COVID-19

The Second Wave, Thoughts About The Pandemic

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Have we entered into phase 3 of the pandemic?

Thoughts and numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden.

In the beginning of this pandemic I wrote daily for 25 consecutive days, from 25th March to 18th April, this is a little update, a lot has a happened since my last post.

In Sweden, if phase 1 was the initial exponentially growing pandemic in Mars/April, and phase 2 the more stable months of May until October, then phase 3 seems to be a second wave of, once again, the exponential (re-)growth of Covid-19. 

Things have changed, we know more about Covid-19 now even if there´s many questions left unanswered still, and we have (it seems) several promising vaccines on the horizon now. Three random thoughts since my last post follow below.

1. Socioeconomic toll: suicide rates in Japan in October are higher than their total Covid-19 toll

At day 24 I wrote about the long lasting socioeconomic effects of Covid-19, and how that would have a far greater toll on peoples lives than the lives the virus takes directly: 

“Disregarding the death toll, and just accounting for the devastating effect this pandemic will end up having on people’s life in the aftermath both economically and socially will be worse than anything we seen in recent history. (…) We will get through this, but what will it cost in the number of life’s both taken by the virus but also by socioeconomic circumstances?”

CNN published an article today about the surge of suicide rates in Japan during October (est. 2 153 deaths) being higher than their total Covid-19 toll for this year so far (est 2 087). They denote that Japan is one of the few major economies that discloses timely suicide data, what is happening there is probably happening everywhere: 

“We didn’t even have a lockdown, and the impact of Covid is very minimal compared to other countries … but still we see this big increase in the number of suicides,” said Michiko Ueda, an associate professor at Waseda University in Tokyo, and an expert on suicides. “That suggests other countries might see a similar or even bigger increase in the number of suicides in the future.” 

2. Treatment: adding cortisone to anticoagulants, as first treatment options for Covid-19 pneumonia

I wrote early about anticoagulants being our first line treatment for severe Covid-19. Since then corticosteroids have been added to that list for treating severe Covid-19 disease. From WHO guidelines: 

“The guideline panel was informed by combining two meta-analyses which pooled data from eight randomized trials (7184 participants) of systemic corticosteroids for COVID-19. The panel discussions were also informed by two other meta-analyses, which were already published and pooled data about the safety of systemic corticosteroids in distinct but relevant patient populations. The resulting evidence summary suggested that systemic corticosteroids probably reduce 28-day mortality in patients with critical COVID-19 (moderate certainty evidence; seven studies,1703 patients; relative risk [RR] 0.80, 95% CI 0.70–0.91; absolute effect estimate 87 fewer deaths per 1000 patients, 95% CI 124 fewer to 41 fewer), and also in those with severe disease (moderate certainty evidence; one study, 3883 patients; RR 0.80, 95% CI 0.70–0.92; absolute effect estimate 67 fewer deaths per 1000 patients, 95% CI 100 fewer to 27 fewer). In contrast, systemic corticosteroids may increase the risk of death when administered to patients with non-severe COVID-19 (low certainty evidence; one study, 1535 patients; RR 1.22, 95% CI 0.93–1.61; absolute effect estimate 39 more per 1000 patients, 95% CI 12 fewer to 107 more). In addition, systemic corticosteroids probably reduce the need for invasive mechanical ventilation (moderate certainty of evidence; two studies, 5481 patients; RR 0.74, 95% CI 0.59–0.93). In contrast, harms, in the context of the mortality reduction in severe disease, are minor.
(…)
We recommend systemic corticosteroids rather than no systemic corticosteroids for the treatment of patients with severe and critical COVID-19 (strong recommendation, based on moderate certainty evidence).
(…)
We suggest not to use systemic corticosteroids in the treatment of patients with non-severe COVID-19 (conditional recommendation).”

3. Logarithmic graph

After exponential growth ebbing out in april, with weekly deaths decreasing for a period there seems to be a new rapid surge in Sweden since late october, as previously observed, the logarithmic graph from Aatish’s page illustrates this well: *

As I previously posted at 20-03-28, day 4, of this previously daily journal, logarithmic graphs are better for visualizing exponential trends.

