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1 hour ago, Pen said:

 

From tonight’s Dr Been question and answer video - links to a few of the articles he used to answer viewer questions for those here who don’t like videos:

 

IDEA protocol (Ivermectin, Dexamethasone + ...) : 

https://www.medrxiv.org/content/10.1101/2020.09.10.20191619v1

 

 

Hydroxychloroquine White Paper - call to depoliticize medicine :

https://secureservercdn.net/72.167.242.48/u22.f6f.myftpupload.com/wp-content/uploads/2020/09/HCQWhitePaper.pdf

 

Herd Immunity issues related to heterogeneous immunity: 

https://science.sciencemag.org/content/369/6505/846.full

 

the video itself: https://youtu.be/I3KHwi7iR6M

https://youtu.be/I3KHwi7iR6M

Haven’t had Time to watch it so apologies if this was answered in the video but how does the IDEA protocol compare to dexamethasone in its own?  I know that has a pretty big impact on survival rates.

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1 hour ago, Ausmumof3 said:

Haven’t had Time to watch it so apologies if this was answered in the video but how does the IDEA protocol compare to dexamethasone in its own?  I know that has a pretty big impact on survival rates.

 

I didn’t see or look for an exact comparison, but I think better. Ivermectin can be used alone earlier and has been getting good results all by itself.  

(I have been personally desirous of HCQ prophylaxis being allowed because I have blood brain barrier issues and should not use Ivermectin.  Otherwise Ivermectin has good anecdotal and similar results at a variety of stages including prophylaxis, as well as at hospital entry. Dexamethasone seems to require being farther along in illness and many people would like to avoid waiting till a later stage to get improved. 

IDEA seems like MATH in having stages and what to do when.  All IDEA at least in USA / AU would be for  doctors with Rx, not OTC.) 

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@Ausmumof3  IDEA:   Added italics to clarify what’s quoted and bold for emphasis of results. 

“No treatment tested worldwide has shown unquestionable efficacy in the fight against COVID 19, according to NICE reports. We have designed an experimental treatment called IDEA based on four affordable drugs already available on the market in Argentina, based on the following rationale: -Ivermectin solution at a relatively high dose to lower the viral load in all stages of COVID 19 -Dexamethasone 4-mg injection, as anti-inflammatory drug to treat hyperinflammatory reaction to COVID-infection -Enoxaparin injection as anticoagulant to treat hypercoagulation in severe cases. -Aspirin 250-mg tablets to prevent hypercoagulation in mild and moderate cases Except for Ivermection oral solution, which was used in a higher dose than approved for parasitosis, all other drugs were used in the already approved dose and indication. Regarding Ivermectin safety, several oral studies have shown it to be safe even when used at daily doses much higher than those approved already. A clinical study has been conducted on COVID-19 patients at Eurnekian Hospital in the Province of Buenos Aires, Argentina. The study protocol and its final outcomes are described in this article. Results were compared with published data and data from patients admitted to the hospital receiving other treatments. None of the patient presenting mild symptoms needed to be hospitalized. Only one patient died (0.59 % of all included patients vs. 2.1 % overall mortality for the disease in Argentina today; 3.1 % of hospitalized patients vs. 26.8 % mortality in published data). IDEA protocol appears to be a useful alternative to prevent disease progression of COVID-19 when applied to mild cases and to decrease mortality in patients at all stages of the disease with a favorable risk-benefit ratio.”

 

I don’t know how to compare that to just Dexamethasone because IDEA was able to start with mild cases not in hospital in many cases, while afaik Dexamethasone in its striking study is only used for more significant hospitalized cases. 

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2 hours ago, Pen said:

 

@Ausmumof3  IDEA:   Added italics to clarify what’s quoted and bold for emphasis of results. 

