobin. It uses a prophyrin structure to bind to O2. Thats the Y axis. The rest of the oxygen is dissolved in the blood - thats PO2 on the x axis of the chart. There's a relationship between the two. As you increase PO2 you have diminishing returns, and once you hit PO2 above 60 mm Hg, you don't get any more oxygen binding to hemoglobin. Some diseases can cause that curve to shift left or right. CO poisoning shifts it to left. Sepsis shifts it to the right. COVID19 causes low PO2 because of damage to the lungs. It also may interfere with O2 binding to the porphyrin structure. Either way causes a curve shift left. Why, we don't know. But it causes less oxygen to get to your tissues, which leads to organ failure. Hydroxychloroquine is used for porphyria and has a known effect on O2 and hemoglobin. It, quinine, methylene blue all are known to shift the curve to the right. Anyway chloroquine inhibits Ebola virus in vitro but not for adults. Sometimes medicine is weird an not obvious. |
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Post by matt@IAA on Apr 9, 2020 20:57:50 GMT -6
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Post by Tbone81 on Apr 9, 2020 21:12:09 GMT -6
Except that it really doesn't (not with this disease, anyway). Which is why the CDC has (quietly, I guess they're embarassed) withdrawn all support for its use against Covid-19 And what "proposed methods of action" means, translated into English, is that they're really just guessing, they don't know, and there's no proof. Incidentally, IL6 IS interleukin 6. IL6 is just an abbreviation. What part of anything that I wrote makes you think that I don't know that IL6 is an abbreviation for interleukin 6? We don't know the method of action for a TON of drugs that we use regularly with success. Proposed method of action means - why it might work. I agree there's no proof, but there's anecdotal evidence, and we have a few clinical trials done now (randomized, not the initial one which was garbage). So far it looks like it helps clear up pneumonia faster on CT, but all of the finished studies have been small sample size. My guess is that it will be useful (if at all) for prophylaxis and to speed recovery of minor cases, but no effect on mortality. Anecdotally it doesn't help with severe cases. Anyway, here's a third method of action. i.imgur.com/aKYMFfJ.jpgThis curve shows how O2 binds to hemoglobin. It uses a prophyrin structure to bind to O2. Thats the Y axis. The rest of the oxygen is dissolved in the blood - thats PO2 on the x axis of the chart. There's a relationship between the two. As you increase PO2 you have diminishing returns, and once you hit PO2 above 60 mm Hg, you don't get any more oxygen binding to hemoglobin. Some diseases can cause that curve to shift left or right. CO poisoning shifts it to left. Sepsis shifts it to the right. COVID19 causes low PO2 because of damage to the lungs. It also may interfere with O2 binding to the porphyrin structure. Either way causes a curve shift left. Why, we don't know. But it causes less oxygen to get to your tissues, which leads to organ failure. Hydroxychloroquine is used for porphyria and has a known effect on O2 and hemoglobin. It, quinine, methylene blue all are known to shift the curve to the right. Dogears, I gotta say I'm impressed with your knowledge of this stuff. I'm a respiratory therapist, and I'm a little floored that anybody would pull up the Oxy/hemoglobin curve and actually understand it!
For what its worth, keeping covid patients adequately oxygenated is going pretty well for us. They require high pressures, which we refer to as PEEP, but that's not new to us. It's kind of ARDS 101, treating with high pressures that is. The hardest part is that they have a longer than usual ventilator length of stay. Normally when I extubate someone, if afterwards it looks like they may still have some respiratory distress I'd throw them on bipap or a heated high flow nasal cannula system. But because of the infection risk that comes with aerosolizing through bipap/hfnc we're not using those modalities for COVID patients. That makes everyone nervous when it comes to extubating and results in leaving people on ventilators for even longer (normally we try to extubate as soon as possible). Re-intubating right after extubation can risky as most people have some measure of upper airway swelling post intubation, hence the wait. That's one of the hard parts of this disease. It takes up a disproportionate amount of resources to treat.