COVID-19 Numbers Sweden 2020-11-27 *

  • 6 681 deaths nationally
    • 2627 of them in Stockholm
  • 243 129 confirmed cases nationally
    DEATHS [SWE]
  • New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates weekdays during mornings at 14:00 so weekends numbers are not yet complete until monday).
    ICU [SWE]
  • New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates weekdays during mornings at 14:00 so this weekends numbers are not yet complete until monday 14:00).
    NEW CONFIRMED CASES [SWE]  
  • New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden,updates weekdays during mornings at 14:00 so this weekends numbers are not yet complete until monday 14:00).
    TOTAL CONFIRMED CASES [SWE]  
  • New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 887 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,5 days from symptoms to ICU
    • 24,7 % women
  • Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it increased rapidly each week for the first 7 weeks, then slowing down at week 18, ebbing out/stabilizing at week 25, and start increasing again i velocity at week 44. Weekly numbers from week ten: 4 →  24  → 131 → 437 → 793 → 1175 → 1525 → 1858 → 2133 → 2363 → 2549 → 2705 → 2876 → 3046 → 3179 → 3282 → 3363 → 3414 → 3437 → 3457 → 3475 → 3495 → 3516 → 3534 → 3544 → 3554 → 3564 → 3575 → 3585 → 3593 → 3608 → 3634 → 3657 → 3713 → 3786 → 3925 → 4082 → 4274 → 4 419 (4419 this week, however since the weekends numbers might not yet have been updated this number will probably increase when revised next week)

COVID-19 Numbers Globally (last updated yesterday 2020-11-28 at 03:48 CET) *

  • 1 439 784 confirmed deaths (139 387 in last post, in April 17th 2020)
  • 61 299 371 confirmed cases (2 074 529 in April 17th 2020)
  • 13 296 new deaths (7 911 in April 17th 2020)

That’s it until next time, keep calm and stay safe!

Summary, Microembolism & Ending the Daily Posts – Day 25, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

COVID-19 Daily Posts Summary & Microembolism Part II 

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

I created this site in 2018 with the first post published 24th April 2018. My ambition for this site was, and still is, to be a placeholder for links and thoughts I find interesting related to emergency medicine (inspired by other similar sites such as EMCrit, LITFL, and the Swedish site STAIRS). I want this site to be an open node in space, adding to the rich culture of FOAM (Free Open Access Meducation) that exists online and, if it gets any traction, also being part of the online conversation of best practices in emergency medicine. However after the first post life – as it often does – had me prioritizing other projects in my life.

Until now.

Fast forward about twenty months later and enter the COVID-19 pandemic that has changed everything. When COVID-19 had us preparing for hell at my hospital in Stockholm, I then decided to write daily, I started the first daily post on 25th Mars 2020, with the aim to, again, organize links and resources and write down some of my thoughts on the emergency medicine aspects while trying to track the daily numbers of COVID-19 deaths both locally and globally.

It’s now twenty five days later and the number of deaths have accumulated globally from 16 362 to 146 088 and in Sweden from 42 to 1 511.

A lot has happened in the interim of these twentyfive days.

We have mobilized resources, learned more about the SARS-CoV-2 virus, an we seem to have passed the worst peak for now (?), and there’s been huge economic stimulus invested (trillions and trillions of dollars) trying to keep society and as many patients as possible from sinking.

The pandemic is far from over and it will have major repercussions for years to come.

But these daily posts have now served their purpose for me as the scope and the pathology of the COVID-19 pandemic is clearer than it was twenty five days ago. I will still keep updating CTSOP regularly, but not daily, and not always with COVID-19 specific posts – the original aim remains to keep adding resources, links and thoughts relating to emergency medicine (both in English and Swedish, and sometimes in Swenglish as they say).

Finally a summary of the 25 posts and some final thoughts on the microembolism theory presented at day 18.

