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For WHOm the Bell Tolls - Covid-19 #11

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44 minutes ago, sologdin said:

totally, but with panache.

WOT?  Utterly lacking panache! one can never use dweeb and panache together, you know.

~~~~~~~~~~~~~~~~~~~

 

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2 hours ago, Raja said:

We've had a lot of posts/ talk about therapies that might work for covid19, there was recently a New England Journal of Medicine (NEJM) paper on Remdesivir, to be clear, this wasn't a clinical trial, but I thought I'd share this post so people had an idea on how even research published in a big journal like NEJM needs to be critically evaluated ( and how that is done) before drawing *any* conclusions from it - imo the NEJM shouldn't even be putting stuff like this out

 

I saw one researcher say something to the effect of "I don't think that these results are even interpretable."  I think the upshot was that it's a small enough n and no placebo so one cannot tell if these folks would have improved/recovered with being dosed with Remdesivir. 

My hunch is that Remdesivir is one of the likeliest existing drugs to work, but yes, we need to have the same standard we're bringing up all the time with why Trump should pump the breaks on Chloroquine.

I do not understand though why one would argue that NEJM shouldn't even publish this yet.  Virtually no one outside of the medical research community will read this, and Trump won't start blabbing about Remdesivir (I think*) given his obsession with the other drug.  But as the medical research community builds a case for a therapeutic they probably tend to want to see all the info that they can.  And there is something we can probably conclude pretty safely from this little study too which is that at least it doesn't look like there's some toxic combination where giving Rem to a COVID patient massively worsens their situation.  So this little study at least keeps alive the possibility that these actual bigger trials (like this one) could ultimately show that this drug can be an arrow in the quiver, so to speak.     

 

*Heh, as I finish my post I am recalling that Trump has actually mentioned Rem before, but I think it was in the opening remarks portion that he is just reading and then he doesn't remember it when his sermon portion of the briefing begins.  

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Everything They did and They didn't do was wrong.  And so here we are, the end of the USA as it ever was known.

https://www.nytimes.com/2020/04/11/us/politics/coronavirus-trump-response.html?

Among all everything They did wrong was the pressure to remove the Cuban doctors from Latin America.  Latin America is begging for their Cuban doctors' return -- Cuban health system was their only bulwark against pandemic.

https://www.washingtonpost.com/world/the_americas/coronavirus-cuba-doctors-trump-ecuador-brazil-bolivia/2020/04/10/d062c06e-79c4-11ea-a311-adb1344719a9_story.html?

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It's worth pointing out that most antivirals don't work all that well. So as much as we might find better evidence that stuff like HCQ and Remdesivir help, treatment will still come down to "best supportive care" (supplemental O2, nutrition, lung protective ventilation, proning, etc.). 

On a personal note, I saw a guy in ER yesterday with symptoms/risk factors (international travel) and a previous negative swab. He's doing a bit worse, so needed to get admitted, and of course we swabbed him again. 

(drumroll)

Positive! COVID-19 detected. 

It really does to show that repeat testing can be/is necessary. I wonder how many cases like this there have been - I really don't know. Suffice it to say, I was sufficiently concerned about the possibility that I was wearing ++PPE including double gloves (and he wasn't coughing or especially symptomatic otherwise). 

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Here's a bit more on that Remdesivir study from Vox that rounds up quotes from few professionals.

 

 

 

Quote

 

“We cannot draw definitive conclusions from these data, but the observations from this group of hospitalized patients who received remdesivir are hopeful,” said Jonathan Grein, lead author of the analysis and director of hospital epidemiology at Cedars-Sinai Medical Center in Los Angeles, in a statement from Gilead. “We look forward to the results of controlled clinical trials to potentially validate these findings.”

“Results are indeed hopeful and promising from this uncontrolled remdesivir intervention study,” tweeted Eric Feigl-Ding, an epidemiologist and health economist at the Harvard T. H. Chan School of Public Health. “TRIALS TRIALS TRIALS PLEASE,” he added.

Paul Goepfert, an infectious disease specialist at the University of Alabama at Birmingham, told the Washington Post that “It’s still a promising drug, but it doesn’t definitively prove anything.” He added, “The main thing you can gather from this study is it doesn’t cause any untoward harm.”

 

 

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Posted (edited)
2 hours ago, Aemon Stark said:

It's worth pointing out that most antivirals don't work all that well. So as much as we might find better evidence that stuff like HCQ and Remdesivir help, treatment will still come down to "best supportive care" (supplemental O2, nutrition, lung protective ventilation, proning, etc.).

Yup.

As an aside, found this educational. Testing, testing, testing.

 

Edited by Raja

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5 hours ago, The Great Unwashed said:

Reports of an F4-F5 tornado on the ground in Mississippi. 

Given that we are heading into hurricane/tornado/wildfire seanson(s), I'd like to see the next stimulus bill have some sort of provision allowing for borrowing as needed to prop up communities hit by natural disasters at this time, instead of having to pass new bills during a pandemic whenever a natural disaster happens.

From the US politics thread. 

I was actually just thinking/worrying about the U.S hurricane season on top of the current crisis. How will States cope with that added burden? Imagine Peurto Rico levels of damage and destruction...its certainly concerning and i hope individual States have some kind decent action plan in place (because obviously not going to receive meaningful or competent help from Trump)

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13 hours ago, Zorral said:

Everything They did and They didn't do was wrong.  And so here we are, the end of the USA as it ever was known.

https://www.nytimes.com/2020/04/11/us/politics/coronavirus-trump-response.html?

Among all everything They did wrong was the pressure to remove the Cuban doctors from Latin America.  Latin America is begging for their Cuban doctors' return -- Cuban health system was their only bulwark against pandemic.

https://www.washingtonpost.com/world/the_americas/coronavirus-cuba-doctors-trump-ecuador-brazil-bolivia/2020/04/10/d062c06e-79c4-11ea-a311-adb1344719a9_story.html?

" A week after the first coronavirus case had been identified in the United States, and six long weeks before President Trump finally took aggressive action to confront the danger the nation was facing — a pandemic that is now forecast to take tens of thousands of American lives — "

Too late for that forecast. 22,000 deaths as of today is already tens of thousands. The question now is can you stop it from taking 100,000 lives, more? With a death rate of around 0.5% you only need 20,000,000 people in the USA to get the disease to probably get 100,000 deaths. It's too late, I think, to eradicate the disease from the USA (most countries in fact) before there is a vaccine. So what really is going to stop the disease getting to that sort of number, and even more before there is an effective vaccine? People will tolerate strong social distancing measures for a time, but they are not going to wear it for several months potentially most of a year. People talk about herd immunity through infection. 100,000 deaths at less than 10% of the country being infected, isn't even close to herd immunity. Herd immunity kicks in, optimistically at 60% of a population having got infected and recovered. That's over 1.5 million dead as the human cost of hoping to get to herd immunity.

The summer will slow the rate of spread, people get healthier and stronger immune systems in the summer and will likely mean a drop in severity of cases that keep bubbling along, they venture out more and interact with more people, but there doesn't seem to be as much disease as before. Late autumn arrives, infections start increasing, a vaccine is still probably 6 months away. Second wave hits. Also what we don't know is how long immunity lasts after you've had the disease or whether there will be some mutation over the coming months. What if you are only immune for 6 months. Everyone infected before May becomes vulnerable again just as the season turns.

It's a pretty bleak picture, that could repeat in almost every country in the world. Things may not go that badly, but so far most talk I've seen with an optimistic view seems more like wishful thinking than sound, science-based logic.

Luckily(??) we in the south are heading into winter, you'd think that's a bad thing, but we are still in the sort of socially tolerant phase of social distancing restrictions, so we might be OK with sticking it out over the winter. People don;t much like going out in winter so there is less chomping at the bit to be let off the leash anyway. A bit of loosening up (esp to be able to enjoy some of the little luxuries, like buying take out) will help people feel more normal without raising risk. Not so many people from overseas want to come south. There is a decent-ish chance that in Australia and NZ, if we keep our heads about us, the disease could be functionally eradicated by the end of winter. Then we just need to close the international arrival gates until there is a vaccine.

12 hours ago, Aemon Stark said:

It's worth pointing out that most antivirals don't work all that well. So as much as we might find better evidence that stuff like HCQ and Remdesivir help, treatment will still come down to "best supportive care" (supplemental O2, nutrition, lung protective ventilation, proning, etc.). 

Serum from recovered patients will work, dosing people up with the thing that will stop the virus: antibodies. The medial system needs to get on to that rather than testing a bunch of anti-virals. But it is harder to profit from donated serum. I think recovered people with a strong antibody response really need to be harvested (voluntarily of course).

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Only 7 new cases were identified here yesterday, the numbers of new cases have been falling for a few days. Tomorrow, first services are going to open - they decided to first allow car repair shops and slowly start opening other businesses. Hopefully the number of new cases will continue falling and we are over the worst ...

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21 hours ago, Zorral said:

WOT?  Utterly lacking panache! one can never use dweeb and panache together, you know.

