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Explaining the Research on Covid-19

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30 July

~ So when a study has a retrospective arm as the control, and they use data from
March or April, when the death rate was higher for standard care, their treatment will look like it reduces mortality, when it might not do so as compared to standard care today.

21 July 2020

~ The falling death rate means that studies done in March and April, or even to some extent in May, will not be applicable in every respect to patients becoming ill with Covid-19 in June and July and later.

15 July 2020

~ COVID Risk Chart at web-comic site XKCD

14 July 2020

~ For the week ending July 11th, there were 5,085 new deaths, and 419,876 new cases, as weekly totals. Compare this to the week ending April 18th, almost 3 months earlier, with 18,437 new deaths and 205,913 new cases, also as weekly totals. Weekly deaths are down by more than two-thirds, while at the same time weekly new cases have more than doubled.

11 July 2020

~ Table 3 Risk Factors Associated with In-Hospital Death. Factors which increase risk of dying in hospital from Covid-19: being over 50 years of age, being over 74 years even more so, being male, low systolic blood pressure, and higher respiratory rate. As compared to whites, african-americans had reduced risk of death. Use of Hydroxychloroquine reduced risk of death 47% in this NYC study of hospitalized patients.

7 July 2020

~ Usually, to identify a study, you give the lead author and the date of the study. For Covid-19, almost all the studies are “2020”, so this approach is not very useful. I suggest a different format: Author Year Journal as in:
Schiem 2020 SSRN
Grant 2020 Nutrients
Kasahara 2013 PloS one

6 July 2020

~ Covid deaths are way down, and kids are less likely to die of Covid in any case. So schools might open in the fall. But Covid-19 is SEASONAL. Which means September will be the mildest month, and then the disease will ramp up in severity through Oct., Nov., and December. The winter could be really really bad — unless we have a massive push for vitamin D supplementation. 10,000 IU of vitamin D3 per day throughout the entire winter.

5 July 2020

~ The week ending July 13th saw a total of 153,680 new Covid cases. Two weeks later the weekly new cases total was 265,959. A week after that, the week ending July 4th, it was 339,233 new cases — more than double three weeks earlier. But new deaths has not increased proportionately. The new deaths totals for those weeks were 5,431 deaths against 153,680 cases, and then 3 weeks later 4,166 new deaths against 339,233 new cases. Good news, or not?

The answer depends on whether the increase in deaths is simply lagging increase in cases, or whether we have gotten a lot better at treating cases. A new case reported on Sunday June 14th (20,004 new cases; 331 new deaths that day) should result in death, if the patient does die, in about 10 days, the average length of time from hospital admission to death. On Sunday June 28th, there were 40,540 new cases but only 285 new deaths. Since Wednesday, June 24th, new cases have exceeded 40,000 every day. The overall death rate, total accumulated deaths to total accumulated cases has recently dropped from 5% to 4.5%. But 4.5% of 40k is 1,800 deaths, and we aren’t seeing anywhere near that number of daily new deaths.

Yesterday, July 4th, was the 10th day since the jump to over 40k new cases per day. If we see a jump in new deaths, it will be this coming week. If we do not see that jump in new deaths, by July 14th — 20 days from the start of the jump in new cases, we are out of the woods (until October). It will mean that the proportion of deaths to cases has dropped significantly. Good news.

I say “until October” because the reason for this drop is partly due to the increase in vitamin D in the blood stream as people get outside in the sun during summer. This effect will increase through September, which should be one of the better months for Covid cases and deaths. But when we hit October, if vitamin D is the reason for the improvement, things will get worse, and worse still in November, and worse still in December. Now, if September sees many more cases, but a low death rate, it will mean that the winter will be particularly bad, as we weren’t able to reign in the number of cases, and now the death rate will rise against a high rate of new cases. That would be devastating.

3 July 2020 – ICU Doctor: Top 10 Things I learned Treating Coronavirus Patients | COVID-19

1 July 2020 – Ivermectin is working better than hydroxychloroquine or Remdesivir. Read this interview on ivermectin and related issues

1 July 2020 – RCTs are not the answer to every problem in medicine. Read what the Frontline Covid-19 Critical Care Working Group says about RCTs and the MATH+ Protocol.