One more thing, it may be anecdotal at this point, but its seems that a lot of these ventilated patients are more susceptible to pulmonary fibrosis and ventilator induced lung injury than more typical ARDS patients. I hear a lot of stories like that coming from other states but its hard to make anything of it with out more info.
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Post by matt@IAA on Apr 9, 2020 21:22:35 GMT -6
My wife is a doctor, my best friend and college roommate is a doctor, my grandfather is a doctor, my mother was premed and dropped out when she got pregnant and has spent her career in medicine. I can’t get away from the stuff.
It’s super fascinating to me, but I’m glad I am not responsible for lives. The pressure y’all are under must be taxing. Prayers for you man, you’re doing the Lord’s work for sure. Be safe.
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Post by donr on Apr 9, 2020 22:09:04 GMT -6
I saw this today: If this sample would hold across the general population, it would explain why we haven't seen hell on earth so far. A lot of the population has already been infected and not everybody gets sick. Yeah, lockdown and distancing have helped, but perhaps that's not really what's going on here. I travel a lot, and I think I might have had it already. Waiting for an easy antibody test. chicagocitywire.com/stories/530092711-roseland-hospital-phlebotomist-30-of-those-tested-have-coronavirus-antibody>A phlebotomist working at Roseland Community Hospital said Thursday that 30% to 50% of patients tested for the coronavirus have antibodies while only around 10% to 20% of those tested have the active virus. Sumaya Owaynat, a phlebotomy technician, said she tests between 400 and 600 patients on an average day in the parking lot at Roseland Community Hospital. Drive-thru testing is from 9 a.m. to noon and 1 to 4 p.m. each day. However, the hospital has a limited number of tests they can give per day. Owaynat said the number of patients coming through the testing center who appear to have already had coronavirus and gotten over it is far greater than those who currently have the disease. Sumaya Owaynat “A lot of people have high antibodies, which means they had the coronavirus but they don’t have it anymore and their bodies built the antibodies,” Owaynat told Chicago City Wire. Antibodies in the bloodstream reveal that a person has already had the coronavirus and may be immune to contracting the virus again. If accurate, this means the spread of the virus may have been underway in the Roseland community - and the state and country as a whole - prior to the issuance of stay at home orders and widespread business closures in mid-March which have crippled the national economy. In addition, those who show signs of already having had the illness should be able to re-enter society -- albeit with some modified social distancing measures in place -- rather than sheltering at home as they are no longer in danger. Of those who contract the coronavirus, around 25 percent may be asymptomatic. A recent study of 1,000 people in the Heinsberg District of Bonn, Germany found that 15% of the population had contracted the virus, many unknowingly and without symptoms. Of those, only 0.37% died from COVID-19, a figure much lower than those previously cited.< |
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Post by svart on Apr 10, 2020 12:05:27 GMT -6
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Post by donr on Apr 10, 2020 12:15:39 GMT -6
In March, much more virus was found in MA wastewater than was estimated for the number of Covid cases reported. Either there was many cases about to explode, or there are many infections that don't exhibit symptoms or illness. A study in the Netherlands showed similar results. www.statnews.com/2020/04/07/new-research-wastewater-community-spread-covid-19/>A series of crucial setbacks in Covid-19 testing has made it difficult to keep up with the virus’ rapid spread, and has inspired some researchers to look to wastewater to help fill in the gap of measuring how prevalent SARS-CoV-2 is in a given community. In a paper posted Tuesday to the preprint server medRxiv, researchers collected samples in late March from a wastewater treatment plant serving a large metropolitan area in Massachusetts and found that the amount of SARS-CoV-2 particles in the sewage samples indicated a far higher number of people likely infected with Covid-19 than the reported cases in that area. Researchers from biotech startup Biobot Analytics, working with a team from Massachusetts Institute of Technology, Harvard, and Brigham and Women’s Hospital, estimate there were at least 2,300 people infected with Covid-19 in the area around the treatment facility. But at the time of analysis, which has not yet been peer-reviewed, there were 446 cases officially reported in that area. A series of crucial setbacks in Covid-19 testing has made it difficult to keep up with the virus’ rapid spread, and has