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Fragile Bird

Stayin' Alive - Covid-19 #10

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1 hour ago, Fragile Bird said:

There are pages and pages of links to studies about cholesterol levels in patients fighting infections, this is just one of many that saw a relationship between cholesterol levels and the ability to fight infections. The fact they are renal patients is irrelevant, the way cholesterol works in your body doesn't change because you are a renal patient.

I don't like just jumping in, but... chronic kidney disease can have a substantial effect on lipid metabolism and production, not least because proteinuric CKD tends to be complicated by increase production. I have never encountered any substantive literature that higher cholesterol has some sort of protective effect on infectious risk or host-response generally. That doesn't mean I can't be wrong about that, but CKD (and end-stage renal disease in particular) certainly matters, particularly with comorbid conditions like diabetes and atherosclerosis. The study you quoted also suggested that all-cause mortality was if anything decreased by dyslipidemia. I very much doubt that is the case. 

1 hour ago, Fragile Bird said:

I am not making any claims about Covid-19 patients with the link. Chinese researchers reported that after looking at 2,000 blood samples they found people with higher levels of cholesterol dealt with Covid-19 better. 2,000 samples was obviously a big enough sample they thought they should report it. The possible role cholesterol plays in fighting infections has been studied for decades. There was a study from the 1990s that I looked at last week when I first mentioned the Chinese story, of residents in nursing homes showing better outcomes fighting the flu in patients with higher cholesterol levels. No Covid-19 back then, either. That does not mean it's irrelevant.

#confounders

These are retrospective case series only. Baseline nutritional status, on the other hand, mitigates against frailty and provides greater physiologic reserve in the face of infection and other disease. 

1 hour ago, Fragile Bird said:

Cardiovascular disease and kidney disease can be linked, which is why cholesterol levels are studied in both cases. High blood pressure can force the heart to work harder, damaging the heart and damaging kidneys because more blood is being pushed through the kidneys. In many renal patients it's a chicken or egg situation, did the patient have damaged kidneys because they had high blood pressure, or high blood pressure because they had damaged kidneys. (My mom was a dialysis patient for many years).

Chronic kidney disease tracks fairly well with atherosclerotic risk. Dialysis patients in particular are prone to this and often has some of the worst outcomes. 

1 hour ago, Fragile Bird said:

Not all people with CVD develop kidney problems, and not all kidney patients develop CVD. Research has shown that dialysis patients with higher cholesterol have fewer hospitalizations and live longer than dialysis patients with lower cholesterol. I'm pretty sure not only the Chinese are going to study cholesterol levels in Covid-19 survivors, because cholesterol does appear to play a role in fighting infection. 

I don't know what this research is, but I can imagine this has at least a bit to do with the fact that people with higher CV risk also have lower LDL targets. Unsurprisingly, people with established coronary artery disease who we try to suppress LDL < 1.8 are overall going to have higher morbidity and mortality. I don't think this statements squares with the literature at all. More important lab findings predicting poorer outcome in COVID-19 include signs of excessive inflammatory response with high serum Ferritin, IL-6, and d-Dimer levels (we've put some of these on our admission order sets). We also know that people with significant comorbid disease fare worse (not all that surprising). 

(Consider: 

PMID: 22910937

"Benefits and harms of statin therapy for persons with chronic kidney disease: a systematic review and meta-analysis."
Palmer SC, Craig JC, Navaneethan SD, Tonelli M, Pellegrini F, Strippoli GF 
Ann Intern Med. 2012;157(4):263.)

43 minutes ago, Mudguard said:

I can see a biochemical reason for high levels of cholesterol and lipids helping for COVID-19 patients.  COVID-19 ravages the lung tissues, which have a huge surface area, which means very large numbers of cells are damaged or destroyed and need to be repaired or replaced.  The cell membrane is made of lipids, cholesterol, and other materials, so having enough of these materials on hand would be helpful for recovery.

Lipid levels tell you something about lipid metabolism, not nutritional status generally. The key to supporting COVID-19 patients - and critically ill people generally - is aggressive supportive care including enteral nutrition. For people whose GI tract isn't working properly, we do add lipid preparations alongside TPN. 

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Posted (edited)

Thanks for that, @Aemon Stark!  Btw, how goes the battle in your neck of the woods?

I am wondering if this paper in the Lancet is what the story was referring too.  The story was written for the lay person, the summary to this paper is not.