25 Day Summary:

  1. 25th March — Are all Systems Go? – A post on preparations before the storm and the mentality of having situational awareness of your resources by checking and rechecking your systems capacity at every shift.
  2. 26th March — Predicting the Critical. – A post about temporal changes in laboratory markers from illness onset in patients hospitalized with COVID-19.
  3. 27th March — Treatment Alternativess. – A brief mentioning of a small study where hydroxychloroquine (Plaquenil) combined with the antibiotic Azithromycin was used to treat COVID-19 patients. During this time the hospitals in Stockholm had started to administer Chloroquine to certain COVID-19 patients, something that is no longer done due the lack of effectiveness and to side-effects such as long QT-time.
  4. 28th March — Exponential Growth. – A look at visualizing the spread and trends of COVID-19 with help of logarithmic scales.
  5. 29th March — 7 Clinical Observations. – My observations of COVID-19 symptoms and diagnostics from the daily clinical work at the ER.
  6. 30th March — Timeline. – An attempt to map out some of the key events of the pandemic.
  7. 31st March — ARDS. – Looking at the age groups and distribution of patients developing severe ARDS and needing intensive care.
  8. 1st April — Damage Control. – Discussing the ethics of prioritizing patients in light of extraordinary circumstances when resources might become completely overwhelmed (thankfully it never got as bad as we expected (yet?) in Sweden, thanks in large part due to mobilization of resources, and also – perhaps – social distancing policies).
  9. 2nd April — The Curve. – On death tolls rising around the globe and NY becoming the new urban epicenter of the SARS-CoV-2 virus.
  10. 3rd April — NOT a Black Swan. – How a virus pandemic was predictable, and how global societies have failed to be prepared despite previous warnings from experts.
  11. 4th April — Amat Victoria Curam. – Thoughts on the previous theme, but with a focus on Sweden and the last decades extreme political dismantling of the number of critical care beds and hospital beds in general (compared to other developed countries), leaving us with no margins, no buffer, for when shit hits the fan.
  12. 5th April — Another Night Shift. – A short post due to a crazy week with 6 nights at the hospital, culminating with the worst weekend we have ever seen in our ER.
  13. 6th April — War-like Scenes in the ER. – As we had our toughest days in the ER with ambulance after ambulance calling in with critically ill patients an article was published at the same time describing similar scenes in the ER of a hospital in NY.
  14. 7th April — Work Eat Sleep — Repeat. – On the importance of routines in the midst of the storm.
  15. 8th April — POCUS. – On Point of Care Ultrasound and COVID-19.
  16. 9th April — STEMI. – Where are all the STEMI patients during this pandemic?
  17. 10th April — Extubation. – More and more patients getting extubated from our ICU, things are a now a bit calmer again compared to the previous weekend, and one model projection on when we will reach peak pandemic.
  18. 11th April — Microembolism. – Can Anticoagulants Protect Against Getting Severe/Critical COVID-19 pneumonia/ARDS?
  19. 12th April — Diarrhea. – The pathophysiology of some patients presenting with diarrhea as a symptom.
  20. 13th April — CT Features. – A retrospective analysis of 120 consecutive patients from Wuhan city and what the typical CT thorax findings are in these patients.
  21. 14th April — Phase 2. – Is the worst when it comes to hospital influx and the number of critically ill patients needing intensive care at the same time, behind us in Stockholm/Sweden?
  22. 15th April — Phenotype L & H. – Categorizing COVID-19 in two types, and how type L is different from severe ARDS (those with type H) , and that there is different optimal treatments for each.
  23. 16th April — Covid 19 Cytokine Storm. – J Infect 2020-04-10 article by Yeet et al, ‘Cytokine Storm in COVID-19 and Treatment‘.
  24. 17th April — Aftermath. This pandemic will have lasting effects on society for years to come.
  25. 18th April. Microembolism part II, summary of the last 25 posts and the last daily post on this pandemic.

 

Microembolism & Anticoagulants part II

Finally, some additional thoughts on the microembolism theory presented at day 18. In brief: we have seen a considerable decrease of patients with atrial fibrillation in our wards, maybe due to the fact that they are already on anticoagulants that protects them from severe COVID-19 pneumonia, the SARS-CoV-2 virus probably causes (besides lung-embolisms) microembolism in the most critical patients resulting in severe ARDS?

The following report on the cardiopulmonary findings of four autopsies performed on patients within the United States, address thrombotic microangiopathy as a significant finding.