inspired some researchers to look to wastewater to help fill in the gap of measuring how prevalent SARS-CoV-2 is in a given community. In a paper posted Tuesday to the preprint server medRxiv, researchers collected samples in late March from a wastewater treatment plant serving a large metropolitan area in Massachusetts and found that the amount of SARS-CoV-2 particles in the sewage samples indicated a far higher number of people likely infected with Covid-19 than the reported cases in that area. Researchers from biotech startup Biobot Analytics, working with a team from Massachusetts Institute of Technology, Harvard, and Brigham and Women’s Hospital, estimate there were at least 2,300 people infected with Covid-19 in the area around the treatment facility. But at the time of analysis, which has not yet been peer-reviewed, there were 446 cases officially reported in that area. . . .< |
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Post by matt@IAA on Apr 10, 2020 13:05:13 GMT -6
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Post by svart on Apr 10, 2020 13:07:39 GMT -6
In March, much more virus was found in MA wastewater than was estimated for the number of Covid cases reported. Either there was many cases about to explode, or there are many infections that don't exhibit symptoms or illness. A study in the Netherlands showed similar results. www.statnews.com/2020/04/07/new-research-wastewater-community-spread-covid-19/>A series of crucial setbacks in Covid-19 testing has made it difficult to keep up with the virus’ rapid spread, and has inspired some researchers to look to wastewater to help fill in the gap of measuring how prevalent SARS-CoV-2 is in a given community. In a paper posted Tuesday to the preprint server medRxiv, researchers collected samples in late March from a wastewater treatment plant serving a large metropolitan area in Massachusetts and found that the amount of SARS-CoV-2 particles in the sewage samples indicated a far higher number of people likely infected with Covid-19 than the reported cases in that area. Researchers from biotech startup Biobot Analytics, working with a team from Massachusetts Institute of Technology, Harvard, and Brigham and Women’s Hospital, estimate there were at least 2,300 people infected with Covid-19 in the area around the treatment facility. But at the time of analysis, which has not yet been peer-reviewed, there were 446 cases officially reported in that area. A series of crucial setbacks in Covid-19 testing has made it difficult to keep up with the virus’ rapid spread, and has inspired some researchers to look to wastewater to help fill in the gap of measuring how prevalent SARS-CoV-2 is in a given community. In a paper posted Tuesday to the preprint server medRxiv, researchers collected samples in late March from a wastewater treatment plant serving a large metropolitan area in Massachusetts and found that the amount of SARS-CoV-2 particles in the sewage samples indicated a far higher number of people likely infected with Covid-19 than the reported cases in that area. Researchers from biotech startup Biobot Analytics, working with a team from Massachusetts Institute of Technology, Harvard, and Brigham and Women’s Hospital, estimate there were at least 2,300 people infected with Covid-19 in the area around the treatment facility. But at the time of analysis, which has not yet been peer-reviewed, there were 446 cases officially reported in that area. . . .< If people were already shedding virus in such quantities, it's more likely it was sourced from a lot of individuals rather than a handful of infected individuals. Having worked on sewer equipment for years, I know a bit about sewer systems. I'm not sure people understand the sheer amount of flow there is in sewers, even from small areas. If it were simply a few people shedding viruses, they would be quickly diluted and washed away. Any significant buildup would need quite a lot of infected people to be detected in any quantity. Based on this, that would mean the number of asymptomatic infections must have been much higher than assumed for the short period of time before draconian quarantine measures were in place, further putting credence on the understanding that the majority of the population was at least exposed well before social distancing was enacted. |
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Post by matt@IAA on Apr 10, 2020 13:49:08 GMT -6
The “everyone already has it” theory will be able to be precluded pretty quickly as fatalities rise. You have high infectiousness or high fatality, but not both. At some point the number of deaths puts an absolute floor on CFR as denominator approaches total population.
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Post by geoff738 on Apr 10, 2020 13:51:01 GMT -6
Does this suggest the incubation period for those that do fall ill and present symptoms might be longer than the week to two weeks, given the biggest surge in North America is happening now?
