Covid19 - clinical / epidemiological thread

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I absolutely despise this article: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30317-2/fulltext

Talk about completely wrong advice on a journal already suffers from many disturbing controversies. When we're dealing with a new virus, why are there blanket unjustified claims that treatments don't work? I'm glad many other studies and trials completely shut down that article

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Have we ever seen so many obsessed psychotic ill informed people in the media freaking out and losing their minds because a man took off his mask ON HIS OWN BALCONY outside like a million feet from the nearest person? Someone please ship them their Haldol and Xanax.
 
Trump is now more unhinged than his usual state of chaotic thinking. He is loosing the election, is desperate, and is likely COVID and the drugs treating it are affecting his brain. It will be a wild ride from here on out, with Trump now threatening to withhold stimulus checks unless he is re-elected. This will not be the last erratic and ill-advised decision he will make before he is kicked out of office forever in January.
 
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Have we ever seen so many obsessed psychotic ill informed people in the media freaking out and losing their minds because a man took off his mask ON HIS OWN BALCONY outside like a million feet from the nearest person? Someone please ship them their Haldol and Xanax.

And then walked inside his empty house to start quarantine by himself? The nerve!
 
Vitamin D can be metabolized and converted into 1-25 dihydroxy vitamin D (active form) either by kidneys or, importantly, by immune system (white blood cells)

High fructose corn syrup can turn vitamin D into its inactive form (1,24,25 trihydroxy vitamin D)

Sunlight may not be enough for those living above 35th parallel (regions in US above southern CA) in winter time

Vitamin D deficiency strongly associated with susceptibility to infection

Inverse association between serum vitamin D and BMI

Vitamin D may play a role in innate immune response

Vitamin D receptor is expressed in myeloid and lymphoid cells (and so vitamin D can increase expression of antimicrobial peptides in monocytes and neutrophils

Risk of vitamin D deficiency increases among elderly (>70) because their skin has decreased capacity to produce previtamin D3

Black and Latino Americans are at higher risk for vitamin D deficiency
 
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Both covid 19 and vitamin D deficiency have elevated IL-6, TNF alpha and IFN gamma and Th1 adaptive response (late stages of covid 19). Both covid 19 and vitamin D deficiency decrease ACE2 expression and have increased coagulability.

Patients who are covid 19 positive seem to have lower vitamin D levels (but it's an association): 25-Hydroxyvitamin D Concentrations Are Lower in Patients with Positive PCR for SARS-CoV-2

But low vitamin D levels are also associated with increased risk of covid 19 infection: Low plasma 25(OH) vitamin D level is associated with increased risk of COVID-19 infection: an Israeli population-based study - PubMed

Another paper: SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels

Compelling figure from the above paper:

journal.pone.0239252.g001.PNG.png


For hospitalized older covid 19 patients, those with vitamin D deficiency have higher D dimer levels and have a greater chance of needing ventilation: Vitamin D status and outcomes for hospitalised older patients with COVID-19

Calcifediol (25-hydroxyvitamin D) reduces covid 19 disease severity and reduced the need for ICU treatment. Larger studies are under way: “Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study”

This paper uses a single large (200,000 IU) vitamin D dose and showed no difference in mortality: Effect of Vitamin D3 Supplementation vs Placebo on Hospital Length of Stay in Patients with Severe COVID-19: A Multicenter, Double-blind, Randomized Controlled Trial

But several doses >>>>>>>>>>>> single large dose

SHADE study of daily uses of vitamin D (60,000 IU) for 7 days decreased fibrinogen levels and had greater fraction of those being tested negative of covid 19 by day 21: Short term, high-dose vitamin D supplementation for COVID-19 disease: a randomised, placebo-controlled, study (SHADE study) | Postgraduate Medical Journal
 
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GSK’s vaccine shows minimal efficacy. Between this and AZ’s results, I think the traditional vaccine technologies may all be ineffective, and Moderna’s and Pfizer’s may be the only vaccines we have for a while.
 
