I was Asthmatic as a child and stayed on medicine through college. Since then (I'm 32 now), I haven't used medicine much to control and haven't had any major attacks. I've got an appointment for the Dr. on Monday in hopes of at least getting an emergency inhaler. Any questions or requests I should make of that Dr. Given my history? Am I worrying too much or too little about Asthma and Covid-19. Any thoughts would be greatly appreciated

Infection_Ag11 said:

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Moxley said:

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Respiratory failure day 7-8 post symptoms or post exposure?

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Symptoms

Disease can take up to 12-14 days post exposure to develop, but most get symptoms by days 2-4 post exposure

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Current data on the virus itself. The timeline is daunting: RESILIENT

BrisketTaco10 said:

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I was Asthmatic as a child and stayed on medicine through college. Since then (I'm 32 now), I haven't used medicine much to control and haven't had any major attacks. I've got an appointment for the Dr. on Monday in hopes of at least getting an emergency inhaler. Any questions or requests I should make of that Dr. Given my history? Am I worrying too much or too little about Asthma and Covid-19. Any thoughts would be greatly appreciated

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A lot of people "grow out" of childhood asthma. If you haven't had any issues in many years it's unlikely your risk is much greater than another individual in your age group. A rescue inhaler for someone with your history is never a bad idea, though.

Patentmike said:

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Infection_Ag11 said:

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As some of you are aware, I'm an infectious diseases physician in the Dallas area. I wanted to provide some clinical information compiled from US patient populations based on discussions with my colleagues around the state and country in ID, EM and pulm crit. Much of this is from the cases in Washington. If you find anything over your head and want further clarification please ask, I know we forget what constitutes professional shop talk sometimes.

This is a very unique virus, it behaves very differently from the more common coronaviruses which cause the common cold and from most respiratory viruses in general. It's actually quite different than influenza in its clinical characteristics. Even compared to the original SARS it's a little unique. Once you see a couple it's actually not too hard to recognize because of this.

Runny nose, congestion and GI symptoms are uncommon (no more than 5-10%) and any of these combined with the absence of or only short lived fever effectively excludes the diagnosis. These people fever consistently for days, often high fevers.

The myalgias are less intense than with influenza.

Everyone has a cough at some point

Kids aren't really becoming ill very often, and symptoms are very rare under age 12 or so. They are possibly serving as asymptomatic carriers however.

Almost all of these patients are lymphopenic (low lymphocyte counts, a type of white blood cell).

Most have mild to moderate liver function test elevations (AST/ALT 3-5x the upper limit of normal)

They all have chest imaging abnormalities and essentially everyone has at least a mild (maybe even sub clinical) viral pneumonia by imaging. The findings are generally bilateral. This is in contrast to influenza which more often results in a post viral bacterial pneumonia, rather than primary viral pneumonia (though both do happen).

We are seeing some young healthy patients do poorly. It's not the norm, but it happens. We will have some 20s-40s die in Texas.

If respiratory failure happens it will occur at day 7-8 almost like clockwork. And it happens FAST, mild hypoxia to full blown ARDS usually in only hours. The critical care guys are saying you can literally watch it happen in front of you some times.

A lot of these patients are dying not of persistently poor oxygenation on a ventilator, but due to cardiac arrhythmias. It's believed to be related to viral myocarditis and many are going into full blown cardiogenic shock. Lots of Vfib/Vtach.

Remdesivir looks promising, it was developed for viral hemorrhagic fevers (think Ebola) but seems to have good activity against many RNA viruses. It's leading to much more rapid improvement of the respiratory failure in our small sample sizes. A few loopholes and exclusion criteria to get through, though.

I'll post more tomorrow, gonna try and get some rest while the pager is silent lol

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Are the Remdesivir results posted where the public can see them. I would like to watch those studies.

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Studies ongoing but at this point it's mostly anecdotal cases and a few case study reviews.

Infection_Ag11 said:

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Patentmike said:

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Infection_Ag11 said:

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As some of you are aware, I'm an infectious diseases physician in the Dallas area. I wanted to provide some clinical information compiled from US patient populations based on discussions with my colleagues around the state and country in ID, EM and pulm crit. Much of this is from the cases in Washington. If you find anything over your head and want further clarification please ask, I know we forget what constitutes professional shop talk sometimes.