“No treatment tested worldwide has shown unquestionable efficacy in the fight against COVID 19, according to NICE reports. We have designed an experimental treatment called IDEA based on four affordable drugs already available on the market in Argentina, based on the following rationale: -Ivermectin solution at a relatively high dose to lower the viral load in all stages of COVID 19 -Dexamethasone 4-mg injection, as anti-inflammatory drug to treat hyperinflammatory reaction to COVID-infection -Enoxaparin injection as anticoagulant to treat hypercoagulation in severe cases. -Aspirin 250-mg tablets to prevent hypercoagulation in mild and moderate cases Except for Ivermection oral solution, which was used in a higher dose than approved for parasitosis, all other drugs were used in the already approved dose and indication. Regarding Ivermectin safety, several oral studies have shown it to be safe even when used at daily doses much higher than those approved already. A clinical study has been conducted on COVID-19 patients at Eurnekian Hospital in the Province of Buenos Aires, Argentina. The study protocol and its final outcomes are described in this article. Results were compared with published data and data from patients admitted to the hospital receiving other treatments. None of the patient presenting mild symptoms needed to be hospitalized. Only one patient died (0.59 % of all included patients vs. 2.1 % overall mortality for the disease in Argentina today; 3.1 % of hospitalized patients vs. 26.8 % mortality in published data). IDEA protocol appears to be a useful alternative to prevent disease progression of COVID-19 when applied to mild cases and to decrease mortality in patients at all stages of the disease with a favorable risk-benefit ratio.”

 

I don’t know how to compare that to just Dexamethasone because IDEA was able to start with mild cases not in hospital in many cases, while afaik Dexamethasone in its striking study is only used for more significant hospitalized cases. 

I guess the closest comparison would be the rates of those hospitalised.  But I agree it more seems to be used in the more severe cases.  Do we have any studies on ivermectin alone?  I know it was mentioned in the Coronacast as a “juries still out” drug.  Shows promise but none of the studies have been without some issues that left things somewhat in doubt.  It seems like most HCQ trials here have not resumed as its basically assumed to be ineffective.  

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3 hours ago, Ausmumof3 said:

I guess the closest comparison would be the rates of those hospitalised.  But I agree it more seems to be used in the more severe cases.  [1] Do we have any studies on ivermectin alone?  I know it was mentioned in the Coronacast as a “juries still out” drug.  Shows promise but none of the studies have been without some issues that left things somewhat in doubt.  [2]  It seems like most HCQ trials here have not resumed as its basically assumed to be ineffective.  

 

[1] In process:

https://clinicaltrials.gov/ct2/show/NCT04438850

 

I can’t imagine that it will have results that will resolve all doubts. 

 

I continue to think that search for single “magic bullet” is wrong. 

 

[2]  strongly recommend you to read: 

 

 

 

https://secureservercdn.net/72.167.242.48/u22.f6f.myftpupload.com/wp-content/uploads/2020/09/HCQWhitePaper.pdf

 

 

(Having lived in HCQ malaria part of world, the social media and news media flipping out about HCQ danger seems ridiculous to me— maybe analogous to how someone in Australia or UK might regard people flipping out about acetaminophen/paracetamol? Yes, both can kill. Absolutely so. (And most of the studies showing bad results for HCQ used dangerous toxic amounts-which could be done for any medicine.)  I had a friend who was an acetaminophen suicide as a teen.  And it acetaminophen is liver toxic in any case, but it hasn’t been politicized into denying its use even if all it does is help relieve some pain, but without being curative of anything. ) 

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6 hours ago, Pen said:

 

(Having lived in HCQ malaria part of world, the social media and news media flipping out about HCQ danger seems ridiculous to me— maybe analogous to how someone in Australia or UK might regard people flipping out about acetaminophen/paracetamol? Yes, both can kill. Absolutely so. (And most of the studies showing bad results for HCQ used dangerous toxic amounts-which could be done for any medicine.)  I had a friend who was an acetaminophen suicide as a teen.  And it acetaminophen is liver toxic in any case, but it hasn’t been politicized into denying its use even if all it does is help relieve some pain, but without being curative of anything. ) 

While I agree with you that HCQ has been very politicized, I do not agree that a fairly healthy person taking it as malaria prophylaxis is the same as a person sick with Covid-19. You cannot necessary apply the fact that something is safe in the first circumstance to the second circumstance. I personally do not see how anyone with an open mind has enough information available to them, at this time, to make a decision that it is either safe and effective, or unsafe and completely ineffective. However from what I’ve read I would lean more toward the doesn’t make any difference side.

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6 hours ago, Pen said:

 

[1] In process:

https://clinicaltrials.gov/ct2/show/NCT04438850

 

I can’t imagine that it will have results that will resolve all doubts. 

 

I continue to think that search for single “magic bullet” is wrong. 