Calcifediol (25-hydroxyvitamin D) reduces covid 19 disease severity and reduced the need for ICU treatment. Larger studies are under way: “Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study”

This paper uses a single large (200,000 IU) vitamin D dose and showed no difference in mortality: Effect of Vitamin D3 Supplementation vs Placebo on Hospital Length of Stay in Patients with Severe COVID-19: A Multicenter, Double-blind, Randomized Controlled Trial

But several doses >>>>>>>>>>>> single large dose

SHADE study of daily uses of vitamin D (60,000 IU) for 7 days decreased fibrinogen levels and had greater fraction of those being tested negative of covid 19 by day 21: Short term, high-dose vitamin D supplementation for COVID-19 disease: a randomised, placebo-controlled, study (SHADE study) | Postgraduate Medical Journal

There is probably something with that first study. An absolute risk reduction of 48%? The effect size is huge. It wasn’t controlled or randomized, they didn’t track 25 (OH) D levels, and they didn’t take certain known risk factors into consideration.

The third one is interesting. Not sure it is good enough evidence. No patients with comorbidities were included, and it was limited to asymptomatic and mildly symptomatic patients only, so not very generalizable. They also state that the placebo was not well matched in taste and consistency. The treatment arm was also quite small (so is the control arm). But it is interesting, especially with the decrease in fibrinogen (though none of the other inflammatory markers decreased—though I wonder if this was just

The second one is actually more interesting I think. It demonstrated a significant difference in vitamin D levels after treatment with an ability in the treatment arm to get a statistically significant higher 25 (OH) level, and yet still no differences were found in hospital stay or mortality (though this was a secondary outcome).

I was wondering if it was just not powered to determine a difference, but they included a sample size calculation for length of stay. Mortality was not significant between the groups, but it was a secondary outcome so the study wasn’t powered for that.

Vitamin D deficiency has been linked to everything under the sun from cancer to Alzheimer’s. And yet in almost every single case, there is huge discordance between observational data and RCTs, which generally have not shown any effect. I think vitamin D is a surrogate for other stuff like age, lifestyle, etc. and just supplementing vitamin D usually won’t do anything.

Course I think Fauci’s and the NHS’s recommendation to take vitamin D is probably sound anyway since so many people are likely even more deficient than normal given the decreased outdoor activity.
 
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LOL wut

I thought even the hardest of die-hard "herd immunity" advocates had admitted that Sweden's approach has been an unmitigated disaster.

10x the death rate of Norway and Finland is the "right" way?
I took it as sarcasm. Look at the poster.
 
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LOL wut

I thought even the hardest of die-hard "herd immunity" advocates had admitted that Sweden's approach has been an unmitigated disaster.

10x the death rate of Norway and Finland is the "right" way?
It was interesting to see how the pendulum swung for the swede's
intially lots of ppl against their approach as they thought the 1st lockdown would only be a minor inconvenice, then reality hit that it was bloody expensive so lots of north americans swung around to backing the swedes. this went back and forth a couple times over the summer before we landed where we are, with the swedes imposing laws and lockdowns about 8months and 8x the death rate later

They are a nice bunch of people but quite sure of themselves bordering on snootiness/touch of arrogance.
Certainly will not like their new reputation

Its certainly been useful that some country did their experiment... we all learned a lot from them
 
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It was interesting to see how the pendulum swung for the swede's
intially lots of ppl against their approach as they thought the 1st lockdown would only be a minor inconvenice, then reality hit that it was bloody expensive so lots of north americans swung around to backing the swedes. this went back and forth a couple times over the summer before we landed where we are, with the swedes imposing laws and lockdowns about 8months and 8x the death rate later

They are a nice bunch of people but quite sure of themselves bordering on snootiness/touch of arrogance.
Certainly will not like their new reputation

Its certainly been useful that some country did their experiment... we all learned a lot from them
Really? Has the US government and its people learned anything?
Because this is like the worst it’s ever been and people are going out and hanging out like it’s nothing.
My little airport was packed yesterday. Haven’t seen it that busy this year.
 
