[conspire] When to get a covid test, brains, and a weird case, and a cardiology vs. immunology joke

[Ruben Safir]

On Thu, Aug 06, 2020 at 09:35:23PM -0700, Rick Moen wrote:
> Quoting Ruben Safir (ruben at mrbrklyn.com):
> 
> > My favorite was preventing patients from being discharged with TD from
> > the hospital which directly resulted in resistant TD spreading into the
> > community killing perhaps millions of innocent people, many of whom
> > never even suffered from AIDS.
> 
> I'm empathetic with your dyslexia problem, Ruben, and applaud you being 
> articulate in public anyway.  However, given that obstacle, you probably
> would be better off writing out words like tuberculosis rather than trying
> to abbreviate them.
> 
> I had fun trying to picture Tardive Dyskinesia (the only medical
> condition generally abbreviated as 'TD') being released into the
> community as a 'resistant' condition.  

:(

hmmm, well, thanks for taking the time to parse that.

> (Tardive Dyskinesia is not, of
> course, infectious, nor is Haldol.)  In all likelihood, this was
> unintentional comedy on your part, as you intended to namedrop the
> abbreviated term for (antibiotic-resistant) tuberculosis, and screwed it
> up.
> 
> In friendship, I'll say:  You should try to avoid that sort of outcome.
> 
> I'm also really extremely unclear on how preventing people with
> tuberculosis from being discharged from institutions was the fault of
> unnamed 'people [who] had a pet paper in their pocket' about AIDS, and
> why this would not be the responsibility of the clinicians who made that
> bad decision.

At the time is was clear that we could never clear Tuberculosis from
these patients, and that they were a minimal threat to the public.
However, continuing to pump them with anti-Mycobacterium therapy was
presenting a public risk to the long term suppression of Tuberculosis,
which has been a national and world-wide effort, by creating resistance
and superbugs inside the hospital, and creating hotspots for
transmission, effectively wiping out and killing ward by ward of
patients.

This was all played out with a paper war, arguing  for and against the
release and treatment of these patients.  The politicians then stepped
in and disallowed the release of patients without having a permanent
home for them, creating warehouses of patients, who all eventually died
slowing, within mostly public hospitals that serviced the poor.  That
was also supported by peer review articles.  Hospital administrations
and ID protocols were overridden.  Patients died.  Resistant
Mycobacterium has now become a permanent part of the infectious disease
landscape.  The public has suffered from this ever since.

This is just one example of how peer reviewed papers are misused during
an epidemic that came to mind.  But it is not the only one.

When peer reviewed papers make there way into therapeutic decisions
prior to the development of consensus, you need to be careful and
understand your working on a very narrow data point created for a
specific purpose by a small group of researchers who are dependent on
funding.  You need to read it carefully and judge it according to the
background of known medical evidence and experience. 

And sometimes even consensus is wrong, and more study develops until a
new consensus is developed.  The use of nifedipine for hypertension
comes to mind.  To this day, I am still skeptical of the broad use of
Amlodipine because of the nifedipine experience.

whatever..

I don't like hysterics in medicine.  One has to be skeptical of all peer
reviewed articles and they need confirmation from multiple sources prior
to acceptance.  We are not just fighting disease.  We are also trying to
manage peoples emotional reaction to disease.  

Will one get neurological disease because one gets COVID-19?  Probably
not.  Don't forget that most people are largely unaffected by the
disease.  This is good news.  Can things go bad, yes.  There is a
rational reason to be rationally fearful of this disease, and we still
don't fully understand the mechanism of the disease pathology.  But
people need to stop panicking and try to rely on there rational mind.
And professionals need to stop throwing gasoline on the fire.  The vast
majority of people will get this disease and not suffer any long term
problems.  We need to better manage those at most risk, and those who
are most suffering.

or maybe I am wrong and this is why so many Zombies are now running
about the Grand Concourse line.