Sharon et al published the report in BMJ 2020-04-06, ‘Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans’: *

The dominant process in all cases was consistent with diffuse alveolar damage, with a mild to moderate mononuclear response consisting of notable CD4+ aggregates around thrombosed small vessels, and significant associated hemorrhage. Important additional mechanisms that may have contributed to death in this initial series of autopsies include a thrombotic microangiopathy that was restricted to the lungs. This process may involve activation of megakaryocytes, possibly those native to the lung, with platelet aggregation and platelet-rich clot formation, in addition to fibrin deposition. Small vessel thrombus formation in the lung periphery was in many cases associated with foci of alveolar hemorrhage. In one case, extensive fibrin and early organization was present, with degenerated neutrophils within the alveoli possibly representing neutrophil extracellular traps.

COVID-19 Numbers Sweden 2020-04-18 *

  • 1 511 deaths nationally
    • 897 of them in Stockholm
  • 13 822 confirmed cases nationally
    DEATHS [SWE]
    18fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    18fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    18fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    18fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 1 042 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,6 days from symptoms to ICU
    • 25,5 % women
      18SIR
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 426 → 761 → 1 111 (1 335 this week up until now, however since it’s only saturday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-18 at 18:00 CET) *

  • 146 088 confirmed deaths
  • 2 160 207 confirmed cases
  • 8 478 new deaths

That’s it for now, this is the last of the daily posts, CTSOP will still update, but not daily, and the theme will be emergency medicine in general and not just COVID-19 specific.

As always, stay calm and keep safe!

COVID-19 Aftermath – Day 24, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

COVID-19 After the Fact 

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

Long after the pandemic gets under control the aftermath will still have long lasting effects on everyday life on this planet. No one knows what the new normal will look like but, for better or for worse, things will never be the same again.

At the same time, that goes for any major crisis, things change in the aftermath, and people adapt.

Yet perhaps this one will be different in sheer scale?

Just looking at the employment filing rate in the US since March 15th, there is no equivalent in the last decades that comes close: *

economic

Disregarding the death toll, and just accounting for the devastating effect this pandemic will end up having on people’s life in the aftermath both economically and socially will be worse than anything we seen in recent history.

The trillions of printed money, adding to the, already big, dept of the leading economy of the world will also end up catching up with the world economy in the future even if we manage avoiding a recession now.

We will get through this, but what will it cost in the number of life’s both taken by the virus but also by socioeconomic circumstances?

COVID-19 Numbers Sweden 2020-04-17 *

  • 1 400 deaths nationally
    • 816 of them in Stockholm
  • 13 216 confirmed cases nationally
    DEATHS [SWE]
    17fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    17fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    17fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    17fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 1 019 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,6 days from symptoms to ICU
    • 25,3 % women
      17sir
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1 111 (1 305 this week up until now, however since it’s only friday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-17 at 18:00 CET) *

  • 139 378 confirmed deaths
  • 2 074 529 confirmed cases
  • 7 911 new deaths

That’s it until tomorrow, keep calm and stay safe!

COVID-19 Cytokine Storm – Day 23, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

COVID-19 Phenotype L & H

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

J Infect 2020-04-10 article by Yeet al, ‘Cytokine Storm in COVID-19 and Treatment‘: *

High levels of expression of IL-1B, IFN-γ, IP-10, and monocyte chemoattractant protein 1 (MCP-1) have been detected in patients with COVID-19. These inflammatory cytokines may activate the T-helper type 1 (Th1) cell response(47). Th1 activation is a key event in the activation of specific immunity(48). However, unlike SARS patients, patients with COVID-19 also have elevated levels of Th2 cell-secreted cytokines (such as IL-4 and IL-10), which inhibit the inflammatory response. The serum levels of IL-2R and IL-6 in patients with COVID-19 are positively correlated with the severity of the disease (i.e., critically ill patients > severely ill patients > ordinary patients)(49). Other studies have found that, compared with COVID-19 patients from general wards, patients in the intensive care unit (ICU) display increased serum levels of granulocyte colony-stimulating factor, IP-10, MCP-1, macrophage inflammatory protein-1A, and TNF-α. The above studies suggest that the cytokine storm is positively correlated with disease severity(47)

COVID-19 Numbers Sweden 2020-04-16 *

  • 1 333 deaths nationally
    • 795 of them in Stockholm
  • 12 540 confirmed cases nationally
    DEATHS [SWE]
    16fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    16fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    16fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    16fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 977 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,6 days from symptoms to ICU
    • 25,4 % women
      16sir
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1105 (1213 this week up until now, however since it’s only wednesday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-16 at 14:00 CET) *

  • 131 037 confirmed deaths
  • 1 995 983 confirmed cases
  • 5 389 new deaths

That’s it until tomorrow, keep calm and stay safe!

