[pescetom]

Today's statistics in Italy: positive 100269 (+3.5%), dead 19468 (+6.5%), no longer infected 32534 (+14%). Intensive care 3381 (-6%). Fatality rate 16.2%.
This time it looks like more than a hickup in the data, the model is clearly changing radically respect to a week or so ago. Still a huge tail of people dying but not so many replacing them in intensive care, a new increase in positives growth rate but quite possibly related to more extensive testing.

[Cyberyeti]

 johnu, on 2020-April-11, 15:05, said:

Wow, just as absolutely bonkers and unbelievable as any suggestion the right fringe Republican politicians and demagogues are willing to sacrifice older or more vulnerable members of US society so that the economy can start a recovery. Oh wait, that one is 100% true and happening every day on places like Fox Propaganda Network.

This is more than that, she is convinced they are deliberately trying to kill her not just put her at risk.

Meanwhile an online gaming friend of mine lives in Utah. Her husband (a pharmacist) had symptoms, was tested and came up negative and was basically told that a negative test was pretty much worthless and they should self isolate anyway. I really don't understand the clamor for mass testing given how unreliable it is.

[johnu]

On a less serious note:

British bakers reintroduce World War II bread in coronavirus fight

Quote

After panic-buyers cleared supermarket shelves of flour, smaller-scale producers like Mungoswells Malt and Milling in East Lothian, Scotland, have seen a surge in sales.

"We normally expect three to five enquiries over a weekend. Last Monday morning when we came in, we had 400 orders, actual concrete orders," baker Angus McDowall told NBC News.

To keep up with the demand, the mill is focusing production on "85 percent extraction" brown flour, like that used in the National Loaf. This is far more efficient to make and allows for a healthier end product, he said.

"It is more nutritious than a white loaf, whether it's bought from a supermarket, made yourself, or whatever. The more of the bran that you can get into the bread, the better it is for you," McDowall said.

Flour is also in short supply in many US food stores as substantially more people are baking at home these days.

[pilowsky]

So at most 12 loaves then 😁.

[johnu]

 Cyberyeti, on 2020-April-11, 15:13, said:

This is more than that, she is convinced they are deliberately trying to kill her not just put her at risk.

Meanwhile an online gaming friend of mine lives in Utah. Her husband (a pharmacist) had symptoms, was tested and came up negative and was basically told that a negative test was pretty much worthless and they should self isolate anyway. I really don't understand the clamor for mass testing given how unreliable it is.

There is a difference between actively trying to kill somebody, letting somebody die when you might have been able to save them, and exposing somebody to additional risks of dying. Which one was it?

As far as accuracy of the tests,

If concerned about 'false negative' coronavirus test, self-quarantine anyway: Experts

Quote

It is too soon to know how many tests are producing false negatives. Molecular tests for viruses like the ones commonly being used for COVID-19 generally have very high sensitivities. According to the CDC, the same kinds of tests used for flu have a sensitivity in the range of 90-95%.
Roche, one of the largest manufacturers of tests, told ABC News that their coronavirus tests have a similarly high sensitivity of 95%, meaning that the tests could miss about 5% of infected people.

Others did not provide ABC News with a figure. Quest, for example, another major manufacturer, told ABC News that because the tests were approved by the FDA under an Emergency Use Authorization, “these FDA EUA assays have not been clinically validated. Hence there are no clinical sensitivity and specificity data for any of the FDA EUA assays.”

Those numbers assume that the test sample was collected correctly and enough genetic material was present for the test to work correctly. Somebody else in the article says that China may have had about 30% false negatives Read the article to see why you might get false negatives. On the other hand, there's a pretty high confidence level if you test positive.

[hrothgar]

 pescetom, on 2020-April-11, 14:49, said:

The NHS advised us that my very old but basically healthy mother currently in a home will not be taken to hospital if she contacts Covid, let alone be ventilated. I can verify that to you if you really need it.

I'm sorry if this is a rude comment, but this might very well be the right call for the NHS to make

My understanding is that there are not enough ventilators to go around.
Some kind of rationing scheme is going to be necessary.