This is a very unique virus, it behaves very differently from the more common coronaviruses which cause the common cold and from most respiratory viruses in general. It's actually quite different than influenza in its clinical characteristics. Even compared to the original SARS it's a little unique. Once you see a couple it's actually not too hard to recognize because of this.

Runny nose, congestion and GI symptoms are uncommon (no more than 5-10%) and any of these combined with the absence of or only short lived fever effectively excludes the diagnosis. These people fever consistently for days, often high fevers.

The myalgias are less intense than with influenza.

Everyone has a cough at some point

Kids aren't really becoming ill very often, and symptoms are very rare under age 12 or so. They are possibly serving as asymptomatic carriers however.

Almost all of these patients are lymphopenic (low lymphocyte counts, a type of white blood cell).

Most have mild to moderate liver function test elevations (AST/ALT 3-5x the upper limit of normal)

They all have chest imaging abnormalities and essentially everyone has at least a mild (maybe even sub clinical) viral pneumonia by imaging. The findings are generally bilateral. This is in contrast to influenza which more often results in a post viral bacterial pneumonia, rather than primary viral pneumonia (though both do happen).

We are seeing some young healthy patients do poorly. It's not the norm, but it happens. We will have some 20s-40s die in Texas.

If respiratory failure happens it will occur at day 7-8 almost like clockwork. And it happens FAST, mild hypoxia to full blown ARDS usually in only hours. The critical care guys are saying you can literally watch it happen in front of you some times.

A lot of these patients are dying not of persistently poor oxygenation on a ventilator, but due to cardiac arrhythmias. It's believed to be related to viral myocarditis and many are going into full blown cardiogenic shock. Lots of Vfib/Vtach.

Remdesivir looks promising, it was developed for viral hemorrhagic fevers (think Ebola) but seems to have good activity against many RNA viruses. It's leading to much more rapid improvement of the respiratory failure in our small sample sizes. A few loopholes and exclusion criteria to get through, though.

I'll post more tomorrow, gonna try and get some rest while the pager is silent lol

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Are the Remdesivir results posted where the public can see them. I would like to watch those studies.

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Studies ongoing but at this point it's mostly anecdotal cases and a few case study reviews.

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That's what I had found online, so I wanted to double check if I'd missed anything.

Redassag94 said:

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erudite said:

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Do you know the testing criteria for corona? I'm looking at the current (6th) edition guidelines published by the CCDC (Chinese CDC)

I also came across this snippet:

Quote:

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There is significant deviation on sterilization regarding novel coronavirus in comparision to SARS/MERS. Adequate methods include

• Intense UV exposure and applied heat at 56C for 30 minutes
• Ethanol 75% concentration
• Chlorine containing disinfectant
• peracetic acid (?) translation literal: "Passthrough Oxygen Methyl acid"
• Choloroform (?) translation literal: "Chlorine inminator"

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Chlorine plus disinfectant... Is that just adding dawn to your beach mixture? Is there a good recipe for beach cleaner that will kill the virus?

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It's some sort of special compound they made for this I think. It's not anything that I have been able to pull up directly.
It literally translates to Chloride containing disinfectant (mixtures).
Back on topic. Sorry.

Infection_Ag11 said:

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Redassag94 said:

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What are your thoughts on the seasonality of this virus? I read COVID 19 does not like warm weather.

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We don't know yet, but I'll say it's pretty warm in Singapore and that didn't seem to stop it

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I live in Panama (Central America) and all I can say is the health officials and government here are not acting like they think the tropical climate is an immunity pill. All schools and public events are closed, travel restricted coming into the country etc.

Had our first case reported on Monday, and this week the number of reported cases by the government at the end of each day has been 1 then 8 then 14 then 27 then 36 (yesterday). Will see what Saturday evening's reported number is.

"The critical care guys are saying you can literally watch it happen in front of you some times."

Who and where are these people and how many cases are these people observing?

Saw an interview with a doctor saying that Chinese docs started fighting it with plasma from survivors of the virus. Not sure what that means, but wanted your thoughts.

Thanks for the info!

Thoughts on this infection_ag?

I've read Kaletra is thought to have some success, along with Chloroquine.

Gilead makes Remdesivir and can only be had through compassionate use, per their website, and studies are ongoing. Have you been able to get any for your patients?