 

[2]  strongly recommend you to read: 

 

 

 

https://secureservercdn.net/72.167.242.48/u22.f6f.myftpupload.com/wp-content/uploads/2020/09/HCQWhitePaper.pdf

 

 

(Having lived in HCQ malaria part of world, the social media and news media flipping out about HCQ danger seems ridiculous to me— maybe analogous to how someone in Australia or UK might regard people flipping out about acetaminophen/paracetamol? Yes, both can kill. Absolutely so. (And most of the studies showing bad results for HCQ used dangerous toxic amounts-which could be done for any medicine.)  I had a friend who was an acetaminophen suicide as a teen.  And it acetaminophen is liver toxic in any case, but it hasn’t been politicized into denying its use even if all it does is help relieve some pain, but without being curative of anything. ) 

A friend (in her 50s, high risk because of asthma) has just now recovered from Covid-19, with a relatively mild course over two weeks. Her last remaining symptom, loss of smell, just resolved.She started HCQ/Z-pack as soon as she got the positive test, four days after exposure. Very interesting to see how she fared in comparison to the person who exposed her (and was in her 30s. low risk). She had a difficult time finding a pharmacy willing to fill the prescription and went out of town.

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52 minutes ago, TCB said:

While I agree with you that HCQ has been very politicized, I do not agree that a fairly healthy person taking it as malaria prophylaxis is the same as a person sick with Covid-19. You cannot necessary apply the fact that something is safe in the first circumstance to the second circumstance. I personally do not see how anyone with an open mind has enough information available to them, at this time, to make a decision that it is either safe and effective, or unsafe and completely ineffective. However from what I’ve read I would lean more toward the doesn’t make any difference side.

 

I think it should be available-  legally available and not virtually impossible to get as a practical matter - for use as prophylaxis. This means use by people who are basically well, similar to when used for prophylaxis for malaria.  Though people who are likely to most benefit are people who are well, but at higher risk for CV19 bad outcomes, but not high risk for HVQ problems.   Unlike for malaria, I see no reason for HCQ as CV19 prophylaxis for healthy young people for example.   I of course also think that making plenty so that it isn’t a problem for people to get it, not taking it from arthritis patients etc, should also be part of that. 

Other than scarcity issues, is there some reason that you feel (or think might be more important than feel, though perhaps both are) you or others would be harmed by other people who want to use HCQ prophylaxis to be allowed to do so?  Consider both OTC as in some countries or with consultation with ones own doctor by prescription (though that may preclude use by many people who are susceptible to CV19 but don’t have access to regular health care, such as many agriculture sector field workers).  

(Again assuming not a scarcity issue) Does it hurt you for someone else to have access to HCQ any more than someone else being allowed to take Tylenol?  If so, how?  

 

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5 minutes ago, GoodGrief1 said:

A friend (in her 50s, high risk because of asthma) has just now recovered from Covid-19, with a relatively mild course over two weeks. Her last remaining symptom, loss of smell, just resolved.She started HCQ/Z-pack as soon as she got the positive test, four days after exposure. Very interesting to see how she fared in comparison to the person who exposed her (and was in her 30s. low risk). She had a difficult time finding a pharmacy willing to fill the prescription and went out of town.

 

Do you mean she (50 yo with asthma) did better on the HCQ/Azithromycin than the person who infected her did without that treatment ?    

 

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I don’t see why people shouldn’t have access to HCQ and I think that many do have access. I think it would be a shame if people taking it prophylactically for Covid stopped people with other illnesses from getting it. 
I do not think it should be put forward as a miracle cure, like it is by some, without solid evidence.

All this anecdotal stuff about knowing someone who took it and was ok is not really convincing because this virus is so weird that it seems virtually impossible to predict who is going to get really sick. I know there are some fairly clear predisposing co-morbidities such as obesity, HTN, and diabetes, but even then some do fine and some get terribly ill and die. 
We have found that much of the time those with COPD and Asthma actually do ok, but not all the time.

A colleague of my husband who is overweight, diabetic, and has had a kidney transplant got it a few weeks ago and has pretty much recovered, although he felt ill for a while. Who would have expected that! That’s why most of this anecdotal stuff really does not help. We just don’t know enough about the illness.

I’m sure I sound grumpy, I feel grumpy because of all the unproven stuff people are spreading around. I’m concerned it detracts from finding some real answers. I’m also feeling grumpy because a number of our patients are not doing well this time round. 

