Medical Discussion of Coronavirus

[VentAlarm]

1/500 of the entire population has already died of COVID and the pandemic is far from over. Even if every American has gotten covid (which is patently absurd) the death rate is 2-20x those figures. In the end the CFR today is still 1.5%, and the IFR (which is likely what you meant) is probably at least 0.5%. For huge swaths of the population this disease has an IFR of 1% or much more: the poor, the elderly, the obese, diabetics, etc. It’s been clear from the outset this disease was going to be very nasty to America because it picked on fat, sick, poor people, of which America has a plethora.

But anyway, I agree that the SCOTUS precedent is not reliable, at least as applies to a society wide mandate.

Sure. But that wasn’t the point I was trying to make. The fatality rate in some subsets is incredibly high. My dad is in his 80s and immunosuppressed. His expected mortality would be through the roof. He got the vaccine as soon as it was available, same with the booster. But the expected mortality for a healthy 20 year old (who’s not pregnant or immunosuppressed) approaches 0. I was simply attempting to point out that the concept of a blanket application for all Americans has some issues. A 70 year old in a nursing home, a 60 year old smoker who lived in Manhattan and a 22 year old who works on a family farm have very different risk profiles and it seems illogical (at least to me) to demand the same policy get applied to all of them.

Regarding CFR vs. IFR, kind of depends how in the weeds you want to get on whether CFR is defined as a diagnosed cohort or ill cohort. I meant symptomatic cases not tested, not asymptomatic infections. My brother got Covid not too long ago. His kids all got a febrile illness but were not tested. When you see the cumulative CFR of 1.6, this isn’t part of the denominator.

[snowcanyon]

https://www.medrxiv.org/content/10.1....30.21262866v1

Why would you give equal weight to a preprint as to a peer-reviewed article?

[FIREshrink]

Sure. But that wasn’t the point I was trying to make. The fatality rate in some subsets is incredibly high. My dad is in his 80s and immunosuppressed. His expected mortality would be through the roof. He got the vaccine as soon as it was available, same with the booster. But the expected mortality for a healthy 20 year old (who’s not pregnant or immunosuppressed) approaches 0. I was simply attempting to point out that the concept of a blanket application for all Americans has some issues. A 70 year old in a nursing home, a 60 year old smoker who lived in Manhattan and a 22 year old who works on a family farm have very different risk profiles and it seems illogical (at least to me) to demand the same policy get applied to all of them.

Regarding CFR vs. IFR, kind of depends how in the weeds you want to get on whether CFR is defined as a diagnosed cohort or ill cohort. I meant symptomatic cases not tested, not asymptomatic infections. My brother got Covid not too long ago. His kids all got a febrile illness but were not tested. When you see the cumulative CFR of 1.6, this isn’t part of the denominator.

Yes That's the difference between IFR and CFR.

the problem with lacking a single policy is that it imagines a fantasy world where those at high risk can be segregated from those at low risk; and where we have infinite health care resources to deploy. Neither is true. We are essentially at rationed care in multiple locations around the country, that isn't a world in which the demands for a public health policy can be ignored.

[PedsCCM]

https://www.medrxiv.org/content/10.1....30.21262866v1

Ah. That’s an interesting way to present the data. I strongly suspect zero vaccines would withstand this type of analysis. The authors analyze the risk of myocarditis post vaccine (#myocarditis / #vaccinated kids in a given age group who got the vaccine). They then compare this with the 120 day hospitalization rate for covid in the age group (COVID admissions in age group over 120 day period / total US pop in that age group).

[pierre]

A 70 year old in a nursing home, a 60 year old smoker who lived in Manhattan and a 22 year old who works on a family farm have very different risk profiles and it seems illogical (at least to me) to demand the same policy get applied to all of them.

I agree. I’m in a hot zone and read a bunch of CT chest and CXRs today, the vast majority of which were COVID related. There were lots of young and old patients. One thing they all had in common (besides being unvaccinated) is that they were all fat.

The local vaccine rate is among the worst in the country. By some accounts nearly 90% of the population in this country are metabolically unhealthy (at least one marker of metabolic syndrome), and it’s clear that this disease affects those people rather severely. So while I’m not necessarily in favor of a one size fits all mandate, I don’t really think the general population are capable of risk stratifying themselves and making the appropriate choice regarding vaccination.

[Hatton]

Some of you need to be careful about overtly political posts. I would hate to have this great thread shut down.

[artemis]

By some accounts nearly 90% of the population in this country are metabolically unhealthy (at least one marker of metabolic syndrome), and it’s clear that this disease affects those people rather severely. So while I’m not necessarily in favor of a one size fits all mandate, I don’t really think the general population are capable of risk stratifying themselves and making the appropriate choice regarding vaccination.

One thing I have been struck by is how many people who have a significant COVID risk factor (particularly obesity) are in complete denial of that risk factor. They seem to think that if they wouldn’t qualify as a star on My 600 Pound Life they are not at risk. This seems to be true of age as well, to a lesser extent. People seem to think that if they are in their 50s or 60s they are still young. Young at heart perhaps, but physiologically no, and it is in the 50 to 60 age range when the COVID mortality rate graph, which was fairly flat at younger ages, begins to show a significant inflection upwards.

[Lordosis]

One thing I have been struck by is how many people who have a significant COVID risk factor (particularly obesity) are in complete denial of that risk factor. They seem to think that if they wouldn’t qualify as a star on My 600 Pound Life they are not at risk. This seems to be true of age as well, to a lesser extent. People seem to think that if they are in their 50s or 60s they are still young. Young at heart perhaps, but physiologically no, and it is in the 50 to 60 age range when the COVID mortality rate graph, which was fairly flat at younger ages, begins to show a significant inflection upwards.