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About 12 hours after getting shot number 2, woke up in the middle of the night, chills galore, headache, body aches, eye pain, bout same amount of shoulder pain. Feels like the flu. Chills have mostly disappeared after about 4 hours, now its just headache, sore arm and a tired body.

EDIT: I feel better after 1g tylenol and 600mg ibuprofen. Not 100% but I will make it through the day I think.
 
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“We're told Dr. Simoni was doing a lip injection on a woman last month ... obviously an elective procedure. She was temperature checked and filled out a COVID questionnaire. She was not tested.

While the doc was hovering over the maskless woman, our sources say she coughed in his face. He had his mask on, but still ... she sprayed on him. She contacted the office a few days later to inform them she had tested positive for COVID.”

 
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Poor guy. Died for a couple hundred bucks
Well, celebrity doc,

Beverly Hills Doctor Offers Anti-Coronavirus Immunity Boosting Therapy
SATURDAY, APRIL 4, 2020, 10AM – 3PM

An immune-boosting therapy similar to the one Payman Simoni, M.D. gives his star-studded patients before procedures is now being offered to the public as a shield for the coronavirus. The Simoni Super Immune Boost IV Therapy is a mix of vitamins, amino acids, rare minerals and powerful antioxidants that will boost peoples’ immune systems as the public deals with the pandemic.
“Since there is no treatment for the coronavirus, our only method of defense against the virus is a strong immune system,” says Simoni, whose patients include some of Hollywood’s best-known celebrities. “When the breakout was announced, I reached out to various specialists to explore fine tuning an immunity-boosting formula that many of my patients already benefit from. Now that we were able to achieve what we set out to do, we hope to have enough supply to help as many people as possible.”

Among the ingredients:

Vitamin B complex
Vitamin C
Antioxidants
Zinc
Essential amino acids including glutamine taurine

The Simoni Super Immune Boost IV Therapy is administered through an IV and takes approximately 30 minutes. He recommends weekly or bi-weekly sessions and they are available on a first-come, first-serve basis. Cost is $1000 per session. For more information, call 310-360-1360.
 
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Well, celebrity doc,

Beverly Hills Doctor Offers Anti-Coronavirus Immunity Boosting Therapy
SATURDAY, APRIL 4, 2020, 10AM – 3PM

An immune-boosting therapy similar to the one Payman Simoni, M.D. gives his star-studded patients before procedures is now being offered to the public as a shield for the coronavirus. The Simoni Super Immune Boost IV Therapy is a mix of vitamins, amino acids, rare minerals and powerful antioxidants that will boost peoples’ immune systems as the public deals with the pandemic.
“Since there is no treatment for the coronavirus, our only method of defense against the virus is a strong immune system,” says Simoni, whose patients include some of Hollywood’s best-known celebrities. “When the breakout was announced, I reached out to various specialists to explore fine tuning an immunity-boosting formula that many of my patients already benefit from. Now that we were able to achieve what we set out to do, we hope to have enough supply to help as many people as possible.”

Among the ingredients:

Vitamin B complex
Vitamin C
Antioxidants
Zinc
Essential amino acids including glutamine taurine

The Simoni Super Immune Boost IV Therapy is administered through an IV and takes approximately 30 minutes. He recommends weekly or bi-weekly sessions and they are available on a first-come, first-serve basis. Cost is $1000 per session. For more information, call 310-360-1360.

Dude really shoulda been taking his own medicine.
 
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Poor guy. Died for a couple hundred bucks

It’s a choice between keeping the office open, or not.

We have doctors here who opted out of call-taking positions at the hospitals and resigned their staff privileges who are now upset because they are not in the topmost tier for vaccines.
 