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Truthfully yeah I wish it was available to those who want it with the doctor giving it telling the patient what the current actual evidence is (that it’s most likely not effective and carries a small level of risk).  I think making it available would take the oomph out of the conspiracy theories.  (That in fact there doesn’t need to be a pandemic at all because everyone could simply be cured by HCQ, and that the left, Bill gates, dr Fauci or whoever the enemy of choice is doesn’t want the public to know so they can sell more vaccines/ control people who want haircuts/ introduce a digital currency / reset the global economy).  I think if it was accessible and people were still dying some of that chatter might fade away.  But maybe the risk is higher than I realise or something.

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Most countries who had an "outbreak" but brought their numbers down seem to all be having outbreaks again, except Italy. However, even Italy is seeing its numbers go up. Basically, strict lockdowns work but as soon as things start opening back up outbreaks happen. 

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25 minutes ago, Teaching3bears said:

Which countries have significantly reduced their case numbers and what have they done?

Nz, Australia, Vietnam, Taiwan and others.  Lockdowns, border closures followed by extensive test and trace and isolate.  Lockdowns are only helpful if they are being used to get on top of contact tracing.  Doing lockdowns then opening up without adequate trace and test is a disaster.  

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1 hour ago, Ausmumof3 said:

Truthfully yeah I wish it was available to those who want it with the doctor giving it telling the patient what the current actual evidence is (that it’s most likely not effective and carries a small level of risk).  I think making it available would take the oomph out of the conspiracy theories.  (That in fact there doesn’t need to be a pandemic at all because everyone could simply be cured by HCQ, and that the left, Bill gates, dr Fauci or whoever the enemy of choice is doesn’t want the public to know so they can sell more vaccines/ control people who want haircuts/ introduce a digital currency / reset the global economy).  I think if it was accessible and people were still dying some of that chatter might fade away.  But maybe the risk is higher than I realise or something.

The problem I see with giving something unproven to be used prophylactically is that it can make people think that they are safe when they aren’t necessarily. I don’t have problems with using them in studies because there is supervision. 

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4 minutes ago, Jean in Newcastle said:

The problem I see with giving something unproven to be used prophylactically is that it can make people think that they are safe when they aren’t necessarily. I don’t have problems with using them in studies because there is supervision. 

Yes you’re right.. I’m just tired of it all.  All the same conspiracy theory stuff and anti lockdown rubbish is taking hold down here.  

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16 minutes ago, Ausmumof3 said:

Nz, Australia, Vietnam, Taiwan and others.  Lockdowns, border closures followed by extensive test and trace and isolate.  Lockdowns are only helpful if they are being used to get on top of contact tracing.  Doing lockdowns then opening up without adequate trace and test is a disaster.  

Three island countries and three countries which didn't have what most would call an outbreak in the first place... Being on an island that has the capability of a stricter lockdown does has benefits to having lower case numbers, but what has worked in those places isn't necessarily at all useful when considering other types of countries that don't have that capability.

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1 hour ago, kdsuomi said:

Most countries who had an "outbreak" but brought their numbers down seem to all be having outbreaks again, except Italy. However, even Italy is seeing its numbers go up. Basically, strict lockdowns work but as soon as things start opening back up outbreaks happen. 

But their deaths are not going up nearly as much, which suggests that they are fairly on top of testing/tracing and may be catching more of the mild cases.

We have already passed Italy and the UK for per capita deaths, and our daily death rate continues to be higher than either of them. The only European country with a per capita death rate worse than the US is Spain (I'm not including Belgium, since they count deaths so differently). Besides Spain, the other countries with worse death rates right now are Peru, Bolivia, Brazil, Chile, and Ecuador (and we are on track to pass Ecuador in the next 2-3 weeks).  Virtually every other country in the developed world has handled this pandemic better than the US. 

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2 hours ago, kdsuomi said:

Three island countries and three countries which didn't have what most would call an outbreak in the first place... Being on an island that has the capability of a stricter lockdown does has benefits to having lower case numbers, but what has worked in those places isn't necessarily at all useful when considering other types of countries that don't have that capability.

On the other hand UK is an island nation and has had a very different outcome.  