The steroid treatment is not recommended. Data from China shows steroids tend to make this worse, not better.

Moxley said:

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The steroid treatment is not recommended. Data from China shows steroids tend to make this worse, not better.

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May be some benefit in those with ARDS.

Thanks for the insights Infectious.

Any tips or tricks for a busy outpatient pediatric practice to minimize the risk of exposure to staff & providers? I am not very worried about my patients but mostly about myself and staff and grandparents. We see a lot of cough & fever every day year round.

I'm currently just planning on masking and rooming febrile URI patients ASAP and a good cleaning of the room when they leave. I am not optimistic that anything will really prevent the staff and/or other patients from being exposed if/when it gets widespread since it is so similar to any other viral infection in children.


Also what do the lungs sound like on auscultation? I have found nothing on this after extensive searching.

McInnis 03 said:

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Thoughts on this infection_ag?

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Would not recommend steroids, there's a good chance it makes things worse

KidDoc said:

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Thanks for the insights Infectious.

Any tips or tricks for a busy outpatient pediatric practice to minimize the risk of exposure to staff & providers? I am not very worried about my patients but mostly about myself and staff and grandparents. We see a lot of cough & fever every day year round.

I'm currently just planning on masking and rooming febrile URI patients ASAP and a good cleaning of the room when they leave. I am not optimistic that anything will really prevent the staff and/or other patients from being exposed if/when it gets widespread since it is so similar to any other viral infection in children.


Also what do the lungs sound like on auscultation? I have found nothing on this after extensive searching.

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Honestly, I'd send a letter or email to your patients asking that for the time being they not come in for mild illnesses with fever and respiratory symptoms. If they are sick enough to need to be seen they need to go to the hospital, but the reality is we don't really do much for these people in clinic for mild disease (a lot of doctors give unnecessary antibiotics for viral respiratory infections, but that's a different discussion) and right now it's better to just wait it out.

If you have a patient with fever and cough immediately put a mask on them, on anyone they came with, put them all in a room and have anyone going don appropriate PPE until you can get the full story. Do NOT screen people before doing these things.

The lung exam isn't particularly sensitive or specific, they generally have mild bilateral crackles and rhonchi that you can see with any viral or atypical bacterial lower respiratory tract pathology.

OlSarge92 said:

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"The critical care guys are saying you can literally watch it happen in front of you some times."

Who and where are these people and how many cases are these people observing?

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The guys in Washington and California, and some critical care docs up there have seen a couple dozen themselves already.

jakeaggie84 said:

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Saw an interview with a doctor saying that Chinese docs started fighting it with plasma from survivors of the virus. Not sure what that means, but wanted your thoughts.

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Another thing that's too early to know, theoretically there's a mechanism behind it so it's not pure witchcraft.

Infection_Ag11 said:

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McInnis 03 said:

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Thoughts on this infection_ag?

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Would not recommend steroids, there's a good chance it makes things worse

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All steroids? I'm not overly worried as a healthy 32 yr old. But I take steroids for well controlled asthma. My wife is an NP at MDA and I assume it's only a matter of time.

Infection_Ag11 said:

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KidDoc said:

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Thanks for the insights Infectious.

Any tips or tricks for a busy outpatient pediatric practice to minimize the risk of exposure to staff & providers? I am not very worried about my patients but mostly about myself and staff and grandparents. We see a lot of cough & fever every day year round.

I'm currently just planning on masking and rooming febrile URI patients ASAP and a good cleaning of the room when they leave. I am not optimistic that anything will really prevent the staff and/or other patients from being exposed if/when it gets widespread since it is so similar to any other viral infection in children.


Also what do the lungs sound like on auscultation? I have found nothing on this after extensive searching.

---

Honestly, I'd send a letter or email to your patients asking that for the time being they not come in for mild illnesses with fever and respiratory symptoms. If they are sick enough to need to be seen they need to go to the hospital, but the reality is we don't really do much for these people in clinic for mild disease (a lot of doctors give unnecessary antibiotics for viral respiratory infections, but that's a different discussion) and right now it's better to just wait it out.

If you have a patient with fever and cough immediately put a mask on them, on anyone they came with, put them all in a room and have anyone going don appropriate PPE until you can get the full story. Do NOT screen people before doing these things.