Rationing treatment based on

1. The likelihood that an individual would benefit from treatment
2. The number of years that individual is likely to survive assuming that they do recover

Seems like a reasonable call.

How would you make such a decision?

[Cyberyeti]

 hrothgar, on 2020-April-11, 15:56, said:

I'm sorry if this is a rude comment, but this might very well be the right call for the NHS to make

My understanding is that there are not enough ventilators to go around.
Some kind of rationing scheme is going to be necessary.

Rationing treatment based on

1. The likelihood that an individual would benefit from treatment
2. The number of years that individual is likely to survive assuming that they do recover

Seems like a reasonable call.

How would you make such a decision?

Atm they have more than enough ventilators, this may change

[Cyberyeti]

 johnu, on 2020-April-11, 15:40, said:

Those numbers assume that the test sample was collected correctly and enough genetic material was present for the test to work correctly. Somebody else in the article says that China may have had about 30% false negatives Read the article to see why you might get false negatives. On the other hand, there's a pretty high confidence level if you test positive.

I'd heard 40% but that's the same ballpark. The problem seems to be that collecting the sample properly is quite an unpleasant process and people are not being unpleasant enough.

[shyams]

 hrothgar, on 2020-April-11, 15:56, said:

I'm sorry if this is a rude comment, but this might very well be the right call for the NHS to make

My understanding is that there are not enough ventilators to go around.
Some kind of rationing scheme is going to be necessary.

Rationing treatment based on

1. The likelihood that an individual would benefit from treatment
2. The number of years that individual is likely to survive assuming that they do recover

Seems like a reasonable call.

How would you make such a decision?

I too am sorry if this offends anyone but I heard (caveat: not very robust sources) that very old people are not put on ventilators because the "intubation" often leads to other complications and death. I recently saw a BBC article of a 101-year old who was admitted to hospital and recovered without being put on a ventilator.

[y66]

More on remdesivir from Hannah Kuchler at FT:

Quote

Gilead’s remdesivir drug has shown early positive signs that it might be effective in treating coronavirus, in a study of patients who have taken it on a compassionate use basis. 

The New England Journal of Medicine published a small study analysing data from 53 patients, which found that about 68 per cent improved after being treated with remdesivir, an antiviral that some experts hope could stop the Sars-CoV-2 virus from replicating. The drug was originally developed for Ebola, but has never been approved.

But the study did not have a control arm, so the results cannot be compared against patients who did not receive the drug, and should not be treated as conclusive. Large randomised control trials evaluating the drug — and others — are underway across the world. 

Jonathan Grien, the epidemiologist who was the lead author of the journal article, said they cannot draw “definitive conclusions from these data, but the observations from this group of hospitalised patients who received remdesivir are hopeful”. 

Remdesivir is one of the most prominent of the many drugs being explored for treating Covid-19 patients. Other antivirals include HIV drugs developed by AbbVie and a flu treatment from Fujifilm. Many trials are also testing hydroxychloroquine and chloroquine, antimalarials, as well as anti-inflammatories to help calm the body’s immune response if it goes into overdrive in the latter stages of the disease. 

The NEJM study, which took in data from patients in the US, Europe and Japan, found no new safety issues, other than those already reported, which include kidney and liver problems. Without a randomised trial it is hard to tell if those problems are complications of the disease or caused by the drug. 

Scientists are researching whether the drug may work better if it is delivered during the early stages of the disease. In this study, the patients were already hospitalised when they were given the drug and more than half were receiving ventilation. Patients who did not improve were more likely to be on invasive ventilation and 70-years-old or over.

Gilead, the California-based biotech company that developed the drug, funded the study. The company initially applied for “orphan status” for the drug, designed to expand intellectual property protection to drugs for rare diseases, but has since rescinded the status. 

Merdad Parsey, chief medical officer at Gilead, said the outcomes were “encouraging” but the data are “limited”. 

