i think it's tempting to assume that vitamin D deficiency is a byproduct of some other bad habit. but if that was so, there's an awful lot of fat white people. is vitamin D deficiency a known thing among them? my wife swims, bikes, runs, looks pretty darned terrific for 61, has always been athletic, never overweight, and has had a vitamin D deficiency her whole life. it's a kind of known thing. in fact, go to google, type in "black people vitamin..." and see how far you get before it's autofilled with "D".

here's an abstract from the first thing that pops up in pubmed: "Vitamin D insufficiency is more prevalent among African Americans (blacks) than other Americans and, in North America, most young, healthy blacks do not achieve optimal 25-hydroxyvitamin D [25(OH)D] concentrations at any time of year. This is primarily due to the fact that pigmentation reduces vitamin D production in the skin."

as to causation. what my wife did NOT say is that she thinks this is the reason why black people suffer from COVID at rates so much higher. she just bypassed the other big thing (lacks the gene for lactase persistence), and went right to, "we're all low in D." neither she nor i have any idea whether a lack of D makes one suffer more with COVID. but we're not taking any chances! we're popping Ds!

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Dan Empfield
aka Slowman

No, I can't quote a study, so take this FWIW. IIRC, darker skin pigmentation is protective against UV at the expense of Vit D synthesis.

If one's ancestors evolved in a UV-Intensive environment (e.g. African savanna), dark pigment was advantageous; If one's ancestors evolved in a UV-weak environment (e.g. Scandinavia), lighter skin was advantageous.

Fast forward to the 21st century, where we all spend most of our lives indoors where it's artificially UV-weak, and it's not too surprising that those with genetic dark pigmentation have disproportionately higher Vit D deficiencies.

[EDIT: I'm sure somebody will bring up dark-skinned Eskimos to refute this. I dunno. I remember learning this somewhere long ago and maybe it's just BS...]

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"100% of the people who confuse correlation and causation end up dying."

Eskimos historically got their Vit D from their diet (seals and whale blubber)

Well, that settles it. I'm going to go give my wife "the D" right now!

Interesting. I have been supplementing vitamin D after it showed low on a blood test. I think a lot of it points to change in lifestyle. I used to be outside multiple times a day - walking to work or walking to the bus, riding outside, walking home, etc. In Tennessee it’s walk three steps out the door to the truck, get in the truck and drive to the parking garage, take the elevator up to the office. Swim indoors, go to the gym indoors, mostly ride indoors.

One good thing about the stay at home is that I am getting outside every day pretty much. And I’m still continuing the Vit D supplementing.

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clm
Nashville, TN
https://twitter.com/ironclm | http://ironclm.typepad.com

I did not say Vit D deficiency was a byproduct of a 'bad habit'. I pointed out what is known about the association of Vit D with specific groups of people. Blacks are in the group, as are lots of other people, like elderly white females. It is simply not known if 'low' levels mean anything clinically. There be more circulating hormone- free or non-bound, in certain groups, and perhaps blacks don't need as much circulating Vitamin D. And we are talking sub-clinical Vit D deficiency, not ricketts-like.

My point is that people are advised to take this supplement mainly for fracture prevention. (There is no proven worth in enhancing immunity...at this point, not unlike Vit C.) The belief is that it helps in CA absorption via PTH. There is evidence that raising Vit D levels to normal, in blacks, did nothing to PTH and there was no proven benefit, just a 'normal Vit D level'.

And AA generally have lower fracture risk despite low D levels...Also, let's not forget that relative Vit D 'deficiency' is hugely prevalent in the USA. Low risk populations are not advised to be screened.

When there's evidence, I'll believe. I'm not advising to do it or not do it-that's up to patients and THEIR physicians.

As additional information, I had labs done a few years ago and my Vit D level came back borderline and I was advised to take a D supplement. Of course, I asked 'why?' He said to prevent fracture, but I pointed out that I had a bone density scan just a year ago showing >100% bone strength and I didn't feel I was at a fracture risk. He agreed.



Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment
Author:Bess Dawson-Hughes, MD Section Editors:Marc K Drezner, MD, Clifford J Rosen, MD Deputy Editor:Jean E Mulder, MD
Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2020. | This topic last updated: Sep 30, 2019.
...
DEFINING VITAMIN D SUFFICIENCY
Serum 25-hydroxyvitamin D — Vitamin D sufficiency is estimated by measuring 25-hydroxyvitamin D (25[OH]D or calcidiol) concentrations. The optimal serum 25(OH)D concentration for skeletal health is controversial.
...
Racial differences — The optimal serum 25(OH)D concentration for skeletal health and extraskeletal health is controversial, and it has not been rigorously established for the population in general or for specific ethnic groups. Black Americans have lower fracture risk and higher bone density than other races [27,28]. Serum 25(OH)D concentrations are variable, depending upon the assay method used. Using a monoclonal sandwich assay in a multiethnic cohort study, low vitamin D-binding protein levels were more common in blacks than whites, and consequently, the amounts of bioavailable vitamin D in blacks and whites were similar [29]. The variability in vitamin D-binding proteins accounted for a large proportion of the variation in serum total 25(OH)D levels. However, this finding has been disputed because of the assay measurement [19,30]. As an example, when the vitamin D-binding proteins were measured with LS-MS/MS, the values were not low [19], and therefore, it is uncertain whether vitamin D-binding protein levels differ by race or whether there are racial differences in serum 25(OH)D. These findings underscore the importance of the assay method used to determine vitamin D and its binding proteins. Whether direct measurement of a bioavailable or "free" serum 25(OH)D would be preferable to current assays for determination of vitamin D status is uncertain.

There is very little evidence about effects of vitamin D (or calcium supplementation) in persons who are not Caucasian, but since racial differences in mineral metabolism are substantial, we cannot apply findings from one race to other races. It has been shown that black women do increase their circulating levels of vitamin D after oral supplementation to levels similar to white women, but it is not clear if this is beneficial [31,32].
...
VITAMIN D DEFICIENCY
Prevalence — The prevalence of vitamin D deficiency depends upon the definition used. In the National Health and Nutrition Examination Survey (NHANES) 2005 to 2006, 41.6 percent of adult participants (≥20 years) had 25-hydroxyvitamin D (25[OH]D) levels below 20 ng/mL (50 nmol/L), consistent with the spectrum of vitamin D insufficiency/deficiency [38]. Multivariate analyses showed that being from a non-white race, not college educated, obese, having low high-density lipoprotein (HDL) cholesterol, poor health, and no daily milk consumption were significantly and independently associated with low vitamin D levels.
...
EVALUATION
The majority of healthy adults with serum 25-hydroxyvitamin D (25[OH]D) of 12 to 20 ng/mL (30 to 50 nmol/L) do not require any additional evaluation




And I'm very, very sorry to lead this thread astray, so I'll circle back to this:

It's not known if Vit D deficiency is a marker of increased risk in Covid patients or not, but there is an association.
Further review is needed.

to be clear, i have no idea of a vitamin D deficiency leads to bad COVID outcomes. i just found it interesting that as i was musing audibly about what separates black people from white people genetically my wife spouted out the vitamin D thing. and then a month later i'm starting to read articles about vitamin D and COVID.

i'm with you. i'm aware of no studies that show this. only correlation. but this is a compelling article (and one of many.) its starts by saying that vitamin D "appears to play a role in COVID-19 mortality rates" and backs this up only with correlation. but if you read down you see that the suspicion is that vitamin D deficiency invites the cytokine storm. i found this article much better.

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Dan Empfield
aka Slowman

Just checking in on you and Sphere.......any updates? I hope the fame from being on the frontpage of slowtwitch hasn't caused you to ignore us commoners.

Appreciate the inquiry. Was on call this weekend and the hospital is certainly less full of covid patients. We are all 'green' (plenty of supply) on PPE. Mood is up and everyone is getting used to the 'new normal' of masks/gowns/handwashing and the extra time it takes to do these things.

Acuity in the rest of the hospital is clearly down. Volume also down. New covid cases in my hospital and across the state are down....until the 'reopening'....of course.