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Well, celebrity doc,

Beverly Hills Doctor Offers Anti-Coronavirus Immunity Boosting Therapy
SATURDAY, APRIL 4, 2020, 10AM – 3PM

An immune-boosting therapy similar to the one Payman Simoni, M.D. gives his star-studded patients before procedures is now being offered to the public as a shield for the coronavirus. The Simoni Super Immune Boost IV Therapy is a mix of vitamins, amino acids, rare minerals and powerful antioxidants that will boost peoples’ immune systems as the public deals with the pandemic.
“Since there is no treatment for the coronavirus, our only method of defense against the virus is a strong immune system,” says Simoni, whose patients include some of Hollywood’s best-known celebrities. “When the breakout was announced, I reached out to various specialists to explore fine tuning an immunity-boosting formula that many of my patients already benefit from. Now that we were able to achieve what we set out to do, we hope to have enough supply to help as many people as possible.”

Among the ingredients:

Vitamin B complex
Vitamin C
Antioxidants
Zinc
Essential amino acids including glutamine taurine

The Simoni Super Immune Boost IV Therapy is administered through an IV and takes approximately 30 minutes. He recommends weekly or bi-weekly sessions and they are available on a first-come, first-serve basis. Cost is $1000 per session. For more information, call 310-360-1360.

JFK SMH
 
What do you guys think about the e484k variant?

Wouldnt that suck if our vaccine immunity is already compromised...

 
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Pretty interesting-- the e484k mutation reduces antibody neutralization comprable to only 1 dose of the Pfizer vaccine. Seems pretty concerning, but not disastrous (yet..)

Definitely we should focus on ramping up vaccination as fast as possible. It's a disgrace to see that most states have only distributed ~40% of the vaccines they've been allocated.

WTF are we doing? We should open the floodgates and set up mass vaccinations at CVS, walgreens, grocery stores. To reduce complexity, do a tiered roll out by age. 65's and older from Jan 15-30, 55's and older from Feb 1-15, etc.
 


Pretty interesting-- the e484k mutation reduces antibody neutralization comprable to only 1 dose of the Pfizer vaccine. Seems pretty concerning, but not disastrous (yet..)

Definitely we should focus on ramping up vaccination as fast as possible. It's a disgrace to see that most states have only distributed ~40% of the vaccines they've been allocated.

WTF are we doing? We should open the floodgates and set up mass vaccinations at CVS, walgreens, grocery stores. To reduce complexity, do a tiered roll out by age. 65's and older from Jan 15-30, 55's and older from Feb 1-15, etc.


the National Guard is a little busy right now.....

But yes, a larger rollout is important, but the logistics are the issue.
 
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Full dose anticoagulation doesn't work for severe covid 19 patients requiring ICU. Full dose anticoagulation can be helpful for non-ICU hospitalized covid 19 patients.

Lots of questions remain though: what if someone who's initially treated with full dose anticoagulation ends up requiring ICU? what happens if they're discharged, and how long should they be on anticoagulants?

@nimbus @vector2 @DocMcCoy @FFP @chocomorsel etc
 
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Full dose anticoagulation doesn't work for severe covid 19 patients requiring ICU. Full dose anticoagulation can be helpful for non-ICU hospitalized covid 19 patients.

Lots of questions remain though: what if someone who's initially treated with full dose anticoagulation ends up requiring ICU? what happens if they're discharged, and how long should they be on anticoagulants?

@nimbus @vector2 @DocMcCoy @FFP @chocomorsel etc

They shouldn’t be if they don’t have a proven DVT/PE/arterial thrombus.
 


Full dose anticoagulation doesn't work for severe covid 19 patients requiring ICU. Full dose anticoagulation can be helpful for non-ICU hospitalized covid 19 patients.

Lots of questions remain though: what if someone who's initially treated with full dose anticoagulation ends up requiring ICU? what happens if they're discharged, and how long should they be on anticoagulants?

@nimbus @vector2 @DocMcCoy @FFP @chocomorsel etc

One problem I have encountered is that patients seem to be resistant to anticoagulants. If you check anti xa on prophylactic doses you'll often find they are normal so I have begun routinely checking this on all the sick covids to make sure I am not under dosing prophylaxis.
 