“Gilead has multiple clinical trials underway for remdesivir with initial data expected in the coming weeks,” he said. “Our goal is to add to the growing body of evidence as quickly as possible to more fully evaluate the potential of remdesivir and, if appropriate, support broader use of this investigational drug.”

[FelicityR]

 y66, on 2020-April-11, 23:02, said:

More on remdesivir from Hannah Kuchler at FT:

This raises an interesting medical and ethical point. When faced with an epidemic like this, are control groups - patients that are given a placebo instead of the actual drug - necessary? Surely if a drug is found to work in part then the protocols for mass laboratory testing with control groups should at least be postponed. And aren't covid-19 patients who are given a placebo rather than remdesivir, or for that matter any other drug available, being given a potential death sentence by not having access to medication?

[shyams]

 FelicityR, on 2020-April-12, 03:21, said:

This raises an interesting medical and ethical point. When faced with an epidemic like this, are control groups - patients that are given a placebo instead of the actual drug - necessary? Surely if a drug is found to work in part then the protocols for mass laboratory testing with control groups should at least be postponed. And aren't covid-19 patients who are given a placebo rather than remdesivir, or for that matter any other drug available, being given a potential death sentence by not having access to medication?

If there is no cure for Covid19, the administering of a placebo would not worsen or disadvantage anyone in the control group. It is not equivalent to a death sentence because the "medication" is not tested.

[Cyberyeti]

 shyams, on 2020-April-12, 04:35, said:

If there is no cure for Covid19, the administering of a placebo would not worsen or disadvantage anyone in the control group. It is not equivalent to a death sentence because the "medication" is not tested.

Also if a drug is found to be particularly effective, the control group can be switched from the placebo.

[helene_t]

 FelicityR, on 2020-April-12, 03:21, said:

This raises an interesting medical and ethical point. When faced with an epidemic like this, are control groups - patients that are given a placebo instead of the actual drug - necessary? Surely if a drug is found to work in part then the protocols for mass laboratory testing with control groups should at least be postponed. And aren't covid-19 patients who are given a placebo rather than remdesivir, or for that matter any other drug available, being given a potential death sentence by not having access to medication?

No, if it isn't tested in a placebo controlled trial then we will never know if it actually works.

Some twenty years ago, the FDA approved a drug based on a small trial without a control group, but that was an unusual situation, namely a scorpion anti-venom. Here the patient population was so small that everyone could be given the experimental drug, and indeed it would be a death sentence to get placebo.

Another example is drugs that have so severe side effects that it will be obvious who gets placebo.

I think a placebo-controlled trial with a Covid drug is no more ethically problematic than so many other drug trials. It is always a prerequisite for randomization that there's clinical equipoise, i.e. one treatment arm is not obviously better for the patient than another. But an experimental drug will rarely be obviously better than standard treatment. Rather the opposite - you're often better off getting the boring, ineffective standard treatment than some over-hyped experimental treatment which doctors have little experience with.

This all said, randomizing individual patients is indeed often problematic, so other designs such as for example stepped wedge designs (where a new treatment is phased in gradually across centers with the ordering of the centers being randomized) could also be considered.

[Cyberyeti]

 johnu, on 2020-April-11, 15:40, said:

There is a difference between actively trying to kill somebody, letting somebody die when you might have been able to save them, and exposing somebody to additional risks of dying. Which one was it?

She was convinced they were actively trying to kill the old and the infirm. Just one flaw among many in this is that if they dispose of the old in this way, they're killing what gave them an electoral majority, so this is vanishingly unlikely.

[pilowsky]

Not how medicine works. First you need a safety trial. And then a bunch of other stuff. And finally you can use it on sick people.

[y66]

Peter Foster in Brighton, Bethan Staton and Naomi Rovnick in London at FT: NHS ‘score’ tool to decide which patients receive critical care

Quote

Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed by the National Health Service.

With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.

Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.

The UK is set to exceed 80,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception.

The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.

The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment, with a patient aged 71-75 automatically scoring four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.

Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.

Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.

A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.

“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.

“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.

But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.

Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules. 

Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms.

“Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.” 

The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.

The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.