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3544826

Edited by Fragile Bird

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Posted (edited)
48 minutes ago, Mudguard said:

What do you mean by this exactly?  I think that I might be able to guess, at least partly of what you mean, but I don't want to assume.

Every country except a relative handful will attempt to control the virus at a level that does not overload the health care system but is otherwise as loose as is possible. Rather than going full lockdown every time things get past test-and-trace, I think most countries will accept that there's a certain amount of spread that will have be tolerated that extends beyond what testing and tracing regimens are simply capable of. That's my view of where this is going.

 

Especially in the US. And not even through Trump's incompetence or malfeasance, but because the United States is a place where you aren't even obligated to provide identification to authorities in most states. The idea that we're going to able to pervasively track and identify carriers within state boundaries, much less across them, in the time it takes this thing to spread a few times is fantastical.

Paul Romer, whom Yglesias mentioned in the embedded tweet, is talking about the US building up the ability to take and process 100 million tests per week to combat a virus that will not be stomped out. It's absurd. The flu season in 2017-2018 may have killed 61,000 Americans, according to the CDC, and it's just something we accept and approach from the perspective of reasonable mitigation.

COVID-19 will also be the subject of reasonable mitigation as we keep seeing these outbreaks, especially if the vaccines people talk about are a pipe dream. I thought vaccination was time consuming but relatively easy, but reading more about it, we have basically never created a coronavirus vaccine before. Not even for SARS. It'd make more sense to try variolation techniques than to hold out hope for a vaccine that may never come and, in any case, may be all rather moot ~12 - 18 months out if most of the world has gone through infection anyways.

Edited by Ran

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7 minutes ago, Ran said:

Paul Romer, whom Yglesias mentioned in the embedde tweet, is talking about the US building up the ability to take and process 100 million tests per week to combat a virus that will not be stomped out. It's absurd. 

Why is it absurd? When you look at the cost of an extended lockdown, or look at the cost of hundreds of thousands of deaths, why not consider the cost of an extraordinarily expansive testing regime instead? It might very well be the cheapest option, and by orders of magnitude.

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6 minutes ago, Fez said:

Why is it absurd? When you look at the cost of an extended lockdown, or look at the cost of hundreds of thousands of deaths, why not consider the cost of an extraordinarily expansive testing regime instead? It might very well be the cheapest option, and by orders of magnitude.

Is it physically possible to do that many tests? Presumably you'd need enough qualified people and specialised equipment to actually process the tests. I'd guess there probably isn't enough of either to do anything like 100 million tests and there's probably a good chance even throwing vast amounts of money at the problem wouldn't change that in anything like the time frame needed for it to be useful.

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Depends a lot on the kind of testing we're doing. 100 million tests a week is probably close to the total test capacity of the US for ALL kinds of bloodwork, so that's unreasonable. 5 million a week, if the test was made a bit better and didn't require both specialized labs and specialized lab workers? Probably far closer to reasonable. 

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23 minutes ago, Ran said:

Every country except a relative handful will attempt to control the virus at a level that does not overload the health care system but is otherwise as loose as is possible. Rather than going full lockdown every time things get past test-and-trace, I think most countries will accept that there's a certain amount of spread that will have be tolerated that extends beyond what testing and tracing regimens are simply capable of. That's my view of where this is going.

Especially in the US. And not even through Trump's incompetence or malfeasance, but because the United States is a place where you aren't even obligated to provide identification to authorities in most states. The idea that we're going to able to pervasively track and identify carriers within state boundaries, much less across them, in the time it takes this thing to spread a few times is fantastical.

Paul Romer, whom Yglesias mentioned in the embedded tweet, is talking about the US building up the ability to take and process 100 million tests per week to combat a virus that will not be stomped out. It's absurd. The flu season in 2017-2018 may have killed 61,000 Americans, according to the CDC, and it's just something we accept and approach from the perspective of reasonable mitigation.

COVID-19 will also be the subject of reasonable mitigation as we keep seeing these outbreaks, especially if the vaccines people talk about are a pipe dream. I thought vaccination was time consuming but relatively easy, but reading more about it, we have basically never created a coronavirus vaccine before. Not even for SARS. It'd make more sense to try variolation techniques than to hold out hope for a vaccine that may never come and, in any case, may be all rather moot ~12 - 18 months out if most of the world has gone through infection anyways.

It's certainly possible that lockdowns are going to be ended, and what remains is a set of less stringent mitigation measures.  We can't keep this up for another 12 months.  China is an interesting test case, since they've recently eased the lockdown of Wuhan, so it will be interesting to see how well they can keep the virus in check.  Unfortunately, we didn't or can't replicate the severity of China's lockdown, so I'm skeptical that we can get case numbers down low enough for containment measures to be even feasible.