I agree. It is my parents generation that is the most in denial about their age. The old gen-xers.

I also agree with you that a lot of people compare themselves to everybody else in regards to weight and do not see the problem.

[Hatton]

Well one cannot change age but You can work on BMI.

[FIREshrink]

One thing I have been struck by is how many people who have a significant COVID risk factor (particularly obesity) are in complete denial of that risk factor. They seem to think that if they wouldn’t qualify as a star on My 600 Pound Life they are not at risk. This seems to be true of age as well, to a lesser extent. People seem to think that if they are in their 50s or 60s they are still young. Young at heart perhaps, but physiologically no, and it is in the 50 to 60 age range when the COVID mortality rate graph, which was fairly flat at younger ages, begins to show a significant inflection upwards.

Exactly why the US was destined to suffer so badly from COVID-19:

The average American man between the ages of 20 to 39 weighed 197 pounds and stood at 5 feet 9 inches tall, according to a 2015-16 health survey by the National Center for Health Statistics. The average woman of that age range was roughly 5 feet 4 inches tall and weighed 168 pounds.
https://www.washingtonpost.com/world...nking-tallest/

[Tim]

One thing I have been struck by is how many people who have a significant COVID risk factor (particularly obesity) are in complete denial of that risk factor. They seem to think that if they wouldn’t qualify as a star on My 600 Pound Life they are not at risk. This seems to be true of age as well, to a lesser extent. People seem to think that if they are in their 50s or 60s they are still young. Young at heart perhaps, but physiologically no, and it is in the 50 to 60 age range when the COVID mortality rate graph, which was fairly flat at younger ages, begins to show a significant inflection upwards.

The surveys show human nature.
Young people think they are invincible and 90% of drivers think they are above average!
Why would Covid be any different?
YOLO at any age or weight.
And remember, life is not fair. Game over.

[Bmac]

Exactly why the US was destined to suffer so badly from COVID-19:

The average American man between the ages of 20 to 39 weighed 197 pounds and stood at 5 feet 9 inches tall, according to a 2015-16 health survey by the National Center for Health Statistics. The average woman of that age range was roughly 5 feet 4 inches tall and weighed 168 pounds.
https://www.washingtonpost.com/world...nking-tallest/

Sadly, the goalposts have been moved. In many (most) parts of the US overweight is the new skinny and obese is the new normal. When everyone around you has a similar body type, there’s no longer even a sense of being atypical or unhealthy.

[FIREshrink]

Sadly, the goalposts have been moved. In many (most) parts of the US overweight is the new skinny and obese is the new normal. When everyone around you has a similar body type, there’s no longer even a sense of being atypical or unhealthy.

obesity is contagious

https://www.nejm.org/doi/full/10.1056/nejmsa066082

[pulmdoc]

That includes the beginning of the pandemic prior to dex and remdesivir. It is also upwardly biased as it depends on confirmed cases. The case fatality rate has since dropped.

Case fatality rate was ~3-4% the first couple months of the pandemic, rapidly declined to ~2% with widespread testing and discovery of steroids/proning for critically ill, and had remained fairly constant since. This wave, despite the patients being younger on average, mortality is stable, with roughly 1/3 of patients critically ill die. At my institution, you don't physically get in the ICU unless you are intubated, so ICU-specific mortality is very high because it selects out all the patients who stabilize on HFNC/NIV and recover without being intubated. In pre-COVID times, everybody on continuous BIPAP was an ICU patient because of the potential for deterioration to needing a vent. These days, floor nurses are getting 6:1 BIPAPs. It's a subtle but real form of health care rationing to get less nursing care than normal. It also makes reporting about hospital capacity less accurate, because if we report that we are at 100% capacity for ICU beds but don't count the 30 patients who are on the floor being denied ICU monitoring it doesn't sound as bad as "we're 200% ICU capacity, if you are on oxygen you get sent home from the ED to hope you don't crash and die at home, if you are on BIPAP you get sent to the floor to hope you don't crash and die waiting for an ICU bed, and if you are in the ICU you've already progressed despite all the medicines we have and are probably going to die."

[G]

Case fatality rate was ~3-4% the first couple months of the pandemic, rapidly declined to ~2% with widespread testing and discovery of steroids/proning for critically ill, and had remained fairly constant since. This wave, despite the patients being younger on average, mortality is stable, with roughly 1/3 of patients critically ill die. At my institution, you don't physically get in the ICU unless you are intubated, so ICU-specific mortality is very high because it selects out all the patients who stabilize on HFNC/NIV and recover without being intubated. In pre-COVID times, everybody on continuous BIPAP was an ICU patient because of the potential for deterioration to needing a vent. These days, floor nurses are getting 6:1 BIPAPs. It's a subtle but real form of health care rationing to get less nursing care than normal. It also makes reporting about hospital capacity less accurate, because if we report that we are at 100% capacity for ICU beds but don't count the 30 patients who are on the floor being denied ICU monitoring it doesn't sound as bad as "we're 200% ICU capacity, if you are on oxygen you get sent home from the ED to hope you don't crash and die at home, if you are on BIPAP you get sent to the floor to hope you don't crash and die waiting for an ICU bed, and if you are in the ICU you've already progressed despite all the medicines we have and are probably going to die."

I love hearing your experience from upstairs--keep it coming.

in terms of capacity, I also haven't been able to figure out the denominator. do they count unstaffed beds and/or unsuitable beds (NICU, L&D, PACU)?

when there are vented and other admitted patients living in the ER, one would think that by definition, the hospital is at 100% capacity...but I have yet to see that reported for my shop. perhaps things are only full when we suggest using the CEO's office to board patients.