COVID-19 Phenotypes – Day 22, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

COVID-19 Phenotype L & H

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

What if I told you that perhaps all COVID-19 pneumonia is not best treated as severe ARDS?

Gattinoni et al suggested yesterday, 2020-04-14, in an editorial to Intensive Care Medicine, that there’s a disparity in symptoms and treatment-response in patients with COVID-19, therefore categorizing them in two different phenotypes of COVID-19 pneumonia that can help explain the different ways in which it presents. They describe how type L is different from severe ARDS (those with type H) , and that there is different optimal treatments for each: *

Yet, COVID-19 pneumonia [2], despite falling in most of the circumstances under the Berlin definition of ARDS [3], is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance (more than 50% of the 150 patients measured by the authors and further confirmed by several colleagues in Northern Italy). This remarkable combination is almost never seen in severe ARDS. These severely hypoxemic patients despite sharing a single etiology (SARS-CoV-2) may present quite differently from one another: normally breathing (“silent” hypoxemia) or remarkably dyspneic; quite responsive to nitric oxide or not; deeply hypocapnic or normo/hypercapnic; and either responsive to prone position or not. Therefore, the same disease actually presents itself with impressive non-uniformity. (…) Type L, characterized by Low elastance (i.e., high compliance), Low ventilation-to-perfusion ratio, Low lung weight and Low recruitability and Type H, characterized by High elastance, High right-to-left shunt, High lung weight and High recruitability. *

The best way to differentiate between type L and type H patients is, according to the authors, by CT scan where type L patients have only ground-glass opacities primarily located subpleurally and along the lung fissures while typ H patients CT scans shows a ‘remarkable increase in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS.’

They also suggest that the relationship between type L & H is dynamic and can change over time, as a patient presenting with type L at admission kan transition into type H over a couple of days:

typelhImage: from Gattinoni et al, “COVID-19 pneumonia: different respiratory treatments for different phenotypes?” editorial published in Intensive Care Medicine, 2020-04-14. *

Nota bene: Gattinoni et al generally advise against non-invasive options (regardless of type) as they argue that they are associated with high failure rates and delayed intubation!

COVID-19 Numbers Sweden 2020-04-15 *

  • 1 203 deaths nationally
    • 702 of them in Stockholm
  • 11 927 confirmed cases nationally
    DEATHS [SWE]
    15fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    15fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    15fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    15fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 970 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,5 days from symptoms to ICU
    • 25,4 % women
      15SIR
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1105 (1213 this week up until now, however since it’s only wednesday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-15 at 14:00 CET) *

  • 123 126 confirmed deaths
  • 1 918 126 confirmed cases
  • 5 389 new deaths

That’s it until tomorrow, keep calm and stay safe!

COVID-19 & Phase 2 – Day 21, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

Have we entered into phase 2 of the pandemic?

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

So the easter holidays have come and gone, and the now famous epidemiologist Anders Tegnell warned against reading too much into COVID-19 numbers over the weekend, since less data might have been reported due to less personal at the hospitals.

Well it’s tuesday and the holidays are now over, yet, judging by the data from the previous days (since the last bar/day updates tomorrow) the pandemic curve in Sweden doesn’t seem to be accelerating anymore:

peak
Image: daily number of COVID-19 deaths in Sweden, taken from FHM. *

Perhaps it’s too soon to make any inferences just yet?

Or perhaps the worst is behind us?

The worst so far being the previous weekend, April 4th-5th, when I posted the following at day 13 — observing in that post that we were seeing similar war-like scenes as the ER at NY that was published the same weekend.

What was happening in NY was happening in Stockholm.

So, clearly, it’s too soon to make any conclusions, but maybe, just maybe, the worst wave is over?

If so, how bad will the second and third waves be?

And will there be 3rd and 2nd waves?

UPDATE 2020-04-14 at 19:15: 

More probably we’re only seeing a temporary fluctuation before exponential growth continues, as previously observed, the logarithmic graph from Aatish’s page illustrates this well: *

14log

As I previously posted at day 4 of this daily journal, logarithmic graphs are better for visualizing exponential trends.