The lung exam isn't particularly sensitive or specific, they generally have mild bilateral crackles and rhonchi that you can see with any viral or atypical bacterial lower respiratory tract pathology.

---

Thanks! Yeah I already got in touch with the office manager to mask and room fever/cough patients immediately. If no rooms available they can wait in their car and we can text them. Then wipe down rooms with bleach wipes when they leave.

The problem is toddlers are not going to keep masks on and they lick everything. Plus there are still normal viral processes going on so I cannot tell them to ignore it if these kids do have flu, bronchitis, pneumonia, acute otitis, etc. Normal illness is still going on as well.

I am taken by the emerging data on how surprisingly long people are infectious before becoming symptomatic, how long people remain infectious even after "recovering" and are asymptomatic again and that people who never become symptomatic at all may nonetheless be infectious.

This is a very clever, determined pathogen.

RangerRick9211 said:

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Infection_Ag11 said:

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McInnis 03 said:

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Thoughts on this infection_ag?

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Would not recommend steroids, there's a good chance it makes things worse

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All steroids? I'm not overly worried as a healthy 32 yr old. But I take steroids for well controlled asthma. My wife is an NP at MDA and I assume it's only a matter of time.

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There's data that steroids in the setting of viral pneumonia worsens prognosis if the patient doesn't have another concurrent condition warranting them (such as relative adrenal insufficiency, refractory septic shock, a severe obstructive lung disease, etc.)

KidDoc said:

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Infection_Ag11 said:

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KidDoc said:

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Thanks for the insights Infectious.

Any tips or tricks for a busy outpatient pediatric practice to minimize the risk of exposure to staff & providers? I am not very worried about my patients but mostly about myself and staff and grandparents. We see a lot of cough & fever every day year round.

I'm currently just planning on masking and rooming febrile URI patients ASAP and a good cleaning of the room when they leave. I am not optimistic that anything will really prevent the staff and/or other patients from being exposed if/when it gets widespread since it is so similar to any other viral infection in children.


Also what do the lungs sound like on auscultation? I have found nothing on this after extensive searching.

---

Honestly, I'd send a letter or email to your patients asking that for the time being they not come in for mild illnesses with fever and respiratory symptoms. If they are sick enough to need to be seen they need to go to the hospital, but the reality is we don't really do much for these people in clinic for mild disease (a lot of doctors give unnecessary antibiotics for viral respiratory infections, but that's a different discussion) and right now it's better to just wait it out.

If you have a patient with fever and cough immediately put a mask on them, on anyone they came with, put them all in a room and have anyone going don appropriate PPE until you can get the full story. Do NOT screen people before doing these things.

The lung exam isn't particularly sensitive or specific, they generally have mild bilateral crackles and rhonchi that you can see with any viral or atypical bacterial lower respiratory tract pathology.

---

Thanks! Yeah I already got in touch with the office manager to mask and room fever/cough patients immediately. If no rooms available they can wait in their car and we can text them. Then wipe down rooms with bleach wipes when they leave.

The problem is toddlers are not going to keep masks on and they lick everything. Plus there are still normal viral processes going on so I cannot tell them to ignore it if these kids do have flu, bronchitis, pneumonia, acute otitis, etc. Normal illness is still going on as well.

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I agree, and I apologize I didn't realize you're a pediatrician (I didn't make note of your handle lol). In the adult realm we essentially do nothing for viral PNA or bronchiolitis until patients get sick enough to require hospitalization. I can just call Tamiflu or antibiotics in for people with presumptive positive presentations. We'll do ribavirin for RSV in certain really sick people (like transplant patients) but there's really not good evidence for it in the adult population. And our patients don't get much otitis/strep once past college age.

All that to say that you don't have the luxury of lumping most all infectious respiratory pathology into "sick/not sick" like I do in the adult world. Peds is more nuanced in this regard.

@Infection_Ag11

How will epidemiologists measure or estimate the total number of people who got infected with this virus, despite the fact that:

1. Clearly some people are able to have it and are asymtomatic or have very mild symptoms
2. There are structural barriers to getting testing in many areas, still.

Do they look at areas with nearly complete testing and extrapolate what that would look like over the whole population? Do they do "polling" to check random samples of the population of varying geographic location, gender, age, etc. and based on a minimum sample make an extrapolation; considering testing barriers, etc.?

