Anecdotally my wife has been getting a lot more positive patients (one who was annoyed because she "did everything right" and in the same breath talked about this restaurant birthday party she went to a few weeks back ). 

Her hospital is completely out of remdesivir.  ICU is getting really tight.  Starting to shut down some of the surgicenters to preserve ventilators and repurposing staff.  

Stockholm testing now showing 28% positive for antibodies. Overall in Sweden the R number has dropped to 1.12.  Prime Minister to address nation tonight to call for more discipline. Masks could be on the table as they are always one of the items in consideration. 

On 11/21/2020 at 8:41 AM, JohnSnowsHair said:

Ok, I don't know your buddy lol. Maybe he's a lying liar. Just stating the guidance.

Are you feeling any better?

My brother's roommates both tested negative after going to that get together with a health care worker who tested positive the day after. My brother said she took the test again a day after that and it was negative. So it was either a false positive or (they are saying this could happen) she has it still and it came back negative.

Anyway, my mom said he is not allowed to go anywhere if he wants to come up for Thanksgiving. Kid was going to go to the gym today (Sigh). He's a smart kid (I'm 45/he's 26), is in the Army reserves, good paying job, etc., but he is like all these younger people. They think they are impervious to this, even though healthy people younger than him have died within a week.

22 minutes ago, DrPhilly said:

Stockholm testing now showing 28% positive for antibodies. Overall in Sweden the R number has dropped to 1.12.  Prime Minister to address nation tonight to call for more discipline. Masks could be on the table as they are always one of the items in consideration. 

This percentage is interesting to track but going to be a bish contextualize for awhile.  Are the antibody percentages naturally going to be higher in more population dense areas like Stockholm? Are antibodies alone a good enough marker immunity or is there a quantitative threshold that needs to be hit? Is T-Cell immunity without positive antibodies giving us a falsely low number of people that are truly immune?

Yes hard to know what it means but good the number is up anyway. 

Just now, DrPhilly said:

Yes hard to know what it means but good the number is up anyway. 

Certainly shouldn't hurt at the very least.

7 hours ago, we_gotta_believe said:

This is what I mean when I say we are F'ed this winter.

 

Cases are going down in Europe?  I thought cases were going up.

23 minutes ago, xzmattzx said:

Cases are going down in Europe?  I thought cases were going up.

Down significantly generally in many countries over the last few weeks.  Not out of the woods just yet for this time but the 2nd wave looks to be much smaller than the 1st overall in Europe.

3 hours ago, DrPhilly said:

Down significantly generally in many countries over the last few weeks.  Not out of the woods just yet for this time but the 2nd wave looks to be much smaller than the 1st overall in Europe.

Was their second wave a couple weeks ahead of the US's?  I figured just about every place around the world was seeing a rise in cases.

Weekly COVID-19 Update from the Doc

THE GREAT BARRINGTON DECLARATION (follow up from last weeks post)

 

I will not enter a side in the debate.  Let reality speak for itself.  Even while attempting to rein in the virus, the numbers have become overwhelming and Healthcare Systems are reeling.  Covid related hospital bed utilization is beginning to compromise the ability of Healthcare Systems to respond to the needs of their catchment areas.   These are not theories or philosophies, just brutal realities.  Based on these undeniable realities, evidenced in the last seven days, it is clear that "letting" the virus spread unrestrained is not tenable.  Hospitals are filling up, especially in the Midwest and hospitals are running out of staff.  We now have more hospitalized patients with Covid than at any time during the Pandemic.  For the week of 11/4 to 11/11, 958 hospitals (19% of all hospitals) faced a staffing shortage. At the peak of the summer surge, the seven day average of daily admissions topped 5000.  This week the same measure topped 10,000.  The shortages are so acute that asymptomatic covid positive healthcare workers are being asked to return to work.  Rural hospitals, which had little exposure to Covid in the spring and summer, but are now quickly being inundated, do not seem to have the rigid protocols in place that would protect their staff.  

 

 We are learning what Sweden has already learned but we failed to heed.

 

FOLLOWING UP ON COVID

NEJM 11/9/20

Kelly Young

 

Using data from 865 US hospitals, amassing 125,000 Covid admissions, 15% died.  Of those patients discharged 9% were readmitted at least once within two months.

 

Risks for readmission were Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, and chronic Chronic kidney disease.

 

It appears that about 5 to 6% of those infected will require hospitalization,

 

CONVERSATONS WITH DR. HOWARD BAUCHNER, Editor JAMA

Covid-19 Critical Care and Pandemic Response

Guests -Rochelle Walensky, MD

Chief, Infectious Diseases, Massachusetts General Hospital, Professor of Medicine Harvard

Derek Angus, MD Chief Healthcare Innovation Officer, UPMC

11/19/20

 

The following discussion is only loosely based on this 45 minute audio presentation.

 

Management issues of Covid 19

1.  Manage hypoxia as long as practicable without intubations.  Obviously a judgement call, where experience with these types of patients will matter.  It is clear that when these patients are intubated, many stay intubated for quite some time.