COVID-19 Numbers Sweden 2020-04-14 *

  • 1 033 deaths nationally
    • 616 of them in Stockholm
  • 11 445 confirmed cases nationally
    DEATHS [SWE]
    14fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    14fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    14fhmk
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    14fhmkk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 887 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,5 days from symptoms to ICU
    • 24,7 % women
      13SIR
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1096 (1155 this week up until now, however since it’s only tuesday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-14 at 19:00 CET) *

  • 117 021 confirmed deaths
  • 1 844 863 confirmed cases
  • 5 692 new deaths

That’s it until tomorrow, keep calm and stay safe!

COVID-19 & CT Features– Day 20, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

Can the CT-scan help differentiate which COVID-19 patients get severe pneumonia?

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

Eur Radiol 2020-04-11 article by Zhang et al, ‘CT features of SARS-CoV-2 pneumonia according to clinical presentation: a retrospective analysis of 120 consecutive patients from Wuhan city‘: *

Discussion:

In line with other studies [12,13,14,15,16,17,18,19], the predominant patterns of abnormalities on CT for our 120 patients were GGOs with a peripheral distribution and bilateral, multifocal lower lung involvement. Compared with those of common cases, some CT features were more common in severe cases, such as crazy-paving patterns, bronchiectasis, hilar or mediastinal lymph node enlargement, white lung, air bronchogram, and pleural effusion. We also found that severe cases usually presented as consolidation larger than segmental consolidation, and only severe cases showed an overall lobar or diffuse pneumonia distribution pattern, which indicated that the affected area or volume could also be an important determinant for the disease severity of SARS-CoV-2 pneumonia. However, these patterns also often overlap because CT manifestations are dynamic [15, 16], and depend on various factors, such as disease severity, the evolution of the disease course [14, 15, 20], treatment [12], comorbidity, and complications. Usually, as the disease progressed, the range of GGO patches and consolidation increased. Afterwards, condition would improve, GGO and consolidation disappeared, and fibrous stripes (reticulation) may appear [20]. *

So, in other words, while bilateral GGOs [ground-glass opacities] are a common find in COVID-19 patients, those that get critically ill might also show features such as bronchiectasis, hilar/mediastinal node enlargements, white lung, air bronchograms, pleural effusions, and crazy-paving patterns * *.

Crazy-paving patterns look like this:

image 1

image 2
Images from: thoracic.org – The American Thoracic Society: “Crazy-paving on CT refers to the findings of ground-glass opacities (patchy or diffuse) with thickened interlobular septae and intralobular lines. It gets its name from the similar appearance to a pathway made up of disorganized paving-stones.” *

COVID-19 Numbers Sweden 2020-04-13 *

  • 919 deaths nationally
    • 543 of them in Stockholm
  • 10 948 confirmed cases nationally
    DEATHS [SWE]
    13fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    13fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    13fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    13fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 857 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,5 days from symptoms to ICU
    • 24,5 % women
      13SIR
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1068 (1087 this week up until now, however since it’s only monday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-13 at 19:00 CET) *

  • 111 652 confirmed deaths
  • 1 773 084 confirmed cases
  • 6 250 new deaths, daily change: -10,02%

That’s it until tomorrow, keep calm and stay safe!

COVID-19 & Diarrhea – Day 19, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

Why do some patients get gastrointestinal symptoms such as diarrhea?

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

Clin Gastroenterol Hepatol 2020-04-08 article by D’Amico et al, ‘Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention and management‘: *

RESULTS:

Clinical studies show an incidence rate of diarrhea ranging from 2% to 50% of cases. It may precede or trail respiratory symptoms. A pooled analysis revealed an overall percentage of diarrhea onset of 10.4%. SARS-CoV uses the the angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 for S protein priming. ACE2 and TMPRSS2 are not only expressed in lung, but also in the small intestinal epithelia. ACE2 is expressed furthermore in the upper esophagus, liver, and colon. SARS-CoV-2 binding affinity to ACE2 is significantly higher (10-20 times) compared with SARS-CoV. Several reports indicate viral RNA shedding in stool detectable longer time period than in nasopharyngeal swabs. Current treatment is supportive, but several options appear promising and are the subject of investigation.