I just can't shake the idea that we really have no idea how many people have this disease or have gotten it.

HotardAg07 said:

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@Infection_Ag11

How will epidemiologists measure or estimate the total number of people who got infected with this virus, despite the fact that:

1. Clearly some people are able to have it and are asymtomatic or have very mild symptoms
2. There are structural barriers to getting testing in many areas, still.

Do they look at areas with nearly complete testing and extrapolate what that would look like over the whole population? Do they do "polling" to check random samples of the population of varying geographic location, gender, age, etc. and based on a minimum sample make an extrapolation; considering testing barriers, etc.?

I just can't shake the idea that we really have no idea how many people have this disease or have gotten it.

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Your concerns are valid, and unless large scale testing is implemented any total would be an educated estimate, almost surely a underestimation at that. Right now it is likely the VAST majority of cases are undiagnosed.

Infection_Ag11 said:

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HotardAg07 said:

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@Infection_Ag11

How will epidemiologists measure or estimate the total number of people who got infected with this virus, despite the fact that:

1. Clearly some people are able to have it and are asymtomatic or have very mild symptoms
2. There are structural barriers to getting testing in many areas, still.

Do they look at areas with nearly complete testing and extrapolate what that would look like over the whole population? Do they do "polling" to check random samples of the population of varying geographic location, gender, age, etc. and based on a minimum sample make an extrapolation; considering testing barriers, etc.?

I just can't shake the idea that we really have no idea how many people have this disease or have gotten it.

---

Your concerns are valid, and unless large scale testing is implemented any total would be an educated estimate, almost surely a underestimation at that. Right now it is likely the VAST majority of cases are undiagnosed.

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They'll do serology tests to find people who have antibodies to the virus, it will be after the fact, but they will get the data.

There are a lot of headlines popping up saying things like:

"86% of people with coronavirus are walking around undetected, study says"
https://nypost.com/2020/03/17/86-of-people-with-coronavirus-are-walking-around-undetected-study-says/?utm_source=reddit.com
That is referencing Chinese data.

"50-75% of COVID-19 cases are completely asymptomatic but contagious (a whole city got tested in Italy, ~3k population)"
https://www.repubblica.it/salute/medicina-e-ricerca/2020/03/16/news/coronavirus_studio_il_50-75_dei_casi_a_vo_sono_asintomatici_e_molto_contagiosi-251474302/?ref=RHPPTP-BH-I251454518-C12-P3-S2.4-T1

However, when I read that, it's not perfectly clear that these are patients never become symptomatic.

For example, it's possible that 100,000,000 people in the US could get Coronavirus, but if only 14% get symptoms and become confirmed cases, that would be 14,000,000 people with a death rate of 0.5% being 70,000 deaths, basically being a death rate similar to the flu.

But, it seems possible to me also that since CV is exponentially growing and that it has a 2-14 day incubation cycle, that it just means that most of the people at any given time are asymptomatic, just because they haven't reached the end of their incubation for most.

If someone in my family gets sick enough to need hospitalization is there a hospital you recommend? We live in Dallas (a couple of miles north of downtown)

Patentmike said:

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Infection_Ag11 said:

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HotardAg07 said:

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@Infection_Ag11

How will epidemiologists measure or estimate the total number of people who got infected with this virus, despite the fact that:

1. Clearly some people are able to have it and are asymtomatic or have very mild symptoms
2. There are structural barriers to getting testing in many areas, still.

Do they look at areas with nearly complete testing and extrapolate what that would look like over the whole population? Do they do "polling" to check random samples of the population of varying geographic location, gender, age, etc. and based on a minimum sample make an extrapolation; considering testing barriers, etc.?

I just can't shake the idea that we really have no idea how many people have this disease or have gotten it.

---

Your concerns are valid, and unless large scale testing is implemented any total would be an educated estimate, almost surely a underestimation at that. Right now it is likely the VAST majority of cases are undiagnosed.

---

They'll do serology tests to find people who have antibodies to the virus, it will be after the fact, but they will get the data.

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Even if widespread serology testing were conducted, it would only confirm exposure and not the true burden of disease. We still really don't know how many asymptomatic/pauci-symptomatic infections there are as a total percentage.