Hi John, hi all,
You raise a number of really interesting points, so I'm also replying to
the list (as you indicated you were ok with in a previous mail).... I am
not sure why you didn't send this mail there as it is a really good
example of a great and interesting mail that I am sure people would love
to read!
So, first point to address which I will also re-address is you are right,
list traffic seems to be a pendulum and has now hit near zero, can we
have a happy medium? I did not want to stop all discussion!
The issue regards testing is, clearly, a major issue in the UK - and
perhaps even more so in the USA. Simply put, if we don't test, we don't
know. But to me, the more important thing is to be very strict and clear
with diagnostic criteria: we saw that already with the Chinese in
January when they changed their diagnostic criteria overnight from those
with a positive PCR test to those with the clinical symptoms - the
numbers jumped and it appeared as if the epidemic had surged. In the UK,
to my mind the biggest problem is the government has not been
clear. Obviously testing is better than clinical diagnosis but mixing
the two (e.g. saying "you probaby have COVID-19 if you have these
symptoms, so stay home for 2 weeks" but only recording people with
positive PCR results in the figures) is actually pretty dangerous as you
just sow confusion. That said, the most useful test is going to be when
we can measure antibodies - i.e. resistance to the disease. As far as I
know, that's not yet possible.
Regarding your question/point in relation to ITU provision... I trained
at Bristol in the South West in the 1990s. I remember the Care of the
Elderly ("geriatrics") placement that we did: like all the other
placements, people got posted from Truro to Gloucester. And the
definition of "elderly" varied very strongly by location, depending upon
the local demographic. In many/most places it was 70-75 - but in Torquay
the care of the elderly team only became involved with patients over 90!
Furthermore, the availability of resources will also influence things -
how many beds are there per local population (and what is that
population make-up)? My second story related to this is that the
implementation of advanced medical technology is very related to (the
perception of) underlying pathology. If you have something that will get
better (pneumonia) you are much more likely to have aggressive treatment
initiated than if there is an irreversible condition (end stage lung
cancer, for example).
Best wishes,
-- Andrei
On Wed, Mar 18, 2020 at 01:08:12AM +0000, John Whittington wrote:
> Hi Andrei,
>
> At 23:44 17/03/2020, Andrei Morgan wrote:
>
> I've spent quite a lot of time today writing some analysis about it:
> [1]https://www.andreimorgan.net/posts/covid_strategy/
>
> Many thanks - that's very interesting, so many thanks for all your
> effort. Needless to say, there are plenty of points you raise that I
> would like to discuss, if there were time, but everything you write seems
> very reasonable.
>
> If you have the time to read, just a couple of thoughts/questions ...
>
> Firstly, I'm not at all clear as to what the reported UK 'case' figures
> will mean as we move forward. Although the politicians are now promising
> that we will 'do a lot more tests', I'm not at all clear on who we will be
> testing, given that the advice given to the UK population a few days ago
> seems to have cut off the supply of indicators of who should be tested.
> Maybe I'm missing something, but it looks as if the figures will come
> increasingly to be dominated by those ill enough to require
> hospitalisation, together with (mainly uninfected) healthcare workers. In
> particular, the potential contacts of those who have been infected cannot,
> in general, now be detected and tested, because infected people have now
> been instructed not to tell anyone who they are (unless they become
> seriously ill)!
>
> Secondly, I'm just had a very interesting look around your website. I
> hadn't realised that you were a clinician, so I will try bounce a clinical
> question off you. We know that the majority of people who develop severe
> illness (including those who die) will be elderly. We are also seeing an
> awful lot of excitement about the availability (or 'overwhelming') of ICU
> resources and the need to manufacture a lot more ventilators etc. This
> leads me to wonder whether perhaps 'times (and expectations) have changed'
> a lot more than I would have imagined.
>
> It's not a particularly comfortable thing for me to think about, given
> that I am now a few months past my 70th birthday, but I think that if, ~30
> years ago, I had suggested that a person in their 70s, let alone 80s, with
> a life-threatening chest infection should be admitted to ICU/ITU and
> ventilated, I might well have been laughed at - both because (even without
> epidemics/pandemics) pressure on ICU beds was always very high but, also,
> since it was generally believed that such a patient would be very unlikely
> to survive even if they were ventilated - but maybe that wasn't correct,
> since what you write in your.report implies that 50% of ventilated
> patients with Covid-19 infection might actually survive.
>
> So I can't help but wonder whether things/expectations have changed. I
> suppose that I might gain some comfort from that, in as much as it seems
> to imply that if I found myself suffering from a life-threatening viral
> pneumonia I could expect to be ventilated (whereas just a few weeks ago I
> would have doubted that anyone would consider doing that!) and that, if I
> were ventilated, I might stand a 50% chance of surviving. Is that how you
> understand the present situation/intent/practice in the NHS? I suppose
> another possibility is that, ironically, expectations of treatment
> available during a crisis situation such as we are in might be greater
> than they would have been in a non-crisis situation - i.e. maybe I would
> be ventilated because we are having a Covid-19 outbreak whereas I wouldn't
> have been ventilated if I had been suffering from an equally severe chest
> infection a few weeks earlier, but from a different cause?!
>
> As a final comment, it certainly does seem that (unless you believe in
> co-incidences!) my taking my activities 'off-list' seems to have put a
> stop to discussions about Covid-19 on RadStats - all we've really seen in
> the past 24 hours are really a small handful of posts with links, and
> nothing that I would call 'discussion'. Although things were getting a
> bit out of hand, I think it's a bit of a pity that we've seemingly 'gone
> from the sublime to the ridiculous' - but maybe that's what people want!
>
> Thanks again, and try to keep safe.
>
> Kindest Regards,
>
> John
> ----------------------------------------------------------------
> Dr John Whittington, Voice: +44 (0) 1296 730225
> Mediscience Services Fax: +44 (0) 1296 738893
> Twyford Manor, Twyford, E-mail: [log in to unmask]
> Buckingham MK18 4EL, UK
> ----------------------------------------------------------------
>
> References
>
> Visible links
> 1. https://www.andreimorgan.net/posts/covid_strategy/
--
Andrei Morgan MRCPCH, MSc, PhD (Epidemiology / Neonatology)
https://www.andreimorgan.net
Honorary Clinical Lecturer,
Department of Neonatology,
Institute for Women's Health,
University College London
******************************************************
Please note that if you press the 'Reply' button your
message will go only to the sender of this message.
If you want to reply to the whole list, use your mailer's
'Reply-to-All' button to send your message automatically
to [log in to unmask]
Disclaimer: The messages sent to this list are the views of the sender and cannot be assumed to be representative of the range of views held by subscribers to the Radical Statistics Group. To find out more about Radical Statistics and its aims and activities and read current and past issues of our newsletter you are invited to visit our web site www.radstats.org.uk.
*******************************************************
|