I don't think lockdowns are going away.  In a densely populated area, an outbreak can quickly overwhelm the local health care system, making a lockdown necessary.  For a less densely populated area where the R0 is naturally lower, as in Sweden, it's possible that lockdowns are not needed, but that remains to be seen.  

Hitting the sweet spot where your health care system can indefinitely keep up with new cases is extremely difficult because no one really has a good idea how effective the various mitigation measures are, and you have to wait around a month after implementation to see an effect.  In addition, all our models have a huge degree of error built into them.  We are talking about numbers of deaths that can vary by one or more orders of magnitude.  A wrong assumption on the degree of effectiveness of the current mitigation measures, even if small, could mean many more cases than expected, due to the nature of exponential growth.

As bad as things are now, consider how bad things would be if we have to rely on reaching herd immunity, which is roughly 50% of the population immune after recovering from infection.  The population of the earth is around 7.5 billion.  Currently, there are about 1.5 million confirmed cases, so if you assume that we only detect 20% of the cases, that would mean there's currently about 7.5 million cases.  That's just 0.1% of the population infected.  To reach herd immunity worldwide, we would need 500 times more people to get infected.  Current deaths stands at roughly 90,000, with the caveat that of the current 1.5 million confirmed cases, 1.1 million cases are active, which means the 90,000 number is just a rough baseline.  90,000 times 500 is 45 million dead, at a minimum, which also excludes the under-reporting of COVID-19 deaths that we are seeing worldwide.  

Anything we can do to avoid this scenario should be attempted.  It's possible that we fail, and herd immunity is the path that we all end up on, but I don't think it's a given yet.

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4 hours ago, Jen'ari said:

TB seems to be something that doesn’t get thought of as still being around much, well in the U.K. anyway, I know it is much more prevalent in the developing world still.

I’m not too knowledgeable on the treatments, is it similar to Syphilis in that it’s a very long antibiotic treatment that spans several months I’m guessing?.

TB gets imported to the UK from places where the healthcare infrastructure isn't quite as good. It's still around. 

Treatment is five different drugs for six months. Compliance for that is a massive issue, as you can imagine. 

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Posted (edited)

edit

Edited by Raja

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    . . . . There is a classic sfnal scenario about what this all means, especially for our now present and future. There were many variations which were in movies, tv, print entetainment and / or warning  between about the 1930's and whenever lock step in grey 1984-Brave New Worlds and other variations were no longer anyone feared because the commiesocialist baddies had been so beaten. But here again is the variation of what was so inspired by certain people's ideas of what it was like in China and Asia then.

Quote

Wuhan emerged from its 76-day lockdown.
Eleven million residents have been given the liberty to move around the city and mainland country again, provided their government-issued “health code” shines green. People are assigned a green, orange or red code, according to their risk of having the coronavirus, and must scan a green QR code before they can enter stores or restaurants, or take public transportation — an electronic passport for daily life. (Anna Fifield and Lyric Li)

Everything feels very strange at the moment. I mean, wot the hell. I mean this is what They Said FDR, Obama, etc, were going to do to us, but it was, as we knew, what They wanted to do to us.

I mean, this is the sfnal template, not the cozy disaster in which the nice people who matter and have relatives who are Super Competents in the military and sciences and they put it all back together even better than before (though they caused it in the first place) and ride in on USA helicopters with vast supplies and ferry their family members and their new community of other super competents back to where civilization has been reinstituted, along with elections.  And even out there at rich country relatives house, summer home, they manage to do well, and certainly well enough and are from the gitgo the defacto leaders of this improvised disaster community -- and everybody else is just, I dunno? collateral damage?

 

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3 hours ago, Fragile Bird said:

Thanks for that, @Aemon Stark!  Btw, how goes the battle in your neck of the woods?

I am wondering if this paper in the Lancet is what the story was referring too.  The story was written for the lay person, the summary to this paper is not.

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3544826

There's a bit over 200 cases in NL now, mostly not hospitalized, and our area has so far been largely spared. For now. 

I think the lipid thing is interesting, because there is retrospective data in the dialysis population regarding outcomes and lipid levels. But it's very hard to know what that means; they tend to be high risk at baseline for infectious and vascular complications, among other things. 

There's still much we don't know about this virus. 