2.  Steroids for the clearly sick make a difference, early on or for those with only moderate disease they are of little benefit.

3.  Remdesivir - Dr. Angus is not a fan of the drug.  Dr. Walensky uses it frequently.  Obviously from my previous comments on this agent, I think the evidence of benefit is weak at best.  There is no debate that there is no death benefit and in the one study which showed the most promise, shortening of hospitalization stay, the authors where dubious of the clinical significance.  WHO recommends against the use of this agent.

4.  In  general immunosuppresses have been disappointing so far.

 

A brief discussion ensued concerning the sky rocketing numbers.  The usual suspects were mentioned, fatigue, behaviors, but again no mention of the success that Southeast Asia has had with the same virus and a much larger population than that of Western Europe and the United States, combined.

 

It is clear from this presentation that there has been little therapeutic gain in the treatment of the virus.

 

In the last few days the first monoclonal has been given EUA.  This is the first therapeutic which will have a proven, significant impact on the rate of hospitalizations.  It is approved for those over 55 and needs to be utilized as soon as possible after diagnosis.  There in lies an apparent dilemma.  Early on, it is not clear who is going to get sick.  But there is clear precedent for prophylactic medications.  Preoperative antibiotic usage to decrease postoperative infections is a good example.  Post operative infections in elective surgery are not common.  The use of preoperative antibiotic usage makes them rare.

 

Currently there is an insufficient supply of the drug.  Risk stratification will need to be utilized to hone in on those at greatest risk who can be treated with the current supply.  Maybe we go to people age 60 with one risk factor, or maybe 65 with two risk factors until supply will meet the need and modify as the supply increases.  Even at 190,000 cases per day there are probably less than 20,000 per day that would fit the higher risk stratified populations.  Lilly says they will have 1.5 million doses by the end of the year.   That would reduce hospitalizations and deaths significantly!!

 

I scratch my head at the lay press bemoaning the logistics and the short supply of staff and room to administer the treatment.  Brilliant men and women have dedicated their lives over the last 10 months to develop these technologies and amazing drugs, please tell me we are not going to stumble over rooms and staff.  How about all the high school gyms that are not being utilized and the county Medical Reserve Units or the National Guard.

 

The same came be said about the Pfizer vaccine that needs to be kept at super low temperatures in special freezers.  There is no lack of these freezers.  We are not going to vaccinate 200 million people (400 million shots) at the countries pharmacies.

 

Every major city has a basketball or hockey arena.  Take the Wells Fargo Center in Philadelphia for instance, lots of parking.  Take a couple of those freezers with tens of thousands of vaccine doses, place then at the center, call in your County Medical Reserve, the national guard,  the army, set up online vaccination schedules just like they did for covid testing.  You have 500 jabbers, 12 hours a day, 10 vaccinations/jabber/hr - 5000/hour, 60,000/day.  Is it too much to ask people to travel an hour to get their vaccination? Probably well over three million people within a one hour drive of the Wells Fargo Center.  Organize free transportation for those who can't drive.

 

The Moderna vaccine will be easier to use because it is stored at normal freezing temperatures, but is in shorter supply, so mesh the supplies of the two vaccines with the logistics.

 

IMPLEMENTATION OF A POOLED SURVEILLANCE TESTING PROGRAM FOR ASYMPTOMATIC SARS-COV-2 INFECTIONS IN A COLLEGE CAMPUS- DUKE UNIVERSITY, DURHAM, N.C. AUGUST 2 TO 0CTIOBER 11.

WMMR 11/17 (CDC)

 

During the time period of 8/2 - 10/11 68,913 specimens from asymptomatic graduate and undergraduate students were tested.  Eighty four specimens were positive (0.8%) out of a population of 10,265 students  Testing as a result of contact tracing identified 24% of the positive cases.  Student athletes were not included in this study. 

 

How did Duke accomplish this phenomenal result?

1.  Students were requested to quarantine for 14 days prior to arrival

2.  Students were tested on arrival and quarantined in school run rooms until test results were available

3.  On campus students were tested twice per week, off campus one to two times per week, graduate students once a week

4.  All dorms were converted to single occupancy

5.  Classroom and common areas were modified to accommodate distancing

6.  Packed meals were distributed to rooms

7.  All students signed the Duke Compact

     a.  observe mandatory masks

     b.  social distancing

     c.  participate in surveillance, compliance was 95%, 5% of the students lost their campus facility privileges

8.  Contact tracing

9.  Exposed contacts were quarantined for 14 days

 

Pooling - 5 students per pool, positive pool specimens then tested each student in the pool

 

Leave it to Duke to get it right!!

 

NUMBERS

 

Deaths - 255,900

 

Hospital bed utilization - I am switching to using the national numbers instead of looking at 18 states.

Between 11/14 and 11/21 bed utilization went from 69,498 to 83,227, an increase of 20%.  A similar increase next week will put us at 100,000, and some systems will not be able to meet the care demands.  The highest number of beds utilized during the summer peak was 59,924.

 

Weekly new cases - every state has experienced an increase in weekly new cases.  The percentage of positive cases is going up, so the increased number of infections is not due to increased testing.