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Nsw recorded 0 new Covid cases today!  Of course there will be more but this seems like a pretty amazing effort, with fairly minimal restrictions.  Contact tracers and public health officials doing a pretty awesome job.

Vic had 16 cases today.  Some restriction changes are being brought forward.  

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4 hours ago, Pen said:

 

Do you mean she (50 yo with asthma) did better on the HCQ/Azithromycin than the person who infected her did without that treatment ?    

 

Hard to say if it was the treatment, but, yes, the high risk person in her 50s who used the HCQ had noticably less severe symptoms than the person who was in her 30s. The virus would presumably be the same strain, as it was the younger person who infected the older.

Side note: both of these people were nurses, and the one who used the HCQ researched the options quite thoroughly early on in the pandemic. She is definitely not an anti-masker.

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8 hours ago, GoodGrief1 said:

A friend (in her 50s, high risk because of asthma) has just now recovered from Covid-19, with a relatively mild course over two weeks. Her last remaining symptom, loss of smell, just resolved.She started HCQ/Z-pack as soon as she got the positive test, four days after exposure. Very interesting to see how she fared in comparison to the person who exposed her (and was in her 30s. low risk). She had a difficult time finding a pharmacy willing to fill the prescription and went out of town.

Although, I think the HCQ/Z-pack should be available to those who want it (along with other drugs) and totally believe that the cat is still out of the bag regarding proof it works, (still haven't seen an early study with zinc) I don't think asthma can really be called a risk factor anymore. 

 

There was a lot of assumption that asthma would be a risk factor, heck mere colds have hospitalized me before when hitting my lungs, but now there is a lot of observational studies and hypothesis on asthma being a protective factor with so few asthmatics getting it or being hospitalized. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300712/

 

https://hospitalhealthcare.com/covid-19/are-patients-with-asthma-protected-against-covid-19/

 

https://www.med.wisc.edu/news-and-events/2020/april/allergies-asthma-may-reduce-covid-19-risk-/

 

So unless there is some other risk factor involved I would almost expect her to do better. Not that I'm ready to go kiss a covid patient on the lips or anything but in general asthma doesn't appear to be a huge risk factor. It was just automatically assumed to at the beginning.

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9 hours ago, frogger said:

There was a lot of assumption that asthma would be a risk factor, heck mere colds have hospitalized me before when hitting my lungs, but now there is a lot of observational studies and hypothesis on asthma being a protective factor with so few asthmatics getting it or being hospitalized. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300712/

 

 

Interesting.

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6 hours ago, Ausmumof3 said:

https://wwwnc.cdc.gov/eid/article/26/11/20-3029_article
 

anyone seen this study?  Seems to show a significantly higher IFR than others?  Are there problems with the methodology or assumptions?  

 

I think

issues may be time and place the study was done? 

 

I can’t recall now exactly what was happening where and when. 

 

It was from May in Louisiana, and  I think the New Orleans area of Louisiana was having major CV19 troubles (high loads since after Mardi Gras) and may have had higher local death rate as well as possibly deaths/infection everywhere were higher in May than they seem to be now. 

I don’t know if there was distancing or masking much in New Orleans and the other area for the study (it was 2 parishes that are the city and some surrounding area outside the city) in order to reduce viral loads, and I don’t know if main approach to care then was still basically nothing until severe and then use ventilators.   

Also it is an area with a racial distribution that might have resulted in a higher overall death rate. 

 

And if vitamin D is significant, even though it is a an area that gets sun, people’s D levels may still have been low from winter or chronically low. 

 

Etc etc

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17 hours ago, TCB said:

I’m concerned it detracts from finding some real answers. I’m also feeling grumpy because a number of our patients are not doing well this time round. 

 

I agree with you that it should not be promoted as a miracle. 

 

I think your concern that it could detract from “finding some real answers” or at least trying to do so is legitimate if people were to halt vaccine and other medicine and therapy trials because of something like HCQ (plus zinc etc) being made available prophylactically, but I don’t personally think that that will happen. The plethora of studies and the number and speed of possible vaccines in development seems unprecedented to me. 

However, I guess if something relatively easy and not expensive were to actually reduce severe cases and deaths, and perhaps especially if it had been used early before a large part of public came to see a problem, maybe it would mean less push for new forms of vaccine such as the mRNA type, or new antiviral drugs, etc etc,  that are getting significant funding and rapid advances and perhaps EUA now which can only happen if death rate / serious illness rate is high and thus media and public fear and motivation were initiated and are maintained?   I do not personally like that as a rationale, but it does make a lot of logical sense both from a drug company financial gain reason, but also perhaps for a rapid scientific advancement reason.   