~~~~~~~~~~~~~~~~~~~

 

I’m finding comparisons between countries particularly unhelpful at the moment because there are generally so many differences between them. So far my main take away is we need to do more of the stuff that Germany is doing.

Comparing the UK to Ireland seems an obviously silly thing to do given the differences between the countries. Here is a tweet that goes some way to discussing that:

Main takeaway being that even accounting for the UK size difference with RoI the UK and especially London is a main international travel hub and probably saw infection earlier. It does beg the question why the UK was not better prepared given its capital is such an international centre, but it makes little sense to put Ireland’s numbers against it and try and draw comparisons 

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RIP Tim Brooke-Taylor. Of the celebrity deaths from COVID-19 I know of this one has hit me hardest. The Goodies was a particularly favourite show of mine back in the 80s.

 

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Well, I'm terrified again. The LA Times has pulled together a summary of all the different reports of potential long-term health problems among recovered COVID-19 patients. https://www.latimes.com/science/story/2020-04-10/coronavirus-infection-can-do-lasting-damage-to-the-heart-liver

Quote

In a study posted this week, scientists in China examined the blood test results of 34 COVID-19 patients over the course of their hospitalization. In those who survived mild and severe disease alike, the researchers found that many of the biological measures had “failed to return to normal

Chief among the worrisome test results were readings that suggested these apparently recovered patients continued to have impaired liver function. That was the case even after two tests for the live virus had come back negative and the patients were cleared to be discharged.

At the same time, as cardiologists are contending with the immediate effects of COVID-19 on the heart, they’re asking how much of the damage could be long-lasting. In an early study of COVID-19 patients in China, heart failure was seen in nearly 12% of those who survived, including in some who had shown no signs of respiratory distress.

Quote

 

Given SARS-CoV-2’s affinity for lung tissue, doctors quickly suspected that some recovered COVID-19 patients would sustain lasting damage to their lungs. In infections involving the coronavirus that cause severe acute respiratory syndrome (SARS), about one-third of recovered patients had lung impairment after three years, but those symptoms had largely cleared 15 years later. And researchers found that one-third of patients who suffered Middle East respiratory syndrome (MERS) had scarring of the lungs — fibrosis — that was probably permanent.

In a mid-March review of a dozen COVID-19 patients discharged from a hospital in Hong Kong, two or three were described as having difficulty with activities they had done in the past.

Dr. Owen Tsang Tak-yin, director of infectious diseases at Princess Margaret Hospital in Hong Kong, told reporters that some patients “might have around a drop of 20 to 30% in lung function” after their recovery.