Some worrisome signs that those that have recovered are able to catch this again. I don’t have a link at hand but this was coming out of South Korea.
Cheers,
Geoff
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Post by chessparov on Apr 10, 2020 14:03:02 GMT -6
FWIW it's seeming like the main wave of the Virus, already swept through Orange County, CA...
Here between December and the end of February. Because they weren't testing for it until recently.
I know of some deaths, where the Patient had it, but the Hospital didn't rule it as that.
Until the patient's family, had them tested, before they died.
My limited understanding is veering towards the primary factors here were a combination of "Herd Immunity"/Stay at Home Policy/Social Distance, that kept the Orange County area... Having less than 3% of the fatalities, compared to NYC, adjusting for population.
We have approximately 3.2 Million people in OC.
Chris
P.S. Thanks again guys, for your input.
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Post by svart on Apr 10, 2020 14:04:24 GMT -6
Does this suggest the incubation period for those that do fall ill and present symptoms might be longer than the week to two weeks, given the biggest surge in North America is happening now? Some worrisome signs that those that have recovered are able to catch this again. I don’t have a link at hand but this was coming out of South Korea. Cheers, Geoff They likely never got totally rid of it to begin with. Viruses have a habit of being biphasic, meaning they can have multiple peaks of infection. Viruses can end up in reservoirs in the body that our immune system can't reach, or be effective in. This isn't something new, but it's something they're seeing in this virus for the first time. It's a common thing that people with the flu or colds will get over the acute sickness and a week or two later feel like it's coming back and they it'll go away. At least for a lot of rhinoviruses, they never truly go away but stay at low levels in the nasal passages causing a lot of "sinus infections" and things. SARS-COV2 could be like that as well. |
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Post by chessparov on Apr 10, 2020 14:15:32 GMT -6
Unfortunately, I suspect this...
Chris
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Post by Tbone81 on Apr 10, 2020 14:19:16 GMT -6
My wife is a doctor, my best friend and college roommate is a doctor, my grandfather is a doctor, my mother was premed and dropped out when she got pregnant and has spent her career in medicine. I can’t get away from the stuff. It’s super fascinating to me, but I’m glad I am not responsible for lives. The pressure y’all are under must be taxing. Prayers for you man, you’re doing the Lord’s work for sure. Be safe. Ahh that makes sense, but family or not you definitely have a great mind for it. I sense a really good practical understanding of this stuff from you. Medicine, like so many other fields isn't practiced the way its taught in text books. There's a pretty big gap between text book/classroom learning and actual clinical practice. And you seem to get that really well. I bet you'd make a great healthcare provider.
Thanks for the kind words btw. The pressure is surreal right now. I'm used to being under extreme pressure, so that's not new, but this is a different kind of stress. I'm not really sure how to describe it, its like a Twilight Zone weirdness/seriousness lol.
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Post by chessparov on Apr 10, 2020 14:46:02 GMT -6
Really appreciate all of you out there, in the Trenches!
Many Thanks, Chris
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Post by svart on Apr 10, 2020 15:15:07 GMT -6
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Post by matt@IAA on Apr 10, 2020 15:43:28 GMT -6
I really hope that’s what we’ll find. If that’s the case have one the sharpest V shaped economic recoveries in history.
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Post by svart on Apr 10, 2020 18:09:10 GMT -6
I really hope that’s what we’ll find. If that’s the case have one the sharpest V shaped economic recoveries in history. Let's hope, but I've seen a lot of chatter about the far left being very unhappy that this isn't yet turning into the Cloward-Piven moment they had hoped for. |
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Post by matt@IAA on Apr 10, 2020 18:34:39 GMT -6
I think most of that is just bullcrap. Some folks can't stop seeing the world through partisan lenses so they assume other people are the same way.