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53 minutes ago, Aemon Stark said:

There's a bit over 200 cases in NL now, mostly not hospitalized, and our area has so far been largely spared. For now. 

I think the lipid thing is interesting, because there is retrospective data in the dialysis population regarding outcomes and lipid levels. But it's very hard to know what that means; they tend to be high risk at baseline for infectious and vascular complications, among other things. 

There's still much we don't know about this virus. 

If you are talking about the Netherlands I think you mean 20,000 not 200.

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Posted (edited)
12 hours ago, Toth said:

Day 23 of the lockdown. I... I'm afraid my body starts to dissolve into a heap of pain. While I am a big couch potato, this amount of sitting at the laptop that I am doing right now is truly ridiculous. Because I have started to fight with constant neck pain and headaches I have started to pick up jogging again yesterday. After a small jog and a shower my pain is like blown away, but over the course of the day and into the night till the next morning it slowly returns. This happened yesterday and this happened today, with me already having my headache back. This... this is super frustrating... I guess I have to look for stuff I can do inside to work on my fitness, but here I have to deal with my usual anxiety attacks that prevent me from doing any exercise for fear of getting seen. Gah...

I am feeling the effects as well..Never ever had so much work every day just for academical issues......but here we can't go jogging as you know.

Well....I have never thought people actually wants or doesn't want to see you go jogging...so don't worry for that. You are just self-conscious. It's not real. And I bet now it would be the least of their priorities...

However training inside should be more admisable now probably.

Edited by Meera of Tarth

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4 hours ago, Ran said:

Every country except a relative handful will attempt to control the virus at a level that does not overload the health care system but is otherwise as loose as is possible. Rather than going full lockdown every time things get past test-and-trace, I think most countries will accept that there's a certain amount of spread that will have be tolerated that extends beyond what testing and tracing regimens are simply capable of. That's my view of where this is going.

 

Especially in the US. And not even through Trump's incompetence or malfeasance, but because the United States is a place where you aren't even obligated to provide identification to authorities in most states. The idea that we're going to able to pervasively track and identify carriers within state boundaries, much less across them, in the time it takes this thing to spread a few times is fantastical.

Paul Romer, whom Yglesias mentioned in the embedded tweet, is talking about the US building up the ability to take and process 100 million tests per week to combat a virus that will not be stomped out. It's absurd. The flu season in 2017-2018 may have killed 61,000 Americans, according to the CDC, and it's just something we accept and approach from the perspective of reasonable mitigation.

COVID-19 will also be the subject of reasonable mitigation as we keep seeing these outbreaks, especially if the vaccines people talk about are a pipe dream. I thought vaccination was time consuming but relatively easy, but reading more about it, we have basically never created a coronavirus vaccine before. Not even for SARS. It'd make more sense to try variolation techniques than to hold out hope for a vaccine that may never come and, in any case, may be all rather moot ~12 - 18 months out if most of the world has gone through infection anyways.

There was an interesting interview with one of the teams here in Australia working on the development of a vaccine. They had been involved in initial research into the development of a vaccine against SARS and MERS but that development didn't proceed because both those outbreaks were successfully contained, not because they didn't believe that a vaccine wasn't possible. Obviously, the development of a vaccine is consuming of both funding and time.

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Very early to come to a solid conclusion, but 2 weeks to the day that our lockdown started we see a precipitous drop in daily cases from 50 new cases yesterday to 29 new cases today. I'm predicting this significant drop will continue and keep dropping now that the 2 week incubation period of pre-lockdown exposure has ended and we start to see the true benefit of the lock down. I expect if we collectively keep up the discipline we should be down below 10 cases per day by the end of the next 2 weeks.

The question now is how do we button off without getting a rebound in daily cases.

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3 hours ago, Zorral said:

    . . . . There is a classic sfnal scenario about what this all means, especially for our now present and future. There were many variations which were in movies, tv, print entetainment and / or warning  between about the 1930's and whenever lock step in grey 1984-Brave New Worlds and other variations were no longer anyone feared because the commiesocialist baddies had been so beaten. But here again is the variation of what was so inspired by certain people's ideas of what it was like in China and Asia then.

Everything feels very strange at the moment. I mean, wot the hell. I mean this is what They Said FDR, Obama, etc, were going to do to us, but it was, as we knew, what They wanted to do to us.