Audrey, who cares for her 90-year-old mother in Tyne and Wear, north-east England, spoke about how her mother signed a DNR order during a recent visit to hospital but it had remained in place even after she had recovered and returned home.

“Mam asked me what CPR was,” Audrey recalled, adding that no one from the hospital had contacted the family, raising worries about how actively her mother’s consent had been obtained.

Carole Walford, the chief clinical officer at Hospice UK, a charity that provides end-of-life care to 225,000 families each year, acknowledged the difficulty of broaching the DNR question, but said the speed at which Covid-19 is advancing is leaving less time for niceties.

With some patients dying within 24 hours, decisions on whether to die at home or go to hospital or a hospice are being compressed in ways that are forcing hospice workers to change the way they prepare individuals for death and families for bereavement.

“Coronavirus is pushing us to the limit as we try to hold on to to the ethos and practice of palliative care,” said Ms Walford, urging families to understand that demanding intensive care or hospital treatment might not be the best course of treatment.

Admission to hospital also means no contact with family, making homes — rather than hospices or hospitals — the haven for many patients.

“It’s important that we don’t see this as an ‘either-or’ decision. If someone is sedated and put on ventilation, is that better than having them on a ward or at home having a different death with dignity — still able have their hair combed, their teeth cleaned, their hand held?” said Ms Walford.

Despite the huge focus on building NHS capacity, the front line against coronavirus is often being fought in care homes and hospices already scarred by a decade of austerity that has placed immense strain on the social care system. 

According to the Health Foundation, a charity, per person government spending was facing a £6bn shortfall by 2018, with local authority funding falling in real terms in a period when the over-85 population has risen by more than 14 per cent. 

Even before the coronavirus pandemic caused up to 30 per cent of care home staff to report sick, the combination of spending cuts and low wages — the average full-time care worker earns little more than £16,000 a year — had left 120,000 vacancies across the sector.

[pescetom]

 hrothgar, on 2020-April-11, 15:56, said:

I'm sorry if this is a rude comment, but this might very well be the right call for the NHS to make

My understanding is that there are not enough ventilators to go around.
Some kind of rationing scheme is going to be necessary.

Rationing treatment based on

1. The likelihood that an individual would benefit from treatment
2. The number of years that individual is likely to survive assuming that they do recover

Seems like a reasonable call.

How would you make such a decision?

Luckily (or potentially luckily) it is not yet the case in UK that there are not enough ventilators to go around.
Even in countries like Italy that did temporarily find themselves in that horrible situation, more ventilators were procured and production of new ventilators was rapidly initiated.
Italy now has an excess capacity of 300 intensive care places, growing slowly every day touch wood, plus intermediate care equipped with ventilators.
The UK is nowhere near saturated yet.
The decision I mentioned was also not just relative to ventilator support but to hospital admission in general.
A hospital can resolve many crises that do not require ventilation but might be fatal at home, as even a relatively young Boris Johnson discovered.

[pescetom]

Today's statistics in Italy: positive 102253 (+2%), dead 19819 (+2%), no longer infected 34214 (+5%). Intensive care 3343 (-1%). Fatality rate 16.3%.
So maybe it was just a hickup in reporting after all. Will see in next few days.

Very difficult to stop Italians from celebrating Easter, the police had their work cut out stopping people sneaking their way to family reunions.
More so in the south, where the situation is not critical yet and the large town boundaries allow more freedom of movement with excuses like buying medicine.

[barmar]

 FelicityR, on 2020-April-12, 03:21, said:

This raises an interesting medical and ethical point. When faced with an epidemic like this, are control groups - patients that are given a placebo instead of the actual drug - necessary? Surely if a drug is found to work in part then the protocols for mass laboratory testing with control groups should at least be postponed. And aren't covid-19 patients who are given a placebo rather than remdesivir, or for that matter any other drug available, being given a potential death sentence by not having access to medication?

It's no more of a death sentence than not being admitted into the trial in the first place. Either way you're not getting the drug.

And what if the drug being tested turns out to be lethal -- the ones who are given the drug get the death sentence.