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One problem I have encountered is that patients seem to be resistant to anticoagulants. If you check anti xa on prophylactic doses you'll often find they are normal so I have begun routinely checking this on all the sick covids to make sure I am not under dosing prophylaxis.

Wait why prophylaxis and not full dose?
 
Wait why prophylaxis and not full dose?
Should therapeutic dose anticoagulation be empirically used in COVID-19 patients requiring ICU level care (i.e., in the absence of confirmed or suspected VTE)?

Microvascular thrombosis is hypothesized to be involved in hypoxemic respiratory failure in some patients with COVID-19. Autopsy studies show large vessel and microvascular thrombosis, pulmonary hemorrhage and high prevalence of VTE. Although retrospective cohort studies of patients treated or not treated with therapeutic anticoagulation have been published, such observational data should not be used to support changes in practice due to survivor bias, confounding by indication, and lack of adjustment for important patient comorbidities and other treatments.

Recently, enrollment of patients requiring ICU level of care in the 3 ongoing multiplatform trials (REMAP-CAP, ATTACC and ACTIV-4A) was paused (as of December 21, 2020) due to an interim pooled analysis demonstrating futility of therapeutic-intensity anticoagulation in reducing the need for organ support over the first 21 days compared with standard-intensity prophylaxis in this specific subgroup. ICU level of care and organ support were defined as requiring high flow nasal oxygen, invasive or noninvasive mechanical ventilation, vasopressor therapy, or ECMO support. Additional outcomes have not yet been reported. This FAQ will be updated as more information becomes available. Enrollment in these three trials is continuing for patients who require hospitalization but do not require an ICU level of care at time of enrollment. Patients who require therapeutic anticoagulation for other indications are not enrolled in these trials.

Consequently, we discourage the empiric use of therapeutic-intensity heparin or LMWH in COVID-19 patients with no other indication for therapeutic anticoagulation, outside a clinical trial. Patients should be given therapeutic anticoagulation only as otherwise indicated. We recommend participation in ongoing clinical trials and epidemiologic studies.

 
Should therapeutic dose anticoagulation be empirically used in COVID-19 patients requiring ICU level care (i.e., in the absence of confirmed or suspected VTE)?

Microvascular thrombosis is hypothesized to be involved in hypoxemic respiratory failure in some patients with COVID-19. Autopsy studies show large vessel and microvascular thrombosis, pulmonary hemorrhage and high prevalence of VTE. Although retrospective cohort studies of patients treated or not treated with therapeutic anticoagulation have been published, such observational data should not be used to support changes in practice due to survivor bias, confounding by indication, and lack of adjustment for important patient comorbidities and other treatments.

Recently, enrollment of patients requiring ICU level of care in the 3 ongoing multiplatform trials (REMAP-CAP, ATTACC and ACTIV-4A) was paused (as of December 21, 2020) due to an interim pooled analysis demonstrating futility of therapeutic-intensity anticoagulation in reducing the need for organ support over the first 21 days compared with standard-intensity prophylaxis in this specific subgroup. ICU level of care and organ support were defined as requiring high flow nasal oxygen, invasive or noninvasive mechanical ventilation, vasopressor therapy, or ECMO support. Additional outcomes have not yet been reported. This FAQ will be updated as more information becomes available. Enrollment in these three trials is continuing for patients who require hospitalization but do not require an ICU level of care at time of enrollment. Patients who require therapeutic anticoagulation for other indications are not enrolled in these trials.

Consequently, we discourage the empiric use of therapeutic-intensity heparin or LMWH in COVID-19 patients with no other indication for therapeutic anticoagulation, outside a clinical trial. Patients should be given therapeutic anticoagulation only as otherwise indicated. We recommend participation in ongoing clinical trials and epidemiologic studies.


The guidelines were recently revised for non ICU cases though:

 
I'm guessing they're in the process of updating because the guidelines you posted linked to a press release
This is the link for the NIH guidelines that’s on the ASH page I shared


As of Dec there is no recommendation for full anti coagulation. We’ll see if it changes.
 
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