> 
> Basically, even though you were just getting warmed up for throwing
> rhetoric around, you were already leaving logic in the dust.  But 
> you weren't done, of course:
> 
> 
> > Any paper that is not supported by clinical observation on the floors is
> > a worthless peice of garbage in a crisis.
> 
> What's amazing is that you think this piece of rhetoric is going to
> impress anyone, let alone that the rest of your overheated rhetoric
> would.
> 
> Science is done by a long conversation among scientists.  Obviously,
> clinical data is vital towards medical judgements, but the notion that
> it's valueless unless done via clinical observation on the floors is
> absurd, and I'll not be buying it.
> 
> Briefly, the authors of the _Lancet_ study found disturbing patterns in
> medical imaging, revealing strong evidence of numerous structural brain
> changes in COVID-19 patients studied.
> 
> The authors also point out that the SARS virus is known to have been
> neuro-invasive, so it's not a stretch for its relative SARS-CoV-2 to be,
> as well.  Morever, they cite to the literature for clinical evidence
> that 1/3 of COVID-19 patients in Wuhan presented neurological symptoms
> during treatment, with those symptoms being more severe in more-severe
> COVID-19 patients.  Also, they cite to the literature for clinical
> evidence in European hospitals of statistically high incidence of sundry
> neurological conditions:  encephalitis, stroke, hemorrhage, cerebral
> embolisms, etc.  Moreover, they also cite to the literature for clinical
> evidence of other nerve damage.
> 
> These observations will either be found to be well founded and their
> methods and findings to be replicable, or they will not, and if the
> observations are replicated, the damage will either be long-term or not
> -- but your declaring ex-cathedra[1] that it cannot have merit is
> obvious bushwah, and you are frankly wasting your time and everyone
> else's, attempting it.
> 
> 
> > You know we have patients to treat here, not just stroke the egos of
> > acamedemic researchers and research centers.
> 
> Um... since you mention it, about that:
> 
> > I'm trying to teach you something here, Dedrie.  I'm not debating this
> > with you because I'm the one that sees the patients, and treats them,
> > and writes the statistics that you largely consume.  It is not the other
> > way around.
> > 
> > You do not make medical decisions based on published papers... NEVER.
> 
> Deirdre can certainly speak for herself.  However, I wish to mildly
> observe:
> 
> 1.  Deirdre isn't making medical decisions at all, for anyone, not even
> herself.  This is why we have medical doctors, who can as required
> consult specialists who are also medical doctors or highly qualified
> medical scientists (usually both, but see footnote 2) for advice.
> 
> 2.  With great respect for the professional skils of pharmacists such as
> your good self, to my knowledge you are not a medical doctor let alone
> an pulmonologist, cardiac specialist, neurologist, or any other relevant
> physician specialty, seeing that to my knowledge you are not a medical
> doctor at all[2].  In that light, and in the conventionally accepted
> sense of the terms, you do not 'see and treat patients'.
> 
> Point being, you are _really_ out of line.
> 
> You have a mailing list with, among its members, some NYC-area people on
> it who work in generally unspecified capacities doing some
> medical-somethings, plus you, a hard-working pharmacist.  I'm glad you
> have that, and I wish you great success in trying to sort through lots
> of diverse sorts of purported information about the pandemic.  But
> neither your profession nor the unspecified professions of your
> acquaintances entitles you to pull rank on, e.g., readers of preprint
> medical journal articles and make some ludicrous attempt to shame them
> for making a good layman's effort at understand the current and evolving
> state of scientific knowledge.  You are not the boss of anyone, here.
> Don't even think of acting that way.
> 
> 
> Turning to (part of) your separate note to me:
> 
> > Sinlge peer reviewed articles are just datapoints, and not the basis
> > for concensus or diagnosis.
> 
> Yeah, we know that.
> 
> Ruben, guess what?  We have the privilege of discussing articles in 
> _The Lancet_ without having an obligation to beat to death the necessary
> and ongoing role of replicability.
> 
> Get used to that.
> 
> > especially when you are already experienced with a few hundred
> > patients, and no one suffers any congitive disorders.
> 
> But we know this is _not_ true.  ICU psychosis is a well established
> thing, the encepalitis and meningitis are things, brain fog is _very_
> much a thing.
> 
> And no, I'm not going to dig out a pile of studies.
> 
> > Actually, skeptism of all published reports at this juncture, is
> > normative, and healthy.  
> 
> (Normal, not normative.)
> 
> Ruben, one of us was variously President or Secretary of Bay Area
> Skeptics for a couple of decades, and it's not you.  So, don't teach
> grandma to suck eggs, please.
> 
> > The studies aren't garbage because they aren't serious.  But they are
> > garbage because they are coming frome everywhere and cover everythihg,
> > are tightly focused, and overstate risks, and usually confirms what we
> > know.  
> 
> As I already said, you would need a lot of persuasive evidence to
> support the assertion that a full study that made it into the pages of
> _The Lancet_ is garbage.  We know that their editors and reviewers
> aren't fallible, e.g., the Wakefield fraud and the ridiculously
> defective datasets from Surgisphere (about which I won't state my full
> views because I'm careful about the defamation statutes) caused
> publication of papers that had to be retracted, but the editors and
> reviewers are really good.
> 
> > It will be years before it is settled out.
> 
> Of course.  _That's how science works._
> 
> Eggs and grandmothers, Ruben.
> 
> 
> > If there [were] serious neurological damage, we would expect to see it
> > boardly in patients, and we aren't. 
> 
> I'm not at _all_ sure you have competent, relevant data to support your
> conclusion ('we aren't') -- unless mayhap you move the goalposts by
> setting the term 'serious' stategically high:  I'm not a neurologist any
> more than you are, _but_ I do know that significant neurological damage
> can manifest in subtle and unexpected ways, and sometimes do so later
> rather than immediately.  
> 
> And, I'm sorry, but the clinical reports have been rather disturbing,
> and I have grave doubts that you can just wave your arms and call them
> 'garbage', like the study out of Minnesota that reported acute
> demyelenating encephalomyelitis in three patients.  That's a small
> study, but I'm not prepared to say it's garbage.  This involve the
> patients' immune systems demylinating their spinal cords. 
> 
> Gosh, I really do hope that was a clinician fantasy or error, because
> it's totally nightmare fuel for me, given that my dad's younger brother,
> my Uncle Ray (Reidar Moen) suffered and deteriorated from 1941 until his
> death in the 1970s from progressive-remitting multiple sclerosis, a
> disease that centrally involves demyelinating of neural chains.
> 
> But clinician fantasy or error doesn't strike me as the way to bet.
> Yell and scream all you want, but that doesn't make it so (and frankly, 
> having had a sister who, until age 18 when she moved out (but then never
> again) was accustomed to getting her way by throwing tantrums, I'm
> utterly unmoved when I see tantrums on a mailing list).
> 
> 
> [1] I've found that, even without being Pope, or Catholic, or Christian,
> that it's possible to speak ex cathedra.  Use that knowledge wisely
> (preferably while sitting in a chair).
> 
> [2] Nor a relevantly qualified non-physician scientist ('relevantly
> qualifed' meaning something like an immunologist or epedemiologist).  
> 
> 
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