I mean, this is the sfnal template, not the cozy disaster in which the nice people who matter and have relatives who are Super Competents in the military and sciences and they put it all back together even better than before (though they caused it in the first place) and ride in on USA helicopters with vast supplies and ferry their family members and their new community of other super competents back to where civilization has been reinstituted, along with elections.  And even out there at rich country relatives house, summer home, they manage to do well, and certainly well enough and are from the gitgo the defacto leaders of this improvised disaster community -- and everybody else is just, I dunno? collateral damage?

 

The Chinese government is pretty fucked up.  There’s plenty out there about the shit they’ve done in Xinjiang, and IMO (and there’s available evidence for this opinion), they are gearing up to go country-wide on the tech based surveillance system they’ve been honing in Xinjiang against the Uyghur's.  China is legitimately on the brink of becoming a highly functioning sci-fi style surveillance state dystopia...  and they’d love to export that system.  

I cannot stand Trump and I have a lot of problems with the way he goes about it, but a tough stance on Xi’s China is not unwarranted.  America has a myriad of problems but if it’s between us (or, say, the West in general) leading the way into the future vs. China, I don’t think that’s a hard call at all.  I have no problem being friendly with China and trading with them, but we really should ensure that we do not depend on them for anything critical.  And we should serve as a check on their ambitions.  

Trump kind of approaches China from a somewhat bizarre trade deficit perspective, but it’s really a national security issue.  China is the big reason why Trump alienating our actual allies with his boorishness makes me so squeamish.  A global community in an era increasingly driven by technology with a dominant China (at least with their current government) is seriously scary. 

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Posted (edited)

A co-worker of an aunt of mine who had a very mild case and no symptoms for 10 days was tested again 16 days after her first positive test and was positive again. This was only done because her doctor made it happen. Other positive co-workers of her with less mild symptoms returned to work 2-4 days after being symptom free without undergoing a test. :(

For the last two days on my way home from work I walked past a construction site where people work and in hand with each other without any protective equipment. The police drove by one of those times without doing anything. 

At work people ignore the rules all the time unless you are aggressive about protecting yourself and don't shy away from confrontation. 

Most things I, famliy or friends experinced in the last few weeks don't match the narrative my goverment and classic media are telling at all. I dunno if you can call it anything else but propaganda at this point. Message control is what our chancellor calls this I belive(classic media in Austria is controlled by a handful of companies). 

Edited by Luzifer's right hand

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Posted (edited)
5 hours ago, The Anti-Targ said:

Very early to come to a solid conclusion, but 2 weeks to the day that our lockdown started we see a precipitous drop in daily cases from 50 new cases yesterday to 29 new cases today. I'm predicting this significant drop will continue and keep dropping now that the 2 week incubation period of pre-lockdown exposure has ended and we start to see the true benefit of the lock down. I expect if we collectively keep up the discipline we should be down below 10 cases per day by the end of the next 2 weeks.

The question now is how do we button off without getting a rebound in daily cases.

The "If I were in charge" - it would be a staged release of lockdown. Each stage being 3 weeks apart (longer if necessary).

1. Anyone who has had symptoms (whether tested or not) is released from lockdown (but hygeine requirements and social distancing still practiced) - this would show a surge in new infections, but should be small and manageable (certainly well below healthcare capacity); with testing and contact tracing. Maybe include something like the South Korean app using bluetooth data as a prerequisite for release.

2. Allow a new category of "sub-essential workers" to be released - so that other occupations can return to work - especially those who cannot work from home; but require strict hygeine guidelines for them - again, this would show a surge in new infections again, which should be manageable with test and contact tracing. This would need to be tracked very carefully to ensure that any surge is kept small.

3. Allow other workers to be released - and again, strict hygeine, track and trace measures.

4. Lockdown is released (barring vulnerable people), but national borders are still secured - track and trace.

5. Gradually ease off on the hygeine and social distancing measures -track and trace.

6. Vaccine found and distributed OR herd immunity otherwise gained.

7. Gradually re-open national borders, initially to countries with successful vaccine programs &/ herd immunity also reached. This is the time to release the vulnerable popultion.

 

But the situation will be fluid, and the government would need to publicise both the plan, and the fact that it's not a linear process, and that they may need to tighten things up again based on the data on the ground - especially if a surge is bigger or faster than expected. You need to be well into the downside of any slope before triggering the next phase - so 3 weeks minimum (preferably more), as the data is always going to be 2 weeks behind what's happening, and you need a good 3-4 days worth of results to know you're looking at a trend, not a fluke.

The bigger the population, and the larger the land border - the tougher it's all going to be.

Edited by Which Tyler

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