I'm pretty tired though-only 4 hrs of sleep last night. G'nite...


COVID19 Preparedness Monday 5/18/20
Incident Command Email -

Saint Francis Hospital Situation

• 131 Colleagues COVID+, 23 Colleagues Home Isolation (Friday)
• Cumulative Successful Extubations 20
• Friday 10 COVID+ Patients Discharged Home/SNF
• Saint Francis Hospital COVID-19 Discharges to Home or SFN (5/13/20): 502

Supply Chain (*all green)
Isolation Gowns
COVID19 Test Kits
Eye Protection
N95 Respirators
Surgical Masks

Any updates from you guys? Lots of traction to a report that the viral load is decreasing making this less potent. Are you guys seeing this?

Stay safe and as always thanks for the work you are doing!

I decided to bump this today. As a nod to sphere, who is hopefully resting and convaslescing well from it right now. And to provide a reminder of what is going on in every hospital in every community right now.

Feel free to reread. None of what is in here is hyperbole. Sure, our underestanding and treatments have evolved and I would even say improved.

But the pain and suffering described in here continues to be reality for many.

Oh, and I dare anyone to justify the neglience in our Federal response that has indisbutably "led" us into this fire. And continues to blow smoke.

Elective surgeries are starting to be put off and the percent of infected people being admitted to hospital is going down as some patients are turned away.

“Faced with a surge of severely ill people, doctors and nurses will have to put beds in hallways, spend less time with patients, and become more strict about whom they admit into the hospital at all. The quality of care will fall; Americans who need hospital beds for any other reason—a heart attack, a broken leg—will struggle to find space. Many people will unnecessarily suffer and die.”

“As hospitals run out of beds, they could be forced to alter the standards for what kinds of patients are admitted with COVID-19. The average American admitted to the hospital with COVID-19 today is probably more acutely ill than someone admitted with COVID-19 in the late summer. This isn’t because doctors or nurses are acting out of cruelty or malice, but simply because they are running out of hospital beds and must tighten the criteria on who can be admitted.
Many states have reported that their hospitals are running out of room and restricting which patients can be admitted. In South Dakota, a network of 37 hospitals reported sending more than 150 people home with oxygen tanks to keep beds open for even sicker patients. A hospital in Amarillo, Texas, reported that COVID-19 patients are waiting in the emergency roomfor beds to become available. Some patients in Laredo, Texas, were sent to hospitals in San Antonio—until that city stopped accepting transfers. Elsewhere in Texas, patients were sent to Oklahoma, but hospitals there have also tightened their admission criteria.”

https://www.theatlantic.com/...nk&ICID=ref_fark

Thanks for your concern. I'm feeling quite well, just a little more tired than usual at night, after a few days of flu-like symptoms. Hopefully that's the extent of it for me (and my fiance, who also picked it up either from her hospital or from me, or vice versa, can't be certain).

When my test came back positive, I immediately called the head of our group, who essentially told me that I should return to work as soon as I'm feeling up to it, and that the hospital administration agrees; no timeline, no requirement for a negative test, just keep the units staffed and operational, and be careful. Those are the conditions we're back in now, with this second wave. It's not been as ferocious as the first assault, but our numbers aren't too far off and we lose one patient per day, on average. We've got a long way to go. It's exhausting.

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The devil made me do it the first time, second time I done it on my own - W

Just after 1:30am here in the ICU. As before, we're over capacity, with the majority of our COVID patients on ventilators. Our census is back up into the high 60s (normal critical care load hovers around 35-40 patients). We're losing two to three patients per day, on average, over the last couple of weeks, since the second wave hit. It's a different feeling here now, though, with the first round of vaccines being distributed--I am ineligible for another 70 days or so given my recent COVID infection--and many of us having contracted and recovered from it. People are generally less fearful now of the unknown, or maybe just desensitized to it. Fatigue has most definitely taken a toll on the staff. Unit nurses have left for travel nursing jobs, a few lost to early retirement, none have been critically ill, thankfully.