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Post by svart on Apr 10, 2020 19:47:37 GMT -6
I think most of that is just bullcrap. Some folks can't stop seeing the world through partisan lenses so they assume other people are the same way. Agreed. One comment from a rather socialist "friend" of mine to a comment about the amount of deaths being low was "well, now nothing will change" and when I asked what he meant he said "everything will end up going back to the way it was". I mean I kind of knew he'd feel this way, as anti-capitalist as he is, but he's also the same person who has been "Look at how callous Trump has been!! People will die!!" and when I mention that his version of "change" means that a lot more people would have to die to meet the cataclysmic curves and spur on "change", it's a lot of sidestepping and redirection trying to explain how it's all capitalism's fault if people die. For some, callousness is abhorrent.. Unless it serves a political purpose.. And I know he's at least associated with some radical characters who are actively politically involved, mostly for Bernie. That's what I really dislike about the whole thing. |
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Post by the other mark williams on Apr 11, 2020 2:07:55 GMT -6
I really hope that’s what we’ll find. If that’s the case have one the sharpest V shaped economic recoveries in history. Let's hope, but I've seen a lot of chatter about the far left being very unhappy that this isn't yet turning into the Cloward-Piven moment they had hoped for. I have no doubt this may be true. I also have no doubt that if true, it is a very, very small percentage. |
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Post by matt@IAA on Apr 11, 2020 8:02:27 GMT -6
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Post by svart on Apr 14, 2020 9:40:25 GMT -6
www.medrxiv.org/content/10.1101/2020.04.01.20050542v1www.economist.com/graphic-detail/2020/04/11/why-a-study-showing-that-covid-19-is-everywhere-is-good-news"One of the few things known for sure about covid-19 is that it has spread faster than official data imply. Most countries have tested sparingly, focusing on the sick. Just 0.1% of Americans and 0.2% of Italians have been tested and come up positive. In contrast, a study of the entire population of the Italian town of Vò found a rate of 3%. The lack of testing has set off a hunt for proxies for covid-19 infection, from smart-thermometer readings to Google searches for “I can’t smell”. A new paper by Justin Silverman and Alex Washburne uses data on influenza-like illness (ili) to show that sars-cov-2 is now widespread in America. Every week, 2,600 American clinicians report the share of their patients who have ili—a fever of at least 37.8°C (100°F) and a cough or sore throat, without a known non-flu reason. Unsurprisingly, ili is often caused by flu. But many other ailments also produce ili, such as common colds, strep throat and, now, covid-19. The authors assume that the share of these providers’ patients with ili who do have the flu matches the rate of flu tests that are positive in the same state and week. This lets them estimate how many people have ili seriously enough to call a doctor, but do not have the flu—and how many more people have had non-flu ili in 2020 than in prior years. They find that non-flu ili has surged. Its rise has the same geographic pattern as covid-19 cases: modest in states with few positive tests, like Kentucky, and steep in ones with big outbreaks, such as New Jersey. In total, estimated non-flu ili from March 8th to 28th exceeded a historical baseline by 23m cases—200 times the number of positive covid-19 tests in that period. This may overstate the spread of covid-19, since non-flu ili has other causes. It could also be too low, because people with asymptomatic or mild covid-19 would not report non-flu ili. This sounds alarming, but should be reassuring. Covid-19 takes 20-25 days to kill victims. The paper reckons that 7m Americans were infected from March 8th to 14th, and official data show 7,000 deaths three weeks later. The resulting fatality rate is 0.1%, similar to that of flu. That is amazingly low, just a tenth of some other estimates. Perhaps it is just wrong, possibly because the death toll has been under-reported. Perhaps, though, New York’s hospitals are overflowing because the virus is so contagious that it has crammed the equivalent of a year’s worth of flu cases into one week. ■ Sources: “Using ILI surveillance to estimate state-specific case detection rates”, by J. Silverman & A. Washburne; Johns Hopkins CSSE"
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Post by Tbone81 on Apr 14, 2020 11:48:51 GMT -6
I just had my blood drawn for a covid-19 antibody testing study that my hospital is conducting. They're sampling people who have no known symptoms only. Its an 8 week study. It'll be interesting to see how it plays out. I'm guessing a lot more people have been exposed to the virus than is currently known, we'll see.
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