 

Case fatality rate - from 10/11 to 11/21 is 0.95%, down from 0.99% a week ago

 

I would again caution about having people (other than those you live with) to your homes without masks on during this period of extremely high prevalence.  No one will join us for a meal during this period of high prevalence.

 

Our neighborhood has more festive, seasonal decorations than I can ever remember!

 

Enjoy the rest of the day

PLEASE be safe over Thanksgiving

Live safer

 

7 minutes ago, xzmattzx said:

Was their second wave a couple weeks ahead of the US's?  I figured just about every place around the world was seeing a rise in cases.

Not in the southern hemisphere, which is expected, since they're heading into summer. For example, this is South Africa...

As for Europe, it depends on the time frame and your definition of what a rise in cases is. If you're using a 7-day rolling average of daily cases over the last couple weeks, some countries are still seeing a rise while others are beginning to tail off or even starting to see a decrease. Belgium fits in the latter category even if your timeframe is 3-4 weeks... 

3 minutes ago, we_gotta_believe said:

Not in the southern hemisphere, which is expected, since they're heading into summer. For example, this is South Africa...

As for Europe, it depends on the time frame and your definition of what a rise in cases is. If you're using a 7-day rolling average of daily cases over the last couple weeks, some countries are still seeing a rise while others are beginning to tail off or even starting to see a decrease. Belgium fits in the latter category even if your timeframe is 3-4 weeks... 

By "rise", I mean simply an increase.  On a side note, I hate the hyperbolic statements from various media where any rise in cases is a "spike", or "surge", or some other word that implies an exponential increase, or spread like wildfire.

Just now, xzmattzx said:

By "rise", I mean simply an increase.  On a side note, I hate the hyperbolic statements from various media where any rise in cases is a "spike", or "surge", or some other word that implies an exponential increase, or spread like wildfire.

You have to be more specific. Without a time frame or normalized metric, a rise could mean any number of things, many of which would be very misleading. Further, confirmed cases on their own can be misleading if testing capacity was ramped up significantly during the same time frame, and this can vary from country to country. For this reason, a look at positivity rate is needed as well.

LA back to a curfew.  Until the end of December is what they are talking about.  

One thing I’m not seeing anyone report on is how the cases here started rising after Halloween. 
 

I’m curious as to how much of what we are seeing is attributed to idiots going out to party. 

5 hours ago, xzmattzx said:

Was their second wave a couple weeks ahead of the US's?  I figured just about every place around the world was seeing a rise in cases.

Yeah, places aren't on exactly the same timelines for all sorts of reasons.  Anyway, most European countries are seeing large declines in the rates of new cases after hitting peaks in the last several weeks.  In the US the various states have different situations as well.  Some have been sky rocketing while others were coming down at the same time.  The big picture looks to be what you describe here though and the US is maybe a couple weeks behind.  Thanksgiving could be an issue though.

More of this, please:

Spoiler

 

(spoilers for language)

These people need to be confronted in a restaurant, in a department store, at a gasoline station, we need to get out and create a crowd. And push back on them. And tell them they're not welcome anymore, anywhere.

2 minutes ago, Kz! said:

More of this, please:

  Hide contents

 

(spoilers for language)

These people need to be confronted in a restaurant, in a department store, at a gasoline station, we need to get out and create a crowd. And push back on them. And tell them they're not welcome anymore, anywhere.

  OK for thee but not for me, fine citizens 

9 minutes ago, Kz! said:

More of this, please:

  Reveal hidden contents

 

(spoilers for language)

These people need to be confronted in a restaurant, in a department store, at a gasoline station, we need to get out and create a crowd. And push back on them. And tell them they're not welcome anymore, anywhere.

"Trump likes my dad"

"No he doesn't"

"Yes he does"

"F you"

 

bwahahahahahhahahaha!  They're still so salty

Joisy trash, gotta love it

Wow what a total piece of garbage being one of the indoor diners he is allowing in restaurants. How irresponsible. 

@JohnSnowsHair, can we get an update? How are you feeling today?

2 hours ago, Kz! said:

More of this, please:

(spoilers for language)

These people need to be confronted in a restaurant, in a department store, at a gasoline station, we need to get out and create a crowd. And push back on them. And tell them they're not welcome anymore, anywhere.

Pot meet kettle.

I'm getting tested tomorrow morning. probably won't get results until friday, I figure.

I feel fine, generally. bit of a headache, but doubt that's related. no fever since Thursday night. 

I have felt a bit of chest tightness at times. that could be stress. I also felt a bit more labored in my breathing when I was raking leaves. I specifically wanted to try and elevate my heart rate and breathing just a little (since I've basically been sitting around the bedroom watching netflix) to see how I would respond. it wasn't much, but I did feel like my breathing was a bit more difficult than it ought to be for light work.

we'll see how it goes. worst case, at least I know this isn't a severe case of covid - if I have it it's very much on the mild end.

44 minutes ago, Kz! said:

@JohnSnowsHair, can we get an update? How are you feeling today?

I bet he's feeling like a winner!

 

But on a serious note, hope everything works out John