1 July 2020 – Hastie, Pell, and Sattar In this brief communication, the authors analyzed data from patients in the UK and found that, after adjustment for confounders, there was no correlation between vitamin D and Covid-19 mortality or severe infection. The authors then stated that “Recommendations for vitamin D supplementation to lessen COVID-19 risks may provide false reassurance.”

However, in studies on any type of correlation or causation, it is common for some studies to find no relation, while other studies do find a relation in the data. One study finding no correlation does not justify the conclusion that supplementation with an essential nutrient, confirmed as helpful by over a dozen other studies, is “false reassurance”.

30 June 2020 – The US has 4% of the world’s population but 25% of its coronavirus cases – Yeah, not really. China and perhaps Japan are lying about how many cases they have. Given that China is the center of the outbreak, and they have over 1.3 billion residents, there’s no way their data is real. Then there are areas of the world where, when someone becomes ill, they are in such an impoverished state that the cases do not get reported or treated. This could account for millions of unreported cases. So, we really don’t have 25% of the cases.

29 June 2020 – Last week (June 21-27) had the highest count of new cases by week for the U.S. ever: 265,959. New deaths have not caught up yet; it takes 10 to 15 days for that to happen. Expect to see a spike in new deaths in early July.

27 June 2020 ~ The statistics at Worldometers say 10 million Covid Cases worldwide, and half a million deaths, as of today. That’s a 5% death rate.

In the U.S., we have averaged over 40 thousand cases per day for the last 5 days (June 23 to 27), with a range of 36k to 48k. That means in about 10 days, we will start to see deaths from that bump in cases. At 5%, it means 2,000 deaths per day instead of our current less than 1,000 deaths per day. Look for that jump in cases around about July 2nd.

26 June 2020 ~ I’m concerned that the data from trials to-date on Remdesivir do not match the sudden extensive usage of it. It reminds me of Hydroxycloroquine. It is a serious problem in medicine generally that natural products with support from studies do not receive the same attention as Big Pharma products. The latter obtain FDA approval faster, as more money is at stake. Natural products might not be patent-able, so less profit is at issue.

* A JAMA article proposes a lottery system for which patients get Covid-19 medications that are in short supply, like Remdesivir.

I have a few things to say about that. A lottery system for medicine to treat a deadly disease is basically a medical version of Russian Roulette. But since 80% of those who are dying are over 65, it’s actually more like a combination of Russian Roulette and Bingo. “Ooo, I’m so sorry, Gramma. Your number didn’t come up. […flatline…] Oh, look at that. I was wrong. Your number is up.”

And to make this lottery system even worse, the JAMA article also proposes that all patients, those who get the drug and those who do not, have their data used in a study to see how many more persons died in the group that didn’t get the medicine, due to the lottery. The article calls this a “natural experiment.” I kid you not. Yes, it is an experiment, to see how many people were killed by substituting a lottery for the medical judgment of doctors. But there is nothing natural about it.

And will they be getting patient permission to be in this study? Or will consent to the study be tied to participation in the lottery? In the latter case, patients are essentially blackmailed into joining a study, because if they refuse, they don’t have even a chance at the meds. The article anticipates this objection:

Some may assert that the proposed lottery would require patient-level consent for research. However, the lottery is not a research maneuver; it is a public health intervention to fairly allocate a scarce resource that creates a type of natural experiment.

Right. It’s not a “research maneuver”, so they don’t need patient consent. It’s just “a natural experiment that could be leveraged by researchers to make causal inferences about the effect of a factor outside their control (eg, the medication lottery) on patient outcomes in a situation resembling an actual experiment.” So, it would be used “to make causal inferences” thereby (rather cynically) using “the occurrence of drug scarcity to advance scientific knowledge.” But since it only resembles an actual experiment, they don’t need patient consent. Oh, and what’s the endpoint of this “natural experiment” that isn’t enough like an experiment to need patient consent? “mortality” — and that’s the endpoint stated in the response to criticisms about patient consent. We don’t need patient consent because we’re only conducting an experiment where we expect to see a difference in what percentage of persons die whose random number didn’t give them a medication to treat a deadly pandemic. OK, here’s a rule of thumb for patient consent, if the end point is the death of the patient, you need consent.