So, in other words, we have ACE2 receptors in our guts too, therefor diarrhea in some patients.

Looks like this:

diarrImage from: D’Amico et al, 2020, Clin Gastroenterol Hepatol. *

COVID-19 Numbers Sweden 2020-04-12 *

  • 899 deaths nationally
    • 528 of them in Stockholm
  • 10 483 confirmed cases nationally
    DEATHS [SWE]
    12fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    12fhmk
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    12fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    12fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 830 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,5 days from symptoms to ICU
    • 23,6 % women
      12sir
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 424 → 754 → (1038 this week up until now, however since it’s only sunday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-12 at 18:00 CET) *

  • 105 952 confirmed deaths
  • 1 696 588 confirmed cases
  • 6 892 new deaths, daily change: -5,29%

That’s it until tomorrow, keep calm and stay safe!

COVID-19 & Micro Embolism – Day 18, Thoughts About The Pandemic

/ Robert Taeri / Leave a comment

Can Anticoagulants Protect Against Getting Severe/Critical COVID-19 Pneumonia?

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

What we are not seeing at our ward (AVA) is any COVID-19 patients with atrial fibrillation. Usually at least half of our patient monitors are filled with irregular rhythms.

Now there is not a single one (at least not who is also positive with COVID-19, which most patients at the ward are).

These patients all have perfectly regular sinus rhythms.

Which makes us ask ourselves a similar question as the one posted two days ago regarding STEMIs: WHERE ARE ALL THE PATIENTS WITH ATRIAL FIBRILLATION?

One theory is: what if anticoagulants protect against the complications associated with a COVID-19 infection?

What if it all fits?

The fact that SARS-CoV-2 seems to cause a cytokine storm (with IL-6 being activated & elevated among other cytokines), and the elevation of D-Dimer, and the fact that these patients simply seem more prone to get embolisms.

Add to that the fact that the patients in the high risk group also seem to have, already, elevated risk for thromboembolism with risk factors such as: smoking, hypertension, obesity, and age.

What if all the pulmonary complications we are witnessing in the hospital are due mostly to microembolism in the lungs?

What if those already on anticoagulants are protected and that’s why we are not seeing patients with atrial fibrillation being admitted to the same extent as we have previously?

What if that, to some extent, also explains the decline in STEMI patients as many of the patients seeking for chest pain might already be on anticoagulants if they had STEMI previously?

Many questions, a theory that seems to fit, but research is needed to get us from guess work to facts.

Until then, since 9th of April we have new guidelines regarding treatment with anticoagulants where basically anyone positive with SARS-CoV-2 with thrombocyte levels that are adequate are administered LMWH from day one.

The patients who are in need of high levels of oxygen or NIV (non-invasive ventilator) or intensive care are administered double the standard prophylactic dose.

It all seems to fit (however, beware of the high risk of confirmation bias!) – have we finally made a breakthrough regarding the best treatment regimen?

Lets see if the data & research, going ahead, also confirms our theory.

COVID-19 Numbers Sweden 2020-04-11 *

  • 887 deaths nationally
    • 523 of them in Stockholm
  • 10 151 confirmed cases nationally
    DEATHS [SWE]
    11fhmd
    New confirmed deaths daily in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    ICU [SWE]
    11fhmi
    New Covid-19 patients Being Treated at the ICU in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    NEW CONFIRMED CASES [SWE]  
    11fhm
    New confirmed cases daily in Sweden.
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
    TOTAL CONFIRMED CASES [SWE]  
    11fhmk
    New confirmed cases accumulated over time in Sweden. 
    (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  • Intensive care Sweden: *
    • 774 COVID-19 confirmed patients treated in the ICU in total so far
    • 10,4 days from symptoms to ICU
    • 23,6 % women
      3sir
      Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 424 → 753 → (997 this week up until now, however since it’s only saturday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-11 at 18:00 CET) *

  • 99 690 confirmed deaths
  • 1 610 909 confirmed cases
  • 7 277 new deaths, daily change: 15,77%

Image: Projected Total COVID-19 Deaths in Sweden by August 4th, 2020 (up yesterday from projected 4 183 to → 13 259) *

modelsweden2

That’s it until tomorrow, keep calm and stay safe!