And to extent that we will probably have more and more of these spillover illnesses, whether they derive from wet markets, Laboratories, or humans moving into animal domains, maybe rapid development of new vaccines and antivirals etc now will have significant future benefits. 

 

Ok. Thanks. Your reply helped me to have a different perspective. 

 

 

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38 minutes ago, Pen said:

 

However, I guess if something relatively easy and not expensive were to actually reduce severe cases and deaths, and perhaps especially if it had been used early before a large part of public came to see a problem, maybe it would mean less push for new forms of vaccine such as the mRNA type, or new antiviral drugs, etc etc,  that are getting significant funding and rapid advances and perhaps EUA now which can only happen if death rate / serious illness rate is high and thus media and public fear and motivation were initiated and are maintained?   I do not personally like that as a rationale, but it does make a lot of logical sense both from a drug company financial gain reason, but also perhaps for a rapid scientific advancement reason.   

I don’t really think that it detracts from the development of a vaccine, and it would be wonderful if something cheap and available should turn out to be something of a magic bullet!

I think I mean the whole conspiracy theory/political angle may be detracting from moving forward. Those who ‘believe’ it to be a miracle cure that is being suppressed don’t seem to be willing to be convinced otherwise. Those who think it has been disproven don’t want to spend any more time on it. Honestly some of my friends in the miracle cure camp literally only had Trumps word on it and that was sufficient to completely convince them without looking at the evidence, either for or against, at all. How do you even reason with that type of thinking? I personally have not looked at the evidence exhaustively enough to say either way for sure, but from what I’ve seen and heard it seems fairly unlikely, but I am not putting my opinion forward as a greatly educated one. I work with some Drs who seem to keep themselves pretty up to date on evidence based practice and they aren’t promoting it so that probably plays into my opinion as well.

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2 hours ago, Pen said:

 

I think

issues may be time and place the study was done? 

 

I can’t recall now exactly what was happening where and when. 

 

It was from May in Louisiana, and  I think the New Orleans area of Louisiana was having major CV19 troubles (high loads since after Mardi Gras) and may have had higher local death rate as well as possibly deaths/infection everywhere were higher in May than they seem to be now. 

I don’t know if there was distancing or masking much in New Orleans and the other area for the study (it was 2 parishes that are the city and some surrounding area outside the city) in order to reduce viral loads, and I don’t know if main approach to care then was still basically nothing until severe and then use ventilators.   

Also it is an area with a racial distribution that might have resulted in a higher overall death rate. 

 

And if vitamin D is significant, even though it is a an area that gets sun, people’s D levels may still have been low from winter or chronically low. 

 

Etc etc

They did fairly careful work with the data to break down racial distribution and it was high in whites, blacks and hispanics I believe and only at the .6 pc mark in people of Asian descent. The viral load thing probably makes sense, though I would assume similar would be true for New York and Italy in early days.  It would make sense if it relates to less masking and precaution because I believe people with Asian heritage were being much careful earlier in the piece.

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1 minute ago, Ausmumof3 said:

They did fairly careful work with the data to break down racial distribution and it was high in whites, blacks and hispanics I believe and only at the .6 pc mark in people of Asian descent. The viral load thing probably makes sense, though I would assume similar would be true for New York and Italy in early days.  It would make sense if it relates to less masking and precaution because I believe people with Asian heritage were being much careful earlier in the piece.

 

Did it show higher IFR than for during similar stage in hard hit parts of NYC or Italy? 

Another possible aspect could be rates of underlying illnesses such as diabetes and obesity in New Orleans area compared to NYC and relevant parts of Italy . 

In several studies I saw, people of East Asian heritage had lower rates of severe illness, especially women.  Some could be precautions, or lifestyles, and some could be some metabolic or genetic factors.  In New Orleans area “Asian” very likely is largely East Asian.  But South Asian seem to be among the more susceptible in some studies particularly iirc in UK—with some speculation that low D levels especially when people with more melanin and perhaps less sun exposed even when there is sun to be exposed to in Northern latitudes could be related to that. 

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