But I’m sure lots of elderly persons will participate. What choice do they have? Our senior citizens are mentally tough. They will take it all in stride. I can just see the elderly patients, on the Covid ward, taking side bets on who will get the meds and who won’t… on who will die next and who will die last. Then some patients won’t want to use a random number in the lottery. They’ll want to play their grandkids’ birthdays, or their lucky numbers.

And if you think that using random numbers to decide who gets a medicine constitutes the randomization portion of a study, you don’t know how studies work. The type of randomization used in studies, such as RCTs, is not truly random. You have two groups. You want each group to have about the same number of persons of each gender, of each age group, of each category of disease stage, and of other factors. True randomness can result in an imbalance of these types of factors. If you flip a coin ten times, you could get 7 heads and 3 tails. That is not the type of randomness you need for a study. So using a state government health department to generate a random lottery number to decide who gets a medication is not experimental randomness.

Who receives a drug should not be random. Randomness is not fairness. You give the medication to the persons who need it most, and who can benefit the most. The system for organ transplants takes into consideration various factors, so as to be as fair as possible with a scarce medical resource. You don’t give a 99 year old, a lifetime smoker, with a history of strokes, a heart available for transplant, just because he got lucky and had the right random number. Random does not equal fair.

24 June 2020 ~ Covid-19 is seasonal, which means that cases and deaths might follow the seasonal pattern of cases of the type of coronavirus that causes colds, with lows in June through September, and increases as the days progress through October, November, and December. Like So:

Seasonality

And this might effect the U.S. Presidential Election of Nov. 2020. As the pandemic suddenly worsens in October and early November, people (not realizing this is merely the usual pattern of a seasonal disease) will blame the government and the current president, Donald Trump. This could weigh against him rather substantially.

I dare say that if the election were held in early October, Trump would be much more likely to win, and if it were delayed until early December, he would be much more likely to lose.

23 June 2020 ~ I just go the results of my vitamin D blood test: 43.2 ng/ml, which is 107.8 nmol/L. That might seem pretty good; it is within normal limits. But I’ve been taking 10,000 IU of vitamin D per day for at least the previous two months (April 13 to June 16). I thought the level would be higher.

So now I’m recommending people take 10,000 IU/day of vitamin D continuously. Period. At least until the pandemic is over.

“a serum 25-hydroxyvitamin D concentration [25(OH)D] from 60-80 ng/ml may be needed to reduce cancer risk…. Universal intake of up to 40,000 IU vitamin
D per day is unlikely to result in vitamin D toxicity.” (Garland Anticancer Research 2011)

Note that the Calgary Vitamin D Study gave participants either 400 or 4,000 or 10,000 IU of vitamin D per day for 3 years. They found that even the highest dosage was safe for that period of time. And it was an RCT. Here is a recent analysis of that data:
Billington, Emma O., et al. “Safety of high-dose vitamin D supplementation: Secondary analysis of a randomized controlled trial.” The Journal of Clinical Endocrinology & Metabolism 105.4 (2020): 1261-1273.

23 June 2020 ~ YouTube channels run by reputable physicians are still having trouble with YouTube censors taking down videos. These are doctors discussing medical studies, studies done by teams of researchers with Ph.D.s and M.D.s etc. And who is deciding that these videos should be banned? Anonymous commentators, who flood YouTube with complaints, and YouTube employees who are low paid and have no medical background.

Then, on social medial, the lead author to an RCT (randomized controlled trial) which showed a one third decrease in mortality for use of dexamethasone in Covid-19, was getting a lot of complaints about the study here. And see the discussion of that problem at MedCram.

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