Friday, April 10, 2020
Good morning. Lots of follow-up from our Q&A time yesterday. And some great examples of how medical information is filtered from the front lines to civic leaders and then through the media to you and me. Another excellent example of why we must be vigilant for bias and logical fallacies. In case you have not reviewed these recently:
https://yourlogicalfallacyis.com/
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Latest data from FT. Updated but no change in data display from yesterday.
https://www.ft.com/coronavirus-latest
On the PEX Q&A call yesterday, there were some questions based on new articles on the possibility of re-infection. The articles were largely from typical news outlets (Fox, etc.). Here is what I am finding:
Case reports of individuals who were reported "recovered" and COVID (-) and then are found to be positive some weeks later.
https://twitter.com/hongsolo9/status/1248129718596947969
Some non-peer reviewed data on a wide range of long-term antibody response in recovered patients
https://www.medrxiv.org/content/10.1101/2020.03.30.20047365v1.full.pdf+html
Some non-peer reviewed articles that are models of re-infection (predictive forecasting)
https://www.medrxiv.org/content/10.1101/2020.04.02.20050930v1#disqus_thread
There does appear to be a third COVID strain, but I have found no data to suggest this strain is different enough to facilitate either co-infection or re-infection with the variants of COVID-19.
My take: PCR testing is not perfect. The IgG/IgM antibody testing is even less sensitive and specific. The case reports are not structured in a way to help definitively clarify the time course, testing methods, or any clinical signs or symptoms. It does not surprise me that there is a wide range of measurable antibody response. I need more data to determine IF re-infection is possible, TO WHAT DEGREE it would clinically manifest, and IN WHOM it is most likely.
Here is a very heartfelt Twitter conversation by physicians discussing the social and personal pressures of being ill and being a physician. It is like they read my mind...
https://twitter.com/AllisonRBond/status/1248302344929857536
I also was asked about a business insider article that stated, "80% of COVID patients requiring a ventilator ultimately die."
This article annoyed me. "Some doctors at some hospitals are seeing high death rates..." Vague and data-free comments.
Here is the AP article referenced:
https://apnews.com/8ccd325c2be9bf454c2128dcb7bd616d
Here is what I think is going on:
there are some clinical presentations of COVID that seem not to respond well to even ventilators, subtle lung findings that manifest as disproportionate hypoxia (low oxygen levels). Unclear what this is yet. Here is an article that describes this phenomenon: https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems
As such, I think these articles are attempting to reflect the clinical uncertainty and questions, "what is the physiologic mechanism of this illness?" "Is it really ARDS or pneumonia-like lung damage?" and "how do I best treat this patient?"
I have not seen any definitive mortality data and the AP article quotes a wide range of percentages from people who are seeing a lot of real-time, anecdotal data. Here is a great thread on the problem with real-time data https://twitter.com/kidney_boy/status/1248260546341863424
Here is what I think:
- Data from one city or hospital reported in real-time is going to be very skew.
- Intubated COVID patients are at high risk for prolonged ICU time, extended time on a ventilator, and a variety of complications as a result, including death.
- There may be a couple of different mechanisms - ARDS, bacterial pneumonia, some vascular shunting and/or oxygen absorption problems. I have not seen anyone writing in detail about whether these are phases of the illness, related to other co-morbidities, or something else. And, the articles you are seeing may be reflecting the diagnostic and therapeutic dilemmas ICU docs are facing, including the uncertainty of their decision making and treatment choices.
My favorite infographic of the day
https://i.redd.it/i91kpf1o3pr41.jpg
---- Bonus Round: Break with the Norm edition
I have a small collection of vintage books that prominently reflect the social norms of earlier times. Some of my favorites are medical in nature - "What a mother should tell her daughter" from 1911. Others are political or policy-focused - "Questions and Answers about Communism" (the Catholic perspective) from 1961 and "So... you're going to the hospital" from 1960. While I don't own a copy of this book, here is an analysis of a similar book on the social phenomenon of woman riding bicycles. It is amusing and a biopsy of the social norms of the time.
https://www.brainpickings.org/2020/04/08/bicycling-for-ladies-maria-ward-1896/
more links
https://www.amazon.com/Mother-Should-Daughter-Isabelle-Thompson/dp/B082VLQ9BJ
https://www.amazon.com/Questions-Answers-Communism-Richard-Cardinal/dp/B00BHK59LC
https://books.google.com/books/about/So_you_re_going_to_the_hospital.html?id=9x86AAAAMAAJ
I came across an O.G. whistleblower and activist that I had not read about before. Bartolome de las Casas was a Spanish settler in the Americas in the early 1500s. He quickly became disillusioned with the way the Spanish colonization of the new world was going and started advocating for the humane and ethical treatment of New World natives. Ultimately, he became a Dominican friar and produced numerous books and writings about early colonization. It was not complimentary of the Spanish. I cannot imagine the political ill-will he generated for his convictions.
https://en.wikipedia.org/wiki/Bartolom%C3%A9_de_las_Casas
an article
https://www.americamagazine.org/issue/las-casas-discovery
Clean hands and sharp minds, team
-Adam
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