 

Quote

 

In a case report published this week in the New England Journal of Medicine, Chinese doctors described a patient with severe COVID-19, clots evident in several parts of his body, and immune proteins called antiphospholipid antibodies.

A hallmark of an autoimmune disease called antiphospholipid syndrome, these antibodies sometimes occur as a passing response to an infection. But sometimes they linger, causing dangerous blood clots in the legs, kidneys, lungs and brain. In pregnant women, antiphospholipid syndrome also can result in miscarriage and stillbirth.

 

 

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Posted (edited)

Can't read any of that even after signing up. Guess it's not free. Hard to make any sort of determination about what they're talking about given that the above quotes are in such general terms.

FeelsBadMan.

Edited by Raja

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Posted (edited)
12 minutes ago, Raja said:

Can't read any of that even after signing up. Guess it's not free. Hard to make any sort of determination about what they're talking about given that the above is in such general terms.

FeelsBadMan.

It lets me read it without signing in. :dunno:

There doesn't really seem to be a whole lot more than a bit of speculation that there might be lasting effects in that article. In terms of actual concrete information there's a couple of small studies of patients who were sick enough to require hospitalisation showing they still aren't fully recovered from the impact of the disease. Perhaps I'm missing something but that doesn't strike me as particularly surprising at this stage.

Edited by ljkeane

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Posted (edited)
32 minutes ago, ljkeane said:

It lets me read it without signing in. :dunno:

Maybe it has a limit on the number of free articles you can read, though I don't recall reading that much LA times stuff. Strange.

Curious as to how they define a lot of those terms in those quotes - a link to the study would be helpful as I'm not sure how you can make conclusions on 'long term complications' when we're in the third or fourth month of the pandemic - you *could* observe effects of the disease that are permanent, but without reading the study it is hard to know what they are talking about given the non specific nature of those quotes.

Edited by Raja

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2 minutes ago, ljkeane said:

There doesn't really seem to be a whole lot more than a bit of speculation that there might be lasting effects in that article. In terms of actual concrete information there's a couple of small studies of patients who were sick enough to require hospitalisation showing they still aren't fully recovered from the impact the disease. Perhaps I'm missing something but that doesn't strike me as particularly surprising at this stage.

Agreed. I'd even say... That sequelae are to be expected. Unfortunately, it would have been too much to hope for that disease to not leave traces (most do).

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Posted (edited)
7 minutes ago, Rippounet said:

Agreed. I'd even say... That sequelae are to be expected. Unfortunately, it would have been too much to hope for that disease to not leave traces (most do).

Sure I suppose. But I really meant that if someone's sick enough to need to be hospitalised it's not particularly surprising that they'd still be showing the effects of that probably at most a couple of months later. As Raja says it's probably hard to draw too many conclusions about the long term complications at this point.

Edited by ljkeane

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Posted (edited)

I read that a Brazilian clinical trial of Chloroquine on COVID-19 patients had to be stopped when some people in the high dose group started getting heart problems. Cardiac side effects are I believe a known side effect? Maybe the low dose could still prove to have some benefit.

Edited by The Anti-Targ

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1 hour ago, The Anti-Targ said:

I read that a Brazilian clinical trial of Chloroquine on COVID-19 patients had to be stopped when some people in the high dose group started getting heart problems. Cardiac side effects are I believe a known side effect? Maybe the low dose could still prove to have some benefit.

I suppose a low dose will protect them from malaria. 

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1 hour ago, The Anti-Targ said:

I read that a Brazilian clinical trial of Chloroquine on COVID-19 patients had to be stopped when some people in the high dose group started getting heart problems. Cardiac side effects are I believe a known side effect? Maybe the low dose could still prove to have some benefit.

It's generally pretty well tolerated chronically; can't say I've seen a lot of clinically significant QT prolongation. Something to monitor though. Long-term the bigger concerns are effects on blood cell counts and retinal toxicity. i even called in a script for HCQ today (for RA)!

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