I can't say there's much good news on the treatment and vent liberation front, however. The mortality rate is still very high for vented patients, and most of the ICU COVID patients end up vented. A few, I've had to convince allow intubation if necessary. They're rightly fearful about never coming off the vent, have told the nursing staff they do not want to be put on a ventilator, and I have to explain that we hold off intubation for as long as reasonably possible, but if you'll die without it, at least it gives you a fighting chance. We ride that razor thin line daily, and sometimes it pays off. Sometimes not.I had that conversation with a gentleman last week, and agreed to tolerate mid-low 80s saturations as long as he looked clinically stable otherwise with strong vitals. Hid did fine, until he didn't 30 minutes later, and the charge nurse called in a panic for me to intubate him. He went from saturating in the 80s to the low 30s before I got an endotracheal tube in him, and ventilated him back up to the low 90s. He never lost a pulse, but others in his same situation have. It's such a fine line to walk with these patients. I coded an elderly gentleman around midnight tonight, who was doing reasonably well on high-flow nasal cannula, until he pulled it off for whatever reason. His sats dropped, heart rate fell to the teens, lost his pulse, and was successfully resuscitated after three rounds of epi, CPR, and intubation. He's not following commands or making purposeful movements, which obviously isn't a great sign, but it's early yet. We'll run him for a head CT then induce hypothermia to minimize neurological damage and reassess after rewarming, provided his lungs cooperate. This is pretty typical of a day in a large COVID unit--multiple intubations and codes, one or two deaths, nurses who are over it six months ago, tired, but hopeful.

We've had at least two LR denizens lose a family member to this disease, at last count. My sincere sympathy for their losses. I know how exceptionally hard it is for these patients and their loved ones.

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The devil made me do it the first time, second time I done it on my own - W

It's shocking

My friends the Chair of 2 hospitals in the South East of the UK

They had ~45 patients at end of first week of Dec, ~110 end of the second week and yesterday just shy of 300 with the peak expected Jan 4th...........

They're stuffed.

Sphere -


You, your co-workers, and everyone else on the front line is a rock star. Seriously...

Without question!

To paraphrase Duffy, “this is what you (and the nurses) signed up for.”

Hang in there pal.

I can’t imagine the emotional toll this takes on you and the team. As I’ve mentioned, my sister is an ER nurse and they’re at capacity. She mentioned that some nurses are calling out with various excuses because they just can’t take the agony of it all. I’m actually a bit worried about her given the added strain of a smaller staff and the crazy hours. At her hospital, not one single patient has survived after being put on the ventilator. They survive for a few days after extubation then rapidly decline and die (exactly what happened to my BIL last week).

She’s depressed and stressed but just keeps plodding along. Thankfully, she got the Pfizer vaccine last week. They’re mostly sending people home with Zithromax and Dexamethosone (sp) and instructions to sleep on their stomach, stay hydrated, and move around every few hours.

I’ve decided if I happen to end up hospitalized that I’ll refuse the ventilator. Now that I’ve read about the long recovery after being on one for 7+ days and the permanent damage and the low probability of a good outcome, I’ll just save everyone the hassle.

Thanks for all you’re doing and your positive attitude. I’m sure your grief doesn’t always translate into your posts.

My father died last spring; he was a nursing home resident and coming off a round of cancer treatment. So many predisposing factors.

Have you all been able to use monoclonal antibody treatments yet, and with any success? Article in WSJ said they are sitting unused in hospital pharmacies.

The kids grandmother (my MIL) was on the vent for three weeks and passed in April. We thought, hoped she could win, sadly as a life long smoker and carrying a little but not huge weight. She never really had a chance though.

At best she would have lived with severly damaged lungs limited mobility and breathing support. Don't know what the the outcomes are for those vented, but it's a horrendous experience.

Thanks for the update, Sphere. Your posts are sobering.

I missed the post earlier in the month about your positive test. Super glad to hear you recovered well. Thanks for what you, and all the other frontline workers, do for us.

Thanks for posting an update Sphere. Always fascinating to get a frontline perspective. Hang in there and fight the good fight.

Keep up the periodic missives please.

.